Commentary on The Creation of Adam.

The neurological examination is part of the art of medicine, but it is not something I had ever likened it to a piece of fine art, much less a 16th-century masterpiece. Then, one day, after countless administrations of cerebellar testing using the finger-to-nose test, I was struck by the similarity between my outstretched index finger paired to the index finger of the patient and the paired, outstretched fingers of God and Adam in Michelangelo’s The Creation of Adam. The Creation of Adam, famously painted on the ceiling of the Sistine Chapel in Italy’s Vatican City, depicts God the Father extending an arm to Adam, the first person on Earth—a gesture indicative of a vital gift. God floats majestically in bearded, billowing glory, thronged by angels. Adam reclines, naked and languid, his drooping arm poised to be touched to receive the spark of life. While Michelangelo has long been associated with his brilliant rendering of the human form, connections between his paintings and sculptures and more detailed anatomy, specifically the nervous system, have been contemplated only recently. Unsurprisingly, his realistic paintings were built upon his vested study of the human anatomy, which included human dissection. 1 An article by Meshberger (1990) was the first to propose that the depiction of God in The Creation of Adam appears similar to the shape of a sagittal section of the human brain, 2 which would fit other theories that Michelangelo purposely reflected anatomical shapes in his artwork. 3,4 Beyond its connections to anatomy, The Creation of Adam also appears to illustrate the patient–physician relationship. Michelangelo worked with like-minded physician friends to learn the human form, in addition to receiving treatment from them. Realdo Colombo supplied him with cadavers to study and treated his nephrolithiasis, 1,5 while Baccio Rontini helped ease the pain of an injured leg after Michelangelo had fallen from scaffolding. 1 His medical care enabled him to continue his art. Indeed, the professional life of the artist is echoed in that of the physician. A close eye for detail, scrupulous technique, and precision are a few parallel traits. A prime example is neurologist Gordon Holmes, MD, who is best known for the eponymous. Holmes honed his craft by treating World War I soldiers with head trauma and telltale neurological deficits. His careful observations led to a more comprehensive understanding of cerebellar function. In particular, he consolidated knowledge reported by others, such as the rebound phenomenon and adiodochokinesis (impaired rapidly alternating movements, better known today as dysdiadochokinesia), and distinguished other localizing signs of neurological function, such as ataxia. 6 Today the finger-to-nose test, as popularized by Holmes, is a staple of cerebellar testing. Patients are asked to reach a finger out to touch a target, such as the examiner’s unilateral index finger, then touch their own nose, and then repeat both steps again. Repeated trials may elicit tremor or dysmetria, localizing the injury to the ipsilateral cerebellum. Although I have used various iterations of the finger-to-nose test thousands of times, I never fully appreciated it until practicing medicine during COVID-19 precluded me from its traditional execution. Since many patient visits occurred over video rather than in person, I adapted a version of the test that I had learned in residency for patients with visual impairment. In this adapted version for telemedicine, I have the patients first extend the left arm fully, touch the index figure on this hand with the right index finger, and then with this same right hand, touch the nose; I then ask them to repeat both actions until several iterations are completed. Once performed, I have the patients switch hands. As useful as this approach was for telemedicine, it was missing that tactile connection between the patient and me. I do not think it is a coincidence that in Michelangelo’s depiction of creation, God needs to touch the hand of Adam to animate him fully. The Creation of Adam captures that pregnant pause just before contact. God, full of vitality and action, extends that gift of self to bestow life to Adam. In the union of their hands, they forge the connection that defines their relationship. While Michelangelo would not, of course, have known about finger-to-nose test, and may not have directly drawn a parallel between the physician–patient relationship, that contact is defining to establish their connection. As a physician, I am privileged to witness and marvel at the beauty of creation within the human body. Whether finger-to-nose, head-to-toe, or hand-to-heart, the patient and I forge a physical and metaphysical connection. With the shift in our practice during COVID-19, I now appreciate that connection all the more.