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Current Anaesthesia & Critical Care 19 (2008) 325–327

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Current Anaesthesia & Critical Care

journal homepage: www.elsevier .com/locate/cacc

FOCUS ON: HISTORICAL ANAESTHESIA

Sepsis and political reason in Europe in the XVI century

Donatella Lippi a,*, Raffaele De Gaudio b

a Department of the History of Medicine, Florence Medical School, University of Florence, Italyb Department of Anatomy, Histology and Legal Medicine, Florence Medical School, Careggi. Viale Morgagni 85, 50134 Florence, Italy

Keywords:Giovanni de’ MediciBlack bandsHistory of medicine

* Corresponding author. Tel.: þ39055410084; fax: þE-mail address: donatella.lippi@unifi.it (D. Lippi).

0953-7112/$ – see front matter � 2008 Elsevier Ltd.doi:10.1016/j.cacc.2008.07.008

s u m m a r y

The famous military leader Giovanni de’ Medici died in 1526, during a battle against the Emperor army.He was wounded in his right thigh and died after the surgical intervention, which was performed byMagister Abraham. His friends suspected that the surgeon had ‘‘poisoned’’ his instruments, but someonewrote that Magister Abraham had purposely left ‘‘too much wounded flesh’’. After five centuries it is nowpossible to confirm this rumour.

� 2008 Elsevier Ltd. All rights reserved.

1. The Medici Family

The Medici Family dominated Florentine politics for two anda half centuries and presided over impressive cultural growth inevery field. Amongst the men Cosimo the Elder, Lorenzo theMagnificent and Cosimo I were all outstanding leaders and twoMedicis became Popes, Clemente VII and Leone X. The Mediciwomen included Caterina and Maria both of whom became queensof France.

Their economic power, their political strategy and theirgenerous mecenatism put Florence and Tuscany in the front line ofthe Italian and European scene, from the XV to the XVIII century.1,3

2. Giovanni of the black bands

One of the most fascinating people of the dynasty is Giovannidalle Bande Nere (John of the Black Bands) Fig. 1. He was born in1498 to Giovanni de’Medici (known as Il Popolano) and CaterinaSforza, one of the most famous women of the Italian Renaissance.He married Maria Salviati, grand-daughter of Lorenzo the Magnif-icent, and Giovanni’s son, Cosimo, became the first Grand-duke ofTuscany.5,7

From an early age, he demonstrated great interest and ability inphysical and martial arts, in particular riding and sword-fighting.Giovanni became a renowned soldier who operated principally asa mercenary military captain in the employment of Pope Leone X.When Leone died, he added black bands to his insignia, whencecomes his nickname.

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In a short, but illustrious career, Giovanni earned an impressiveand fearsome reputation. He died relatively young from septicae-mia secondary to war wounds in Mantua, in the North of Italy, onNovember 30, 1526.6,8

3. The wound

Giovanni had been hit in the leg by shot from a small cannonwhilst fighting against Carlo V’s Imperial army (Lanzichenecchi)near Governolo, a town close to Mantua. Despite the severity ofhis injuries, Federico II Gonzaga, Lord of Mantua, initiallyforbade Giovanni’s entry into the town presumably as with twowarring factions at his gates, providing succour to Giovannimight prejudice his relationship with Carlo V. The delay proveddisastrous.

The description of the injury is recounted by Guicciardini, whowrites that he was hit in his right thigh. Further descriptions areprovided by Pietro Aretino, the famous author, satirist, playwright,and close friend of Giovanni’s, who was present at his deathbed. Inparticular he described the scene and Giovanni’s courage in the faceof death.9,12,15

Eventually Giovanni was allowed access to Mantua and tomedical attention. It was not the first time that Giovanni had beenwounded, but this time the wound was particularly serious. Mag-ister Abraham, a surgeon who had already treated him ona previous occasion, examined him and stated that amputation wasthe only hope.

At that time, the XVI century, open wounds still representeda major challenge for the surgeon. The options were limited. Theideal management of open wounds, particularly in warfare, was bycauterising the wound with hot oil while leeches were used to treatthe swelling. Ambroise Pare famously discovered a new method oftreating open wounds, by a combination of ligature and concocting

Fig. 2. Giovanni da le Bande Nere disinterred.

Fig. 1. Giovanni da le Bande Nere.

D. Lippi, R.D. Gaudio / Current Anaesthesia & Critical Care 19 (2008) 325–327326

an ointment from egg yolk, rose oil and turpentine which waspresumably antiseptic. He did this while under siege because hehad run out of hot oil. He noted that the patients treated this waydid better. However, if the wound was clearly too severe or infected,the situation was different. In Hippocratic medicine, an infectedwound was clear evidence that the body was spontaneouslyexpelling a toxic substance. The free passage of pus was considereda positive event as it prevented infection affecting the whole body.Accordingly local infection could be encouraged to drain but if thewound was too severe, or if gangrene was seen to be present, theseconservative measures rapidly gave way to the scalpel. Not a lot haschanged.

For Giovanni with a severe injury and an untoward delay inseeking treatment, surgery was the only option.

Amputation had become very common in that particular periodbecause the increased use of explosive gunpowder had changed thecharacter of wounds. Lead bullets and other kinds of projectiles torethrough flesh, shattered bones and drove foreign bodies deep intowounds. Infection became a major problem, giving rise to the beliefthat some kind of ‘‘gunpowder poison’’ entered the wound. Addedto this was the regular failure of conservative management withoutknowledge or recourse to either antisepsis or antibiotics. Low orperipheral amputation was very common, but even high amputa-tions were regularly attempted but carried an awesome morbidityand mortality. High amputations prior to the use of ligature wereusually fatal through haemorrhage.

Back to Giovanni. He had no treatment for a whole day. Heprobably had devitalised tissues and almost certainly foreignmaterial in the wound. He was predisposed to serious infection andby the time the surgeon saw him gangrene was already present.

The surgeon would have known that the only realistic hope wasthat an aggressive amputation would prevent systemic spread ofinfection. Surgery was performed.

Pietro Aretino relates that Giovanni did not want anybodyholding him during the amputation. In fact he held the candlestick

himself, a remarkable display of courage. Post-operatively, Gio-vanni held his own amputated foot showing it to everybody. He wastotally confident of the success of the procedure.

Regrettably the operation and ordeal that he underwent did notprevent his deterioration and death from gangrene. Giovanni diedan awful death in terrible pain.

4. Negligence, manslaughter or murder?

The various descriptions of events and different testimoniesfrom that time are confusing but they provide circumstantialevidence that all was not as it seems.

According to Guicciardini, Giovanni was hit in his right thigh bycannon shot which would be a devastating injury to the thigh. YetPietro Aretino is quite specific when he describes Giovanni’scourage in showing his amputated foot to the people present. Thislimited operation fits with a chronicle of the time that states thatthe surgeon had ‘‘left too much wounded flesh’’, the infection fromwhich presumably caused Giovanni’s death.17

The question therefore arises that if the injury was at thigh levelwhy would the surgeon remove only the foot?

5. The evidence

Further evidence comes much later. Giovanni was buried in hisarmour in Mantua but in 1685 his corpse was moved to Florenceand re-interred.4,11,12,13 There it remained until 1857 when thecorpse was again exhumed Fig. 2. Leopold II of Lorraine was puttingin order all the Medici tombs. On that occasion, when the coffin was

Fig. 3. The amputated foot with the injury above.

D. Lippi, R.D. Gaudio / Current Anaesthesia & Critical Care 19 (2008) 325–327 327

opened the body was complete with the amputated shin boneFig. 3. This is the record of the event signed by the official entrustedwith exhumation and description:

‘‘All the bones were there, except the hand; the skull was inside thehelmet. The right leg, cut off by the surgeon after it was hit andbroken by the bullet.and it was evident that the imperfection ofthe cut was the cause which led to the death of the Great Captain.And it is true because I have seen the bone which appears cut bya carpenter’s saw.and the famous Anatomy Professor Paganucciobserved in front of the Commission that unlucky sawing had killedGiovanni’’.18,19

This description clearly demonstrates that the physician whoattended Giovanni’s exhumation in 1857 attributed his death tothe rough cut performed by the surgeon, rather than infection.Even in the middle of the XIXth century the concept of

overwhelming sepsis in this context was far from beingcompletely understood.

The most striking feature of this description is that the ampu-tated shin bone confirms that the surgeon had cut only Giovanni’sfoot despite the injury being sustained well above the knee.

Given Giovanni’s clinical condition after he was wounded, itis highly likely that he would have died as a consequence ofthese injuries whatever the surgery. Removing the foot wasclearly the wrong operation and in performing this procedureMagister Abraham may have been complicit in the death ofGiovanni.

6. Motive; the political reason

Giovanni was both powerful and greatly feared at that time. Hisenemies of whom there were many, tried on numerous occasionsand in countless way to get rid of him on the battlefield.

When he was grievously injured close to Mantua the opportu-nity to eliminate Giovanni may have been an irresistible temptationto the Lord of Mantua, Federico II Gonzaga. In removing Giovannihe could ingratiate himself with the powerful and influentialEmperor Carlo V whose empire was described as so boundless thatthe ‘‘sun did never set upon it’’.

It was a perfect opportunity and the circumstantial evidencesuggests this is what happened. It was untreated sepsis that killedGiovanni but it was ably abetted by Political intrigue, and if this wasthe case, by a criminally negligent surgeon. The evidence favourscriminality not negligence and intent and motive make it murdernot manslaughter.

A wiser surgeon might have waited.

References

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des memoires particuliers, relatif a l’histoire de France. Paris–London 1786, vol.XVII, pp. 205–206.

4. Ferrucci M. Inscriptiones prostantes florentinae in hypogeo Mausolei Medici.Pisa, ex-Officina Nistriana; 1858.

5. Gauthiez P. Giovanni dalle Bande Nere. Milano: Elettra; 1937.6. Guicciardini F. Storia d’Italia. Ed. by S. Seidel Menchi. Torino: 1971.7. Langedijk K. The portraits of the Medici. 15th–18th centuries. Firenze: SPES;

1981–1987.8. Lapini A. Diario fiorentino dal 252 al 1596 ora per la prima volta pubblicato da

Gius. Odoardo Corazzino. Firenze: Sansoni; 1900.9. Larivalle P. Pietro Aretino. Roma: Salerno; 1997.

11. Lippi D, Bietti M. The last Medici. Archaeology 2005;58/4:41.12. Mallett ME. Mercenaries and their Masters: Warfare in Renaissance Italy. London:

The Bodley head; 1974.13. Moreni D. Delle tre sontuose cappelle medicee situate nell’imperiale basilica di San

Lorenzo. Firenze: Carli e Comp; 1813.15. Pieraccini G. La stirpe dei Medici di Cafaggiolo. Firenze: Nardini; 1947.17. Rossi GG. Vita di Giovanni de’ Medici pubblicata in Vite d’Uomini d’arme d’affari

del secolo XVI. Firenze; 1866.18. Sommi Picenardi G. Esumazione e ricognizione delle Ceneri dei Principi Med-

icei fatta nell’anno 1857. Processo verbale e note. Archivio Storico Italiano 1888;Tomo I-II. Firenze: M. Cellini e C; 1888.

19. Varchi B. Storia fiorentina. Ed. by L. Arbib. Firenze; 1843–44.