The Babinski sign in Renaissance paintings: the fallacy of mis-framed observationsBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n574 (Published 04 March 2021) Cite this as: BMJ 2021;372:n574
All rapid responses
We would like to thank Brian Hurwitz for his interesting response to our article on the Babinski sign in Renaissance paintings (1,2). He proposes that the extension of the big toe that we often observe in paintings of the Christ Child is not in fact a Babinski sign.
We agree that the interpretation of paintings is a difficult exercise and is open to debate. As an example, both an unremarkable yawn and an unnatural posture have been previously misinterpreted as dystonia, whereas they can in fact be attributed to a mannerist artistic style (3,4).
In the case of our study of the Babinski sign in Renaissance paintings, Hurwitz implies that the inconsistent presence of stimulation of the sole means that the dorsiflexed toes cannot be attributed to a reflex phenomenon. However, the absence of visible stimulation in some of the paintings only confirms the composite nature of these artistic works. Dynamic elements, such as the stimulation of the sole may be missing in the final rendering.
Hurwitz states that “babies under 12 months of age frequently dorsiflex great toes spontaneously”. This assertion is unsubstantiated: spontaneous extension of the big toe is never mentioned in dedicated studies in children (5,6). Additionally, we rarely observe isolated extensions of the big toe in children in practice, unless after sole stimulation. We suspect that Hurwitz is thinking of the fanning of the toes, which is more frequently spontaneous.
We are in agreement with Hurwitz that "the appearance of this postural motif in
Renaissance religious paintings shows that artists of the time were attentive when observing infants", and that this does "not [prove] that they observed plantar reflexes centuries before neurologists". In fact, the painters' lack of understanding of the phenomenon could also explain why they did not find it necessary to include the stimulus in their paintings.
Interestingly, Hurwitz also suggests a religious explanation for the dorsiflexed toes, proposing that the artist’s intention is to “call attention to the religious significance of feet in the Scriptures”. This is something of an "act of faith". No one will be able to prove him wrong, but there are much simpler explanations that are easier to prove.
1. Sellal F, Tatu L. The Babinski sign in Renaissance paintings-a reappraisal of the toe phenomenon in representations of the Christ Child: observational analysis. BMJ. 2020 Dec 10;371:m4556. doi: 10.1136/bmj.m4556.
2. Hurwitz B. The Babinski sign in Renaissance paintings : the fallacy of mis-framed observations. BMJ2021;372 :n574.
3. Sellal F, Frismand S. Cervico-facial dystonia as depicted in sculpture before its scientific description. Rev Neurol (Paris) 2019 ;175 :198-200.
4. Charlier P, Lippi D, Perciaccante A, Appenzeller O, Bianucci R. Neurological disorder? No, Mannerism. Lancet Neurol 2019;18:135. doi:10.1016/S1474-4422(18)30447-2 pmid: 30663602
5. van Gijn J. The Babinski sign: the first hundred years. J Neurol. 1996 Oct;243(10):675-83. doi: 10.1007/BF00873972
6. Gingold MK, Margaret EJ, Bodensteiner JB, Romano JT, Hammond MT. The rise and fall of the plantar response in infancy. J Pediatr 1998 ; 133; 4:568-70.
Competing interests: No competing interests