Rheumatology Advance Access published January 30, 2014

RHEUMATOLOGY 53, 119

Review doi:10.1093/rheumatology/ket459

Art and rheumatology: the artist and the

rheumatologist’s perspective
Andrea Hinojosa-Azaola1 and Jorge Alcocer-Varela1

Abstract

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The reflection of medicine in the universal arts has motivated several rheumatologists to discover features
of rheumatic diseases depicted by the artist’s eyes long before they were defined as specific pathologic
entities. The result has been the identification of several pieces of art dating from the Middle Ages, the
Renaissance, the Baroque and Post-Impressionist periods that depict clear features of several rheumatic
diseases such as RA, OA, camptodactyly and temporal arteritis, among others. On the other hand, great
artists such as Pierre-Auguste Renoir, Antoni Gaudı́, Raoul Dufy, Paul Klee, Frida Kahlo and Niki de Saint

R EV I E W
Phalle are good examples of how rheumatic diseases such as RA, scleroderma and chronic pain can
influence the artist’s perspective, the technique used and the content of their work. Art can serve as a
powerful resource to understand the natural course of diseases. By learning through the artist’s eyes the
way illnesses behave and evolve in time, rheumatologists can trace the history of several conditions.
Key words: rheumatology, art, history.

Introduction previously thought) stimulated certain experts to look for

traces of this disease before that time. These experts
The reflection of medicine in the universal arts has both identified paintings that date from 1400 to 1600 AD and
intrigued and captivated the medical profession for cen- that depict hand changes suggestive of RA. It was in 1853
turies. This attraction has motivated several rheumatolo- AD when the term progressive articular rheumatism was
gists to look at catalogues and reproductions of paintings described in Charcot’s thesis, and later, in 1859 AD,
with a magnifying glass, trying to discover features of Sir Alfred Baring Garrod adopted the term RA [3–5]. This
rheumatic diseases depicted by artists long before these anecdote shows the delay in finding pictorial and scientific
diseases were defined as specific pathologic entities. evidence of the disease.
Although a work of art may provide evidence of ancient Discovering evidence of rheumatic diseases in the
disease, the interpretation may be difficult, leading to visual arts raises the questions of whether the artist re-
errors in diagnosis due to misinterpretation of the artistic flected what surrounded him in a realistic fashion or suf-
convention or technique [1]. The accurate diagnosis of fered from the disease himself and, in the latter case, how
rheumatic diseases that are portrayed in the visual arts the illness influenced his art. It is clear that art reflects
therefore requires tracing the historical background of every moment of human thought, influenced by the his-
the piece of art. torical backdrop. For example, in the 14th century, master
Evidence of rheumatic diseases in history dates from painters searched for perfection in human anatomy,
1279 BC, during the reign of Ramses II. A retrospective whereas artists from the 20th century created realities re-
radiologic analysis of his mummy showed severe changes flective more of their own inner visions than what lay
associated with SpA, with post-inflammatory hip arthritis before them in nature. As a result, 20th century painting
and cervical ankylosis [2]. Moreover, evidence of the movements and trends inspired artists to set out in many
origin of RA in 1400 AD (and not in 1800 AD, as divergent directions [6]. Painters and sculptors have long
been recognized as professionally prone to conditions
1 such as lead intoxication and stone dust silicone expos-
Department of Immunology and Rheumatology, Instituto Nacional de
Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico. ition, although the mean age at death for artists has been
Submitted 12 August 2013; revised version accepted described as higher than that of the general population [4].
27 November 2013. The artist and the rheumatologist’s perspective con-
Correspondence to: Jorge Alcocer-Varela, Department of Immunology verged in Andreas Vesalius, a brilliant anatomist of the
and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición
Salvador Zubirán, Vasco de Quiroga 15, Col. Sección XVI, Tlalpan, CP 1500s with a remarkable practical skill in dissecting
14000, México D.F., México. E-mail: jorgealcocer2@gmail.com bodies, and the author of De Humani Corporis Fabrica.

! The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com 1
Andrea Hinojosa-Azaola and Jorge Alcocer-Varela

FIG. 1 Detail from clay hand dating to the classic Veracruz FIG. 2 Detail from Sandro Botticelli’s ‘Portrait of a Youth’
period in Mexico (200–650 AD) (tempera on panel, 1482/1485)

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Swelling of the IP joint of the thumb represents a
Heberden’s node. Adapted from Alarcón-Segovia [9].

He served as imperial physician at the court of Emperor Swelling of the wrist, MCP and PIP joints of the hand
Charles V and during that time he treated injuries from suggestive of possible JIA. National Gallery of Art,
battle and tournaments, but most important, he treated Washington DC.
Charles V, who was affected by gout [7, 8]. The
common situation in which the artist and rheumatologist
collide as both spectator and patient is the focus of this succession of men without precedents. Man, freed from
review. the medieval ties that restricted him, could now reflect the
human body in his art, with strict attachment to anatomy
Rheumatic diseases depicted by artists and mathematics (perspective). During these years,
rheumatic features such as camptodactyly (congenital
Many artists have depicted rheumatic diseases in their fixed-flexion deformity of the proximal IP joint in combin-
work. Several characterizations are summarized in this ation with hyperextension of the MCP and DIP joints, with
section in chronological order. a preference for the fifth finger) were depicted in paintings
by Dieric Bouts (1415–75) and his son, including ‘The Last
200–650 to 1200 AD
Supper’, ‘Mater Dolorosa’ and ‘The Ascension of Maria’
During the Middle Ages, Europe avoided renovation and [11]. This deformity is not present in works by other artists
redefinition, so artistic and scientific production during from the same time or later. In the panel of St. John the
that period was very poor and strictly and solely depend- Baptist in the ‘Adoration of the Lamb’ (1432) by Jan van
ent on approval by the church or monarchy. The medieval Eyck, a typical Heberden’s node can be observed on the
man believed that the universe rotated around the Earth left thumb [12]. In the drawing ‘John IV, Duke of Brabant’
and did not have free access to knowledge and therefore (1441) by the same Flemish artist, swan-neck and bouton-
was not an actor in the world in which he lived. Despite nière deformities of the fingers are depicted [13]. In an-
this concept, there are several pieces of art that deserve other famous painting by van Eyck, dating from 1436 and
attention because they belong to that period of time in known as ‘The Virgin with the Canon’, the artist charac-
America. A nearly life-size clay hand belonging to the clas- terises Canon Van der Paele’s left temporal region with
sic Veracruz period in Mexico (200–650 AD) shows swel- prominent arteries, scar formation, a loss of hair in front
ling of the IP joint of the thumb, representing a Heberden’s of the left ear and from the eyebrows and diffuse swelling
node [9] (Fig. 1). Moreover, a sculpture of a male from of the left hand [14]. These findings are very suggestive of
Jalisco, Mexico, dating from 300 BC to 200 AD exhibits TA with PMR. Horton et al. [15] first described TA as a
a suffering face due to a lesion of his right tibia, which is specific entity in 1932. Another depiction of the same vas-
possibly osteomyelitis, a fracture or a tumour [10]. cular disease can be found in Piero di Cosimo’s portrait of
Francesco Giamberti, dating from 1505.
1400–1500 In 1983 Alarcón-Segovia et al. [16] described swelling of
The willingness to have a place in the universe before the wrist, MCP and PIP of the hand depicted in ‘Portrait of
God and man himself resulted in a generation of brilliant a Youth’ (1483) (Fig. 2) by the Florentine artist Sandro
intellectuals and poets (e.g. Dante Alighieri, Giovanni Botticelli. These changes are suggestive of possible JIA
Boccaccio and Francesco Petrarca) who transformed and were not ascribed to faulty technique. However,
Occidental ideology. The overwhelming enthusiasm accu- 1 year later, Dequeker [17] and Leden [18] questioned
mulated during the 14th and 15th centuries gave place to these findings by mentioning other paintings by Botticelli
the most important artistic movement in history: the (i.e., ‘The Birth of Venus’) with similar characteristics of the
Renaissance. During this period, the world observed a hands and swelling of the ankles and forefeet, suggesting

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 Art and rheumatology

stylistic configuration and artistic convention rather than a Three Graces’ (1638–40), depicts benign familial hyper-
diagnosis of arthritis. mobility syndrome and the Trendelenburg sign in
Botticelli triumphed where Pollaiuolo failed by achieving Rubens’ second wife and her sisters, showing that the
a perfect and harmonic scheme. By doing so, he sacri- artist was a keen observer [23].
ficed some resources: Botticelli’s figures seem less solid; The presence of multiple progressive hand deformities
they are not as rightly drawn as the ones of Pollaiuolo or in Rubens’ paintings and the realism that characterized his
Masaccio. The graceful movements and melodic lines that art have raised the question of whether such deformities
form his compositions remind one of the gothic tradition of represent different models affected by the disease or
Ghiberti and Fra Angelico, and the art of the 14th century, whether the artist projected his disease onto his models
including pieces by Simone Maritini and Lippo Memmi. (self-portraits of his rheumatic illness). The hypothesis
Botticelli took liberties with nature in order to achieve regarding Rubens’ rheumatic condition comes from his
graceful silhouettes, enhance beauty and harmony, paintings and letters. The disease affected his hands,
and give the impression of incredibly delicate human knees and feet and was chronic, disabling and compli-

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beings [6]. cated by flares. Possibilities include RA, chronic tophac-
Drawings and paintings serve as important tools eous gout and saturnine gout [22–24].
for understanding the natural history of diseases. One of Evidence of rheumatic diseases represented in visual
the most representative examples of this concept is the arts dating from this period often includes religious per-
famous medieval drawing ‘The Procession of the Cripples’ sonages. Examples of these are found in paintings by the
by the Dutch painter Hieronymus Bosch (1450–1516), in Catholic Dutch artist Claes Cornelisz Moeyaert dating
which 31 disabled individuals are depicted [19]. An expert from 1631, as clinical signs of RA are depicted in portraits
analysis performed by a rheumatologist, an orthopaedic of the priest Siebrandus Sixtius [25], and the painting
surgeon and a neurologist showed that the drawing rep- ‘Archangel Raphael and Bishop Francisco Domonte’
resents several diseases, including rheumatic entities (1680) by the Spanish Baroque painter Murillo, in which
such as Pott’s disease, SpA, hyperostosis vertebralis several features of scleroderma are depicted in the
and post-infectious osteomyelitis. bishop’s face and hands (e.g. telangiectases, tight skin
Possible pagetoid lesions of the skull and clavicles and swollen fingers) [26].
(osteitis deformans) are characterized in the painting Vincent van Gogh, the famous Dutch Post-
entitled ‘A Grotesque Old Woman’, attributed to the Impressionist artist, executed a group of portraits of the
Flemish artist Quinten Metsys (1465–1530) [20]. The Roulin family during his time in Arles. Among these por-
same artist also portrayed Erasmus of Rotterdam in traits is ‘La Berceuse (Augustine Roulin)’ (1888), in which
1517, depicting synovial thickening at the MCP joints features of hand arthritis are clearly depicted in the
and hyperextension of the left thumb. Information from woman portrayed [27].
paintings, drawings, letters and post-mortem reports sug-
gest that this humanist of the Reformation period suffered
from pustulotic arthro-osteitis [21]. The influence of rheumatic diseases
Arthritis-like lesions have been discovered in other on artists
Flemish paintings dating from 1400 to 1700, including
Rheumatic diseases have affected several artists from the
the works of artists such as Jan Rombouts, Joos
19th and 20th centuries in different ways, influencing their
(Justus) van Gent, Jacob Jordaens and Jan Gossaert
techniques and legacies. The arts have served as a means
[13]. These findings support the recognition of the disease
by which man expresses life’s broad range of emotions:
before this condition was formally described.
love, the appreciation of beauty, despair and loneliness.
However, the works of several prominent artists also re-
1600–1800 flect the pain and frustration of arthritis and other illnesses
These years comprised the Baroque period (1600–1750), from which they suffered [28].
characterized by the splendour and flourish of God, and The 20th century was characterized by the emer-
the Neoclassical period (1750–1850), when art recaptured gence of several artistic movements, including Fauvism,
Greco-Roman grace and grandeur. At the same time, the Expressionism, Cubism, Futurism, Constructivism,
Thirty Years’ War between Catholics and Protestants Dadaism and Surrealism. A poetic vision characterises
occurred (1618–48), followed by the Enlightenment and the art and ideology of the 20th century.
the Industrial Revolution (1760–1850). In 1608, the Italian Surrealism, a powerful movement, emerged in the post-
artist Caravaggio depicted JIA in his painting entitled ‘The war period as a call for freedom and for the supremacy of
Sleeping Cupid’ [1]. Moreover, Peter Paul Rubens subjectivity and desire over objectivity. This movement
(1577–1640), the Flemish Baroque painter, depicted fea- represents the part of man that cannot be reduced to
tures of hand arthritis in several paintings dating from reason or science, which is his symbolic and oneiric part.
1609 to 1640, including ‘Saint Mathew’, ‘The Drunken Impressionism, characterized by emphasis on the ac-
Sleeping Satyr’, ‘Suzanna and the Elders’, ‘Portrait of curate depiction of light and its changing qualities, with
Marie de Medici’, ‘Saint Augustine between Christ and the inclusion of movement and unusual visual angles,
the Virgin’, and ‘The Holy Family with St Anne’ [22]. occurred during the 19th century. Among the most repre-
Furthermore, one of the later paintings by Rubens, ‘The sentative artists of this movement was the French painter

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Andrea Hinojosa-Azaola and Jorge Alcocer-Varela

Pierre-Auguste Renoir (1841–1919), who created 6000 FIG. 3 Paul Klee, ‘Little Regatta’, 1922 (watercolour on
works and suffered from severe RA for the last 25 years paper, 14.6  22.8 cm)
of his life. Evidence from personal letters, photographs
and biographical notes gives testimony to the way that
the artist’s technique evolved to overcome the difficulties
of the rheumatic disease, which was enhanced by a
stroke that he suffered when he was 71. The so-called
painter of happiness did not know about the benefits con-
ferred by disease-modifying anti-rheumatic drugs and
was treated with purges and antipyrine. As a result, he
was a victim of the natural course of the illness. He was
unable to wear shoes, had fixed flexion of his knees and
suffered from destruction and ankylosis of his right shoul-

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der and ruptures of several extensor tendons of the
hands. Renoir also experienced complications such as
pleuritis, weight loss, nodules, cutaneous vasculitis and
This small-scale composition shows Klee’s detailed and
bedsores. The progressive deformities and disability
technical style before the diagnosis of scleroderma was
obliged him to ask for his palette to be fixed on the arm
made. Reproduced with permission from The Phillips
of his wheelchair and the brushes to be attached to his
Collection, Washington, DC.
hands with the aid of bandages to prevent maceration
when painting. Because of his illness, the artist made im-
portant changes to his technique and the materials used,
painting with small and rapid strokes and inventing the 1936 at the age of 57, 4 years before he died. The disease
moving canvas or picture roll [29, 30]. was manifested as RP, characteristic skin changes, fa-
Antoni Gaudı́ i Cornet (1852–1926), a Catalan architect tigue, exhaustion, dysphagia with weight loss, dyspnoea,
with a unique style, suffered from a recurrent form of arth- arthritic pain, disability, difficulty in holding paintbrushes
ritis since he was 6 years old. Although little information is and ultimately heart failure. Klee’s early work was charac-
available, it is known that he presented articular pain that terized by prints, etchings and pen and ink drawings
mainly involved the ankles and that he wore espadrilles, (Fig. 3). The diagnosis of scleroderma was associated
followed a very strict vegetarian diet and underwent with an initial decrease in productivity and a subsequent
homeopathic treatments. Among the diagnoses sug- recovery in the last year of his life. Parallel to the illness his
gested are JIA and rheumatic fever, although other paintings evolved, showing greater simplicity, intensity
joints, such as in the hands and the knees, were spared. and the use of rough materials such as burlap and news-
It is said that the artist’s disease influenced the develop- paper (Fig. 4). Small-scale compositions were substituted
ment of his great skills: observational power and nature by larger pieces of a flat style, characterized by simple,
analysis [31]. heavy, black crayon-like lines, symbols, dull colours
Raoul Dufy (1877–1953), a French Fauvist painter, suf- and titles that reflected suffering, death and war
fered from RA from his early youth and later in life was one (e.g. ‘Forgetful Angel’, ‘Hurt’, ‘The Sick One in the Boat’,
of the first patients to receive corticosteroids (adrenocor- ‘Death and Fire’) [34, 35]. The dramatic change in Klee’s
ticotropic hormone and cortisone acetate). During the first style reflected a new technique that made it easier for his
years of the disease he received physiotherapy and chry- hands to hold larger brushes. Several of his later drawings
sotherapy to ameliorate his condition and suffered from reflect disfigured faces and changes in the hands that re-
severe flares that obliged him to use crutches and even a semble scleroderma, suggesting awareness of his condi-
wheelchair. The quality of Dufy’s art represents the benefit tion. The precipitating cause of Klee’s scleroderma has
of the treatment that he received. His medical history been speculated to be either a viral infection, such as
shows how corticosteroids helped him to improve his measles, that triggered an autoimmune process or expos-
mobility and to squeeze his paint tubes unassisted, thus ure to toxic heavy metals [36].
his art became freer and the lines less laboured. Frida Kahlo (1907–54), a Mexican painter, political ac-
Nevertheless, due to his disease, the size of Dufy’s paint- tivist and feminist icon, was the first Western artist to
ings was reduced, the plots were less accurate and the include anatomical interpretations of reproduction within
subjects were restricted to what he could imagine or con- her art [37]. Her work was described by several as more
template without moving. Furthermore, he represented obstetric than aesthetic, because the art incorporated
distorted, swollen and erased hands in his late paintings. overtly medical iconography, from scenes of childbirth to
Dufy suffered from the adverse events that the treatment her own wounds, using medical imagery to record her
caused, presenting with massive intestinal haemorrhages story [38]. Affected by poliomyelitis, Kahlo was involved
that were produced by the combination of cortisone and in a tram accident when she was 18 and suffered devas-
aspirin and which finally caused his death [32, 33]. tating injuries (she was impaled through her pelvis by a
Paul Klee (1879–1940), a very influential Post- steel bar and sustained multiple fractures of the spine,
Impressionist artist, was diagnosed with scleroderma in pelvis, right leg and foot). She underwent numerous

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 Art and rheumatology

FIG. 4 Paul Klee, ‘Young Moe’, 1938 (coloured paste on FIG. 5 Frida Kahlo, The Broken Column, 1944 (oil on
newspaper on burlap, 53  70.1 cm) masonite)

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Simple and heavy lines, symbols, materials and colours
reveal a dramatic change in Klee’s technique as a result of
the disease. Reproduced with permission from The
Phillips Collection, Washington, DC.

orthopaedic operations and was confined to plaster cor-

sets for several months. Certain experts believe that from
that time Kahlo suffered from widespread severe, chronic
pain and profound fatigue suggestive of post-traumatic
FM [39], although it is difficult to attribute all of the symp- This self-portrait embodies isolation, a broken body,
toms that she presented to only one medical condition. intense suffering and pain. Collection of Dolores Olmedo
The anguish and pain suffered due to the accident, more Museum, Xochimilco, México. ! 2013, Banco de México,
than 30 surgeries and three therapeutic abortions, are re- ‘Fiduciario’ en el Fideicomiso relativo a los Museos Diego
flected in her painting, which was a way of creating psy- Rivera y Frida Kahlo (reproduced with permission).
chological aliveness from the deadness arising from her
tragic life experiences. Both the titles and content of her
paintings describe her pain: ‘Henry Ford Hospital’ (1932), These stories are good examples of painting as a cre-
‘My Birth’ (1932), ‘The Broken Column’ (1944) (Fig. 5) and ative act that cannot be observed apart from the artist’s
‘Without Hope’ (1945) [40]. In Kahlo’s own words: ‘My body. Painting constitutes a unit that encompasses the
painting carries within it the message of pain . . . painting artist and his personal history, the canvas and the influ-
completed my life. I lost three children . . . Painting substi- ence of the environment.
tuted for all this. I believe that work is the best thing’ [41].
In the case of Niki de Saint Phalle (1930–2002), a French
Conclusions
painter and sculptor, it was occupational exposure to the
materials that she used in her work that presumably Art can serve as a powerful resource to understand the
caused several of her illnesses. She worked with materials natural course of diseases. On the one hand, by learning
such as oil paint, plaster, wire netting, fabric, clay, poly- about the way in which illnesses behave and evolve over
ester and polystyrene and had a special fondness for time through the artist’s eyes, rheumatologists can trace
glass, mirrors and ceramic. The artist suffered from sev- the history of several currently known conditions. Artists
eral health problems, including mental crises and depres- are keen observers of nature and details; their legacy of
sion, chronic lung disease attributed to polystyrene realism depicted through their perception is an outstand-
exposure, transient selective IgA deficiency and recurring ing source of information and a delightful way to catalyse
and debilitating attacks of erosive RA that prevented her emotions. On the other hand, as patients suffering from
from continuing to model. She received treatment for RA rheumatic diseases, artists have contributed enormously
late in the course of the disease, after hand deformities to teaching rheumatologists about the importance of ill-
and weight loss, and developed several adverse events nesses manifested in the changes that the artists made in
related to corticosteroids. Her work reflected both anger their artistic technique to cope with their disease. It is
and violence as a product of her suffering, but she through detailed and chronological analysis of the artists’
emerged from each physical and emotional crisis with work that we can unravel certain aspects of rheumatic
new force and new ideas [33, 42]. diseases that science alone cannot elucidate.

www.rheumatology.oxfordjournals.org 5
Andrea Hinojosa-Azaola and Jorge Alcocer-Varela

Rheumatology key messages 16 Alarcón-Segovia D, Laffón A, Alcocer-Varela J. Probable

. There is evidence of rheumatic diseases in art depiction of juvenile arthritis by Sandro Botticelli. Arthritis
before their description as pathological entities. Rheum 1983;26:1266–8.
. Artists suffering from rheumatic diseases adapted 17 Dequeker J. Arthritis in the paintings of Sandro Botticelli.
their technique and the content of their work. Arthritis Rheum 1984;27:1196–7.
. Art can serve as a powerful resource to understand
18 Leden I. Doubts about Sandro Botticelli’s depiction of
the natural course of a disease.
juvenile rheumatoid arthritis. Arthritis Rheum 1984;27:
1197–8.
19 Dequeker J, Fabry G, Vanopdenbosch L. Hieronymus
Bosch (1450–1516): paleopathology of the Medieval dis-
Acknowledgements abled and its relation to the bone and joint decade
2000–2010. Isr Med Assoc J 2001;3:864–71.
We are indebted to The Phillips Collection, Washington,
20 Dequeker J. Paget’s disease in a painting by Quinten
DC and to the Dolores Olmedo Museum, Xochimilco,

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Metsys (Massys). Br Med J 1989;299:1579–81.
Mexico, who gave permission to reproduce Paul Klee’s
and Frida Kahlo’s paintings, respectively. 21 Dequeker J. Art, history, and rheumatism: the case
of Erasmus of Rotterdam 1466–1536 suffering
Disclosure statement: The authors have declared no con- from pustulotic arthro-osteitis. Ann Rheum Dis 1991;50:
flicts of interest. 517–21.
22 Appelboom T, Boelpaepe C, Ehrlich GE et al. Rubens and
the question of antiquity of rheumatoid arthritis. JAMA
1981;245:483–6.
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