Rheumatology Advance Access published January 27, 2009

Rheumatology 2009; 1 of 3

doi:10.1093/rheumatology/ken493

Concise Report

The gout of the Medici, Grand Dukes of Florence:

a palaeopathological study
Gino Fornaciari1, Valentina Giuffra1, Sara Giusiani1, Antonio Fornaciari2, Natale Villari3 and
Angelica Vitiello1
Objective. According to the written sources several members of the famous Medici family of Renaissance Florence suffered from an arthritic
disease, 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 Dukes
Cosimo 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, consequent
obesity 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 and
palaeopathological investigation to perform a study of 49 funerary depositions of the Medici Grand Dukes, in the famous Medici
Chapels of the Basilica of San Lorenzo in Florence. The Medici
Project represents a unique opportunity to reconstruct the health
and lifestyle of the members of this important family of the Italian
Renaissance. Up until now 15 tombs, including the burials of nine
children, have been investigated [13].
The clinical history of the Medici family, including the reports
of the ambassadors and court physicians, is well known from the
extremely rich archives that were examined and published in the
fundamental opera of the Florentine physician and historian
Gaetano Pieraccini [4]. From these records it emerges that several
members of the Medici family suffered from arthritic diseases. The
term frequently reported by contemporary sources to indicate
these 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 lifestyle
typical of the upper classes, seems to have been a family disease
among the Medici, as attested by the nickname the gouty
attributed to Piero (141669). It should be remembered that the
term gout was used in those times to indicate several pathological
conditions of rheumatic origin; the word was first introduced in
the 13th century and derives from the Latin gutta, which means
1
Department 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 and
3
Department 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

drop, similar to a liquid falling on the foot and reflecting the idea
that this condition was caused by an imbalance of a humour that
had entered the affected joint, causing pain and inflammation.
The distinction between gout and rheumatism was introduced
later in the 17th century [5].
Palaeopathology allows verification of the nosological information obtained from the written sources and clarification of the
nature 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 son
Ferdinand I (15491609), 3rd Grand Duke of Tuscany, have
shown evidence of arthritic diseases.
The archive data indicate that Cosimo I suffered from several
illnesses, including an acute articular disorder of the right knee,
named gout by the court physicians, which appeared at the age
of 49 and 5253 yrs [4].
The palaeopathological study of Cosimos remains reveals a
series of lesions of the axial and appendicular skeleton. The skull
shows hyperostosis frontalis interna. The anterior longitudinal
ligament on the right-hand side of the column is ossified at the
level of the T6, T7 and T8 vertebral bodies; this flowing ossification forms a bony bridge between the vertebrae, appearing as a
continuous line of bumps. Two other vertebrae, L2 and L3, are
fused on the left-hand side through a bony bridge. Several thoracic
and lumbar vertebrae present syndesmophytes, but without vertebral fusion. Marked bone spurs at the insertion of the ligamenta
flava are also visible. Intervertebral disks and articular surfaces
are normal.
Ligament and tendon attachments of the appendicular skeleton
show enthesopathies, in particular at the level of clavicles, humeri,
ulnae, radii, coxal bones, femurs, patellae, tibiae and calcanei. A
diffuse and severe arthritis affecting the lower thoracic and lumbar
spine and the great joints is also visible.
As far as Ferdinand I is concerned, the historic documentation
attests that he suffered from many acute attacks of gout, generally
of the left foot, typically positioned in the big toe, from the age of

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Gino Fornaciari et al.

33 yrs until death. The first attack seems to have been dated back
to 1582, when Ferdinand wrote to his brother, the Grand Duke
Francesco I, referring that he was confined to bed or chair because
of . . . some catarrh has fallen down to my left foot. By Gods
grace, may it not be podagra!. In 1591 the court physician Giulio
Angeli accurately describes a typical gout attack: yesterday the
gout started to pinch the big toe of the Grand Dukes left foot and
then continued to advance rapidly! Overnight the toe has become
swollen, inflamed and painful. The crises afflicted the Grand
Duke also in the following years; furthermore, he started to
become obese at the age of 41 [4].
The paleopathological investigation carried out on the skeleton
of Ferdinand I reveals pathological features similar to those
observed in his father. The vertebral bodies from T5 to T11 are
fused in a unique block for the ossification of the right anterior
ligament, conferring the typical aspect of a candle wax to this
spine segment (Fig. 1A and B, arrows; Fig. 1C). The body of
several cervical and thoracic vertebrae presents partial ossification
of the right anterior ligament, but with no formation of bony
bridges between the vertebrae. The intervertebral spaces and the
apophyseal 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 and
calcanei. The thyroid cartilage and the epiglottis are ossified and
well preserved. Large rough bilateral calcifications of the sternocostal cartilages of the first and of the last ribs are present, leading
to a sternum with multiple ribs attached. Ferdinand I was affected
by diffuse OA, involving not only the spine and major joints, but
also several articulations of his hands and feet.
Furthermore, the skeleton of Ferdinand shows a peculiar lesion
in the left foot. The interphalangeal joint of the big toe presents
cavitations, erosions and osteophytic margins (Fig. 2A, arrow). At
the peri-articular and articular surface of the joint a scooped-out
defect (Fig. 2C), with partial destruction of the sub-chondral plate
(Fig. 2D), is also visible. X-ray examination reveals an evident
sclerotic margin, which involves both bones of the joint (Fig. 2B,
arrow).
The changes observed in Cosimo I and Ferdinand I meet the
standard major criteria established for the diagnosis of diffuse
idiopathic skeletal hyperostosis (DISH) [6]. Both skeletons
showed hyperostosis of the column, with the involvement of at
least three contiguous vertebrae in Cosimo I, and up to seven
vertebrae in Ferdinand. Such changes were limited to the right
side of the thoracic segment and diffuse ossifications of the
articular ligaments and entheses were present. Features often
associated 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 the
written sources may be due to the fact that, despite the dramatic
radiological aspect, DISH is generally asymptomatic, as its
manifestations are limited to back stiffness and mild pain.
Paleopathological literature has reported several cases of DISH
from different geographical sites and different periods [7, 8];
extensive studies have also been carried out to evaluate the incidence of DISH in large skeletal series [912]. The aetiology of this
condition remains uncertain, but has been related to various
metabolic disorders, in particular obesity and type II diabetes
mellitus. Recent studies have highlighted a link between the incidence of diffuse idiopathic skeletal hyperostosis and high social
status, with particular regard to lifestyle and nutritional patterns.
The Italian Renaissance aristocratic classes had access to a wide
variety of food resources. Historical data report a diet based on
wine and meat, occasionally enriched by eggs and cheese and, on
penitential occasions, by fish. The consumption of vegetables was
scarce and fruit was almost totally absent from alimentation [13].
A palaeonutritional study performed recently on the Medici
Grand Dukes and their families confirmed the written sources.

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

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

Carbon and nitrogen stable isotope analysis revealed a diet

very rich in meat, as demonstrated by the
15N high values at the
level of the carnivores. The
13C values, related to the consumption of fish, revealed an intake of marine proteins at 1430% [14].
The present study seems to further confirm the association
between DISH and elite status. Among the five individuals
belonging to the Medici family of >40 yrs of age that have been
studied so far, two were affected by DISH. Furthermore, it is
worth 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 DISH
in the Medici family is remarkable and a significant lifestyle
indicator, supporting the link between social status and risk of
developing DISH in mature age.

The gout of the Medici

Furthermore, the case of Ferdinand I is of particular interest
for the diagnosis of gout, of which very little evidence has been
found in palaeopathology [16]. Genetic and/or environmental
factors, with particular regard to diet, may be involved in the
aetiology of gout. An alimentation rich in animal proteins, as
attested by the palaeonutritional investigation carried out on the
Medici family [14], may have favoured the onset of this disease.
An association with obesity, diabetes and hyperinsulinaemia is
ascertained [17].
Modern clinical studies report a significant association between
diffuse idiopathic skeletal hyperostosis and gout [18].
Not only do the typical skeletal and radiological features
observed in the bone remains of Ferdinand I confirm the data
reported by the written sources regarding the arthritic left foot
gout that affected the Grand Duke, but this represents the first
documentation of the coexistence between diffuse idiopathic
skeletal hyperostosis and gout attested in palaeopathological
literature.

Rheumatology key messages

 The results elucidate the true nature of the famous gout of the
Medici.
 The coexistence between DISH and gout in Ferdinand is first
documented in the palaeopathological literature.

Disclosure statement: The authors have declared no conflicts of

interest.

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