Hieronymus Bosch (1450-1516): Paleopathology of the Medieval Disabled and its Relation to the Bone and Joint Decade 2000-2010
By Jan Dequeker, Guy Fabry and Ludo Vanopdenbosch
The Israeli Medical Association Journal, Vol.3 (2001)
Background: At the start of the Bone and Joint Decade 2000-2010, a paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders and attitudes towards the afflicted in the past compared to today.
Objective: To analyze The procession of the Cripples, a representative drawing of 31 disabled individuals by Hieronymus Bosch in 1500.
Methods: Three specialists – a rheumatologist, an orthopedic surgeon and a neurologist – analyzed each case by problem-solving means and clinical reasoning in order to formulate a consensus on the most likely diagnosis.
Results: This iconographic study of cripples in the sixteenth century reveals that the most common crippling disorder was not a neural form of leprosy, but rather that other disorders were also prevalent, such as congenital malformation, dry gangrene due to ergotism, post-traumatic amputations, infectious diseases (Pott’s, syphilis), and even simulators. The drawings show characteristic coping patterns and different kinds of crutches and aids.
Conclusion: A correct clinical diagnosis can be reached through the collaboration of a rheumatologist, an orthopedist and a neurologist. The Bone and Joint Decade Project, calling for attention and education with respect to musculoskeletal disorders, should reduce the impact and burden of crippling diseases worldwide through early clinical diagnosis and appropriate treatment.
The visual arts, especially in combination with historical data, can be an important tool for paleopathological research. Works of art of different kinds may serve as a source of evidence of disease and contribute to a better understanding of the natural history of the disease.
When searching for the paleopathology of musculoskeletal disorders in pictures, one encounters many paintings and miniatures of the medieval era depicting the physically disabled, particularly lower limb amputees. They are usually considered to be victims of leprosy. Helmut Vogt, in his book Das Bild des Kranken, states that the neural form of leprosy was the most common cause, but proposes that a differential diagnosis of joint tuberculosis, polyarthritis, osteomyelitis, lues (syphilis) and war wounds could be made. However, other diagnostic possibilities have to be considered, in particular congenital malformations and dry gangrene due to ergotism. Ergotism was epidemic in medieval times in the Netherlands.