Hypothesis: Rubens—one of the first victims of an epidemic of rheumatoid arthritis that started in the 16th–17th century?

Series Editor: M. I. V. Jayson

T. Appelboom

Erasmus Hospital, University of Brussels, 808 route de Lennik, B-1070 Brussels, Belgium. E-mail: tappelbo{at}ulb.ac.be

On 6 December 1630, the Antwerp-born artist Paul Rubens (1577–1640), the master of European baroque painting and a creator of genius, took as his second wife the young and pretty Hélène Fourment, aged 16; he loved her and her ravishing beauty was his inspiration. The last 10 yr of his life were the most intimate lyrical period of his creative life; he achieved an unrivalled balance between the acute observation of reality and its transposition into idealized forms; he celebrated as much as he could the beauty of women and his wife.

Yet the painting The Three Graces, painted in 1638 (Fig. 1), shows a right hand clumsily represented for some but deformed by rheumatoid arthritis for others. This last option may have been deliberately chosen, because realism is characteristic of Rubens and sometimes his sense of observation and representation is accompanied by violent dramatization, which is to be found in the paintings of his earliest youth.



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FIG. 1. The Three Graces (1638; Prado Museum, Madrid, Spain). The swan's neck deformity of the Grace on the right can be seen. Reproduced with permission from the Prado Museum, Madrid, Spain. Copyright © Museo Nacional del Prado, Madrid.

 
From a doctor's view of things [1], the joints of the middle of the fingers on the right hand of the Grace on the right are half bent and are in hyperextension; this particular position cannot be adopted by a normal hand since the joints on the same finger can only be bent at the same time, possibly extended slightly, but the joints of the same finger cannot move in opposite directions unless the finger has suffered an accident (but in general this involves only one finger) or is affected by rheumatism (in most cases several articular groups are affected) that has distended the capsuloligamentary system. Here, the third, fourth and fifth figures are deformed (the other fingers are hidden or only partially visible).

The first diagnosis evoked (even if the left hand cannot be examined) is that of rheumatoid arthritis, an illness which affects (at the present time in the Western world) 1–2% of the adult population—above all, women—and which is characterized by painful, symmetrical swelling (wrists, finger, knees, etc.). If it is not treated, this condition distends the joints, swells and dislocates, which results in ‘swan's neck’ or ‘buttonhole’ deformities of the fingers (strikingly similar to those observed in the Rubens painting).

Specialists agree that Hélène Fourment served as a model for the three Graces in the painting. Was she therefore suffering from rheumatoid arthritis or a related disease? The so-called buttonhole deformity takes several years to appear; the young woman was only 23 when the painting was completed, which would mean that the she suffered from arthritis from her teenage years. However, Rubens also represented arthritic deformities in far older paintings (for example, The Miracle of Saint Ignatius Loyola, 1618) (Fig. 2), produced long before he met Hélène Fourment.



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FIG. 2. The Miracle of St Ignatius of Loyola (1618; Kunsthistorisches Museum, Vienna, Austria). Swelling of the metacarpophalangeal and interphalangeal joints can be observed. Reproduced with permission from the Kunsthistorisches Museum, Vienna, Austria. Copyright © Kunsthistorisches Museum, Wien oder KHM, Wien.

 
Who is the patient who served as a model for Rubens for more than 20 yr and represented in several paintings (they are rare), and sometimes in a very subtle way, the development of arthritis (sometimes a swelling of the wrist, ankles, toe or finger can be distinguished in certain paintings) (Fig. 3)?



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FIG. 3. The Adoration of the Magi (1628; Prado Museum, Madrid, Spain). Interosseous muscle atrophy of the right hand can be seen. Reproduced with permission from the Prado Museum, Madrid, Spain. Copyright © Museo Nacional del Prado, Madrid.

 
It is clear from his voluminous correspondence that Rubens suffered from a gouty rheumatism which affected several joints chronically, chiefly his hands, feet and knees, and was sometimes so disabling that it prevented him from accomplishing certain commissions, such as the decoration of the ceiling of Whitehall. Occasionally this rheumatism left him bed-ridden; nothing could ease the pain. But at that time most types of rheumatism were called gout and with the progress of medicine, new diagnosis could be made at the end of the 18th century by Landré Bauvais, a house doctor at La Salpétrière.

In these circumstances, several hypotheses can be advanced: (i) the diagnosis of gout in Rubens can reasonably be called into question; (ii) given the characteristics of rheumatism, Rubens perhaps suffered from rheumatoid arthritis; and (iii) the artist represented his own hands in some of his works as if he had wanted to ward off ill fortune by illustrating the development of his own disease.

Rubens was surrounded by more than 70 assistants who helped him in his artistic work, and very often he restricted himself, following his ‘gout’, to painting faces and hands, which in the end was his personal touch. (A radiological examination of the artist's bones would have been able to confirm the diagnosis, but it has not be possible to find them.)

These conclusions remain hypothetical, but they also fall within the scope of historical epidemiology. Numerous scientists are amazed at the lack of arguments in favour of the existence of rheumatoid arthritis in the Old World, before the 18th century, whereas spondylarthritis, whose clinical picture is similar, has been detected from Egyptian bones dating back 3000 yr, although many palaeopathological specimens previously reported as ankylosing spondylitis are examples of diffuse idiopathic spine hyperostosis [3]. In addition, in the New World, skeletons of Indians living in Alabama between 4500 and 450 BC have shown traces of rheumatoid arthritis.

If Rubens suffered from and represented symptoms of rheumatoid arthritis (he was not the only person to represent rheumatoid arthritis; several of his contemporary Flemish Primitives also did so), the disease must have existed in Europe before the 16th century. It is conceivable that it might have been imported from the New World by sailors returning from America.

Rubens lived in Antwerp, a port, a cultural centre and the crossroads of Europe, under Spanish domination. This city was frequented by sailors returning from the New World with shipments that revolutionized eating habits, doubled the available therapeutic assortment of medicinal plants, mixed the genes of populations, swapped infectious plants, changed living conditions and the local ecology, etc. This series of conditions, taken together, enabled an infectious, but in principle not aggressive, American agent to find genetically more receptive European hosts, with mixed blood, triggered from certain cities which were transit points in an ‘epidemic’ of rheumatoid arthritis.

Over the centuries, new diseases have appeared while others have disappeared. The plague, smallpox, polio, anthrax etc. have almost disappeared in Europe; on the other hand, AIDS appeared in Europe a quarter of a century ago (at the time of the wide-scale vaccination of African populations). Many ‘old’ rheumatologists also note that the most dramatic forms of arthritis are increasingly rare and that a certain number of arthritis sufferers experience a period of remission, either linked to their treatment or for unknown reasons, as if the epidemic of rheumatoid arthritis which occurred in the 16th century was disappearing. Has the agent which triggers it lost its virulence? Has a genetic leap been accomplished? Have the ecological changes of the last 20 yr been accompanied by the elimination of certain diseases? Is it due to different conditions of hygiene, eating, pregnancy, etc?

Could Rubens have imagined that, by representing rheumatic hands, he was going to overwhelm the conquistadors, reinforce the arguments of ecologists, focus rheumatology research on genetic factors, offer art experts an additional means of identifying the super-Rubens, allow doctors to look at art in a different way, open a new forum for debate between doctors, historians and artists...?

The author has declared no conflicts of interest.


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 References
 

  1. Appelboom T, De Boelpaepe C, Famaey JP, Ehrlich G. Rubens and the question of antiquity of rheumatoid arthritis. JAMA 1981;245:483–6.[Abstract]
  2. Appelboom T, Halberg P. Rheumatoid arthritis and other synovial disorders: History. In: Hochberg M, Siman A, Smolen J, Weinblatt M, Weisman M, eds. Rheumatology, 3rd edn. 2003; pp 753–6. Mosby, an imprint of Elsevier Ltd.
  3. Rogers J, Watt I, Dieppe P. Palaeopathology of spinal osteophytosis, vertebral ankylosis, ankylosing spondylitis and vertebral hyperostosis. Ann Rheum Dis 1985;44:113–20.[Abstract]
Submitted 12 January 2004; revised version accepted 10 May 2004.