Brussels, Belgium - The idea that rheumatoid arthritis (RA) is a relatively "new" disease in Europe has been debated for years. Dr Thierry Appelboom (Erasmus Hospital, Brussels, Belgium) argues in the May 2005 issue of Rheumatology that the artist Peter Paul Rubens was "one of the first victims of an epidemic of rheumatoid arthritis that started in the 16th-17th century" and that details of Rubens's paintings illustrate the progression of rheumatoid joint damage [ 1 ].
Appelboom writes, "[Antwerp, where Rubens lived] was frequented by sailors returning from the New World with shipments that revolutionized eating habits, doubled the available therapeutic assortment of medicinal plants, mixed the genes of populations, swapped infectious plants, changed living conditions and the local ecology, etc. This series of conditions, taken together, enabled an infectious, but in principle not aggressive, American agent to find genetically more receptive European hosts."
The evidence that Rubens had RA rather than gout comes from his correspondence and from his paintings. Appelboom notes that Rubens writes of suffering from a "gouty rheumatism that affected several joints chronically, chiefly his hands, feet, and knees, and was sometimes so disabling that it prevented him from accomplishing certain commissions." Appelboom also thinks that Rubens used his own hands and feet as models for the damage depicted in some of his paintings.
In The Three Graces, painted in 1638, Appelboom says, "From a doctor's view of things, the joints of the middle of the fingers on the right hand of the Grace on the left are half bent and are in hyperextension; this particular position cannot be adopted by a normal hand since the joints on the same finger can be bent only at the same time, possibly extended slightly, but the joints of the same finger cannot move in opposite directions unless the finger has suffered an accident . . . or is affected by rheumatism . . . that has distended the capsuloligamentary system." One reason Rubens is suspected of painting images of his own hands is that the model for the figures of the Three Graces was his young wife, Helene Fourment, who was only 23 and not known to have had joint problems.
Abnormalities in Rubens's paintings show a progression that roughly parallels the natural progression of RA. Appelboom says that paintings from 1609 show some swelling at the metacarpophalangeal joints of the second and third fingers. The following year's images included swelling of the wrist. By 1615 Rubens was including symmetrical involvement of the hands. The proximal interphalangeal joints were included in abnormalities painted in 1629, and the 1633 painting of The Holy Family with St Anne included dorsal subluxation of the ulnae, suggesting rupture of the articular disks. Paintings in 1633 also included dorsal concavity of the hands, and images of swan neck deformities appeared in 1638.
RA rare in early Europe, common in America
Several researchers have commented on the relative rarity of RA joint changes in skeletons from European sites before Rubens' time. For example, Dr Bruce M Rothschild (Arthritis Center of Northeast Ohio, Youngstown) recently reported an analysis of 688 skeletons from European sites ranging from the Bronze Age to the Black Plague epidemic of 1485-1486. "Erosive disease was uncommon and always oligoarticular in distribution," Rothschild said [ 2 ].
Meanwhile, on the other side of the globe, there is considerable evidence of RA in American Indians during those periods, which opens the possibility that RA originated in the Americas and spread worldwide when European explorers came into contact with Indian tribes and then returned to European ports such as Rubens's home of Antwerp [ 3 ]. Interestingly, although RA is common and sometimes severe in groups of American Indians, it is not associated with HLA-DR4, as it is in whites.
The evil weed? Or aspirin? Or marrying the girl not next door?
The history of RA has been discussed in recent years by other groups, and these researchers have focused both on pinpointing the earliest reliable evidence of RA in Europe and on sorting out factors that might have contributed to the clear increase in RA incidence after the 16th century. For instance, writing in Journal of Rheumatology, Dr FJ Aceves-Avila (Hospital de Especialidades, Guadalajara, Mexico) et al point to changes in European diet and customs by products from the New World, specifically tobacco, as factors possibly contributing to the increase incidence of RA [ 4 ].
"Unknown in Europe before 1492, [tobacco] has been proposed in recent years as an independent risk factor for RA. The physiopathogenic mechanisms proposed are endothelial damage and increased production of rheumatoid factors," Aceves-Avila says.
And there is another surprising possibility. "Could it be," Drs Watson Buchanan and Rodger M Laurent ask, "that aspirin, introduced in 1899, is an environmental factor leading to the apparent increase in incidence of rheumatoid arthritis, by causing gastrointestinal erosions, so allowing access of gut bacteria and food allergens to pass more readily into the bloodstream? [ 5 ]"
Appelboom tells rheumawire , "So far, we do not have solid data to show that the transmission is due to microbes, viruses, or environmental factors. Food has changed, clothes have changed, climate has changed, cities have changed, comorbidity factors have changed, and genetic factors have changed because marriage is no longer limited to people who happen to live not far from one another." As his analysis shows, this initially arcane focus on one painter's images of hands has now become part of the broader stream of research on RA etiology and on what the history of that disease might imply for its future.
Rothschild BM, Coppa A, Petrone PP. "Like a virgin": Absence of rheumatoid arthritis and treponematosis, good sanitation, and only rare gout in Italy prior to the 15th century. Reumatismo 2004; 56:61-66. Abstract
Medscape Medical News © 2005
Cite this: Janis Kelly. Did RA travel from New World to Old? The Rubens connection - Medscape - Jun 14, 2005.