A Roast Duck & Three Litres of
“Simpex veri sigillum.”
(The great seal of truth is simplicity.)
– Hermann Boerhaave –
Boerhaave conducted an autopsy the next day.
Examination of the outside of the body showed subcutaneous emphysema to palpation, but no other abnormalities.
When the thoracic cavity was opened large quantities of gas escaped. Attention was immediately drawn to a strong smell of duck meat and jupin beer. The lungs had collapsed and floated on a liquid filling almost the entire thoracic cavity, equally much on each side. Altogether there was close to three litres. Boerhaave examined the left pleural cavity more closely and there discovered the cause of the matter: a ruptured hole into the oesophagus. Everybody present was allowed to put a finger through this hole to prove its existence. Boerhaave concluded that the oesophagus, previously healthy, had been ruptured by the excessive force of vomiting after taking emetics. The overfull contents of the admiral’s stomach had escaped into his chest and caused his death.
One of the greatest clinicians of all time (some say the greatest) was a Dutchman called Hermann Boerhaave, who practiced in the 18th century. Among Boerhaave’s greatest accomplishments was his introduction of the clinicopathological correlation: correlating what is seen in pathology (such as at autopsy) with the clinical features of the patient. We have already met Morgagni, who used this tool to great effect.
Let us look at the death of Baron Jan van Wassenaer, Grand Admiral of the Dutch Fleet, attended in his last moments by Boerhaave. This case stands as the landmark in clinicopathological correlation. See if you can work out why the admiral died.
First, the clinical picture…
The Death of Grand Admiral Jan van Wassenaer
It was 11:30 on the evening of October 29, 1723, when Boerhaave was personally called upon by the son of Baron Jan van Wassenar, Grand Admiral of the Dutch Fleet and Prefect of Rhineland. Crying, he asked Boerhaave to come quickly: his father was in death cramps or perhaps was even already dead.
Boerhaave duly attended in great haste, and on arriving found the admiral sitting on his bed, bent forward. He recorded the following history:
The admiral was 51 years of age, and his only medical problem was gout, exacerbated by drinking and eating much. On this occasion, some three days beforehand, the admiral had taken an especially heavy meal in the company of good friends. On the evening in question, again eating heavily and feeling particularly ‘burdened’, he took a few small cups of a mild emetic to purge himself – as was his custom. However, he did not vomit, and found that the heavy feeling persisted. He next drank 28 grams of olive oil and around 180 more grams of jupin beer to try to clear the feeling. Shortly after, he vomited, but only a little, and this not easily. So he took another four cups of the beer and again tried to purge himself.
The next moment, the admiral emitted a loud scream and gripped at his chest, stating that it felt as if something had been ‘broken there’. He then immediately declared himself dying and started praying.
It was a very sick patient who met Boerhaave. The admiral spoke with a clear voice and did not cough, even though he had extreme pains in the chest. He was free of fever. There were no symptoms of any known disease or poisoning.
The house physician, Dr de Bye, had already tried bleeding and the two physicians ordered another bleeding, something non-alcoholic to drink and warm compresses. But, in vain, the Baron succumbed the next day.
What do you think?
Why did the admiral die?
Let’s now see how Boerhaave answered this question…
This condition – rupture of the oesophagus – is now known as Boerhaave’s Syndrome.
Herman Boerhaave (1668-1738)
Herman Boerhaave was born to a preacher and his second wife, just outside Leyden in Holland where he was to spend his entire life. At school he showed a flare for languages, learning Hebrew, Arabic, English and German. When he was twelve he was attacked by a swarm of bees causing a ‘stubborn painful and malignant ulcer upon his left thigh, which, for near five years, defeated all the art of the surgeons and physicians.’ It may have been the suffering at the hands of these ineffective clinicians that spurred Boerhaave’s interest in medicine, and indeed it was eventually Boerhaave himself who cured the lesion, ‘by tormenting the part with salt and urine’. He showed exceptional talent at school, breezing through in rapid time with the top prizes.
Boerhaave first completed a doctor of theology before taking up study of medicine, chemistry and botany. When his father died, he supported himself and his family by tutoring in mathematics. As he came to doubt the ‘purity’ of his theological beliefs, Boerhaave became more and more devoted to the study of medicine. He learnt by avidly reading every great medical work to date, from Hippocrates to Vesalius and Sydenham, and made a practice of avoiding all lectures apart from demonstrations in anatomy. His thesis was on examining patients’ excrements for diagnostic purposes.
As a practicing clinician Boerhaave developed a reputation for brilliance but also kindness amongst patients because he spared them the radical speculative treatments common in the day – a practice that reflects his Hippocratic readings. He once said “my best patients are the poor, because the Lord has taken it upon himself to pay me for them.”
When appointed lecturer in 1701, his first lecture was a recommendation to study the works of Hippocrates, and so began a career as one of the most inspiring and well-loved teachers who has ever lived. His reputation rapidly spread, and soon students from all over Europe were descending on Leyden to learn from his great wisdom. The lectures, given in Latin with great zeal and energy, were so popular that richer students were known to hire men to get to the classroom extremely early to reserve seats. His greatest contribution and legacy – which we all must still thank Boerhaave for today – was to introduce the practice of teaching medical students at the bedside of patients.
When he died in 1738, from heart failure, it is said that Boerhaave left a book to his students, which laid out all the secrets of medicine. After he died it was opened, and all pages were blank apart from one. It read “Keep the head cool, the feet warm and the bowels open”.
Acquire your knowledge at the bedside. Lectures are the transmission of the lecturer’s notes to your notes – without passing through either brain.
The great variation in medicine can be learned only from the one true teacher of disease that the student of medicine encounters – the patient. And it is a lifetime’s work.