708

ARTHRITIS & RHEUMATISM Vol. 43, No. 3, March 2000, pp 708709 2000, American College of Rheumatology

CONCISE COMMUNICATION
Fibromyalgia in Frida Kahlos life and art
The great Mexican painter Frida Kahlo (19071954) is without doubt one of the most intense and emotive artists of the twentieth century. Fridas life changed dramatically at the age of 18, when she was involved in a terrible accident. A streetcar violently impacted the bus in which she was riding. She suffered multiple bone fractures, including the third and fourth lumbar vertebrae, and had a deep abdominal wound inflicted by a metal rod. She was confined for several months in a plaster corset. From that time on, Frida suffered severe, widespread pain and profound fatigue. Generalized pain and exhaustion lingered with her for the remainder of her life (15). Through the years, a variety of diagnoses were offered to explain her chronic illness, such as tuberculosis and syphilis, that were later ruled out. She received diverse types of treatments, including medications and long periods of confinement in a metal or plaster corset. In efforts to relieve her pain, she underwent several orthopedic operations on her spine, both in Mexico and in the United States, without improvement in her symptoms. Despite her debilitating illness, Frida was engaged in an active social life. She had a tempestuous marriage to the famous Mexican muralist Diego Rivera. She traveled extensively and had relationships with the world leaders and artistic personalities of her time. Frida began painting after her accident. During periods of immobilization in a plaster corset, she used a special easel, and a mirror was attached to the canopy of her bed so that she could focus on herself. Although her painting skills were largely self-taught, she was also acquainted with the traditional schools of painting. Both in her oeuvre and in her customs, she looked back with devotion to her Mexican roots. The Surrealists claimed her as one of their own. The stillness of her self-portraits reflects the influence of her father, who was a photographer (3). Frida used to describe her own paintings as the most frank expression of myself (1). Her self-portraits are impassioned. Anguish and pain are the common themes of her work. These emotions are dramatically expressed in her oil painting, The Broken Column (Figure 1). As Hayden Herrera observed, Fridas determined impassivity creates an almost unbearable tension. Pain is made vivid by nails driven into her naked body. A gap resembling an earthquake fissure splits her torso. The opened body suggests surgery. Inside her torso, we see a cracked ionic column. The corsets white straps accentuate her beautiful body. Her hips are wrapped in a cloth suggestive of Christian martyrdom. She stares straight ahead with dignity. Tears dot her cheeks, but her features refuse to cry. An immense and barren plain in the background conveys physical and emotional suffering (1). To explain Fridas chronic illness, we offer an alternative diagnosis. Our opinion is that she suffered posttraumatic fibromyalgia. This prevalent syndrome is characterized by persistent widespread pain, chronic fatigue, sleep disorders, and vegetative symptoms, and by the presence of tender points in well-defined anatomic areas (6,7). The concept of fibromyalgia as a clinical entity as we know it today was probably unknown to most physicians of the early twentieth century.

Figure 1. The Broken Column (1944), oil painting on masonite, 42 33 cm. Reproduced, with permission, from the Museum Dolores Olmedo Patin o in Mexico City.

Our diagnosis explains her chronic, severe, widespread pain accompanied by profound fatigue. It also explains the lack of response to diverse forms of treatment. The onset of fibromyalgia after physical trauma is well-recognized (8). A drawing in Fridas diary reinforces our diagnostic impression (9). She depicts herself in pain, and 11 arrows point to anatomic sites that are near the conventional fibromyalgia tender points (6). Of course, because fibromyalgia is an illness without anatomic sequelae, our contention cannot be proven or disproven. What appears certain is that Fridas self-portraits convey widespread pain and anguish with the emotional overtones that fibromyalgia patients frequently use to describe their illness.
We are indebted to Dr. Leonardo Zamudio, who allowed us to have access to Frida Kahlos medical records, to Ms Dolores Olmedo, who gave permission to reproduce The Broken Column, and to Dr. Robert Kalish, who kindly reviewed the manuscript.

CONCISE COMMUNICATIONS

709

Manuel Mart nez-Lav n, MD Mary-Carmen Amigo, MD Javier Coindreau, MD Instituto Nacional de Cardiolog a Ignacio Cha vez Mexico City, Mexico Juan Canoso, MD American British Cowdray Hospital Mexico City, Mexico
1. Herrera H. Frida: a biography of Frida Kahlo. New York: Harper Row; 1983. 2. Tibol R. Frida Kahlo: una vida abierta. Mexico City: Universidad Nacional Auto noma de Me xico; 1998. 3. Zamora M. Frida Kahlo: the brush of anguish. San Francisco: Chronicle Books; 1990. 4. Monsiva is C. Vazquez-Bayod R. Frida Kahlo: una vida, una obra. Mexico City: Conaculta; 1992.

5. Del Conde T. Frida Kahlo: la pintora y el mito. Mexico City: Universidad Nacional Auto noma de Me xico; 1992. 6. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160 72. 7. Mart nez-Lav n M, Hermosillo AG, Rosas M, Soto M-E. Circadian studies of autonomic nervous balance in patients with fibromyalgia: a heart rate variability analysis. Arthritis Rheum 1998;41: 196671. 8. Buskila D, Neumann L, Vaisberg G, Alkalay D, Wolfe F. Increased rate of fibromyalgia following cervical spine injury: a controlled study of 161 cases of traumatic injury. Arthritis Rheum 1997;40:44652. 9. Freeman P. Frida Kahlo: Diario: autorretrato ntimo. Mexico City: La Vaca Independiente; 1995.

Clinical Images: Tuberculous arthritis

The patient, a 62-year-old woman, presented to our hospital with pain in the right foot, which had started 1 year previously and had increased constantly until she was unable to walk on the foot. Physical examination revealed swelling and erythema of the middle area of the right foot. The white blood cell count was 9,000/l, with 76% neutrophils. The C-reactive protein level was 2.3 mg/dl. Sagittal magnetic resonance imaging (T1-weighted, fat-suppressed, spin-echo) with contrast medium showed massive uptake of contrast medium in the navicular, cuboid, and cuneiform bones, with subchondral destruction consistent with inflammation (A). Aspiration of the cuneonavicular joint was performed. Synovial analysis showed an increased white cell count (41,000/l; 20% lymphocytes). Microscopic examination with Ziehl-Neelsen staining revealed acid-fast bacilli (B). Polymerase chain reaction and culture demonstrated Mycobacterium tuberculosis. Tuberculous arthritis was diagnosed, and the patient began treatment with quadruple tuberculostatic therapy (isoniazid, rifampin, ethambutol, pyrazinamide). Symptoms resolved slowly. Rika Draenert, MD Herbert Kellner, MD Medizinische Poliklinik Ludwigs-Maximilians-Universita t Munich, Germany