Journal of Nephrology | 2021
Gout: a papal disease—a historical review of 25 gouty popes (34-2005 AD)
Abstract
Gout is a common, complex, systemic chronic inflammatory arthritis. It is due to the deposition of sodium monourate crystals in peripheral joints and periarticular tissues, driven by hyperuricemia at or above 6.8 mg/dl. The latter is caused by genetic or environmental factors, as well as by urate transporter dysfunction in the gut and in the kidneys. Hyperuricemia is due to either renal overload (overproduction or extrarenal underexcretion caused by dysfunctional variants of transporters in the gut and intestine), or to renal underexcretion, or to a combination of both. A kidney affection may cause hyperuricemia, but the kidney is also the target of hyperuricemia (kidney stones, renal disease) [1]. Gout is the oldest recorded inflammatory arthritis whose first descriptions date back to 2460 BC. The prevalence of gout is about 1% in Italy and in France, 2.5% in the United Kingdom, 3.9% in the USA and 1% in China. It is rare in Portugal, Czech Republic, former Soviet Union, Turkey, Malaysia, Japan, Korea, and in Africa. The prevalence increases until 70–80 years of age. Gout is considered a disease of the rich. However, it has been studied less in popes than in kings, and the available list of gouty popes is incomplete. Popes are by definition people of affluence and distinction and have a life expectancy that by far exceeds that of laymen [2, 3]; their lives have been scrutinized thoroughly since they have been active protagonists of history in Europe and beyond. Studying the prevalence of gout in popes may be a way to analyze the environmental conditions, their dietary habits, or their attitudes towards physical activity. The chronic effects of gout on the quality of life of the popes, the remedies they received from the archiaters and personal physicians and the causes of death may also provide some interesting historic insights. This historic commentary attempts to shed light on all gouty popes in the history of the papacy, to provide an indepth analysis on the narratives of gout in popes, and to provide a clinical picture of a disease that has disappeared from the Vatican. Overall, 25 of 264 Roman popes were gouty (9.47%); 17 of 25 (68%) had renal disease and kidney disease was the main cause of death in 12 of the 17. In 14 out of 25 (58%) other risk factors were present, and 5 out of 25 presented severe comorbidities [4]. The disease severely impaired daily life: a degree of inability to perform daily duties was described in 21/25 (84%). Conversely, renal disease did not seem to affect age at death and inability to perform duties (Table 1). Twenty-three gouty popes were born in Italy, while Sisinnius was Syrian, and Clement VI was French. They ruled in periods ranging from 590 to 1830: Gregory I was the first gouty pope, and Pius VIII the last one. The mean age at the end of their pontificates was 70.6 ± 9.7 years. The clinical presentations were protean: podagra (a gouty inflammation of the foot or big toe) and chiragra (gout occurring in the hands) were common and were associated with kidney disease in 17 popes. Marcellus II experienced gout flares with long intercritical periods, until a long-lasting flare accompanied him to the grave. Arthritis at uncommon sites affected Nicholas V (the shoulder) and Honorius IV (the spine). Severe pain affected Nicholas V, Callixtus III, Pius III, Innocent XII and Benedict XIV; the pain was so excruciating that Gregory I Magnus was reported to desire death, and, possibly also because of pain, he was depressed * Natale Gaspare De Santo [email protected]