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History of Medicine Gout in Duke Federico of Montefeltro (1422-1482)

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History of Medicine Gout in Duke Federico of Montefeltro (1422-1482) Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch Year: 2018 Gout in Duke Federico of Montefeltro (1422-1482): a new pearl of the Italian Renaissance Fornaciari, Antonio ; Giuffra, Valentina ; Armocida, Emanuele ; Caramella, Davide ; Rühli, FrankJ; Galassi, Francesco Maria Abstract: The article examines the truthfulness of historical accounts claiming that Renaissance Duke Federico of Montefeltro (1422-1482) suffered from gout. By direct paleopathological assessment ofthe skeletal remains and by the philological investigation of historical and documental sources, primarily a 1461 handwritten letter by the Duke himself to his personal physician, a description of the symptoms and Renaissance therapy is offered and a final diagnosis of gout is formulated. The Duke’s handwritten letter offers a rare testimony of ancient clinical self-diagnostics and Renaissance living-experience ofgout. Moreover, the article also shows how an alliance between historical, documental and paleopathological methods can greatly increase the precision of retrospective diagnoses, thus helping to shed clearer light onto the antiquity and evolution of diseases. Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-169608 Journal Article Published Version Originally published at: Fornaciari, Antonio; Giuffra, Valentina; Armocida, Emanuele; Caramella, Davide; Rühli, Frank J; Galassi, Francesco Maria (2018). Gout in Duke Federico of Montefeltro (1422-1482): a new pearl of the Italian Renaissance. Clinical and Experimental Rheumatology, 36(1):15-20. History of medicine Gout in Duke Federico of Montefeltro (1422-1482): a new pearl of the Italian Renaissance A. Fornaciari1, V. Giuffra1, E. Armocida2, D. Caramella3, F.J. Rühli4, F.M. Galassi4 1Division of Paleopathology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy; 2University of Bologna, Italy; 3Division of Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Italy; 4Institute of Evolutionary Medicine, University of Zurich, Switzerland. Abstract The article examines the truthfulness of historical accounts claiming that Renaissance Duke Federico of Montefeltro (1422–1482) suffered from gout. By direct paleopathological assessment of the skeletal remains and by the philological investigation of historical and documental sources, primarily a 1461 handwritten letter by the Duke himself to his personal physician, a description of the symptoms and Renaissance therapy is offered and a final diagnosis of gout is formulated. The Duke’s handwritten letter offers a rare testimony of ancient clinical self-diagnostics and Renaissance living-experience of gout. Moreover, the article also shows how an alliance between historical, documental and paleopathological methods can greatly increase the precision of retrospective diagnoses, thus helping to shed clearer light onto the antiquity and evolution of diseases. Key words gout, paleopathology, rheumatology, Federico of Montefeltro, Renaissance Clinical and Experimental RheumatologyClinical 2018 and Experimental Rheumatology 2018; 36: 15-20. Gout in Federico of Montefeltro, Duke of Urbino (1422–1482) / A. Fornaciari et al. Antonio Fornaciari, PhD Introduction Valentina Giuffra, PhD In medieval medicine gout was used as Emanuele Armocida, MD a general word encompassing several Davide Caramella, MD nosological entities (1-2). The term, Frank J. Rühli, MD, PhD th Francesco M. Galassi, MD adopted since the 13 century, derives from the Latin gutta (i.e. drop), and re- Please address correspondence to: Dr Antonio Fornaciari, flects the idea that this condition was Division of Paleopathology, caused by an imbalance of a humour Department of Translational Research entering the affected joint, thus causing and New Technologies in Medicine pain and inflammation. The distinction and Surgery, between gout and other forms of rheu- University of Pisa, matism was only introduced in the 17th Via Roma 57, century (3-4). 56126 Pisa, Italy. E-mail: [email protected] While the historico-medical records al- Received on May 8, 2017; accepted in low us to retrospectively identify the revised form on December 22, 2017. presence of gout in the past, it is often difficult to make a precise diagnosis of © Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2018. this rheumatic form of arthritis exclu- sively on the basis of osteoarchaeologi- cal material; the cases of gout are in fact Fig. 1. Duke Federico of Montefeltro in rare and, above all, the most important the “Double portrait of the Dukes of Urbino” (1465–1472) by Piero della Francesca, Uffizi aspects of the diagnostic process, i.e. Gallery, Florence, Italy [inventory no. 1890] (by the anamnesis or the patient’s history, permission of the Uffizi Gallery Director. Not to are generally missing. It should also be be copied or duplicated by any means). remarked that, while in many instances we have an indirect description of the magna region, northern Italy), where disease suffered by prominent histori- on 10 September 1482 he was struck cal characters, we very rarely have any by fever and died probably of an infec- documentation in which these impor- tious disease like malaria, contracted tant figures provide an account of their in the marshy theatre of war (5-6). His problems, depicting for example the corpse was taken to Urbino (Marche signs and symptoms by which they are Region, central Italy) for the celebra- affected. In this paper we report on the tion of the funeral rites (5-6). After em- detailed self-written description of an balming, the Duke’s body was placed acute attack of arthritis experienced in a wooden coffin hung on the wall, to by Federico of Montefeltro, one of the the right of the main altar in the church eminent representatives of the Italian of San Bernardino. It remained there at Renaissance, and compare it with an least until 1620, when two cenotaphs, accurate analysis of his medical history still present, were built and positioned and of his skeletal remains through the against the walls, while the body was lens of palaeopathology. placed in a burial chamber under the floor. The corpse was exhumed twice Archaeological, taphonomic throughout history: in 1824 and, more and historical background recently, in 1938; on both occasions Federico of Montefeltro (1422-1482), the clothes and skeletal remains were Duke of Urbino, is still remembered as found in a rather poor state of preser- one of the chief warlords of the Italian vation. The last exhumation in 2000 Renaissance. His profile portrait paint- confirmed the very bad conservation ed by the renowned artist Piero della status of his skeletal remains. In par- Francesca (1416/1417-1492), exhib- ticular, the bones were reduced to only ited in the Uffizi Museum in Florence a few hardly recognisable fragments, (Fig. 1), shows the sewn contours of as a result of an extremely damp mi- his nose and the gravitas-filled expres- croclimate and post-depositional inter- sion of a victorious commander and ac- ventions by tomb raiders (7). claimed patron of the arts. Aged sixty, While historical research is still inves- he set out for his last military campaign tigating the Duke’s complex political Competing interests: none declared. in the plains near Ferrara (Emilia-Ro- career, the medical conditions that af- 16 Clinical and Experimental Rheumatology 2018 Gout in Federico of Montefeltro, Duke of Urbino (1422–1482) / A. Fornaciari et al. from Montalto has come on again [me è tornato quello male al dito del pe derit- to che fe alaltra volta], as you certainly remember, and in my opinion this time I feel worse than I did last time [jo so sta- to peggio questa volta che alora], just because the pain has lasted longer and has probably increased for the hard- ships of the camp [solamente perché el male è durato più · et questo è forse proceduto per li desdaxi del campo]”. Federico informs his physician that the pain in his right toe has returned; he as- signs the greater crudeness of the pain to the hardships suffered during the military campaign, and then describes the typical symptoms of gout attacks in detail: “The pain came on the night between Thursday and Friday, on day 18 of this month, with very little pain [cum pochissimo dolore] until Fri- day at 20 hours; from 20 hours until the third hour of Saturday morning I had tremendous pain, then the pain ceased because [jo hebbi grandissimo dolore da poi el dolore cessò], since I was not eating, my foot did not hurt [che non manegiando el pe non me doleva], but until now, which is Mon- day, the 29th of the month, I have not been entirely free from this pain, be- cause it hurts a little when I walk, but it does not last long [non so ancora in tucto libero che non mi dogla um- poco quando camino · ma poco ce res- ta]. I have been on an extreme diet of bread and water […]”. Having recognised the symptoms, Federico self-diagnosed gout: “I think Fig. 2. Federico of Montefeltro’s handwritten letter to his physician Battiferro of Mercatello [inven- it must be gout [jo credo certamente tory number: Archivio di Stato di Firenze, Ducato di Urbino, Serie I, Filza 104, carta 44 r-v] (by permission of the Italian Ministry of Cultural Heritage and Tourism. Not to be copied or duplicated che la sia gotta], and I will do what I by any means). can to cure it as if I were sure it was. […]. This use of the term “gout”, as fected him throughout his existence curred on November 27, 1471 in San seen above, was however quite broad, have basically remained neglected. Marino, greatly affected his locomo- meaning rheumatic ailments in general. With the exception of a robust discus- tion and capacity to take an active part The Duke adds some comments on sion on the mystery of the strange mor- on the battle-field (5-6).
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