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Jacques-Louis David is regarded as one of France's most recognized painters, who's most famous work—the Death of Marat (1793)—has been subject to medical review, as it was well-known that Marat suffered from an exasperating chronic skin condition.1
It is interesting to note, however, that David's life-story and self-portrait also reveal an underlying pathology, that to date has not received attention in the medical literature. In his youth, David suffered from a deep left peri-oral sword wound after a fencing incident, whereupon he subsequently lost his left nasolabial groove while his left cheek gradually swelled.2 As a result, he found it difficult to make left-sided facial movements, particularly those around his left mouth, which led to a noticeable asymmetry during facial expression. Furthermore, eating or speaking in public became strenuous, which, when added to a longstanding speech impediment whereby he could not pronounce some consonants (such as ‘r’), made him highly and understandably self-conscious. Biographers and art historians over the centuries have defined this post-traumatic pathology as a ‘benign tumour’ or ‘exostosis’.2
Looking at David's self-portrait (Figure 1A), it becomes clear that a discernible scar representing the rapier wound is visible at the left labiomarginal sulcus (painted on the right side in the image as it was based on a mirror's reflection), extending for a short distance laterally into the midface. Anatomically, this corresponds to a path taken by some of the buccal branches of the facial nerve, which have an inconstant origin and variable course from the parotid gland, passing horizontally to a distribution below the orbit, to the nose and mouth. Those branches ending close to the labiomarginal sulcus include the deep lower branches that supply buccinator, orbicularis oris and joint filaments of the buccal branch of the mandibular nerve.3 Furthermore, in view of some of the complex routes taken by the buccal branches of the facial nerve, a number of the divisions that supply the lip elevators and small nasal muscles may also correspond to this area of trauma. This therefore could explain David's facial affliction as a result of a likely injury to the buccal branch of the facial nerve, resulting in the difficulties with left facial movement and the associated loss of the left nasolabial groove. Other differentials include facial asymmetry as a result of a lesion centrally or more proximally in the course of the facial nerve.
The subsequent description of a facial ‘growth’ following traumatic injury may therefore be ascribable to recognized complications of midface soft tissue injury, which could include either a post-traumatic rapier wound, a foreign body granuloma,4 or even a post-traumatic neuroma.5 These could have caused the artist significant anxiety regarding self-image, and thus (being a shrewd propagandist), he is reputed to have diminished the extent of his disfigurement from his own self-portrait. This only becomes conspicuously evident when one studies sculptures of Jacques-Louis David produced during his lifetime by other artists, who would have probably presented his facial characteristics with more objectivity (Figure 1B).