1. Unraveling the death of Cangrande della Scala,
Prince of Verona in the XIV century
Prof. Franco Tagliaro
Director and Chair
Unit of Forensic Medicine
Department of Diagnostics and Public Health
University of Verona, Verona, Italy

2. Historical Background
Cangrande della Scala ruled Verona from 1311 to 1329, being celebrated as conqueror and patron of the arts.
Cangrande’s life is a typical Italian Medieval story, when the most important ciries tried to keep their independence by joining in alternative with the Emperor of the Sacred Roman Empire (Party of «Ghibellini») or with the Pope (Party of «Guelfi»)
Enrico VII of Luxembourg
Emperor of the Sacred Roman Empire
Pope Clemente V

3. Historical Background
1259 A.D.
Death of Ezzelino da Romano
Ezzelino, Lord of Marca Trevigiana, appointed by the Emperor Federico II «imperial vicar of italy», ruled Verona from 1223 to his death, which occurred in 1259.
1262 A.D.
Mastino della Scala is elected by the citizens of Verona «Capitano del Popolo» . He rules Verona until 1277 when he is killed in the frame of a cospiracy.
1277 A.D.
Alberto I della Scala, the brother of Mastino, becomes Lord of Verona. In 1263 he had got married Verde di Salizzole from which he had 6 children, among which, Bartolomeo, Alboino and Cangrande

4. Historical Background
1301 A.D.
Death of Alberto I della Scala
His oldest son Bartolomeo becomes Lord of Verona
1304 A.D.
Death of Bartolomeo della Scala
His oldest brother Alboino becomes Lord of Verona.
Cangrande, even if very young, had high inclination for the arms and partecipated to all the military campaigns carried out by Alboino to expand the Verona dominion in the frame of the war between the Ghibellino party and the Guelfo party.
1308 A.D.
Cangrande marries Giovanna di Svevia (nephew of Federico II) and is appointed by Alboino Lord of Verona with him.
1311 A.D.
Enrico VII, emperor of Sacred Roman Empire, appointed Alboino and Cangrande «imperial vicarious of Verona».

5. Historical Background
November A.D.
Death of Alboino della Scala
Cangrande becomes the sole Lord of Verona.
In the following years, always mantanining his loyalty to the emperor, he expands, through numerous military campaigns, the dominion of Verona.
He firstly brings under his control the city of Vicenza (1314) and, after several
years of intermittent and brutal conflicts he takes possession of Padua (1328) and Treviso (1329).
Just before to die (July ) he is lord of Verona, Vicenza, Padova, Treviso, Belluno, Feltre, Monselice, Bassano, Imperial Vicar of Mantova and Leader of Ghibellino Party in Italy.
Della Scala dominion in 1336

6. Cangrande and Dante
Cangrande hosted many artists, among which the poet Dante Alighieri, who stayed in Verona from 1312 to 1318 composing the most part of “Paradiso”, which was dedicated by the poet to Cangrande.
Dante Alighieri
Epistulae
« Magnifico atque victoriosissimo Domino, Domino Kani Grandi de la Scala, sacratissimi Cesarei Principatus in urbe Verona et civitate Vicentie Vicario Generali, devotissimus suus Dantes Alagherii, Florentinus natione non moribus, vitam orat per tempora diuturna felicem, et gloriosi nominis perpetuum incrementum.»
Dante Alighieri
Dedication of Heaven’s Cantica of The Divine Comedy to Cangrande della Scala
« To the magnificent and victoriosus Lord Cangrande della Scala, general vicar of the Sacred Roman Empire in the cities of Verona and Vicenza, his faithful Dante Alighieri, Florentine by birth and no by habits, wishes a longlasting happy life with endless improvement of his name’s glory. » 

7. The death of PRINCE Cangrande
On July Cangrande starts the siege on Treviso
On July The city of Treviso capitulates
On July Cangrande triumphally enters into the city of Treviso.
However, the same day, after he received the homages from his new vassals, becomes seriously ill as a result of vomit and diarrhoea, which he had contracted a few days before by “drinking from a polluted spring”, according to contemporary accounts.
On July , at noon, Cangrande died. He was 38 years old.
As Cangrande had no legitimate sons his titles passed to his nephews Mastino and Alberto della Scala.
The contemporary chronicles describe the death of Cangrande as a NATURAL DEATH caused by drinking to cold water. The historians, through the following centuries, have always accepted this version …

8. The FATE of THE BODY
Just after death, the body of Cangrande was taken out of Treviso at nightfall and drawn on a bier to Verona where it was escorted by the nobles into the city preceded by twelve knights.
The body was temporarily housed in the church of Santa Maria Antiqua, then was moved twice, once to a marble tomb in the church yard and finally to the marble tomb over the church entrance, topped with an equestrian statue of Cangrande

9. The burial remained closed until 1921, when the tomb was inspected by a group of historians. The body was found unexpectedly naturally mummified in a good state of preservation and was left untouched, being the attention focused on garments, artefacts and belongings.

10. In February 2004 Cangrande’s tomb was re-opened with a specific interest in a paleopathological study of the corpse.
Again, after the stone lid of the sarcophagus was raised, the mummified body appeared well preserved still wrapped in precious silk textiles wearing some clothes.

11. The aim of the study was to perform a
multidisciplinary study of the corpse, which included archaeological,
palaeopathological, palynological, toxicological and historical
analyses in order to
to investigate the causes of death of Cangrande.
PARTICIPANTS:
Prof. G. Fornaciari and co-workers,
Archeopathologists
Dr. Gortenuti
Radiologist
Dr. Marvelli and dr. Marchesino
Palinologists
Prof. F. Tagliaro and co-workers
Forensic Toxicologists

12. CAUSE OF DEATH OF CANGRANDE
THE INVESTIGATION OF
CAUSE OF DEATH OF CANGRANDE
As in every forensic case, the investigation was based on the integrated evaluation of data coming from:
- THE CIRCUMSTANCES OF DEATH
- THE MEDICAL HISTORY OF THE SUBJECT
THE RADIOLOGICAL FINDINGS
THE AUTOPSY’S FINDINGS
THE TOXICOLOGICAL FINDINGS

13. THE MEDICAL HISTORY OF CANGRANDE AND THE CIRCUMSTANCES OF DEATH
1315: injury during a battle
1325: “severe illness
at the time of death (1329):
Cangrande was 38 years old in good health
he had drunk water from a spring in the periphery of Treviso
symptoms: abdominal pain, “fluxus ventris” (diarrhea), fever.

14. AUTOPSY’S AND RADIOLOGICAL FINDINGS
Natural mummy
The paleopathological study revelead that Cangrande suffered from mild osteoarthritis of the column, elbows and hips, with a meniscus calcification of the knees, probably related to the strong physical activity of the Prince. The liver was well recognizable. The presence of faeces in the rectal ampulla was observed
No evidences of fractures or traumatic injuries
No evidences of natural pathologies

15. Gastro-intestinal infection Another infectious disease
The integrated evaluation of clinical, circumstancial and pathological data brought to formulate THREE HYPOTHESES:
Gastro-intestinal infection
Another infectious disease
Poisoning or acute intoxication

16. POISONING OR ACUTE INTOXICATION HYPOTHESIS
1. RESEARCH OF ARSENIC (a. most common poison from the Roman times; b. arsenic acute intoxication symptoms resemble that of a gastrointestinal infection).
It was performed by ICP-MS on samples from bone, hair, liver, muscle.
The metal analysis showed no toxic concentration of arsenic or other heavy metals

17. POISONING OR ACUTE INTOXICATION HYPOTHESIS
2. RESEARCH OF HERBAL POISONS IN HAIR EXCRACT (opium, cannabis components) (these drugs and their effects were known in the Middle Age)
Immunochemical, chromatographic and electrophoretic analyses ruled out the presence of morphine and cannabinoids

18. The presence of harman in hair was also confirmed by HPLC-QTOF
… HOWEVER
a capillary electrophoresis screening with diode array UV detection of hair showed a peak with an electrophoretic mobility and a UV spectrum compatible with harman, an indolic alkaloid contained in passion flower.
The presence of harman in hair was also confirmed by HPLC-QTOF

19. HPLC-TOF CHROMATOGRAM OF HAIR EXTRACT
HARMAN
Exact mass:
MS SPECTRUM OF THE PEAK AT t which shows an exact mass of
HPLC-TOF CHROMATOGRAM OF HAIR EXTRACT
Administration of herbal therapeutic preparation from passion flower, traditional sedative remedy

20. … MOREOVER
By using HPLC-Ion Trap in the hair of the mummy also santonin, a compound contained in Artemisia Maritima, was detected.
The data were confirmed by HPLC-QTOF
administration of herbal therapeutic preparation from artemisia, traditional remedy against intestinal parasitic worms

21. … HOWEVER
notwithstanding some pharmacological activity, neither harman nor santonin display a significant toxicity …
IMMUNOCHEMICAL ANALYSES OF FAECES AND LIVER EXCTRATS TO INVESTIGATE THE PRESENCE OD DIGITALIS GLYCOSIDES
DIGITOXIN
DIGOXIN

22. ANALYTICAL METHODS
Samples of liver and faeces were pulverised and rehydrated with distilled water in a proportion of 50:50. After 24 h, the samples were submitted to ultrasonication for 3 min and then centrifuged.
DIGOXIN analysis:
Digoxin Immulite (Diagnostic Products Corporation, Los Angeles, CA, USA)
Digoxin Tina-Quant®, Roche Diagnostic, Mannheim, Germany) Digoxin AssayEmit® 2000, SyvaCompany, Dade Behring Inc., Cupertino, CA, USA).
DIGITOXIN analysis:
Immulite/Immulite® 1000 (Diagnostic Products Corporation, Los Angeles, CA, USA).

23. DEGRADATION OVER THE CENTURIES
RESULTS
Digoxin-DPC
Digoxin Roche
Digoxin Syva
Digitoxin-DPC
Liver (ng/g)
14.0
5.6
16.8
62.4
Faeces (ng/g
15.6
7.2
11.2
41.6
No MS confirmation because of the low concentrations of the analytes
Lethal plasmatic level of
Digoxin: 15 ng/ml
Digitoxin: 320 ng/ml
Lethal hepatic level of Digoxin: 22 ng/g
DEGRADATION OVER THE CENTURIES

24. Palynological analyses
In the left hemi-abdomen (524 pollen grains/g) 2 taxa , Matricaria chamomilla (83,3%) and Morus nigra (black mulberry (16,7% were found. In the rectum (863 pollen grains/g) large amounts of Matricaria chamomilla and few pollen grains of Digitalis were identified (11,1%)
Pollen of Digitalis
Pollen of Chamomilla
The palynological spectra showed the intake of vegetal components by the Prince in the last moments of his life.
In particular, they showed the ingestion of foxglove leaves and flowers.

25. Digitalis acute intoxication
Symptoms: vomiting and diarrhoea with acute pain
(“fluxus ventris”, “fluxu obiit”, “corporeus fluxus stomachique dolor acutus”); sometimes there is reference to fever (“fluxum et febrem continuam ob laborem exercitus”)
Toxicological analyses: identification of high concentration of Digitoxin and Digoxin.
Palynological analysis: few pollen grains of Digitalis
Digitalis acute intoxication

26. INTENTIONAL POISONING?
CONCLUSIONS 1.
The death of Prince Cangrande can be ascribed to acute intoxication with a preparation from Digitalis.
THERAPEUTICAL ATTEMPT ENDED UNSUCCESSFULLY?
INTENTIONAL POISONING?

27. CONCLUSIONS 2. THERAPEUTICAL ATTEMPT ENDED UNSUCCESSFULLY
the cardioactive effects of Digitalis were discovered only in the 18th century by William Withering.
the fine dosage of Digitalis required for achieving a therapeutic result conflicts with the limited pharmaceutical technology available in the 14th century.
accidental ingestion of a vegetal mixture including
flowers and leaves of Digitalis
Ingestion could be occurred as a result of an erroneous identification
of leaves, not always easy to distinguish from those of other
edible plants. May be the leaves could be present in decoction containing also chamomilla an morus nigra
…. or …

28. CONCLUSIONS 3.
3. INTENTIONAL POISONING
the toxicity of the plant was probably known in ancient times (Witches' Gloves and Dead Men's Fingers).
At the time of death Prince Cangrande was at the apex of his military success, after the conquest of Treviso, possibly seen as a direct menace to Venice (40 km far from Treviso).
Some details about poisoning of Cangrande are reported in the
15th century by a Treviso chronicler (Anonimo foscariniano), who
claims that the physician accused of poisoning had been imprisoned and hung after the confession….

29. … FOR MORE DETAILS

30. Thank you Aknowledgements
Prof. P. Apostoli, Institute of Hygiene, Epidemiology and Public Health, University of Brescia.
Dr. Silvia Martinucci, Dept. of pharmacokinetic and metabolism, GSK, Verona.
Thank you