Case of Occupational Disease

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International Journal of OsteoarchaeologyInt. J. Osteoarchaeol. 13: 294–302 (2003)

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/oa.701

Luigi Boccherini and the Barocco Cello:

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Century Striking Case ofOccupational Disease

R.CIRANNI*ANDG.FORNACIARI

Department of Oncology, Transplants and Advanced Technologies in Medicine, Section

of History of Medicine and Paleopathology, University of Pisa, Pisa, Italy

ABSTRACT The aim of this paper is to elaborate an ergonomic model based on the study of acquiredmuscle-skeletal lesions related to Boccherini’s intensive activity as barocco cellist. The bodyof the famous musician was submitted to external examination, macroscopic analysis andradiographic study. Palaeopathological studies of the skeleton showed a considerable

number of changes such as severe rhizoarthritis of the right thumb, heavy epicondylitis ofthe left elbow, loss of physiological cervical and lumbar spine lordosis and high thoracic leftscoliosis with maximum on T3-T4. A case of tibiae valgae was diagnosed at the level of the legs.The acquired muscle-skeletal lesions found seemed to be correlated to Boccherini’s celloactivity. Direct observation of a present-day cellist allowed us to better understand howrepetitive strain injuries were responsible for the situation which appears in the ergonomicmodel described. Copyright 2003 John Wiley & Sons, Ltd.

Key words: palaeopathology; posture; ergonomics; acquired lesions; rachigram

Introduction

Luigi Boccherini (Figure 1), the famous musicianfather of the instrumental trios, quartets andquintets (De Mesonero, 1927), was born in Lucca(Italy) on 19 September 1743. The third son of avery large family, he inherited his passion formusic from his father. Luigi was only 13 years oldwhen he began to play as orchestral cellist andthen travelled to Vienna and Paris, and to variousforeign countries where his talent was largelyappreciated. However, in 1765—at the age of22—he started to have health problems and was

badly affected by violent attacks of fever (DellaCroce, 1988). Such was the fame he acquired inFrance that it led Don Juan, Infant of Spain andbrother of the King, to invite Boccherini toMadrid. At the Royal Court of the Bourbon

King Charles III and under Don Juan’s protection,the musician was appointed royal composer andofficial cellist. Unfortunately, owing to the unsta-ble situation at court and to the death of Don

Juan the musician was forced to leave Spain,looking for a new patron. The Prince of Prussia,who was later to become King Frederick II, enga-ged him as royal chamber-composer, offeringhim a generous annual salary. Boccherini heldthis position for several years, enjoying materialcomfort and high esteem, but his health condi-tions were becoming more and more serious: in aletter written in French and sent to an Italian

friend, he wrote that he was frequently sufferingfrom crachements de sang (expectoration of theblood), strong enflure de pieds (feet oedema) andfrom severe disparasion a peu pres comple te de mes forces(physical and mental weakness) (Di Colo, 1988).Following the death of Frederick II in 1779, havinglost both protection and money, Boccherinidecided to go back to Spain where he spent hislast years living in solitude and in conditions of

Copyright# 2003 John Wiley & Sons, Ltd. Received 14 January 2003 Revised 17 February 2003

Accepted 14 May 2003

* Correspondence to: Department of Oncology, University ofPisa, via Roma, 57-56126 Pisa, Italy.e-mail: [email protected]



deep indigence. He was choked to death by ahaemorrhagic coughing fit (De Rotschild, 1962)on 28 May 1805 at 62 years of age. His body wasburied in the Pilgrim’s Crypt of Saint Giusto inMadrid.

At the beginning of the Italian Fascist regimenthe Mayor of Lucca asked the Spanish Govern-ment for restitution of Boccherini’s body. In1927, the sarcophagus containing the well pre-served mummy of the musician was transferredfrom Madrid to Lucca and was buried, with greatceremony, in the Church of San Francesco (Len-cioni, 1997).

In 1993, on the two hundred and fiftieth anni-versary of his birth, the body was exhumed andsubmitted to palaeopathological study. Explora-tion of the tomb revealed a corpse entirely wrap-ped in cloth according to the Franciscan funerarypractice. The remains were those of a badly— but

originally very well-preserved—natural mummy(Figure 2(A)). The environmental conditions ofthe secondary burial had caused severe degrada-tion of most of the soft tissues since the groundwater table under the floor of San Francesco’schurch, where the sarcophagus was immersed,produced partial skeletonization of the body(Figure 2(B)). The skeleton was instead very wellpreserved: macroscopic and radiographic studies

showed a number of acquired muscle-skeletallesions correlated to Boccherini’s cello activity.

The aim of the present paper is to elaboratean ergonomic model, peculiar of Barocco celloperformers and to investigate this striking caseof 18th century occupational disease.

Materials and methods

Boccherini’s body remains were submitted toexternal examination, macroscopic and radiolo-gical study.

Radiological study

The specimen was X-rayed by a portable X GILS.G. type (70 kV; 7 mA) apparatus produced byGilardoni (Italy), using Du Pont, CRONEX 4Blue Base film, 30 40 cm. Negative films weremanually developed, using Agfa solution and afixative. About 10 X-rays with antero-posteriorand latero-lateral projection were performed.

Results

External examination

The body presented some areas of preserved softtissue in the thoraco-abdominal cavity and at thelevel of the thighs and tibiae. The studies con-cerning the residual soft tissues will be discussedseparately as soon as the results are ready.

The well-kept skeleton belonged to a maleindividual older than 60 years of age, of mediumheight (165 cm tall) (Angel, 1980) and lean build,anthropologically belonging to the Mediterra-nean coast type, presenting some features con-sistent with those of the human ‘Lucchese’Biasutti type (Biasutti, 1967). The anthropologi-

cal age (Angel, 1980) agrees with the radiologicalone and with the literary sources.The macroscopic and radiological studies per-

formed on Boccherini’s skeleton made it possibleto detect a large number of lesions.

Study of the entire skull revealed a severe wearresulting in destructive caries and a high degreeof periodontal disease. Most of the teeth hadbeen lost before death. The temporomandibular

Figure 1. Physiognomic reconstruction of Luigi Boccherini’s headbased onthe skull andproduced by Alessandro Carpita (by cour-tesy of the Istituto Storico Lucchese,Lucca,Italy).

Luigi Boccherini and the Barocco Cello 295

Copyright# 2003 John Wiley & Sons, Ltd. Int. J. Osteoarchaeol. 13: 294–302 (2003)



joint was affected by severe bilateral arthritis,probably due to sub-total loss of the teeth and/orto a phenomenon of malocclusion.

Bilateral cartilaginous ossification of the ster-num and the ribs was observed; the sternumappeared deformed; the pectoral girdle was intactwith the left muscle stronger than the right

muscle insertions.The bones of the upper limb were all wellpreserved; some distal phalanges of the righthand were missing while the left hand was intactwith no alterations.

The coxal bones were normal; the pubic sym-physis was levelled, assuming the typical shapepresent in people over 50 years of age (Krogman,1986). The bones of the legs were present,

but some of the distal bones of the feet weremissing.

The following is a description of the patholo-gical alterations found.

Right hand

The right carpo-metacarpal joint showed severearthritis of the trapezium bone (Figures 3(A) and3(B)), with the production of an enormous girdleof pathological bone characterized by roughmarginal osteophytes; the first metarcapal bonewas also affected by severe arthritis with jointeburnation (Figure 3(C)). This picture is typicalof rhizoarthritis of the right thumb (osteoarthritisat the ’root’ of the thumb; the left one is not

Figure 2. (A) The wellmummified bodyof Boccherini during exhumation in Madridin1927. (B) Thepartially skeletonizedbodyafterexhu-mation in Lucca in1993.

296 R. Ciranni and G. Fornaciari




Figure 3. (A) Skeletal segments of the right hand: severe rhizoarthritis (osteoarthritis of the ‘root’) of the thumb is evident; (B) X-ray ofthe same hand shows marked osteosclerosis and bone pseudocystis (arrows); (C) the trapezio-metacarpal joint appears levelled andeburnated (large arrow); the articular margins are maskedby new bone with osteophytes (thin arrows).





involved), a well known pathology. Insertions ofthe opposer and of the long abductor muscles ofthe thumb were exceptionally strong. Finally, theinterphalangeal joint of the right thumb revealedmoderate arthritis.

Left armUnlike the right one, the joint of the left elbowrevealed some bumps, irregular grooves and lat-eral cicatrical dimples at the level of the epicon-dyle of the humerus (Figures 4(A) and 4(B)).This is the typical picture of severe chronicepicondilytis. The forearm, as well as the leftpectoral girdle, showed a strong insertion of theextensor carpi radialis brevis muscle, of the extensor carpi ulnaris muscle, and of the supinator andanconeus muscles.

LegsThe superior third of the tibiae showed bilateral,symmetric and external bending, shaping a typi-cal picture of genu valgum (Figure 5).

SpineThe macroscopic and radiological study of thespine revealed the loss of cervical and lumbar

Figure 4. Epicondyle ofthe left humerus: (A) some bumps (arrow); and (B) irregulargrooves andlateral cicatrical dimples are wellevident(arrow).

Figure 5. Bilateral tibiae valgae. Arrows show the maximumvalgism.





Figure 6. (A) The spine reveals loss ofcervical (arrow) and lumbarlordosis; (B) scoliosis is lateral, left-convex with the maximum onT3 andT5 (arrows); (C) Arrows underlinedsevere arthritis ofthe articular facets.





lordosis (Figure 6(A)); the thoracic column wasaffected by severe scoliosis characterized bylateral left-convex deviation with the maximumon T3 and T5 (Figure 6(B)); X-rays underlined asevere arthritis of the articular facets (Figure6(C)). The lack of cervical and lumbar lordosisis described in detail in the rachigram (Figure 7).

Discussion

Repetitive strain injuries (RSIs) are caused bystrenuous and repeated movements which pro-duce damage to the tendons, nerves, musclesand— indirectly— to the bones. Musicians repre-sent a group of people who have characteristicRSIs resulting from the type of instrument theyplay. Since all the above reported skeletal lesionsof Boccherini are not real pathologies, butchanges acquired in the course of life in responseto environmental circumstances, they need to beergonomically evaluated (Culf, 1988; Shell, 1995).

Rhizoarthritis of the thumb, chronic epicon-

dylitis, lesions to the column and genu valgum werestudied by analysing the muscular movements ofa cellist during the performance of one of Boc-cherini’s adagios (Figures 8(A)–(C)).

When the cellist is pushing the bow, from tipto heel, the thumb tends to stretch out; on theother hand, when he is pulling it, from heel to tip,it bends by flexion of the phalanges (Figure8(C)). Boccherini, composer and concert player,

spent most of his life playing the cello andtherefore submitted the thumb joint to this con-tinuous and repeated movement which graduallyevolved into rhizoarthritis of the right thumb.This disease usually arises after the age of 50 andis often due to overexertion of the trapeziometa-carpal joints. In living people the disease ischaracterized by strong pain of the radial areaof the hand and generally evolves into ankylosis,producing the typical square-hand shape. Allthese bibliographic descriptions (Kohler & Zim-merman, 1970) agree with the macroscopic andradiological observations made on Boccherini’sskeleton. The joint eburnation of the first meta-carpal bone diagnosed on Boccherini’s righthand demonstrates that the musician continuedto play the cello despite the pain, thus preventingankylosis.

Our conclusions are strongly supported bydifferential diagnosis; for instance rheumatoidarthritis, which involves the metacarpophalan-geal and proximal interphalangeal joints, is ero-sive and symmetric; gout, as well as rhizoarthritis,

is asymmetric and could involve the carpo-meta-carpal joint of the thumb but it is destructive andcharacterized by geodi formations which are notpresent in our case. Boccherini’s thumb pathol-ogy is certainly a monoarticular arthritis, thereare no Herberden’s nodes and the distal inter-phalangeal joint is not involved.

Observing the movements of the cellist, theleft hand sustained the neck of the cello and, at

Figure 7. Rachigram of Boccherini’s column: sagittal, frontal and transversal indexes were evaluated.





the same time, produced the movement of thefingers on the stringboard; during this doubleaction, the left arm and, in particular, the leftelbow, are constantly solicited (Figure 8(B)). Inthe case of Boccherini, this continuous solicita-tion of the muscles and tendons produced, duringan entire life of performances, the severe, chronicepicondylitis of the left elbow. This diseaseusually affects workers, for example shoemakersand glassblowers (De Se ` ze & Ryckewaert, 1979),who submit their elbows to strong and constantmuscle-tedinous tension. The baroque cello wasdifferent from the present-day instrument: it wassmaller and without the point. The absence ofthis metallic point, which forces the musician tosustain the instrument with a tonic contraction ofthe knees and the legs, was responsible for theaquired tibiae valgae (Figure 8(A)), a deformingprocess that started when the child Boccherini

began to play the cello.The human body was not designed to remainseated with the knees and hip bent close to a 90

angle, since the maximum free movement of thethigh in the hip socket is about 60. This incor-rect position of the legs and the stiff postureproduced by sitting upright on a flat chair, withthighs and torso at an angle of 90 (Figure 8(B)),produced the loss of cervical and lumbar lordosis,

flattening of the diaphragm and collapse of thechest (Roberts, 1995), scoliosis was instead dueto the position of the body on the instrument: itsshortness and the absence of the point forced theposition of the body which was bent at the frontand on the right (Figure 8(B)), producing left-convex scoliosis which reached its maximumdegree on T3 and T4. The lack of cervical andlumbar lordosis do not depend on artificial‘articulation’, as demonstrated by the elaborationof the rachigram (Figure 7) (Mafart, 1983).

One lesion, less important, was the deformityof the sternum: it may have been congenital butwas probably produced by the pressure of theinstrument against the breast.

The cartilaginous ossification of the sternumand the ribs is compatible with age, but can beworsened by the thorax pressure and incorrectposture maintained during the performances.

Finally, even if the left forearm as well as theleft pectoral girdle were characterized by hyper-trophied muscle insertion, stronger than the rightones, Boccherini was not a left-handed indivi-dual. The greater muscular development of theupper left body muscles was exclusively due tothe natural conformation of the cello whichrequires strenuous work of the left arm on theneck and on the stringboard.

Figure 8. (A) Professor Carlo Benvenuti, cellist, duringthe performance ofone of Boccherini’s adagios. (B) The positionof the body, legs,shoulderand left arm, and (C) the handling ofthe bow are well visible.





Conclusions

Luigi Boccherini was of medium height, of deli-cate constitution, anthropologically belonging tothe Mediterranean, coastal variety. Anthropolo-gical and radiological age agree with the literary

sources according to which his death dates backto the year 1805, when he was 62 years old.

The palaeopathological study performed onhis skeleton made it possible to reconstruct thescenario of his health conditions (unreporteddata). On the other hand, macroscopic and radi-ological studies allowed the elaboration of a veryinteresting ergonomic model peculiar to baroccocellists. As a matter of fact, Boccherini wasaffected by a number of lesions acquired in thecourse of his life and certainly due to his occupa-tional state of cellist.

Modern acquisition (20th century) of the pointand increased height of the tool have reduced thepossibility of development of genu valgum andscoliosis, but the cello still forces the performerto maintain an unnatural position. The stiff pos-ture of the back against the chair, the hip andknees bent to a degree of 90 (Mandel, 1982;Norris, 1993), the unchanged use of the bow andstrenuous work of the left arm make the describedergonomic model partially superimposable tothat of contemporary cello performers. Instru-mental musicians generally represent a particularrisk group: they are repetitively submitted to anumber of chronic injuries— incorrect posture,non-ergonomic techniques, stress—that cancause pain, disability and, sometimes, the endof their career as musicians. Boccherini wouldprobably have suffered a similar fate if tubercu-losis had not killed him at 62 years of age.

Acknowledgements

We would like to thank Professor Carlo Benve-nuti, cellist (Academy of Music ‘Luigi Boccherini’,Lucca, Italy) and the Istituto Storico Lucchese forthe picture of Boccherini’s head fisiognomic re-construction.

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Case of Occupational Disease

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