220 • Jan Dequeker 



Discussion 



Since the publication of my first findings in the British Medi- 

 cal Journal in 1977, and more extensively in Organorama in 

 1979, two further papers on rheumatoid arthritis in art have 

 been published. 



Appclboom and associates (1981) described a peculiar 

 tendency of Peter Paul Rubens (1577- 1640) to paint appar- 

 ent swelling of the wrists and deformities of the hands, and it 

 has been suggested that either he or his second wife, Helena 

 Fourment. or both, may have had rheumatoid arthritis. In- 

 deed, biographical information on Rubens suggests that he 

 suffered from rheumatism. In his abundant correspondence, 

 the term "gout" is used to define the recurrent pains and 

 swellings afllicting his hands and feet. 



Alarcon-Segovia and associates (1983) pointed out that 

 the "Portrait of a Youth," painted in 1483 by the Florentine 

 artist Sandro Botticelli, has features of rheumatoid arthritis in 

 the hand of the subject, who would be young enough to be 

 considered as having juvenile arthritis. This painting has also 

 been discussed by Short (1974) as a possible example of a 

 rheumatoid arthritis hand, although he admits that it also 

 could be an artistic convention or stylistic trait, since Bot- 

 ticelli's hands often have this appearance. When painting an 

 extended hand Botticelli, like many other painters of the 

 Renaissance, placed both middle fingers together and the 

 second and fifth apart, as if to relieve the monotony the 

 fingers would create if all were spread. A bent fifth finger is 

 often encountered not only in Botticelli's paintings but also in 

 the paintings of Rogier van der Weyden and many others. 



In another painting by Botticelli, "The Birth of Venus," 1 

 recently described swelling of the proximal interphalangeal 

 joints and a sausagelike swelling of the left index finger 

 (Dequeker 1984). Is it significant that the fingers of the right 

 hand point in the same direction as the drifting hairlocks? 



An interesting anecdote is that the model for Venus was a 

 well-known individual, namely the 16-year-old Simonetta 

 Vespucci, girlfriend of Giuliano di Piero, brother of Lorenzo 

 il Magnifico. Simonetta died a few years later from tuber- 

 culosis (Alarcon-Segovia 1985). 



It is obvious that caution is called for in drawing medical 

 conclusions from paintings and engravings. This is particu- 

 larly the case when the hands are taken as the basis, for hands 

 are often used by painters as a means of expression for feel- 

 ings and sometimes as the hallmark of a particular school of 

 painting. For example, it is striking to note that many fingers 

 in the canvases of Rogier van der Weyden show very fine 

 long fingers, often with a clinodactylic deformation of the 

 little finger. 



It is also well known that most of the figures in El Greco's 

 paintings show a picture of Marfan's syndrome. The abnor- 

 malities described in this article are of a different nature. 

 They are not the consequence of a style, except perhaps for 

 the hands in the painting by Jan Gossacrt; these could point to 

 an expression of a mannerism typical of this artist. Similar 



deformations of the hands can be seen in a portrait of a 

 woman in the Rijksmuseum in Amsterdam and in that of the 

 man with the garland of roses in the National Gallery in 

 London. Both of these works are ascribed to Jan Gossaert. 



Probably a rheumatologist sees more in the pictures of 

 cripples than another doctor or a layman because of the 

 knowledge he has acquired in daily practice. What we do not 

 know, we do not see. Although none of the deformations and 

 swellings of the joints which have been found constitute 

 irrefutable examples of rheumatoid arthritis, they neverthe- 

 less give grounds for a strong suspicion that polyarthritis 

 occurred so frequently in the Middle Ages that it must have 

 caught the attention of the masters, and this at a period in 

 which infectious diseases such as leprosy and tuberculosis 

 dominated pathology in every field. Arthritis was recognized 

 in all sections of the population, among rich and poor, and 

 men and women alike. 



Ten out of 24 paintings, described in full elsewhere, in 

 which arthritic lesions were recognized, represent donors or 

 well-known personalities of whom a "portrait" was made 

 (Dequeker 1987). This supports the idea that in fact these 

 individuals might have been suffering from rheumatic dis- 

 eases. Almost all of these paintings were in the time of the 

 Flemish realistic school infiuence, introduced by Jan Van 

 Eyck. Since scrupulous recording like this of wrinkles, 

 veins, warts, stubble on the chin, and congenital malforma- 

 tions are typical for 15th- 16th century Flemish art, the 

 rheumatoid-like hand deformities cannot be ascribed to 

 carelessness, incompetence, or mannerism of the painters. 



It is thanks to the realism of the Flemish, Dutch and Italian 

 schools of the late Gothic era that we can recognize these 

 deformities. During the Renaissance and the Baroque the 

 figures were so idealized and perfected that signs of disease 

 are seldom recognizable in the works of these periods. Al- 

 though the paintings in those earlier days were generally 

 commissioned by patrons who also figured in them, the 

 painters did not always spare their benefactors, as we saw in 

 Jan Gossaert's and Van Heemskerck's paintings, and in the 

 portraits of Federico da Montefeltro, Michelangelo, Canon 

 Van der Paele, Jordan's Servant, Gambetti, Aegidius, Eras- 

 mus, and Vespucci. 



These descriptions and pictures do not, of course, provide 

 any scientific proof that rheumatoid arthritis and associated 

 systemic disorders occurred frequently in the Middle Ages. 

 But the argument that rheumatoid arthritis does not occur in 

 old paintings equally does not provide scientific proof for the 

 assertion that rheumatoid arthritis is a recent or modem dis- 

 ease. The main reason why they were not noted historically is 

 that the mean lifespan was too short for a sufficient number of 

 cases to develop and be recognized as examples of a specific 

 disease. Rheumatoid arthritis was rare becau.sc age expecta- 

 tion was low, and potential sufferers died before contracting 

 the disease. There is already evidence that this is a reason for 

 the low prevalence of rheumatoid arthritis in underdeveloped 

 countries. In contrast, ankylosing spondylitis is historically 



Zxif^reh Paleopathoto^y S\mp I9HS 



