Dva portreta Celestina Medovića kao polazište u razmatranju mogućnosti dijagnosticiranja obostrane blefaroptoze

Denis Čerimagić, Ervina Bilić

Cilj: Autori prikazuju dva medicinski zanimljiva portreta poznatoga hrvatskog slikara Mata Celestina Medovića, s ciljem rasprave o mogućnostima dijagnosticiranja obostrane blefaroptoze prikazanih osoba. Materijal i metode: Portreti su analizirani u skladu s postulatima ikonodijagnostike. S diferencijalno-dijagnostičkog aspekta prikazani su hipotetski uzroci stečene, obostrane blefaroptoze. Također je analiziran prikaz ovog kliničkog znaka na djelima poznatih europskih slikara 14. – 20. stoljeća te hrvatskih slikara 19. – 20. stoljeća. Rezultati: Mogući uzrok ptoze na Portretu starice mogao bi biti aponeurotski, uzrokovan atrofijom mišića gornje vjeđe. Ne može se sa sigurnošću isključiti niti okularni oblik miastenije gravis. Mogući uzrok blefaroptoze na Portretu Konavoke je miastenija gravis s pozitivnim antitijelima na mišić-specifičnu tirozin kinazu, s obzirom na evidentnu atrofiju lijevog m. massetera. U oba slučaja može se raditi i o miogenoj blefaroptozi uzrokovanoj okularnom miopatijom ili okulofaringelanom mišićnom distrofijom. Ostali mogući uzroci blefaroptoze kod portretiranih žena isključeni su s većom ili manjom sigurnošću. Analogno principima medicine temeljene na dokazima, zaključci ikonodijagnostičke analize klasificiraju se u skupine: A (gotovo sigurno), B (vjerojatno), C (nesigurno), D (nevjerojatno) i E (nemoguće). Zaključak prikazane analize pripadao bi skupini B, što znači da su naša zapažanja „vjerojatno točna“, uzevši u obzir da se ista temelje isključivo na kliničkim zapažanjima, bez uvida u povijesne okolnosti ili dokumente koji bi to mogli potvrditi. Komparativnom analizom prisutnosti kliničkog znaka ptoze na djelima poznatih europskih slikara od 14. do 20. stoljeća isti smo detektirali na ukupno jedanaest slika. Na djelima hrvatskih majstora 19. i 20. stoljeća ptoza je detektirana na četiri slike i jednoj brončanoj bisti. Zaključak: Ovaj rad nas podsjeća na važnost poznavanja kliničke propedeutike, nasuprot danas prevladavajućem medicinsko-tehnološkom pristupu koji favorizira brojne, često nepotrebne procedure u procesu postavljanja dijagnoze. Možda tzv. „muzejske vizite“, s ciljem poboljšanja sposobnosti uočavanja kliničkih znakova na umjetničkim slikama od strane studenata medicine, jednom postanu i dio nastavnog programa na hrvatskim sveučilištima.

Aim: The authors present two medically interesting portraits of the famous Croatian painter Celestin Medović, with the aim of discussing the possibilities of diagnosing bilateral blepharoptosis. Material and methods: The portraits were analyzed in accordance with the postulates of iconodiagnosis. Hypothetical causes of acquired bilateral blepharoptosis are presented from the differential-diagnostic aspect. The presence of this clinical sign was also analyzed in the works of famous European painters from the 14th to the 20th centuries and Croatian painters of the 19th and 20th centuries. Results. Ptosis in “Portrait of an Old Woman” could be aponeurotic, caused by atrophy of the muscles of the upper eyelid. The ocular form of myasthenia gravis cannot be ruled out with certainty either. Muscle-specific tyrosine kinase myasthenia gravis is a possible cause of ptosis in “Portrait of a Lady from Konavle,” especially because of the left masseter muscle atrophy. Ocular myopathy or oculopharyngeal muscle dystrophy can also be a reason for bilateral blepharoptosis in both cases. Other possible causes of blepharoptosis in the portrayed women are excluded with greater or lesser certainty. Analogous to the principles of evidence-based medicine, the conclusions of the iconodiagnostic analysis are classified into four groups: A (almost certain), B (probable), C (uncertain), D (improbable), and E (impossible). The conclusion of the presented analysis
would belong to group B, which means that our observations are “probably correct,” considering that they are based solely on clinical observations without insight into historical circumstances or documents that could confirm this. Through a comparative analysis of the presence of the clinical sign of ptosis in the works of famous European painters from the 14th to the 20th centuries, we found the same in a total of 11 paintings. In the works of Croatian painters of the 19th and 20th centuries, ptosis was detected in four paintings and one bronze bust. Conclusion: This paper reminds us of the importance of knowing clinical propaedeutics, in contrast to the medicaltechnological approach prevailing today, which favors numerous, often unnecessary, procedures in the process of establishing a diagnosis. Maybe the so-called “museum visits” with the aim of improving the ability of medical students to observe clinical signs on art paintings will become part of the curriculum at Croatian universities.