Were camptodactyly and boutonniere deformity considered pathological in late fifteenth century Italy? Evidence from the sculptures of Francesco di Simone Ferrucci (1437-1493).

Representations of disease in Renaissance paintings have been discussed in medical literature, in the context of historical epidemiology, as potential sources of information about the incidence and appearance of particular conditions in earlier times. The present study seeks to show how Renaissance art can also contribute to historical nosology by casting light on the question of whether particular conditions recognized as abnormal today were understood as pathological in the past. The hands of two Renaissance Madonna figures are examined in sculptures produced by Francesco di Simone Ferrucci (1437-1493). Because the Virgin Mary was considered physically perfect by believers, and because Francesco was a successful producer of devotional sculptures for a wide audience, it is highly probable that any abnormal conditions found in the hands of Madonnas sculpted by him would not have been regarded as pathological at the time. The sculptures examined appear to depict camptodactyly and boutonniere deformity in the hands of Madonna figures. These uncommon conditions are also found in Renaissance artworks that show other individuals of high social status, but their presence in the hands of the Madonna gives the strongest indication that they were not considered pathological, due to religious belief in the Virgin's physical perfection. Examination of Madonna figures in late fifteenth century Renaissance art can contribute to historical nosology by identifying abnormal conditions that were not regarded as pathological at the time. The examples of such conditions identified in the present study are camptodactyly and boutonniere deformity.

Arthritis in the hands of saints shown in 15th century Venetian altarpieces by Bartolomeo Vivarini.

Bartolomeo Vivarini (1432-1499) was the most prolific member of a prominent 15th-century Venetian family of artists who specialised in religious art, particularly altarpieces. Unlike their Florentine counterparts, Venetian artists of this period were typically more concerned with decorative effects than with accuracy of description, so their paintings often lacked detailed anatomical information. Bartolomeo, however, began the move toward anatomical realism in the Vivarini family. Two pictures of saints from his altarpieces are presented here to illustrate his depiction of arthritic hand deformities. The hands of Saint Louis of Toulouse (painted c. 1465-7), a young man who died in his 20s, show signs of inflammatory arthritis, while the effects of degenerative osteoarthritis can be seen in the hands of Saint Mark (painted c. 1470), who is portrayed as a man in late middle age. These observations extend the findings of previous studies of Florentine altarpieces from the same period, as well as more general studies of deformed extremities in Italian, Flemish and French Renaissance paintings. They also support the broader proposition that when 15th-century Venetian painters began to embrace anatomical realism they were capable of providing sufficient detail to enable pathological deformities in their figures to be identified.

Three saints with deformed extremities in an Italian Renaissance altarpiece.

A fifteenth-century Florentine altarpiece painted by the Pollaiuolo brothers, Antonio (1433-1498) and Piero (1443-1496), shows three saints with evident deformities of the hands and feet. The pathologies concerned are tentatively identified, and various rationales for their presence in the painting are discussed. Of particular importance is the location of the altarpiece in a chapel which houses the tomb of the Cardinal of Portugal, Prince James of Lusitania (1433-1459). It is argued that both the artistic style of the day and the religious symbolism of the Cardinal's funeral chapel contributed to the artists' decision to portray the saints with deformities. An unnatural curvature of the fifth finger was apparently considered elegant in fifteenth-century paintings, and the depiction of bare feet with hallux valgus gave them a shape which approximated and could have been caused by fashionable pointed shoes. But in addition, deformities in religious art could be symbolic of suffering and martyrdom, a theme which the Cardinal's chapel emphasised in a number of ways. It is suggested therefore that the Pollaiuolo altarpiece reconciles these two disparate factors, portraying genuine deformities in a way that was artistically stylish and symbolically meaningful.

Hand deformities in Filippino Lippi's Magrini Altarpiece (c. 1482).

Examination of the four saints in Filippino Lippi's Magrini Altarpiece (c. 1482) shows that they all have hand deformities of various kinds. The two saints on the viewer's left, St Rocco and St Sebastian, are portrayed as young, aristocratic men. Those on the viewer's right, St Jerome and St Helena, are depicted as a much older man and a young woman, respectively. It is of interest that the two young men have more significant deformities, while the older man and the young woman are less severely affected. The realism of the depiction of the young men's hands makes it probable that the artist deliberately chose models with arthritic deformities or else painted the hands from memory after having observed other arthritis sufferers. As a more speculative concluding note, it is also suggested, on the basis of comparisons with other paintings from the same period, that the artist may have chosen to depict the young male saints' hands in this way to emphasise both their aristocratic standing and the role of suffering and martyrdom in their traditional biographies.

The illnesses of Carlo di Ferdinando I de' Medici: a second opinion.

OBJECTIVES: To offer a second opinion on the recently published retrospective diagnosis of Cardinal Carlo de' Medici (1596-1666), a prominent member of the grand ducal family then ruling Tuscany. METHODS: Retrospective diagnosis of historical figures is difficult and at times controversial, even with modern technology. It is based on contemporaneous medical descriptions and historical reviews, inherited iconography, and rarely - as in the case of the Medici of Florence - skeletal assessment, completed with radiological, histological and even immunological studies. Modern clinical work is often complemented with a second opinion obtained from specialists in the relevant fields. It is this type of second opinion that our collaborative Australian and Italian team, comprised of an orthopaedic/spinal surgeon, a rheumatologist and two medical historians, now offers. RESULTS: The authors concur with the first opinion's diagnosis of Klippel-Feil syndrome in Carlo de' Medici, but disagree with the diagnoses of tuberculosis (Pott's disease) and rheumatoid arthritis. We find evidence, instead, for a psoriatic-DISH arthropathy with involvement of Klippel-Feil syndrome. CONCLUSIONS: A psoriatic-DISH arthropathy, previously described by the present authors as the 'Medici syndrome', was commonly found in the males of the primary branch of the family. The diagnosis of this condition in Cardinal Carlo de' Medici represents its first identification in a male of the secondary (grand ducal) branch of the family.

Rapid urinary antigen diagnosis of infectious diseases: the legacy of Dr. Ludwik Fleck.

Reviewing recent pages on social studies of science, the authors found several articles dealing with Dr. Ludwik Fleck's philosophical work. Fleck's interest was even more intensive in medical science. Apart from the typhus serology; he worked extensively in the field of microbiology and described the "Leukergy" phenomenon. A modest contribution was recently added to this list, dealing with Fleck's scientific legacy, namely his contribution to the early diagnosis of infectious diseases. Presented as "Fleck's hypothesis", an outline was given on antigens in the urine of patients with typhus exanthematicus, a disease that needed an early diagnosis or a preventative vaccination. The urine antigen discovery by Fleck is generally unknown to today's practitioner making the diagnosis of infectious agents with sophisticated methodology. We present the widespread use of a simple urine-drop test for antigen detection, feasible even in peripheral community environment. This clinical application is attributed to L. Fleck.

Paul Klee (1879-1940) as a tragic figure: What the artist learned from his illness.

Paul Klee was a major contributor to the development of modern European art. An ethnic German (although born in Switzerland) and a German citizen, he was persecuted by the Nazi government on political rather than racial grounds because of his allegedly "degenerate" artistic style. Dismissed from his teaching position, he emigrated to Switzerland in 1933; shortly afterward he became ill with systemic sclerosis and struggled with this condition for the remaining years of his life. Many publications have examined the effect of social rejection and illness on his art, but the present study considers the effect of these adversities on Klee's attitude toward his fellow humans. After being an extreme misanthrope in his early adult years, he developed an attitude of cosmic indifference toward humanity during the First World War, which he then maintained until the end of 1939. Although his rejection by Germany had been a significant emotional blow, it was the physical suffering caused by his illness that led him, at the end of his life, to show compassion toward the suffering of other individuals. In this he was like tragic figures such as King Lear who learned from their great misfortunes to value humanity.

Ribera's depiction of the sense of taste: A case of 'gouty arthritis' resulting from overindulgence?

Jusepe de Ribera's seventeenth-century painting devoted to the sense of taste, part of a series on the five senses, depicts a man from one of 'the humbler walks of life' enjoying his meal. The redness of the man's cheeks and nose, and the swollen index finger on his left hand, are discussed in relation to the food and drink shown in the painting. It is suggested that the man's high purine intake combined with a substantial quantity of alcohol supports the hypothesis that the swollen finger is affected by gout, which was traditionally considered a 'patrician disease'. Ribera's portrayal of a well-fed but non-patrician figure with gouty arthritis of the finger may have been intended as a warning against overindulgence and gluttony at all levels of society.

'Epidemic' of hand deformities in the French Renaissance paintings of Jean and François Clouet.

This article analyses the nature of the multiple finger anomalies found in portraits by the French Renaissance artistic dynasty, the Clouets. The multiplicity of finger anomalies could be either innocent congenital variants, or pathological and traumatic deformities. In view of the presence of such `beautifying variations' in the works of other Renaissance artists, the authors decided that these features were not the result of an epidemic of deformities, but instead represented a stylistic approach in paintings of this period at the French Court.

Trauma to anomalous cervical spine.

A case of aplastic arch of the atlas (Keller's type) with severe injury to the cervical spine is presented. The impact of the accident was intense enough to produce bony compression of the C7 vertebra, but no injury occurred to the neural elements in the upper cervical spine. The presence of the ligamentous apparatus maintaining the stable movements of the first vertebral connections is of interest. No delay in recovery occurred, and no late complications developed in the seven months following the accident.

Lumbar spinal canal stenosis in Paget's disease.

Three patients with Paget's disease of the spine presented a non-characteristic lumbar syndrome with minor neuromuscular dysfunction. It is proposed that this be called a premyeloneuropathic syndrome since it is an early stage of an imminent severe myelopathic syndrome. The suspected lumbar canal stenosis in Paget's disease is diagnosed by computerised tomography and successfully reversed by calcitonin.

The value of CT in diagnosing postoperative lumbar conditions.

A series of 15 postlumbar laminectomy patients was investigated for residual disease. Clinical, myelograpic, and CT correlation was studied. With the assistance of contrast material injections, a "fibrographic effect" was obtained in scar tissue, differentiating it from residual disc material. The viability of free fat graft is detectable with CT technique.

Spinal imaging: will MRI replace myelography?

A retrospective study on the value of magnetic resonance imaging (MRI) in replacing contrast studies of the lumbar spine has been undertaken. Studying pre- and postoperative conditions, the authors attempted to answer the question, Will MRI replace myelography? In this retrospective study, comparison is made in 20 patients between MRI and myelography and with 12 intra-operative findings. The overall impression was that MRI is equally sensitive as the invasive myelogram in diagnosing both protruded lumbar discs and postoperative fibrosis. The practical conclusion was an almost complete abandonment of myelography.

Ossifying surgical scar in Forestier's disease.

A case of heterotropic ossification of an abdominal surgical scar in a patient with spinal ankylosing hyperostosis is reported, and the pertinent literature reviewed.

Lumbar canal stenosis an occupational hazard.

The theory of Spinal Reserve Capacity (SRC) a Computerised Tomography technique, proving symptomatic spinal stenosis, has been applied to industrial accident patients with pre-existent developmental canal narrowing. In five cases, a mild disc bulge or protrusion into the lumbar canal produced obliteration of the intracanalar space, necessary for the mobility of the neural tissue. The symptomatology was disproportionate to the extent of the disc bulge, the effect of decompression was dramatic. This CT technique of SRC is suggested as a diagnostic test, to prove liability in a relatively minor injury responsible for a major disability.

Pharmacological inhibition of digestive secretions in the management of pancreaticoduodenal fistulas.

We report the pharmacological inhibition of secretions of the gastrointestinal tract for the prevention and management of pancreatic and duodenal fistulas. Nasogastric aspiration to remove gastric secretions and decrease motility and an anticholinergic drug, a carbonic anhydrase inhibitor and intravenous hyperalimentation to inhibit secretions were used to prevent pancreatic fistulas. Patients with established duodenal and/or pancreatic fistulas received local treatment consisting of lavage of the fistulous tract and skin protection in addition to the parenteral therapy. Three cases of successful prevention of pancreatic fistulas and three cases of managemtnt of duodenal fistulas are presented.

Erasmus of Rotterdam (1466-1536): renaissance advocate of the public role of medicine.

The great Renaissance scholar Erasmus of Rotterdam was a pioneering advocate of the importance of medicine for social as well as individual welfare. Erasmus' "Oration in praise of the art of medicine" (1518) illustrates his literary approach to this topic. Although the original version of his text did not address the state's role in promoting the health of the populace, Erasmus inserted new material on this topic into the "Oration" for a 1529 edition. This new material and references in some of his other writings from the same period indicate that it was in the 1520s that Erasmus first became a strong advocate of government intervention in public health matters. It is suggested that medical events in Erasmus' own life-his experiences both as a patient and as an observer of diseases-may explain why his interest in public health legislation increased significantly around this time.

"It is wisest here, as always, to maintain a balance": the medical dissertations of Friedrich Schiller.

Johann Christoph Friedrich Schiller (1759-1805) is remembered today for his contributions to literature and aesthetic theory-it is less well known that his first career was in medicine (an army appointment). Scholars have generally held that his primary interest lay in psychology and the psychological aspects of medicine, and that his commitment to other aspects of medicine was perfunctory at best. The present paper argues that a study of Schiller's three medical dissertations-two on psychological aspects of medicine and one on fevers-reveals his attempt "to maintain a balance" between the mind and the body in his approach to medicine.