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Adele Bloch-Bauer (1881-1925): Possible diagnoses for Gustav Klimt's Lady in Gold ..... The portrait, Adele Bloch-Bauer ...

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Original Article

Adele Bloch-Bauer (1881–1925): Possible diagnoses for Gustav Klimt’s Lady in Gold

Journal of Medical Biography 0(0) 1–8 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0967772014533058 jmb.sagepub.com

Licia MH da Mota1, Fernando Neubarth2, Joze´lio F de Carvalho3, Leonardo R Diniz4, Rodrigo B Aires5 and Leopoldo L dos Santos-Neto6

Abstract One of the most famous works by the Austrian symbolist painter Gustav Klimt and one of the most widely reproduced works of art worldwide, Adele Bloch-Bauer I, portrays the beautiful wife of Austrian magnate Ferdinand Bloch-Bauer. Adele was the only woman painted by Klimt on more than one occasion. Apart from the beauty and value of the painting, the daring sea of gold that surrounds Adele and the gentle intimacy with which her fragile figure is portrayed have shrouded the history of this painting in mystery. Beyond speculation as to a special bond between artist and model, observation of the painting with a keener, clinical gaze yields evidence of potential illness in the model: facial erythema which, if not produced artificially by makeup, could represent a malar rash; pallor or cyanosis of the hands; and her draped fingers, which seemingly attempt to hide a deformity. This paper seeks to provide a biographical review both of the painter, Gustav Klimt, and of the subject, Adele Bloch-Bauer; to analyse Klimt’s two portrayals of her in a search for evidence of a potential intimate relationship between artist and muse and, finally, to compile clinical evidence of possible diagnoses for the Lady in Gold.

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Introduction Vienna at the end of the 19th century was a creative epicentre that spawned radical artistic and intellectual innovation. Schorske noted that ‘Vienna in the fin de sie`cle, with its acutely felt tremors of social and political disintegration, proved one of the most fertile breeding grounds of the 20th century’s a-historical culture. Its great intellectual innovators – in music and philosophy, in economics and architecture and, of course, psychoanalysis – all broke, more or less deliberately, their ties to the historical outlook central to the 19th-century liberal culture in which they had been reared’.1,2 The Austrian symbolist painter Gustav Klimt (1862– 1918) was one of the products of this cultural crucible. Klimt was a central figure in the Viennese secessionist movement (which rejected the classical realist tradition in painting) and became famous for his abstractly ornamented sensual portraits of women. He had been deeply influenced by his exposure to the Byzantine mosaics of Venice and Ravenna. These provided the inspiration for the ornamentation of his paintings, at the centre

of which was often an alluring woman. Schorske drew a parallel between the Viennese contemporaries Freud and Klimt: ‘Both loosed their chosen fields – psychology and art respectively – from their biological/anatomical moorings – both plunged into the self and embarked on a voyage inte´rieur – [and] explorations of the world of instinct’).1,2 Adele Bloch-Bauer I, best known as The Lady in Gold, one of Klimt’s most famous paintings and one of the most widely reproduced works of art worldwide, 1

Universidade de Brasilia School of Medicine, Brazil Hospital Psiquia´trico Sa˜o Pedro, Brazil 3 Department of Rheumatology, Centro Me´dico Alianc¸a, Brazil 4 Corpo Clı´nica de Fisioterapia, Brazil 5 Department of Anaesthesiology, Instituto de Cardiologia do Distrito Federal, Brazil 6 Universidade de Brası´lia School of Medicine, Brazil 2

Corresponding author: Licia Maria Henrique da Mota, SHLS 716 Bloco E, salas 501/502, Brası´lia, DF 70930-904, Brazil. Email: [email protected]

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2 portrays, in a magnificent blend of oils, silver and gold, the beautiful Adele, wife of Austrian magnate Ferdinand Bloch-Bauer.3 Adele was the only woman portrayed by Klimt on more than one occasion apart from his lifelong companion, Emilie Flo¨ge.4 Adele Bloch-Bauer I is currently owned by the Neue Galerie New York, and at the time of its acquisition by Ronald Steven Lauder, heir to the multimillion-dollar Este´e Lauder Company, for the sum of US$135 million, was compared to Leonardo da Vinci’s Mona Lisa.3 Transcending the beauty and value of the painting – it remains one of the most expensive ever sold – the daring sea of gold that surrounds Adele and the gentle intimate nuance with which her fragile figure is portrayed have made the history of this painting one shrouded in mystery, which includes the possibility of an affair between the painter and his muse.4 Beyond speculation as to a special bond between artist and model, observation of this painting with a keener, clinical gaze yields evidence of potential illness in the model: facial erythema which, if not produced artificially by makeup, could represent a malar rash; pallor or cyanosis of the hands; and the elegant arrangement of her fingers, which seemingly attempts to hide a (questionable) deformity. The objective of this article was to provide a biographical review both of the painter, Gustav Klimt, and of the subject, Adele Bloch-Bauer; to analyse Klimt’s two portrayals of her, Adele Bloch-Bauer I and Adele Bloch-Bauer II, in a search for evidence of a potential intimate relationship between artist and muse and, finally, to compile clinical evidence of possible diagnoses for the Lady in Gold.

The painter: Gustav Klimt Gustav Klimt was born on 14 July 1862 in Baumgarten, near Vienna, Austria. The second of seven children born to Anna and Ernst Klimt, Gustav would become one of the greatest exponents of Expressionism.5 After completing his primary education at the local school of the 7th District of Vienna, Klimt, then aged 14, was admitted to the Vienna School of Decorative Arts, with ties to the Imperial and Royal Austrian Museum of Art and Industry. At the time, the cornerstones of the school’s teaching were history painting, naturalist painting and copying from the masters; there, Klimt became proficient in drawing from life.5 After completing his studies, prompted by his instructors at the School, Klimt worked on the stained glass windows of the Votive Church, the first major public work of the Ringstrasse, a ring road that marked the start of the reconstruction of Vienna.5

Journal of Medical Biography 0(0) Shortly thereafter, he founded the Ku¨nstlerkompagnie (Artists’ Company) with his brother Ernst and friend Franz Matsch, with the intent of providing large-scale decorative painting services. The Company worked on the ceilings and staircases of the new k.k. Hofburgtheater (Imperial Court Theatre) and Kunsthistorisches Museum (Museum of Art History) and helped with interior decorating at the old Imperial Museum.5 The latter commission brought Klimt substantial fame; he was awarded the Golden Order of Merit by Emperor Franz Josef I of Austria and became an honorary member of the Universities of Munich and Vienna.6 In 1883 Klimt began his break from the classical tradition in the arts when he created a series of frescoes for the four Faculties of the University of Vienna. Later on, in 1894, to coincide with the Vienna Secession movement (of which he was a founding member and president), Klimt rejected the proposed theme for a commission of three paintings meant to represent three faculties (Philosophy, Medicine and Jurisprudence) of the new University on Ringstrasse.7 The works provoked massive outcry in academic circles and the press alike, and Klimt was barred from exhibiting them at the 1904 St Louis World’s Fair.5,8 One of the paintings, Medicine, for example, was presented in 1901, scandalously focusing on the powerlessness of the art of healing and ignoring achievements in prevention and cure, at a time when Vienna was leading the world in medicine.8 In view of the controversy and ban on public exhibition of the works, Klimt decided to rescind his contract for the Faculty Paintings commission and took the paintings to Germany where he displayed them at the exhibition of the Association of German Artists (Ausstellung des Deutschen Ku¨nstlerbundes) and was awarded the Villa Romana Prize. The State eventually repossessed the paintings, which were ultimately burned at Schloss Immendorf by retreating Nazi troops in 1945.5,6,8 In the early 1890s, Klimt met Emilie Flo¨ge who would become his companion until the end of his life, his open relationships with other women notwithstanding. Klimt is known to have fathered at least 14 children. The work of Gustav Klimt progressed in clear phases. Paintings including Sculpture and Tragedy are representative of his first phase, characterised by historical realism. His last great mural was the Stoclet Frieze which combined repetitive geometric shapes with a smattering of realist elements.5 His second phase was characterized by mosaic-like, Byzantine-inspired imagery, as in Portrait of Adele Bloch-Bauer I. It was during this period that Klimt created the work that be regarded as the zenith of his Golden Phase and the ultimate symbol of the Vienna Secession, Der Kuss (The Kiss).5 With the dawn of the

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da Mota et al. 20th century, Expressionism fell out of favour and Klimt left for Paris where he was influenced by Toulouse-Lautrec. He began to focus on less elaborate paintings, including natural landscapes and buildings, and absorbed some influence from the nascent movement of Cubism. This period, which corresponds to the third phase of his work, included paintings including The Virgins, Death and Life and Black Feather Hat.5 The fourth and last phase was frankly erotic and included works such as Adam and Eve, The Bride and Woman seated with thighs apart.5 After the death of his mother in 1915, Klimt’s work became darker and more subdued, with a predominantly monochrome palette. Klimt died on 6 February 1918 of pneumonia and the effects of a stroke (‘apoplexy’). He was buried in Vienna and left works unfinished.5

The Lady in Gold: Adele Bloch-Bauer The story of Adele Bloch-Bauer (1881–1925) begins in Vienna, the great capital of the Austro-Hungarian Empire, a vigorous melting pot of cultures, ethnicities and radical renewal in the arts and sciences. Adele was born on 9 August 1881, the youngest of the seven children of banker Moritz Bauer (1840–1905) and Jeannette Bauer ne´e Honig (1844–1922), and raised in the western suburb of Hu¨tteldorf, now part of Vienna’s 14th District where the family Summered. Her father was the general director of the influential Viennese bankers’ association and President of the Orient railway company.3,9 The sheltered private life of her family was shaken by a series of tragic deaths in a relatively short time span. Raphael, the Bauers’ oldest son, left Vienna to become a banker in New York. The four Bauer brothers who stayed behind in Vienna did not live long after that. In 1897 when Adele was 16, her brother Karl died of pneumonia at the age of 26. In 1905, only weeks after the death of Adele’s father, her brother Leopold died of ‘insanity’ (a euphemism of the time for syphilis) in Brussels at the age of 37. Her youngest brother died in 1911, at the age of 32, followed by Eugen, aged 46, of tuberculosis. Eugen was the only Bauer sibling to bear children: two girls, Marie and Bettina.3 On 19 December 1899, the 18-year-old Adele married sugar industrialist Ferdinand Bloch, who was 17 years her senior. Adele followed in the footsteps of her sister, Therese, who had married Ferdinand’s brother, Gustav, one year earlier. As the Bauer bloodline had come to an end with the death of Eugen, the Bloch brothers added their wives’ maiden name to their family name, originating the Bloch-Bauer surname and sealing the bond between the two families.3

3 During their first year of marriage, Adele and Ferdinand lived in an elegantly appointed apartment on Schwindgasse. In 1904 they bought a castle in Jungfern-Breschan (Panenske´ Brˇ ezˇany), near Prague, as a summer home.3 As any woman of her time, Adele was denied a university education; undeterred, she followed a highly disciplined regimen of self-study and sought out the company of artists and intellectuals. ‘If fate has given me friends who may be counted intellectually and ethically as extraordinary, then I owe these friendships to one of my main qualities: the strongest self-criticism’, she once said; ‘I have always been and still am, my strictest judge’. Her words evince her struggle for personal development and her utter lack of complacency with her own privilege. She studied German, French and English classical literature. Among her prominent guests were composers Gustav Mahler (1860–1911) and Richard Strauss (1864–1949), Alma Mahler-Werfel (1879–1964), authors Stefan Zweig (1881–1942) and Jakob Wassermann (1873–1934), artists from the circle of Gustav Klimt (1862–1918), actors from the Burgtheater and, after World War I, the socialists Karl Renner (1870–1950) and Julius Tandler (1869– 1936) who became her physician. Possibly due to their influence, she began to support socialist causes.3,9 Adele Bloch-Bauer gave the impression of a refined mixture of romantic personae: delicate, tending to be sick and giving the impression of someone who suffered on the one hand, and a self-conscious, proud salon lady on the other. Indeed, she may have found her role models in romantic literature. ‘Her narrow face appeared both elegant and intellectual and arrogant and smug. She was often caught in the unladylike modern habit of smoking’.9 Adele eschewed popular taste and directed her sensibilities to the more subtle aesthetic of fin-de-sie`cle Vienna and its powerful concern with the conditions of the human psyche. Maria Altmann, her niece, described Adele as introverted, demanding, intense and aloof.3,9 Adele personified a series of contradictions of her generation – a generation on the edge of modernity. Although she was rooted to the traditions and privilege of her social class, she was a stalwart defender of social reform, workers’ education and universal suffrage; she supported socialist organisations for the care of orphans and associations dedicated to social reform. She disavowed her Jewish origins, proclaiming herself an agnostic, and chose to be cremated after death, an extraordinarily defiant act at the time, demonstrating her belief that rationality should supplant religion. It has been speculated that the death of her brother Karl may have influenced Adele’s break from religion.3,9 More significant, Adele revered Gustav Klimt who, through the Vienna Secession, defended art from the

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4 conventions of academia. Klimt’s unwavering commitment to socio-cultural renewal earned him vast financial resources and helped establish the Bloch-Bauers as major patrons of the Arts. The couple held a salon dedicated to works by the artist, known as Klimt Hall.3 In the summer of 1903, Ferdinand Bloch-Bauer asked Klimt to paint a portrait of his wife as a present for her parents’ wedding anniversary in October although the veracity of this intent is controversial. The portrait, Adele Bloch-Bauer I, was exhibited only in 1907. Five years later, in 1912, a second painting, Adele Bloch-Bauer II, was presented.3,9 In addition to the two portraits of Adele, the BlochBauers also purchased four landscapes and several drawings by Klimt. They were proud of their collection which included paintings by famous Austrian artists including Ferdinand Georg Waldmu¨ller (1793–1865), Rudolf von Alt (1812–1905) and Emil Jakob Schindler (1842–1892), as well as a valuable collection of Viennese classical porcelain.9 After the fall of the Austrian-Hungary monarchy in 1918, Ferdinand and Adele requested Czech citizenship with the address of their castle in Jungfern-Breschan, near Prague. Nevertheless, their home base remained in Vienna where Adele continued her role as a salon lady.3 Shortly after the end of World War I, in December 1919, Ferdinand and Adele purchased a small mansion on Elisabethstrasse in downtown Vienna, which would become known as the Bloch-Bauer Palace. The mansion was located on the corner of Elisabethstrasse and Schillerplatz, across the street from the Academy of Fine Arts, near the Kunsthistorische Museum and the National Library. The area around the Schillerplatz was the cradle of a new, cultured business elite, a ‘second’ high society that would later replace the aristocracy after the fall of the Habsburg Empire.3,9 Adele and Ferdinand moved into the Elisabethstrasse mansion in 1920. Since its conception, the palace had been the preeminent meeting point for high Viennese society, a tradition carried on by the couple until shortly before Adele’s death.3 Adele died in 1925, aged 43, of encephalitis (other sources cite meningitis9 or tuberculosis as her cause of death), leaving Ferdinand as her sole heir. The couple was childless: their first child was stillborn and their second, Fritz, died in 1904, one day after birth. Adele bequeathed her money to the Kinderfreund and Bereitschaft associations and her books to an adult education school, and asked Ferdinand to donate her two Klimt portraits and four landscapes to the Belvedere gallery upon his death.3 After Adele’s death, the ‘Klimt Hall’ was turned into a memorial for her. In 1938, following the Anschluss or annexation of Austria to Nazi Germany, the paintings were

Journal of Medical Biography 0(0) ‘Aryanised’. Ferdinand fled to Czechoslovakia and then to Zurich, where he died shortly after the end of the war. He is buried beside Adele in Vienna.3,9 Ferdinand did not live to see the recovery of his Klimt paintings and other works in his magnificent collection. Based in California, Maria Altmann, Adele’s niece and the family heir, sued the Republic of Austria, demanding that the Klimt paintings be returned to her ownership.9

Adele Bloch-Bauer I and II – the paintings In the first and most famous of the two portraits, Adele Bloch-Bauer I (1.38  1.38 m), painted between 1903 and 1907 (Figure 1), Adele is portrayed astride a golden throne, the modern icon of a grande dame, a golden starry sky in the background complementing her rich golden robe. To some critics, the ‘fervent movement of erotic symbols such as triangles, eggs, eyes, in the flow of her gown hints at an intimate relationship between the artist and his model’.3,9 Adele Bloch-Bauer I marks the pinnacle of Klimt’s Golden Phase, a remarkable synthesis of reality and abstract geometry in which Adele seems to hover

Figure 1. Adele Bloch-Bauer I, 1907, Gustav Klimt.10 Neue Galerie, New York. Adele is portrayed sitting on a golden throne, the modern icon of a grande dame. Forming the background, a golden, starry sky complements her rich golden robe. There is a mysterious air about her; her lips are sensuous and her hands twisted near her face to conceal a deformed finger (perhaps due to arthritis). Her pale, purplish fingers are suggestive of Raynaud’s phenomenon (inset) and her marked facial erythema (inset) might represent a malar rash or the flushing of heart disease.

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before cascading geometric shapes, which conceal her body and render her silhouette indistinguishable from the elements that surround her. Her delicately painted face stands out amid the rich ornamentation, as if overlaid on the background in a two-dimensional plane of its own. The effect resembles a photomontage, its cutout quality stressed by the neckband Adele wears, which seems to separate her head from her body.3,9 For all her delicacy and frailty, Adele commands the composition. She sits rather awkwardly, her hands folded peculiarly as if to conceal a deformity in her right hand. Her gaze is distant and pensive, almost melancholic, but her luminous eyes and skin betray a sensuality hidden just beneath the surface.3,9 In the second portrait, Adele Bloch-Bauer II (Figure 2), dated 1912, Adele wears an elegant gown and stands to face the viewer. The colourful wallpaper in the background evokes a faraway, exotic, Eastern fantasy world.3,9 Adele Bloch-Bauer I and II are the only two works of Klimt for which Adele modelled officially but in a third, earlier (1901), portrait of a femme fatale, entitled Judith

(Figure 3), Adele is presumably recognised through her facial features and the garish neckband she wears, a centrepiece of the painting. A contemporary critic identified Judith as ‘a modern Jewish lady’. As Judith precedes both Adele Bloch-Bauer I and Adele Bloch-Bauer II, the relationship between Adele and Klimt may have been far more longstanding than official sources suggest.12

Figure 2. Adele Bloch-Bauer II, 1912, Gustav Klimt.11 Wearing an elegant gown, Adele stands to face the viewer. The colourful wallpaper in the background evokes a faraway, exotic, Eastern fantasy world.

Figure 3. Judith, 1901, Gustav Klimt.13 This painting portrays a femme fatale – allegedly Adele, as indicated by the similarity in facial features and the garish neckband she wears, a centrepiece of the painting.

Adele and Gustav: the nature of their relationship Speculation as to a possible affair between Adele BlochBauer and Gustav Klimt may be no more than mere conjecture – an exercise in dubious taste that remains in

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6 vogue, in the form of paparazzi and gossip magazines reporting on the lives of celebrities. Nevertheless, although much has been suggested on this topic, nothing is certain. The stage on which this tale is set is yet again Vienna, then a restless geographic, cultural and ethnic centre that served as a backdrop for major changes in ideas and knowledge that would ultimately shake humankind to its core. A cast of characters both determined by and acting as determinants of that time and space wrought a veritable revolution in several fields, breaking paradigms in psychology and neuroscience in literature and in the arts as a whole. While Sigmund Freud shocked the public with his interpretations of dreams, symbols and behaviours as expressions of repressed desire, eroticism and aggression, Arthur Schnitzler innovated in literature and drama by introducing the interior monologue as a means of revealing latent female sexuality, and the paintings of Gustav Klimt, Oskar Kokoschka and Egon Schiele evoked the unconscious to express pleasure, desire, anxiety and the fear of death.14 Viennese society, at once hypocritical and revolutionary, ebullient, both driven by hedonism and rife with prejudice, held a ‘serpent’s egg’ within its bosom: the end of an era known as the Belle e´poque, the twilight of an empire of Romantic pomp and the nefarious, ultimately devastating dawn of Nazi-Fascist terror. This was the stage for the meeting between an artist unlike any other (Klimt) who was able to gild sensuality in vibrant, iconic colours, and a young woman (Adele) married to a much older man – a wealthy young woman, not only financially but intellectually an atheist, a feminist, well-known in social circles for her close relationship with the exalted painter and, even more so, for having served as a model for at least two of his works (some maintain that she also modelled for Klimt’s 1901 Judith, which would have the two meeting long before Adele’s marriage to Bauer). The painter’s liberal proclivities, his model’s feminist leanings and boldness, their time spent together at Klimt’s studio and the very atmosphere of eroticism the painting seems to exude all weigh in favour of a more intimate relationship between the two. Still, despite Klimt’s involvement with countless women, there is no definitive proof whatsoever of the aforementioned relationship, as natural and obvious as such a liaison might seem. In an interview, Maria Altmann, Adele’s niece, both lays to rest and perpetuates the mystery: ‘People always asked me, did your aunt have a mad affair with Klimt? My sister thought so. My mother – she was very Victorian – said ‘‘How dare you say that? It was an intellectual friendship’’’. She concludes ‘Adele was a modern woman, living in the world of yesterday’.15

Journal of Medical Biography 0(0) If Portrait of Adele Bloch-Bauer I can be regarded as a Mona Lisa of the 20th century, one may assume that, just as that enigmatic smile was preserved for eternity by Leonardo da Vinci, so the mystery, the doubt, the secret in Adele’s eyes shall remain. But what of it? All that matters is that artist and muse shall be together forever, made immortal by the beauty of art.

Possible diagnoses for the Lady in Gold Now, let us speculate as to potential diagnoses for Adele Bloch-Bauer. There is little to work with in terms of evidence since her private life was shrouded in mystery. Adele was almost constantly tired and afflicted by headaches and vague symptoms.15 There are no records of her having received medical treatment and she refused to go the doctor’s surgery for examination. In the famed portrait, there is a mysterious air about her; her lips are sensuous and her hands twisted near her face to conceal a deformed finger (perhaps due to arthritis). Her pale, purplish fingers are suggestive of Raynaud’s phenomenon (inset), and her marked facial erythema (inset) might represent a malar rash or the flushing of heart disease (although it may also be the result of makeup or an artistic decision, as flushed cheeks are seen in other Klimt paintings of the female figure). Through the presence of these potential clinical signs and references available from other sources, we may outline some diagnostic hypotheses for the Lady in Gold as an exercise in diagnostic reasoning. This is, of course, merely speculative, since there is no further evidence to support our assumptions. The first possibility is that the purported malar rash, joint deformity (perhaps due to arthritis), fatigue, possible Raynaud’s phenomenon, and headache, as well as the coma and fever preceding death, may have been manifestations of systemic lupus erythematosus (SLE). Indeed, malar rash is a very common manifestation in SLE, affecting 60% of patients.16 The prominence of Adele’s reddened cheeks in the painting immediately calls to mind a diagnosis of lupus. In a 1979 study, Raynaud’s phenomenon was detected in 40% of patients with SLE and was found to be associated with a better prognosis.17 Recent research suggests an even higher prevalence of Raynaud’s phenomenon in lupus, in the region of 55%; interestingly, this vasomotor manifestation was associated with both central and peripheral nervous system involvement in the patients studied. A recent Chinese study might be helpful in elucidating the Adele affair. After assessing 917 patients with SLE, the authors found associations between certain clusters of clinical manifestations and the

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da Mota et al. presence of certain antibodies. One such cluster was characterised by Raynaud’s phenomenon, malar rash, photosensitivity and presence of anti-Ro, antiSm and anti-RNP antibodies.18 Remarkably, our ‘patient’, Adele, may have exhibited these manifestations. The presence of coma and fever at the time of her death is suggestive of central nervous system involvement, leading to lupus encephalitis with a fatal outcome. The second hypothesis in our differential diagnosis is rheumatic fever (RF) or, rather, its late cardiovascular sequelae of adulthood. Indeed, flushed cheeks occur in some patients with mitral valve disease, particularly in mitral stenosis, a sign that has long been known and referred to as mitral facies or facies mitralis. This manifestation, characterised by a dusky flushing of the cheeks and – in the later stages – surrounding cyanosis is due to low cardiac output and vasodilatation in the skin. The second sign that can help establish this diagnosis is the possibility of joint deformity which might be a manifestation of Jaccoud’s arthropathy, an articular deformity first described in patients with RF. Mild-to-moderate mitral stenosis can be asymptomatic from a cardiorespiratory standpoint (i.e. present without dyspnea) with symptoms occurring only on exertion which would justify Adele’s refraining from physical activity. The fatigue reported in accounts of Adele’s life is another classic symptom of mitral stenosis attributable to low cardiac output. Near the end of her life, fever may have been due to infection of a deformed mitral valve, producing infectious endocarditis, a relatively common condition at that time in patients with a history of rheumatic disease. Cerebral embolisation from thrombi, septic emboli or, alternatively, cardiac arrhythmias leading to a marked reduction in cardiac output and, consequently, poor cerebral perfusion might explain her coma and its fatal outcome. A third diagnostic possibility would be rheumatoid arthritis (RA). Indeed, the posture in which ‘our patient’ is portrayed may have been an attempt to conceal a deformity in her right hand. Raynaud’s phenomenon is present in approximately 9.4% of patients with RA, as shown and confirmed in a recent meta-analysis of 3730 patients.19 Furthermore, Adele’s history of smoking heightens her susceptibility to two of these hypothetic rheumatological conditions since tobacco exposure is a known risk factor for lupus and RA alike.20 A fourth possible diagnosis would be mixed connective tissue disease (MCTD), a connective tissue disorder commonest in women at or after the third decade of life and characterized by manifestations of SLE, scleroderma and myositis. Raynaud’s phenomenon is present in almost 100% of patients and the arthritis visible in Adele Bloch-Bauer I might be a manifestation of lupus.

7 The fatigue described in her history may have been due to anaemia, muscle involvement or systemic involvement. Initial reports regarded MCTD as a benign condition, but later studies have associated it with headache, aseptic meningitis and neuropsychiatric manifestations.21 Last but not least, syphilis might be a possibility. Joint deformities, facial redness, fatigue, perhaps encephalitis in her last days, having lived at a time when the disease was epidemic and incurable, all make syphilis an appealing possible diagnosis for Adele. The aforementioned fact that one of Adele’s brothers, Leopold, died insane – seemingly of tertiary syphilis – corroborates the epidemic nature of the condition at the time and in the light of the suspected intimate relationship between Adele and Klimt, AnneMarie O’Connor’s note in the above-cited The Lady in Gold bears repeating ‘Klimt had always had a terrible fear of syphilis, and now the ageing Pan was suffering signs of its dreaded advance. Klimt’s letters complained of the skin eruptions that mark the advanced stages of the illness. ‘‘Results good. Boil seems to be closing’’ – he wrote Emilie Flo¨ge’.15 Were they available, further information on the medical history and physical examination findings of Klimt’s muse might help shed light on the mystery of her illness. The presence of a heart murmur or the confirmation of Jaccoud’s arthropathy or arthritis would be invaluable for diagnostic confirmation. At present, a single, definitive, diagnosis is beyond the realm of possibility but the case of Adele Bloch-Bauer can still encourage clinical reasoning and prompt extensive scientific and artistic reflexion.

Conclusions Gustav Klimt’s stunning Adele Bloch-Bauer I is currently an exhibit featured at the Neue Galerie New York, a gallery whose mission is to collect, preserve and showcase the fine arts and decorative arts of Germany and Austria from the first half of the 20th century. Adele Bloch-Bauer is assured a place of honour in the permanent collection of this institution.3 According to Lillie and Gaugusch, Adele BlochBauer I shall remain in the possession of the Neue Galerie ‘as a memorial to the life and legacy of two outstanding individuals, Ferdinand and Adele BlochBauer, and as a magnificent example of fin-de-sie`cle Vienna. But the painting will also be a lasting witness to all that was destroyed by the Holocaust, to a generation annihilated by the Nazis . . . Not least, Adele Bloch-Bauer I will forever remind us the heroes of our own lifetime and all that can ultimately be achieved, against all odds, in the name of justice’.3

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8 Many mysteries still surround the life and, above all, medical history of Adele Bloch-Bauer, as well as her potential relationship with the artist who portrayed her. This paper discusses a few potential diagnoses for the Lady in Gold, using as a foundation what little data are available about her and details visible in the work itself, made immortal by the genius of Gustav Klimt. References and notes 1. Buckley PJ. Gustav Klimt Egon Schiele, and Fin de Siecle Vienna. American Journal of Psychiatry 2012; 169: 692. 2. Schorske CE. Fin-de-sie`cle Vienna: politics and culture. New York: Vintage Books, 1981. 3. Lillie S and Gaugusch G. Portrait of Adele Bloch-Bauer. New York: Neue Galerie Museum for German and Austrian Art, 2007. 4. Sabine C. Who is that woman? Adele Bloch-Bauer http:// www.sabineclappaert.com/pdf/whoisthatwoman.pdf (accessed 17 October 2012). 5. Rogoyska J and Bade P. His life. In: Gustav Klimt (Best of Collection). New York: Parkstone International, 2011. 6. Rogoyska J and Bade P. Biography. In: Gustav Klimt (Best of Collection). New York: Parkstone International, 2011. 7. Rogoyska J and Bade P. The Viennese secession. In: Gustav Klimt (Best of Collection). New York: Parkstone International, 2011. 8. Bitsori M and Galanakis E. Doctors versus artists: Gustav Klimt’s Medicine. British Medical Journal 2002; 325: 1506–1508. 9. Shapira E. Adele Bloch-Bauer 1881–1925 http://jwa.org/ encyclopedia/article/bloch-bauer-adele (last accessed 28 October 2012). 10. Lillie S and Gaugusch G. (op. cit. ref. 3): p. 12. 11. Lillie S and Gaugusch G. (op. cit. ref. 3): p. 42.

Journal of Medical Biography 0(0) 12. Grimberg S Adele. Private love and public betrayal in turn-of-the-century Vienna: a tale hidden in the paintings of Gustav Klimt. Art & Antiques 1986; 90: 70–74. 13. Rogoyska J and Bade P. In: Gustav Klimt (Best of Collection). New York: Parkstone International, 2011, p.424. 14. Kandel E. The age of insight: the quest to understand the unconscious in art, mind, and brain, from Vienna 1900 to the present. Random House Publishing Group, 2012. 15. O’Connor AM. The Lady in Gold: the extraordinary tale of Gustav Klimt’s masterpiece, Portrait of Adele BlochBauer. Knopf, 2012. 16. Gronhagen CM, Gunnarsson I, Svenungsson E, et al. Cutaneous manifestations and serological findings in 260 patients with systemic lupus erythematosus. Lupus 2010; 19: 1187–1194. 17. Dimant J, Ginzler E, Schlesinger M, et al. The clinical significance of Raynaud’s phenomenon in systemic lupus erythematosus. Arthritis and Rheumatism 1979; 22: 815–819. 18. Tang X, Huang Y, Deng W, et al. Clinical and serologic correlations and autoantibody clusters in systemic lupus erythematosus: a retrospective review of 917 patients in South China. Medicine (Baltimore) 2010; 89: 62–67. 19. Hartmann P, Mohokum M and Schlattmann P. The association of Raynaud’s syndrome with rheumatoid arthritis–a meta-analysis. Clinical Rheumatol 2011; 30: 1013–1019. 20. Kallberg H, Ding B, Padyukov L, et al. Smoking is a major preventable risk factor for rheumatoid arthritis: estimations of risks after various exposures to cigarette smoke. Annals of the Rheumatic Diseases 2011; 70: 508–511. 21. Fujita Y, Fujii T, Nakashima R, et al. Aseptic meningitis in mixed connective tissue disease: cytokine and antiU1RNP antibodies in cerebrospinal fluids from two different cases. Modern Rheumatology 2008; 18: 184–188.

Author biographies Licia Maria Henrique da Mota, MD, PhD, is a Rheumatologist. Advisor, Postgraduate Program in Medical Sciences, Universidade de Brasilia School of Medicine. Fernando Neubarth, MD, is President, Brazilian Society of Rheumatology (2006–2008), Vice-President, Pan American League of Associations for Rheumatology. Director of Education and Research, Hospital Psiquia´trico Sa˜o Pedro, Rio Grande do Sul State Department of Health. Joze´lio Freire de Carvalho, MD, PhD, works in the Department of Rheumatology, Centro Me´dico Alianc¸a. Leonardo Rios Diniz, PT, PgDip Orthopaedics, DO, works in the Corpo Clı´ nica de Fisioterapia. Rodrigo Barbosa Aires, MD, works in the Department of Anaesthesiology, Instituto de Cardiologia do Distrito Federal. Leopoldo Luiz dos Santos-Neto, MD, PhD, FACP, is Associate Professor of Internal Medicine, Universidade de Brası´ lia School of Medicine.

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