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Art and dystonia
Journal of the Neurological Sciences 356 (2015) 49–54
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Review article
Art and dystonia Pedro J. Garcia-Ruiz a,⁎,1, Jaroslaw Slawek b,c,1, Emilia J. Sitek b,c, Juan Carlos Martinez Castrillo d,1 a
Movement Disorder Unit, Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain Department of Neurological and Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland c Department of Neurology, St. Adalbert Hospital, Copernicus PL Sp. z o.o, Gdansk, Poland d Movement Disorder Unit, Department of Neurology, IRYCIS, Hospital Ramon y Cajal, Madrid, Spain b
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 7 April 2015 Received in revised form 17 June 2015 Accepted 23 June 2015 Available online 25 June 2015
Dystonia has a recent history in medicine. Focal dystonia was described in the 19th century by classic authors including Gowers, whilst generalized dystonia was described at the turn of the century. However, it is possible to find precise descriptions of dystonia in art, centuries before the medical definition. We have reviewed several pieces of art (sculpture, painting and literature) across the history that might represent descriptions of dystonia, from ancient period to nowadays. In classic times, the first reference to abnormal postures can be tracked back to the new Empire of Egypt (equinus foot), not to mention some recently described examples of dystonia from the Moche sculptures in Peru or Veracruz culture from Mexico. In Middle Ages it is possible to find many examples of sculptures in European cathedrals representing peasants with dramatic, presumably dystonic postures that coexist with amputation of limbs. This unique combination of dystonia and limb amputation probably represents ergotism. The painters Brueghel, Ribera and Velazquez also represented figures with postures likely to be dystonic. Literature is also a source of precise pre-neurological descriptions, especially during the 19th century. In David Copperfield, Dickens depicts characters with generalized dystonia (Uriah Heep), cervical dystonia (Mr. Sharp) and spasmodic dysphonia (Mr Creakle). Finally, even in modern Art (19th and 20th centuries), there are dramatic descriptions of abnormal postures that are likely to be dystonic, such as painful cervical dystonia (Brancusi), cervical dystonia with sensory trick (Modigliani) and upper limb dystonia (Wyspianski). However some postures presented in works of art may simply be a form of artistic expression and only bear unintentional resemblance to the dystonic postures. Art may be a source of neurological information, and that includes primary and secondary dystonia. © 2015 Elsevier B.V. All rights reserved.
Keywords: Dystonia Art History Movement disorders Medieval art Brancusi Modigliani Wyspianski
Contents 1. Introduction . . . . . . . . . . . . . 2. Ancient and classical periods . . . . . 3. Middle Ages . . . . . . . . . . . . . 4. New world: ancient period . . . . . . 5. Modern history . . . . . . . . . . . 6. Contemporary history . . . . . . . . 7. Literature and dystonia. Charles Dickens 8. Summary . . . . . . . . . . . . . . Author roles . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . .
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1. Introduction ⁎ Corresponding author at: Department of Neurology, Fundacion Jimenez Diaz, Avda Reyes Católicos 2, Madrid 28040, Spain. E-mail address: [email protected] (P.J. Garcia-Ruiz). 1 These authors equally contributed to this work.
http://dx.doi.org/10.1016/j.jns.2015.06.049 0022-510X/© 2015 Elsevier B.V. All rights reserved.
Dystonia has a relatively short history in medicine. Focal dystonia as a neurological syndrome was described in 19th century by several authors including Gowers [1] and the American Neurologist Horatio
50
P.J. Garcia-Ruiz et al. / Journal of the Neurological Sciences 356 (2015) 49–54
Wood [2] whilst generalized dystonia was reported at the turn of the 19th and 20th centuries by Luis Barraquer Roviralta in 1897, Marcus Walter Schwalbe in 1907; Hermann Oppenheim and Georg Theodor Ziehen in 1911; and in the same year the Jewish-Polish neurologists Edward Flatau and Wladyslaw Sterling described the condition [3–5]. However, it is possible to find precise descriptions of dystonia in art, even centuries before the first medical descriptions. The paintings or sculptures that represent people affected by various conditions usually lack the documentation of the disorder, so dystonia as the cause of unusual postures or gestures may be only hypothesized. Finally, some postures presented in works of art may simply be a form of artistic expression and only bear unintentional resemblance to the dystonic postures. This paper presents selected pieces of art and literature dating from antiquity to modern times, that are likely to contain the representations of dystonic postures. Rather than a general review this is a personal selection of those pieces that impressed us most.
2. Ancient and classical periods The first description of an abnormal posture can be found in Egyptian art (new Empire, Fig. 1). The affected individual had a clearly equinus foot which was attributed to polio [6] (there are no descriptions of polio before the 18th century). An alternative hypothesis may be an equinus gait secondary to cerebral palsy. There are several sources commenting on historical figures affected by neurological diseases, among whom Alexander the Great
is mentioned. It was suggested that Alexander the Great suffered from cervical dystonia [7]. His abnormal neck posture was described by Plutarch, who noted that Lyssipus, the emperor's personal sculptor, modeled the first statue of Alexander which represented him looking up with his face turned toward the heavens (Fig. 2). Archelasus, among others, also confirmed Alexander's abnormal posture. In our opinion, the diagnosis of spasmodic torticollis is questionable as there are various statues representing Alexander and not all of them exhibit clear cervical deviation. 3. Middle Ages Cathedrals all over Europe represent the quintessence of medieval art. Some of the figures from the tomb of San Pedro de Osma in El Burgo de Osma cathedral (Soria, Spain) show clear cervical dystonic postures and some have other dystonic features or residual limbs (Figs. 3–4). We suggest that the statues with dystonic features plus residual limbs might represent patients with ergotism, or St Anthony fire [8], which was mainly characterized by peripheral vascular disease and gangrene resulting in limb loss [9,10]. In addition, ergotism (convulsive ergotism in particular) was also characterized by severe muscular spasms and abnormal postures [10]. Ergotism was due to long-term poisoning by Claviceps purpurea fungus, formed on cereals, and widespread all over Europe during XII–XVI centuries [8,9]. Ergotism was graphically described in paintings by Mathias Grunewald, in some of his paintings severe dystonia can be recognized [11]. However, some authors suggest that ergotism was in fact a serotonin syndrome [10,12]. If this was the case, movement disorders in patients with ergotism can be easily explained, since dystonia, myoclonus and other movement disorders have been associated with serotonin syndrome [10,12]. 4. New world: ancient period Moche artists (from pre-Columbian culture developed in Northern Peru, 100–700 AD) had exceptionally sophisticated ceramic techniques,
Fig. 1. Funeral stele of the priest Ruma (XIX dynasty). Around 1500 BC, Carlsberg Museum of Copenhagen.
Fig. 2. Head of Alexander the Great, Lyssipus. Istambul Archeological Museum.
P.J. Garcia-Ruiz et al. / Journal of the Neurological Sciences 356 (2015) 49–54
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Fig. 5. This potter is part of the Moche collections of the Museo Nacional de Arqueología y Antropologıa (Lima). It represents a man with his eyes closed and facial grimacing probably in an attempt to open his eyes.
(Fig. 5) represents a man with his eyes closed and facial grimacing probably in an attempt to open his eyes. The lips are horizontally tensed and the nasolabial folds are pronounced. In our opinion, this sculpture may be an artistic representation of blepharospasm with oromandibular dystonia [13]. A very similar representation of cranial dystonia, resembling the classical Meige's syndrome is shown at Fig. 6. The sculpture (XipeTotec Head, 300–900 AD) shows the closed eyes and lower face dystonia (jaw-opening), but also tongue dystonia (protrusion). This sculpture made of terracotta is a part of Veracruz Culture heritage from Mexico. Sensory tricks (fr. gestes antagonistes) are characteristic features of dystonia. Figs. 7 and 8 represent examples resembling such movements. The first one was made probably somewhere in Tokyo graveyard and the second one represents art of Melanesia, Papua, New Guinea.
Fig. 3. Peasant with head tilt to the right and painful expression (center), note the amputated hands. The peasant right to the man with cervical deviation seems to have both his legs amputated under the knee, the naked stumps appear under the garment. El Burgo de Osma (Spain).
which they often used to represent their people, particularly individuals affected by diseases or with physical deformities, as they believed that the handicapped were touched by the gods. The potter presented here
Fig. 4. A lady with a baby in her arms and cervical deviation to the left. Note the peasant just beside the woman, he has no hands, perhaps amputated. El Burgo de Osma (Spain).
Fig. 6. A possible representation of cranial dystonia, resembling the classical Meige's Syndrome. This sculpture found in New Orleans Museum of Art (NOMA), US (Xipe-Totec Head, 300–900 AD) shows the closed eyes and lower face dystonia (jaw-opening), but also with tongue dystonia (protrusion). This sculpture made of terracotta is a part of Veracruz Culture heritage from Mexico.
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5. Modern history The great Flemish Renaissance painter Pieter Brueghel the Elder had a fascination with human physiognomy, both normal and pathologic. Historians of art contend that Fig. 9 depicts a huge yawn and have titled this work “Yawning Man” or “De Gaper”. However, Marsden credited R.E. Kelly for noting the similarity of this painting to the syndrome of blepharospasm–oromandibular dystonia and suggested the eponym “Brueghel's syndrome” [14]. Marsden claimed that Brueghel “clearly recognized the syndrome”, but of course, it may be an overinterpretation of this undated, and untitled painting. “El patizambo” or “The clubfooted boy” (Jose de Ribera, 1642, Fig. 10) is a representation of a beggar with a right hemidystonia. Velazquez painted in “The boy from Vallecas”, (1643–45, Fig. 11) a boy with some degree of mental retardation and mixed cervical dystonia with a right torticollis and retrocollis. 6. Contemporary history The turn of the 19th and 20th centuries was the time of great transformation in art from classical figurative or descriptive forms to very modern, expressive and abstractive forms. It is possible to find descriptions of dystonia in contemporary art; this is the case of “Suffering” from Constantin Brancusi (1876–1952) (Figs. 12 and 13), which represents a boy with a very notorious painful cervical deviation. Brancusi is believed to have observed and represented a real patient with cervical dystonia [15]. Modigliani was contemporary of Brancusi. He is known for portraits and nudes in a modern style characterized by elongated faces and figures. Some of his paintings suggest cervical dystonic features including “sensory tricks” (Fig. 14). However, it is doubtful that all these paintings actually represented real people with dystonia. Stanislaw Wyspiaski, born in Cracovia (1869–1907) was also an interesting author at the turn of the 19th and 20th centuries. This artist practiced a variety of arts including poetry, theater and painting. He worked fast and with extraordinary intensity, his highly diverse output produced in a mere dozen years. We show one of his most realistic and beautiful artworks (The girl with red hat, Fig. 15), a young lady with upper limb dystonia, possibly related to cerebral palsy. 7. Literature and dystonia. Charles Dickens Many writers described neurological conditions across the centuries. Charles Dickens (1812–1870) had a special interest in individuals displaying neurological symptoms, and his novels are a source of precise neurological descriptions. Brain already quoted some Dickensian neurological diagnosis [16]. Besides Pickwickian syndrome, many other neurological descriptions can be found in Dickens' novels [16–19] including David Copperfield [19]: 1. Generalized dystonia: Uriah Heep. This character, one of the villains of the novel is described as a very tall, strange man with Marfanlike features: “Uriah, with his long knees drawn up under his coffeecup”. Uriah Heep displayed clear dyskinesias, most probably generalized dystonia: “He writhed himself quite off his stool in the excitement of his feeling…” “He had a snaky undulation pervading his frame from his chin to his boots…”, “…Uriah exclaimed, with a sickly, angular contortion of himself…”, “… I am sure, said Uriah, writhing himself into the silence like a Conger eel”. 2. Spasmodic dysphonia: Mr Creakle. “ The circumstances about Mr Creakle which impressed me most was, that he had no voice, but spoke in a whisper. The exertion this cost him, or the consciousness of talking Figs. 7 and 8. The first statue was made probably somewhere in Tokyo graveyard and the second one represents the not-dated art of Melanesya, Papua, New Guinea (New Orleans Museum of Art).
P.J. Garcia-Ruiz et al. / Journal of the Neurological Sciences 356 (2015) 49–54
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Fig. 9. “Yawning Man” or “De Gaper”. Pieter Brueghel the Elder, around 1560. Musées Royaux des Beaux–Arts Bruxelles.
in that feeble way, made his angry face so much angry, and his thick veins so much thicker when he spoke” As Mr Creakle struggled to make his voice audible, he had no voice but a whisper, spasmodic dysphonia (abductor type) could be a plausible explanation of this presentation. 3. Mr Sharp: Cervical dystonia. “Mr Sharp was a limp, delicate-looking gentleman, with good deal of nose, and a way of carrying his head on one side, as if it were a little too heavy for him”. In this paragraph, Dickens described a man with neck rotation, which may be due to cervical dystonia.
Fig. 10. “El patizambo (The clubfooted boy)” from Jose de Ribera, 1642. Louvre Museum. A beggar with a right hemidystonia probably related with cerebral palsy.
Author roles Pedro J Garcia Ruiz: conception and design, acquisition, analysis and interpretation of data, drafting the submitted material, administrative support.
8. Summary In summary, we have reviewed a personal selection of art (sculpture, painting and literature) that may represent real patients with dystonia or dystonic movements. Our descriptions add to the growing body of reports on the pieces of art representing movement disorders [20,21]. Artists from ancient times throughout the centuries and up to now, from all over the world (e.g. from Europa, Asia and the New World) frequently described or depicted neurological diseases decades or centuries before the official reports by neurologists. Thus, history of neurology may be enriched by the history of art. Finally, we should like to include two recent papers related to art and dystonia: Bono et al. recently called attention to Giovanni Agostino da Lodi (Italian renaissance painter of the Leonardeschi) who made a clear depiction of cranial–cervical dystonia [22]. Gondim et al. reviewed neuropsychiatric phenomena described in Cantigas de Santa Maria; a collection of 427 canticles composed between 1252 and 1284 at the Court of King Alfonso X the Wise of Spain (1221–1284). In these cantigas the authors found several descriptions of dystonic movements [23].
Fig. 11. “El niño de Vallecas (The boy from Vallecas)” from Diego Velazquez, 1643–45, Museo del Prado, Madrid, depicts a boy with some degree of mental retardation, perhaps affected from cretinism, who has a mixed cervical dystonia, with right torticollis and retrocollis.
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Fig. 15. “The girl with red hat” from Stanislaw Wyspianski (1893), Upper Limb Dystonia (Spastic Dystonia?), Poznan, National Museum, Poznan, Poland.
Emilia J. Sitek: acquisition of data, analysis and interpretation of data; critical revision and editorial support. No conflict of interests reported. References
Figs. 12 and 13. “Suffering” from Constantin Brancusi 1907. Museum of Fine Arts. Chicago.
Jaroslaw Slawek: conception and design, acquisition, analysis and interpretation of data drafting part of the submitted material, critical revision and supervision. Juan Carlos Martinez Castrillo: acquisition, analysis and interpretation of data; critical revision and supervision.
Fig. 14. Portraits of Modigliani. A young woman with dystonic features and sensory tricks.
[1] W.R. Gowers, in: W.R. Gowers (Ed.), A Manual of Diseases of the Nervous System, P Blakiston, Philadelphia 1893, p. 659. [2] H.C. Wood, Nervous Diseases and Their Diagnosis: A Treatise Upon the Phenomena Produced by Diseases of the Nervous System, JB Lippincott, Philadelphia, 1887. 1937. [3] H. Oppenheim, Dysbasia lordotica progressiva, dystonia musculurum deformans, Neurol. Centralblatt 30 (1911) 1090–1107. [4] E. Flatau, W. Sterling, Progressiver Torsionspasms bei Kindern Z. Gesamte, Neurol. Psychiatr. 7 (1911) 586–612. [5] J.M.S. Pearce, Lluis Barraquer i Roviralta and the origins of torsión dystonia, J. Neurol. Neurosurg. Psychiatry 75 (2004) 582. [6] S. Levin, Crippling disorders in the Bible, S. Afr. Med. J. 31 (1957) 16–17. [7] J. Lascaratos, A. Damanakis, Ocular torticollis: a new explanation for the abnormal head posture of Alexander the Great, Lancet 347 (1996) 521–522. [8] P. García Ruíz, J.J. Ruíz Ezquerro, A. García Torres, S. Fanjul, Ancient descriptions of movement disorders: Cathedral el Burgo de Osma (Soria, Spain), J. Neurol. 253 (2006) 731–734. [9] J.E. Ayarragaray, Ergotism: a change of perspective, Ann. Vasc. Surg. 28 (2014) 265–268. [10] M.J. Eadie, Convulsive ergotism: epidemics of the serotonin syndrome? Lancet Neurol. 2 (2003) 429–434. [11] J. Garcia de Yebenes, P. Garcia de Yebenes, Dystonia in the painting of Matias Grunewald. Epidemic ergotism in the late middle ages, Arch. Neurobiol. 54 (1991) 37–40. [12] R.A. Bodner, T. Lynch, L. Lewis, D. Khan, Serotonin syndrome, Neurology 45 (1995) 219–223. [13] J.C. Martinez-Castrillo, A. Mariscal, P. Garcia-Ruiz, Ancient representation of Meige syndrome, Mov. Disord. 25 (2010) 405–406. [14] C.D. Marsden, Blepharospasm-oromandibular dystonia syndrome (Brueghel's syndrome). A variant of adult-onset torsion dystonia? J. Neurol. Neurosurg. Psychiatry 39 (1976) 1204–1209. [15] P.J. Garcia Ruiz, J.C. Martinez Castrillo, Cervical dystonia and Constantin Brancusi, Mov. Disord. 24 (2009) 1849–1850. [16] R. Brain, Dickensian diagnoses, Br. Med. J. ii (1955) 1553–1556. [17] J.E. Cosnett, Dickens, dystonia and dyskinesia, J. Neurol. Neurosurg. Psychiatry 54 (1991) 184–187. [18] J.E. Cosnett, Charles Dickens: observer of sleep and its disorders, Sleep 15 (1992) 264–267. [19] P.J. Garcia Ruiz, L. Gulliksen, Movimientos anormales en David Copperfield, Neurologia 14 (1999) 359–360. [20] P.E.M. Smith, Neurology in the National Gallery, J. R. Soc. Med. 92 (1999) 649–652. [21] Rose F. Clifford, The Neurology of Art: An Overview, in: Rose F. Clifford (Ed.), Neurobiology of the arts, Imperial College Press, London 2004, pp. 43–76. [22] F. Bono, M. Morelli, A. Quattrone, Facial dystonia as depicted in art in the time of Leonardo da Vinci, Lancet Neurol. 14 (2015) 351. [23] A. Gondim Fde, S.H. Griesbach, F.P. Thomas, Neuropsychiatric phenomena in the medieval text Cantigas de Santa Maria, Neurology 84 (2015) 1991–1996.
Contents lists available at ScienceDirect
Journal of the Neurological Sciences journal homepage: www.elsevier.com/locate/jns
Review article
Art and dystonia Pedro J. Garcia-Ruiz a,⁎,1, Jaroslaw Slawek b,c,1, Emilia J. Sitek b,c, Juan Carlos Martinez Castrillo d,1 a
Movement Disorder Unit, Department of Neurology, Fundacion Jimenez Diaz, Madrid, Spain Department of Neurological and Psychiatric Nursing, Medical University of Gdansk, Gdansk, Poland c Department of Neurology, St. Adalbert Hospital, Copernicus PL Sp. z o.o, Gdansk, Poland d Movement Disorder Unit, Department of Neurology, IRYCIS, Hospital Ramon y Cajal, Madrid, Spain b
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 7 April 2015 Received in revised form 17 June 2015 Accepted 23 June 2015 Available online 25 June 2015
Dystonia has a recent history in medicine. Focal dystonia was described in the 19th century by classic authors including Gowers, whilst generalized dystonia was described at the turn of the century. However, it is possible to find precise descriptions of dystonia in art, centuries before the medical definition. We have reviewed several pieces of art (sculpture, painting and literature) across the history that might represent descriptions of dystonia, from ancient period to nowadays. In classic times, the first reference to abnormal postures can be tracked back to the new Empire of Egypt (equinus foot), not to mention some recently described examples of dystonia from the Moche sculptures in Peru or Veracruz culture from Mexico. In Middle Ages it is possible to find many examples of sculptures in European cathedrals representing peasants with dramatic, presumably dystonic postures that coexist with amputation of limbs. This unique combination of dystonia and limb amputation probably represents ergotism. The painters Brueghel, Ribera and Velazquez also represented figures with postures likely to be dystonic. Literature is also a source of precise pre-neurological descriptions, especially during the 19th century. In David Copperfield, Dickens depicts characters with generalized dystonia (Uriah Heep), cervical dystonia (Mr. Sharp) and spasmodic dysphonia (Mr Creakle). Finally, even in modern Art (19th and 20th centuries), there are dramatic descriptions of abnormal postures that are likely to be dystonic, such as painful cervical dystonia (Brancusi), cervical dystonia with sensory trick (Modigliani) and upper limb dystonia (Wyspianski). However some postures presented in works of art may simply be a form of artistic expression and only bear unintentional resemblance to the dystonic postures. Art may be a source of neurological information, and that includes primary and secondary dystonia. © 2015 Elsevier B.V. All rights reserved.
Keywords: Dystonia Art History Movement disorders Medieval art Brancusi Modigliani Wyspianski
Contents 1. Introduction . . . . . . . . . . . . . 2. Ancient and classical periods . . . . . 3. Middle Ages . . . . . . . . . . . . . 4. New world: ancient period . . . . . . 5. Modern history . . . . . . . . . . . 6. Contemporary history . . . . . . . . 7. Literature and dystonia. Charles Dickens 8. Summary . . . . . . . . . . . . . . Author roles . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . .
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1. Introduction ⁎ Corresponding author at: Department of Neurology, Fundacion Jimenez Diaz, Avda Reyes Católicos 2, Madrid 28040, Spain. E-mail address: [email protected] (P.J. Garcia-Ruiz). 1 These authors equally contributed to this work.
http://dx.doi.org/10.1016/j.jns.2015.06.049 0022-510X/© 2015 Elsevier B.V. All rights reserved.
Dystonia has a relatively short history in medicine. Focal dystonia as a neurological syndrome was described in 19th century by several authors including Gowers [1] and the American Neurologist Horatio
50
P.J. Garcia-Ruiz et al. / Journal of the Neurological Sciences 356 (2015) 49–54
Wood [2] whilst generalized dystonia was reported at the turn of the 19th and 20th centuries by Luis Barraquer Roviralta in 1897, Marcus Walter Schwalbe in 1907; Hermann Oppenheim and Georg Theodor Ziehen in 1911; and in the same year the Jewish-Polish neurologists Edward Flatau and Wladyslaw Sterling described the condition [3–5]. However, it is possible to find precise descriptions of dystonia in art, even centuries before the first medical descriptions. The paintings or sculptures that represent people affected by various conditions usually lack the documentation of the disorder, so dystonia as the cause of unusual postures or gestures may be only hypothesized. Finally, some postures presented in works of art may simply be a form of artistic expression and only bear unintentional resemblance to the dystonic postures. This paper presents selected pieces of art and literature dating from antiquity to modern times, that are likely to contain the representations of dystonic postures. Rather than a general review this is a personal selection of those pieces that impressed us most.
2. Ancient and classical periods The first description of an abnormal posture can be found in Egyptian art (new Empire, Fig. 1). The affected individual had a clearly equinus foot which was attributed to polio [6] (there are no descriptions of polio before the 18th century). An alternative hypothesis may be an equinus gait secondary to cerebral palsy. There are several sources commenting on historical figures affected by neurological diseases, among whom Alexander the Great
is mentioned. It was suggested that Alexander the Great suffered from cervical dystonia [7]. His abnormal neck posture was described by Plutarch, who noted that Lyssipus, the emperor's personal sculptor, modeled the first statue of Alexander which represented him looking up with his face turned toward the heavens (Fig. 2). Archelasus, among others, also confirmed Alexander's abnormal posture. In our opinion, the diagnosis of spasmodic torticollis is questionable as there are various statues representing Alexander and not all of them exhibit clear cervical deviation. 3. Middle Ages Cathedrals all over Europe represent the quintessence of medieval art. Some of the figures from the tomb of San Pedro de Osma in El Burgo de Osma cathedral (Soria, Spain) show clear cervical dystonic postures and some have other dystonic features or residual limbs (Figs. 3–4). We suggest that the statues with dystonic features plus residual limbs might represent patients with ergotism, or St Anthony fire [8], which was mainly characterized by peripheral vascular disease and gangrene resulting in limb loss [9,10]. In addition, ergotism (convulsive ergotism in particular) was also characterized by severe muscular spasms and abnormal postures [10]. Ergotism was due to long-term poisoning by Claviceps purpurea fungus, formed on cereals, and widespread all over Europe during XII–XVI centuries [8,9]. Ergotism was graphically described in paintings by Mathias Grunewald, in some of his paintings severe dystonia can be recognized [11]. However, some authors suggest that ergotism was in fact a serotonin syndrome [10,12]. If this was the case, movement disorders in patients with ergotism can be easily explained, since dystonia, myoclonus and other movement disorders have been associated with serotonin syndrome [10,12]. 4. New world: ancient period Moche artists (from pre-Columbian culture developed in Northern Peru, 100–700 AD) had exceptionally sophisticated ceramic techniques,
Fig. 1. Funeral stele of the priest Ruma (XIX dynasty). Around 1500 BC, Carlsberg Museum of Copenhagen.
Fig. 2. Head of Alexander the Great, Lyssipus. Istambul Archeological Museum.
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Fig. 5. This potter is part of the Moche collections of the Museo Nacional de Arqueología y Antropologıa (Lima). It represents a man with his eyes closed and facial grimacing probably in an attempt to open his eyes.
(Fig. 5) represents a man with his eyes closed and facial grimacing probably in an attempt to open his eyes. The lips are horizontally tensed and the nasolabial folds are pronounced. In our opinion, this sculpture may be an artistic representation of blepharospasm with oromandibular dystonia [13]. A very similar representation of cranial dystonia, resembling the classical Meige's syndrome is shown at Fig. 6. The sculpture (XipeTotec Head, 300–900 AD) shows the closed eyes and lower face dystonia (jaw-opening), but also tongue dystonia (protrusion). This sculpture made of terracotta is a part of Veracruz Culture heritage from Mexico. Sensory tricks (fr. gestes antagonistes) are characteristic features of dystonia. Figs. 7 and 8 represent examples resembling such movements. The first one was made probably somewhere in Tokyo graveyard and the second one represents art of Melanesia, Papua, New Guinea.
Fig. 3. Peasant with head tilt to the right and painful expression (center), note the amputated hands. The peasant right to the man with cervical deviation seems to have both his legs amputated under the knee, the naked stumps appear under the garment. El Burgo de Osma (Spain).
which they often used to represent their people, particularly individuals affected by diseases or with physical deformities, as they believed that the handicapped were touched by the gods. The potter presented here
Fig. 4. A lady with a baby in her arms and cervical deviation to the left. Note the peasant just beside the woman, he has no hands, perhaps amputated. El Burgo de Osma (Spain).
Fig. 6. A possible representation of cranial dystonia, resembling the classical Meige's Syndrome. This sculpture found in New Orleans Museum of Art (NOMA), US (Xipe-Totec Head, 300–900 AD) shows the closed eyes and lower face dystonia (jaw-opening), but also with tongue dystonia (protrusion). This sculpture made of terracotta is a part of Veracruz Culture heritage from Mexico.
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5. Modern history The great Flemish Renaissance painter Pieter Brueghel the Elder had a fascination with human physiognomy, both normal and pathologic. Historians of art contend that Fig. 9 depicts a huge yawn and have titled this work “Yawning Man” or “De Gaper”. However, Marsden credited R.E. Kelly for noting the similarity of this painting to the syndrome of blepharospasm–oromandibular dystonia and suggested the eponym “Brueghel's syndrome” [14]. Marsden claimed that Brueghel “clearly recognized the syndrome”, but of course, it may be an overinterpretation of this undated, and untitled painting. “El patizambo” or “The clubfooted boy” (Jose de Ribera, 1642, Fig. 10) is a representation of a beggar with a right hemidystonia. Velazquez painted in “The boy from Vallecas”, (1643–45, Fig. 11) a boy with some degree of mental retardation and mixed cervical dystonia with a right torticollis and retrocollis. 6. Contemporary history The turn of the 19th and 20th centuries was the time of great transformation in art from classical figurative or descriptive forms to very modern, expressive and abstractive forms. It is possible to find descriptions of dystonia in contemporary art; this is the case of “Suffering” from Constantin Brancusi (1876–1952) (Figs. 12 and 13), which represents a boy with a very notorious painful cervical deviation. Brancusi is believed to have observed and represented a real patient with cervical dystonia [15]. Modigliani was contemporary of Brancusi. He is known for portraits and nudes in a modern style characterized by elongated faces and figures. Some of his paintings suggest cervical dystonic features including “sensory tricks” (Fig. 14). However, it is doubtful that all these paintings actually represented real people with dystonia. Stanislaw Wyspiaski, born in Cracovia (1869–1907) was also an interesting author at the turn of the 19th and 20th centuries. This artist practiced a variety of arts including poetry, theater and painting. He worked fast and with extraordinary intensity, his highly diverse output produced in a mere dozen years. We show one of his most realistic and beautiful artworks (The girl with red hat, Fig. 15), a young lady with upper limb dystonia, possibly related to cerebral palsy. 7. Literature and dystonia. Charles Dickens Many writers described neurological conditions across the centuries. Charles Dickens (1812–1870) had a special interest in individuals displaying neurological symptoms, and his novels are a source of precise neurological descriptions. Brain already quoted some Dickensian neurological diagnosis [16]. Besides Pickwickian syndrome, many other neurological descriptions can be found in Dickens' novels [16–19] including David Copperfield [19]: 1. Generalized dystonia: Uriah Heep. This character, one of the villains of the novel is described as a very tall, strange man with Marfanlike features: “Uriah, with his long knees drawn up under his coffeecup”. Uriah Heep displayed clear dyskinesias, most probably generalized dystonia: “He writhed himself quite off his stool in the excitement of his feeling…” “He had a snaky undulation pervading his frame from his chin to his boots…”, “…Uriah exclaimed, with a sickly, angular contortion of himself…”, “… I am sure, said Uriah, writhing himself into the silence like a Conger eel”. 2. Spasmodic dysphonia: Mr Creakle. “ The circumstances about Mr Creakle which impressed me most was, that he had no voice, but spoke in a whisper. The exertion this cost him, or the consciousness of talking Figs. 7 and 8. The first statue was made probably somewhere in Tokyo graveyard and the second one represents the not-dated art of Melanesya, Papua, New Guinea (New Orleans Museum of Art).
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Fig. 9. “Yawning Man” or “De Gaper”. Pieter Brueghel the Elder, around 1560. Musées Royaux des Beaux–Arts Bruxelles.
in that feeble way, made his angry face so much angry, and his thick veins so much thicker when he spoke” As Mr Creakle struggled to make his voice audible, he had no voice but a whisper, spasmodic dysphonia (abductor type) could be a plausible explanation of this presentation. 3. Mr Sharp: Cervical dystonia. “Mr Sharp was a limp, delicate-looking gentleman, with good deal of nose, and a way of carrying his head on one side, as if it were a little too heavy for him”. In this paragraph, Dickens described a man with neck rotation, which may be due to cervical dystonia.
Fig. 10. “El patizambo (The clubfooted boy)” from Jose de Ribera, 1642. Louvre Museum. A beggar with a right hemidystonia probably related with cerebral palsy.
Author roles Pedro J Garcia Ruiz: conception and design, acquisition, analysis and interpretation of data, drafting the submitted material, administrative support.
8. Summary In summary, we have reviewed a personal selection of art (sculpture, painting and literature) that may represent real patients with dystonia or dystonic movements. Our descriptions add to the growing body of reports on the pieces of art representing movement disorders [20,21]. Artists from ancient times throughout the centuries and up to now, from all over the world (e.g. from Europa, Asia and the New World) frequently described or depicted neurological diseases decades or centuries before the official reports by neurologists. Thus, history of neurology may be enriched by the history of art. Finally, we should like to include two recent papers related to art and dystonia: Bono et al. recently called attention to Giovanni Agostino da Lodi (Italian renaissance painter of the Leonardeschi) who made a clear depiction of cranial–cervical dystonia [22]. Gondim et al. reviewed neuropsychiatric phenomena described in Cantigas de Santa Maria; a collection of 427 canticles composed between 1252 and 1284 at the Court of King Alfonso X the Wise of Spain (1221–1284). In these cantigas the authors found several descriptions of dystonic movements [23].
Fig. 11. “El niño de Vallecas (The boy from Vallecas)” from Diego Velazquez, 1643–45, Museo del Prado, Madrid, depicts a boy with some degree of mental retardation, perhaps affected from cretinism, who has a mixed cervical dystonia, with right torticollis and retrocollis.
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Fig. 15. “The girl with red hat” from Stanislaw Wyspianski (1893), Upper Limb Dystonia (Spastic Dystonia?), Poznan, National Museum, Poznan, Poland.
Emilia J. Sitek: acquisition of data, analysis and interpretation of data; critical revision and editorial support. No conflict of interests reported. References
Figs. 12 and 13. “Suffering” from Constantin Brancusi 1907. Museum of Fine Arts. Chicago.
Jaroslaw Slawek: conception and design, acquisition, analysis and interpretation of data drafting part of the submitted material, critical revision and supervision. Juan Carlos Martinez Castrillo: acquisition, analysis and interpretation of data; critical revision and supervision.
Fig. 14. Portraits of Modigliani. A young woman with dystonic features and sensory tricks.
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