Concise Report

The gout of the Medici, Grand Dukes of Florence:a palaeopathological study

Gino Fornaciari1, Valentina Giuffra1, Sara Giusiani1, Antonio Fornaciari2, Natale Villari3 andAngelica Vitiello1

Objective. According to the written sources several members of the famous Medici family of Renaissance Florence suffered from an arthriticdisease, called gout by contemporary physicians; a palaeopathological study allowed verification of the true nature of the gout of the Medici

referred by archive document data.Methods. The skeletal remains of the Grand Dukes and their families, buried in the Basilica of San Lorenzo in Florence, were examined

macroscopically and submitted to X-ray investigation.Results. Out of 15 investigated individuals, two cases of diffuse idiopathic skeletal hyperostosis (DISH), with ossification of the anterior

longitudinal ligament and massive hyperostotic changes of the extra-spinal ligaments, were detected in the skeletons of the Grand DukesCosimo I (151974) and his son Ferdinand I (15491609). The left foot of Ferdinand also revealed typical lesions of the uratic gout, confirming

the archive data, which describe the disease in detail.Conclusions. The association between DISH and elite status, highlighted in recent research, receives further confirmation in the present

study, furnishing evidence to the significance of this disorder as a lifestyle indicator, linked specifically with a high-caloric diet, consequentobesity and type II diabetes mellitus. Furthermore, the coexistence between DISH and gout observed in Ferdinand represents the first

documentation of this association in the palaeopathological literature.

KEY WORDS: Renaissance, Florence, Medici, Cosimo I, Ferdinand I, Diffuse Idiopathic Skeletal Hyperostosis, Gout.

Introduction

The Medici Project is a multidisciplinary archaeological andpalaeopathological investigation to perform a study of 49 funer-ary depositions of the Medici Grand Dukes, in the famous MediciChapels of the Basilica of San Lorenzo in Florence. The MediciProject represents a unique opportunity to reconstruct the healthand lifestyle of the members of this important family of the ItalianRenaissance. Up until now 15 tombs, including the burials of ninechildren, have been investigated [13].

The clinical history of the Medici family, including the reportsof the ambassadors and court physicians, is well known from theextremely rich archives that were examined and published in thefundamental opera of the Florentine physician and historianGaetano Pieraccini [4]. From these records it emerges that severalmembers of the Medici family suffered from arthritic diseases. Theterm frequently reported by contemporary sources to indicatethese morbid episodes, characterized by violent pain in the hands,feet, shoulders, knees and thoracic-lumbar spine, is gout. Gout,also called the disease of kings for its association with a lifestyletypical of the upper classes, seems to have been a family diseaseamong the Medici, as attested by the nickname the goutyattributed to Piero (141669). It should be remembered that theterm gout was used in those times to indicate several pathologicalconditions of rheumatic origin; the word was first introduced inthe 13th century and derives from the Latin gutta, which means

drop, similar to a liquid falling on the foot and reflecting the ideathat this condition was caused by an imbalance of a humour thathad entered the affected joint, causing pain and inflammation.The distinction between gout and rheumatism was introducedlater in the 17th century [5].

Palaeopathology allows verification of the nosological informa-tion obtained from the written sources and clarification of thenature of the rheumatological condition that afflicted the Medici.Among the individuals studied so far, the skeleton of Cosimo I(151974), 1st Grand Duke of Tuscany, and those of his sonFerdinand I (15491609), 3rd Grand Duke of Tuscany, haveshown evidence of arthritic diseases.

The archive data indicate that Cosimo I suffered from severalillnesses, including an acute articular disorder of the right knee,named gout by the court physicians, which appeared at the ageof 49 and 5253 yrs [4].

The palaeopathological study of Cosimos remains reveals aseries of lesions of the axial and appendicular skeleton. The skullshows hyperostosis frontalis interna. The anterior longitudinalligament on the right-hand side of the column is ossified at thelevel of the T6, T7 and T8 vertebral bodies; this flowing ossifi-cation forms a bony bridge between the vertebrae, appearing as acontinuous line of bumps. Two other vertebrae, L2 and L3, arefused on the left-hand side through a bony bridge. Several thoracicand lumbar vertebrae present syndesmophytes, but without verte-bral fusion. Marked bone spurs at the insertion of the ligamentaflava are also visible. Intervertebral disks and articular surfacesare normal.

Ligament and tendon attachments of the appendicular skeletonshow enthesopathies, in particular at the level of clavicles, humeri,ulnae, radii, coxal bones, femurs, patellae, tibiae and calcanei. Adiffuse and severe arthritis affecting the lower thoracic and lumbarspine and the great joints is also visible.

As far as Ferdinand I is concerned, the historic documentationattests that he suffered from many acute attacks of gout, generallyof the left foot, typically positioned in the big toe, from the age of

1Department of Oncology, Transplants and Advanced Technologies in Medicine,

Division of Paleopathology, University of Pisa, 2Department of Archaeology and

History of Arts, Section of Medieval Archaeology, University of Siena and3Department of Clinical Physiopathology, Section of Clinical Radiology,

University of Florence, Italy.

Submitted 5 August 2008; revised version accepted 4 December 2008.

Correspondence to: Gino Fornaciari, Department of Oncology, Transplants and

Advanced Technologies in Medicine, Division of Palaeopathology, University of

Pisa, Via Roma 57, 56126 Pisa, Italy. E-mail: g.fornaciari@med.unipi.it

Rheumatology 2009; 1 of 3 doi:10.1093/rheumatology/ken493

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33 yrs until death. The first attack seems to have been dated backto 1582, when Ferdinand wrote to his brother, the Grand DukeFrancesco I, referring that he was confined to bed or chair becauseof . . . some catarrh has fallen down to my left foot. By Godsgrace, may it not be podagra!. In 1591 the court physician GiulioAngeli accurately describes a typical gout attack: yesterday thegout started to pinch the big toe of the Grand Dukes left foot andthen continued to advance rapidly! Overnight the toe has becomeswollen, inflamed and painful. The crises afflicted the GrandDuke also in the following years; furthermore, he started tobecome obese at the age of 41 [4].

The paleopathological investigation carried out on the skeletonof Ferdinand I reveals pathological features similar to thoseobserved in his father. The vertebral bodies from T5 to T11 arefused in a unique block for the ossification of the right anteriorligament, conferring the typical aspect of a candle wax to thisspine segment (Fig. 1A and B, arrows; Fig. 1C). The body ofseveral cervical and thoracic vertebrae presents partial ossificationof the right anterior ligament, but with no formation of bonybridges between the vertebrae. The intervertebral spaces and theapophyseal joints are normal. Ossifications of ligamenta flava,interspinal and supraspinal ligament insertions are largely present.The extra-spinal ligaments show massive hyperostotic changes.Enthesopathies were present at the muscular insertion of clavicles,scapulae, humeri, ulnae, coxal bones, femurs, patellae, tibiae andcalcanei. The thyroid cartilage and the epiglottis are ossified andwell preserved. Large rough bilateral calcifications of the sterno-costal cartilages of the first and of the last ribs are present, leadingto a sternum with multiple ribs attached. Ferdinand I was affectedby diffuse OA, involving not only the spine and major joints, butalso several articulations of his hands and feet.

Furthermore, the skeleton of Ferdinand shows a peculiar lesionin the left foot. The interphalangeal joint of the big toe presentscavitations, erosions and osteophytic margins (Fig. 2A, arrow). Atthe peri-articular and articular surface of the joint a scooped-outdefect (Fig. 2C), with partial destruction of the sub-chondral plate(Fig. 2D), is also visible. X-ray examination reveals an evidentsclerotic margin, which involves both bones of the joint (Fig. 2B,arrow).

The changes observed in Cosimo I and Ferdinand I meet thestandard major criteria established for the diagnosis of diffuseidiopathic skeletal hyperostosis (DISH) [6]. Both skeletonsshowed hyperostosis of the column, with the involvement of atleast three contiguous vertebrae in Cosimo I, and up to sevenvertebrae in Ferdinand. Such changes were limited to the rightside of the thoracic segment and diffuse ossifications of thearticular ligaments and entheses were present. Features oftenassociated with DISH, such as hyperostosis frontalis interna,ossification of the neck and rib cartilages and massive OA,confirm the diagnosis. The lack of evidence of these diseases in thewritten sources may be due to the fact that, despite the dramaticradiological aspect, DISH is generally asymptomatic, as itsmanifestations are limited to back stiffness and mild pain.

Paleopathological literature has reported several cases of DISHfrom different geographical sites and different periods [7, 8];extensive studies have also been carried out to evaluate the inci-dence of DISH in large skeletal series [912]. The aetiology of thiscondition remains uncertain, but has been related to variousmetabolic disorders, in particular obesity and type II diabetesmellitus. Recent studies have highlighted a link between the inci-dence of diffuse idiopathic skeletal hyperostosis and high socialstatus, with particular regard to lifestyle and nutritional patterns.The Italian Renaissance aristocratic classes had access to a widevariety of food resources. Historical data report a diet based onwine and meat, occasionally enriched by eggs and cheese and, onpenitential occasions, by fish. The consumption of vegetables wasscarce and fruit was almost totally absent from alimentation [13].A palaeonutritional study performed recently on the MediciGrand Dukes and their families confirmed the written sources.

Carbon and nitrogen stable isotope analysis revealed a dietvery rich in meat, as demonstrated by the 15N high values at thelevel of the carnivores. The 13C values, related to the consump-tion of fish, revealed an intake of marine proteins at 1430% [14].

The present study seems to further confirm the associationbetween DISH and elite status. Among the five individualsbelonging to the Medici family of >40 yrs of age that have beenstudied so far, two were affected by DISH. Furthermore, it isworth mentioning the case of Cosimo the Elder (13891464),whose remains showed the stigmata of this condition as well [15].Despite the narrowness of the sample, the high incidence of DISHin the Medici family is remarkable and a significant lifestyleindicator, supporting the link between social status and risk ofdeveloping DISH in mature age.

FIG. 1. The DISH of Ferdinand I: (A) anterior view of the column with ossification ofthe anterior right vertebral ligament, at the level of the 5th11th thoracic vertebralbodies, conferring the typical candle wax appearance (arrows); (B) right lateralview of the thoracic column with DISH (arrows); (C) anteroposterior X-ray of thethoracic column.

FIG. 2. The gout of Ferdinand I: (A) left foot with lesion at the level of theinterphalangeal joint of the big toe (arrow); (B) X-ray of the left foot, showingsclerotic margins of both the bones of the joint (arrow); (C) particular of the left bigtoe with scoped-out defect at the interphalangeal joint of the hallux dorsum;(D) articular surfaces of the interphalangeal joint with partial destruction of the sub-chondral plate.

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Furthermore, the case of Ferdinand I is of particular interestfor the diagnosis of gout, of which very little evidence has beenfound in palaeopathology [16]. Genetic and/or environmentalfactors, with particular regard to diet, may be involved in theaetiology of gout. An alimentation rich in animal proteins, asattested by the palaeonutritional investigation carried out on theMedici family [14], may have favoured the onset of this disease.An association with obesity, diabetes and hyperinsulinaemia isascertained [17].

Modern clinical studies report a significant association betweendiffuse idiopathic skeletal hyperostosis and gout [18].

Not only do the typical skeletal and radiological featuresobserved in the bone remains of Ferdinand I confirm the datareported by the written sources regarding the arthritic left footgout that affected the Grand Duke, but this represents the firstdocumentation of the coexistence between diffuse idiopathicskeletal hyperostosis and gout attested in palaeopathologicalliterature.

Disclosure statement: The authors have declared no conflicts ofinterest.

References

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Rheumatology key messages

The results elucidate the true nature of the famous gout of theMedici.

The coexistence between DISH and gout in Ferdinand is firstdocumented in the palaeopathological literature.

The gout of the Medici 3 of 3