LAUSR

The article by Albury and Weisz recently published was well written and enjoyable to read [1]. Despite the authors excellent exposition of the topic, I remain skeptical of the inferences made of Saint Louis Bishop of Toulouse, and Saint Mark paintings as depicting inflammatory arthritis and osteoarthritis, respectively. The history given in the article of Saint Louis is that of a teenageer afflicted with fever who subsequently developed arthritis 7 years latter. This would suggest conditions such as juvenile arthrits, rheumatic fever or even lupus. The possibility of rheumatoid arthritis would not fit wellwith the differential diagnoses of the time since rheumatoid disease became evident after the return of Christopher Columbus (1490s) from the “West-Indies”. Examining the paintings one notices the swelling on the dorsum of the right hand, but nowhere else, especially over the fingers. There is no indentation or soft tissue swelling around the rings on the thumb and 3rd finger. The clinodactyly and camptodactyly mentioned are congenital deformities and not related to any recent inflammatory response, although, a similar looking lesion known as Boutonniere deformity describes a medical condition in which the finger are flexed at the proximal interphalangeal joint (PIP) and hyperextended at the distal interphalangeal joint (DIP). This deformity is the result of chronic persistent inflammation that takes time to develop and maybe too short in the life of this young bishop. The most significant sign in the painting that would point to an inflammatory arthritis is what looks like metacarpalphalangeal subluxation (MCP) in the knuckles. On closer inspection, there is no associated ulnar deviation of the fingers. More pertinent to the discussion is the fact that other figures painted by Bartolomeo Vivarini show similar swollen hands in others. By way of contrast, the housemaids hands in “The painters family” by Jacob Jordaens (Prado, Madrid, Spain) shows the second and third MCP and proximal PIP joints as swollen in keeping with rheumatoid arthritis. One has to be careful not to misinterpret the clinical signs with common hand gestures or artistic licence as real medical conditions. For instance the Preachers hand outstretched to give a blessing (Benediction sign) can easily be mistaken for a peripheral nerve lesion [2]. To suggest that the painting of St Marks’ hands illustrate “significant osteoarthritis in all joints of his hands, both the metacarpo-phalangeal and interphalangeal ones” I think is misleading and needs further clarification. Unless St Mark had haemochromatosis that affects the 2nd and 3rd MCP joints it is very unlikely the prominant knuckles are due to osteoarthritis (OA). The swollen proximal interphalangeal joints that one sees in OA (Bouchards nodes) are not so prominant. Significantly there are no swellings in the distal interphalangeal joints (Heberdens nodes) that one would expect to see. Again one observes the features of MCP subluxation and Boutonniere deformity of right little finger in the painting that are not features of OA. Byzantine artists (fourth-fifteenth century) were less concerned with mimicking reality. The lack of anatomical structure in hands with what appeared to be deformities, in this case, may have been a carry over feature of Byzantine art which depicts religious figures with long deformed fingers lacking detail so that the viewer is not distracted from praying to God by the beauty of colour and detail in the painted figure. Icons painted in this way are meant to be a visual language that transports us into the realm of spiritual experience that conveys to us the absolute essence of the object by not portraying any accurate physical reality or worse invoking sentimentality. There is no “drama” and the paintings (icons) are silent creating an atmosphere of prayer and contemplation. In essence, I agree with the authors when they say “the question of whether the hands are depictions of Rheumatology INTERNATIONAL