Infection (2014) 42:795–796 DOI 10.1007/s15010-014-0644-y
CORRESPONDENCE
Leonardo da Vinci’s Five Grotesque Heads: early evidence of cranio-facial mycobacterial infection M. Tan • L. Harling • H. Ashrafian
Received: 23 March 2014 / Accepted: 7 June 2014 / Published online: 26 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Leonardo da Vinci was a master artist of the renaissance era. He was well known to follow extraordinary people around Florence to sketch their features in his notebooks, and his genius of observation, insight and artistic mastery has thus given us many of the first anatomical [1] and pathological illustrations [2]. The Five Grotesque Heads, painted in 1494 and now owned by the British Royal Collection Trust, represents one of his most well known sketches of the grotesque. The grotesques are a series of depictions of faces and busts, sketched or painted by renaissance artists such as Leonardo da Vinci and Michelangelo. These are thought to portray observations of human physiognomy or physical manifestations of personality, and whilst some are pure caricatures, others are recognised to depict pathology [3]. There are two notable interpretations of Leonardo’s Five Grotesque Heads within the literature. The first and most accepted is the depiction of a scene of con-artistry, with the central figure being tricked and robbed by gypsies [4]. This can be seen in the arm of the left foreground character (B) reaching behind the central character’s (A) back into his pocket or sleeve. However, it is unlikely that Leonardo meant this sketch as purely a story of deception, and it is postulated that da Vinci added the arm performing the deed after its completion. An alternative interpretation suggests that the sketch represents purely physiognomical exploration, with the four peripheral characters representing manifestations of the four humors governing the central
M. Tan L. Harling H. Ashrafian (&) Department of Surgery and Cancer, Imperial College London, 10th Floor Queen Elizabeth the Queen Mother (QEQM) Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK e-mail: [email protected]
human figure [5, 6]. However, neither interpretation accounts forthe anatomical deformities depicted in these figures. Instead, we believe that da Vinci may have actually been depicting a common pathology, far beyond medical knowledge of the era. On closer inspection, the characters display distinct anatomical deformities suggestive of the granulomatous diseases leprosy or tuberculosis, which are caused by mycobacteria infection. The earliest evidence of these conditions dates back to 2000 BC, and both medical and religious texts clearly document their pathological manifestations [7]. Although the understanding of both leprosy and tuberculosis was limited in Europe during the renaissance period, Leonardo da Vinci’s illustrative precision allows us to detect subtle clinical signs of these two diseases. In Fig. 1, two of the characters in the foreground (A, B) clearly have smooth parotitis or nerve abscesses [8]. The central character (A) also has a skin nodule on his pinna. The leftmost foreground character (B) has poor dentition, as evidenced by dental attrition and missing teeth compared to the left background character (C), whose full set of teeth are depicted. Although this may be representative of a number of pathologies, taken with these other observations it could also be a manifestation of oropharyngeal mycobacterial infection. In addition, the right foreground character (E) demonstrates macrocheilia as would be seen in both leprosy and tuberculosis. In the background, the details of the characters are almost insufficient to make anatomical observations. However, the left character (C) is drawn with his mouth agape, light reflecting in a variable manner on the hard palate, giving anappearance suggestive of oropharyngeal granulomas. The right background character (D) also demonstrates periorbital manifestations consistent with mycobacterial infection, including a prominent supraorbital
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nerve palsy and lymphadenopathy, none of which can be observed here. In Sjogren’s syndrome, patients present with sicca symptoms. The autoimmune destruction of parotid glands results in a swollen appearance. However, based on the sketch, it is not possible to comment on the presence or absence of xerophthalmia or xerostomia. Pleomorphic adenoma is the most common benign parotid tumor and presents as a painless swelling of the gland. However, this would not account for the other pathological features depicted in this sketch. In summary, we present an alternative explanation of Leonardo da Vinci’s Five Grotesque Heads (1494) as representing the clinical signs of a granulomatous disease such as tuberculosis or leprosy. Once again Leonardo da Vinci’s illustrative precision allows us to detect subtle clinical signs far beyond the medical knowledge of the era, emphasising his fundamental contributions in both the arts and medical science. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
References Fig. 1 A man tricked by gypsies. Leonardo da Vinci (Vinci 1452– Amboise 1519). Courtesy of The Royal Collection Trust/Ó her Majesty Queen Elizabeth II 2013
ridge on the right. These illustrations are clearly distinct from the normal peri-orbital region depicted on his left side. The scene of the sketch itself may also be interpreted as depicting the social isolation of mycobacterium infection. Rather than illustrating a central figure being tricked and robbed [4], the sketch can be interpreted as the middle character being a new victim of the disease, welcomed into a ‘‘colony’’ as was practice with leprosy and tuberculosis. Key differential diagnoses producing similar clinical signs include sarcoidosis, Sjogren’s syndrome and pleomorphic adenoma. Sarcoidosis may manifest at a number of distinct anatomical sites, however, is less common among the European population from which da Vinci gained his subjects. Furthermore, it exhibits a female preponderance and is associated with a number of extra-pulmonary features including conjunctivitis or uveitis, facial
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1. Ashrafian H, Harling L, Athanasiou T. Leonardo da Vinci and the first portrayal of quadricuspid semilunar valves and the nodules of Arantius. Int J Cardiol. 2013;165:560–1. doi:10.1016/j.ijcard.2012. 09.010. 2. Tan M, Goh S, Ashrafian H. Michelangelo’s John the baptist and thalassemia. Ann Hematol. 2013;92:1293–4. doi:10.1007/s00277013-1710-8. 3. Cook C. A grotesque old woman. BMJ. 2009;339, doi:10.1136/ bmj.b2940. 4. Clayton M. Leonardo da Vinci: the divine and the grotesque. London: The Royal Collection; 2002. 5. Britton PDG. The Signs of faces: leonardo on physiognomic science and the ‘four universal states of man’. Renaissance Studies. 2002;16:143–62. doi:10.1111/1477-4658.t01-1-00009. 6. Trutty-Coohill P. Bracketing theory in Leonardo’s Five Grotesque Heads. Analecta Husserliana. 1998;56:87–102. 7. Donoghue HD. Insights into ancient leprosy and tuberculosis using metagenomics. Trends Microbiol. 2013;21:448–50. doi:10.1016/j. tim.2013.07.007. 8. Mastronikolis NS, Papadas TA, Marangos M, Karkoulias KP, Tsamandas AC, Goumas PD. Tuberculosis of the parotid gland. Tuberkuloz ve toraks. 2009;57:84–8.
CORRESPONDENCE
Leonardo da Vinci’s Five Grotesque Heads: early evidence of cranio-facial mycobacterial infection M. Tan • L. Harling • H. Ashrafian
Received: 23 March 2014 / Accepted: 7 June 2014 / Published online: 26 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Leonardo da Vinci was a master artist of the renaissance era. He was well known to follow extraordinary people around Florence to sketch their features in his notebooks, and his genius of observation, insight and artistic mastery has thus given us many of the first anatomical [1] and pathological illustrations [2]. The Five Grotesque Heads, painted in 1494 and now owned by the British Royal Collection Trust, represents one of his most well known sketches of the grotesque. The grotesques are a series of depictions of faces and busts, sketched or painted by renaissance artists such as Leonardo da Vinci and Michelangelo. These are thought to portray observations of human physiognomy or physical manifestations of personality, and whilst some are pure caricatures, others are recognised to depict pathology [3]. There are two notable interpretations of Leonardo’s Five Grotesque Heads within the literature. The first and most accepted is the depiction of a scene of con-artistry, with the central figure being tricked and robbed by gypsies [4]. This can be seen in the arm of the left foreground character (B) reaching behind the central character’s (A) back into his pocket or sleeve. However, it is unlikely that Leonardo meant this sketch as purely a story of deception, and it is postulated that da Vinci added the arm performing the deed after its completion. An alternative interpretation suggests that the sketch represents purely physiognomical exploration, with the four peripheral characters representing manifestations of the four humors governing the central
M. Tan L. Harling H. Ashrafian (&) Department of Surgery and Cancer, Imperial College London, 10th Floor Queen Elizabeth the Queen Mother (QEQM) Building, St Mary’s Hospital, Praed Street, London W2 1NY, UK e-mail: [email protected]
human figure [5, 6]. However, neither interpretation accounts forthe anatomical deformities depicted in these figures. Instead, we believe that da Vinci may have actually been depicting a common pathology, far beyond medical knowledge of the era. On closer inspection, the characters display distinct anatomical deformities suggestive of the granulomatous diseases leprosy or tuberculosis, which are caused by mycobacteria infection. The earliest evidence of these conditions dates back to 2000 BC, and both medical and religious texts clearly document their pathological manifestations [7]. Although the understanding of both leprosy and tuberculosis was limited in Europe during the renaissance period, Leonardo da Vinci’s illustrative precision allows us to detect subtle clinical signs of these two diseases. In Fig. 1, two of the characters in the foreground (A, B) clearly have smooth parotitis or nerve abscesses [8]. The central character (A) also has a skin nodule on his pinna. The leftmost foreground character (B) has poor dentition, as evidenced by dental attrition and missing teeth compared to the left background character (C), whose full set of teeth are depicted. Although this may be representative of a number of pathologies, taken with these other observations it could also be a manifestation of oropharyngeal mycobacterial infection. In addition, the right foreground character (E) demonstrates macrocheilia as would be seen in both leprosy and tuberculosis. In the background, the details of the characters are almost insufficient to make anatomical observations. However, the left character (C) is drawn with his mouth agape, light reflecting in a variable manner on the hard palate, giving anappearance suggestive of oropharyngeal granulomas. The right background character (D) also demonstrates periorbital manifestations consistent with mycobacterial infection, including a prominent supraorbital
123
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M. Tan et al.
nerve palsy and lymphadenopathy, none of which can be observed here. In Sjogren’s syndrome, patients present with sicca symptoms. The autoimmune destruction of parotid glands results in a swollen appearance. However, based on the sketch, it is not possible to comment on the presence or absence of xerophthalmia or xerostomia. Pleomorphic adenoma is the most common benign parotid tumor and presents as a painless swelling of the gland. However, this would not account for the other pathological features depicted in this sketch. In summary, we present an alternative explanation of Leonardo da Vinci’s Five Grotesque Heads (1494) as representing the clinical signs of a granulomatous disease such as tuberculosis or leprosy. Once again Leonardo da Vinci’s illustrative precision allows us to detect subtle clinical signs far beyond the medical knowledge of the era, emphasising his fundamental contributions in both the arts and medical science. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.
References Fig. 1 A man tricked by gypsies. Leonardo da Vinci (Vinci 1452– Amboise 1519). Courtesy of The Royal Collection Trust/Ó her Majesty Queen Elizabeth II 2013
ridge on the right. These illustrations are clearly distinct from the normal peri-orbital region depicted on his left side. The scene of the sketch itself may also be interpreted as depicting the social isolation of mycobacterium infection. Rather than illustrating a central figure being tricked and robbed [4], the sketch can be interpreted as the middle character being a new victim of the disease, welcomed into a ‘‘colony’’ as was practice with leprosy and tuberculosis. Key differential diagnoses producing similar clinical signs include sarcoidosis, Sjogren’s syndrome and pleomorphic adenoma. Sarcoidosis may manifest at a number of distinct anatomical sites, however, is less common among the European population from which da Vinci gained his subjects. Furthermore, it exhibits a female preponderance and is associated with a number of extra-pulmonary features including conjunctivitis or uveitis, facial
123
1. Ashrafian H, Harling L, Athanasiou T. Leonardo da Vinci and the first portrayal of quadricuspid semilunar valves and the nodules of Arantius. Int J Cardiol. 2013;165:560–1. doi:10.1016/j.ijcard.2012. 09.010. 2. Tan M, Goh S, Ashrafian H. Michelangelo’s John the baptist and thalassemia. Ann Hematol. 2013;92:1293–4. doi:10.1007/s00277013-1710-8. 3. Cook C. A grotesque old woman. BMJ. 2009;339, doi:10.1136/ bmj.b2940. 4. Clayton M. Leonardo da Vinci: the divine and the grotesque. London: The Royal Collection; 2002. 5. Britton PDG. The Signs of faces: leonardo on physiognomic science and the ‘four universal states of man’. Renaissance Studies. 2002;16:143–62. doi:10.1111/1477-4658.t01-1-00009. 6. Trutty-Coohill P. Bracketing theory in Leonardo’s Five Grotesque Heads. Analecta Husserliana. 1998;56:87–102. 7. Donoghue HD. Insights into ancient leprosy and tuberculosis using metagenomics. Trends Microbiol. 2013;21:448–50. doi:10.1016/j. tim.2013.07.007. 8. Mastronikolis NS, Papadas TA, Marangos M, Karkoulias KP, Tsamandas AC, Goumas PD. Tuberculosis of the parotid gland. Tuberkuloz ve toraks. 2009;57:84–8.
