Trepanation to Treat a Head Wound: A Case of Neurosurgery from 13th-Century Tuscany.

During the archaeological excavations conducted in the 13th century cemetery of the Church of Sant'Agostino in Poggibonsi (Tuscany, Italy), a skull with evidence of neurosurgical intervention was brought to light. The skull, belonging to an adult male, shows two traumatic lesions produced by bladed instruments. The first lesion, located on the anterior part of the parietal bones, involved only the outer cranial table; bone remodeling indicates that the individual survived the injury for a long time. The second lesion, located on the frontal bone, involved all the thickness of the bone; the absence of reparative processes allows a diagnosis of peri mortem lesion. To treat this wound, the patient underwent surgical intervention. In fact, in correspondence to the lesion, an oval bone loss, with clean and well-defined cutting edges, can be interpreted as the result of a trepanation, probably performed to clean the wound and to remove any bone splinters. Half of the bone "rondella" was found in situ; it can be hypothesized that the surgeon decided to replace the bony piece to protect the brain. However, the surgical intervention failed, and the patient died soon afterwards. Trepanation for the treatment of cranial traumas is described by several medical classical and medieval authors, whose texts were available in the 13th century. This case represents rare Middle Ages evidence of neurosurgery used to treat a bone injury.

On the history of gout: paleopathological evidence from the Medici family of Florence.

OBJECTIVES: Throughout history, gout has been referred to as the "disease of the kings", and has been clearly associated with the lifestyle of the aristocratic social classes. According to the written sources, several members of the famous Medici family of Florence suffered from an arthritic disease that contemporary physicians called "gout". A paleopathological study carried out on the skeletal remains of some members of the family, exhumed from their tombs in the Church of San Lorenzo in Florence, offered a unique opportunity to directly investigate the evidence of the arthritic diseases affecting this elite group. METHODS: The skeletal remains of several members of the family were examined macroscopically and submitted to x-ray investigation. RESULTS: The results of the study allowed us to ascertain that the so-called "gout of the Medici" should be considered the clinical manifestation of three different joint conditions: diffuse idiopathic skeletal hyperostosis, rheumatoid arthritis and uratic gout. In particular, uric acid gout was diagnosed in the Grand Duke Ferdinand I (1549-1609). Recently, a new case of this disease was diagnosed in Anton Francesco Maria (1618-1659), a probable illegitimate member of the family. CONCLUSIONS: With this new case, uratic gout was observed in 2 out of 9 adult males, leading to suppose that the disease should have been a common health problem within the family. The aetiology of the disease has to be searched in environmental factors, since both historical and paleonutritional studies demonstrated that the diet of this aristocratic court was rich in meat and wine.

Autoptic practices in 16th-18th century Florence: Skeletal evidences from the Medici family.

During the late Middle Ages and the Renaissance autopsy started to be practised for medico-legal purposes in order to investigate the causes of death. The other reason for dissecting a body was embalming, a diffused custom typical of the elitarian classes. The exploration of the Medici tombs in the Basilica of San Lorenzo in Florence offered the opportunity to investigate the practice of autopsy on these aristocratic personages of the Renaissance and Early Modern Age. A total of 25 currently skeletonized individuals, almost all of whom formerly artificial mummies, were exhumed. Accurate examination of the skeletons revealed evident signs of autoptic practices such as horizontal and oblique craniotomies, longitudinal and transversal cuts of the sternum, and sectioning of the sternal extremities of the ribs. In this group, women were treated differently to men at autopsy, as only men underwent craniotomy; autopsy and embalming were carried out also for the illegitimate members of the family and for subaldults. The extremely rich documentary archives of the Medici family confirm that the corpses were in several cases submitted to autopsy. The present study offers important direct information on the 16-18th century autoptic practices that the court surgeons in Florence performed on the members of the elite class.

THE MEDICI CHILDREN (FLORENCE, XVI-XVII CENTURIES): ANTHROPOLOGICAL STUDY AND PROPOSAL OF IDENTIFICATION.

Exploration of the Medici chapels in San Lorenzo in Florence revealed the burials of nine infantile members of the Medici family. Eight children were found in the intact tomb of the last Grand Duke Giangastone (1671- 1737). The crypt contained several small coffins collapsed to the floor or randomly spread over a raised plank, as a result of the disastrous flood of the Arno river in 1966, which partly upset the tomb and left a layer of dry mould. The children's remains, mostly skeletonised, were found inside the coffins or scattered on the floor or on the plank, probably transported by the water. Another child was exhumed from the chapel of Grand Duke Ferdinand I (1549-1609) and Cristina from Lorena (1565-1636). The infantile remains were submitted to anthropological study, which allowed to establish the number of individuals buried in the crypt, and to estimate the age at death. The anthropological results were compared with information provided by archival documents, related to members of the family who died in infantile age. An identification of the children is proposed.

A possible case of Garre's sclerosing osteomyelitis from Medieval Tuscany (11th-12th centuries).

Archaeological excavations carried out at the castle of Monte di Croce near Florence brought to light a small cemetery complex belonging to the castle church, dated back to the 11th-12th centuries. An elite stone tomb contained the skeletal remains of a male aged 35-45 years with obvious pathology of the right tibia. The proximal metaphysis and the upper half of the diaphysis appear massively enlarged as a result of severe chronic periostitis. A transverse section illustrates complete obliteration of the medullary cavity by new spongy bone, with some large cavitations. The primary, but completely remodeled tibial shaft is still recognizable. This finding and the strong sclerotic reaction with some central cavitations rule out any form of bone tumor and indicate a chronic inflammatory disease. The morphological and radiological picture and the tibial localization suggest a diagnosis of chronic sclerosing osteomyelitis of Garré, a rare form of chronic osteomyelitis characterized by an intense periosteal reaction with little or no suppuration.

RICKETS AT THE MEDICI COURT OF FLORENCE: THE CASE OF DON FILIPPINO (1577-1582).

Among the children found in the crypt of the Grand Duke Giangastone in S. Lorenzo Basilica (Florence), the skeletal remains of a 5-year-old child still wearing his fine high social status clothing were recovered. This child of the Medici family was identified as Don Filippino (1577-1582), son of the Grand Duke Francesco I (1541-1587) and Giovanna from Austria (1547 - 1578). The prince showed several pathological deformities of the cranial and post-cranial skeleton, including enlargement of the cranium, thinning of the cranial vault bones (craniotabes), platybasia and marked bending of femora, tibiae and fibulae. Differential diagnosis suggests that Don Filippino was affected by rickets. The occurrence of this metabolic disease related to vitamin D deficiency in a Renaissance high social class individual can be explained by the practice of very prolonged breast-feeding, up until two years of age. Maternal milk contains insufficient vitamin D ratios and retarded weaning severely exposes children to a higher risk of developing rickets, especially if dietary habits are combined with inadequate exposure to sunlight. Historical sources describe Don Filippino as frail and sickly, with frequent illnesses and persistent slight fevers, and it can be supposed that the child was frequently confined indoors, especially in the cold season. Integration of osteoarchaeological evidence with historical documentation suggests that bone lesions observed in the skeletal remains of Don Filippino are compatible with a diagnosis of rickets, caused by the custom of prolonged breast-feeding associated with inadequate sunlight exposure to sunlight. Historical sources describe Don Filippino as frail and sickly, with frequent illnesses and persistent slight fevers, and it can be supposed that the child was frequently confined indoors, especially in the cold season. Integration of osteoarchaeological evidence with historical documentation suggests that bone lesions observed in the skeletal remains of Don Filippino are compatible with a diagnosis of rickets, caused by the custom of prolonged breast-feeding associated with inadequate sunlight exposure.

The privileged burial of the Pava Pieve (Siena, 8th Century AD).

RATIONALE: The 6(th) archaeological excavation campaign performed at the 'Pieve di Pava' (San Giovanni d'Asso, Siena, Italy) unearthed a privileged stone burial of a single individual (US 2378), covered by a monolithic slab and placed in front of an altar. The skeletal remains of a young male (18-20 years old), not in anatomical connection, were found at the bottom floor of a tomb (160 cm long, 40 cm large and over 70 cm deep). METHODS: A multidisciplinary study has been carried out concerning that privileged bone burial. The study combines paleopathology studies, stable isotope palaeodietary reconstruction, radiocarbon dating and archaeological analyses. RESULTS: (14) C dating of the skeleton revealed a date between 650 and 688 AD. Stable isotope analysis (δ(18) O, δ(13) C, δ(15) N) attested that he was probably a member of the local population, whose diet was rather rich in animal proteins. The paleopathological study diagnosed a case of acromesomelic dysplasia, a congenital anomaly with disproportion of the limbs. Archaeological evidence regarding the circular delimitation of the bones suggested that the skeleton was a secondary deposition, transported to the church in a sack. CONCLUSIONS: We argue that the relic was used for the re-consecration of the church, following the restoration work in the 8(th) century. We conclude that the skeleton belonged to an eminent personage (e.g., either the member of a local elite family or a saint).

Diffuse idiopathic skeletal hyperostosis in the Medici, Grand Dukes of Florence (XVI century).

Diffuse idiopathic skeletal hyperostosis (DISH) is a common systemic disorder characterised by the ossification of the anterior longitudinal spinal ligament involving at least three contiguous vertebrae and by diffuse extraspinal enthesopathies. The condition is associated with the male sex and with advanced age; its aetiology is uncertain, but seems to be related to obesity and diabetes. The most recent studies in archaeological series demonstrated a relation between high social status and the incidence of DISH. The present study examines two cases of DISH found amongst the members of the Medici family buried in the Basilica of San Lorenzo in Florence. The skeletons of the Grand Dukes Cosimo I (1519-1574) and his son Ferdinand I (1549-1609) showed the typical features of the condition. This result is related to the obesity of the Grand Dukes, attested by the written and artistic sources, and to the protein-based alimentation demonstrated by a paleonutritional study, thus furnishing further evidence to the significance of DISH as a life style.

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

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 (1519-74) and his son Ferdinand I (1549-1609). 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.

The Medici Project first anthropological and paleopathological results of the exploration of the Medici tombs in Florence.

Within the framework of the Medici Project, a paleopathological team of experts from the University of Pisa, the University of Florence and the Superintendence for Florentine Museums, is carrying out a study on 49 tombs of some of the Medici family members (16th-18th centuries) housed in the so-called Basilica of San Lorenzo in Florence. The project involves disciplines such as paleopathology, funerary archeology, physical anthropology, paleonutrition, parasitology, histology, histochemistry, immuno-histochemistry, electron microscopy, molecular biology, and identification of ancient pathogens. The most recent biomedical imaging technologies have been employed to obtain as much information as possible about the genetic make-up, eating habits, life styles and diseases of these important rulers of Renaissance Florence. The first anthropological and paleopathological results are presented here.