Depression, physical illness, and the faces of Rembrandt
Authors: Carlos H Espinel
Journal: The Lancet (1999)

Rembrandt by Himself The first exhibition ever of Rembrandt's self-portraits. Showing at the National Gallery, London, until Sept 5, 1999, and at the Mauritshuis, The Hague, the Netherlands, from Sept 25, 1999, to Jan 9, 2000. I have been following Rembrandt for years (see Lancet 1997; 350: 1835–37). Since biographical documents are scarce, I have studied his works that are on exhibit worldwide. In this quest, there is much a physician can learn. Rembrandt was a shrewd, meticulous observer, a master teacher of the expression of mood. Now, London's National Gallery presents the largest exhibition of Rembrandt's self-portraits ever staged. In the Glasgow portrait (1632), Rembrandt is only 26 years old. His skin is fair, smooth, healthy, with a touch of pink on his cheeks. His eyebrows curve evenly. He opens his eyes wide, freely. His brilliant eyes reflect the light—there is a white dot, a spark in his right eye. His nose is in proportion. Neither the nasolabial grooves nor the buccolabial grooves can be seen. His mouth is closed. He merely contracts the lateral and superior modiolar muscles, retracting the corners of his mouth, puckering his lips, as if about to speak. Rembrandt dresses like a member of the Dutch gentry. He enjoys talent, health; nothing seems to be in his way. He seems ready to challenge time itself. In the London portrait of 1640, Rembrandt is 34 years old. By now he might believe he has overcome time, achieved immortality with his work. His eyes shine. There are no grooves. His facial muscles are at rest. He dresses lavishly—in silks, velvet, fur—but he turns his face and underneath his haughty pose one discovers distressing signs. He has gained some weight. A slight crease bridges his eyebrows. Three lines cross his forehead; two others lie underneath his right eye. Note, however, that these lines do not contribute to his expression. They are wrinkles, showing prematurely for his age. Why? With his self-portraits, Rembrandt left a trail of masterpieces. No two are the same. In each, Rembrandt tells us a different story. Deception or truth? Is he battling with his own moods? Let us see what he tells us next. The Edinburgh portrait is startling. It was painted in 1659, so Rembrandt must be 53 years old. Time has passed quickly. But what has it done to him? His face is covered with wrinkles. His skin is thick in places, thin in others. Rembrandt has changed his art, as if to describe his reality. In places he uses multiple layers of paint, in others he leaves the canvas bare. I follow each brush stroke. Red pointed dabs trace the temporal vessel on the right. Crimson smudges spot his cheeks. Ruddy impastos thicken his nose. Rembrandt looks ill. He also seems sad. He glances at you from over his shoulder. There is no spark in his eyes. The nasolabial groove is obvious, wide. He contracts the depressor labii inferioris and anguli oris muscles, bringing down the corners of his mouth, in a grimace. I believe that Rembrandt may also have had clinical depression. His portraits reveal it. Sometimes slouching, his weight fluctuating, his muscles tense, in his last years his sadness was morbid, sustained—all signs that point to this diagnosis. By 1659, he had lost family, fortune, and contracts; he survived in vexing poverty. There are no records of his symptoms or habits. But in his work one wonders about his preference for dark colours and the portrayal of bleak moods in his subjects. Rembrandt would withdraw, go months without working, and at the end he became dependent on others—all behaviours suggestive of depression. The Washington portrait is well known to me. Now, a deep black crevice splits his eyebrows. His dermachalasis has been complicated with brow and eyelid ptosis. But Rembrandt has made a decision. He wants to establish contact with us, face us straight on. And the price is high, for to over-come the effect of his illness he has to overcontract the muscles of his forehead, deepening his wrinkles. The spark has returned to his eyes. But notice the ominous sign—a white arc in his left eye, denser than the normal reflection of light, suggests arcus senilis, cholesterol deposits. The creamy impastos underneath his eyes suggest xanthelasma, high triglycerides. I have counted nine blotches of rosacea on his face. His nose is bulbous with rhino-phyma. Diagnosing Rembrandt demands knowledge of his technique. His images change with the distance and with the angle at which they are observed. One has to scrutinise each brush stroke. With stabbing strokes he has created the winding path of the left temporal vessel. In its depths he has left the canvas bare, its grey priming exposed. So the vessel appears tortuous, discoloured, suggestive of temporal arteri-tis—a disease that does not necessarily progress to blindness, that in every patient has its own course. But there is another clue. Come close, observe. A dab of a dingy brown pigment outlines a lump, like a nodule at the vessel's root Sorrow clings to Rembrandt. The nasolabial groove cuts deep at a sharp angle with his nose. And the contraction of the depressor and modiolar muscles draws the skin, in yet another wrinkle that hacks a deep verticle furrow down his mouth, retracting his chin, as if in pain. Rembrandt reveals his illnesses. With brush strokes he calls us in, summons our compassion. And what an experience it is. Notice that in the other portraits Rembrandt places the light on the right. But in the Washington portrait he puts it directly on his forehead, on his left temporal artery, as if to say: "Look at me. See what is happening to me." Examining a face is venturing into the depths of the human condition—a daily journey for a physician. Please go and see Rembrandt by Himself. Let his brush strokes guide you, and give yourself time.