Michelangelo's gout in a fresco by Raphael
Authors: Carlos Hugo Espinel
Journal: The Lancet (1999)

", with many a knee bowed low in the dust,…" Aeschylus, The Oresteia1Aeschylus."Agamemnon", in A Trilogy: The Oresteia. Trans. George Thomson. Cambridge University Press, Cambridge1989Google Scholar Understanding a complex medical problem may require the physician to seek clues beyond science, a pursuit central to the integration of medical science with art and humanities.2Espinel CH Masaccio's cripple: a neurological syndrome. Its art, medicine, and values.Lancet. 1995; 346: 1684-1686Abstract PubMed Google Scholar, 3Espinel CH Art and neuroscience: how the brain sees Vermeer's "Woman Holding a Balance".Lancet. 1998; 352: 2007-2009Summary Full Text Full Text PDF PubMed Scopus (9) Google Scholar In Raphael's fresco at The Vatican, School of Athens (figure 1), one figure has a sign of disease and may be Michelangelo (figure 2).Figure 2Michelangelo's right knee with gouty tophiShow full captionPhotograph by author with approval.View Large Image Figure ViewerDownload (PPT) Photograph by author with approval. Our obsession with immortality is inherent in the human condition. About 500 years ago, Pope Julius II, advised by scholars decided to leave a testimony, suggested by the newly rediscovered Greek philosophy, to perfection.4PlatoPlato the Collected Dialogues of Lincluding the letters.in: Cooper Cornford FM Guthrie WKC Hamilton, Edith and Cairns, Huntington. Princeton University Press, Princeton NJ1985Google Scholar, 5CB Scmitt Skinner Q E Kessler Kraye J The Cambridge History of Renaissance Philosophy. Cambridge University Press, New York1988Google Scholar They thought perfection could be found in art. Michelangelo was summoned to Rome. A scaffolding covered the ceiling of the Sistine chapel, and above he toiled to represent images of divine creation. But rumours spread. Why the secrecy? Michelangelo was taking too long, he was a great sculptor but an inexperienced painter. Julius II demanded to see the work. And it was said that when stepping down from the scaffolding, his face was transfixed with awe.6Lucki E History of the Renaissance 1350–1550; Book IV Literature & Art. University of Utah Press, Salt Lake City1965Google Scholar, 7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar, 8"The High Renaissance".Gardner's Art Through the Ages, 9th edition, vol. II.in: de la Croix H Tansey RG Kirkpatrick D Harcourt Brace College Publishers, New York, NY1987: p 645-p 665Google Scholar, 9Jones R Nicholas P Raphael. Yale University Press, New Haven, CT1983: p 1-p20Google Scholar, 10The Sistine Chapel.A Glorious Restoration. Pierluigi de Vecchi. Harry N. Abrams, Inc, Publishers, New York, NY1994Google Scholar The Pope, ageing, his obsession worsening, decided to fill his own quarters with images of human creation. On Jan 13, 1509, Raphael, a famous painter of beautiful Madonnas, was commissioned to decorate the Pope's own library, the Stanza della Signatura.7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar, 8"The High Renaissance".Gardner's Art Through the Ages, 9th edition, vol. II.in: de la Croix H Tansey RG Kirkpatrick D Harcourt Brace College Publishers, New York, NY1987: p 645-p 665Google Scholar, 9Jones R Nicholas P Raphael. Yale University Press, New Haven, CT1983: p 1-p20Google Scholar The practical problems, however, seemed insurmountable. The library was a small cubicle. Theology, law, and poetry being prerequisites; one wall remained to depict philosophy, the disciplines of which are difficult to envision. Raphael grounded his art in science. In linear perspective he designed a grand architectural structure where he portayed luminaries of thought. In the School of Athens, in which Plato holds his "Timaeus" and Aristotle his "Ethics", as Socrates touches his forefinger. Pythagoras writes on harmonic relations, while the turbaned Avicenna watches. Diogenes reclines on the steps. Euclid demonstrates a theorem. Ptolemy holds a terrestrial globe, and Zoroaster, a celestial globe. Raphael portrayed himself, the young man on the far right with the black cap, among the scientists. Who, then, is the man in the foreground, in the centre? Some scholars say he looks "brooding and alone", and claim, solely on this basis, that he is Heraclitus.8"The High Renaissance".Gardner's Art Through the Ages, 9th edition, vol. II.in: de la Croix H Tansey RG Kirkpatrick D Harcourt Brace College Publishers, New York, NY1987: p 645-p 665Google Scholar But no investigation has established his identity.9Jones R Nicholas P Raphael. Yale University Press, New Haven, CT1983: p 1-p20Google Scholar To identify the figure, let us first study Raphael's technique. He was meticulous. He first calculated spaces and sketched the scene on paper. He drew the subjects in the nude, muscles and bones in action. He added the skin, dressed the figures, and detailed their gestures. He transcribed the drawings to cardboard sheets the size of the fresco; the cartoon. He proceeded in precise, timed steps. When the plaster was ready, smooth, and wet, he laid the cartoon on its surface and traced the drawings. He pulled away the cartoon; ghosts of images appeared in the plaster. Now there was no stopping. These cartoons reveal Raphael's plans. The ones for the School of Athens are in the Ambrosiana Gallery in Milan. The figure in question, however, is not in it. Did Raphael overlook Heraclitus? This is unlikely; as he is the most important pre-Socratic philosopher.5CB Scmitt Skinner Q E Kessler Kraye J The Cambridge History of Renaissance Philosophy. Cambridge University Press, New York1988Google Scholar Who is this man? Analysis of the plaster shows that this figure was painted last, about the time when, on Aug 14, 1511, Michelangelo had allowed a viewing of the Sistine ceiling.7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar, 8"The High Renaissance".Gardner's Art Through the Ages, 9th edition, vol. II.in: de la Croix H Tansey RG Kirkpatrick D Harcourt Brace College Publishers, New York, NY1987: p 645-p 665Google Scholar, 9Jones R Nicholas P Raphael. Yale University Press, New Haven, CT1983: p 1-p20Google Scholar, 10The Sistine Chapel.A Glorious Restoration. Pierluigi de Vecchi. Harry N. Abrams, Inc, Publishers, New York, NY1994Google Scholar Raphael, working nearby, his own frescos finished may have visited the cavernous chapel. And scanning the divine images above, realising that now he would have to change, and the world would have to change, Raphael may have decided to add a portrait of Michelangelo. The style of this portrait, the figure's space, mass, and perspective are free from geometric canons, more akin to the images in the Sistine Chapel. The man sits on the steps and leans on a marble block. Unlike the others who are dressed in classical robes, he is in contemporary clothes, a simple purple cassock and boots. Vasari, a painter and art historian who knew Michelangelo, describes him dressing modestly and wearing boots, "buskins of dogskin".7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar The added man is the only one with such boots. Of the Sistine Chapel's more than 300 figures, it is in that of Jeremiah, one of Michelangelo's alleged self-portaits, which has a hint of boots. The man appears to be Michelangelo's age at that time, about 35 and of his average size. Similarly, his hair is black with beard and moustache. His head bowed, his face cannot be fully seen, but his nose appears to be twisted. "His nose was somewhat flattened, broken in his youth by Torrigiano's fist," Vasari states. His lower lip is seen despite his position: "It was pronounced" Vasari adds. His ears, "large", are hidden. The man does match the description of Michelangelo. When studying Raphael's borders between light and darkness there is a crucial clue, a sign of disease. The figure's brightest part is the right knee. He bends over, and his own shadow frames and highlights the knee. The boots are rolled down, the right has a ruddy shadow on the flap at the knee, like a worn patch. The knee, bent at 120°, is enlarged and deformed. By contrast, other knees in the fresco appear normal, like those of Diogenes a few steps away. It is not a hot knee: its skin, pale and tense, shows no signs of inflammation, nor is there ulceration. But underneath the skin there are lumps; knobs of a light yellow that appear dense and hard. There are three clusters of knobs: two above the patella, one to the side, over the bursa, and another, with three distinct protuberances, leads down to the head of the tibia. These findings indicate gouty tophi, called gonagra when on the knees. Other possibilities, including osteoarthritis and synovial chondromatosis, are unlikely because of his age and the location of the lesions.11Text book of Rheumatology. 5th Edition. Vol 2. W B Saunders Company, Philadelphia1998: 1313-1351Google Scholar In this portrait Michelangelo holds a quill pen. He was also a poet.12Tusianai J The Complete Poems of Michelangelo. Noonday Press, New York, NY1960Google Scholar In his writings various episodes of kidney and bladder colic throughout his life are described. In 1549 he had an episode of anuria that in letters to his nephew he tells was followed by the passing of gravel and stone fragments.13The Letters of Michelangelo: Vols 1 and 2.in: Ramsden EH Stanford University Press, Stanford, California1963Google Scholar Vasari adds, "The master suffered from dysuria and from gravel, which developed into the stone."7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar Michelangelo laments in a poem written about 1546–50. "I'ho 'imparato conoce l'orina12Tusianai J The Complete Poems of Michelangelo. Noonday Press, New York, NY1960Google Scholar" (I have learned to know the urine). In practice, in an adult man with both kidney stones and tophi, the diagnostic possibilities are reduced to gout.11Text book of Rheumatology. 5th Edition. Vol 2. W B Saunders Company, Philadelphia1998: 1313-1351Google Scholar In Michelangelo's case, gout would explain the gravel in his urine as caused by uric acid and his stone formation as urate urolithiasis.14Espinel CH Diagnosis of acute and chronic renal failure.Clin Lab Med. 1993; 13: 89-102PubMed Google Scholar, 15Kokko J Approach to the patient with renal disease.in: Bennett JC Plum F Cecil's Textbook of Medicine. Edition 20. WB Saunders, Philadelphia1996: 511-517Google Scholar Seeking the cause of Michelangelo's gout his family history is not contributory.6Lucki E History of the Renaissance 1350–1550; Book IV Literature & Art. University of Utah Press, Salt Lake City1965Google Scholar, 7Vasari G "The Life of Michelangelo Buonarroti" and "The Life of Raffaello Da Urbino".in: Sonino M The Great Masters. Trans: Gaston Du C, de Vere. Hugh Lauter Levin Assoc, Inc, China1986: 127-328Google Scholar Plumbism should be considered. Vasari states the master, obsessed with his work, would go for days on bread and wine. Wine was processed in lead containers. He might also have been exposed to lead-based paints. History abounds with written descriptions of gout, those of Hippocrates, Galen, Avicenna, Sydenham, Garrod, and others.16Hippocrates: The genuine works of Hippocrates, vols I and II. Trans by Francis Adams. Wood, New York1886Google Scholar, 17Copeman WSC A Short History of the Gout. Univ California Press, Berkeley1964Google Scholar But its illustration is scant. In Hogarth's drawings and in caricatures, bandaged lower extremities imply gout.18Rodnan GP. A gallery of gout. Arthritis Rheum 4 27–46Google Scholar In medical textbooks, ink drawings and photographs illustrate anonymous tophi. Michelangelo's knee, as portrayed by Raphael, is an early pictorial description of gout. This study shows an early pictorial description of gout; medical evidence that identifies the figure added to Raphael's School of Athens as Michelangelo; and a diagnosis of gout associated with tophi, gonagra, and nephrolithiasis.