A great enigma of the Italian Renaissance: paleopathological study on the death of Giovanni dalle Bande Nere (1498-1526) and historical relevance of a leg amputation.

BACKGROUND: The Medici project consisted in archeological and paleopathological researches on some members of the great dynasty of the Italian Renaissance. The remains of Giovanni de' Medici, so-called "dalle Bande Nere" (Forlì 1498- Mantua 1526) have not been investigated yet. The enigma of the fatal injury and leg amputation of the famous Captain excited curiosity of paleopathologists, medical scientists and Italian Society of Orthopedic and Traumatology which contributed to realize the project of exhumation and study of his skeletal remains. The aim of the study is to report the first anthropological and paleopathological results. CASE PRESENTATION: The tomb of Giovanni and his wife Maria Salviati was explored and the skeletal remains were investigated. Anthropological and paleopathological examination defined: age at death, physical constitution and activity, skeletal diseases. The bones of the leg were studied macroscopically, under stereoscopic microscope, at X-ray and CT scans to detect type of injury and level of amputation. CONCLUSIONS: The skeleton and muscular insertions of Giovanni revealed a young-adult and vigorous man, subjected to stresses of military activity since adolescence. Right tibia was amputated below the proximal half of diaphysis leaving long tibio-fibular stumps with a horizontal cut only at the lateral portion. Thus, the surgeon limited to complete the traumatic hemi-amputation. Amputation in the Sixteenth Century technically consisted in guillotine incisions below the knee using crescent shaped knife and bony saw, usually leaving a quite long tibial stump. Amputations in the Sixteenth Century were contaminated and grossly performed not providing vascular binding nor wound closure. The surgeon performed the procedure in conformity with surgical knowledge of that period.

History of lower limb reconstruction after trauma.

BACKGROUND: The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important. METHODS: This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time. RESULTS: Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%. CONCLUSIONS: Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.

[Rendering surgical care for the wounded presenting with injuries to limb vessels].

The proffered paper provides the information about rendering surgical care for the wounded presenting with vascular injuries inflicted and sustained during wars Russia was engaged in, to be followed by a detailed description of the haemorrhage-arresting methods and techniques used in N. I. Pirogov's time, during World War I, the Great Patriotic War, as well as in local military conflicts and combat operations. Also depicted herein is the role surgeons of Russia have played in the development of vascular surgery, and, finally, due coverage is given to the statistical data concerning the methods of rendering care for those having suffered firearm wounds and injuries involving vascular lesions.

Military lower extremity amputee rehabilitation.

The role of the military has changed over the past eight decades. Although the threat of global warfare still exists, the military of today faces new challenges as a peacekeeper in countries under turmoil. Despite these changes, the fear of bodily injury, such as limb loss and even the possibility of death, are real concerns for our active duty personnel. The military physician must be aware of the appropriate surgical, rehabilitative, and psychosocial needs of the lower extremity traumatic amputee. The physical medicine and rehabilitation specialist is a physician particularly suited to provide direction for and to oversee the overall care of the amputee's condition. An amputee center providing a multidisciplinary team approach has worked well for the military during war and peacetimes. The physical medicine and rehabilitation inpatient service at WRAMC continues the tradition and philosophy of the military amputee centers dating back to WWI. By growing with the fast-paced technologic advances in prosthetic devices, yet keeping true to the fundamentals of prosthetic prescription and design, physical medicine and rehabilitation in the military has remained at the forefront of amputee rehabilitation. Patient satisfaction with the rehabilitation process and his or her new artificial limb remain priorities whether the goal is to return to active duty or to resume an active lifestyle in the civilian world.

The brain tumor of George Gershwin and the legs of Cole Porter.

George Gershwin died in 1937 of a glioblastoma of the right temporal lobe. He had been in psychoanalytical care for some time and was hospitalized a few weeks before his death, when he was thought to have a functional illness. The controversies about George Gershwin's death, duration of neurologic symptoms, and problems in diagnosis are discussed. Cole Porter fell off a horse he was riding in 1937 and sustained multiple open fractures of both legs. There probably was some nerve injury in the right leg, at least, from this fall. Despite intensive pain, many hospitalizations, and 33 operations on his legs, Porter continued to write music and lyrics until his amputation in 1958. After the amputation, all creative activities ceased. The explanations for this are discussed.

Flaps and grafts revisited: cross-leg and thigh flaps for lower extremity wounds.

Soft tissue reconstruction of the lower extremity has evolved considerably over the last 25 years. We no longer have to rely only on awkward pedicle flaps, or ultimately, amputation in order to heal a leg wound. The following is a brief history of the flaps prior to the development and use of the operating microscope and an increased knowledge of the circulation distal to the knee.

'A leg to stand on': an existential-phenomenological analysis.

The analysis of a paradigm-case (a person with an injured leg, an autobiographical history related by Dr Sacks) presented here is an illustration of how existential-phenomenological analysis can be done. The aim of existential-phenomenological research is to analyse and to describe some dimensions of being. The person with an injured leg appears 'to bescotomized'. Well then, 'being-scotomized' can be analysed and described as a particular mode of 'being', even as a particular mode of 'being-ill'. 'Being' has been studied (in the philosophical tradition of Husserl, Heidegger, Merleau-Ponty and Sartre) as that existential movement that brings an individual, the 'self', towards the world, meanwhile 'affecting' the personal body, personal time and space, the objects in a person's life-world, the individual's life-world and, finally, coexistence. The study of 'being-ill' is the study of the particular way the self, the body, time and space, the objects, the life-world, and coexistence are affected when being-ill. 'Being-scotomized' may appear as affecting: (i) the self, isolating the subject and leading to a personal disintegration; (ii) the body to which he maintains an ambiguous relationship: being a body and having a body, and not having a part of the body any more; (iii) time and space being vanished with the vanished leg. The subject is 'at' a nowhereness and 'at' a motionless time; there is no meaningful future; (iv) the things in the person's life-world, to which it appears impossible to give the 'right' sense; (v) the life-world, revealing itself as a noland, characterized by silence and motionlessness; (vi) the others in this life-world that appears no-man's-land, uninhabitable nearly by definition. Coexistence reveals not to be possible.

A yellow-stained human femur from Tell esh-Shuqafiya, Egypt: evidence of ancient trauma.

Excavation at Tell esh-Shuqafiya, Egypt, during the 1982 season exposed several Ptolemaic Period burials. One of these, a young adult male, showed a bright yellow stain on the right femur. Analysis of the stain demonstrated it to be hematoidin, a degradation compound derived from hemoglobin associated with old hemorrhage. The specific location of the stain on the skeleton suggests death a few weeks after a severe injury to the thigh.

A historical perspective of injuries in professional football. Twenty-six years of game-related events.

A professional football franchise was studied consecutively from 1960 through 1985 for injuries incurred during regular-season games. A "significant" injury was defined as one requiring the player to miss at least two consecutive games (N = 331) and a "major" injury as one that caused the player to miss at least eight games or the equivalent time (N = 130). Significant injuries averaged 0.89 per game and major injuries 0.35 per game for the entire 26 years. Following a high injury rate prior to 1965, significant injury rates were episodic. Major injuries declined (rs = -.68; P less than .01). Since the team's first games on synthetic surfaces in 1968, there was no difference in the rates of significant injuries per game (0.57 vs 0.67) or major injuries per game (0.22 vs 0.33) between games played on grass or artificial turf, respectively. Since 1969 there has been a decline in major knee injuries (rs = -.51; P less than .05) and a decline in major injuries incurred during special-teams play (rs = -.55; P less than .05). The data indicate that this team suffered fewer injuries with the passing of time, primarily in injuries that caused a player to miss at least eight consecutive games. Observations of short duration do not lend themselves to current media perception that injury rates are higher and more serious today in professional football.