Rev. Bras. Reumatol. vol.56 número5

rev bras reumatol.2016;56(5):464–467

ww w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Brief

communication

Did

Father

Cicero

suffer

from

rheumatism?

Francisco

Airton

Castro

Rocha

DepartamentodeClínicaMédica,FaculdadedeMedicina,UniversidadeFederaldoCeará(UFC),Fortaleza,CE,Brazil

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Articlehistory:

Received30October2015 Accepted21January2016 Availableonline12April2016

Keywords: Spondylitis Religion

HistoryofMedicine

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FatherCiceroRomaoBatistaisprobablythemostfamousCearácharacterofalltime.An importantprotagonistoftheCaririregion,situatedinthesouthofCearaState,inthelate nineteenthcenturyandthefirstthirdofthetwentiethcentury,FatherCicerohadgreat polit-icalandreligiousactivity,aswellasotherlesswell-knownachievements,forinstance,his ecologicalteachingsthatledhimtobeawardedthetitleof“PatronofForests”,besidesan enormouseffortandpersonalsacrificefortheimprovementoftheconditionsofhumanlife. Inspiredbyreadinghisbiography,wefindthatthe“PadimCic¸o”couldhaveinflammatory spondyloarthropathy.Inthisarticle,wepresenttheplausibilityofthisdiagnostic hypoth-esis,seekingtoemphasizethatanattentiveearandclinicalobservation,albeitindirectly andwithouttheprivilegeofapersonalcontactwiththepatient,areunparalleledtoolsfor bringingforthadiagnosis.

©2016PublishedbyElsevierEditoraLtda.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Padre

Cícero

teria

um

reumatismo?

Palavras-chave: Espondilite Religião

HistóriadaMedicina

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OpadreCíceroRomãoBatistaéprovavelmenteomaiscélebrepersonagemcearensedetodos ostempos.ImportanteprotagonistadaregiãodoCariri,suldoEstadodoCeará,nofimdo séculoXIXeprimeiroterc¸odoséculoXX,tevegrandeatuac¸ãopolíticaereligiosa,paraalém deoutrosfeitosnãotãoconhecidos,comoensinamentosecológicos,queolevaramser agra-ciadocomotítulodePatronodasFlorestas,bemcomoenormesesforc¸osesacrifíciopessoal pelamelhoriadascondic¸õesdevidahumana.Atravésdaleituradesuabiografia,veio-nos àpercepc¸ãoapossibilidadedequeoPadimCic¸otenhasidoportadorde espondiloartropa-tiainflamatória.Aplausibilidadedessahipótesediagnósticaéaquiapresentada,busca-se enfatizarqueoouvidoatentoeaobservac¸ãoclínica,aindaquedeformaindireta,semo priv-ilégiodocontatocomopaciente,constituemferramentasincomparáveisnapropositurade umdiagnóstico.

©2016PublicadoporElsevierEditoraLtda.Este ´eumartigoOpenAccesssobuma licenc¸aCCBY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

E-mail:[email protected]

http://dx.doi.org/10.1016/j.rbre.2016.03.010

2255-5021/© 2016 Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://

rev bras reumatol.2 0 1 6;56(5):464–467

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FatherCiceroRomaoBatistalivedfor90years,wasborn in1844and died onJuly 20,1934.Even today,such along lifeisunusual.Thus, inadditionto otherpersonal giftsof the“PatronofForests”,atitleawardedbyGreenPeace(http://

blogdocrato.blogspot.com.br/2010/02/greenpeace-adota-padre-cicero-como-o.html), a non-governmental

organiza-tion,thismanwastouchedbydivineprovidence.Despitethe vast literature on political and religious aspects on Father Cicero,1–4_{detailsabout“JuazeiroPatriarch”healtharescarce.}

FatherCicerodidnotleavedependents,becausehissisters hadnochildren.Abouthismother,Mrs.Quinô,itisknownthat shebecame“paralyzed”andwouldhavepresentedan“eyelid inflammation”formanyyears.2

AmaliadeOliveira,2_{whoenjoyedforseveralyearsa}

con-tactwithFatherCicero,reportsinhisbookthatatabout50 yearsoldFatherCicerohadhisheadtiltedandfixedtothe rightside.Atleastbytheageof41,FatherCiceroalreadyused astaffthat,althoughmayberepresentingapastoralsymbol, maywellhavelentitselftosupporthiswalking.2,3_In1888,a

photoofFatherCiceroattheageof44withoneofhissisters revealsalateraldeviationofhishead,whichcanalsobeseen inlaterimages(Figs.1and2).Inhismostrecentbiography,3

theauthorreportsa“painfulscoliosis,”necktortuosityand

Fig.1–FatherCiceroandhissister,inaphotographfrom

1888–attheageof44,onecanseeaslightlateraltiltingof

theneck.

Fig.2–FatherCiceroanddoctorLuisMalzone,founderof

HospitalSãoLucas;photographfromthedecadeof

1920–1930,showinglateraltiltingoftheneck.

backpainwithalifelongsuffering.3_{Inanotherbook,}5_his

pos-turalproblemandrecliningambulationareagainmentioned, whichareattributedtoascoliosiscontractedearlyinhislife, aswellasakyphosisthatlenta“grotesqueappearance”to “Padim Cic¸o”.Thislatterreportwould refertohislooksin 1926;thuswhentheholymanwasalreadyattheageof82. Aboutthistime,anotherbook6_{byanauthorwhovisitedFather}

Cicerodescribeshisgibbosityandstoopedposture. Interest-ingly,averycriticalauthorofFatherCicerodescribestheman in1926as“beingankylosedandsufferingfrequentintestinal colic, whichrequiredastrict diet”.4 _{Anepisodeofarthritis}

(withnofurtherdetails),whentheholymanwasattheageof 60,hasbeendiagnosedasbeingthe“firstsignsofagout cri-sis”byDr.AntonioMariz,oneofhisdoctors.3_{Inseveralbooks}

onthisholyman,episodesofstrongabdominalcrampsare reported,whichwouldhaveoccurredforseveralyears(and thatattimesresultedinpatriarch’sprostration).2–4,7

There are several reportsthat Father Cicerodid notget muchsleep,andattimeswassurprisednappingduringthe day,infrontofhisinterlocutors,andevenwhenonthesaddle ofhisdonkey.2–5,7,8_{Thisholymanalwayssleptinahammock,}

despitehavingabedinhisbedroom,3_{fedsparinglyandhad}

ahabitoffastingforlongperiods.1–4,6,8,9_{In1910,assumingto}

bestrickenwithakidneycondition,andfollowingtheadvice ofDr.MiguelCouto,FatherCicerohascometobelievethathis problemstemmedfromdrinkingJuazeirowater;sincethen,he startedtodrinkonlycoconutwaterortea,andneverreturned todrinkingcleanwater.3–5,10_{Therearedescriptionsof}

hemop-tysisinFatherCicero’sbiographies,althoughinouropinion theywerehemoptoicepisodes,whenattheageof76.2,3_While

thereisnoreportofotherrespiratorysymptoms,and consid-ering that Father Cicerowould havesmoked (certainly not commercial cigarettes)forafew yearsand evenbeforehis arrivalatJuazeiro,4,10_{onecannotignorethepossibilitythathe}

466

Apparentlyitisquiteevidentthatinthelastyearsofhis life,FatherCicerohassufferedrepeatedinfectionsofthelower limbs,describedaserysipelas.2,3,7_{Thepresenceofcutaneous}

anthraxintheneck,alreadyclosetohisdeath,wasareason forsurgery,aswellasalikelycataractsurgicallyapproached unsuccessfullylittlemorethanamonthbeforehisdeath.3

Inoneofhisbiographies,thedescriptionofhislast clini-calpicture3_{suggeststhedevelopmentofabowelobstruction.}

WhereasFatherCiceroalreadywas90yearsold,presenting boilsandevenrepetitionerysipelas,inapre-antibioticeraand withinappropriatedisinfectioncare,itisquitepossiblethat hisfinalpicturewasthatofageneralizedinfectionstemmed fromacutaneousfocus,leadingtobowelinvolvementwith aclinical picture ofacuteabdomen, as mightoccur inthe initialphaseofasepticshockcompoundedbydehydration andconsequentdeficitofkidneyirrigationandanuria(which, incidentally,isreportedafterhisdeath).2

Clinical

integration

Afterreading PadreCicero’s biography, I was motivated to think that it is reasonable to propose the hypothesis that thisholymanwouldhaveachronicinflammatory spondy-loarthropathy,unsuspecteduntilnow.Thedescriptionwasof alowerbackpaincondition,alsoaffectingthecervicalspine inawhite,malesubject,startingbeforetheageof50andwith apartialankylosisofthespine,particularlyvisibleinthe cer-vicalsegment.Atleastonedocumentedepisodeofarthritis wouldhaveoccurred,aswellasmultipleintestinaldisorder episodes,whichcouldbeassociatedwithanintestinal inflam-matorycomponentandbeingpartofthemaindiagnosis.In hisfamilyhistory,thereisjustonereport,thathismotherhad an“inflammationoftheeyelids”withseveralyearsofduration andwouldhavebeen“paralyzed”in1897,atabouthersixth decadeoflife.

Differential

diagnosis

Hismovementswereregularlydone,eveninhislastdecade oflife.Drowsinesscould mean anon-restorativesleep and hispreferencefor the hammockis commonin spondylitis patientsin“theseBrazilianNortheastplaces,”althoughthere isnotechnicalbasistosupportthathabit.Thus,theseaspects thatsuggestanon-restfulsleep strengthensthehypothesis thatspinalpain,reportedinseveralbooksaboutFatherCicero, wasofan inflammatorynature.There isnotrauma report thatcouldjustifyafracture,theconsolidationofwhichwould bethecauseofhissubsequentcervicaldeformity.Itisalso unlikelythattheconditionwouldbeascoliosis,whichisnot anusualcauseofbackpain,contrarytocommonbelief,and onlyrarelythereiscervicalinvolvement,andthisisthe seg-mentwiththemostnoticeabledeformityinFatherCicero.A pictureoftheholyman(Fig.3),whenhewasaboutto com-pletehisstudiesattheseminary(circa23years)doesnotshow anecktilt,whichshouldalreadyexistatthetimeifthe rea-sonforthis condition were astructuraljuvenileidiopathic scoliosis.Itisunlikely thatthis couldbeacaseofprimary osteoarthritis inthe facetothe male gender, and thatthe

Fig.3–FatherCiceroasayoungman,beforehisordination

(rightside,withabout23yearsold),thephotographdoes

notshowanylateraltiltingoftheneck,andanormal

posture.

problemhaditsbeginningwhenFatherCicerowasunder50 years old.Judgingbythephotofrom1888(Fig.1),inwhich theFatheralreadyappearswithanecktiltedtotheright,and consideringreportsofpainand“scoliosis”aroundtheageof 50,itisquiteplausiblethatthisholymansufferedpainfor sometime, startingbeforethe ageof45,asitwould occur inacaseofspondyloarthritis.11_{Infectiouscausesand}

rev bras reumatol.2 0 1 6;56(5):464–467

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tabeticaspect,aswouldbelikelytoexistinacaseoftertiary syphilisinvolvingthespinal cord.Thetuberculous,leprosy andfungaletiologies,despitehishemoptoicepisodes,seem tousunlikelycausestoexplainthespinalpicture,intheface ofthelongcourse(morethan 40yearsofevolution)andof theankylosedaspectsuggestedbytherigiditypresentduring hiswalks.Wedonothaveelementstoexplainthehemoptoic episodes,buttheycouldalsobecausedbysequelaeof respira-toryinfections.2,3,9_{Wecanexcludethepossibilityofaprimary}

osteoporosisleadingtotheoccurrenceoffractures,thanksto themalegender,hisgoodphysicalactivity,frequentintakeof dairyproducts,intensesunexposureformanyyears,itsonset beforetheageof45,andalsoforthearthritisandbowelpicture incompatiblewithosteoporosis.

Thereissomeepidemiologicalevidencethatwecanstill consider.FatherCicerowasablondman,withblueeyes,of directPortuguese descent,and possibly hismother was of Indiandescent.2,3,7_{Becausethediseaseismoreprevalentin}

whitesubjectsandFatherCicerowasofwhiteMediterranean ancestry, it ispossiblethat, in this case,agenetic compo-nentexists.Thereisastrongpossibilityofinterbreedingofhis mother,withalikelyPortugueseparentage.Althoughinthe fieldofpurespeculation,oneshouldalsotakeintoaccountthe ophthalmicproblemsofhismother.Althoughconsideredas an“inflammationoftheeyelids”,thedescriptionisoneofan apparentlyrecurrenteyeredness;aboutthis,wecanspeculate thatthesewereepisodesofuveitis.

Conclusion

Itis notunusual – quite the contrary –that even today a diagnosisofspondyloarthritisgoesunnoticed.Sofarasour knowledgegoes,itishardlysurprisingthatnobodyeverhas contemplatedthispossibilityinthecaseofFatherCicero.In ourview, the personality ofFather Cicero could have con-tributed to an absolutely productivelife, with a strenuous andcontinuousdailyactivity,evenifhewasstrickenbyan inflammatory disease of the spine. It does not seem that motivationhadbeenaproblemforthismanofsuch deter-mination,evenwithoutbeingabletouseanti-inflammatory agentsforreliefofsymptoms.Lastbut notleast,onemust highlightthat perhapsisthemainreasonforthis descrip-tion and speculation about the disease that Father Cicero wouldhavesuffered.Byreadinghisbiography,thebookcalled ourattention tothe several photos in which the Patriarch ofJuazeiroisdepictedwithacervicallateraldeviation.Itis unlikelythatinpicturesfromvariousperiodsofhislife,for noapparentreason,hehadmanagedtokeephisstance virtu-allyunchanged.Althoughnotexhibitingtheclassical“skiing” posture,Father Ciceroappears tohavehis neckina more anterior positionwith respectto the dorsal region (Fig. 3), aswellasanapparentanterior projectionoftheabdomen. And the description ofepisodes of back pain and intesti-naldisorder hasgone unnoticed, whichmay also occur in spondyloarthritis.WhenevaluatingavideoofFatherCicero

(https://www.youtube.com/watch?v=S4twtECfeHA), featured

in the 1920s, we realized that the Father, when walking through the crowd and having his attention apparently attractedbybystanders,makesabodymovement inwhich

heturnscompletelytoaddresstheinterlocutor,virtuallywith nolateralmovementoftheneck,moving“enbloc,”asifhis spinehadnomobilityinthecervicalsegment.Asa descrip-tionofafriendofmine,“FatherCiceromovesinthesameway thata“Olindapuppet”.Clearlythismovementoccursthree timesforbothsides,stronglysuggestingthatFatherCicero, regardlessofhisageatthetime,hadseverelimitationtothe movementoflateralflexionoftheneck.

Theneedforattentiontodetailisalwaysemphasizedin thecollectionofarheumatologicmedicalhistory.Most diag-nosesinthisspecialtydependonadoctorwhoknowshowto listenandonacarefulobservationofthepatient,inorderto adequatelycharacterizeintime,spaceandintensity,among otherthings,thedescriptionofthesymptoms.Wereiterate thattheancillaryexamsdonotoutweightheclinicalhistoryin definingthediagnosisand,nolessimportant,thetherapeutic conductforspondyloarthritis.

Thereading of Father Cicero’sbiography has the power toalerttherheumatologistforaplausiblediagnosisinsuch illustrious characterandalsodemonstratestheimportance ofhavingattentiveeyesandearsduringtheanamnesis.Our “Padim”–certainlyours,because,likehim,Ialsowasborn inCeará–swungintoactiononceagain,andmorealivethan ever,callingourattentiontothebestidentificationofpeople affectedbythesediseases.Currently,oftenthetimeintervalto confirmthediagnosisexceeds10yearsofsymptoms.Thismay beonemoremiracleofFatherCicero;itsimplydoesnot mat-ter.Itseemstomethat,throughadescriptionofhishistory byathirdparty,thisman,91yearsafterhisdeath,continues tocontributetoimprovethelifeandhealthofthepeopleand, thistime,possiblyinthewholeBrazil.

Conflict

of

interest

Theauthordeclaresnoconflictsofinterest.

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