A medical evaluation of Rembrandt. His self-portrait: ageing, disease, and the language of the skin

See him in me, as helpless and as old!—Homer (The Illiad)1Homer The Iliad. Book 24. Pope A, transl. Easton Press, Norwalk, Connecticut1979: 467Google Scholar The old man sits, clenches his hands, turns his head (figure 1). He is like the patient who postpones a visit, who waits to be the last one seen. Now it is dark and he melts into the penumbra. He moves his face towards the light—a ruddy, blotchy, haggard face. His brow is wrinkled, his eyes steady, deep set in dark sockets. He engages us; there is an intensity, an urgency, in his stare. His posture is neither humble nor imposing. But he has presence. He waits to be examined; not like a convict fearing a judge's decision, but like a patient seeking a physician's care, as if he expects our diagnosis, understanding, compassion. Every patient has his own language. It is not only symptoms and physical signs that are revealing, but also attire, posture, and gestures. The old man's clothing is telling. Muddy shadows shape his fading doublet. Amber dabs suggest not a fur, new and chic, but a worn-out, old coat. Swipes of black make a simple beret: a sign of his trade. He is a painter. Yellow specks adorn the beret; it is a gold chain, a remnant of the crown that once sat upon the great master's head. He is Rembrandt. His hands motionless, his jaw tense, his lips tight, he remains silent. Examining his portrait, what can we learn about Rembrandt? At first glance, it seems as if Rembrandt is actually present. As one accomodates to examine the skin, its texture seems palpable; its colour undergoes subtle variations in tone. It is like examining a living person. How does Rembrandt create this illusion?2Gifford M Technical examination report on file. Book 24. Conservation Department. National Gallery of Art, Washington1992Google Scholar, 3Wheelock A Rembrandt van Rijn. Dutch paintings of the seventeenth century. Oxford University Press, New York1995: 261-265Google Scholar, 4Strauss W van der Meulen M The Rembrandt documents. Abaris Books, New York1979Google Scholar, 5van de Wetering E The invisible Rembrandt: the results of technical and scientific examination.in: Brown C Kelch J van Thiel P Rembrandt: the master & his workshop. Yale University Press, New Haven1991: 12-49Google Scholar, 6Bomford D Brown C Roy A Rembrandt's painting materials and methods. Art in the making: Rembrandt. National Gallery Publications, London1988: 21-26Google Scholar, 7Laurie AP From “The Night Watch” to “The Jewish Bride”. The brushwork of Rembrandt and his school. Oxford University Press, London1932: 23-27Google Scholar In the portrait, the skin's texture is not depicted with lines and shadows. It rises from an ingenious device— areas deprived of paint. The threads of the canvas show through, covered only by a thin layer of priming grey. It is as if the paint has been chipped away. But on close inspection, it is evident that the brushstrokes have stopped, deliberately, to allow these deep, grey patches. And they are all over the face. The effect is striking. It is from around these patches that meticulously, and stroke by stroke, the paint mounts to create the wrinkled, haggard skin. Nor is the skin's colour uniform; it does not result, as happens with other artists' work, from applying pigments previously blended on the palette. It is myriad brushstrokes, each of a different hue, that create the colour. There are glazes and impastos of white, black, cream, yellow, ochre, salmon, orange, brown, maroon, and red. It seems a chaotic barrage, but each brushstroke contributes to the illusion of a flushed, ruddy, living complexion. An orderly examination, working downwards, uncovers critical details of how Rembrandt constructed his face. White and black paints tangle wet-in-wet, to form his grey hair. Scrapes with the brush butt are the curls, freeing themselves from the constraints of the beret. On the left side of the forehead a grey swathe traces the winding path of the temporal vessel. A black brushstroke cuts vertically and wrinkles his brow. The composition begets a troubled face. Was Rembrandt in pain? Brown and black smears deepen his eye globes. Thick brushstrokes create the eyelids. The heavy wrinkles close in. But two opaque circles manage to surge forth from under the weight of wrinkles—Rembrandt's eyes (figure 3). Raised black dots with white specks are the pupils reflecting the light. In the left eye, the light reflects in a white arc. The total effect is that Rembrandt's stare is alive, intense. A clump of paint with a flush at its tip protrudes from the face and creates his nose (figure 4). A black line forms his lips, shut tight.Figure 4Rembrandt's rosaceaShow full captionNose with papular lesions and rhinophyma, and cheeks with telangiectasia and papular lesions.View Large Image Figure ViewerDownload (PPT) Nose with papular lesions and rhinophyma, and cheeks with telangiectasia and papular lesions. There are additional brushstrokes that call for explanation; blotches of red, daubed with the tip of the brush—nine in total. The one under the right eye has a crimson core with a fading halo. The one to the left of the mouth is a maroon spot highlighted by an ochre smudge (figure 4). What are these marks? A stylistic device, a dramatic effect, disease? Moving down the composition, one sees that grey wisps and patches without paint create the sparse beard. And in the jowls the paint drags, and the flesh sags and hangs upon the collar. The success of Rembrandt's illusion is that it is directed beyond the eyes–as if he intuitively understood how the visual system works.8Kendal ER Schwartz JH Jessell TM Principles of neural science. Elsevier, New York1991: 400-480Google Scholar Smears, blotches, dabs, specks, scrapes, patches without paint, and our brain realises them into a face. Rembrandt looks old. But is he ill? Rembrandt's skin is severely wrinkled. In the forehead, nose, and cheeks its texture is coarse. In the areas rendered without paint, the skin seems atrophied and transparent. The discoloration of the forehead serves as bed for the temporal vessel. The skin thins in the wrinkles of the eyes, cheeks, and chin. He has brow ptosis, the thick forehead wrinkles suggesting chronic contraction of the frontalis muscles to lift the brow. The skin sags, notably on the cheeks. Thus, Rembrandt presents features of dermachalasis. Observations of Rembrandt's eyes concur with the above findings (figure 3). The upper eyelids hang over, more on the left, tending to narrow the palpebral fissura and obliterate the eyes with pseudoptosis. His eye globes recede, as if with a decrease of their supporting fat and enophthalmos. The temporal margins of the eyelids are furrows devoid of paint that radiate as crow's feet. The lower eyelids are creased. On the left, four wrinkles mar the infraorbital furrow and present cream-coloured lines as if with xanthelasma. It also seems that the conjunctival edges are exposed and congested. The left eye has a light reflection, white and semicircular. And the nasal conjunctiva is elevated, as if with pinguecula. In our era, this severity of ageing is that of the eighth, even the ninth, decade.9Goldfarth M Ellis C Voorhees J Dermatologic diseases and problems. In: Cassel C, Cohen H, Larson E. Geriatric medicine, 3rd ed. Springer, New York1997: 667-681Google Scholar, 10Spaeth G Plastic surgery.in: In: Ophthalmic surgery: principles and practice. 2nd ed. WB Saunders, Philadelphia1990: 528-637Google Scholar, 11Martin G Turker M Genetics of human disease, longevity, and aging.in: Hazzard W Bierman E Blass J Principles of geriatric medicine and gerontology. McvGraw Hill, New York1994: 19-35Google Scholar, 12Kligman A Grove G Balin A Aging of human skin. Rowe J, Minaker K. Geriatric medicine.in: Finch C Schneider E Handbook of the biology of aging. Van Nostrand Reinhold, New York1995: 820-841Google Scholar In 1659, Rembrandt was 53 years old. Rembrandt's face also presents signs of inflammatory dermatosis: an erythematous, papular skin disease (figure 4)—the nine spots. Eight seem to be papular lesions: one on the chin, three on the nose, and four on the left cheek. The blotch under the right eye, with a fading halo, as if with spider's legs, resembles a telangiectatic lesion. These findings suggest a diagnosis of rosacea. The bulbous nose with a coarse skin indicates rhinophyma (figure 4).13Habif T Acne, robacea, and related disorders. Clinical dermatology: a color guide to diagnosis and therapy. Mosby, St Louis1996: 148-189Google Scholar Rembrandt deliberately shows his temporal vessel. He places his forehead under the light, and with a dab of brown paint depicts a bulge, like a nodule, at the onset of the vessel's tortuous path. Rembrandt may have been subject to the ravages of temporal arteritis (figure 2). I suggest that at the time of the portrait, Rembrandt presented (a) the changes associated with ageing (premature by current life-expectancy), including brow and eyelid ptosis indicating dermachalasis; (b) possible xanthelasma and arcus senilis; (c) lesions of a specific inflammatory skin disease, rosacea with complicating rhinophyma; and (d) temporal arteritis. In the elderly patient, the physician has to differentiate the signs of ageing from those of disease. In ageing, the three layers of the skin suffer. The epidermis atrophies. The dermis loses proteoglycan and collagen, and its elastic fibres thicken and break. The capillaries erode. The subcutaneous fat decreases. The hair turns grey and thins. The sweat glands dry up. The sebaceous glands enlarge. The ageing skin appears wrinkled, thin, saggy, discoloured, coarse.9Goldfarth M Ellis C Voorhees J Dermatologic diseases and problems. In: Cassel C, Cohen H, Larson E. Geriatric medicine, 3rd ed. Springer, New York1997: 667-681Google Scholar, 10Spaeth G Plastic surgery.in: In: Ophthalmic surgery: principles and practice. 2nd ed. WB Saunders, Philadelphia1990: 528-637Google Scholar, 11Martin G Turker M Genetics of human disease, longevity, and aging.in: Hazzard W Bierman E Blass J Principles of geriatric medicine and gerontology. McvGraw Hill, New York1994: 19-35Google Scholar, 12Kligman A Grove G Balin A Aging of human skin. Rowe J, Minaker K. Geriatric medicine.in: Finch C Schneider E Handbook of the biology of aging. Van Nostrand Reinhold, New York1995: 820-841Google Scholar The skin thus records the struggle with time. Rembrandt's ageing demands further research into possible risk factors. It would be interesting to know Rembrandt's degree of sun exposure–photoageing. Is the white arc in the left eye arcus senilis, and the cream-coloured lines in the eyelids xanthelasma? Could these be lipid deposits, thus implicating arteriosclerosis?14Bierman E Aging and atherosclerosis.in: Hazzard W Bierman E Blass J Principles of geriatric medicine and gerontology. McGraw Hill, New York1994: 509-516Google Scholar Tobacco damages the skin, and Amsterdam was a centre of its commerce.15Read R Systemic effects of smoking.Am J Surg. 1984; 148: 706Summary Full Text PDF PubMed Scopus (50) Google Scholar Did Rembrandt smoke? Alcohol worsens rosacea, but his consumption is questionable, for at that time he was supposedly living a simple, ascetic life.17Dudok van Heel S Rembrandt van Rijn: a changing portrait of the artist.in: Brown C Kelch J van thiel P Rembrandt: the master and his workshop. Yale University Press, New Haven1991: 50-67Google Scholar Stress exacerbates rosacea, and Rembrandt was going through difficult times.17Dudok van Heel S Rembrandt van Rijn: a changing portrait of the artist.in: Brown C Kelch J van thiel P Rembrandt: the master and his workshop. Yale University Press, New Haven1991: 50-67Google Scholar, 18Benesch O Emmons J transl. Rembrandt. Editions d'Art Albert Skira, Vienna1957Google Scholar, 19Mee C Rembrandt's portrait: a biography. Simon & Schuster, New York1988Google Scholar In about 1626–30, Rembrandt portrayed a woman from Leiden, his birthplace, 12 times. In all the paintings and etchings, irrespective of her pose, she shows a most severely wrinkled, parched skin. This woman is believed to be his mother.17Dudok van Heel S Rembrandt van Rijn: a changing portrait of the artist.in: Brown C Kelch J van thiel P Rembrandt: the master and his workshop. Yale University Press, New Haven1991: 50-67Google Scholar, 18Benesch O Emmons J transl. Rembrandt. Editions d'Art Albert Skira, Vienna1957Google Scholar, 19Mee C Rembrandt's portrait: a biography. Simon & Schuster, New York1988Google Scholar But in 1626 she was only 58 years old. Could these paintings be documenting a syndrome of environmental or inherited risk factors for premature ageing in Rembrandt?14Bierman E Aging and atherosclerosis.in: Hazzard W Bierman E Blass J Principles of geriatric medicine and gerontology. McGraw Hill, New York1994: 509-516Google Scholar, 15Read R Systemic effects of smoking.Am J Surg. 1984; 148: 706Summary Full Text PDF PubMed Scopus (50) Google Scholar, 16Leber W Premature aging and alcoholism.Int J Addiction. 1982; 1: 1982Google Scholar, 17Dudok van Heel S Rembrandt van Rijn: a changing portrait of the artist.in: Brown C Kelch J van thiel P Rembrandt: the master and his workshop. Yale University Press, New Haven1991: 50-67Google Scholar, 18Benesch O Emmons J transl. Rembrandt. Editions d'Art Albert Skira, Vienna1957Google Scholar, 19Mee C Rembrandt's portrait: a biography. Simon & Schuster, New York1988Google Scholar, 20Pesce K Rothe M The premature aging syndromes. Clinics in dermatology. Elsevier Science, New York1996: 161-170Google Scholar Rosacea fits Rembrandt's age, race, and sex; it is seen in the fair-skinned, middle-aged to older patient. The disease presents as erythema, telangiectasia, and papules in the nose, cheeks, chin, and forehead. It is associated with blepharitis and conjunctivitis. And, frequently in men, the connective tissue hypertrophies, and the sebaceous glands enlarge and malfunction, resulting in rhinophyma.9Goldfarth M Ellis C Voorhees J Dermatologic diseases and problems. In: Cassel C, Cohen H, Larson E. Geriatric medicine, 3rd ed. Springer, New York1997: 667-681Google Scholar, 10Spaeth G Plastic surgery.in: In: Ophthalmic surgery: principles and practice. 2nd ed. WB Saunders, Philadelphia1990: 528-637Google Scholar, 11Martin G Turker M Genetics of human disease, longevity, and aging.in: Hazzard W Bierman E Blass J Principles of geriatric medicine and gerontology. McvGraw Hill, New York1994: 19-35Google Scholar, 12Kligman A Grove G Balin A Aging of human skin. Rowe J, Minaker K. Geriatric medicine.in: Finch C Schneider E Handbook of the biology of aging. Van Nostrand Reinhold, New York1995: 820-841Google Scholar, 13Habif T Acne, robacea, and related disorders. Clinical dermatology: a color guide to diagnosis and therapy. Mosby, St Louis1996: 148-189Google Scholar Temporal arteritis often presents as a prominent, nodular, tortuous vessel accompanied by skin discoloration. Its course can be insidious and only occasionally complicated by devastating blindness and stroke. The disease frequently affects the elderly white northern European,21Hazleman BL Polymyalgia rheumatica and giany cell arteritis.in: Klippel JH Dieppe PA Practical rheumatology. Times Mirror, London1995: 385-392Google Scholar someone like Rembrandt. Insight into Rembrandt's emotional state contributes to his medical evaluation.17Dudok van Heel S Rembrandt van Rijn: a changing portrait of the artist.in: Brown C Kelch J van thiel P Rembrandt: the master and his workshop. Yale University Press, New Haven1991: 50-67Google Scholar, 18Benesch O Emmons J transl. Rembrandt. Editions d'Art Albert Skira, Vienna1957Google Scholar, 19Mee C Rembrandt's portrait: a biography. Simon & Schuster, New York1988Google Scholar By 1659, he had lost his wife and three of his five children. Gone was his wealth, his art collection, and his grand house in the Sint-Anthonisbreestrat that he had purchased for 13 000 guilders. He had been involved in several law suits. 3 years earlier he was declared insolvent. He had withdrawn, produced little. Did he have bouts of clinical depression? In 1659, his Moses and the Tablets was rejected. He received no new contracts. In extreme poverty, he moved to the Jordaan district, where plague periodically struck. He rented, for 225 guilders, a small house on the banks of the dilapidated Rozengracht canal. It is here that he most probably painted this self-portrait. For a medical evaluation of Rembrandt, my method of study integrates art technique, history, and clinical observation.