Clinical picture: A haemophiliac patient with synovial osteochondromatosis of the ankle.

THE LANCET • Vol 358 • December 22/29, 2001 2155 The heart did not feature in European art until the later Middle Ages. The first illustration of a heart outside the anatomical literature occurred as late as the 13th century, in a French manuscript, written by an unknown poet and entitled Roman de la poire (Romance of the pear). This story takes its title from a scene in which the damsel offers a pear, analogous to Eve’s apple, to her sweetheart. In the tale, the suitor’s gaze is represented as an actual character called Douz Regart (Sweet Looks). In a miniature, within the calligraphic curve of a golden capital S, he is pictured kneeling before a lady and offering her the lover’s heart. The shape of this heart resembles the form of a pine cone—a shape that accords with descriptions of the heart in anatomical literature since Galen and Avicenna. This image of the heart was painted in a Paris studio in about 1255. There is a picture of a similarly shaped heart on an enamel pyxis from Limoges, which dates from the same period or perhaps slightly later. Both these hearts are held upside down, with their tips pointing upwards. It was not until half a century later that an image of the heart appeared for the first time in a public work of art, in one of the innovative murals painted by Giotto di Bondone in the Arena Chapel in Padua, Italy, which dates from about 1305. Beneath images of the lives of the