The Seven Works of Mercy; a 16th century Dutch picture gallery of skin disease

The Works of Mercy represent a distinct genre in 16th- and 17th-century Dutch painting.1 These works draw inspiration from the biblical text in the Gospel of Matthew, which urges Christian believers to show compassion and to help those who are poor or disabled as a matter of public responsibility. The Gospel lists seven acts of mercy, ranging from ‘feeding the hungry’ to ‘caring for the sick’. Paintings in this genre depict these charitable actions, often showing recipients in need—with visible deformities or signs of disease—within the context of urban life. The Works of Mercy thus present a vivid and realistic gallery of disabilities and disorders known in the 16th and 17th centuries, as exemplified by a painting displayed in the Rijksmuseum in Amsterdam.2 At Museum Twenthe in Enschede, the Netherlands, a fine example of this genre is exhibited under the title Seven Works of Mercy, painted by an unknown Dutch master in 1510.3 Commissioned by a wealthy family and donated to the church as an altarpiece, the work consists of nine panels, each illustrating a specific act of charity. The donors ensured that their own likenesses were included as the benefactors, a common practice reflecting both their piety (and their wealth!). Close examination of these panels reveals several figures showing external signs of disease. These depictions can now be interpreted from the perspective of modern medical knowledge, offering insights into possible afflictions of the early 16th century. In the second panel, which depicts the feeding of the hungry, the man standing third from the right uses a crutch for support (Figure 1a). His exposed arms show skin eruptions and sores, and he carries his left arm in a sling. The fingers of his right hand appear bluish-red, and the visible toes of his right foot are similarly discoloured. These physical signs are suggestive of skin ulcers and impending gangrene of the extremities due to ergotism, known in that period as Saint Anthony's fire. The condition, characterized by severe burning pain and gangrene of the hands, fingers, feet and toes, was caused by the consumption of rye grain infected with the ergot fungus Claviceps purpurea. Growth of this fungus produces toxic ergot alkaloids that induced arterial spasms, leading to severe peripheral ischaemia and, ultimately, dry gangrene.5-7 In the 16th century, the poor—who often subsisted on inferior bread made from flour of the contaminated rye—were especially vulnerable, leading to epidemic proportions of the disease. Other common infectious diseases at that time such as syphilis or leprosy may however, also be considered.5, 8 The third panel, which depicts the act of quenching the thirst of those in need, shows a young man (second from the right) with scalp hair loss and several round, yellowish saucer-shaped crusts suggestive of tinea capitis favosa, a fungal infection caused by Trichophyton schoenleinii (ringworm) (Figure 1b). The saucer-shaped scutula are characteristic of favus, a severe form of the affliction.9 In the sixth panel, which shows the homeless being given shelter, a boy exhibits clusters of similar saucer-shaped scutula on his scalp accompanied by alopecia, representing another case of favus (Figure 1c). In advanced cases, the scutula can coalesce, covering the scalp with a thick, grey-white, mortar-like crust. A striking example of such a case is seen in Ferdinand Bol's 1649 masterpiece—Bol being a pupil of Rembrandt—depicting a boy with extensive favus being presented by his father to the governors of a leprosy infirmary that cared for patients with infectious diseases4 (Figure 1d). Both Saint Anthony's fire and favus were highly prevalent in the 16th and 17th centuries, primarily affecting the poor living in unsanitary conditions. Although these diseases have largely been eradicated thanks to improved socio-economic circumstances, better hygiene, and effective drug treatments, favus is still present in some regions of Africa, Asia and South America.9 Interestingly, ergot derivatives—owing to their vasoconstrictive properties—still play a role in modern medicine, particularly in the treatment of migraine headaches and postpartum haemorrhage.7, 10 However, adverse effects related to prolonged use of ergot alkaloid-containing drugs include generalized vasospasm of small arteries, leading to peripheral ischaemia as well as various neurological complications. The Seven Works of Mercy on display at Museum Twenthe thus blend art and medicine into a remarkable picture gallery of the past, showing skin manifestations of fungal infections not commonly seen in the modern era. The authors wish to thank Ruud ter Beeke, curator at the Museum Twenthe in Enschede, for offering us access to Seven Works of Mercy in its collection. The authors would also like to thank Hendrik Jan Hulsebosch (dermatologist), Piet Kager (internist, tropical medicine), Menno de Rie (dermatologist) and William Faber (dermatologist), for their valuable comments concerning the images. The authors have no related financial support to disclose. The authors have no related conflicts of interest to declare. Not applicable. Not applicable. The data that support the findings of this study are available from the corresponding author upon reasonable request.