Crutch art painting in the middle age as orthopaedic heritage (Part I: the lepers, the poliomyelitis, the cripples)

Abstract

Throughout time from antiquity, the major objective of crutches was to restore, as close as possible, the functional capacity formerly held by a limb deficient person. The crutch is probably the oldest tool of the orthopaedist. It is probably also the most neglected in terms of progress from antiquity until the 20th century. The aim of this paper is to give a view of the different crutches used in this period by different people and to observe the influence of this period on the progress of the design of crutches.

The middle ages has many illustrations in manuscripts (Figs. 1 and 2) that drew people with crutches. The earliest known records of a crutch are during the Egyptian period [5]. In Fig. 3 the Egyptian is represented as leaning on a crutch with an axillary traverse, i.e. the right hand grasps the middle of the stick. Figure 4 is an Egyptian stele thought to depict a poliovirus victim in the 18th Dynasty (1580–1350 BC). About this same time, there are several interesting wall carvings in the caves on the isle of Elephantine, in the Nile. There is no literature about crutches until Ambroise Paré [2–4]. The Middle Ages, however, offer many examples of the study of crutches. Even if no medical report can be found, the immense patronage of the Church, encouraging artists to portray the saints and their miracles, has left great illustrations that drew people with crutches. Pictures and the history of medieval conceptions of disability appear to be an interesting chronicle or story of how man rose above the handicap of disease, trauma and deformity. In medieval times, the percentage of impaired persons was probably higher than we think. Artists have not lacked cripples with peg-legs and crutches as models. The aim of this paper is to give a view of the different crutches used in this period by different people and to observe the influence of this period on the progress of the design of crutches. The illustrations in the Middle Ages can be classified according to three different populations who used crutches for different reasons: the population of lepers, polyomyelitis, and cripples.

Fig. 1.

Enluminure with crutches

Fig. 2.

Doctor and patients; De proprietatibus rerum (BNF Fr. 216), 14th–15th century

Fig. 3.

Egyptian using a crutch with an axillary traverse (leper or poliovirus victim)

Fig. 4.

An Egyptian stele thought to depict a poliovirus or leper victim, 18th Dynasty (1580–1350 BC)

The leper and the polyomyelitis causes of bilateral limb paralysis

1. The leper: A comparison of Figs. 5, 6, and 7 demonstrates the heritage from the Middle Ages. Figure 5 is a miniature of a crippled man using a pair of crawling wooden blocks to move himself during the 11th century. Figure 6 represents the same crutches in the Science Museum in London; it is thought that these crutches were used by someone who had leprosy and who had also lost the use of their legs. They are dated around 1800, which means that between 1000 and 1800 there was no progress in the design of these crawling wooden blocks. Figure 7 is a photograph taken of a man with leprosy in India in the 20th century demonstrating that the same system of crawling wooden blocks is still used today.

   Leprosy, a bacterial disease, today known as ‘Hansen’s Disease’, was one of the first causes of disability in the Middle Ages. First known in Egypt, it did not spread to Europe proper until after the Romans invaded Egypt several hundred years before Christ. While Phoenecian seamen probably spread it to Greek and other Mediterranean ports, Roman soldiers brought it back to Italy and then farther into Europe. Occurrences of the disease increased rapidly in England and it became a plague during the Crusades. During the 12th and 13th centuries, the disease assumed terrible proportions with possibly a quarter of northern Europe’s population being afflicted at one time.

   Globally in 2012 the number of current cases of leprosy was 180,000. In 2011 the approximate number of new cases diagnosed was 220,000. The number of cases decreased significantly from the 1960s to the 2010s. Although the number of cases worldwide continues to fall, pockets of high prevalence continue in certain areas such as Brazil, South Asia (India, Nepal), some parts of Africa (Tanzania, Madagascar, Mozambique), and the western Pacific.

2. The polyomieleitis: Poliomyelitis has been totally eradicated in countries with strict immunization programs. In 2008, poliomyelitis however remained endemic in India, Pakistan, Afghanistan, and Nigeria. Poliomyelitis was not known nor described in the Middle Ages. Probably during this period the differential diagnosis between leper and poliomyelitis was not made. The following pictures, Figs. 8, 9 and 10 (a painting of Bruegel, Pieter the Elder [c.1525–69]), Fig. 11 (deformities of the untreated polio patient) and Fig. 12 (a polio patent in 1980), demonstrate that the differential diagnosis between leper and polio patient was not evident during this period. Figure 13 demonstrates that despite their disability these people were able to fight with their crutches.

Fig. 5.

Detail of a miniature of a crippled man using wooden blocks to move himself around Topographia Hiberniae (British Library Royal 13 B VIII, fol. 30v), c. 1196–1223

Fig. 6.

Science Museum London. It is thought that these crutches were used by someone who had leprosy and who had also lost the use of their legs

Fig. 7.

A man with leprosy in India in the 20th century

Fig. 8.

A leper house, from ‘Science and Literature in the Middle Ages’ by Paul Lacroix (1806–84), published in London, 1878

Fig. 9.

This medieval illustration shows a man on crutches entering a leper hospital. Before and even after the discovery of its biological cause, leprosy patients were stigmatized and shunned. For example, in Europe during the Middle Ages, leprosy sufferers had to wear special clothing, ring bells to warn others that they were close, and even walk on a particular side of the road, depending on the direction of the wind

Fig. 10.

1568 (oil on panel); painter of Bruegel, Pieter the Elder (c.1525–1569), probably representing people with poliomyelitis or leprosy, although the painting is entitled the “beggars”

Fig. 11.

Deformities of the untreated polio patient in pediatric orthopaedic textbook

Fig. 12.

A polio patent in 1980

Fig. 13.

Crutch fight; illustration from the 14th-century Bodleian Alexander (MS Bodl. 264), depicting “dispute with crutches”

The cripples

1) The wooden axillary crutch: During the Middle Ages, representation of crippled religious subjects is frequent. These representations are present in books and paintings. The cripples use heavy leg rests and heavy simple crutches (waiting in a monastery yard for a free meal from the Prior; Figs. 14 and 15).

Fig. 14.

Detail of a miniature of an allegorical figure on crutches embodying Vieillesse (Old Age), Roman de la Rose (Harley 4425, fol. 10v), 1490–1500c Netherlands, S. (Bruges)

Fig. 15.

Detail of a man with two heavy crutches

The crutch is usually one stick with an axillary part and is not exactly equivalent to the modern axillary crutch (Fig. 16) that today has an axillary support, such as a handle between two pieces of wood or metal. However, as demonstrated in this picture (Fig. 17) of injured WWI soldiers performing exercises (U.S. Army Base Hospital Number 69, Savenay, France National Library of Medicine, Prints and Photographs), the handle between the two pieces of wood appear only at the beginning of the 20th century, some of the soldiers ares still using Middle-Aged crutches (Fig. 18), while others are using “modern” crutches (Fig. 19).

Fig. 16.

The modern axillary crutch

Fig. 17.

Rehabilitation of American soldiers during World War I in U.S. Hospital Number 69, Savenay, France (Army Base) National Library of Medicine, Prints and Photographs

Fig. 18.

Patient with a Middle-Aged axillary crutch

Fig. 19.

Patient with a modern design axillary crutch

Emile Schlick (Fig. 20) patented a walking stick [1, 6, 7] in 1917 that could be called the first commercially produced form of crutches. In this design, there was a support for the upper arm to rest on. However, it was A.R. Lofstrand, Jr. who patented the first deign for crutches that could be adjusted to suit the height of the user. The design of the forearm crutches (Fig. 21) is accredited to Thomas Fetterman (Fig. 22), who contracted polio in the 1950s when he was only eight years old. Because of the dangers associated with continuous use of underarm crutches, such as slipping and falling and possible nerve damage in the armpit area, he set about designing crutches that he could use safely. He knew that crutches needed a greater ability to grab the ground and developed a crutch tip with a shock-absorbing gel cap. This type of crutch now is the most recommended by orthopaedic specialists. Interestingly enough, in the United States these types of crutches are often found being used in seriously debilitating walking conditions or various other serious disabilities. However, in Europe, and in various other continents, these are the types of crutches that are used for everyday injuries, as usual walking equipment. Forearm crutches or elbow crutches are used by having the individual slip their hands through a ring and hold a grip which allows them to have control of the crutches and gives them a sense of stability, because with the rings near the arms, the crutches cannot slip out from under one’s arms and cause any further injury by falling. Throughout the history of the United States forearm crutches are most commonly associated with those who suffered from polio and other debilitating diseases, in which walking increasingly became a struggle for individuals.

Fig. 20.

Photography of Emile Schlick

Fig. 21.

Forearm crutches

Fig. 22.

Photography of Thomas Fetterman