To the Editor:
Rheumatic diseases (RD) occur at a relatively high frequency in the population. We hypothesize that some of these diseases may have affected some artists and possibly influenced their works. In this article, a systematic review of all studies that described the occurrence of rheumatic diseases in famous artists in the world was performed. A PEO format (P = population, E = exposure, O = outcome) to elaborate the research question, “Famous artists (P), with rheumatic diseases (E), have their works changed (O) due to these diseases?” was used.
An extensive literature search in Pubmed/MEDLINE, Scielo, and LILACS, following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, was performed without language restriction, from 1965 to June 2020. After the review of titles and abstracts, 116 out of 1026 articles were selected for reading the full texts, of which 68 were selected for this review. We have identified 20 famous artists who had RD. Table 1 is a summary of all data regarding the artists1–20. Most of them had rheumatoid arthritis (RA) as a confirmed or presumptive diagnosis (n = 8), followed by gout (n = 3), systemic sclerosis (SSc; n = 2), reactive arthritis (n = 2), juvenile idiopathic arthritis (n = 1), ankylosing spondylitis (AS; n = 1), fibromyalgia (FM; n = 1), pycnodysostosis (n = 1), pustulotic arthro-osteitis syndrome (n = 1), and Susac syndrome (n = 1). Of note, some artists had 2 or more potential diagnoses: Lisboa (“Aleijadinho”) with syphilis, leprosy, RA, or porphyria cutanea tarda; Rubens with gout; and Joyce with AS.
A confirmed diagnosis was verified in 8 of 20 and a presumptive diagnosis in 11 of 20. All of them continued to perform their artistic activities despite the limitations secondary to RD. Importantly, most (n = 15/20) of these artists had an art style change after the beginning of the RD. For only one (1/20) artist (Michelangelo), the RD seemed to not interfere with his artistic abilities, and for 4/20 (Aleijadinho, Barrie Cook, Benvenuto Cellini, and Erasmus of Rotterdam), we do not have information regarding this aspect. Further, artists with RA had polyarthritis (n = 5/8) and some of them had extraarticular manifestations (n = 3/8). Frida Kahlo had a medical history that was tragic and complex, including scoliosis, poliomyelitis, spina bifida, and multiple fractures after a car accident (needing more than 30 surgeries). These diagnostic hypotheses of postpoliomyelitis and posttraumatic FM also need to be considered21. One artist (Michelangelo) had probable saturnine gout secondary to lead paint exposure. Reactive arthritis was seen in 2 artists; they had suspected sexual contact as well as ocular inflammation followed by arthritis. SSc was a presumptive diagnosis for Aleijadinho, who had phalanx amputations. Treatments varied from nonpharmacological therapies such as diets (n = 3), spas (n = 4), exercises/physical therapy (n = 4), surgeries (n = 2), occupational therapy (n = 2), synoviorthesis with yttrium (n = 1) and use of antiinflammatory drugs (n = 5), cortisone (n = 2), methotrexate (n = 1), antimalarials (n = 1), gold (n = 2), colchicine (n = 1), homeopathy (n = 2), and biologicals (n = 1).
Of note, RD in other artists were reported by Appelboom18, but articles were not found about them in our literature review. These artists are Marquise de Sevigné (writer, probable RA), Samuel Johnson (writer, gout), Mozart (composer, rheumatic fever), Niccolò Paganini (composer and violinist, Marfan or Ehlers-Danlos), Paul Scarron (poet, AS), Paul Verlaine (poet, knee arthritis), and Flannery O’Connor (writer, systemic lupus erythematosus).
A possible explanation for RA being the most frequent RD in these patients is that the occupational exposure to the color inks as well as heavy smoking may have had a role in the development of RA in Renoir, Jawlensky, Niki, and Dufy. In addition, vapor from smoking contains several heavy metals such as cadmium. Metals are used in ink composition, such as in chrome yellow, molybdenum orange, and cadmium red; iron black and copper-zinc alloy powder (gold bronze) are used in novel silver and gold inks.
It has been reported that mercury, as well as gold, induces autoimmunity in genetically susceptible animals. Delayed hypersensitivity to metals was already evaluated in patients with RA, and significant amounts of mercury, titanium, and palladium were observed in these patients.
Rubens, Renoir, Dufy, and Klee used significantly brighter and clearer colors based on toxic heavy metals, and fewer earth colors containing harmless iron and carbon compounds. There is evidence of occupational exposure to cadmium by Barrie Cook. Another relevant risk factor for the development of RD is vitamin D deficiency. For those people who work indoors, it is a concern, as many artistic activities are developed in an indoor environment.
When we discovered that the majority of the artists that had RD changed their style due to their rheumatic conditions, we were able to conclude that there is a close relationship between disease and art22. In the same way that the pain and functional limitation caused by RD evoked sadness in these artists, that pain also provoked them to create beauty in their artistic works. Therefore, these diseases may be considered a “therapeutic method”22. We must remember that the arts are a way of expressing deep feelings, including suffering.
- Copyright © 2021 by the Journal of Rheumatology
REFERENCES
- 1.
- 2.
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- 4.
- 5.
- 6.
- 7.
- 8.
- 9.
- 10.
- 11.
- 12.
- 13.
- 14.
- 15.
- 16.
- 17.
- 18.
- 19.
- 20.
- 21.
- 22.