Mind On Canvas: Anatomy, Signs And Neurosurgery In Art

B ritish J ournal of Neurosurgery, 2008; 1 – 12, iF irst article

ORIGINAL ARTICLE

Mind on Canvas: anatomy, signs and neurosurgery in art

F. GERANMAYEH & K. ASHKAN

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North West London Hospitals NHS Trust, and Department of Neurosurgery, Kings College Hospital, London, UK Abstract Throughout the ages, art and neuroscience have had a delicate yet definite relationship with reciprocal influence. By virtue of their superior power of observation, artists have often preserved neurological signs through detailed brush strokes or meticulous carvings long before it is described in scientific literature. There has been an increasing tendency to use paintings and drawings as independent sources for investigation of scientific history. In neuroanatomy, these tools have helped reveal the complex interrelation between arts and neurosciences that on the surface often appear as highly polarized worlds. In this article we begin by giving a brief introduction to the general relationship between neuroscience and art as depicted in paintings and drawings, and describe the artistic tendencies of the early neuroanatomists. We aim to highlight the existence of neurosurgical themes within paintings and drawings from different eras.

Key words: Drawing, neuroanatomy, neurosurgery, neurology, painting.

Art is born of the observation and investigation of nature. (Cicero, Roman author and orator, 106–43 BCE). Introduction Connections between the arts and the sciences have existed throughout history. As the most creative endeavours of human activity, both disciplines have developed in parallel based on temperament and philosophical milieu of their time. Neuroscience per se manifests through art in several ways. Not uncommonly, neurological ill health can be recognized by the observant eye of an artist. Thus, portraits have been described by Zeki, a pioneer in neuroaesthetics, to use ‘the accidents of each individual face to reveal inner life’.1 For instance de Ribera and El Greco were inspired by neurological phenomenon in their subjects, and transformed their view of neurological signs to a language of paint they found easy to disseminate. At other times the will for better understanding and teaching has pushed neurosurgeons, such as Harvey Cushing to document their own studies through drawing. Yet, artists such as Leonardo da Vinci have become anatomists undertaking and drawing their own investigations. Furthermore, sometimes it is a work of art that is a confirmation of the presence of a neurological disease in its creator.2–5

Science has also had a more direct influence on art, for example, through Michel-Euge`ne Chevreul’s The Law of Simultaneous Colour Contrast (1839) that strengthened the foundations of colour theory. More recently, the concepts of cerebral localisation of creativity and talent, and neuroaesthetics have attracted interest by the neuroscientists. Pioneered by Samir Zeki, neuroaesthetics investigates the neurological response towards an aesthetic phenomenon such as art and examines the neural correlates of beauty.1,6 There is a mind on each canvas—the artists use colours, perspectives, shapes and lines to activate specific neuronal pathways. Thus, exploiting our common visual organization and arousing shared experiences beyond the reach of words. In this paper, we will focus on a review of paintings and drawings that portray knowledge of neuroanatomy throughout history, as well as those that show neurosurgically relevant signs. We also describe examples of neurosurgical procedures in paintings that have contributed to our understanding of the neurosurgical environment, techniques and reasoning prevalent at the time of the paintings. Our aim is to highlight the existence of neuroscientific themes, as shown in paintings and drawings, amongst the neurosurgical community. It is worth mentioning in the outset that, whilst pictorial documents enable medical historians to drive conclusions about a depicted scene, such

Correspondence: Mr K. Ashkan, D epartment of Neurosurgery, Kings College Hospital, D enmark Hill, London SE5 9RS, U K. Tel: 0044 203 299 3285. Fax: 0044 203 299 3280. E-mail: keyoumars.ashkan@ kingsch.nhs.uk Received for publication 13 November 2008. Accepted 6 April 2008. ISSN 0268-8697 print/ ISSN 1360-046X D OI: 10.1080/ 02688690802109820

online ª The Neurosurgical Foundation

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interpretations can become erroneous, especially in cases where no original written documentation is available or where the picture is analysed out of its historical context. One such example is a woodcut in Fabricius Hildanus’ description of a novel way to apply a seton in the neck, which was later misread by an author of History of Neurological Surgery, 1951 edition, as a method of reduction of cervical dislocation.7

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Neuroanatomical drawings There are extensive ancient Egyptian and Greek manuscripts that contain fascinating textual descriptions of neuroanatomy including E dwin- Smith papyrus from 3500 BCE, I liad of the Greek poet Homer and writings of Hippocrates, Herophilus, and Galen, which are beyond the scope of this article and have been covered thoroughly in the literature.8–12 After the Greek period of medicine, the centres of intellectual enquiry moved to the Islamic cultures, where it remained influential from 750 to 1200 CE. Physicians, including Avicenna (980–1037 CE), made major contributions to the body of knowledge about neuroscience in this period. Fig. 1 is a watercolour drawing of the nervous system taken from the legendary book A l- Q anun F i A l- Tib b (The Canons of M edicine) by Avicenna known as the ‘Second D octor’ (the first being Aristotle). The figure is viewed from the back, with the head hyper-extended so that the mouth is at the top of the page. D ifferent colours were used to represent pairs of nerves. The spine is drawn in continuity with the brain stem where some cranial nerves emerge from it. The spine has been numbered into eight cervical, 12 thoracic, five lumbar and four sacral segments. Some fibres from the cervical segments are shown to cross each other at the level of brachial plexus. Avicenna systematically reviewed the medical knowledge by the previous scientists and complemented them by his own findings. Chapters 6–13 of The Canons are designated to spinal anatomy and its biomechanical aspects.13 On a personal level, Avicenna was a gifted child born in the Persian village of Afshama, who was a practicing physician at the age of 20. In addition to Canons, he demands credit for his encyclopaedia of philosophy, Shafaa, meaning healing. His choice of names for these two books, Canon (law), for a medical text book, and Shafaa (healing) for a philosophical one, is intriguing. A very similar drawing can be seen in The A natomy of the Human B ody ( Tashrih- i b adan- i insane) by Mansur Ibn Muhammad Ilyas (14th century), another Persian physician, suggesting this may have been a common method of illustrating neuroanatomy at the time (Fig. 2). This book has five coloured illustrations of skeleton, muscles, intestine, blood vessels and nerves. Through the latter he describes the anatomy of the spinal cord and nerves.

FIG. 1. Study of the nervous system, from Avicenna’s 11th century treatise Canons of M edicine, al- Q anun F i A l- Tib b , Folio 123 verso. Published in Isfehan, Iran 1632, Wellcome Library, London. L0013312.

Neuroanatomy in R enaissance A rt In Europe, the Renaissance heralded the blossoming of medicine and art. Leonardo da Vinci (1452– 1519), who created 190 pages of drawings and writings devoted to anatomy, was particularly fascinated with the nervous system. Born in the Italian village of Vinci, he was an illegitimate son of Ser Piero d’Antonio, a notary, and a peasant woman named Caterina. He produced over 5000 known leaves of notebooks decorated with detailed direct observational drawings ranging from mechanics to anatomy, some written in his characteristic reversed script or ‘mirror writing’. He made many contributions to neurosciences, including the discovery of neuroanatomical structures such as meningeal arteries and frontal sinuses.14 He injected hot wax into the brain of an ox and produced a cast of the ventricles. This represented the first attempt at using a solidifying medium to determine the structure of an internal body organ (Fig. 3). Leonardo’s thoughts on ventricles were influenced by previous physicians, such as Mondino, Avicenna

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FIG. 2. Watercolour drawing of the nervous system from The A natomy of the Human B ody by Mansur Ibn Ilyas. The figure is viewed from the back, with the head hyper-extended so that the mouth is at the top of the page. D ifferent colours were used to represent pairs of nerves. Wellcome Library, London. L0006435.

and Galen, who wrote extensively on the ‘reciprocal symmetry’ or ‘reciprocal harmony’ of the brain. In Fig. 4, Leonardo draws an onion that shows by analogy, the layered structure of the membranes covering the eye and the brain. The main drawing and the one below show Leonardo’s division of the cerebral ventricles into anterior, middle and posterior.15 He located the senso comune (literally common sense) or the amalgamation of the senses in the brain, which was also the location of the soul. He assigned the anterior ventricle to the senso comune alongside fantasy and imagination, the middle to cognition, and the posterior ventricle was assigned to memory.16 In Leonardo’s eyes, the only certifiable and reliable knowledge was that obtained directly by sight and experience from the external world: ‘The eye, which is termed the window to the soul, is the chief organ whereby the senso comune can have the most complete and magnificent view of the infinite works of nature’.14 Leonardo is referred to by some as an artist with the mind of a physician, but Vesalius (1514–1564) is thought to be the opposite.17 He produced three masterly anatomical text books; Tab ulae A natomicae

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Sex , E pitome and De Humani Corporis F ab rica. These contain unrivalled artistic quality woodcut illustrations by Titian’s pupils, largely based on human dissection. In the third and seventh parts of De Humanis Corpora F ab rica ( Structure of the Human B ody) , Vesalius describes peripheral nerves, and central nervous system, respectively.18 D etailed drawings of the cerebellum, vagus nerve and arachnoid space are particularly fascinating (see http: / / archive.nlm.nih.gov/ proj/ ttp/ flash/ vesalius/ vesalius.html, accessed 1 April 2008). Vesalius criticized both the medieval methods of dissection, which were mainly based on animal, rather than human anatomy (due to prohibition of human dissections in ancient Rome), and the dependence of anatomy on authoritative texts without questioning them. Trusting his own eyes, Vesalius gradually observed some errors in Galen’s work, which attracted animosity from his contemporaries. He also reproduced some Galenic errors such as his drawing of the five-lobed liver in Tab ulae A natomicae Sex , reminding us that sometimes the presumed infallible text is more powerful than the artist’s eye. Michelangelo Buonarroti (1475–1564), the Italian painter, sculptor and poet, began dissecting human bodies at the age of 18 in the Monastery of Santo Spirito in Florence, using corpses from surrounding hospitals. His paintings have been referred to by many medical specialists.19 Of particular note to neuroanatomy is his famous fresco, on the ceiling of the Sistine Chapel, ‘The Creation of Adam’ (http: / / mv.vatican.va/ 3_ EN/ pages/ x-Schede/ CSNs/ CSNs_ V_ StCentr_ 06_ big.html, accessed 1 April 2008). Meshberger20 has argued that the billowing cloth structure and angels surrounding God resemble a sagittal view of the brain including the frontal lobe, whilst the major sulci are outlined by the contours of the figures of angels. Optic chiasm, brain stem and the pituitary gland are shown by the bifid foot of an angel, and the vertebral artery is represented by a green robe. He argues that perhaps this is a coded message from Michelangelo implying that the divine gift received from God to Adam is intellect, rather than life itself. Adam appears alive, stretching out with his eyes open just before being touched by God to be created. In fact, some have argued that given the physical similarities between God and Adam, it is not clear who the creator is; is God creating Adam, or does God exist in Adam’s mind? 21 God’s left arm is wrapped around a female figure. Some see her as Eve awaiting creation, whilst others think her to be Sophia the Goddess of divine wisdom and the feminine side of God.

Neurosurgical / neurol ogical signs in art P araplegia Scenes depicting paraplegia are not rare within the art world, probably because this is a common

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FIG. 3. D rawing of cerebral ventricles after injection with liquid wax by Leonardo da Vinci. The Royal Collection ª 2007, Her Majesty Q ueen Elizabeth II.

debilitating neurological deficit. An alabaster wall relief from the Nebuchadnezzar’s palace in Nineveh (650 BCE) showing the Neo-Assyrian king hunting lions from his chariot, has been used to suggest that the early hunters were aware of the phenomenon of paraplegia. Fig. 5 shows a section of this relief. Here, arrows penetrate a lioness through the back resulting in what appears to be paraplegia of her hind limbs. A more contemporary painting ‘The Paraplegic’ (Fig. 6), by the London born Claude Rogers (1907–1979) is a more evident example. Here, two nurses are supporting a patient’s upper body and right thigh, encouraging her to take a step forward. Perhaps she has suffered a stroke. M uscle atrophy An example of limb atrophy may be seen in ‘St Peter Healing the Sick with his Shadow’, a fresco painting

by Masaccio (1401–1428) in Brancacci Chapel, at Santa Maria del Carmine Church in Florence (http: / / en.wikipedia.org/ wiki/ Image: Masacc14.jpg, accessed 1 April 2008). Here, a beggar is shown kneeling on the ground in front of St Peter and the crowd. His bilaterally wasted legs have been attributed to polio, but this has been contested by some, as the first known epidemic of polio occurred after this piece was painted, in the 18th century.22 ‘Seiz ure’ D riven from the Greek word epilam- b anein, to be seized or attacked, the term epilepsy was introduced into the medical terminology by Avicenna.23 Although physicians of ancient Greek, Byzantine or Persia, regarded seizures as a disease process, historically people who suffered from epilepsy were often viewed as possessed. In Homer’s time,

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FIG. 4. Sagittal and axial sections of the human head and eye by Leonardo da Vinci c.1490. The onion shows by analogy, the layered structure of the membranes covering the eye and the brain. Leonardo divided the cerebral ventricles into three parts and assigned the anterior ventricle to the senso comune (literally common sense), as well as fantasy and imagination, the middle to cognition, and the posterior ventricle was assigned to memory. The Royal Collection ª 2007, Her Majesty Q ueen Elizabeth II.

epilepsy was regarded as a miasma casted upon the soul by the goddess Hecate, although this belief was later refuted by Hippocrates in his text The Sacred Disease.24 In early Christianity the act of J esus driving out the unclean spirit of the boy with seizure, suggests that people with epilepsy were regarded as being seized and needing exorcism. This is depicted in Raphael’s (Rapha –el meaning He/ God has healed) last painting, ‘The Transfiguration’ (Fig. 7), which was almost finished before his death on Good Friday, 1520. The painting tells two stories; the Transfiguration of Christ on Mount Tabor in the upper section and the healing (or rather just prior to) of the boy with evil spirits in the lower part. The latter account comes immediately after the description of the transfiguration in the

Gospel and is based on the following passage in the Bible: Teacher, I brought my son to you, because he has an evil spirit in him and cannot talk. Whenever the spirit attacks him, it throws him to the ground, and he foams at the mouth, grits his teeth and becomes stiff all over. (Mark, Chapter 9, verses 17–18) The father wearing green, a symbol of hope, is shown supporting his son who appears to be convulsing. Interestingly, it is only the boy who looks up to J esus, transcending in white light amongst Moses, Elijah and the three disciples. Some have argued that Raphael’s simultaneous depiction of these two biblical events in one painting acts as a simile for

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FIG. 5. Alabaster wall relief from the Assyrian North Palace at Nineveh shows an arrow penetrating a lioness in the back resulting in paraplegia. ª Copyright the Trustees of the British Museum.

beliefs about epilepsy in those times, people with this disease also received great empathy in the church by distinguished individuals such as St Valentine, the patron saint of people with epilepsy. B ab insk i sign J oseph Franc¸ois Babinski (1857–1932) was the first to recognize the neurological significance of Babinski sign. Nevertheless, many artists had observed this natural phenomenon in paintings of young infants much earlier.26 Two such examples are ‘Madonna and Child with Angels’ (http: / / it.wikipedia.org/ wiki/ Immagine: Sandro_ Botticelli_ 062.jpg, accessed 1 April 2008 and ‘Madonna and Child with Eight Angels’ (http: / / www.wga.hu/ frames-e.html? / html/ b/ botticel/ 22/ 1madonna.html accessed 1 April 2008) by Sandro Botticelli (1445–1510). FIG. 6. ‘The Paraplegic’ (1970–1971), by Claude Rogers. Two nurses are shown supporting a patient. ª Tate, London 2005.

J esus’ transfiguration through suffering, death and resurrection.25 ‘St Catherine exorcising a possessed woman’ by Girolamo de Benvenuto (1470–1524 CE), and ‘St Zeno exorcising the D aughter of Emperor Gallienus’ (Fig. 8) are two other paintings that portray epilepsy. The latter is by Fra Filippo Lippi who completed this painting as part of the predella of ‘The Trinity with Saints Mamas, J ames, Zeno, and J erome’ by Pesellino, after his death. The unclean spirit is shown leaving the mouth in the shape of a dragon. It is imperative to mention that despite such

F acial palsy An example of facial muscle weakness can be viewed in a painting by Francisco de Goya (1746–1828), a leading Spanish painter of the courts of Charles III, Charles IV and Ferdinand VII of Spain. Fig. 9 depicts a portrait of his friend and fellow artist, ‘D on Andre´s del Peral’, who has an evident left facial nerve palsy that is still apparent despite the artist’s chosen angle to paint the portrait as an effort to minimize this asymmetry. It has been suggested that del Peral suffered from a left upper motor neuron facial nerve lesion, most probably due to a stroke.27 Of interest, Goya fell ill at the age of 46, and subsequently was left with partial blindness, loss of hearing and dizziness probably due to Vogt–Koyanagi Syndrome.28

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FIG. 7. ‘The Transfiguration’ by Raphael, commissioned in 1517 and based on the biblical passage; ‘Teacher, I brought my son to you, because he has an evil spirit in him and cannot talk. Whenever the spirit attacks him, it throws him to the ground, and he foams at the mouth, grits his teeth and becomes stiff all over’. A boy who appears to be convulsing can be seen in the bottom right corner. ª Photo Vatican Museums.

P tosis Portraits of King Henry III (1207–1272) of England (http: / / www.npg.org.uk/ live/ search/ portrait.asp? search¼ap&title¼&npgno¼4980% 286% 29&set¼&e D ate¼&lD ate¼&subjNoJ s¼&subj¼&setNoJ s¼& medium¼&rNo¼0, accessed 1 April 2008), and his son Edward I (http: / / www.npg.org.uk/ live/ search/ portrait.asp? LinkID ¼mp67807&rNo¼1&role¼sit accessed 1 April 2008) have been used to suggest that the father and son both suffered from congenital ptosis.29 In this portrait, Henry III is shown with a raised right eyebrow, compensating for the drooping of the right eyelid. The portraits date back to the 17th and 18th centuries, respectively, and are based on an

earlier portrait from their lifetime, the former by an unknown artist, and the latter by George Vertue. Club foot The Spanish borne artist, J osepe de Ribera (1591– 1652), spent part of his youth in Italy, living a life of half beggar and later became the painter to the Spanish Viceroy in Naples. His earlier works had a religious theme, but his later paintings, such as ‘The Beggar’ or ‘The Clubfoot’ (http: / / www.abcgallery. com/ R/ ribera/ ribera8.html, accessed 1 April 2008) were of a more popular genre. Although the title of the painting suggests an orthopaedic problem, the underlying disease depicted may have been neurolo-

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FIG. 8. ‘St Zeno exorcising the D aughter of Emperor Gallienus’ by Fra Filippo Lippi and workshop. This is likely to depict an epileptic seizure. A spirit is shown leaving the body of a woman as she is exorcised by St Zeno. Photo ª the National Gallery, London. Presented by Mr. and Mrs. Felix M Warburg through the National Art Collections Fund, 1937.

gical; in this painting a beggar is shown holding a message that reads ‘give me alms for the love of God’, suggesting that he cannot speak. He has an evident deformity of the right leg, and flexion deformity of the right wrist and fingers. Some have suggested that he suffers from right infantile hemiparesis.30 Nevertheless, others have argued that if the beggar had this disease, with the causative lesion being on the left cerebral hemisphere, he would most likely not be aphasic as in this childhood condition the functioning hemisphere, right in this case, would usually take on the capacity for language. They have suggested that either he has a bilateral cerebral lesion, or he is just seeking sympathy and ‘alms’.22 Neurosurgical p ersp ective th rough th e artist’ s eye Today’s sophisticated neurosurgical knowledge, techniques and environment is a far cry from the primordial neurosurgery that dates back to the Neolithian period. Furthermore, the prehistoric cranial operations had elements of magic, ritual and religious motivations, where cranial bones obtained from postmortem operations, were worn as charms, amulets or talismans.31 Through art, much can be learnt about previous neurosurgical procedures, as well as the context and environment in which they occurred. Trephination Trephining or trepanning, believed by some to be the oldest surgical procedure, is the removal of a piece of

FIG. 9. ‘D on Andre´s del Peral’ by Francisco de Goya (1795–1798). A left facial palsy is still apparent despite the artist’s chosen angle as an attempt to minimize the facial asymmetry. Photo ª the National Gallery, London.

bone from the skull by a trepan or trephine, a name derived from the Greek trypanon or borer. It began in the late Paleolithic period and has been used

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Smithsonian Institution, U SA), by Alton S. Tobey, a contemporary historical artist, is a depiction of this practice. Tobey and his family spent weeks in South America and in the ancient Inca city of Machu Picchu, where he extensively researched this 16th century practice of South American Inca Empire. He paid attention to the excavated primitive trephination instruments and methods of handling them, as well as costumes and artefacts from the Peruvian culture in order to reproduce an accurate scene. ‘The Inca Trephination’ (http: / / www.myimagezone.com/ lib/ Thumb.aspx? f¼/ data/ 0/ 88/ 88120.J PG&l¼950, accessed 1 April 2008) shows trephination by a

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throughout history. It was extensively discussed in Hippocrates’ O n Wounds in the Head.32 Ancient surgeons used scarping, grooving, boring and making rectangular intersecting incisions to remove pieces of cranial bone in skull injuries, or even treat melancholy and mental disorders.33–35 Trephination has been reported in many cultures including Indians of Canada and the U nited States, Europe, Africa, ancient Iran and Peru, where comparative osteology has shown that up to 70% of patients survived the procedure with relatively low rate of infection.36–41 ‘The Inca Trephination’ mural (installed at the Hall of Physical Anthropology,

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FIG. 10. Woodcut drawings showing trephination in process in a home environment with an audience that includes pets and children. From D ella Croce’s Chirugiae . . . lib ri septem, q uamplurimis instumentorum imaginib us arti chirurgicae opportunis . . . ex ornata, theoricam, practicam, ac v erissimam ex perimentiam continents . . . Venice, G. Ziletti, 1573. (A) Folio 53 verso. (B) Folio 54 recto. Wellcome Library, London.

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K. A shk an The climate of Florence and Midi of France were regarded as very pestiferum—unfavourable.42 Cranial inj ury Hippocrates’ (460–377 BCE) treatise entitled De Capitis V ulnerib us, O n Wounds in the Head or O n I nj uries of the Head, was a pioneering work in the field of management of head injuries despite the lack of animal or human dissections. In this treatise he describes cranial thickness and relation to injury, classifies cranial fractures, describes contrecoup injuries and various bandaging techniques.43 Neurosurgery later developed in the Islamic era, when cauterization of wounds to stop bleeding was practiced.44 The renaissance and post-Renaissance periods that saw the emergence of the concept of a specialized surgeon, were also noteworthy for their art of warfare

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priest-surgeon of the Inca Empire on an injured warrior in the setting of the granite-made city of Machu Picchu, perched high in the Andes Mountain. Two woodcut drawings (Fig. 10a,b) from the 16th century treatise Chirurgiae univ ersalis opus ab solutum by Giovanni Andrea D alla Croce, probably one of the most comprehensive surgical textbooks, show detailed scenes of trephination within a home setting. In Fig. 10b the patient is lying prone on the bed, surrounded by the surgeon, a woman crying, two men warming a cloth and observers, including a child. The presence of animals in this operating environment provides an interesting insight into the concepts of cleanliness and sterility prevalent at the time. The operating room and dressings were warmed as the cold was cereb ro fringes inimicissimus, very dangerous to the brain. Additionally, climate was thought to affect the outcome of the operation.

FIG. 11. ‘The Cure of Folly’ or ‘The Stone Operation’ by H. Bosch showing a medical charlatan attempting to apparently surgically remove a stone from the head of patient. The translation of the inscription reads ‘Master, dig out the stones of folly, my name is castrated dachshund’, where ‘castrated dachshund’ was a nickname for a person lacking commonsense. Museo Nacional D el Prado, Madrid.

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and, later, the invention of firearms and treatments of gunshot wounds.42 Pare´, the founder of modern French surgery and a military surgeon who served a succession of kings, wrote numerous treatise on management of battlefield injuries, including wounds to the head. These contained numerous drawings, not all by him, of surgical instruments used at the time. Of particular note is a drawing of an elev atorium that was used to elevate a depressed skull fracture. (See http: / / www.nlm.nih.gov/ exhibition/ historicalanatomies/ Images/ 1200_ pixels/ ccclii.jpg, accessed 1 April 2008.) D epressed skull fractures were common in battlefields that used maces, pole-arms and fire arms. In using the elevator, dura was spared and bony fragments were removed leaving gaps for the extradural pus to escape. Within such an environment, it is amazing that soldiers could survive such injuries.

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entities continue to influence each other. We have briefly described drawings and paintings that, although ambiguous at times, can be used to illustrate neuroanatomical and neurosurgical themes that exists in art. As history continues in the making, the art and neuroscience will continue to flow, their paths will cross and the human experience will enrich on both accounts. Ack nowl edgements The authors would like to thank Professor G. W. Kreutzberg for his advice and correspondence regarding the topic of paraplegia. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Stone remov al Several Renaissance painters have painted scenes where attempts are made, often by medical charlatans or itinerant quacks, to apparently surgically remove stones from the heads of people with mental disorders through making superficial incisions and palming stones. There are two schools of thought on this subject: some regard these paintings as allegory for human idiocy and gullibility, whilst others think them to be an actual medical procedure prevalent at that time. Perhaps the basis for this perception could have been the occasional postmortem finding of a calcified frontal lobe meningioma as the cause of apparent madness, although there is no solid evidence for this theory. Fig. 11, ‘The Cure of Folly’ or ‘Stone Operation’ by Hieronymus Bosch (c. 1450–1515) is one of the first of such paintings. The translation of the inscription reads ‘Master, dig out the stones of folly, my name is castrated dachshund’, where ‘castrated dachshund’ was a nickname for a person lacking common sense. There are many symbolisms in this painting. The doctor wearing a funnel (symbolic of deceit or false alchemist) performs the operation and removes a tulip lying on the table, instead of a stone. The tulip traditionally carried the connotation of folly. The closed book balanced on the head of the nun, overlooking the operation adds to the sense of ‘stupidity’ of human affairs.45,46 This theme has been repeated in many paintings including ‘The Extraction of the Stone of Madness’ (1556–1557) by Pieter Bruegel the Elder, ‘The Extraction of the Stone’ (1650–1655) by J an Steen, and ‘A Q uack D rawing Stones from the Head of a Patient’ (17th century), attributed to J an de Bray (1627–1697). Concl usion Here, we have attempted to explore the complex relationship that exists between art and neuroscience, and to show how these two apparently distinct

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