An angel with Down syndrome in a sixteenth century Flemish Nativity painting.

Artistic representation of malformation syndromes has been of ongoing interest, often as a point of departure for discussion of medical history. We have identified a 16th-century Flemish Nativity painting in which one angelic figure appears distinctly different from other individuals in the painting with an appearance of Down syndrome. Several prior observers have identified Down syndrome in premodern art, sometimes stimulating ongoing discussions concerning its history, its prevalence, and its relationship to hypothyroidism. This may be one of the earliest European representations of Down syndrome. The depiction of an individual with Down syndrome as an angel raises several questions regarding the status of such an individual in late medieval times and societal recognition of minor anomalies, as contrasted with major malformations, in their predictive value for disabilities. In contrast, Langdon Down's description of the condition occurred only after evolution of concepts regarding the clinical significance of physical appearance and measurement. Copyright 2003 Wiley-Liss, Inc.