Familial Hypercholesterolemia, Tendinous Xanthomas, and Frans Hals

To the Editor.—  Although the molecular mechanisms underlying familial hypercholesterolemia have only recently been described,¹ Frans Hals, the 17th-century Dutch painter, was probably the first to observe the tendinous xanthomas that accompany the clinical disorder. In the December 9, 1988, issue of JAMA, the painting on the cover, Portrait of an Elderly Lady, shows the classic tendinous lesions on the dorsum of the hands of a 60-year-old woman who probably had heterozygous familial hypercholesterolemia.² There is no evidence in the painting that she had xanthelasma as well. Although the clinical diagnosis was not made by Dr Southgate, and the woman's fingers were described as "gnarled and swollen," the cause of the lesions seems clear.Hypercholesterolemia is a common abnormality in the Netherlands, although it is mostly on a polygenic and/or dietary basis. Heterozygous familial hypercholesterolemia occurs in only 1 per 500 people, while the homozygous form is much more