Rheumatic Disease and Artistic Creativity

Home , Saturn Devouring His Son

Rheumatic disease and artistic creativity

Katerina Chatzidionysiou

Mediterr J Rheumatol 2019;30(2):103-9

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G E Y MEDITERRANEAN JOURNALM OF RHEUMATOLOGY June 2019 | Volume 30 | Issue 2 MEDITERRANEAN JOURNAL 30 MEDITERRANEANMEDITERRANEAN JOURNALJOURNAL 30230 MEDITERRANEANOF RHEUMATOLOGY JOURNAL 22019230 OFOF RHEUMATOLOGYRHEUMATOLOGY 201920192 OF RHEUMATOLOGY 2019 © ...... MEDITERRANEAN JOURNAL 30 ©This Chatzidionysiou...... work is licensed K. 2 under a Creative Commons ©This ...... work is licensed Attribution-NonCommercialOF RHEUMATOLOGY 2019 under a Creative Commons 4.0This International work is licensed License. Attribution-NonCommercial under a Creative Commons ORIGINAL PAPER 4.0 International License. Attribution-NonCommercial ORIGINAL PAPER © ...... REVIEW 4.0 International License. ORIGINAL PAPER This work is licensed under a Creative Commons RheumaticAttribution-NonCommercial disease and artistic creativity Rheumatic4.0 International License. disease and artistic creativity ORIGINAL PAPER RheumaticKaterina Chatzidionysiou disease and artistic creativity Katerina Chatzidionysiou Katerina1st Department Chatzidionysiou of Propaedeutic and Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian 1st Department of Propaedeutic and Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian UniversityRheumaticst of Athens, disease Athens, and Greece artistic creativity University1 Department of Athens, of Propaedeutic Athens, Greece and Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian UniversityKaterina Chatzidionysiouof Athens, Athens, Greece Mediterr1st Department J Rheumatol 2018;30(2):103-9of Propaedeutic and Internal Medicine, Laiko Hospital, Medical School, National and Kapodistrian https://doi.org/10.31138/mjr.30.2.103University of Athens, Athens, Greece INTRODUCTION Keywords:DiseaseINTRODUCTION in general, Rheumatic and especially disease, rheumatic creativity, disease, art. INTRODUCTION hasDisease inspired in general, artists for and centuries especially and rheumatichas often beendisease, de- Disease in general, and especially rheumatic disease, pictedhas inspired in paintings. artists 1for There centuries are several and has examples often been of that; de- has inspired artists 1for centuries and has often been de- INTRODUCTIONpicted“The Gout” in paintings., by James There Gillray are in several1799, depicts examples a bare of that; foot pictedDisease in inpaintings. general,1 Thereand especially are several rheumatic examples disease, of that; with“The classicalGout”, by signs James of Gillrayinflammation in 1799, in depicts gout aattack bare footsuch has“The inspired Gout”, byartists James for Gillraycenturies in 1799, and has depicts often a beenbare footde- aswith extreme classical swelling, signs of redness inflammation and severe in gout pain attackpresented such pictedwith classical in paintings. signs1 ofThere inflammation are several in examples gout attack of that;such as aextreme demon swelling, biting the redness foot (Figure and 1severe);2 “A goutypain presented man who “Theas extreme Gout”, swelling,by James redness Gillray inand 1799, severe2 depicts pain apresented bare foot asis drinking a demon wine biting and the playing foot (Figure the cello” 1); “byA gouty H. W. man Bunbury who withas a demonclassical biting signs the of footinflammation (Figure 1);2 in “A goutgouty attack man whosuch is drinkinganother wineexcellent and playingdepiction the ofcello” the byexcruciating H. W. Bunbury pain asis drinking extreme wine swelling, and playingredness the and cello” severe by painH. W. presented Bunbury andis another burning excellent (also represented depiction byof athe demon excruciating here) caused pain asis anothera demon excellent biting the depiction foot (Figure of 1the);2 “Aexcruciating gouty man whopain byand the burning deposition (also ofrepresented natrium urate by acrystals demon in here) the jointscaused of isand drinking burning wine (also and represented playing the by cello” a demon by H. here) W. Bunbury caused patientsby the deposition with gout, of and natrium also urategives crystalsimportant in theinformation joints of isby anotherthe deposition excellent of natriumdepiction urate of crystalsthe excruciating in the joints pain of aboutpatients the with close gout, connection and also betweengives important gout and information alcohol, andpatients burning with (also gout, represented and also gives by a important demon here) information caused oneabout of thethe closemost commonconnection risk between factors forgout gout and (Figure alcohol, 2); byabout the thedeposition close connection of natrium uratebetween crystals gout in and the alcohol,joints of inone “The of the Virgin most and common Child with risk factorsCanon forvan gout der (Paele”Figure 2by); patientsone of the with most gout, common and also risk gives factors important for gout information (Figure 2); thein “ TheEarly Virgin Netherlandish and Child painter with Canon Jan van van Eyck der, Canon Paele” van by Figure 1. “The Gout”, Hames Gillray, 1799. aboutin “The the Virgin close and connection Child with between Canon vangout der and Paele” alcohol, by Figure 1. “The Gout”, Hames Gillray, 1799. theder EarlyPaele Netherlandish is depicted with painter a prominent, Jan van Eyckswollen, Canon left tem van- onethe Early of the Netherlandish most common painter risk factors Jan van for Eyck gout, Canon (Figure van 2); Figure 1. “The Gout”, Hames Gillray, 1799. derporal Paele artery, is suggestivedepicted with of temporala prominent, arteritis swollen (Figure left 3 tem);3 in- inder “ ThePaele Virgin is depicted and Child with with a prominent, Canon van swollen der Paele” left tem 3by- Sandroporal artery, Boticelli’s suggestive “Portrait of temporal of a Youth” arteritis, we (canFigure observe 3); in theporal Early artery, Netherlandish suggestive painterof temporal Jan vanarteritis Eyck (Figure, Canon 3); van3 in Figure 1. “The Gout”, Hames Gillray, 1799. swellingSandro Boticelli’sof the wrists “Portrait and PIPof ajoints, Youth” as, wewell can as deformiobserve- Sandroder Paele Boticelli’s is depicted “Portrait with aof prominent, a Youth”, swollenwe can leftobserve tem- swellingty of the offifth the digitwrists of andthe PIPhand, joints, that ascould well beas deformiattributed- swellingporal artery, of the suggestive wrists and of temporalPIP joints, arteritis as well (Figure as deformi 3);3 in- toty ofarthritis the fifth (Figure digit 4 ).of4 However,the hand, some that couldauthors be claim attributed that Sandroty of the Boticelli’s fifth digit “Portrait of4 the hand,of a Youth” that could, we canbe attributedobserve tothis arthritis is a misinterpretation, (Figure 4). However, and the some way authors he painted claim hands that swellingto arthritis of (Figurethe wrists 4).4 andHowever, PIP joints, some as authors well as claim deformi that- wasthis is a a stylistic misinterpretation, configuration and theseen way in he paintedother paintings hands as tythis of is the a misinterpretation, fifth digit of the andhand, the that way could he painted be attributed hands well;was 5a in stylistic “The Three configuration Graces” by Rubens,seen in we other can observepaintings as towas arthritis 5 a stylistic (Figure configuration 4).4 However, seensome inauthors other claim paintings that as deformitieswell; in “The suggestive Three Graces” of rheumatoid by Rubens, arthritis we can (RA) observe (Fig- thiswell; is5 ina misinterpretation,“The Three Graces” and by the Rubens, way he we painted can observe hands uredeformities 5). This suggestssuggestive not of only rheumatoid the presence arthritis of RA(RA) at (Figthat- deformitieswas a stylistic suggestive configuration of rheumatoid seen inarthritis other (RA) paintings (Fig- as time,ure 5 ).but This also suggests that Rubens not only himself the presence might suffered of RA at fromthat urewell; 55). in This “The suggests Three Graces” not only by the Rubens, presence we ofcan RA observe at that thetime, disease. but also6 We that can Rubens learn a himselflot about might the naturalsuffered history from time,deformities but also suggestive6 that Rubens of rheumatoid himself might arthritis suffered (RA) (fromFig- the disease. We can learn a lot aboutof rheumatic the natural diseas history- urethe disease.5). This suggests6 We can notlearn only a lot the about presence the natural of RA historyat that esof rheumaticthrough paintings, diseas- time, but also that Rubens himselfof mightrheumatic suffered diseas from- aboutes through the characteris paintings,- the disease.6 We can learn a lot aboutes through the natural paintings, history ticsabout and the the characteris course of- Corresponding author: ofabout rheumatic the characteris diseas- KaterinaCorresponding Chatzidionysiou, author: MD, PhD thetics diseaseand the atcourse different of Figure 2. “A gouty man who is drinking wine and play- Corresponding author: estics throughand the coursepaintings, of “A gouty man who is drinking wine and play- 1stKaterina Department Chatzidionysiou, of Propaedeutic MD, PhD and periodsthe disease of time. at different ingFigure the cello”,2. H. W. Bunbury, 1785. Katerina Chatzidionysiou, MD, PhD aboutthe disease the characteris at different- ingFigure the cello”,2. “A gouty H. W. man Bunbury, who is1785. drinking wine and play- Internal1st Department Medicine, of LaikoPropaedeutic Hospital and periods of time. 1st Department of Propaedeutic and ticsperiods and of the time. course of ing the cello”, H. W. Bunbury, 1785. MedicalInternalCorresponding Medicine,School, Nationalauthor: Laiko Hospital and KaterinaInternal Medicine, Chatzidionysiou, Laiko Hospital MD, PhD the disease at different Figure 2. “A gouty man who is drinking wine and play- KapodistrianMedical School, University National of andAthens 1stMedical Department School, ofNational Propaedeutic and and periods of time. ing the cello”, H. W. Bunbury, 1785. 11527Kapodistrian Athens, University Greece of Athens InternalKapodistrian Medicine, University Laiko of Hospital Athens Tel.:11527 +30 Athens, 6982094640 Greece Medical11527 Athens, School, Greece National and E-mail:Tel.: +30 [email protected] 6982094640 E-mail:KapodistrianTel.: +30 [email protected] 6982094640 University of Athens 11527E-mail: Athens,[email protected] Greece 130Tel.: +30 6982094640Cite this article as: Galanopoulos N. The use of Canakinumab in treating resistant gouty disease in patients with limited therapeutic options: 130CiteE-mail: this [email protected] articleTheCite experiencethis as: article Chatzidionysiou as:of theGalanopoulos Rheumatology K. Rheumatic N. The Clinic diseaseuse of of Asklipeion Canakinumab and artistic General creativity. in treatingHospital Mediterr resistant of Voula, J Rheumatol gouty Greece. disease Mediterr 2019;30(2):103-9. in patients J Rheumatol with limited 2019; therapeutic 30(2):...... options:103 130 TheCite experiencethis article as:of theGalanopoulos Rheumatology N. The Clinic use of of Asklipeion Canakinumab General in treatingHospital resistant of Voula, gouty Greece. disease Mediterr in patients J Rheumatol with limited 2019; therapeutic 30(2):...... options: The experience of the Rheumatology Clinic of Asklipeion General Hospital of Voula, Greece. Mediterr J Rheumatol 2019; 30(2):...... 130 Cite this article as: Galanopoulos N. The use of Canakinumab in treating resistant gouty disease in patients with limited therapeutic options: The experience of the Rheumatology Clinic of Asklipeion General Hospital of Voula, Greece. Mediterr J Rheumatol 2019; 30(2):...... MEDITERRANEAN JOURNAL 30 2 OF RHEUMATOLOGY 2019 RHEUMATIC DISEASE AND ARTISTIC CREATIVITY

Figure 3. Detail from “The Virgin and Child with Canon Figure 4. “Portrait of a Youth” by Sandro Boticelli, van der Paele” by Jan van Eyck, 1434-36. We can 1483. The changes depicted in his right hand with observe the prominent temporal artery suggestive of swelling and deformity of the fifth digit has been inter- arteritis. preted as arthritis, possibly juvenile.

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Figure 6. “What the water gave me” by Frida Kahlo, 1938. The sore between her toes are typical lesions of the congenital defect of spina bifida. RHEUMATIC DISEASE AND ITS INFLUENCE IN inARTISTIC his self-portrait CREATION (Figure 7). He also suffered a stroke. developed many ways in order to continue creating art. BySome the authorsend he wasclaim wheelchair-bound, that the influence which of illness could onhave ar- He used to fix his palette on the arm of his wheelchair, beentistic creationdue to post-strokeis little, and hemiplegia,most of the butassociations some authors often attached the brushes to his hands with bandages and claimmade thatare merelyit was duespeculations. to neurological However, complications if we take from into used a moving canvas or picture roll in order to counter- hisconsideration RA.8 He died that in art1919 is theof pneumonia.supreme way of expressing poise the lack of ability to move his arm and stand up.8,9 ourRemarkably innermost for feelings, that time, as happiness,Renoir created fear, hisdespair, own exerpain,- “Les Grandes Baigneuses” is one of his masterpieces bothcises, physical played the and piano mental, and thereball games are some as a wayindisputable to retain painted in this way (Figure 8). His deformities and the examplesas much functionalityof the close ofrelationship the joints betweenas possible. disease He alsoand ways he used to overcome his limited movement and artistic work. Apart from the obvious influence of disease in painter’s art in expressing their feelings relating to the disease, rheumatological conditions have often played a crucial role in the artistic style of many painters, and in some cases, it was the change of the style due to the disease that led to the creation of some of the greatest masterpieces of the artists. Figure 5. “The Three Graces”, by Rubens, 1630-1635. Frida Kahlo (1907-1954) was a famous Mexican painter The changes depicted in the right hand of the Grace in and a feministic icon, famous for depicting paintings her the left of the painting could be attributed to rheumatoid increasingly painful congenital disorder in her. Although it arthritis. is often wrongly considered that her suffering was due to injuries suffered when a streetcar plowed into a bus she was riding when she was 18, the main cause of her suf- impressionist, suffered from severe RA the last 25 years fering was a congenital malformation, spina bifida.7 This of his life.8 Living in a time before the emergence of the was the cause of her progressive trophic ulcers on her potent disease-modifying drugs that are available today, lower extremities (Figure 6). Most of her paintings deal he developed severe deformities and loss of function of with pain, despair and death: as she herself stated, “my his joints. His right shoulder was ankylosed, as were his painting carries with it the message of pain”, and thus hands. He also developed several extra-articular mani- herFigure art is7. closely Self-portrait, related Renoir, to chronic 1910. pain. Cachexia Figure 8. “Lesfestations, Grandes pleuritis, Baigneuses” vasculitis, by Renoir,with sores 1918-1919, and at the one end of Pierre-Augusteis obvious. Renoir (1814-1919), the famous Frenchhis paintings gangrene, that was creatednodules, with rheumatoid the “moving cachexia, canvas” the technique. latter seen

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Figure 9. “La Fee Electricite”, Dufy, 1937. Figure 10. “La Cortisone”, Dufy, 1950. continue painting unavoidably led to adaptions in his bolt. Could it be a symbolism of his own rheumatism? style. He started using small and rapid strokes of thinned Rheumatic pain is sometimes described by patients as paint, and he stopped mixing the colour on the canvas. electricity, and the depiction of a rheumatic hand next to These changes led to the creation of some of the great- the bolt might not be by chance. est masterpieces of impressionism. It has been claimed that Dufy’s style changed as his dis- Renoir was an extremely prolific painter, despite his se- ease progressed. The size of his paintings was reduced, vere illness. He used art as a way to cope with his the plots were less accurate, the hands were represent- pain. “Blessed painting. Even late in life, you are still cre- ed often distorted or sometimes were absent.11 Dufy was ating illusions and occasionally giving joy,” he wrote to one of the first patients with RA to receive corticoste- his friend, the painter Albert André.10 His bright colours roids, after a personal invitation from Freddy Homburger, he used to capture the beauty of real life and of humans an oncologist and Professor of Medicine in Boston, who without problems and the deification of nature, justi- was also an amateur painter.12 At the time of his hospi- fy his title as “painter of happiness”. In contrast to Kah- talization, his RA was highly active and Dufy was almost lo, Renoir gives us a different example of how suffering completely immobilized. The result of the therapy was and pain can lead to the need to express the beauty of amazing, with Dufy becoming mobile within a few days life; perhaps as a way of therapy. As Matisse witnessed: and able to start physiotherapy. He regained his creativ- “A lengthy martyrdom – his fingers-joints were swollen and ity for several more years. Among many other paintings, horribly distorted – yet he now painted his best works! he painted a beautiful bouquet of anemones entitled “La While his body wasted away, his soul seemed to gain Cortisone” (Figure 10). Interestingly, Renoirs’ last paint- strength and he expressed himself with increasing ease”. ing was an anemone. In 1953 Dufy died of an intestinal Raoul Dufy (1877-1953) was a French fauvist also fa- haemorrhage, possibly as a complication of the cortico- mous, as Renoir is, for his positive approach to life steroids in combination with aspirin.13 through his paintings, featuring happiness, luxury and Paul Klee (1879-1940) was a post-impressionist artist pleasure. Gertrude Stein once admiringly said: “Raoul considered one of the most influential artists of the 20th Dufy is pleasure itself”. He developed RA, his symptoms century.14 His highly individual style was influenced by starting in the beginning of 1930. In 1937 he completed several art movements, including expressionism, cub- his masterpiece “La Fee Electricite”, a huge fresco for the ism and surrealism. He developed systemic sclerosis at International Exposition in Paris (Figure 9). Dufy includ- the age of 57, with many typical manifestations of the ed portraits of 110 famous scientists and thinkers who disease, such as Raynaud’s phenomenon, scleroderma contributed to the invention and development of electric- with flexion contractures and subsequently ulcerations, ity, as well as elements of mythology and allegory. If we dysphagia, arthralgia, dyspnoea probably due to lung fi- look closer, we can see a figure with swollen joints in his brosis or pulmonary hypertension, and ultimately heart right hand, holding a cane, next to an electric lightning failure. He finally died 4 years after diagnosis.15

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Figure 11. “Death and fire”, Klee, 1940, one of Klee’s Figure 12. “The sick one in the boat”, Klee, 1940. last paintings. Another example of how his illness affected his art, both his style and his thematology.

RHEUMATIC DISEASE AND ITS INFLUENCE IN ARTISTIC CREATION Some authors claim that the influence of illness on artistic creation is little, and most of the associations often made are merely speculations. However, if we take into consideration that art is the supreme way of expressing our innermost feelings, as happiness, fear, despair, pain, both physical and mental, there are some indisputable Figureexamples 13. of “ Captive”,the close Klee,relationship 1940. Thebetween prison disease might and Figure 14. “Endure!”, Klee, 1940. Possibly his last symboliseartistic work. his Apart hopelessness, from the obvious fear, loneliness influence and of disease painting. The resemblance with one of his photos entrapmentin painter’s artdue in to expressing his disease. their feelings relating to the from his last years is striking, showing the changes his disease, rheumatological conditions have often played a systemic sclerosis made on his image. crucial role in the artistic style of many painters, and in some cases, it was the change of the style due to the Klee’sdisease style that changedled to the profoundly creation of as some a consequence of the greatest of example of how much impact his disease had on him, hismasterpieces disease. His of theproductivity artists. declined at the beginning, Figureshowing 5. his “The disfigured Three Graces” face. , by Rubens, 1630-1635. butFrida one Kahlo year (1907-1954) before his wasdeath, a famous he created Mexican more painter than TheGoing changes back in depicted time, we in will the examine right hand the of case the Graceof anoth in - 1000and a worksfeministic of icon,art. Intricate, famous forsmall-scale depicting compositionspaintings her theer great left of master, the painting the Spanish could be painter attributed Francisco to rheumatoid de Goya gaveincreasingly way to painful larger congenitaland coarser disorder pieces. in However,her. Although while it arthritis.(1746-1828). At age 46, Goya suffered from a severe ill- atis oftenthe beginning wrongly considered he used bright that her colours, suffering after washis diagdue to- ness that lasted several months. It was characterized by nosis,injuries his suffered style is characterizedwhen a streetcar by plowedbroad brush into a strokes,bus she loss of vision and hearing, as well as neuropsychiatric heavy,was riding black when crayon-like she was lines18, the and main dull causecolours. of 15her Many suf- impressionist,symptoms such suffered as severe from headaches, severe RA hallucinations the last 25 yearsand offering the waspaintings a congenital he created malformation, during the spinalast period bifida. 7of This his ofconfusion. his life.8 17Living After ina fewa time months before he therecuperated, emergence but of was the lifewas exemplify the cause the of impact her progressive his illness trophichad to ulcersthe theme on her of potentleft deaf disease-modifying forever. He suffered drugs a milderthat areepisode available with today,similar hislower art, extremities depicting dysmorphia,(Figure 6). Most pain, of suffering her paintings and fear deal of hesymptoms developed two severe years before,deformities suggesting and loss a relapsing of function con of- upcomingwith pain, despairdeath:16 and “Death death: and as fire she” (Figure herself 11 stated,), “The “mysick hisdition. joints.4 In Hisaddition right toshoulder the physical was ankylosed, effects, hisas emotionalwere his paintingone in the carries boat” (Figurewith it 12),the message“The mask of”, “pain”,Repair and”, “A thussick hands.health was He affected.also developed The precise several cause extra-articular of this illness mani has- herman art making is closely plans related”, “Captive to chronic” (Figure pain. 13 ). The drawing, festations,long been pleuritis,debated. vasculitis One early with yet sores unlikely and hypothesisat the end Pierre-Auguste“Endure!” (Figure Renoir 14), maybe (1814-1919), his last drawing,the famous is anotherFrench gangrene,was that he nodules, had syphilis. rheumatoid18 Another cachexia, possible the latterdiagnosis seen

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Figure 16. “Two old men eating soup”, Goya, 1819-1823.

CONCLUSION There is a close relationship between disease and art. Figure 15. “Saturn Devouring His Son”, Goya, Rheumatic disease has inspired many painters as a 1819-1823. theme, but most importantly it has deeply influenced painters who suffered from diverse rheumatological conditions, to express their suffering, pain, despair, but also hope, through their art. It could therefore be considered an excellent, complex and complete patient-reported could have been a rare syndrome called Vogt-Koyan- outcome, and at the same time a therapeutic method. agi-Harada or uveomeningoencephalytic syndrome. This More interestingly though, from an artistic perspective, is an autoimmune disorder which involves the visual and and almost ironically, the disease was in many cases cochlear pigment derived from the neural crest.19 Lead the force that led to change in style and technique that poisoning could also explain the clinical picture, at least contributed substantially to their establishment as great partially. However, the relapsing nature of the disease, the masters, supporting the fact that some of the greatest, regression of symptoms without therapy and the classic most beautiful art is born of great suffering. triad of encephalopathy, branch retinal artery occlusions and hearing loss are suggestive of Susac’s syndrome, a REFERENCES rare primary vasculitis of the central neural system.20 1. Dequeker J. What can a rheumatologist learn from paintings? Acta Goya started his career in Madrid’s Royal Tapestry and Reumatol Port 2006; 31(1):11-3. [PMID: 17058381] 2. Appelboom T, Ehrlich GE. Historical note: the concept of later as a painter to the King, in 1786, creating portraits gout in 1880. Arthritis Rheum 1998;41(8): 1511-2. [https:// very “mainstream” for that time. In 1790 he became ill doi.org/10.1002/1529-0131(199808)41:8%3C1511::AID- for the first time, and 2 years later, he had a second at- ART24%3E3.0.CO;2-L] [PMID: 9704653] tack with the symptoms described above. He became 3. Hinojosa-Azaola A, Alcocer-Varela J. Art and rheumatology: the artist and the rheumatologist’s perspective. Rheumatology (Oxford) isolated because of his permanent deafness. Perhaps 2014;53(10):1725-31. [https://doi.org/10.1093/rheumatology/ as a result of his disease, he started expressing disas- ket459] [PMID: 24489013] ter, chaos, fear and terror in his works after recovery. His 4. Smith PE, Chitty CN, Williams G, Stephens D. Goya’s deafness. paintings became dark and macabre. An example of this Pract Neurol 2008;8(6): 370-7. [https://doi.org/10.1136/ jnnp.2008.161349] [PMID: 19015297] is his famous black paintings, a collection of fourteen, 5. Dequeker J. Arthritis in the paintings of Sandro Botticelli. Arthritis horrifying paintings including “Saturn Devouring His Son” Rheum 1984;27(10):1196-7. [PMID: 6386005] (Figure 15), “Two old men eating soup” (Figure 16), “Men 6. Appelboom T, de Boelpaepe C, Ehrlich GE, Famaey JP. Rubens Reading”, and others. and the question of antiquity of rheumatoid arthritis. JAMA 1981;245(5):483-6. [PMID: 7005475] It is unquestionable that Goya became known due to his 7. Sandblom P. Creativity and Disease; how illness affects literature, later works with a unique style, when he explored ideas art and music. New York: Marion Boyars Publishers Ltd; Revised of naturalism, fantasy and self-expression.21 This is highly edition, 2013. possible that it was trigger by his illness. Thus, the “first 8. Boonen A, van de Rest J, Dequeker J, van der Linden S. How Renoir coped with rheumatoid arthritis. BMJ 1997;315(7123):1704- of the moderns” might not have reached the same levels 8. [https://doi.org/10.1136/bmj.315.7123.1704] [PMID: 9448547] of creation without his terrible disease. [PMCID: PMC2128020]

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9. Zeidler H. Great artists with rheumatoid arthritis: what did their disease and coping teach? Part I. Pierre-Auguste Renoir and Alexej von Jawlensky. J Clin Rheumatol 2012;18(7):376-81. [https://doi. org/10.1097/RHU.0b013e31827bf916] [PMID: 23211585] 10. House J. Renoir’s worlds. In: Raeburn M. ed. Renoir. Rugby: Jolly & Barber;1985:11-18. 11. Kahn MF. Raoul Dufy’s rheumatoid arthritis. Rev Rhum Engl Ed 1998;65(7-9):499-503. [PMID: 9785397] 12. Homburger F, Bonner CD. The treatment of Raoul Dufy’s arthritis. N Engl J Med 1979;301(12):669-73. [https://doi.org/10.1056/ NEJM197909203011224] [PMID: 224316] 13. Zeidler H. Great artists with rheumatoid arthritis. What did their disease and coping teach? Part II. Raoul Dufy and Niki de Saint Phalle. J Clin Rheumatol 2012;18(8):p.431-6. [https://doi. org/10.1097/RHU.0b013e31827bf916] [PMID: 23211585] 14. Gieldion-Welcker C. Paul Klee, Rowohlt, Reinbeck. 1961. 15. Wolf G. Endure!: how Paul Klee’s illness influenced his art. Lancet 1999;353(9163): 1516-8. [https://doi.org/10.1016/S0140- 6736(98)09455-0] [PMID: 10232334] 16. Varga J. Illness and art: the legacy of Paul Klee. Curr Opin Rheumatol 2004;16(6):714-7. [PMID: 15577609] 17. Ravin JG, Ravin TB. What ailed Goya? Surv Ophthalmol 1999;44(2):163-70. [PMID: 10541154] 18. Gordon AG. Goya had syphilis, not Susac’s syndrome. Pract Neurol Figure2009;9(4): 3. Detail 240. from [https://doi.org/10.1136/jnnp.2009.181974]“The Virgin and Child with Canon Figure 4. “Portrait of a Youth” by Sandro Boticelli, van[PMID: der Paele” 19608777] by Jan van Eyck, 1434-36. We can 1483. The changes depicted in his right hand with 19. Vargas LM. The black paintings and the Vogt-Koyanagi-Harada observesyndrome. the Jprominent Fla Med Assoc temporal 1995;82(8):533-4. artery suggestive [PMID: 7561730] of swelling and deformity of the fifth digit has been inter- arteritis.20. Hertzano R, Tomlinson JA, Mackowiak PA. Goya’s Lost Hearing: preted as arthritis, possibly juvenile. A Twenty-First Century Perspective on Its Cause, Effects and Possible Treatment. Am J Med Sci 2019;357(4):275-79. [https:// doi.org/10.1016/j.amjms.2018.12.009] [PMID: 30711190] 21. Rockett P. Francisco Goya (Inspiring Artists). Franklin Watts; RHEUMATICIllustrated edition DISEASE edition (10 AND Mar. 2016) ITS 2016.INFLUENCE IN ARTISTIC CREATION Some authors claim that the influence of illness on artistic creation is little, and most of the associations often made are merely speculations. However, if we take into consideration that art is the supreme way of expressing our innermost feelings, as happiness, fear, despair, pain, both physical and mental, there are some indisputable examples of the close relationship between disease and artistic work. Apart from the obvious influence of disease in painter’s art in expressing their feelings relating to the disease, rheumatological conditions have often played a crucial role in the artistic style of many painters, and in some cases, it was the change of the style due to the disease that led to the creation of some of the greatest masterpieces of the artists. Figure 5. “The Three Graces”, by Rubens, 1630-1635. Frida Kahlo (1907-1954) was a famous Mexican painter The changes depicted in the right hand of the Grace in and a feministic icon, famous for depicting paintings her the left of the painting could be attributed to rheumatoid increasingly painful congenital disorder in her. Although it arthritis. is often wrongly considered that her suffering was due to injuries suffered when a streetcar plowed into a bus she was riding when she was 18, the main cause of her suf- impressionist, suffered from severe RA the last 25 years fering was a congenital malformation, spina bifida.7 This of his life.8 Living in a time before the emergence of the was the cause of her progressive trophic ulcers on her potent disease-modifying drugs that are available today, lower extremities (Figure 6). Most of her paintings deal he developed severe deformities and loss of function of with pain, despair and death: as she herself stated, “my his joints. His right shoulder was ankylosed, as were his painting carries with it the message of pain”, and thus hands. He also developed several extra-articular mani- her art is closely related to chronic pain. festations, pleuritis, vasculitis with sores and at the end Pierre-Auguste Renoir (1814-1919), the famous French gangrene, nodules, rheumatoid cachexia, the latter seen

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