Did Father Cicero suffer from rheumatism?

Abstract

Father Cicero Romao Batista is probably the most famous Ceará character of all time. An important protagonist of the Cariri region, situated in the south of Ceara State, in the late nineteenth century and the first third of the twentieth century, Father Cicero had great political and religious activity, as well as other less well-known achievements, for instance, his ecological teachings that led him to be awarded the title of “Patron of Forests”, besides an enormous effort and personal sacrifice for the improvement of the conditions of human life. Inspired by reading his biography, we find that the “Padim Ciço” could have inflammatory spondyloarthropathy. In this article, we present the plausibility of this diagnostic hypothesis, seeking to emphasize that an attentive ear and clinical observation, albeit indirectly and without the privilege of a personal contact with the patient, are unparalleled tools for bringing forth a diagnosis.

Keywords
Spondylitis; Religion; History of Medicine

Resumo

O padre Cícero Romão Batista é provavelmente o mais célebre personagem cearense de todos os tempos. Importante protagonista da região do Cariri, sul do Estado do Ceará, no fim do século XIX e primeiro terço do século XX, teve grande atuação política e religiosa, para além de outros feitos não tão conhecidos, como ensinamentos ecológicos, que o levaram ser agraciado com o título de Patrono das Florestas, bem como enormes esforços e sacrifício pessoal pela melhoria das condições de vida humana. Através da leitura de sua biografia, veio-nos à percepção a possibilidade de que o “Padim Ciço” tenha sido portador de espondiloartropatia inflamatória. A plausibilidade dessa hipótese diagnóstica é aqui apresentada. Busca-se enfatizar que o ouvido atento e a observação clínica, ainda que de forma indireta, sem o privilégio do contato com o paciente, constituem ferramentas incomparáveis na propositura de um diagnóstico.

Palavras-chave
Espondilite; Religião; História da Medicina

Father Cicero Romao Batista lived for 90 years, was born in 1844 and died on July 20, 1934. Even today, such a long life is unusual. Thus, in addition to other personal gifts of the “Patron of Forests”, a title awarded by GreenPeace (http://blogdocrato.blogspot.com.br/2010/02/greenpeace-adota-padre-cicero-como-o.html), a non-governmental organization, this man was touched by divine providence. Despite the vast literature on political and religious aspects on Father Cicero,^1–4 details about “Juazeiro Patriarch” health are scarce.

Father Cicero did not leave dependents, because his sisters had no children. About his mother, Mrs. Quinô, it is known that she became “paralyzed” and would have presented an “eyelid inflammation” for many years.²

Amalia de Oliveira,² who enjoyed for several years a contact with Father Cicero, reports in his book that at about 50 years old Father Cicero had his head tilted and fixed to the right side. At least by the age of 41, Father Cicero already used a staff that, although maybe representing a pastoral symbol, may well have lent itself to support his walking. ^2,3 In 1888, a photo of Father Cicero at the age of 44 with one of his sisters reveals a lateral deviation of his head, which can also be seen in later images (Figs. 1 and 2). In his most recent biography,³ the author reports a “painful scoliosis,” neck tortuosity and back pain with a lifelong suffering.³ In another book,⁵ his postural problem and reclining ambulation are again mentioned, which are attributed to a scoliosis contracted early in his life, as well as a kyphosis that lent a “grotesque appearance” to “Padim Ciço”. This latter report would refer to his looks in 1926; thus when the holy man was already at the age of 82. About this time, another book⁶ by an author who visited Father Cicero describes his gibbosity and stooped posture. Interestingly, a very critical author of Father Cicero describes the man in 1926 as “being ankylosed and suffering frequent intestinal colic, which required a strict diet”.⁴ An episode of arthritis (with no further details), when the holy man was at the age of 60, has been diagnosed as being the “first signs of a gout crisis” by Dr. Antonio Mariz, one of his doctors.³ In several books on this holy man, episodes of strong abdominal cramps are reported, which would have occurred for several years (and that at times resulted in patriarch's prostration).^2–4,7

Fig. 1
Father Cicero and his sister, in a photograph from 1888 – at the age of 44, one can see a slight lateral tilting ofthe neck.

Fig. 2
Father Cicero and doctor Luis Malzone, founder of Hospital São Lucas; photograph from the decade of 1920–1930, showing lateral tilting of the neck.

There are several reports that Father Cicero did not get much sleep, and at times was surprised napping during the day, in front of his interlocutors, and even when on the saddle of his donkey.^2–5,7,8 This holy man always slept in a hammock, despite having a bed in his bedroom,³ fed sparingly and had a habit of fasting for long periods. ^1–4,6,8,9 In 1910, assuming to be stricken with a kidney condition, and following the advice of Dr. Miguel Couto, Father Cicero has come to believe that his problem stemmed from drinking Juazeiro water; since then, he started to drink only coconut water or tea, and never returned to drinking clean water.^3–5,10 There are descriptions of hemoptysis in Father Cicero's biographies, although in our opinion they were hemoptoic episodes, when at the age of 76.^2,3 While there is no report of other respiratory symptoms, and considering that Father Cicero would have smoked (certainly not commercial cigarettes) for a few years and even before his arrival at Juazeiro,^4,10 one cannot ignore the possibility that he has developed some respiratory problem of his lower airway tract, which could have led to hemoptoic episodes.

Apparently it is quite evident that in the last years of his life, Father Cicero has suffered repeated infections of the lower limbs, described as erysipelas. ^2,3,7 The presence of cutaneous anthrax in the neck, already close to his death, was a reason for surgery, as well as a likely cataract surgically approached unsuccessfully little more than a month before his death.³

In one of his biographies, the description of his last clinical picture³ suggests the development of a bowel obstruction. Whereas Father Cicero already was 90 years old, presenting boils and even repetition erysipelas, in a pre-antibiotic era and with inappropriate disinfection care, it is quite possible that his final picture was that of a generalized infection stemmed from a cutaneous focus, leading to bowel involvement with a clinical picture of acute abdomen, as might occur in the initial phase of a septic shock compounded by dehydration and consequent deficit of kidney irrigation and anuria (which, incidentally, is reported after his death).²

Clinical integration

After reading Padre Cicero's biography, I was motivated to think that it is reasonable to propose the hypothesis that this holy man would have a chronic inflammatory spondyloarthropathy, unsuspected until now. The description was of a lower back pain condition, also affecting the cervical spine in a white, male subject, starting before the age of 50 and with a partial ankylosis of the spine, particularly visible in the cervical segment. At least one documented episode of arthritis would have occurred, as well as multiple intestinal disorder episodes, which could be associated with an intestinal inflammatory component and being part of the main diagnosis. In his family history, there is just one report, that his mother had an “inflammation of the eyelids” with several years of duration and would have been “paralyzed” in 1897, at about her sixth decade of life.

Differential diagnosis

His movements were regularly done, even in his last decade of life. Drowsiness could mean a non-restorative sleep and his preference for the hammock is common in spondylitis patients in “these Brazilian Northeast places,” although there is no technical basis to support that habit. Thus, these aspects that suggest a non-restful sleep strengthens the hypothesis that spinal pain, reported in several books about Father Cicero, was of an inflammatory nature. There is no trauma report that could justify a fracture, the consolidation of which would be the cause of his subsequent cervical deformity. It is also unlikely that the condition would be a scoliosis, which is not an usual cause of back pain, contrary to common belief, and only rarely there is cervical involvement, and this is the segment with the most noticeable deformity in Father Cicero. A picture of the holy man (Fig. 3), when he was about to complete his studies at the seminary (circa 23 years) does not show a neck tilt, which should already exist at the time if the reason for this condition were a structural juvenile idiopathic scoliosis. It is unlikely that this could be a case of primary osteoarthritis in the face to the male gender, and that the problem had its beginning when Father Cicero was under 50 years old. Judging by the photo from 1888 (Fig. 1), in which the Father already appears with a neck tilted to the right, and considering reports of pain and “scoliosis” around the age of 50, it is quite plausible that this holy man suffered pain for some time, starting before the age of 45, as it would occur in a case of spondyloarthritis.¹¹ Infectious causes and reactive arthritis are unlikely possibilities due to the chronology, as well as a microcrystalline arthritis, even that with a hyperuricemic cause. Father Cicero was a slender man that followed a frugal diet, with low intake of red meat, who did not drink alcoholic beverages and showed a predominant involvement of the axial skeleton. It would not be excessive, despite the speculation inherent in the present text, to consider that the arthritis reported when he was aged 60 would be the result of a peripheral joint involvement from a spondyloarthritis with axial predominance. The possibility of syphilis, a highly prevalent disease at the time, may be excluded by the celibate condition of the patriarch, who took on this commitment when he was yet a teenager (aged 12 years, according to several testimonies) and that was not questioned even by his most bitter critics.^3,4,9 Moreover, his walking pattern had no tabetic aspect, as would be likely to exist in a case of tertiary syphilis involving the spinal cord. The tuberculous, leprosy and fungal etiologies, despite his hemoptoic episodes, seem to us unlikely causes to explain the spinal picture, in the face of the long course (more than 40 years of evolution) and of the ankylosed aspect suggested by the rigidity present during his walks. We do not have elements to explain the hemoptoic episodes, but they could also be caused by sequelae of respiratory infections.^2,3,9 We can exclude the possibility of a primary osteoporosis leading to the occurrence of fractures, thanks to the male gender, his good physical activity, frequent intake of dairy products, intense sun exposure for many years, its onset before the age of 45, and also for the arthritis and bowel picture incompatible with osteoporosis.

Fig. 3
Father Cicero as a young man, before his ordination(right side, with about 23 years old), the photograph does not show any lateral tilting of the neck, and a normal posture.

There is some epidemiological evidence that we can still consider. Father Cicero was a blond man, with blue eyes, of direct Portuguese descent, and possibly his mother was of Indian descent.^2,3,7 Because the disease is more prevalent in white subjects and Father Cicero was of white Mediterranean ancestry, it is possible that, in this case, a genetic component exists. There is a strong possibility of interbreeding of his mother, with a likely Portuguese parentage. Although in the field of pure speculation, one should also take into account the ophthalmic problems of his mother. Although considered as an “inflammation of the eyelids”, the description is one of an apparently recurrent eye redness; about this, we can speculate that these were episodes of uveitis.

Conclusion

It is not unusual – quite the contrary – that even today a diagnosis of spondyloarthritis goes unnoticed. So far as our knowledge goes, it is hardly surprising that nobody ever has contemplated this possibility in the case of Father Cicero. In our view, the personality of Father Cicero could have contributed to an absolutely productive life, with a strenuous and continuous daily activity, even if he was stricken by an inflammatory disease of the spine. It does not seem that motivation had been a problem for this man of such determination, even without being able to use anti-inflammatory agents for relief of symptoms. Last but not least, one must highlight that perhaps is the main reason for this description and speculation about the disease that Father Cicero would have suffered. By reading his biography, the book called our attention to the several photos in which the Patriarch of Juazeiro is depicted with a cervical lateral deviation. It is unlikely that in pictures from various periods of his life, for no apparent reason, he had managed to keep his stance virtually unchanged. Although not exhibiting the classical “skiing” posture, Father Cicero appears to have his neck in a more anterior position with respect to the dorsal region (Fig. 3), as well as an apparent anterior projection of the abdomen. And the description of episodes of back pain and intestinal disorder has gone unnoticed, which may also occur in spondyloarthritis. When evaluating a video of Father Cicero (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 attracted by bystanders, makes a body movement in which he turns completely to address the interlocutor, virtually with no lateral movement of the neck, moving “en bloc,” as if his spine had no mobility in the cervical segment. As a description of a friend of mine, “Father Cicero moves in the same way that a “Olinda puppet”. Clearly this movement occurs three times for both sides, strongly suggesting that Father Cicero, regardless of his age at the time, had severe limitation to the movement of lateral flexion of the neck.

The need for attention to detail is always emphasized in the collection of a rheumatologic medical history. Most diagnoses in this specialty depend on a doctor who knows how to listen and on a careful observation of the patient, in order to adequately characterize in time, space and intensity, among other things, the description of the symptoms. We reiterate that the ancillary exams do not outweigh the clinical history in defining the diagnosis and, no less important, the therapeutic conduct for spondyloarthritis.

The reading of Father Cicero's biography has the power to alert the rheumatologist for a plausible diagnosis in such illustrious character and also demonstrates the importance of having attentive eyes and ears during the anamnesis. Our “Padim” – certainly ours, because, like him, I also was born in Ceará – swung into action once again, and more alive than ever, calling our attention to the best identification of people affected by these diseases. Currently, often the time interval to confirm the diagnosis exceeds 10 years of symptoms. This may be one more miracle of Father Cicero; it simply does not matter. It seems to me that, through a description of his history by a third party, this man, 91 years after his death, continues to contribute to improve the life and health of the people and, this time, possibly in the whole Brazil.

References

• ¹
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• ²
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• ³
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• ⁴
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• ⁶
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• ⁷
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• ⁸
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• ⁹
  Sobreira A. O patriarca de Juazeiro. 3rd ed. Fortaleza: Edicões UFC; 2011.
• ¹⁰
  Feitosa N. As virtudes do padre Cícero. Juazeiro do Norte: Instituto José Marrocos de Pesquisas e Estudos Socioculturais (Ipesc); 1991.
• ¹¹
  Rudwaleit M. Classification and epidemiology of spondyloarthritis. 5th ed. Philadelphia, PA: Elsevier Ltd.; 2011.p. 3–7.

Publication Dates

• Publication in this collection
  Sep-Oct 2016

History

• Received
  30 Oct 2015
• Accepted
  21 Jan 2016