Psychiatry

This week's grand rounds will focus on the world of art! Some of history's greatest artistic achievements came at the price of terrible psychiatric illnesses, and in our reverence for these works we tend to romanticize the plight of the artists. However, there was little romance in it for them, so let's take this opportunity to examine the personal hardships they went through. As psychiatric diseases are fairly simple to identify on paper, see if you can name the artist along with the disease.

1. In the world of ballet, the names Mikhail Baryshnikov and Rudolf Nureyev are ubiquitous, but there was one male dancer who is said to have towered above both as the greatest of all time. In the early 1900s he toured the world with the Ballet Russes, and became a worldwide phenomenon owing to his gravity-defying leaps, inspired technique, and intense eroticism. However, problems arose due to "sexual and moral issues," and only a few years after his debut he disappeared from the stage and spent the rest of his life in and out of mental institutions. His psychiatrist noted his "marked lack of social interest... wholly disillusioned and hopeless" and his "irrational imagination." He would also sit silent and motionless for long stretches of time, occasionally "breaking off into a friendly laugh." He died in 1950, and is buried in the famous Montmartre Cemetery in Paris.

2. Known as a introverted, impersonal man throughout his life, this artist became more and more troubled as he grew older. He became so unsatisfied with his work that he began burning his drawings and attacking his own statues. His neighbors said he would wake up in the middle of the night, go down to his workshop and stare at unfinished works for hours with a candle stuck in his hat, unable to finish them because of his disgust at their mistakes. Before he died he said he regretted ever becoming an artist. In one of his pantings he included a figure that encapsulated what he felt throughout his life:

An artist who was a contemporary of his included a "psychiatric" portrait of him in one of his larger paintings (also note the severe gout):

3. This musician, if he were diagnosed today, would probably qualify for three or four different disorders. He experienced repeated episodes of hypomania, waking up at 6am and composing nonstop until 2am, and wrote letters that seemed incoherent and inappropriate, but there were other periods where he would procrastinate endlessly and waste his time with billiards or other solitary activities. In the final years of his life, he was reported to have felt a "pervasive sadness" and disinterest in composing, which included a loss of energy and excessive feelings of guilt. His personality was also quite strange. He had a constant need for attention and nurturing even as an adult, a lingering emptiness, a tendency to throw away money, and a constantly fluctuating and impulsive mood. Many fellow composers including Tchaikovsky, Chopin, Wager, Schubert, and Brahms considered this man the greatest musical genius of all time.

 

He was also easily distracted, and did little doodles while composing


4. In her lifetime she was best known for her volatile affaire with French sculptor Auguste Rodin, but she is now regarded as an inspired sculptor in her own right. Part of the reason she is not so well recognized is that she ended up destroying many of her statues. At the age of 41 she began showing signs of mental illness, she had intense paranoia, violent outbursts, and accused Rodin of leading a conspiracy to kill her and steal her ideas. Eight years later she was involuntarily committed to a psychiatric hospital in the outskirts of Paris. Despite reports from doctors that her condition improved when she resumed her work, her family insisted that she remain in treatment. She died in 1943, having lived 30 years in an asylum. 

 

The Mature Age, Musee d'Orsay

5. This painter's work is divided into two categories, the first "is characterized by joy and light, the second by horror and ghosts." It is believed that a strange illness took place between the two. In 1792 he became extremely ill and suffered severe depression together with hallucinations, delirium, and weight loss. He also had a wide range of physical symptoms including tinnitus, headaches, dizziness, right arm paresis, and hearing loss. While a wide range of pathologies have been proposed, including Meniere's disease, lead poisoning, syphilis, and mercurial encephalopathy, none can explain the full extent of his symptomatology. What is one thing we have learned about that may have contributed to his physical symptoms?

Yard with Lunatics, painted during the onset of his illness




ANSWERS (highlight to see):
1. Vaslav Nijinski, schizophrenia with "negative symptoms" and automatisms (catatonic)
2. Michelangelo, major depressive disorder. Paintings: Sistine Chapel and The School of Athens (by Raphael)
3. http://www.youtube.com/watch?v=k1-TrAvp_xs bipolar/cyclothymia, major depressive disorder, or borderline personality disorder
4. Camille Claudel, schizophrenia
5. Francisco De Goya, Conversion Disorder?

Have a nice winter break everybody! Hope to see you next semester for some compelling historical cases of leukemia, asthma, diabetes, hypogonadism, bowel issues, etc.

-Michael 

Cardiology (Ancient Egypt Edition)

Hello friends. Early humans saw that all life depended on the continuous pulsing of the heart, and therefore assigned the most fundamental elements of life to this organ. To the Egyptians, the heart was the seat of all love, thought, and emotion, and was necessary to keep the body and soul together after death, which is why the heart is the only organ we find intact in ancient mummies. Yet the Egyptians were far more than a bunch of ancient mystics. The Ebers Papyrus, a compendium of Egyptian medical knowledge from 1500BC, spends a great deal of time explaining some very real diseases of the heart, so let's take a look and see what we can decipher...


The Weighing of the Heart: A measure of worth in the afterlife

1. There is a warning in the papyrus: "If thou examinest a man for illness in his cardia and he has pains in his left arm, and in his breast and in one side of his cardia, it is death threatening him." The phenomenon of angina leading to left arm pain was well known, and it inspired them to name the left fourth finger the "heart finger" (Romans later had the idea to wear rings on it to symbolize marriage). Since atherosclerosis was a lot less common back then, can you name a cause of angina pectoris that is not due to coronary artery plaques?


A page from the Ebers Papyrus

2. They also described certain disorders of the cardiac conduction system: "When the heart is diseased, its work is imperfectly performed: the vessels proceeding from the heart become inactive, so that you cannot feel them … if the heart trembles, has little power and sinks, the disease is advanced and death is near." What do you think they are describing?

3. The scroll includes descriptions of over 700 medications. Most sound like nonsense, but perhaps a few of them had some benefit. If the heart was "weak due to old age" or suffered from "heart dancing", they would prescribe the bulb of the squill plant, which we now know contains a kind of natural glycoside. What variant of this chemical do we use today for these same problems and what does it do?


Squill Plant

4. The Egyptians were also familiar with aneurisms (for which it was advised "to treat it with a knife and burn it with a fire so that it bleeds not too much") as well as other anomalies of the great vessels. However, one modern study identified a mummy with a finding that the Egyptians likely did not diagnose (they never conducted autopsies). A scan showed its ribs having irregular notches along their edges. Which vessel abnormality would explain this?


Interdisciplinary Research

5. One last excerpt: A "Debility that has arisen in the heart... its arching out as far as the borders of the lung and liver. It happens there from to him that his vessels become deaf, having fallen down as a result of their heat.” Which chronic problem could they be describing? Hint: Egyptians were not foreign to alcohol consumption.


ANSWERS (highlight to see):
1. Coronary vessel spasm (Prinzmetal's angina or Cardiac syndrome X)
2. Likely ventricular tachycardia (no pulse, heart trembles)
3. Digitalis, it slows the beats per minute (gets rid of the dancing) and increases the force of each beat (reduces the weakness)
4. Coarctation of the aorta
5. Dilated cardiomyopathy (for one)

Dermatology (Guest Contributions Edition)

Dear friends,

It gives me great pleasure to present a very special "Guest Contributions Edition" of the Historical Grand Rounds. There is no higher mark of friendship than lending time and enthusiasm to another's interests, and I'd like to sincerely thank those who took part. I hope you find each other's cases as interesting and inspiring as I did.

1. George Washington, by Jason

We start at the beginning. Our beloved American patriarch, George Washington, is best known as the first United States President, the president of Constitutional Convention in 1787, and the commander-in-chief of the Continental Army during the American Revolution. Unfortunately, all of the time he spent outdoors fighting the British would have made for a dermatologist’s nightmare, especially given Washington’s pale complexion. Check out the following portrait by William Joseph Williams for the Alexandria Masonic Lodge number 22. The portrait was completed in 1794, during Washington’s second term as President. Do you notice anything on his right cheek? How about next to his right ear?



Fortunately, Washington had access to the best medical care 18th Century America had to offer. Washington wrote a testimonial letter on behalf of Dr. James Tate on February 25, 1795 in which he might have been referring to this lesion:“I have, myself, experienced the fruits of his skill, in this art; being cured by him of an irritable spot on my right cheek which had for years been increasing in pricking and disagreeable sensations; and in June last assumed the decided character of a Cancer; of which I was perfectly relieved by Doctor. Tate in about two months by an easy course, under the operation of which I felt no confinement, or other inconvenience at that time, nor any injury to my constitution since.” Further sources indicate that Washington was treated with the repeated application of a cream or paste. Based on these clues, what is the most likely diagnosis?

2. Rembrandt van Rijn, by Ruyan

Rembrandt van Rijn is considered one of the greatest painters and etchers in Dutch history and well known for his masterful contributions to European Art. His work paved the way for the Dutch Golden Age with innovative and creative pieces that moved away from the Baroque style of the past. Rembrandt achieved great success as a young painter and was respected and popular throughout his life. His ability to portray the human condition with empathy and sincerity marked him as “one of the great prophets of civilization.” His self-portraits are considered to be among his greatest artistic triumphs, offering raw and unadulterated insight into his life. He portrayed himself without vanity, including features such as an enlarged nose, visible blood vessels, and pimples in many areas of his face. In some paintings he depicted several papular lesions, a telangiectatic lesion under his right eye, and a bulbous nose. These signs indicate the presence of an inflammatory dermatosis – which one?


Rembrandt van Rijn (1606-1669)

3. Viktor Yushchenko, by Abraham (old friend of Michael's)

 The political situation of Ukraine in the past decade has created a deeply divided society. One particular incident was the illness of presidential candidate Viktor Yushchenko. After having a rowdy night eating sushi and drinking plenty during a political meeting, Yushchenko's face began to grow a very serious amounts of acne and pockmarks.  Skin colour turned a gluey, greenish-yellow. One eye was partly paralyzed and everything in his face looks swollen. His back ached, his stomach hurt. After a few days of these symptoms he checked himself in to a prestigious clinic in Austria where doctors suggested his symptoms were due to severe pancreatitis due to viral infection. A few doctors worldwide suspected a very different illness that reminded them of patients in a few isolated incidents in italy, and victims and veterans of the vietnam war. What is the likely cause of Yushchenko's deformity?


He's since mostly recovered from the Kafkaesque appearance and illness but his face remains largely scarred.

4. Remus Lupin, by Roberta

Professor Remus John Lupin of the Hogwarts School of Witchcraft and Wizardry secretly sought treatment from Professor Severus Snape for a medical condition. The primary manifestation of Professor Lupin’s disease was hypertrichosis. In addition, Professor Lupin demonstrated a biphasic anagen phase with his hair growing at the normal rate of half an inch each month until the last day of the month when his hair growth rate skyrocketed and his main symptom of hypertrichosis was most apparent. This acceleration in hair growth rate was followed by an accelerated telogen phase, so Professor Lupin’s symptom of hypertrichosis resolved by the first day of the month each month.  What disease did Professor Lupin suffer from, and what mythological creature was he mistaken for in the Harry Potter series?

 
Professor Snape made a potion to treat Professor Lupin from the pictured flower, aconitum (wolfsbane).

5. Paul Klee, by Monica (Michael's mom)

Paul Klee (December 18, 1879-June 29, 1940) was a painter born in Switzerland. The son of a music teacher, he was a talented violinist growing up. As a teenager, his attention turned from music to the visual arts. His style was influenced by expressionism, cubism, surrealism and orientalism, and his signature technique including drawing with a needle on a blackened pane of glass. Klee also experimented with and eventually got deep into color theory. Ad Parnassum is widely considered to be his masterpiece.

Klee was plagued by stomach problems and suffered from weight loss and hardening of the skin, as well as difficulty swallowing and incontinence. His doctors failed to diagnose his true condition, and he was misdiagnosed in 1935 with bronchitis and measles. He was bedridden until 1936, when he resumed painting on a limited basis. He died in June 1940 from cardiac paralysis. He once wrote, “Everything vanishes around me, and works are born as if out of the void. Ripe, graphic fruits fall off. My hand has become the obedient instrument of a remote will.” What was his diagnosis?


Ad Parnassum, by Paul Klee

6. Madame X, by Marissa

Painted in 1884, John Singer Sargent's portrait of Madame X caused a great stir when it was first displayed in a Paris Salon. The portrait is of Virginie Amélie Avegno Gautreau, a socialite born in New Orleans who moved to Paris with her mother and sister after her father died in the Civil War. Her revealing dress and prominent décolletage were perhaps the most provocative features of the painting. Her pale translucent almost bluish-purple tinged skin was considered the epitome of a beautiful complexion in that day.  It is rumored that she ingested small wafers containing this substance (let's  call it substance X) in order to achieve her fair complexion. Exposure to substance X can cause Mee's Lines in the nails. Exposure to substance X can also cause Basal Cell Carcinoma. Other common etiologies of Basal Cell Carcnioma include UV exposure, X rays and scars/chronic inflammation.


Madame X, by John Singer Sargent

7. Salif Keita, by Alex

Salif Keita is a world-famous musician who is said to be a descendant of the founder of the Malian empire, Sundiata Keita, who lived in the 13th century. Although he was born into wealth and status, he was disowned by his family because of this instantly noticeable skin disorder, which is said to be an omen of bad luck in Madinke culture. He eventually fled Mali, taking his group Les Ambassadeurs with him, and eventually moved to Paris. He went on to work with musicians from all over the world, including renowned jazz saxophonist Wayne Shorter and Carlos Santana. Who knows what would have become of Keita if he had not been disowned, though, as one Wikipedia editor pointed out, because of the Malian caste system, “he should never have become a singer, which was deemed to be a griot’s role.” In 2009, he dedicated his album La difference to fellow sufferers of this condition. What kind of deficiency most likely caused his skin disorder?



8. Jean-Paul Marat, by Michael

When Napoleon said "vanity made the revolution; liberty was only a pretext," perhaps he was referring to the man featured in our final case. Jean-Paul Marat was a Swiss physician who in 1789, set his sights to the world of political journalism in favor of France's new revolutionary government. With his self-stylized title of "Friend of the People", he became one of the most vocal supporters of the bloodshed that came to define Robespierre's Reign of Terror, and his daily newspaper columns encapsulted the odd combination of savagery, fraternity, and enlightenment that defined the revolution. Interestingly, most of his political musings were written as he lay in an oatmeal bath, which he used for three years to help treat a severe and debilitating skin condition. The condition started in his late 40s and originated in the anogenital area. It was extremely itchy and at times purulent and blistering, and was sometimes accompanied by headaches, insomnia, polydipsia, and "paranoia". It spread to his entire body, and certainly did not do any favors for a man already considered to be ferociously ugly. Some doctors thought syphilis, other eczema, but a more recent diagnosis based on the late-onset and chronicity lead to speculation that Marat may have also had a certain gastrointestinal disease. What could it be? 

As you would expect, Marat's fiery public persona earned him a few enemies, and in 1793 a young woman named Charlotte Corday stabbed him as he lay in his bath. The event would be immortalized by Marat's friend and fellow revolutionary Jacques-Louis David in one of the most famous propaganda paintings of all time:


The Death of Marat, by Jacques-Louis David


Answers (highlight to see):
1. Actinic Keratosis that underwent acute solar degeneration, possibly to squamous cell carcinoma in situ (Bowen’s disease).
2. Rosacea
3. Chloracne from digoxin poisoning
4. Porphyria, Werewolf
5. Scleroderma
6. Arsenic
7. tyrosinase (albinism)
8. Dermatitis herpetiformis (goes with celiac disease)