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Doubts about Sandro Botticelli's depiction of juvenile rheumatoid arthritis.

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LETTERS
1197
It is difficult to judge at the present time whether the
artist shaped the locks of hair according to the hand configuration or vice versa. Perhaps it was just an artistic coincidence! In view of the findings at the other joints, it is more
likely that the artist depicted the hand deformities first and
that the person who served as the model for the goddess
Venus was suffering from rheumatoid arthritis.
The left hand, ankle, and configuration of the feet
shown in Figure 2 are also not fully normal. The fifth finger is
crooked; the index finger, as compared with the other
fingers, is marked by a sausage-like swelling, while the wrist
shows a possible modulation in radial flexion. Despite the
danger of overinterpretation, one can also observe a swelling
of the ankles and forefeet, with swollen right toes in flexion
contracture.
At any rate, it is amusing to observe the paintings of
great masters and discover traces of rheumatoid arthritis in
the past (4).
J. Dequeker, MD, PhD, FRCP
University of I-rrtven
Pellenbrrg, Belgirrm
I . Alarc6n-Segovia D, Laff6n A, Alcocer-Varela J: Probable depiction of juvenile arthritis by Sandro Botticelli. Arthritis Rheum
26:1266-1268. 1983
2. Dequeker J: Arthritis in Flemish painting4 (l400-l7OO).Br Med J
1:1203-1205, 1977
3. Dequeker J: Polymyalgia rheumatica with temporal arteritis as
painted by Jan Van Eyck in 1436. Can Med Assoc J 124:15971598, 1981
4. Boyle JA, Buchanan WW: Clinical Rheumatology. Oxford, England, Blackwell Scientific Publications, 1971, p 74
Doubts about Sandro Botticelli’s depiction of juvenile
rheumatoid arthritis
To the Editor:
In the October 1983 issue of Arthritis and Rheumatism, Alarcon-Segovia and coworkers revive the old debate
about whether Sandro Botticelli’s painting “Portrait of a
Youth” shows hand deformities of chronic arthritis (1).
Doubts about this interpretation have been expressed by
several authors (2,3). Alarcon-Segovia et a1 suggest that the
swelling of the proximal interphalangeal (PIP) joints of the
youth’s right hand cannot be attributed to a stylistic trait.
Experts have claimed an opposite view, e.g., several of the
hands in Botticelli’s painting “uniformly have this appearance and thus represent an artistic convention rather than
the diagnosis of a disease” ( 2 ) . This is easily accepted by a
layman after studying monographs about Botticelli (4,5).
Changes similar to those in the right hand of the youth are
found in famous paintings such as “iMadonna with Child”
(the infant’s right hand), “The Spring” (the left hand of the
man with the sword), and “The Birth of Venus” (her right
hand). Still another example is given in Figure 1. Note that
Figure 1. “Madonna with Child, San Giovannino and Six Angels”
(detail) by Sandro Botticelli, c. 1490. Painting on wood. (Reproduced with permission of The Borghese Gallery, Rome. Italy.)
the changes under discussion are always located in the PIP
joints-there is no example of metacarpophalangeal joint
abnormality.
As stated by Alarcon-Segovia et al, credit for the first
report of juvenile rheumatoid arthritis is usually given to the
Frenchman, V. Cornil. This is inaccurate, however, Cornil’s
paper pointed out that systemic changes in skin, chest
organs, and urinary tract were sometimes found in patients
with “le rhumatisme chronique” (6).The article is based on
detailed case reports. In case 4 (a 29-year-old woman who
died at Salp6triore with cardiopulmonary insufficiency) it is
mentioned in passing that the joint disease started when she
was 12 years old. This is not further commented on, no
conclusion is drawn, and it is apparent that Cornil only saw
the patient during the final stages of her disease.
In my opinion, it was the famous Frenchman, JeanMartin Charcot (1825-1893) (Figure 2) who first reported
juvenile rheumatoid arthritis. In his thesis, published in
1853, in a passage discussing age at onset of rheumatoid
arthritis (RA), he mentions 4 patients who fell ill before the
age of 20 (7). In another work, he discusses 3 children with
“rhumatisme articulaire chronique progressif” who fell ill at
4, 10, and 16 years of age (8). Undoubtedly, it was from
Charcot’s work that Alfred Garrod (1819-1907) became
aware of the presence of chronic arthritis in children; hence
in his third edition of The Nature and Treatment of Gout and
1198
Figure 2. J-M Charcot depicted on a stamp issued by France in
1960. On the right is Salp&triore.
he took the opportunity to report and depict 2 cases of his
own (9), and probably published the first pictures of chronic
arthritis in a child (Figure 3). However, it should be mentioned that William Heberden had already described a joint
disease ( 3 t n o doubt rheumatoid arthritis-although initially, deceptively benign compared with gout and acute rheumatism, “but in its consequences, it is much more formidable than either of them” (10). “In some it has begun at the
age of twelve years; in others not till they were past sixty”
(10).
Finally, pertaining to the question of whether rheumatoid arthritis is a new diseasc, passages in the classic
works of Hippocrates, Aretaios, Scribonius Largus, and
Soranos from Ephesus suggest the existence of a chronic,
deforming joint disease (3,ll). However, as stated by Alar-
Figure 3. Chronic arthritis in a child, depicted by Garrod, 1876.
LETTERS
c6n-Segovia et al, the question can only b e settled by studies
of skeletal remains from antiquity or medieval times.
Convincing archaeologic evidence has not yet been
presented. Probably a coordinated effort involving anthropologists, osteologists, and physicians will be necessary to
reach a definite answer. Recently tentative and promising
trials using this approach have been published and, as
expected, changes have been found which suggest chronic
erosive arthritis in multiple peripheral joints, small as well as
large (12,13).
In conclusion, evidence has been presented by several authors that a chronic deforming polyarthritis of RA-type
has existed as a human disease since ancient times. It seems
doubtful, however, that Botticelli’s paintings can be used in
support of this idea.
Ido Leden, MD
Central Hospital
Kristianstad, Sweden
1. Alarc6n-Segovia D, Laffh A, Alcocer-Varela J: Probable de-
piction of juvenile arthritis by Sandro Botticelli. Arthritis
Rheum 26:1266--1268, 1983
2. Short C: ’The antiquity of rheumatoid arthritis. Arthritis Rheum
17:193-205, 1974
3. Leden I: Ledgingsreumatism och gikt-en historisk iterblick.
(Rheumatoid arthritis and gout-a historical review). Sydsv
Med Hist Sallsk (South Swedish Society of Medical History)
18165-97, 1981
4. Argan CG: Sandro Botticelli. Lausanne, A Skira color studio,
1957
5. Fabbri F: I Maestri del Colore. Translated to Swedish by
Adlerberth R-Konstens mastare i farg, no 7, Botticelli. Orebro, IPC 1967
6. Cornil V: MCmoire sur les coincidences pathologiques du rhumatisme articulaire chronique. C R SOCBiol (Paris) 3:3-25, 1864
7. Charcot J-M: Etudes pour servir a I’histoire de I’aEection
dCcrite sous les noms de gouttc asthknique primitive, nodosites
des jointures, rhumatisrne articulaire chronique (forme primitive), etc. (thesis). Paris, 1853. p 38
8. Charcot J-M: Lecons Cliniques sur les Maladies de Vieillards el
les Maladies Chroniques. Paris, P. Asselin, 1866, pp 223-224
9. Garrod AB: A treatise on gout and rheumatic gout (rheumatoid
arthritis). London, Longmans, Green & Co, 1876, pp 501-515
10. Heberden W: Commentaries on the history and cure of diseases. London, T Payne, 1803, p 500
1 1 . Copeman WSC: A short history of gout. Los Angeles, Universit y of California Press, 1964, pp 21-37
12. Rogers J, Watt J , Dieppe P: Arthritis in Saxon and medieval
skeletons. Br Med J 283:1668-1670, 1981
13. Englund S: StenAldersboplatsen vid Fridtorp. The Central
Board of National Antiquities and the National Historical
museums. RAGU 1:106-108, 1982
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