Expert answer:biomedical engineering
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DEPARTMENT OF MEDICAL HISTORY
Department of medical history
Ancient Egyptian prosthesis of the big toe
Andreas G Nerlich, Albert Zink, Ulrike Szeimies, Hjalmar G Hagedorn
Introduction
The mummy
Up to now, there has been mainly indirect evidence from
written sources that the ancient Egyptians practised
surgery, and none that their medical treatments also
included therapeutic replacement of amputated limbs
with prostheses. Medical papyri describe treatment of
traumatic lesions, but fail specifically to mention the use
of surgery. However, findings such as an externally treated
fracture of the forearm with wooden splints1 and a 19th
dynasty bone (circa 2100 BC) from a presumably posttraumatic amputation of the forearm with subsequent
distal synostotic fusion of radius and ulna,2 do imply that
surgical treatment took place in ancient Egypt.
Furthermore, a new report3 of a skull with a large posttraumatic osseous defect and missing fracture fragment,
but intact internal (dura mater) and external (skin) soft
tissue layers, argues in favour of some kind of surgical
removal of that fragment. During our palaeopathological
survey of human remains in the necropolis of ThebesWest, the large cemetery of the capital of ancient Egypt
during the New Kingdom and subsequent periods (about
1550–700 BC), we discovered an Egyptian mummy with
an intravital amputation of the big toe.
In the additional chamber, we found the fragmented, but
otherwise well-preserved mummy of a woman (figure 1).
The corpse had been broken into several parts, so that the
skull, abdominothoracic torso, right thigh, both shins, and
both arms were separate, but could easily be reassembled.
All parts of the mummy were extensively wrapped in linen
bindings and only the embalmed left thigh and both hands
were missing. The torso, probably because of grave
robberies, was ventrally disrupted and fragmented. Most
of the internal organs were missing and whether their
absence was due to the embalming process or to
disruption during plundering is unclear. However, a
12 cm segment of aorta, found immediately above the
vertebral column, could be anatomically identified.
Anthropological investigation of cranial sutures of the
skull and symphyseal pubis morphology indicated that the
mummy was a 50–60-year-old woman.5 Age of the
mummy at death was confirmed by histological
examination of incremental lines of the dental cement of a
tooth,6 which showed her to be 50–55 years old. The
woman was about 169 cm tall, calculated from the length
of her long bones.7
A subsequent extensive palaeopathological examination
showed that the big toe of the right foot had been
amputated. The toe had been removed during her
lifetime, because the amputation site was covered by an
intact layer of soft tissue, including skin (figure 2, A). The
missing toe had been replaced by a wooden prosthesis
(figure 2, B), painted dark brown and made up of three
separate components. The main component consisted of a
longitudinal wooden corpus (12⫻3·5⫻3·5 cm) and
replaced the toe. This corpus was attached to two small
wooden plates (together about 4⫻2·5⫻0·3 cm). These
plates were fixed to each other by seven leather strings. All
wooden parts were delicately manufactured and the major
corpus of the prosthesis perfectly shaped like a big toe,
even including the nail. A broad textile lace was fixed to
the small plates and to the prosthetic corpus, which was
tied around the forefoot (see figure 2, B), fixing the toe
firmly in place. This construction provided sufficient
stability to keep the prosthesis in the correct position, and
allow the user to move without major restrictions. Careful
inspection revealed clear marks of use on the sole of the
prosthetic toe (figure 2, C).
Further examination of the forefoot by macroscopy,
plain radiology, and computed tomograms (CT) showed
that the first metatarsal bone was somewhat
demineralised, and that extensive osteophytic osseous
overgrowth of the amputation end had taken place (figure
2, D). By contrast, the other metatarsals, as well as the
digits, were shaped and mineralised regularly, and did not
show pathological features. However, CTs of the
mummified soft tissues revealed small peripheral arterial
cross-sections with irregular and focal calcifications of the
small arterial walls, suggesting segmental or focal
peripheral arteriosclerosis (figure 3, A). The aortic
segment, found in the mummy’s abdomen, revealed an
The Thebes-West tomb
During an excavation campaign at the necropolis of
Thebes-West (Sheik-Abd-el-Gurna), by the German
Institute of Archaeology, Cairo, and the Supreme Council
of Antiquities in Egypt, we investigated the human
remains of burial chamber TT-95, one of the tombs of the
nobles. This tomb was built during the 18th dynasty
(circa 1550–1300 BC) by a high royal official and,
according to archaeological findings, was originally used
by members of his family. However, in subsequent
periods, the tomb complex was reused as a burial place by
others. This practice holds particularly true for an
additional burial chamber located at the end of a shaft
originating from the transverse hall of the burial chapel.
The room was built in the third intermediate period (circa
1065–650 BC) and the presence of cartonnage and coffin
fragments (yellow type coffins), and funerary pottery,
typical of the 21st and 22nd dynasty (circa 1065–740
BC),4 suggests that it was used during that period. Lack of
funerary material from later periods excludes its
subsequent use. Therefore, the remains of several
individuals found in the chamber were archaeologically
dated to the early third intermediate period (21st/22nd
dynasty).
Lancet 2000; 356: 2176–79
Departments of Pathology (Prof A G Nerlich MD, A Zink PhD,
H G Hagedorn MD), and Diagnostic Radiology (U Szeimies MD),
Ludwig-Maximilians-University Munich, D 80337 München,
Germany
Correspondence to: Prof A G Nerlich
(e-mail: Andreas.Nerlich@lrz.uni-muenchen.de)
2176
THE LANCET • Vol 356 • December 23/30, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
DEPARTMENT OF MEDICAL HISTORY
Figure 2: Views of right foot and prosthesis
A, well-healed amputation area covered by intact layer of skin. B, wellcrafted wooden prosthesis, attached to the forefoot by a textile lace.
C, basal surface of prosthesis showing abrasion of the wooden surface
and several scratch marks indicating intravital use. D, radiograph showing
bony overgrowth of the first metatarsal indicating longstanding intravital
amputation of the big toe. Note the enhanced demineralisation of the first
metatarsal.
Figure 1: A complete overview of the mummy after
reconstruction
and indicated severe calcifying arteriosclerosis of the aorta
(macroangiopathy).
Further inspection of the mummy revealed, on several
cross-sections through the bones, slight mineral
deficiency (mild osteopenia) which was, however,
restricted to the bones of both legs and did not obviously
affect the trabecular structure of the vertebral bodies, the
long bones of the arms, or the ribs. This pattern of
osteopenia excludes age-related or hormonally-induced
osteoporosis such as is commonly seen in present-day
people, and suggests that a general disuse of the legs
might have been the underlying cause. Since both legs
were affected, an isolated disease of the side with the
prosthesis is unlikely.
Finally, we noticed severe abrasion of all teeth,
presumably caused by dental wear. Such wear is a feature
generally seen in ancient Egyptian populations and is
assumed to result from sand and debris from stone mills
found in food, particularly in bread.8 In addition, six teeth
had carious processes and one of these showed an apical
inflammatory process, as is frequently seen in these
people.8 Three teeth had been lost during life.
Discussion
irregular distension of the arterial walls and focal severe
calcifications. This observation was confirmed by
radiographs taken from an aortal segment (figure 3, B)
THE LANCET • Vol 356 • December 23/30, 2000
We describe possibly the oldest known intravital limb
prosthesis. Up to now, several investigators have reported
prosthetic replacements of limbs in ancient Egyptian
2177
For personal use only. Not to be reproduced without permission of The Lancet.
DEPARTMENT OF MEDICAL HISTORY
Figure 3: CT scans of forefoot proximal to the amputation site (A) and radiological examination of a segment of abdominal aorta (B)
Of note are small arterial vessels (arrow) in (A) which show calcification of the vessel wall, and severe calcifications indicating major arteriosclerosis in (B).
mummies. However, their findings suggest that the
replacements were made to prepare the mummy for its
afterlife. For example, a previously found forearm
prosthesis of an elderly man from the Ptolemeic period
(332–30 BC) revealed attempts by embalmers to
complete the mummy for the afterlife.9 Gray10 has detailed
further similar prosthetic replacements of limbs. Similarly,
a wooden prosthesis of the nose of a male mummy from
the Roman period (about 1st century AD)11 is believed to
have been added after death to restore the mummy’s
external integrity, and not for aesthetic reasons during life,
since it was attached to the mummy by a delicate rope
turned around the skull and fixed tightly to the
mandibula.11 There is also a debate about two dental
prostheses found several years ago near Cairo (Saqqara,
4th dynasty, and El-Qatta, Ptolemeic period).12,13 The
teeth were initially interpreted as intravitally used dental
prostheses, however, the absence of dental wear and
dental calculus on the teeth argues against use in life.14
Recently, CT analysis of a female mummy from the
Albany Institute of History and Art (Albany, NY)
provided evidence that the right big toe of this corpse had
been replaced by a prosthesis.15 However, only CT
investigation of this object exists, and whether the
prosthesis had been used during life or if it had been
added after death remains unclear. Furthermore, both
the source and function of this prosthesis are uncertain,
because measurement of the radiological density suggests
that the toe consisted of some form of high-density
ceramic; a material unknown in ancient Egypt. Notably,
the mummy comes from the Theban necropolis and dates
back to the 21st dynasty, thereby closely resembling the
2178
spatial and temporal origin of our case.
A further example of an ancient Egyptian toe prosthesis
is housed in the Egyptian department of the British
Museum. This prosthesis, made from a certain kind of
cartonnage, had been brought to the British Museum in
1881 and also originated from Thebes. Although no
information is available on the individual who used the
toe, distinct signs of wear and subsequent refurbishment
suggest that this prosthesis was also used during life.16
These observations provide compelling evidence that
the surgical expertise to carry out toe, and possibly other
amputations, sometimes followed by prosthetic
replacement, was present in Egypt during this period. The
big toe usually bears about 40% of walking weight and its
replacement is, therefore, of certain importance to the
user’s physical integrity. The loss of this digit results in a
transfer of weight to the end of the first metatarsal,
resulting in instability while standing and in limping when
attempting to run. Use of a prosthesis would have solved
these problems.
In addition to the amputation and prosthetic
replacement of the big toe, we present evidence that the
underlying pathological condition could have arisen from
clinically significant systemic arteriosclerosis, since
radiographs and CT scans show severe arteriosclerotic
macroangiopathy of the aorta with extensive calcifications
and arteriosclerotic microangiopathy of small arterial
vessels of the affected foot. We cannot speculate on
whether this amputation was done by surgery or if it took
place naturally. Traumatic loss of the toe, however, is
unlikely. Unfortunately, we were not able to do further
CT scans on other body regions of the mummy.
THE LANCET • Vol 356 • December 23/30, 2000
For personal use only. Not to be reproduced without permission of The Lancet.
DEPARTMENT OF MEDICAL HISTORY
The presence of arteriosclerosis in ancient Egyptian
mummies has been repeatedly documented.17,19 In our
case, the arteriosclerotic lesions affected not only the
major arterial vessels, but also small peripheral vessels,
suggesting a metabolic disorder such as diabetic
angiopathy. Although this diagnosis cannot be
substantiated, and there are of course several other major
contributing factors possibly involved, we suggest that
ischaemic gangrene could have led to amputation of the
big toe.
5
6
7
8
9
Acknowledgments
This study was supported by a grant from the Deutsche
Forschungsgemeinschaft (Ne 575/3-3). We thank several co-workers, in
particular, Christin Weyss and Ulrike Hobmeier, for their help in the field
work; the cooperating group of Egyptologists for their continuous and
effective support, in particular Andrea Loprieno, Daniel Polz, and
Rainer Stadelmann; Deutsches Archaeologisches Institut Kairo; and the
Supreme Council of Antiquities of Egypt. The analysis of dental age was
kindly supplied by A Cipriano.
References
1
2
3
4
Smith E, Dawson W. Egyptian mummies. London; Allen & Unwin,
1924.
Brothwell DR. Moller-Christensen V. A possible case of amputation
dated to c. 2000 BC. Man 1963; 244: 192–94.
Nerlich AG, Zink A, Szeimies U, Hagedorn H, Rösing FW. Skull
trauma in ancient Egypt and evidence for early neurosurgical therapy.
Presented at International colloquium on cranial trepanation in human
history. Arnott R, Breitwieser R, Lichterman B, eds. Birmingham:
University of Birmingham, 2000: 36–37 (abstract).
Ikram S, Dodson A. The mummy in ancient Egypt. Cairo: American
University in Cairo Press, 1998.
THE LANCET • Vol 356 • December 23/30, 2000
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Ferembach D, Schwidetzky I, Stloukal M. Empfehlungen für die
Alters: und Geschlechtsdiagnose am Skelett. Homo 1979; 30:
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Condon K, Charles DK, Cheverud JM, Buikstra JE. Cementum
annulation and age determination in Homo sapiens: II) Estimates and
accuracy. Am J Phys Anthropol 1986; 71: 321–30.
Bach H. Zur Berechnung der Köperhöhe aus den langen Gliedmassen
weiblicher Skelette. Anthrop Anz 1965; 20: 20–21.
Harris JE, Storey AT, Ponitz PV. Dental disease in the royal
mummies. In: Harris JE, Wente EF, eds. An x-ray atlas of the royal
mummies. Chicago: University of Chicago Press, 1980:
328–45.
Gray PHK. Radiography of ancient Egyptian mummies. Med
Radiograph Photograph 1967; 43: 34–44.
Gray PHK. Embalmer’s restorations. J Egypt Archaeol 1967; 52:
138–40.
Merei G, Nemeskeri J. Bericht über eine bei einer Mumie verwendete
Nasenprothese. Z ägypt Sprach Altertumskun 1959; 84: 76–78.
Junker H. Bericht über die Grabungen auf dem Friedhof des AR bei
den Pyramiden von Giza. Denkschrift Kaiserl Akad Wissenschaft Wien,
Phil-hist Kl, 1929; 69: 256.
Harris J, Iskander Z, Farid S. Restorative dentistry in ancient Egypt:
an archaeological fact. J Michigan Dent Ass 1975; 57: 401–04.
Hoffman-Axthelm W. Zahnprothetik im alten Ägypten: eine
archäologische Tatsache? Quintessenz 1976; 11: 155–63.
Wagle WA. Toe prosthesis in an Egyptian human mummy. Am J
Radiol 1994; 162: 999–1000.
Reeves N. New lights on ancient Egyptian prosthetic medicine. In:
V Davies, ed. Studies in honour of Egyptian antiquities: a tribute to
TGH James. London: British Museum, Occasional paper 123, 1999:
73–77.
Long AR. Cardiovascular renal diseases. Arch Pathol 1931; 12: 92–94.
Ruffer MA. On Arterial lesions found in Egyptian mummies (1580
BC–525 AD). J Pathol Bacteriol 1911; 15: 453–62.
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Med Hist 1962; 6: 77–81.
2179
For personal use only. Not to be reproduced without permission of The Lancet.
BME 201
Found. of BME
Fall 2017
HW #3
Due Friday, October 27
Name:
1. You may work together but each person should turn in his/her own work in his/her own
handwriting.
Problems
#1
(20 pts) _____________
#2
(20 pts) _____________
#3
(12 pts) _____________
/52
Total: _______________
1. Biomaterials
[20 pts]
Read the article “Ancient Egyptian prostheses of the big toe,” by A.G. Nerlich, Al. Zink, U. Szeimies, and
H.G. Hagedorn in Lancet, 2000; 356: 2176-79. The article can be found in our Kodiak classroom. Answer
the following questions related to the article:
A. The mummy described in the article is estimated to originate from what time period (range of
dates)?
B. How did the researchers estimate the age and sex of the woman was mummified?
C. The big toe usually bears what percentage of walking weight? Why is this important to the
researchers’ conclusion that the prosthetic toe was used during the woman’s life (as opposed to
being created as part of a burial ritual)?
D. What are some possible reasons why the woman had the prosthetic toe that are postulated by
the researchers?
2. Artificial Organs Part I
[20 pts]
The hemodialysis unit shown below contains 10,000 fibers, and each fiber has a diameter of 300 μm and
is 20 cm long.
Fiber cross-section
20 cm
300 μm
Figure adapted from http://www.homedialysis.org
A. What is the total surface area for contact between blood and dialysate? Display your answer in
m2. [10 pts]
B. What is the volume of blood contained in the fibers (in total)? Display your answer in mL. [10
pts]
3. Artificial Organs Part II
[12 pts]
A dialyzer is operating with a blood flow rate of 250 mL/min, so that the outlet concentration of urea is
10 mg/dL when the inlet concentration is 60 mg/dL.
A. What is the clearance, CL, for this device operating under these conditions? Display your answer
in units of mL/min. [10 pts]
B. The target extraction ratio for the device is 0.9. Did the device meet the target specification?
Show your work and explain your answer. [2 pts]
…
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