The diagnosis of art: Albrecht Dürer and the Christ Child's drooped shoulder
Authors: Manoj Ramachandran, Jeffrey K Aronson
Journal: Journal of the Royal Society of Medicine (2008)

Albrecht Durer (1471-1528) was perhaps the greatest exponent of the Northern European Renaissance, known for his painting, printmaking and engraving, and his books on perspective and anatomy. The son of a goldsmith, Durer was trained as a metalworker at a young age and applied the meticulous methods that he learned to his woodcuts and engravings, notably the Four Horsemen of his Apocalypse series (1498), and his Knight, Death and the Devil (1513). Following two visits to Venice, in 1494/1495 and 1505/1507, he became acquainted with Giovanni Bellini, whose influence is evident in the Madonna and Child (Figure 1). The athleticism of the Christ Child, the Virgin's pyramidal form, the sculpture-like modelling of the figures, and the contrast of Mary's dark blue robes against red drapes all recall Bellini's treatment of the same subject. Further analysis reveals the complexity of the panel's composition. The Madonna and Child adopts Netherlandish concepts of devotional images in portraying the corner of a room with a window open on a distant view. Jesus' squirming posture and the attention to surfaces and textures are typically German. The coat of arms in the lower left corner is that of the wealthy Nuremberg mercantile family of Haller von Hallerstein, patrons and friends of the artist.1



Figure 1

Madonna and Child C. 1496/1499; oil on panel, 52.4 × 42.2 cm; Samuel H Kress Collection, National Gallery of Art, Washington, DC, USA [In colour online.]





In the painting, the Christ Child holds his apple in exactly the same position as Eve holds hers in Durer's engraving of Adam and Eve (Figure 2), implying that this is the forbidden fruit that brought disaster on humanity, which he has been born to redeem.2



Figure 2

Adam and Eve 1504; engraving, 25.2 × 19.4 cm, Staatliche Kunsthalle, Karlsruhe, Germany [In colour online.]



There are alternative medical explanations for the abnormal posture. For example, the infant depicted in this painting may have suffered from Erb's palsy (a form of neonatal brachial plexopathy), the left upper limb being held in the typical ‘waiter's tip’ posture.3,4 There is internal rotation and pronation of the left upper limb with accentuation of the skin folds of the anterior axillary region, along with drooping of the left shoulder.

Although Erb's palsy is a possibility, further differential diagnoses for this abnormal posture are worth entertaining, including amyoplasia congenita, anterior horn cell lesions, hereditary brachial plexus neuropathy and pseudoparalysis. Amyoplasia congenita, a form of arthrogryposis, is characterized by bilateral upper limb involvement along with congenital contractures and micro-gnathia. Central nervous system lesions of the anterior horn cells, such as congenital spinal atrophy and congenital varicella syndrome, present with generalized hypotonia, in contrast to the more common presentation of unilateral weakness or paralysis seen in brachial plexus injuries. Congenital varicella is also differentiated by the presence of skin scarring and finger amputations. Hereditary paediatric brachial plexus neuropathy is an autosomal dominant disorder that presents with shoulder and arm weakness, pain and atrophy. It is differentiated from brachial plexus injuries by its episodic nature and its tendency to present after the neonatal period, most often in the teenage years.





Pseudoparalysis from a fractured clavicle or humerus causes limited movement, because of pain, and clinically can look like a neonatal brachial plexopathy. Indeed, on closer inspection of the painting (Figure 3), there is a lump (visible as a dark shadow) arising from the left clavicle of the child just above the Madonna's left thumb, consistent with a clavicular fracture. Pseudoparesis is therefore the most likely diagnosis for the abnormal left upper limb posture seen in the painting, although clavicular fractures can co-exist with neonatal brachial plexopathies in about 10% of neonates.5



Figure 3

Detail from Madonna and Child [In colour online.]



On the whole, however, we prefer the metaphorical interpretation.