Richard III: a study in medical misrepresentation

The place of Richard III in English history

King Richard III's reign lasted a mere 25 months, yet he is undoubtedly one of the most notorious monarchs in English history. His reputation has been emblazoned in our memories as a consequence of Shakespeare's theatrical presentation. In addition, his involvement in the Battle of Bosworth, one of the most publicized English conflicts, has ensured that he is not readily forgotten, given the flurry of Tudor propaganda constructed after his death. His reputation has taken a number of beatings over the centuries due to a series of unfortunate incidents in which he played a central role.

The misfortune began in 1483, following the death of Richard's illegitimate brother King Edward IV. Edward's sons were too young to take the throne, so Richard became their protector. However, in the same year, Richard was crowned King after both of the young princes died under mysterious circumstances. Many believe that Richard played some part in their death. Shortly after, in 1484, Richard's own son died, followed by his wife. Many suspected that Richard had poisoned her as she was too old to bear another child. It has been suggested that he wanted to marry his niece, who was still of childbearing age. In so doing, he would have been able to father another heir. Indeed, considerable conflict surrounded the issue of whether Richard should become King, with Henry Tudor claiming he was the rightful heir. This led to civil war in 1485, which was resolved by the Battle of Bosworth. This battle claimed the life of 33-year-old Richard and led to multiple assaults on his reputation during the reigns of the Tudor monarchs.

Descriptions of Richard III

Historically, Richard has been portrayed as ‘… a man children used to be taught to consider as the archetypal wicked uncle’.¹

The earliest reference to Richard being a hunchback comes from the records of the city of York in 1491. A local schoolmaster, John Payntour, was accused of having referred to Richard as ‘… a hypocrite, a crook and a crook back’.²

But it was Thomas More, the well-known Tudor humanist scholar, who created the image that became a fixture in the Tudor imagination, stating that Richard was of ‘… little stature, ill featured of limbs, crook backed, his left shoulder much higher than his right, hard-favoured of visage … malicious, wrathful, envious from before birth and ever forward’.³

Sir Thomas More, Chancellor of England 1529–1532, was 8 years old when the Battle of Bosworth was fought. This virulent piece of character assassination directed against the last Plantagenet king by someone later canonized as a saint has always been a paradox and a puzzle. Contemporary historian, Alison Hanham, has recently drawn attention to the fact that More was a famous intellectual joker and suggests More's account of Richard III is largely ironic, and simply an unlikely tale with which he expected to gull the public. Thomas More never completed or sought to publish this work, but what he wrote was published after his death and has been read straight ever since. This piece is now believed to be ironical because of the opening words:

‘King Edward, of that name the fourth, died after he had lived fifty and three years, seven months and six days ….’¹

Yet Edward, in fact, died 19 days before his 41st birthday. This is such an enormous error that it must be assumed to be a deliberate mistake and More was laughing up his sleeve from line one.

Richard had previously been described as Shakespeare's first major character and his second most substantial, after Hamlet, in terms of the number of lines he was given. Shakespeare's image of Richard III, written in 1597, is based on the reports of several Tudor historians, including More's caricature of him, none of which chose to be sympathetic towards Richard.³ He is always displayed as a limping hunchback with a withered arm, an evil disposition and a mean face.² But, Shakespeare did not display conspicuous reliability about Richard III. For example, in Henry VI Part II, act V, scene ii, Richard is shown killing the Duke of Somerset at the Battle of St Albans (May 1455). Richard was only 2 years old at the time of this battle, providing an insight into Shakespeare's prioritization with regard to fictional over factual value.⁴

Accounts from near the time of Richard's reign agree that Richard was unusually small, with the majority of sources describing a slight shoulder abnormality, although the reported severity of this deformity varies greatly between authors. In addition, More's report hint at a deformity affecting Richard's left arm. More's description of a meeting which took place on 13 June 1483, describes how Richard pulled up his left sleeve to show his withered arm, and states that all those present were aware that it had been this way from birth.

However, there is no reliable evidence for the popular Tudor idea that Richard was hunchbacked. Not even the hostile John Rous, author of the renowned Historia Regum Angliae, who has been reported to have seen Richard, and claimed that Richard was born with teeth and hair down to his shoulders after the unlikely term of two years in his mother's womb, calls him a crookback – merely stating that his right shoulder was higher than his left.

To cloud the issue further, some sources indicate that Richard's deformity may have been nothing more than a slight but normal unevenness of shoulders. This theory is supported by the majority of contemporaries who mention his appearance (the Crowland Chronicler, Mancini and Commines, for example), who all have agreed that he was not deformed. This adds weight to the theory that any deformity, whether it affected Richard's shoulders or his arms, could not have been very noticeable, and may have been exaggerated or played down depending on the source's political affiliations.¹

The nature of the portrait in 15th century

Portraits are always a compromise between the patron's individual requirements and the traditions of the genre within which the painter is working. According to Norbert Schneider, the portrait was used by the sitter to define his role in society and to tell the spectator something about his interests, intentions and values. Probably all portraits were intended to impress. Therefore, rank would primarily be displayed by means of opulent robes and heraldic or emblematic attributes.⁵

Portraits of Richard III are very similar to the style of Jan van Eyck, a Flemish painter in the first half of the 15th century. He used the same pose – with the sitter facing the spectator with their face slightly averted. Van Eyck did not try to express the feelings of the subject in the face. Unlike later painters, he made no attempt to extract the essence of the subject. He was essentially making a photographic record of what he saw.⁵

Portraits in the late 15th century assumed an important role in helping to identify individuals, intensifying the demand for a faithful pictorial imitation of reality. Verifiable resemblance therefore became an essential criterion of portrait painting during the late middle ages. Portraits were often shown to prospective suitors. There is a suggestion that the portrait of Richard in the Royal Collection was a copy of one executed during Richard's life, when he re-entered the marriage market after the death of his wife. The inscription on the Royal Collection portrait certifies its authenticity. Its purpose was to verify the identity of the likeness to the sitter. There was a growing tendency to document legal transactions in writing during the 15th century. The writing is almost stating: ‘This is a legal representation of Richard III’.⁵

The importance of royal artists producing a true likeness of the sitter was exemplified some 20 years later, in a celebrated episode, when Hans Holbein was commissioned to paint the German princess, Anne of Cleves, whom King Henry VIII was considering for marriage. Previous portraits sent to Henry had concealed Anne's face, and Holbein, as the King's trusted artist, was dispatched to Duren to get an accurate likeness. However, Holbein found himself caught between accurately depicting the unattractive sitter, and appeasing those who had commissioned him. Holbein resorted to a strongly geometrical layout, a costume bedecked in gold and jewels, and a sumptuous green background to distract from the sitter, and provide a flattering portrait. Batschmann and Griener rather unkindly describe the result as ‘akin to a cheap stone mounted in too rich a setting’.⁶ Rather, the face is neutral and characterless and, in the eyes of some critics, designed to offend no-one. Deceived by Holbein's artful diplomacy, as is notorious, Henry VIII agreed to marry Anne. However, on meeting Anne, Henry immediately realized the disparity between the portrait and reality, and felt misled, declaring the unfortunate Anne a ‘fat Flanders mare’. Holbein lost favour with the King, and never received another royal commission. Henry sought the annulment of his marriage and within six months it was dissolved.⁶ Although Henry was an exceptionally terrifying and demanding patron, this incident exemplifies the need at this time for monarchs to repose a level of trust in these essentially political portraits representing reasonably true likenesses of the sitter.

Some of the Flemish painters, like Rogier, official painter to the city of Brussels in 1436, idealized his sitters, lending them greater sophistication. Rogier paid particular attention to the refined delicacy of the sitter's hands.⁵ The hands in the portrait in the Royal Collection are very carefully portrayed. Around the 1480s, Leonardo da Vinci was using landscaped backgrounds to indicate something about the psychology of the sitter.⁵ The artists painting Richard are not doing that. Therefore, when we interpret the portraits we must regard them as photographic legal documents. Hence, the X-ray evidence of alterations to the original document is as significant as the defacing of a passport photograph.

Towards the end of the 15th century, portrait painters focused increasingly on inward states, on the evocation of atmosphere and the portrayal of mental and moral attitudes.⁵ It may be that, as the portraits of Richard were repeatedly copied, there was a tendency to introduce feelings into the face or demeanor of the sitter, reflecting current attitudes to the sitter. Such attitudes at this time were very hostile to Richard's memory.

The portraits of Richard III

The portrait in the Royal Collection has been copied many times and is almost certainly a copy itself (Figure 1a). Through tree-ring dating, it has been estimated to have been painted between 1518 and 1523, and has been shown to have had an original straight shoulder line under recent X-ray examination. Many copies were made of this painting – each only slightly different from the original.^1,7

Figure 1a.

The Royal Collection portrait

The portrait was executed with a normal right shoulder line, which was altered later to give a slight tilt. This change has been carried through in all copies made of it. The detailing is remarkably contemporary and there is evidence that the overtones of villainy and deformity are later alterations. In common with many Flemish portraits, it is half-length and he is looking to his left.¹ He is shown playing with the ring on the little finger of his right hand. The ring is a symbol of authority, or delegated authority. It can also symbolize union, as in the marriage ceremony.⁸ It is difficult to ascertain if there was any deformity, as men's garments were padded in the late 15th century, not only in the shoulders, but also on the chest to emphasize a slim waist line. However, an asymmetry in the detailing of the elaborate jeweled chain across his chest may hint that the position of his right shoulder has been altered to appear higher than his left.

This is confirmed by X-rays ( Figure 1b) of this portrait which reveal an alteration in the outline of the king's right shoulder; as originally drawn, it was lower than at present.

Figure 1b.

X-ray of Royal Collection portrait

With the X-ray evidence, the earlier silhouette becomes visible to the eye, with some jewels positioned above the original shoulder line. The alteration is enough to hint at shoulder deformity, a deformity which is then reproduced in all versions of this portrait. In addition, the underlying layers of paint also show that Richard's eye was originally drawn in a slit-like fashion.^7,9 The alterations are consistent with Tudor propaganda, and could have been made following the Battle of Bosworth.¹ As the picture was not painted before 1485, when Richard was alive, it is hard to see why these features were not incorporated from the beginning.

Another portrait of Richard ( Figure 2) is held at the Society of Antiquaries in London. Based on tree-ring dating of the panel, it is estimated to have been painted in 1516, 31 years after Richard's death.¹ There is no suggestion of deformity. A portrait of his brother Edward IV, who predeceased him, has been painted on a panel from the same tree. The portrait of Edward suggests a slightly raised right shoulder. This time, Richard faces towards his right against a plain background. He is putting a ring onto the fourth finger of his left hand, which to us is the marriage finger, although this was not strictly observed during the 15th and 16th centuries. There is an inscription, ‘Richard Rex tertius’ in a humanist script typical of the Flemish painters, and his hands are delicately rendered in the style of Rogier.⁵ The detail in the portrait provides evidence of it having been a faithful copy of a lost original painted during Richard's lifetime. The workmanship is of outstanding quality – for example, the jeweled chain across his chest has a three-dimensional quality which contrasts with the flat arrangement of the one in the Royal Collection and its copies (Figure 1a).¹

Figure 2.

Society of Antiquaries painting

Figure 3 shows a portrait of Richard holding a broken sword. It is thought to have been painted around 1550, at the time of More's description of Richard's shoulders, which it closely follows – with his left shoulder higher than the right. X-ray evidence has revealed that when the portrait was originally painted, Richard was shown to have a prodigious humpback, with the sitter's shortened left arm having been painted to spring unnaturally from the left shoulder.⁹ At some point before 1787, during the 17th and 18th centuries, radical alterations were made to correct these abnormalities. The shoulder line was altered so that it receded into the background and the deformities no longer appeared prominently, allowing the raised shoulder line to be easily overlooked.¹ The deformities of his left arm were also removed.⁹ However, despite the removal of abnormal posturing of his shoulders and left arm, Richard's left hand remains in an arguably abnormal position. His hand is shown to have extension of the metacarpophalangeal joints and flexion of the proximal interphalangeal joints in the little and ring fingers. This could be suggestive of a neural injury, potentially caused by injury to the lower brachial plexus or ulnar nerve.

Figure 3.

Broken Sword portrait

Interpreting the original symbolic meaning of this painting is difficult. It could have been an attack on Richard, with it being painted after his death, and the deformities being included on the original. Support for this theory is suggested by its close adherence to More's virulent description of Richard. The broken sword, which he rests on his left shoulder, in the upright ceremonial position, could symbolize the defeat of the House of York at Bosworth.¹ However, broken swords have also had a tradition of representing the symbol for impotence, which could be interpreted as an attack on Richard. An alternative explanation is that the broken sword could represent a symbol of peace.⁸ These three alternative interpretations are by no means mutually exclusive.

Based on the potentially contradictory interpretations of this painting's symbolic meaning, the fact that it was most probably based on More's description of Richard, which has already been called into question, and on the fact that it was altered radically some time after it was painted, must cast a shadow of doubt over the extent to which we can rely on it as a true likeness of the sitter. Hence, its use is limited in providing qualitative evidence of what Richard looked like.

Reported abnormalities in Richard's appearance

The evidence described provides contradictory evidence regarding Richard's appearance and extreme caution needs to be applied when interpreting these sources due to limitations in the availability of reliable, untainted contemporary data. Despite this fact, not all sources can be dismissed, and this is demonstrated through several reports having agreed on certain key points, and in so doing providing enlightening insights into what one may consider to be the truth of the matter.

Several different authors have indicated that Richard had an unevenness of his shoulders. However, which shoulder was affected is a matter for debate. John Rous, who is reported to have seen Richard, claims his right shoulder was higher than his left. This is supported by the alterations made to the Royal Collection portrait (Figure 1a) and its many copies. However, More, who had spoken to people who had seen Richard (Cardinal Morton, for example), claims that it was his left shoulder which was raised. This is supported by the Broken Sword portrait (Figure 3). Other reports have indicated that Richard was not deformed, with no more than slight but normal unevenness of his shoulders.¹ These reports are supported by the original Royal Collection portrait and the Society of Antiquaries portrait (Figure 2), which both display him as having a normal shoulder line.

Based on previous source analysis, the reliability of More's descriptions and therefore the Broken Sword portrait, have both been called into question. The unaltered Society of Antiquaries painting, with its outstanding workmanship and correlation with contemporary sources, would lend great weight to the theory that Richard did not have any great abnormality, but rather an unevenness of his shoulders, with most probably the right being slightly higher than the left (according to the altered Royal Collection portraits and Rous).

An additional factor for consideration is whether Richard had a deformity of his forearm and hands. More comments that Richard had a ‘wearish withered arm and small, as it was never other’.¹ In addition, the Broken Sword portrait displays Richard's left hand with abnormal positioning of his fingers. However, a hand deformity is contradicted by Richard being shown to be using the small muscles of his left hand in the Royal Collection portrait when he fiddles with the ring on his right hand, with no abnormal posturing, finger positioning or limited finger movement. The Society of Antiquaries painting also clearly depicts his hands in fine detail, and no abnormal finger positioning is evidence. However, in both the Royal Collection and Society of Antiquaries portraits, the fingers being used are not the ones which would have been affected by the type of injury described. Admittedly, the fingers do not appear to be abnormally positioned, but equally, it cannot be dismissed that Richard may have had a mild injury affecting these fingers, hence limiting their movement, and this would have been revealed by the pose he has taken in these portraits. In addition, none of the portraits display Richard's naked left forearm, and hence More's suggestion that he may have had an abnormality cannot be completely disregarded. However, as previously stated, More's reports must be treated with great caution.

Medical explanations for reported abnormalities

Potential medical explanations for Richard's abnormality will therefore have to take into account both the unevenness of his shoulders, with his right being higher than his left, and conditions which could have affected his left forearm muscle bulk and the small muscles of his left hand.

Compensatory development of uneven shoulder muscle mass

In the first 20 years of Richard's life, there was continuous war. Throughout his youth, great value was placed upon Richard attaining the skills of warfare, in an effort to ensure he would be able to wield a sword and other weapons when in battle.¹⁰ The heaviest single-handed sword that was used during combat weighed approximately 6–7 lbs. Generally two-handed swords weighed between 5–8 lbs.¹¹ For Richard to be able to use these swords effectively he would have needed to have had well-developed arm, shoulder and back muscles.

In addition, reports from the Battle of Bosworth have indicated that Richard was a proficient fighter and was described to be swinging a heavy battle axe with manic energy until he was finally struck down himself.¹⁰ A great deal of strength and space were required to use these implements effectively, indicating that Richard must have had at least one exceptionally strong arm. Based on the assumption that Richard may have had an injured left arm, his uneven shoulders could have been due to him building up a considerable muscle mass on his stronger right side, in an attempt to compensate for this weaker left side.

Sprengel's deformity

Richard's uneven shoulders may alternatively be accounted for by him having Sprengel's deformity. In this there is under-development of the scapula, which may be attached to the vertebral column by bone or fibrous tissue with the muscles attached to the scapula being hypoplastic ( Figure 4).¹² The condition restricts scapula movement, and also limits arm movements on the affected side, specifically abduction, and can occur unilaterally or bilaterally. Richard could have been unilaterally affected on one side of his body, leading to his reportedly elevated shoulder. If he maintained an exceptionally strong muscle mass in his other arm, he theoretically could still have been an effective fighter. To an extent, the features of this condition correlate with More's description of Richard's left shoulder being raised and his forearm being wasted. However, as previously discussed, more reliable contemporary sources have indicated that any unevenness of shoulders was more probably due to Richard's right shoulder being elevated, and neither descriptions nor portraits have specifically indicated any problems with Richard's right arm.¹ This would make a diagnosis of right-sided Sprengel's deformity unlikely.

Figure 4.

An anteroposterior plain X-ray demonstrating an 11-year old girl's unilateral Sprengel's deformity¹⁹

Obstetric neural injuries

Richard was his mother's 11th pregnancy. On statistical grounds, an 11th baby is more likely to have been large. A large baby can lead to a prolonged labour, with greater difficulty when delivering the shoulders and head.¹³ Descriptions of Richard's birth provide key insights into what may have caused the reported abnormalities in Richard's appearance. Unfortunately, More is the main source for this type of information, and as previously discussed, serious doubt has been cast over the reliability of his reports regarding Richard. However, very few contemporary sources are available describing Richard's birth and More's account provides an enlightening insight into the possible type of neural injury affecting Richard. Hence, his account cannot be completely disregarded, but should be interpreted with the utmost caution.

More reported that Richard was born by breech delivery and that ‘… the Duchess “his mother” had so much ado in her travail that she could not be delivered him uncut …’²

This suggests that she had an episiotomy, although this operation is usually ascribed to the 18th century. However, this does not deny the possibility of the procedure being performed occasionally at an earlier date. The account also indicates that Richard's birth involved a difficult breech delivery, and hence could have been associated with complications, for example a brachial plexus injury.¹

Brachial plexus injuries

Brachial plexus injuries of the neonate are a recognized complication of difficult deliveries and can result in upper limb abnormalities. They are more frequent when the baby is the later child of multiparous women, when the baby is large and when there is a breech presentation.¹³ All of these features have been described in reports of Richard's birth.²

Brachial plexus injuries occur more frequently during difficult deliveries when the person assisting the delivery must exert force to extract the baby from the birth canal. When excessive lateral traction is applied, the neonate's head is pulled away from its shoulder, leading to stretching of the neonate's neck as the shoulder crosses the pubic arch.^13,14 This force on the brachial plexus can cause varying degrees of injury to the nerves, including rupture of the nerve roots or trunks, avulsion of the nerve roots from the spinal cord, and traction preserving the continuity of the nerve but causing excessive scarring.¹⁵ Damage to the brachial plexus can result in failure in the development of the child's shoulder, girdle, upper arm muscles and scapula on the affected side.¹⁴ Such injuries range from inflicting temporary to devastating sequelae, with the child being left with a flaccid, insensate arm.¹⁶

The main injuries affecting the brachial plexus reported following vaginal breech delivery are Erb-Duchenne syndrome (affecting essentially C5 and C6) and Klumpke's paralysis (affecting C8 and T1). There may of course be any mixture of these two syndromes up to total avulsion of the brachial plexus from the spinal cord (total brachial plexus palsy). This is characterized by complete arm paralysis, decreased sensation and a pale extremity.¹⁷

Erb-Duchenne syndrome: Erb-Duchenne syndrome (also known as Erb's palsy) occurs when the upper trunk of the brachial plexus is damaged. The suprascapular branch is also involved since it arises from the plexus at this point. The resultant deformity affects the upper limb, essentially the shoulder girdle and arm muscles.¹⁴ This produces a classic ‘waiter's tip’ arm position due to an imbalance in musculature. The shoulder is adducted internally in a rotated position, with the elbow in extension, forearm in pronation and flexion of the wrist and fingers due to weakness in the wrist and finger extensors.¹⁸ None of the sources describe or show Richard to be holding either arm in this position, making this diagnosis highly unlikely.

Klumpke's paralysis: Clinical effects of Klumpke's paralysis are seen mainly through weakness of the small muscles of the hand and part of the forearm.¹⁴ The forearm weakness is due to the fact that the ulnar nerve supplies the flexor carpi ulnaris (which is involved in flexing and adducting the wrist joint) and the medial half of the flexor digitorum profundus could be affected. Hence, if Richard had had Klumpe's paralysis he may indeed have had the ‘withered forearm’ More described.¹ If Richard was affected by Klumpke's paralysis on his left side, then the affected arm would have been weaker, and this would support the earlier suggestion that Richard may have had uneven shoulders due to excess shoulder muscle mass on the stronger right side of his body to compensate for his injured left side. The ulnar nerve usually supplies extensors of the ring and little finger, resulting in a claw hand deformity.¹⁴ This deformity correlates with the abnormal hand positioning seen in the Broken Sword portrait. However, this portrait also shows Richard as having a raised left shoulder, which would not fit with this diagnosis. In addition, the validity of both the aforementioned sources has been previously called into question.

Peripheral ulnar nerve injury

The ulnar nerve can also be injured more distally during injuries at the elbow or wrist, which can occur during forceful obstetric traction. As with Klumpke's paralysis, if the injury is proximal to the wrist joint, then the flexor carpi ulnaris and flexor digitorum profundus can be affected.¹⁴ This would mean that the ‘withered forearm’ described by More could have been observed.¹ In addition, injuries of the peripheral ulnar nerve could also result in a claw hand deformity, correlating with the Broken Sword portrait's depiction of Richard.

Conclusion

Most probably, King Richard had no great bodily abnormality. He was slight of build, and to make up for his deficiency in height he vigorously exercised. In addition, he may have had a raised right shoulder, but probably nothing else of interest or importance. The cause of this could have been due to his early exercises which led to him building a considerable mass of muscle unilaterally on his right shoulder. The most likely explanation for this would have been that he had sustained a left-sided ulnar nerve injury from birth. This may have been at the brachial plexus, or more peripherally. The weakness in his left arm would have made him more dependent on his one good shoulder and arm. Hence, the popular suggestion that Richard had a raised right shoulder was no more than a man compensating for a weak left arm by using his remaining asset to its full potential. His portrayal as a monstrous hunchback therefore has to be seen as a malicious attempt to tarnish his reputation for political reasons. Indeed, history can be seen to be repeating itself once again through the work of Gerald Scarfe, the great contemporary cartoonist, who has worked the same magic with his brilliant cartoons of Margaret Thatcher.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor IT

Contributorship IT is the sole contributor