Jacques-Louis David's Tumour, An Opportunity to Study the Natural History of a Pleomorphic

8/13/2019 Jacques-Louis David's Tumour, An Opportunity to Study the Natural History of a Pleomorphic

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Jacques-Louis Davids tumour: an

opportunity to study the natural

history of a pleomorphic

adenoma of the parotid glandHumphrey Wine1 + Michael Baum2

1 National Gallery, London, French 17th and 18th century

2 University College London Division of Surgery, 2 Cotman Close, London NW11 6PT, UK

Correspondence to: Michael Baum. E-mail: [email protected]

Summary

The great artist and one-time revolutionary, Jacques-Louis David died in

1825.The cause of his death has been open to speculation. An extraordinary

sequence of portraits of the artist describes his transition from handsomemiddle age to a deformed old man. During this phase a swelling appears at

the angle of his left jaw and over a period of 20 years a facial palsy can be

diagnosed. We submit that this evidence suggests that malignant

transformation of a pleomorphic adenoma of the parotid gland was the

proximal cause of his death.

The life and times of

Jacques-Louis David

Soon after the celebrated painter and one timeregicide, Jacques-Louis David, died on 29 De-cember 1825 at the age of 77, a Dr Chalupt carriedout an autopsy and concluded that death hadoccurred from hypertrophia of the heart.1 The

previous summer his breathing had been re-ported as beginning to be laboured and his mo-rale a little weakened:

. il a un commencement dasthme et le moraleun peu affaibli

(Cavaignac in a letter to Drolling).1 By the autumn

of 1825 he claimed to feel stronger than ever andwas painting,1but in November a visitor to David

reported that he was experiencing a continualchoking sensation which disabled him from walk-ing leading to a suspicion of a heart aneurism:

.Il prouve un touffement continuel qui nelui permet pas mme de marcher et faitprsumer un anurisme du coeur.

(Talma in a letter to Ducis the date of which,however, is not certainly November of 1825),1

and by the end of that month he had lost the useof his drawing hand.1 On 19 December David

managed to go to the theatre,1 but then became

more ill and in his final illness was conscious onlyintermittently.1

This relatively peaceful end belied an eventful,even stressful, life in which after early struggles he

had successively claimed moral then actual leader-

ship of the French School, taken a leading part in

the most radically republican phase of the FrenchRevolution, been twice imprisoned, and became

Napoleons painter before going into exile in Brus-sels in 1816 soon after the restoration of the French

monarchy. It was above all Davids political in-

volvement during the Revolution as a supporter of

figures such as Robespierre and Marat, and as onewho had voted for the execution of Louis XVI,

which earned him the undying enmity of monar-

chists and constitutionalists on both sides of theChannel. This enmity seems to have influenced a

number of disparaging remarks about his physiog-

nomy. Thus in July 1792 Le journal 2 liards,directed by the royalist Pouteau, wrote:

I have seen this David so dumb, so mean look-ing, and so truly tagged with the seal of con-

demnation. No one is more hideous nor more

diabolically ugly. If he is not hung, you shouldnot believe in physiognomy.1

When the author Walter Scott visited Paris in1815 he is said to have thought that Davids physi-

ognomy was the most hideous he had ever seen,

and his disgust was not lessened by knowledge

that he had just met the painter

of the blood-stained brush.2

DECLARATIONS

Competing interests

None declared

Funding

None

Ethical approval

Not applicable

Guarantor

MB

Contributorship

Both authors

contributed equally

Acknowledgements

None

ESSAY

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Scott and Pouteau were both referring to amarked swelling of Davids left cheek. This seemsto have been apparent by 17841785 when the Eng-

lish gem-engraver, Nathaniel Marchant,3 metDavid in Rome and some 12 years later com-mented to the artist Farington:

One side of his face is much larger than theother and appears as if swelled

Marchant's reference to David's wife, whom hehad married in 1782, in another part of the diaryentry cited makes it clear that he met David duringthe latter's second stay in Rome in 17841785, andnot during the artist's first stay in 17751780.4

By the time Marchant met David the latter was

no more than 37 years old. According to the artistsgrandson, himself reporting what Davids chil-

dren had told him, the cause of the swelling was a

badly cared for sword wound to the upper jawsuffered by the artist when he was about 25. Thisapparently led to

an exostosis which never stopped growing andadded to his speech defect.5

Although Farington in 1802 described Davidsright cheek as much swelled,6 extant portraits ofthe artist show that it was his left cheek which was

affected if they show the swelling at all. That theswelling was on the left side is most apparent in aposthumous maquette of c. 1826 (Figure 1) pre-paratory to a marble bust portrait by Franois

Rude (17941855) made in 1831 and now in theLouvre,7,8 and in a portrait by one of Davids pu-

pils, Jrme-Martin Langlois (17791838), signedand inscribed as having been made in the year ofDavids death.

That the swelling was on the left side is alsoclear from a print made by Jean-Pierre-Marie Jazet

(17881871) in 1822 after a drawing of the same orprevious year by a former pupil Joseph Odevaere(17751830).8

Unfortunately no certain portrait of David as a

young man exists so, save in respect of Marchantstestimony, it is impossible to say how early theswelling on his cheek became apparent. The earli-est known portraits of David show him in profile,

or virtual profile, from the right (so indirectly con-firming the probability that his features were dis-torted on the left). Among these is a profile portrait

by Jean-Baptiste Wicar (17621834) made in 1788

after a lost portrait by another pupil of David,Anne-Louis Girodet de Roucy-Trioson (17671824), itself perhaps made around 1786.9 The sameapplies to another drawn portrait made by Jean-

Baptiste Isabey (17671855) in 1789. Davids self-portraits of 1791 and 1794 are mirror images andshow the artists left cheek in shadow, not thatDavid was ever likely to feature what was said to

be his nickname, namely grosse joue.10 At allevents by 1812 or 1813 when Davids trusted as-sistant, Georges Rouget, made a portrait of themaster, the swollen cheek was evidently becoming

impossible to ignore.11

It was the art historian, Jacques Wilhelm, whoin 1960 first mentioned that Davids swollen cheekmight have a cause other than a poorly cared for

wound.5 In an article on portraits of DavidWilhelm published Dr Ledoux-Lebards sugges-tion that the swelling was more likely the result ofa mixed slowly evolving tumour of the parotid

gland,12

and this explanation has been generallyaccepted ever since.

Figure 1Franois Rude, 17941855, a portrait of Jacques-Louis David, c.

1826 Terracotta maquette 22.5cm high. Daniel Katz Ltd., UK

Journal of the Royal Society of Medicine

J R Soc Med 2008:101:583586. DOI 10.1258/jrsm.2008.080221584


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Swellings of the parotid gland

The parotid gland overlies the angle of the jaweach side of the face and is the most important

of the four major salivary glands (the othertwo being the submandibular glands). Allmedical students are taught that a swellingoverlying the angle of the mandible arisesfrom the parotid gland until proved other-wise. The parotid gland drains through itsduct into the mouth just alongside the secondmolar tooth. Perhaps the commonest swellingof the parotid occurs in childhood as acuteviral parotitis or mumps. Next in frequencyis an impacted salivary stone that leads to asudden painful swelling in this area aggra-

vated by the smell or taste of food. Any swell-ing in the parotid area that is painless andslow growing is almost always a pleomorphicadenoma or mixed parotid tumour.13 The pa-rotid gland consists of a superficial and a deeplobe separated by the facial nerve that splitsinto five filaments like branches around anisthmus that joins the two lobes. The facialnerve supplies the muscles of facial expres-sion. Fortunately for the surgeon the majorityof mixed parotid tumours occur in the super-ficial lobe allowing for their removal withoutdamaging the facial nerve. The consequencesof damaging even one branch of the facialnerve can produce hideous changes known asfacial nerve palsy. This appearance may occurspontaneously from an acute viral infectionknown as Bells palsy. Mixed parotid tu-mours grow slowly and are quite benign butare usually removed at an early stage so it isdifficult nowadays to understand their natu-ral history. The portraits of David allow us arare opportunity to study how the conditionprogressed in the days before surgery mighthave been considered. Over a 30- or 40-year

period we can see the slow growth of theswelling on the left side of the cheek.

However something dramatic appears to hap-pen after about 20 years when Davids physiog-nomy changes as the ugly drooping of the lip and

flaccidity of the left side of the face gradually devel-ops. These are the characteristic signs of a facial

palsy. Mixed parotid tumours are benign and there-fore cannot infiltrate or compress the facial nerve.However in about 10% of neglected cases malignant

transformation can occur (adeno-carcinoma) lead-ing to facial nerve palsy (Figure 2).14

It was claimed that Davids disfigurement wasas a result of a badly treated sword wound. This is

highly unlikely as the facial palsy would have beeninstant had the facial nerve been transacted not ofgradual onset over a number of years.

It was also claimed that Davids autopsyshowed death from hypertrophia of the heart.However this has no modern clinical meaning as acause of death. For example, left ventricularhypertrophy might be as a result of uncontrolledhypertension; whereas right ventricular hypertro-

phy might result from chronic lung disease. If the

unchecked growth of a parotid cancer slowly oc-cluded his airways then a state of chronic hypoxiawould have developed that in itself might lead tohypertrophy of both sides of the heart as it at-tempted to compensate for the diminished flow ofoxygen by increasing the pump rate to exhaustion.

We can therefore reasonably claim that Jacques-Louis David died as a consequence of the unchecked

spread of adeno-carcinoma of the parotid gland.

References

1 Wildenstein D, Wildenstein G.Documents complmentaires

au catalogue de loeuvre de Louis David. Paris: WildensteinFoundation; 1973

Figure 2An elderly man with a malignant parotid

tumour. Note drooping of the corner of the

mouth from infiltration of the buccal branch of

the facial nerve

Jacques-Louis Davids tumour

J R Soc Med 2008:101:583586. DOI 10.1258/jrsm.2008.080221 585


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2 Lockhart JG.The Life of Sir Walter Scott. Abridged from thelarger work by JG Lockhart with a prefatory letter by JR HopeScott.Edinburgh: Adam and Charles Black; 1871

3 Seidman G. Nathaniel Marchant, Gem Engraver17391816. Walpole Society1987;53:1105

4 Garlick K, Macintyre Y, Cave K, ed. In: (eds)The Diary ofJoseph Farington.Volume 2 of 16. New Haven, CT: YaleUniversity Press; 197884, p. 650

5 Jules David JL.Le Peintre Louis David 17481825. 1880, p. 86 Garlick K, Macintyre Y, Cave K, ed. In: (eds)The Diary of

Joseph Farington.Volume 5 of 16. New Haven, CT: YaleUniversity Press; 1978-84, p. 1898

7 Portraits publics portraits privs 17701830.ExhibitionParis, London, New York 20062007, cat. 127 (entry byGuilhem Scherf) for the Louvre bust. Thanks to TomassoBrothers for information on the maquette

8 Bordes P.Jacques-Louis David Empire to Exile. ExhibitionLos Angeles and Williamstown 2005, cat. 57 and p.331 forthe Louvre bust

9 Bellenger S.Girodet (17671824).Exhibition Paris,Chicago, New York, Montreal 20052007, cat.3

10 Montjoie F-L.Histoire de la Conjuration de MaximilienRobespierre.Paris; 1796, p. 2012

11 Eitner L.French Paintings of the Nineteenth Century. Part I:Before Impressionism.Washington, DC: National Gallery ofArt; 2000, p. 3303

12 Wilhelm J. David et ses portraits.Art de France1964:16013 Banerjee AK, Ubhi CS, Pegg CA. Diagnostic approaches to

parotid swellings.Br J Hosp Med1994;51:5162114 Spiro RH. Salivary neoplasms: overview of a 35-year

experience with 2,807 patients. Head Neck Surg1986;8:17784

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Jacques-Louis David's Tumour, An Opportunity to Study the Natural History of a Pleomorphic

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