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Rheumatology 2004;43:803–805
Advance Access publication 15 August 2003
doi:10.1093/rheumatology/keg474
Heberden Historical Series/Series Editor: M. Jayson
Art and history: a large research avenue for
rheumatologists
T. Appelboom
The historical analysis of rheumatology basically developed
around gout and rheumatoid arthritis (RA), mainly because
until the nineteenth century, all rheumatic conditions were called
gout (this blanket term also included diseases that had nothing
to do with gout) and because the question mark over the late
appearance of RA in the Old World is a topic currently the subject
of debate [1–4].
These rheumatic conditions and spondylarthritis have affected
emperors, kings, politicians, religious leaders and artists, among
others [5]; they probably contributed to the fall of the Roman
Empire [6], to epidemics of gout in the well-to-do of the British
Empire since the sixteenth century [2], and to American
independence [7]. These so-called epidemics of gout are explained
by the Roman custom during antiquity of preparing food and
wine in receptacles made of lead, which caused lead poisoning
and gout [6] and by the Navigation Act (1659) passed by the
English Parliament to combat commercial competition by the
Dutch fleet. This banned the importation of French wines, a
cargo not carried by the British, in favour of Spanish and
Portuguese wines, in particular port, which was particularly rich
in lead [7, 8]. This may explain the large number of people
suffering from gout seen in caricatures of the time and also the
attack of gout that prevented the Prime Minister William Pitt
(1708–1778) from attending Parliament for the vote on taxing tea
originating in the New World [7, 8]. If these attacks of gout had
not happened, perhaps the face of the world would have been
different? A gallery of people suffering from gout is found not
only in England [2] but also in France, where it is said that 20 of
the 34 kings (Capet, Valois and Bourbons) suffered from gout
[9]. Moreover, easy chairs and footwear were specially made to
help sufferers [10].
But rheumatic conditions have had repercussions other than
political as they have influenced artistic output. The rheumatoid
arthritis that struck Peter Paul Rubens (1577–1639) probably had
an impact on his creativity up to a point, since he seems to have
represented the evolving course of his rheumatism with its
swellings and deformities, on some of his canvasses [11]. Dufy also
suffered from rheumatoid arthritis and was one of the first to be
treated with cortisone; did he not call cortisone one of the most
colourful of his canvasses [12]?
The scleroderma of Paul Klee offers an explanation for the
changes of theme (more sombre), form (distinctly more contracted)
and colour (much more sombre, drawing on black and brown) of
his canvasses at the end of his life [13].
In the domain of literature, several writers and dramatists have
also been affected by their rheumatic conditions, which they have
made the theme of their works, or the suffering or its treatment
have influenced the style or the content [14]. A popular legend has
it that the goddess Podagre (Gout) was born through the seduction
of Aphrodite by Dionysos (the Greek god of wine); the Iliad
reports that the Trojan Anchises began to limp after having been
struck by a thunderbolt from Zeus [1, 15]. Erasme of Rotterdam
(1466–1536), the great writer and European humanist of the
Renaissance, probably suffered from spondylarthritis; he often
refers to his rheumatism in his correspondence [16]. Paul Scarron
(1610–1660), considered to be the initiator of the burlesque style,
was severely affected by a spondylarthritic condition that affected
the peripheral joints and was probably complicated by iritis. He
chose to deride his health and his suffering; even in his epitaph, he
poked fun at the swollen joints that tormented him [14, 17]. Arthur
Conan Doyle wrote about non-arthritic gout in the journal The
Lancet with the same minutiae of observation as his hero Sherlock
Holmes [18].
From its origins in arguments of greater or lesser relevance, the
historical analysis of rheumatology is gradually advancing to more
or less well-founded and convincing hypotheses. The processes are
in the majority of cases based on a scientific approach since we can
very often proceed with the reasoning of the clinician and compare
findings with those of experts from other disciplines; this has
resulted in conclusions that could not have been imagined at
earlier times. Tackling the problem in a multidisciplinary mode,
the lack of available information and the possibility of calling on
sophisticated techniques link the approach of doctors with that of
police officers.
There is a multiplicity of source documents: ancient texts,
chronicles, papyrus, the Bible, correspondence, plays and old
medical books that bear analysis not only under the doctor’s
microscope but also from the perspective of the historian. This
approach enables us to reconstruct a medical history after the
event, the first step towards the diagnosis. For example, an
analysis of the genealogy of the Medicis, Florentine art patrons of
the fifteenth to seventeenth century, has enabled us to investigate
a series of rheumatics that includes Cosimo, Piero the Gouty
and Lorenzo the Magnificent. It is interesting to record that the
majority are male members of the family and that Cosimo is
represented by Pontormo in one of his paintings as having a stiff
neck. This supports the hypothesis that rheumatism may not be
the same as gout—the term used to denote all forms of rheumatic
conditions until the nineteenth century—but spondylarthritis,
which has been confirmed by the radiographic analysis of
exhumed skeletons [19]. Another example shows how reading
passages from the Bible about Moses (who seems to have suffered
from rheumatism) correlates with an examination of radiographs
taken of the vertebral column of Ramses 2, who is thus shown to
have had ankylosing spondylitis. This provides an additional
argument in support of Freud, who claimed that Moses was of
Egyptian origin [20].
The physical examination is the second stage of a diagnosis. It is
sometimes possible to suspect rheumatic deformities when certain
drawings, sketches, designs or paintings are examined, but the
analysis and the conclusions must be made with extreme prudence
to avoid the trap of the purely stylistic representation [11]. The
curved position of the wrist and the partially flexed fingers on
Botticelli’s tableaux may not be interpreted as rheumatic
deformities but are purely stylistic [21]. Nevertheless the more
realistic style of the Flemish Primitives of the sixteenth and
seventeenth century permits a cautious medical interpretation;
several of these artists have represented swollen and/or deformed
Division of Rheumatology, Erasmus University Hospital, 808 route de lennik, B-1070 Brussels, Belgium. E-mail: [email protected]
803
Rheumatology Vol. 43 No. 6 ß British Society for Rheumatology 2003; all rights reserved
804
T. Appelboom
FIG. 1. Suffering is expressed by this Jalisco personage (West
Mexico, –300 þ200) with a lesion of his right tibia; possibly
osteomyelitis, a fracture or a tumour.
joints suggesting that they were aware of patients suffering from
polyarthritis [22].
Although rheumatoid arthritis may be a condition that
appeared recently in the Old World (the first description of it
dates back to the end of the eighteenth century), it probably existed
in America before that. It may have been imported by the sailors of
Christopher Columbus and, in these conditions, the ports of the
Spanish Netherlands (including those of the present-day Belgian
Flanders) could have been a way in; this might explain why the
Flemish were among the first to depict the disease. Caution is
nevertheless essential to avoid medical over-interpretation for
hands that are only pure realizations of style.
Realistic sculpture (Figs 1 and 2) may also be a source of
information: on an Egyptian bas relief from Armana, the blind
harpist is elderly and wasted; his face is emaciated and the
temporal artery is prominent; what is to say he was not suffering
from temporal arteritis [23]?
As in modern medicine, medical imaging also has a place. The
three-dimensional CT scan of a Peruvian mummy seen by Hergé
during a visit to the Royal Museum of Art and Historical Analysis
in Brussels, that he later named Rascar Capac in the Tintin
cartoon The Temple of the Sun, revealed an abnormality of the
lumbosacral joint with reactional sacroiliac arthritis [24]. On the
other hand, nuclear magnetic resonance imaging has not yet found
its place in the analysis of human remains because they usually no
longer contain any water.
Autopsy is an approach that can be applied to the investigation
of traces of rheumatic conditions in the past. This brings in
historical epidemiology [25, 26]; thus the visual examination of
bones has enabled traces of symmetrical erosive peripheral polyarthritis to be discovered in indigenous people from Alabama
whose remains are more than 3500 years old [27]. Other techniques,
such as genetic analyses [28], have also found their place.
In conclusion, the historical investigation of rheumatology is
multifaceted and has a bright future; in addition to its primary
mission which is to honour its pioneers, it makes a posteriori
diagnoses, leads to historical epidemiology and tackles the
particularly pertinent question ‘will rheumatoid arthritis disappear?’ [29]. This question is raised because some rheumatic
FIG. 2. An angular kyphosis suggestive of Pott’s disease is
represented on this Djenné terracotta (Mali 1400–1700).
conditions have disappeared or their characteristics have changed,
others have appeared recently. It could bring up to date obsolete
or forgotten therapeutic approaches, explain some behaviour and
turning points in the course of historical analysis affected by
factors other than war. If the approach is rigorous, it may be
able to claim its rightful place in the development of the
rheumatology of tomorrow. This is more than a challenge, it is its
objective!.
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