JOURNAL OF THE ROYAL SOCIETY OF MEDICINE Volume 92 December 1 999

Neurology in the National Gall

Philip E M Smith MD FRCP

J R Soc Med 1999;92:649-652

'A person afflicted with disease can serve an artist's purpose just as
well as a tumble-down house or a gnarled tree'l.

Illness, though ever present, is seldom the deliberate subject

of art. Obvious malformations may appear as examples of
the grotesque2'3 but more subtle depiction of disease is
sometimes detected in classical works4'5. Neurology
encompasses a broad range of medical disorders and so
neurological themes in art are often recognized, either
directly appearing in the pictures themselves69 or
indirectly resulting from neurological disease in the
artist10-13. The National Gallery, in Trafalgar Square,
London, houses representative works from all major
European artists in its magnificent collection of over two
thousand paintings. Here are described several of the
Gallery's paintings with neurological themes.

Figure 1 Frans Hals: Portrait of a Young Man With a Skull,

THE SKULL c. 1626-1628 [National Gallery, London, reproduced by
permission]
The skull is a vivid neurological image; consideration of its
shape and dimensions forms the starting point of the
neurological examination. As a universal symbol of death it
appears frequently in the Gallery's collection. An attractive
example is Frans Hals' (1580-1666) Portrait of a Young Man
With a Skull (Figure 1), where the energy and liveliness of a
Hamletian youth contrasts with the inevitability of his
death.
Hans Holbein the Younger (1497/8-1543), best
known for his portraits of Henry VIII, presents a skull
more covertly in his magnificent double portrait The
Ambassadors (Figure 2). Jean de Dinteville, French
ambassador to England, is seen with his friend Georges
de Selve, Bishop of Lavaur. The scientific and musical
instruments arranged around them indicate their learning
and importance. Reminders of their certain death,
however, are also evident. The diagonal foreground
object must be viewed a metre up from the right of the
picture to be seen clearly as a skull. The theme of death
is further emphasized by the broken lute string and by
the skull motif on Dinteville's hat. For Holbein, the skull
was also a personal symbol: the German hohle Bein
meaning hollow bone.

Department of Neurology, University HospiW of Wales, Heath Park, Cardiff CF4 Figure 2 Hans Holbein the Younger: The Ambassadors, 1533
4XW, UK [National Gallery, London, reproduced by permission] 649
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Figure 3 Antonio Giovani Boltraffio: The Virgin and Child, date
unknown [National Gallery, London, reproduced by permission]
PLANTAR RESPONSE
Antonio Giovani Boltraffio's (1467-1516) The Virgin and
Child (Figure 3) shows the response of a normal baby to
stroking of the foot. As any parent might observe, the toe
extends. The Babinski response, so named after Joseph
Franqois Babinski (1857-1932), is a normal phenomenon in
young babies, reflecting incomplete myelination of the
central motor pathways. It might reappear in adults
following a lesion of these pathways in the brain or spinal
cord. The physiological Babinski response in babies had
been recorded hundreds of years before Babinski's
Figure 4 Jean-Joseph Taillasson (1785-1809): Virgil Reading the
Aeneid to Augustus and Octavia, 1787 [National Gallery, London,
650 reproduced by permission]
Volume 92 December 1 999
description, in several well-known paintings14. Boltraffio's
attention to physiological detail is no more than one would
expect of a pupil of Leonardo.
SYNCOPE
In Jean-Joseph Taillasson's (1785-1809) Virgil Reading the
Aeneid to Augustus and Octavia, the Emperor and his sister
listen to the poet reading his twelve book epic (Figure
4). Octavia has apparently fainted with emotion at the
reference to her dead son (Augustus' adopted heir)
Marcus Claudius Marcellus. The Emperor is moved but
ignores her reaction. Octavia, the great-niece of Julius
Caesar, was a strong person for whom emotional syncope
seems out of character. After her first husband's death,
she had agreed to marry Mark Antony to reconcile him
to Augustus but Antony had abused her and left for
Cleopatra. Such was Octavia's loyalty and virtue that,
following Antony's death, she brought up not only
Antony's children by Fulvia, his first wife, but also those
by Cleopatra. Acts of moral courage such as these
enhanced her reputation as an ancient queen of people's
hearts. Probably the scene in this picture was invented to
appeal to the neoclassical taste of late eighteenth century
polite society, where simulated swooning ('feinting') was
an encouraged female behaviour.
FACIAL WEAKNESS
Francisco de Goya's (1746-1828) Don Andres del Pe'ral
(Figure 5) is an example of facial asymmetry, attributable to
unilateral facial weakness. Minor facial asymmetry is
common in the normal population and frequently appears
in portraits. Andres del Peral, craftsman, painter and
Figure 5 Francisco
de Goya: Don Andres
del Peral, 1797
[National Gallery,
London, reproduced
3l.z6
...
-
,
4a
tbypermission]
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
Figure 6 Pieter Bruegel the Elder: The Adoration of the Kings,
(detail) 1564 [National Gallery, London, reproduced by permission]
guilder, was a friend of Goya's in the Madrid Court. Goya
painted him from the right side, minimizing the impact of
an otherwise disfiguring left facial weakness. The weakness
predominantly affects the lower face, suggesting upper-
motor-neuron facial nerve involvement, most likely
following a stroke.
Goya himself had an acute and serious neurological
illness in 1792 (at age 47) which remains undiagnosed and
which left him profoundly deaf. Vogt-Koyanagi disease was
Cawthorne's explanation of the transient visual disturbance
with deafness and ataxial5. Diphtheria or bacterial
meningitis seem equally likely. His deafness changed him
from a colourful philanderer to an embittered and socially
isolated figure, his work coming to reflect his increasingly
sombre mood.
MYOTONIC DYSTROPHY
In Pieter Bruegel the Elder's (c. 1525-1569) Nativity scene
The Adoration of the Kings (Figure 6), Bruegel's interest in
human physiognomy and caricature is clear. A man on the
right wears spectacles, implying inability to see the truth.
Balthazar, the Moorish king, stands on the right and Caspar
kneels at the lower left. Melchior, tightly holding a golden
pot of frankincense, shows bilateral facial drooping, partial
ptosis and premature frontal balding, all features of
myotonic dystrophy. This condition, relatively common
and with a characteristic facial appearance, would have
appealed to an observant artist such as Bruegel who
specialized in portraying expressive heads. Bruegel would
probably have encountered such cases when seeking unusual
faces to paint amongst the peasantry. His other work
suggests that he would then have exaggerated the blemishes.
His disregard for idealism (as here in the Madonna and
Child) was quite startling for the time.
Volume 92 December 1 999
Figure 7 Peter Paul Rubens (1577-1640): Samson and Delilah,
1609 [National Gallery, London, reproduced by permission]
MYASTHENIA GRAVIS
Peter Paul Rubens' (1577-1640) beautiful painting
(Figure 7) depicts Samson's betrayal by his Philistine
mistress, Delilah (judges 13-16). She had discovered the
secret to Samson's immense strength and plotted his haircut
during post-coital sleep. Once shorn, Samson was
weakened, and was easily overcome by the guards waiting
in the doorway, blinded and enslaved. Later, when
exhibited at the festival of Dagon, his hair regrown and
his strength restored, he pulled down the temple pillars,
burying three thousand Philistines and himself in the ruins.
Although the 11th century BC story is legendary, it must
surely be based upon fact. How might a normally muscled
previously healthy man develop sudden-onset but reversible
weakness? Guillain-Barre syndrome is the commonest cause
in clinical practice: other explanations include porphyria,
polymyositis, or chronic inflammatory polyradiculoneuro-
pathy. Myasthenia gravis, however, explains both the acute
weakness and (autoimmune) hair loss, the haircut
explanation perhaps being added later to incriminate
Delilah, a hated Philistine (J Newsom-Davis, personal
communication).
CONCLUSION
This brief dip into the London National Gallery's collection
demonstrates how neurological themes are often apparent
in classical art. Viewing paintings from a neurological
perspective adds a special dimension to art appreciation for
physicians.
Acknowledgment A small part of this article was
originally published in the Journal of the Royal College of
Physicians of London, 1999;33:364. 651
 JOURNAL OF THE ROYAL SOCIETY OF MEDICINE
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