Francesco M. Galassi

Palaeopathology: Current challenges and medical impact

Palaeopathology is the science which studies ancient human diseases. Throughout its relatively young history it underwent tremendous technological and methodological improvements (from pure morphology and histology to CT scanning) that have constantly reshaped its scientific rationale. Among other achievements, the study of mummies and fossilized hominids has allowed to effectively extract ancient DNA, prove the existence of atherosclerosis in ancient times, demonstrate the presence of disease vectors, better clarify the etiology of infectious diseases otherwise only postulated on the basis of ancient accounts as well as to show the presence of spine pathology in our hominid ancestors. The research levels in this discipline are three: basic research, individual cases, population. The first and the third levels contribute most to the discipline, while the second is the one more appealing to the general public on account of its description of important cases reports. In addition, a recently introduced sub‐specialty of palaeopathology, pathography is aiming to use an interdisciplinary approach to find traces of diseases in ancient literary sources and artistic representations. In spite of its discoveries, palaeopathology is not always viewed positively by clinicians because certain old‐fashioned techniques are still due to technical restrictions. The authors provide a set of suggestions on how to strengthen the scientific recognition of this subject and explain at length how it could contribute to the progress of medical research. Clin. Anat. 29:816–822, 2016.

A case of Horton's disease (with its potential neurological symptoms) depicted in a portrait by Andrea Mantegna

The painting ‘‘Portrait of a Man in Profile’’ (Fig. 1), attributed to the painter Andrea Mantegna (1431–1506) is part of the ‘‘Poldi Pezzoli’’ Museum (Milan). It shows an aged man in a lateral pose whose extremely realistically depicted traits immediately capture the onlooker’s attention. In particular, the windy turgidity of the temporal artery may suggest that the subject suffered from Horton’s disease (also known as giant-cell arteritis), a condition which typically affects patients over 50, principally causing neurological symptoms such as headache as well as being associated to systemic symptoms such as fever and discomfort, polymyalgia rheumatica, visual loss—more specifically blindness—being its most severe complication [1]. Besides headache, neurological symptoms may include neuropathies, neuro-otologic syndromes, tremor, neuropsychiatric syndromes, TIA/strokes, tongue numbness and myelopathy, as found to occur in a set of patients with biopsy-proven giant-cell (temporal) arteritis [2]. Since Andrea Mantegna used to pay a great deal of attention to pathological conditions in his representations—as shown in the depiction of rickets in the young offspring of the Gonzaga family in the Camera degli Sposi in the Mantua Ducal Palace [3]—it is reasonable to think that, while in the act of portraying an old man with the traditional attributes of humanistic gravitas, he may have not neglected to paint an objectively patent pathological trait. Fig. 1 Andrea Mantegna. Profilo d’uomo (between 1448–1450 and 1460–1462). Tempera on panel. 32.3 9 28.8 cm. Poldi Pezzoli Museum, Milan. Public domain image from Wikipedia uploaded by user: Shakko https://it.wikipedia.org/wiki/Profilo_d%27uomo#/ media/File:Andrea_Mantegna_114.jpg (accessed 12 Aug 2015)

Has the diagnosis of a stroke been overlooked in the symptoms of Julius Caesar

Julius Caesar (100–44 BC) is considered one of the greatest military leaders and conquerors of all time. His health status has been the source of a longstanding debate within the historical and medical community who generally suggests epilepsy and Ménière disease as the two prime differentials when considering his morbus comitialis (disease of the assembly hall). To-date, however possible cardiovascular explanations have always been ruled out on the grounds that until his death he was supposedly otherwise physically well during both private and stately affairs. When re-evaluating his symptoms, it can be noted that Caesar suffered falls during his campaigns in Spain and Africa at Cordoba and Thapsus. He reported symptoms of headaches, vertigo and later on mentioned giddiness and insensibility, when he could not stand up as senators honoured him. Together the symptoms of headache, vertigo and falls as a possible result of limb paresis, gait disturbance, sensory deficit or syncopal episode can be considered in terms of cerebrovascular insults and stroke [1, 2]. Furthermore, Caesar also suffered from other symptoms including depression and personality changes (exampled by emotional lability when listening to a moving oration by Cicero), which may also be consistent with cerebrovascular disease [1, 2]. Pliny the Elder reports in his Natural history that both Caesar’s father and another forefather died without any apparent cause whilst putting on their shoes. This has been explained by some in terms of SUDEP (sudden unexpected death in epilepsy); however, these events can be more readily associated with the cardiovascular complications of stroke episode or a lethal myocardial infarction. Even if Caesar participated in an active lifestyle and may have benefited from an environmental background of a Mediterranean diet, there is the added possibility of genetic predisposition towards cardiovascular disease. When assessing other differentials for Caesar’s disease, there is little evidence suggesting Ménière’s disease as no primary source mentions unilateral deafness (unlike Shakespeare). Whilst epilepsy is a possibility, this would have to derive from acquired adult-onset aetiologies (such as head trauma, neurocysticercosis from his Egyptian campaign, arteriosclerosis, syphilis, genetic, malaria, tuberculosis, and glioma) [3]; as there are no clear records of Caesar having suffered seizures in his youth. Furthermore, if Caesar had suffered from epilepsy, his seizures might have been better documented in such a prominent individual [4]. Caesar and his adopted son Octavius may have contributed to the diagnosis of epilepsy, as this was considered a ‘‘sacred disease’’ so that they would have publicised this disorder to better fit with a Caesar’s public profile. In summary, many of the symptoms reported during Caesar’s life are compatible with an underlying diagnosis of cardiovascular disease and repeated cerebrovascular events. Whilst Caesar’s death ultimately derived from his assassination, the possible diagnosis of stroke during his life may offer some novel interpretations regarding several notable incidents during his time as a Roman leader.

A likely case of goiter in the Madonna col Bambino dormiente (1465/1470) by Andrea Mantegna (1431-1506).

the Boston Museum of Fine Arts by one of Mantegna’s followers has also been identified as a representation of goiter, which highlights how the painter and his school have not The Gemälde Gallerie in Berlin exhibits the famous painting Madonna col Bambino dormiente (Eng. Madonna with sleeping child, Fig. 1) painted around 1465/1470 by Andrea Mantegna (1431–1506). A common theme of the Italian Renaissance, the Madonna with child was often studied and represented by Mantegna throughout his life. In comparison with previous representations characterized by a stiff and awkward rendering of shapes, this is a more intimate and private interpretation of the divine duo with a softer pictorial and more harmonious compositional quality. The particular attention paid to representing reality reveals that the Virgin Mary shows an enlarged neck, with a protruding ovoidal mass. Elsewhere identified lobulations being absent, the pictorial evidence alone would not allow to formulate a clearcut semeiological diagnosis of goiter and more differential diagnoses could be considered, e.g., lipoma, cyst, abscess, lymphadenopathy, carotid artery aneurism, etc. Nonetheless, the very suggestive anatomical position and the fact that several more examples by different artists of Renaissance [1, 2] have been identified as portrayed with the typical pathological morphology of a goitrous enlargement strongly point in that interpretative direction. Another Madonna with child in

Depiction of differential etiologies of dwarfism by Il Veronese (1528–1588)

Paolo Caliari (1528–1588), mainly known as il Veronese, is regarded as one of the most influential painters of the Italian Renaissance. Some of his depictions may conceal interesting insights into the historical presentations and social relevance of different types of dwarfism. Like Diego Velázquez (1599–1660), he chose to depict dwarfs, acting as court jesters to the amusement of their masters. At least two examples may be identified and have only briefly touched upon by Castillo-Ojugas in his 1985 review of rheumatology in art [1]. He focused on the genu recurvatum of a dwarf from the painting “The Finding of Moses” (Fig. 1a) and on another such dwarf in the “Wedding at Cana” (Fig. 1b). At first glance his observation seems correct since the dwarfs not only show a short stature and genua recurvata, but also a large head, prominent frontal bossing, midface

A Case of Sudden Death in Decameron IV.6: Aortic Dissection or Atrial Myxoma?

Giovanni Boccaccios Decameron contains a novella that details the sudden death of a young man called Gabriotto, including a portrayal of the discomfort that the protagonist experienced and a rudimentary autopsy performed by local physicians. The intriguing description of symptoms and pathologies has made it possible to read a 7-century-old case through the modern clinical lens. Thanks to the medical and philological analysis of the text-despite the vast difference between modern and medieval medicine-2 hypothetical diagnoses have emerged: either an aortic dissection or an atrial myxoma.

Methodological limitations of an etiological framing of Ariarathes’ goitre: response to Tekiner et al.

In conclusion, the effort by Tekiner et al. to diagnose Ariarathes IV with goitre from an artistic representation is very commendable and it follows in the footsteps of an established pathographic tradition. Nevertheless, more interdisciplinary research may be necessary to provide compelling evidence for the origin of Ariarathes’ disease. On account of this, this letter is meant to encourage the authors, as well as all scholars interested in the life and character of the Cappadocian monarch, to develop this preliminary study into a full research paper, from whose scientific worth both classicists and medical humanists would certainly benefit.

Poliomyelitis in Ancient Egypt

Although asymptomatic in 95 % of cases, in 1 % of them poliomyelitis involves the central nervous system resulting in muscular weakness and acute flaccid paralysis. This has meant a heavy health burden for millions in the past. Global efforts combining surveillance, financial support to developing countries and immunization in the last 30 years have achieved a 99 % decrease in cases of poliomyelitis. However, since no real cure exists, a lot of effort has still to be made [1]. The antiquity of the condition is accepted, and commonly even traced back to Ancient Egypt. Two lines of evidence are adduced, pictorial and paleopathological. The ca. 1500 BCE stele of a priest called Ruma with a shorter leg and helping himself with a stick (Copenhagen, Ny Carlsberg Museum ÆIN 0134) is considered to be one of the first representations of a polio victim [2]. The famous relief in Berlin (Egyptian Museum Inventory 15000) showing a late Amarna royal couple (ca. thirteenth century BCE) is also regarded to show the king as a polio victim with a shortened leg using a cane, yet it is even possible that the relief is a counterfeit or the clumsy work of a lesser artist [3]. Pharaoh Siptah’s (1205–1187 BCE, Cairo, National Museum CG 61080) mummy shows a severely deformed Pes equinovarus-like left foot and a shortened left leg, a situation also encountered with the clubfoot of KhnumuNekht (ca. 2500 BCE, Manchester Museum, Inv. No. 21471): these may be interpreted either as evidence of neuromuscular disease suggestive of poliomyelitis infection [4] or (especially Siptah) as congenital malformations [2] or mummification-produced modifications. In conclusion, while the paucity of potential cases identified may confirm that even in the past only a small percentage of cases manifested a full clinical syndrome, pictorial evidence alone gives no definitive proof, still lacking from mummies. Until further incontestable paleopathological data are produced, the presence of poliomyelitis in Ancient Egypt should be considered speculative.

Palaeopathology of the earlobe crease (Frank's sign): New insights from Renaissance art

Several studies have associated the earlobe crease sign, discovered by Sanders T. Frank in 1973, with cardiovascular pathology, yet very few studies have focused on the antiquity of this trait, with the most ancient one thought to date back to the Roman Emperor Hadrian (76-138CE). This article presents two more cases from the Italian Renaissance in the works of the artist Andrea Mantegna (1431-1506) and examines them in a multidisciplinary fashion.

Teofilo Folengo's facial paralysis and unknown demise.

Teofilo Folengo (1491–1544), also known by the pseudonym Merlino Coccajo, is regarded as a very prominent 16th century Italian poet. Born in Vergil’s homeland, Mantua, he is remembered for a series of writings in macaronic Latin, amongst which stands out the heroicomic poem Baldus, destined to influence even the work of Rabelais. After retiring to a secluded life in the village of Campese, near Bassano del Grappa, he passed away at the age of 53 [1]. Although some paintings allegedly portraying him exist, the anonymous oil on canvas exhibited in the Palazzo San Sebastiano Museum in Mantua is considered to depict the real lineaments of the Mantuan poet, since a Latin inscription easily allows one to attribute the portrayed character to him: Theophilos Folengo/poeta Merlinos/Obyt 1545 (Fig. 1). What immediately catches the onlooker’s attention is the rather abnormal crooked grin his face shows, which cannot be thought of as a natural facial expression and may indeed be interpreted in the light of medical diagnostic principles. As of a result of a typical facial nerve (7th cranial nerve) paralysis, integumentous mimicry muscles are affected thus yielding a patently visible facial asymmetry showing a deviation of the oral fissure in the direction of the unaffected half, while the affected half does present a certain lowering of the labial commissure. Interestingly, Folengo’s forehead is shown as still capable of frowning symmetrically, which would be consistent with the superior branch of the facial nerve being unaffected by the pathology. Such an observation— with all the limitations imposed by the bidimensional nature of a pictorial representation—potentially allows one to rule out a peripheral, Bell’s type, palsy, suggesting instead a supranuclear location of the lesion [2]. Fig. 1 Teofilo Folengo by anonymous painter. Museo della città di Palazzo San Sebastiano, Mantova (online figure)