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Helle Mathiasen, CandMag, PhD, Section Editor
Malaria Was “the Killer” of Francesco I de’ Medici
Gino Fornaciari, MD,
Valentina Giuffra, PhD,
Ezio Ferroglio, DVM, PhD,
Raffaella Bianucci, PhD
Division of Paleopathology, History of Medicine and Bioethics, Department of Oncology, Transplants and Advanced Technologies in
Medicine, University of Pisa, Italy;
Laboratory of Parasitology and Parasitic Diseases, Department of Animal Production,
Epidemiology and Ecology, University of Turin, Grugliasco Torino, Italy;
Laboratory of Anthropology, Department of Animal and
Human Biology, University of Turin, Torino, Italy;
UMR 6578 CNRS-EFS (Biocultural Anthropology), University of Marseille,
The sudden deaths of Francesco I de’ Medici (1531-1587),
Second Grand Duke of Tuscany (Figure 1a), and his wife,
Bianca Cappello (1548-1587), have been shrouded in mys-
tery, and the cause of death has been debated for the past 4
Francesco was the first child of Cosimo I de’ Medici
(1519-1574), First Grand Duke of Tuscany, and his wife,
Eleonora of Toledo (1522-1562). He became Grand Duke of
Tuscany in 1564, ruling until his death. Francesco was not
interested in political affairs, which he delegated to his
functionaries. Instead, he became a patron of the arts and
sciences and a passionate alchemist. In 1565, he married
Joan of Austria (1548-1578), and they had 7 sons. During
this marriage, Francesco began a relationship with a Vene-
tian noblewoman, Bianca Cappello, whom he married in
1579 after the death of his wife.
In October 1587, the Grand Duke and his wife died
unexpectedly within 24 hours of each other. Contemporary
medical documents attributed the deaths to tertian malarial
Rumors soon spread that Francesco and Bianca had
been poisoned with arsenic by Francesco’s brother, Cardi-
nal Ferdinando I (1549-1609) (Figure 1b).
The rumors
were apparently instigated by courtiers who knew of the
long-standing disagreements between the brothers.
Ferdinando I never tolerated the presence of the new
Grand Duchess at the Medici court. The Cardinal also re-
sented Bianca’s meddling in court affairs and accused his
brother of behaving in a manner unbecoming his ducal role.
Two weeks before their deaths, on September 25, 1587,
Ferdinando, Francesco, and Bianca met at the Medici villa
in Poggio a Caiano, where they were thought to have at-
tempted a reconciliation.
Francesco I’s skeleton was unearthed from the topsoil of
the Medici Chapels in San Lorenzo Church (Florence, Italy)
in 2004.
Bianca Cappello’s remains have not been recov-
ered; her burial site remains unknown. Recently, the ancient
rumors of murder have received apparent support from a
toxicologic study that excluded malaria as the cause of
Francesco’s death.
Malaria was endemic in Central Italy, especially Tus-
cany, from the 2nd and 3rd centuries BC to the end of World
War II. To determine whether the original death certificates
might have been correct and the rumors false, we carried out
an immunologic investigation to determine whether Plas-
modium falciparum malaria might have caused the death of
Francesco I.
Cancellous bone was harvested from a vertebra of
Francesco I. Bone samples of Cosimo I de’ Medici, who
died of pneumonia, and his daughter-in-law, Joan of Aus-
tria, who died in childbirth, were used as negative controls.
In addition, 2 medieval bone samples from 2 sites known to
be free from malaria (Briançon, France, 17th century; Augs-
burg, Germany, 14th century) also were used as negative
Extracts prepared from spongy bone samples were ex-
amined for the presence of P. falciparum histidine-rich
protein 2 and P. falciparum lactate dehydrogenase using 2
commercial qualitative double-antibody immunoassays:
Malaria Antigen RAPYDTEST and Malaria Detect RAPYDTEST
(DiaSys, Waterbury, Conn).
Positive results were obtained from both dipstick assays.
We therefore provide the first biological evidence of the
Funding: None.
Conflict of Interest: None of the authors have any conflicts of interest
associated with the work presented in this manuscript.
Authorship: All authors had access to the data and played a role in
writing this manuscript.
Requests for reprints should be addressed to Gino Fornaciari, MD,
Department of Oncology, Transplants and Advanced Technologies in Med-
icine, Division of Paleopathology, University of Pisa, Via Roma 57, 56126
Pisa, Italy.
E-mail address:
0002-9343/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
presence of both P. falciparum ancient proteins (P. falcipa-
rum histidine-rich protein 2 and P. falciparum lactate de-
hydrogenase) in the skeletal remains of Francesco I de’
Medici. No mixed falciparum infections or non-falciparum
infections were identified. Bone samples from Cosimo I,
Joan of Austria, and control samples were all negative, as
Our recent findings support the detailed medical docu-
ments recorded by court physicians who carefully described
the different stages of the sudden illness that affected the
Grand Duke Francesco I until his demise.
Muscle has, thus far, been considered the best tissue for
the detection of P. falciparum malaria because of its abun-
dant red cell content.
We now show that malaria antigens
also can be detected in ancient bone samples.
With the use of modern methods, we provide robust
evidence that Francesco I had falciparum malaria at the time
of his death. Our immunologic results confirm the archival
sources that described the onset, course, and fatal outcome
of the disease. Our findings also absolve Ferdinando I from
the shameful allegation of being the murderer of his brother
and sister-in-law.
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dynastic period. J Archaeol Sci. 2008;35:1880-1885.
Figure 1 Portraits of Francesco I de’ Medici (Scipione Pulzone, Uffizi) (a) and Ferdi-
nando I de’ Medici (Scipione Pulzone, Uffizi) (b). (With permission from the Ministry of
Cultural Heritage.)
569Fornaciari et al Malaria of Francesco I
... eventually were able to conclude that any parasite eggs that once could have been present in the embalming jars may have just perished in the chemical environment (Fornaciari et al., 2010;Morrow et al., 2016). ...
Paleoparasitological data on the Iberian Peninsula is in particular scarce. This work provides an introduction to the field of Paleoparasitology, demonstrates the application of its techniques in archaeological contexts and adds to the knowledge of the disease in the past. To achieve this, we constructed ancient parasite eggs sampling strategies, soil-sampled and tested three Neolithic sites: El Mirador cave (fumiers deposits) (c. 5300-3500 cal. BC), Can Sadurní cave (fumiers deposits) (4709-4555 cal. BC), and La Draga (5300-4700 cal. BC) permanent open-air settlement (cultural layer, sector A). In total, we collected 109 samples, represented as a 6513 g of sediment. Analysis results provided in this work are based on 46 fully processed and analysed samples. La Draga site remains to be the only parasitological data providing lakeside settlement associated with the Mediterranean route of Neolitization with our new findings of Trichuris sp. and Taenia or Echinococcus sp. We consider our study of El Mirador and Can Sadurní fumiers deposits to stand for one of the first paleoparasitological works in the contexts of the fumiers in general. Analysed deposits from both caves tested negative for ancient parasite eggs presence. In this work, we argue that negative samples could potentially indicate false negatives due to the burning practices in the caves and do not display the absence of the infection.
... Approximately 92% of the positive cases revealed signs of chronic anemia (see above). Later studies in an Early Dynastic mummy (12) and Renaissance period European skeletal remains (from the famous de' Medici family) confirmed positive results (13,14). Accordingly, several members of the de' Medici family had malaria, as evidenced by a positive immunological reaction. ...
... Francesco I, 2 nd Grand Duke of Tuscany, died of pernicious malaria at 46 years of age, after a deer hunting in the marshy Arno river valley, with his second wife, Bianca Cappello, who died with the same symptomatology 24 hours later (8). The court physicians report a detailed description in Latin of the autopsy of Francesco. ...
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During the Renaissance and Early Modern Age dissection began to be practiced for medico-legal purposes, in order to investigate the causes of death. In particular, during the 15 th century evidences of autopsies performed by doctors on their private patients emerge. These dissections were requested by those families who can afford the expenses, in order to search the possible presence of hereditary diseases and to predispose a prevention and cure. The diffusion of this practice is attested also by the work of Antonio Benivieni (1443-1502), who is considered a pioneer of the pathological anatomy. The extremely rich documentary archives of the Medici family, one of the most important family of the Italian Renaissance, report several description of necropsies carried out on the bodies of the members of the family. The analysis of these reports offers important direct information on the autopsy practices performed by court surgeons of the members of an aristocratic class in a period comprised between the 16 th and the first half of the 18 th century, and allows in some cases also to propose a retrospective diagnosis on the diseases that afflicted the Medici. In this paper the analysis will be focused on the evidences about autopsies carried out during the 16 th century. An evolution through time can be observed, as from the first very brief notes at the beginning of the period the reports become more detailed and accurate at the end of the century.
... In recent years, the paleopathological study of malaria has been revolutionized by successful applications of immunological and ancient DNA (aDNA) analyses to archaeological specimens. To detect malaria-related proteins, researchers performed the dipstick assay or new-generation immunoassays on ancient mummies [17][18][19] or skeletons [20,21]. The immunological assay became an effective screening method to secure the evidence of ancient malarial infection [5]. ...
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Malaria, one of the deadliest diseases in human history, still infects many people worldwide. Among the species of the genus Plasmodium , P. vivax is commonly found in temperate-zone countries including South Korea. In this article, we first review the history of malarial infection in Korea by means of studies on Joseon documents and the related scientific data on the evolutionary history of P. vivax in Asia. According to the historical records, malarial infection was not unusual in pre-20th-century Korean society. We also found that certain behaviors of the Joseon people might have affected the host-vector-pathogen relationship, which could explain why malarial infection prevalence was so high in Korea at that time. In our review of genetic studies on P. vivax , we identified substantial geographic differentiation among continents and even between neighboring countries. Based on these, we were able to formulate a strategy for future analysis of ancient Plasmodium strains in Korea.
... Approximately 92% of the positive cases revealed signs of chronic anemia (see above). Later studies in an Early Dynastic mummy (12) and Renaissance period European skeletal remains (from the famous de' Medici family) confirmed positive results (13,14). Accordingly, several members of the de' Medici family had malaria, as evidenced by a positive immunological reaction. ...
Paleopathology and Paleomicrobiology of Malaria, Page 1 of 2 Abstract Malaria, one of the deadliest diseases of humankind, remains a major global health problem in the 21st century ( 1 , 2 ). In 2014, 198 million persons were infected, with more than 0.5 million deaths from malaria globally. Malaria is recognized as the second leading cause of death from infectious diseases in Africa, after HIV/AIDS, and is the fifth most frequent cause of death from infectious diseases worldwide, after respiratory infections, HIV/AIDS, diarrheal diseases, and tuberculosis ( 2 ).
... The affluence of the Medici likely played a role in the lack of parasitism (Morrow et al., 2013); however, a variety of taphonomic factors may have prevented the preservation of parasites. Interestingly, even their affluence did not spare them from malaria (Fornaciari et al., 2010). It is noteworthy that even monarchs were parasitized by common parasites . ...
Archaeoparasitological analyses of human remains can present interpretative challenges arising from diverse preservation environments. Three archaeoparasitological studies are used to demonstrate the impacts of five major types of taphonomic factors on parasite egg preservation. In the first case, an analysis of a historic Lithuanian mummy revealed infections with Trichuris trichiura and Ascaris lumbricoides and illustrates taphonomic issues unique to mummies. The second case involved the analysis of coprolites collected from medieval burials in Nivelles, Belgium. One burial demonstrated a high concentration of T. trichiura eggs (approximately 1,577,679 total eggs) and A. lumbricoides eggs (approximately 202,350 total eggs). Preservation was affected mostly by water percolation with differential preservation of eggs based on morphological characteristics. The third case is based on material from embalming jars of the Medici family. No parasite eggs were recovered; however, an abundance of mites and dipteran puparia were encountered, suggesting that arthropods may play a larger role in parasite egg preservation than previously supposed. Differential parasite egg preservation is discussed in light of variances in five major types of taphonomic factors: abiotic, contextual, anthropogenic, organismal, and ecological. Accounting for these factors is a vital component in the interpretation of archaeoparasitological data and should be included in future archaeoparasitological reports.
... Francesco died on 19 October and Bianca followed a few hours later [8]. Recent analyses suggested they might have been poisoned with arsenic by Cardinal Ferdinando, Francesco's younger brother and potential successor [9], but later investigations have confirmed P. falsiparum as the cause of their deaths [10]. Malaria was then endemic in Tuscany, and today by World Health Organization's calculation, there are at least 219 million cases and 660 000 deaths per year globally [11] though this may be a considerable underestimate [12]. ...
... The authors used gut tissue from unembalmed, desiccated mummies that were >3000 years old from the site of Camarones in the Atacama Desert near Arica, northern Chile, as a negative control (32). Recently, P. falciparum was detected using qualitativedouble antibody immunoassays to analyze the skeletons of four members of the Medici family from 16th century Italy (38,49). In our laboratory, we now use ELISA to detect Y. pestis in dental pulp collected from plague victims from Venice, Italy, (14th to 16th centuries) and Poitiers, France, (16th to 18th centuries); dental pulp collected from 10 individuals without evidence of infection was used as a negative control (D. ...
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Identifying the causes of past epidemics depends on the specific detection of pathogens in buried individuals; this field of research is known as paleomicrobiology, an emerging field that has benefited from technological advances in microbiology. For almost 15 years, the detection, identification, and characterization of microbes in ancient environmental and human specimens emerged on the basis of ancient DNA (aDNA) analyses. aDNA limitations due to potential contamination by modern DNA and altered aDNA led to the development of alternative methods for the detection and characterization of nonnucleotidic biomolecules, including mycolic acids (of ancient mycobacteria) and proteins. Accordingly, immunohistochemistry, immunochromatography, and enzyme-linked immunosorbent assay techniques have been developed for the specific detection of microbes from ancient human and environmental specimens. Protein analysis by mass spectrometry, a standard for ancient animal identification, has also recently emerged as a technique for ancient mycobacteria detection, while immuno-PCR is yet another promising technique. As with aDNA, strict protocols must be enforced to ensure authenticity of the data. Here we review the analysis of nonnucleotidic biomolecules from ancient microbes and the ability of these analyses to complement aDNA analyses, which opens new opportunities for identification of ancient microbes as well as new avenues to potentially resolve controversies regarding the cause of some historical pandemics and study the coevolution of microbes and hosts.
The use of paleomicrobiological techniques in leprosy has the potential to assist paleopathologists in many important aspects of their studies on the bones of victims, solving at times diagnostic problems. With Mycobacterium leprae, because of the unique nature of the organism, these techniques can help solve problems of differential diagnosis. In cases of co-infection with Mycobacterium tuberculosis, they can also suggest a cause of death and possibly even trace the migratory patterns of people in antiquity, as well as explain changes in the rates and level of infection within populations in antiquity.
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Paleoparasitological research has made important contributions to the understanding of parasite evolution and ecology. Although parasitic protozoa exhibit a worldwide distribution, recovering these organisms from an archaeological context is still exceptional and relies on the availability and distribution of evidence, the ecology of infectious diseases and adequate detection techniques. Here, we present a review of the findings related to protozoa in ancient remains, with an emphasis on their geographical distribution in the past and the methodologies used for their retrieval. The development of more sensitive detection methods has increased the number of identified parasitic species, promising interesting insights from research in the future.
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Modern analytical techniques have allowed re-evaluation of the cause of death of Francesco I de' Medici and his wife, Bianca Cappello. It now seems that the grand-ducal couple died of acute arsenic poisoning and not malaria as previously believed
A 15–18 months old child mummy, presently housed in Turin's Museum of Anthropology, was discovered in Gebelein (Upper Egypt) during excavations carried out by the Missione Archeologica Italiana, most likely in 1914.Atomic Mass Spectrometry radiocarbon dating indicated that the mummy belongs to the end of the Early Dynastic Period – beginning of the Old Kingdom.Whole body spiral CT scan and 3D reconstructions did not show evidence of congenital malformations or fractures.Immunochromatographic and immunohistochemical analyses on skin and muscle samples were positive for Plasmodium falciparum malaria and for Plasmodium spp. malaria.Our data provide clear evidence for the presence of P. falciparum infection in the sample we examined and show the usefulness of the immunological investigations for the detection of malaria in ancient human remains.
Medici di Cafaggiolo: saggio di ricerche sulla trasmissione ereditaria dei caratteri biologici. Firenze: Nardini Editore
  • G Pieraccini
  • La
  • De
Pieraccini G. La stirpe de' Medici di Cafaggiolo: saggio di ricerche sulla trasmissione ereditaria dei caratteri biologici. Firenze: Nardini Editore; 1986.
Della morte di Francesco I de' Medici e di Bianca Cappello. Archivio storico italiano, Nuova serie
  • G E Saltini
Saltini GE. Della morte di Francesco I de' Medici e di Bianca Cappello. Archivio storico italiano, Nuova serie. 1863;XVIII:21-81.
The role of laboratory diagnosis to support malaria disease management. Focus on the use of rapid diagnostic tests in areas of high transmission. Report of WHO Technical Consultation
  • Health World
  • Organization
World Health Organization. The role of laboratory diagnosis to support malaria disease management. Focus on the use of rapid diagnostic tests in areas of high transmission. Report of WHO Technical Consultation. Geneva 25-26 October 2004;1-32.