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Scoliosis and Trendelenburg sign in a painting by P P Rubens
  1. S E Hansen1
  1. 1Clinic of Rheumatology, H:S Bispebjerg Hospital, DK-2400 Copenhagen NV, Denmark
    1. J Dequeker2
    1. 2Department of Rheumatology, University Hospitals, K U Leuven, B-3000 Leuven, Belgium

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      In an article on Rubens' painting “The Three Graces” Dequeker suggests that hypermobility is a medical explanation of the seeming scoliosis and Trendelenburg sign in the middle figure.1 But the posture of this middle figure should probably be interpreted as an artistic phenomenon without medical reference.

      Sculptors in classical Greek and Roman periods often used the contrapposto posture. In this, by putting most weight on one leg, the other leg can be shown in a relaxed and semiflexed position. This undulating between tension and relaxation will animate the figure. A person with normal muscular function and a normal back can perfectly well pose in this way with relaxed hip abductors on the weightbearing side, a descending hip on the opposite side, and a compensating scoliotic posture. This posture is facilitated by support from the arm as in Rubens' painting. If the person tries to take a forward step, relaxation of the muscles of the weightbearing hip can no longer be maintained, and the positive Trendelenburg sign will disappear.

      In the Renaissance period the use of this contrapposto posture was revived. During his stay in Rome Rubens eagerly studied the then recently excavated Laokoön sculpture with its three distorted figures.2 He often used such distorted postures in his paintings to give the impression of vigorous muscular characters capable of performing great tasks. The best example is probably “The Debarkation at Marseilles” in the Maria de Medici cycle from 1622 to 1625 for the Luxembourg Palace in Paris.3 Here, three young women, nereides, with curved muscular backs at the bottom of the picture nearly seem to carry the ship of Maria de Medici.

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      Author's response

      Dr Hansen's remarks about our recent article in the Annals1 are pertinent and have to be taken as a alternative explanation for the observed functional scoliosis and positive Trendelenburg sign. I am grateful for this artistic-historical information. However, this does not exclude the possible diagnosis of benign familial hypermobility syndrome. In several other paintings by Rubens, where the three sitters (sisters) of the graces are represented, clinical signs of hypermobility can be seen. In the painting “The Judgement of Paris” (London National Gallery) a positive Trendelenburg sign and scoliosis can be seen in the two blond sisters who are now in a walking position without support. In one of them the right wrist is in 90° hyperflexion. In the painting “Sine Cerere et Baccho friget Venus” (Brussels Koninklijke Musea voor Schone Kunsten), subluxation of the left wrist is seen in the dark blond sister and hyperextension of the distal interphalangeal (DIP) joint of the fourth finger in another sister with brown hair. Hyperextension of a DIP and metacarpophalangeal finger joint and hyperflexion of a wrist joint is also seen in the brown haired sister of the painting “The Madonna and Saints” (Antwerp, Sint-Jacobskerk).

      I, as well as Sven Hansen, am fully aware that errors of diagnosis are commonly made either by seeing disease where none exists or by interpreting at face value a pathological appearance that is only the expression of an artistic convention. The observations made in P P Rubens' painting, representing the sitters for “the graces” painting who are Rubens' second wife Helen Froment and her younger sisters, are very suggestive of the diagnosis of benign familial hypermobility syndrome and not a purely artistic phenomenon.

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