The art of diagnosis

Diagnosis, as we know, depends on history and examination. A work of art lacks the former, but it’s interesting to consider what artists notice.

In the ancient civilizations of Greece and India the sculptor’s purpose was to portray human perfection. Representations of real, imperfect human beings are also rare in Egyptian art. There is a man with a withered leg, propping himself up on a staff – polio? Perhaps not coincidentally he features on a stele from the reign of the apostate pharaoh Akhenaten, who allowed himself to be depicted with a pot belly.

Religion, war and madness have long been popular subjects for European artists with an interest in disease. In medieval times, depictions of the Last Judgement reminded people that their fate in the life to come depended on their godliness in this one. The afflictions of those condemned to hell, however, owe more to the imagination of the artist than to any known pathology. But in hospitals, patients saw horribly realistic images of dread diseases. The Antonine monastery at Isenheim was devoted to the care of victims of the plague and of St Anthony’s fire – ergotism. Matthias Grünewald’s altarpiece, painted for the monastery in 1512, shows a man rotting with sores. Christ’s anguish on the cross is intensified by the pustules which cover his body. Did these portrayals of their diseases really make the sick feel less isolated in their suffering?

150 years later patients were permitted more comforting images. Murillo’s painting in the Hospital de La Caridad in Seville shows St Elizabeth of Hungary carefully washing a realistically unpleasant sore on one patient’s head while another unwraps his filthy bandages.

Doctor-artists have recorded the medical consequences of war. Sir Charles Bell (he of the palsy) painted watercolours of the wounds sustained by soldiers on the battlefield of Waterloo. In the Great War, Henry Tonks, FRS and formidable professor at the Slade School of Art, documented the work of Harold Gillies whose pioneering plastic surgery techniques restored function and a more-or-less acceptable appearance to hideously damaged faces. At the time Tonks’ delicate pastels were a technical record; now they are valued as sensitive tributes both to his subjects, their appalling injuries and their courage, and to the surgeons who treated them. Julia Midgley, not a medic, has depicted the injuries of victims of 21st century wars and their rehabilitation. She points out that, unlike a photograph, the original work of an artist 'in residence’ in a war zone cannot be photoshopped for political convenience.

Madness and how societies manage it has been a popular subject. Some works just indulge the prurient. Others bear witness to the experience of madness and to the miserable conditions of those committed to asylums. By the 20th century artists such as Edvard Munch and Frida Kahlo were portraying their own suffering, maybe somewhat self-indulgently but perhaps offering their experience to the rest of us.

Likenesses of living people begin to appear in the Renaissance and by the 17th century portraiture was a respectable way to earn a living. But artists were expected to flatter their subjects. Someone of Goya’s skill might get away with being fairly honest about his king’s prognathous jaw by emphasising the grandeur of his robes, but for most artists a bit of photoshopping was essential if you wanted more commissions. Hence the fame of Oliver Cromwell’s demand that he be portrayed “warts and all”.

Artists were more candid about themselves. Titian and Rembrandt, for example, portrayed their old age unsparingly. And they had no obligations to people who weren’t paying to have their portrait painted. Look at secondary figures or imagined scenes and you can learn something about diseases of the times: club foot and other deformities that these days are surgically corrected; rickets, perhaps; goitre, apparently commoner in paintings by Italian artists who lived among the Florentine hills than in those of Venetians.
I recently saw a painting of a group of elderly women. Almost all had the sunken mouth of the edentulous, probably reflecting dental health at that time. But you have to be careful about making assumptions; in the 18th century rotten teeth showed that you could afford sugar.

Some artists have painted themselves in ill-health. In 2006 I wrote about Goya’s ‘Self portrait with Dr Arrieta’. If you want to know what an elderly man in a toxic confusional state looks like, Goya’s picture tells you.

Sometimes artists may record pathology without being aware of it. In Rembrandt’s painting of his wife Hendrickje as Bathsheba she has puckering at five o’clock on the left breast. Breast cancer specialist Professor Michael Baum has suggested that she had breast cancer. But she continues to look healthy in later portraits until she died nine years later, apparently of plague. So maybe she had mastitis after the birth of her daughter Cornelia.
Many artists struggle to depict hands and feet. Renoir’s figures so often have rheumatoid hands that it is no surprise to find that he himself suffered from RA. Perhaps he used his own hands as models and wanted to normalise them. Or, completing the details of his pictures after his sitters had gone, he may have rendered their hands in the image of his own. And look closely at La Primavera. One of the graces has hallux valgus. Whose feet was Botticelli using as a model?

Goya’s portrait of the Duke of Wellington in the National Gallery was painted at the end of the Peninsula War. But unlike most portraits of victorious generals, it’s not all swagger. Wellington is remote, watchful. In an earlier sketch Goya shows Wellington looking tired, pinched, withdrawn. Maybe after seven years of campaigning, he was suffering what we would now diagnose as PTSD?

Lucian Freud’s portraits tend not to spare their subjects, but was he aware of the lesion on his first wife’s hand – granuloma annulare, surely?

So next time you go to an art exhibition, take along your diagnostic skills, and if you identify any pathology, let me know.

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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