The mummies of s. Domenico maggiore: disease at the aragonese court

The Basilica of San Domenico Maggiore, which dates back to the beginning of the 14th century, is one of the largest and most important churches in Naples.  The humanist Giovanni Pontano and the philosophers Tommaso Campanella and Giordano Bruno studied in this Abbey.  Saint Thomas Aquinas taught in the annexed convent of the Dominicans.  The impressive Sacristy of San Domenico Maggiore, in a suspended gateway close to the vault, contains 38 wooden coffins, or “arks”, with the bodies of 10 Aragonese princes and other Neapolitan nobles, who died in the 15th and 16th centuries.  The coffins were initially placed in different parts of the church, but in 1594 Philip II, King of Spain, ordered that they should be gathered in the Sacristy (Miele 1977).  The sarcophagi, richly dressed in precious clothes made of silk, brocade and other material, are distributed in two rows, one above the other.  The smaller coffins of the lower row are generally of anonymous individuals, while the larger coffins of the upper row are identified by the coats-of-arms and the names of the personages buried inside.  In particular they include the Aragonese kings Alfonso I (who died in 1458), Ferrante I (1494), Ferrante Il (1496), Queen Giovanna IV (1518) and the Marquis of Pescara Ferdinando d’Avalos, who won the famous battle of Pavia against the French King François I in 1525.
The mummies of San Domenico Maggiore are unique in Italy not only for the antiquity and excellent state of preservation of the bodies, but also for the fame of the personages, whose lives and causes of death are well known.  King Ferrante II, for example, died of malaria, while the Marquis of Pescara died of pulmonary tuberculosis.  The possibility of comparing the paleopathological with the historical data provided extremely interesting results.  Up to now, the only mummies of this type known in Europe have been those of the Hapsburg princes in Vienna (Kleiss 1977).
The sarcophagi of San Domenico Maggiore were carefully examined from 1984 to 1987 by a team of the Institute of Pathology of Pisa University.  Radiography followed by anthropological and autoptic examination on site were carried out on the mummies; the laboratory studies were performed in Pisa.  The extremely precious clothes and the jewels of the buried individuals have been carefully recovered and will soon be restored and displayed at the Museum of Capodimonte by the Superintendence of Naples.
Let us now summarize the results obtained so far: of the 38 sarcophagi explored, 8 were found to be empty, while one contained a double deposition.  All depositions resulted to be more or less disturbed.  There were 27 primary depositions and 4 secondary depositions, or redepositions. Fifteen individuals, equal to 48.4% of the totality, had been submitted to embalming, while 12, equal to 38.7%, had not been treated. Therefore, the majority of the individuals had been embalmed and this is certainly not surprising, considering the high social class of the individuals buried in San Domenico.  From the physician Ulisse Aldrovandi we know that during the Renaissance "the European kings and great personages used to entrust embalming of their bodies to their doctors and surgeons" (Aldrovandi 1602). 
These very complex evisceration and embalming methods indicate long-practiced and diffused customs but as already said some well preserved individuals show no apparent signs of embalming.  Natural mummification of the bodies can probably be attributed to the warm and dry climate of Naples during the summer.  Preservation of the bodies may have been favored by the particular microclimatic conditions of San Domenico Maggiore, as well as by the disposition of the coffins, placed near the windows of the sacristy, at about 5 m of height.  Furthermore, two large rooms, certainly devoted to dehydration of the bodies, have been discovered recently in the crypts of San Domenico.  These two rooms were provided with numbered spaces for the coffins, with wide ventilation shafts, and with thick sand beds, for the gathering of the cadaveric fluids.  The mummies of San Domenico are likely to have been submitted to the previously described treatment of natural mummification practiced in Naples until the last century.
We shall now describe two cases of infectious disease and two cases of neoplastic pathology, from a strictly paleopathological point of view.
The mummy of an anonymous 2-year-old boy, whose death dates back to the mid 16th century (radiocarbon dating is 1569± 60), presented a diffuse vesiculo-pustular exanthema type eruption. Macroscopic aspects and regional distribution suggested a case of smallpox.  This possibility was confirmed by light microscopy and indirect immunofluorescence with anti-smallpox virus antibody.  Electron microscopy revealed, among the residual bands of collagen fibers, pyknotic nuclei, and membrane remains with rare desmosomes, many egg-shaped, dense virus-like particles (250 x 50 nm), composed of a central dense region (or core) surrounded by a low density area.  Following incubation with human anti-vaccinia-virus antiserum, after protein A-gold complex immunostaining, the particles were completely covered by protein A-gold.  These results showed that the antigenic structure of the viral particles was well preserved and that this Neapolitan child died of a severe form of smallpox some four centuries ago (Fornaciari and Marchetti 1986a, 1986b, 1986c, 1986d, 1986e; Fornaciari et al. 1989i).
The study of a case of treponematosis in the mummy of Maria of Aragon (1503-1568), Marquess of Vasto in southern Italy, appeared to be particularly interesting.  Famous for her beauty, this noblewoman of the Italian Renaissance belonged to the intellectual and religious circles of lschia, which also included a friend of Michelangelo’s, the poetess Vittoria Colonna.  An oval 15×10 mm cutaneous ulcer covered by a linen dressing with ivy leaves appeared on the left arm of the mummy. lndirect immunofluorescence with human anti-treponema pallidum antibody identified a large number of filaments with strong yellow-green fluorescence and the morphological characteristics of fluorescent treponemes. Morphological aspects typical of the spirochetes, as for example the axial fibril, were evidenced by the ultrastructural study. lmmunohistochemical and ultrastructural findings clearly demonstrated treponemal infection and the cutaneous ulcer resulted to be typical of third-stage luetic gumma.  Venereal syphilis was the most probable diagnosis (Fornaciari et al. 1989c, 1989d, 1989e, 1994a).  This discovery is extremely important since it dates back to the 16th century and can help to clarify the biology of treponema in the epidemic phase of the disease.
Another important paleopathological case is that of Ferdinando Orsini, Duke of Gravina in Apulia, who died in 1549.  The mummy presents wide erosion of the upper orbital margin and the glabella, and complete destruction of the right nasal and retro-orbital bones.  Histology showed solid neoplasia, with cords of spindle-shaped cells destroying compact and spongy bone and forming osseous lacunae, with no bone reaction.  A widely destroying skin epithelioma seems to be the most probable diagnosis (Fornaciari et al. 1989b).
The artificial mummy of Ferrante I of Aragon, King of Naples, who died in 1494 at 63 years of age, was submitted to autopsy which revealed in the small pelvis a fragment of  a cave muscular organ, which reached the dimensions of 6x4x1cm after dehydration.  Histologically, neoplastic epithelial cells disposed in cords, nests and glands  were disseminated in a fibrous stroma containing scattered striated muscular fibres.  The cells were tall, crowded, with abundant cytoplasm and pseudo-stratified pleomorphic hyperchromatic nuclei.  The scarce mucus was limited to the pseudoglandular formations, as appeared from the specific Alcian-blue staining.  The use of a monoclonal antibody versus pancytokeratin displayed strong intracytoplasmic immunoreactivity of the tumoral cells.  The ultrastructural study evidenced well preserved pleomorphic nuclei with indented membranes.  These results clearly indicate a mucinous adenocarcinoma infiltrating the muscular-fibrous layers of the small pelvis.  However, the site of the primary neoplasm was at first impossible to establish: the histological features only suggested prostatic adenocarcinoma or an adenocarcinoma of the digestive tract (Fornaciari et al. 1993).  Since colorectal tumours are characterised by frequent mutations of the K-ras oncogene – whereas in prostatic adenocarcinomas such mutations are extremely rare – we decided to investigate the status of the K-ras gene in the DNA tumour extracted from the mummified tumour tissue (Caligo et al. 1994).  The samples were subjected to a nested PCR protocol designed to yield a 77 bp K-ras fragment encompassing codon 12, the main hotspot for mutations in colon cancer.  The hybridization with 32P-labelled mutation specific oligonucleotide probes showed the presence, in the tumour sample, of a K-ras codon 12 point mutation: the normal sequence GGT (glycine) was altered to GAT (aspartic acid).  This data clearly demonstrates that Ferrante I was affected by a cancer of the digestive tract, most probably a colon adenocarcinoma (Marchetti et al. 1996). This is the first time an oncogene mutation has been evidenced in an ancient tumor.
The recorded genetic change represents the most frequent mutation of the K-ras gene in sporadic colorectal cancer and is characteristic of the effects of alkylating agents (Topal 1988). Recent studies have focused the importance of some alkylating agents, such as the endogenous N-nitroso compounds (NOC). Increased intake of red meat, such as beef, lamb or pork, induces a significant 3-fold increase of faecal NOC levels, with a range of exposure in faeces similar to that from tobacco-specific NOC in cigarette smoke (Bingham et al. 1996). The study of alimentary regimens of the Italian Renaissance courts, and in particular of the Aragonese court of Naples, evidences very high red meat assumption, attested also by the paleonutritional data (Fornaciari et al. 1988). Therefore, the alimentary “environment” of the Neapolitan court of the XV century can well explain, with its abundance of natural endogenous alkylating agents, the K-ras mutation causing the tumor which killed the Aragonese king over five centuries ago.
In conclusion, the paleopathological study of the mummies of eleven adult individuals from the Abbey of San Domenico Maggiore, with good or excellent preservation, allowed us to diagnose two cases of cancer.  The number of available specimens was very limited ;  however, it was possible to observe an incidence of neoplastic pathology (18.8%), similar to the one we find nowadays.
Among the “minor” pathologies we wish to point out the mortal stab-wound, with surrounding hemorragic infarction, between the eighth and the ninth left rib in the mummy of an anonymous gentleman who died at the age of  about 27 in the second half of the 16th century (Fornaciari et al. 1989a); a case of Wilson’s cirrhosis; a case of acute edema, or pneumonia, in an individual with severe anthracosis; an individual affected by calculosis of the gall-bladder with chronic colicystitis (Fornaciari et al. 1989g).

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