Surgical amputation of a limb 31,000 years ago in Borneo.

The prevailing view regarding the evolution of medicine is that the emergence of settled agricultural societies around 10,000 years ago (the Neolithic Revolution) gave rise to a host of health problems that had previously been unknown among non-sedentary foraging populations, stimulating the first major innovations in prehistoric medical practices1,2. Such changes included the development of more advanced surgical procedures, with the oldest known indication of an 'operation' formerly thought to have consisted of the skeletal remains of a European Neolithic farmer (found in Buthiers-Boulancourt, France) whose left forearm had been surgically removed and then partially healed3. Dating to around 7,000 years ago, this accepted case of amputation would have required comprehensive knowledge of human anatomy and considerable technical skill, and has thus been viewed as the earliest evidence of a complex medical act3. Here, however, we report the discovery of skeletal remains of a young individual from Borneo who had the distal third of their left lower leg surgically amputated, probably as a child, at least 31,000 years ago. The individual survived the procedure and lived for another 6-9 years, before their remains were intentionally buried in Liang Tebo cave, which is located in East Kalimantan, Indonesian Borneo, in a limestone karst area that contains some of the world's earliest dated rock art4. This unexpectedly early evidence of a successful limb amputation suggests that at least some modern human foraging groups in tropical Asia had developed sophisticated medical knowledge and skills long before the Neolithic farming transition.

On some paleopathological examples of amputation and the implications for healthcare in 13th-17th century Lithuania.

OBJECTIVE: To explore care that was likely provided to an adult male amputee from medieval Lithuania, positioning analysis within what is known of contemporary amputation practices. MATERIALS: Three sets of skeletal remains with evidence for amputation, dating to between the 13th-17th centuries AD and recovered during different archaeological excavations in Vilnius, Lithuania. METHODS: Macroscopic inspection of lesions, with additional X-ray analysis of the main subject. The Index of Care was used to investigate possible caregiving. RESULTS: Two individuals experienced amputation of a single element, and the third experienced bilateral hand amputation. Only one individual displayed healing. Historic sources suggest use of amputation for punitive purposes during this period, and judicial punishment is proposed as the most likely reason for amputation in at least two cases. CONCLUSIONS: Evidence of long-term healing in one individual suggests receipt of care. This individual likely relied on family and/or community members for survival immediately following amputation, and subsequently for support in managing disability. SIGNIFICANCE: Successfully combining osteology with history in a framework for analyzing care provision in past Eastern European society, this study underlines the critical importance of context in undertaking bioarchaeology of care analyses. It also adds two examples of perimortem abscissions in this region to the paleopathological record. LIMITATIONS: Our approach relied on skeletal interpretation. Soft tissue was lost to decomposition and no relevant archaeological evidence was found in association with the remains. SUGGESTIONS FOR FURTHER RESEARCH: A review of skeletal collections may allow identification of overlooked cases of amputation (and care).

National and State-Level Trends in Nontraumatic Lower-Extremity Amputation Among U.S. Medicare Beneficiaries With Diabetes, 2000-2017.

OBJECTIVE: Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. RESEARCH DESIGN AND METHODS: To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], or above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. RESULTS: NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, P < 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P < 0.01). Trends were similar across most age, sex, and race/ethnic groups, but absolute rates were highest in the oldest age-groups, Blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates. CONCLUSIONS: This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (<65 years) in the general population. Preventive foot care has been shown to reduce rates of NLEA among adults with diabetes, and the findings of the study suggest that those with diabetes-across the age spectrum-could benefit from increased attention to this strategy.

Jean Dominique Larrey and his recognition in Mexico.

The figure of Jean Dominique Larrey, military surgeon who participated in the Napoleonic wars, is analyzed. The objectives of the study are to highlight their contributions, including the creation of ambulances that allowed the injured to be given prompt assistance. Also note the post-mortem recognition that Larrey had in Mexico through an academic group founded by the surgeon Francisco Montes de Oca y Saucedo. The facts cited show the progress of military surgery, its institutionalization and professionalization as well as the communication and updating of knowledge in one and another continent.

Se analiza la figura de Jean Dominique Larrey, cirujano militar que participó en las guerras napoleónicas. Los objetivos de estudio consisten en destacar sus aportaciones, entre ellas la creación de las ambulancias que permitieron dar una pronta asistencia al herido. Asimismo, señalar el reconocimiento post mortem que Larrey tuvo en México a través de una agrupación académica fundada por el cirujano Francisco Montes de Oca y Saucedo. Los hechos citados muestran el progreso de la cirugía militar, su institucionalización y profesionalización, así como la comunicación y la actualización de saberes en uno y otro continente.

In Close Combat: Vice-Admiral Lord Horatio Nelson's Injuries in the Napoleonic Wars.

Born in Norfolk, England, on September 29, 1758, Horatio Nelson was the sixth of eleven children in a working-class family. With the help of his uncle, Maurice Suckling, a captain in the Royal Navy, Nelson began his naval career as a 13-year-old midshipman on the British battleship Raisonnable. His courage and leadership in the battle marked him for promotion, and he rose quickly from midshipman to admiral, serving in the West Indies, East Indies, North America, Europe, and even the Arctic. As his rank ascended, Nelson's consistent strategy was close engagement, an approach that led to success in combat but placed him in direct danger. Thus, Britain's greatest warrior was also her most famous patient: Nelson suffered more injuries and underwent more operations than any other flag officer in Royal Navy history. His career reached a climax off Cape Trafalgar, where he not only led the Royal Navy to victory over the combined French and Spanish fleets but also met his own death.

Hallmarks of amputation surgery.

PURPOSE: To highlight the most important innovations and milestones in the historical evolution of amputation and disarticulation surgery through the ages, from the early antiquity until the modern era. METHOD: A thorough search of the literature was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize current and classic literature on the hallmarks of the history of amputation surgery in the course of medical history. RESULTS: Amputation of a limb is one of the oldest surgical procedures. Initially, it was fraught with complications and dismal outcome of the patients because of hemorrhage and infection. Due to lack of analgesics and narcotics the operation had to take only a few minutes. Obtaining experience, the surgeons evolved the operative technique and refined the procedure, anesthesia and perioperative analgesia was introduced, instruments were developed, and rehabilitation has enabled functional and social reintegration of amputees. CONCLUSION: From the Hippocratic era until currently, the surgical approach to amputation has changed little. However, the indications for amputations have changed a lot and had been refined, especially in diabetic patients and in those with severe chronic peripheral vascular disease. An exponential decrease in mortality for an operation once fraught with complications was due to the development of the tourniquet, proper vessel ligation and repair, antisepsis, and anesthesia.

Survival to amputation in pre-antibiotic era: a case study from a Longobard necropolis (6th-8th centuries AD).

The Longobard necropolis of Povegliano Veronese dates from the 6th to the 8th centuries AD. Among the 164 tombs excavated, the skeleton of an older male shows a well-healed amputated right forearm. The orientation of the forearm fracture suggests an angled cut by a single blow. Reasons why a forearm might be amputated include combat, medical intervention, and judicial punishment. As with other amputation cases reported in literature, this one exhibits both healing and osteoblastic response. We argue that the forelimb stump morphology suggests the use of a prosthesis. Moreover, dental modification of RI2 shows considerable wear and smoothing of the occlusal surface, which points to dental use in attaching the prosthesis to the limb. Other indications of how this individual adjusted to his amputated condition includes a slight change in the orientation of the right glenoid fossa surface, and thinning of right humeral cortical bone. This is a remarkable example in which an older male survived the loss of a forelimb in pre-antibiotic era. We link archaeological remains found in the tomb (buckle and knife) with the biological evidence to show how a combined bioarchaeological approach can provide a clearer interpretation of the life history of an individual.

Wilhelm Fabricius von Hilden (1560-1634): The Pioneer of German Surgery.

Wilhelm Fabricius von Hilden (1560-1634) or also known with his Latinized name Guilielmus Fabricius Hildanus is considered the founder of scientific German surgery. He introduced new surgical techniques and invented new surgical instruments for the surgical treatment of nasal polyps, stone bladder, breast and ocular cancer, hydrocele, and ascites, while very ingenious were his amputation techniques. His most important surgical treatise was Observationem et curationem chirurgicam centuriae sex ( Six Hundred Surgical Observations and Treatments) first published in 1606.

Ambroise Paré (1510-1590) and His Innovative Work on the Treatment of War Injuries.

The purpose of this study is to summarize the innovations of Ambroise Paré (1510-1590) on the treatment of war wounds and improving amputation technique through ligature in arteries and veins. Ambroise Paré debunked the widely accepted idea that gun powder was poisonous for wounds. He also minimized the use of cautery of wounds by his dressing methods and the application of ligature during amputations. All these innovative rationales revolutionized the practice of war surgery during the Renaissance and paved the way for the introduction of modern surgery. Nevertheless, although his wound dressing innovations became widely accepted, the same did not happen with ligature and amputation; those techniques could become widely applicable if one could somehow control bleeding until the blood vessels had been tied. This became possible much later in the 18th century when Jean Louis Petit invented the first useful and efficient tourniquet.

Three cases of feet and hand amputation from Medieval Estremoz, Portugal.

Peri-mortem limb amputations are rarely reported in the paleopathological literature. The cases reported here concern severing of both hands and feet observed in three adult male skeletons, exhumed from the medieval Portuguese necropolis of Rossio do Marquês de Pombal, Estremoz, Portugal. The fact that they were found in the same site, in graves placed side by side, that all are young males, and that the three skeletons show similar perimortem injuries, make this a unique case meriting detailed analysis. Considering the lesions' location and pattern, as well as historical data, we hypothesize that this is a case of amputation as a consequence of judicial punishment. Estremoz was an important city in sustaining the Royal power at a regional scale during the medieval period.

[The injured of the summer of 1914 and their stories]. / Les blessés de l'été 14 et le roman.

The situation of the French Military Health Service was particularly precarious at the beginning of the Great War. Contemporary novelists wished to expose the lies of propaganda and described without any complacency the disorganisation, the improvisation and the mistakes of the first weeks of the conflict. In this context they show the initiatives taken by civilians, especially the ladies from the aristocracy, to help the wounded. From the battlefield to the hospitals they describe the stations of the cross of the soldiers, those hoping for "la bonne blessure" and those who end up being amputated when alternatives could have been possible.

The Torments of Spring: Jake Barnes's Phantom Limb in The Sun Also Rises.

While critics recently have found The Sun Also Rises a fruitful text for reexamining issues of gender and sexuality in Hemingway's work, a significant aspect of Jake Barnes's genital wounding has been overlooked. At least from the time of the American Civil War, a diverse body of medical literature has documented the psychosomatic reality of phantom genitalia in traumatically injured men. Revisiting the novel from this perspective-imagining that Jake Barnes is haunted by a penile ghost-allows us to see this character as something more than a victim of disability. Instead, we might think of Jake's material self as figuratively masculine but accidentally transgendered: a body that others can desire and that still can choose, or not, to reciprocate sexual feeling.

Paul Wittgenstein's right arm and his phantom: the saga of a famous concert pianist and his amputation.

Reports of postamputation pain and problems linked to phantom limbs have increased in recent years, particularly in relation to war-related amputations. These problems are still poorly understood and are considered rather mysterious, and they are difficult to treat. In addition, they may shed light on brain physiology and neuropsychology. Functional neuroimaging techniques now enable us to better understand their pathophysiology and to consider new rehabilitation techniques. Several artists have suffered from postamputation complications and this has influenced not only their personal life but also their artistic work. Paul Wittgenstein (1887-1961), a pianist whose right arm was amputated during the First World War, became a famous left-handed concert performer. His case provides insight into Post-World War I musical and political history. More specifically, the impact on the artistic life of this pianist illustrates various postamputation complications, such as phantom limb, stump pain, and especially moving phantom. The phantom movements of his right hand helped him develop the dexterity of his left hand. Wittgenstein played piano works that were written especially for him (the most famous being Ravel's Concerto for the Left Hand) and composed some of his own. Additionally, several famous composers had previously written for the left hand.