THE LANCET Medicine and art The art of visual neglect Peter W Halligan, John C Marshall To draw, paint, and sculpt in a “realistic” style requires paintings showed fluctuating left visual neglect and loss of the integration of a wide range of complex visuospatial depth. A French painter, after his stroke, continued to and visuomotor skills, to say nothing of whatever more produce elegant line drawings, but characterised by purely aesthetic capacities the artist must possess. These neglect of the left of the sheet and some neglect of the left technical skills reflect the side of figures across the picture cooperation of several highly space.3 Otto Dix (1891–1969), specialised areas of the brain. Lovis Corinth (1858–1925), The anterior left hemisphere and Anton Räderscheidt cortex is implicated in the (1892–1970) all had right planning of limb and eye hemisphere strokes. In a movements. The occipital and drawing that Dix made 4 days temporal cortex is concerned after his stroke, there was a with the perception of form and clear neglect, but his later depth. Parietal areas of the right drawings and lithographs, hemisphere are particularly though freer than before, involved in the perception of showed no impairment. space and the control of Räderscheidt and Corinth made movement in space. Damage to slower recoveries, which can be any of these areas would traced through their work compromise most kinds of completed after stroke.4 There graphic endeavour. is also one report of right One of the most common and neglect after left hemisphere disruptive impairments of visuoneoplasm in a right-handed spatial processes is unilateral painter.5 neglect. The condition, found in We here describe the case of over 80% of patients with acute a well-known English artist right hemisphere stroke, is whose left neglect after stroke characterised by failure to initially impaired both his attend or respond to objects drawing and his painting, as in left space and is associated reported in previous studies. with poor functional recovery. We also show how neglect can The impairment is found in affect the ability to sculpt. free vision and can occur in Clinical presentation patients without visual field This 75-year-old painter and deficits.1 Although the number of sculptor had a right hemisphere relevant studies is small, it is stroke in August, 1989. The known that a life-long devotion symptoms included a mild to the production of graphic art sensory-motor weakness of the provides little or no protection left leg and arm, left lower against the abrupt curtailment quadrantanopsia, and left visual of the ability to attend to objects Figure 1: Sculpture done before (top) and after neglect. 8 years before the in left space, or to the left side of (bottom) the artist’s stroke stroke, he lost the use of his objects throughout the visual right (dominant) hand in a field. For example, Schnider and colleagues2 describe a farming accident. Despite the loss of his right hand, he Swiss artist who experienced visual illusions and transferred his artistic skills to his left hand and continued hallucinations during the first few days after right to exhibit and sell his paintings and sculptures in many hemisphere stroke. Subsequently, his drawings and galleries throughout the world. In the 6 months after his stroke, the patient became Lancet 1997; 350: 139–40 increasingly frustrated with his sculptures and drawings, despite good physical recovery of the capacities of his left Neuropsychology Unit, University Department of Clinical Neurology, Radcliffe Infirmary, Woodstock Road, Oxford OX2 6HE, UK hand. His family noted that his drawings were poorly (P W Halligan PhD, J C Marshall PhD) constructed and less elaborate than the work he did before his stroke. They also observed that he concentrated Correspondence to: Dr P W Halligan Vol 350 • July 12th, 1997 139 THE LANCET Figure 2: Drawing made after the artist’s stroke on the right side of his drawings and sculptures. In addition to this neglect of the left, some of his sculptures and drawings showed distorted, exaggerated, or deformed figures. Neuropsychological examination, in May, 1990, showed no evidence of aphasia, apraxia, anosognosia, or significant memory loss. On the behavioural inattention test,6 he scored 125/146, indicative of visuospatial neglect. On the star cancellation test,6 he missed seven stars, all located on the left side of the page. On line bisection (279 mm lines⫻ten trials) his mean score of ⫹10 mm (SD 12·5) was outside normal limits.7 Neglect was also obvious in everyday life, in which he would occasionally ignore people or objects on his left side and not eat food on the left side of the plate. The art The top part of figure 1 shows the high degree of artistic skill that the artist acquired with his left non-dominant hand before the stroke. By contrast, the clay sculpture (figure, bottom) done 3–4 months after his stroke is clumsily modelled and poorly proportioned. More 140 pertinently (and despite a full range of head and eye movements), he was unable to bring the left side of the face to even the minimum degree of completion that he had achieved on the right. In this model of a woman’s head, one can make out the nose, mouth, and right side of the face, including hair and right eye. The left side, however, is distorted and incomplete, even though the sculpture was made on a turntable. The artist could (and did) turn both the sculpture and himself around it but could no longer integrate multiple views into the coherent three-dimensional wholes that he had so successfully created before his stroke. In the drawing made after the stroke (figure 2), most of the face and upper torso on the left is missing, whereas the ear and part of the lower arm on that side of the picture are included. The chair’s back (on the left) is omitted, as is the left side of the man’s shoes and ankles. The drawing exhibits both space-based and object-based neglect8 and is remarkably vibrant in its mix of detail and suggestion. Although the obvious impairments cleared up within a year, residual traces of neglect were still discernible in much of the artist’s subsequent drawing and painting until his death in August, 1994. In most cases so far studied (including our own), the artists seem eventually to have integrated their neglect into the overall structure of their pictures. Their later works are thus sketchy, but not obviously the product of brain damage. By contrast, in sculpture our artist never regained his former fluency and he continued to feel thwarted by his incapacity to make the medium obey his will. We thank the artist’s wife and family for all their help and hospitality. Our work is supported by the Medical Research Council and the Stroke Association. References 1 2 3 4 5 6 7 8 Robertson IH, Marshall JC, eds. Unilateral neglect: clinical and experimental studies. Hove: Lawrence Erlbaum, 1993. Schnider A, Regard M, Benson F, Landis T. Effects of a righthemisphere stroke on an artist’s performance. Neuropsychiatry, Neuropsychol Behav Neurol 1993; 6: 249–55. Vigouroux RA, Bonnefoi B, Khalil R. Réalisations picturales chez un artiste peintre présentant une héminégligence gauche. Rev Neurol (Paris) 1990; 146: 665–70. Jung R. Neuropsychologie und Neurophysiologie des Kontur- und Formsehens in Zeichinerie und Malerei. In: Wieck HH, ed. Psychopathologie musischer Gestaltungen. Stuttgart: FK Schattauer, 1974: 27–88. Marsh GG, Philwin B. Unilateral neglect and constructional apraxia in a right-handed artist with a left posterior lesion. Cortex 1987; 23: 149–55. Halligan PW, Cockburn JC, Wilson BA. The behavioural assessment of visual neglect. Neuropsych Rehab 1991; 1: 5–32. Halligan PW, Marshall JC. The bisection of horizontal and radial lines: a case study of normal controls and ten patients with left visuospatial neglect. Int J Neurosci 1993; 70: 149–67. Marshall JC, Halligan PW. Visuo-spatial neglect: a new copying test to assess perceptual parsing. J Neurol 1993; 240: 37–40. Vol 350 • July 12th, 1997