What is Super Mario?

Mario is a platform-based game created by Shigeru Miyamoto. However, Mario has not always been called “Mario”. His first appearance was in Donkey Kong arcade game in 1981, and his name was simply “Jumpman” (Figure 2).

Fun fact
Back in 1981, Nintendo of America rented a warehouse for their headquarters. The owner was Mario Arnold Segale, a business man. One day, he was fed up of Nintendo late payment and barged right into their office. He then scolded Minorobu Arakawa, the president of Nintendo of America back then, in front of all his employees. Nintendo later confirmed that they named the character after Mario Arnold Segale [1], [2].

The Mario franchise is considered one of the best-selling video games franchise of-all-time, and is ranked in the top 5 [3], [4]. There is even a “Super Mario Bros.” movie that is coming out in April 7 of 2023 in the US!

Game mechanics

You control Mario and to complete the game, you have to go through many obstacles, collecting items with one core ability: jumping. When Mario touches an enemy, he instantly dies. Collecting a mushroom (known as Toad) allows Mario to switch from a small form to a bigger Mario.

In that bigger form, you have access to more abilities in the game and touching an enemy does not kill Mario instantly. The gameplay is rather simple… yet these are the foundations of one of the most successful games in history!

What is the historical era of Mario?

In order to discuss medical stuff about Mario, we have to know in which period of time the world is set. We will consider Mario in his entire universe.

Rational elements

- Gold coins: Invented in the 6th century BC in Anatolia [5], they do not give us much information.

- Blue Jeans: Considering he is wearing blue jeans, we can assumed that it is after 1873 (when the blue jean was invented according to Levi Strauss & Co. [6]).

- Plumbing system: If we assume that pipes in Mario game are made of steel/copper (shown by the shiny aspect in-game as shown in Figure 4). According to Wikipedia, copper material was widely used for domestic water plumbing system in latter half of 20^th century (1950  and so) [7].

- Mario “Kart”: in the Mario Kart series, all the characters are driving a motorized racing kart!  The first racing kart was built in Southern California in 1956 by Art Ingels [8].

According to these elements, we can presumably say that Mario era is set something around 1950. That’s true here we assume Mario is American, as all the references are seen through this perspective. Well, as an argument we can say that Mario is surrounded by lots of different ethnicity (Figure 5. Toad, Bowser, Donkey Kong, Yoshi etc.).  So it is reasonable to say that Mario, even though the name sounds Italian, could be an inhabitant of a multicultural country such as the US. Let’s keep it simple and assume that for now!

Irrational elements

I will not discuss some gravity-defying phenomena such as flying platforms and levitating blocs… Nor about flying turtles and fishes as shown in Figure 6. Alright, we can always assume that with a 2D view, one cannot see the “behind the scene”: maybe the platforms or these levitating blocks are somewhere far away from the screen, appended to a post, which is connected to the ground. But seriously, flying turtles?

How was the medical care back in 1950s?

According to Cleveland Clinic, 1950 was the golden age of medical innovation [10]. Indeed, other articles talk about the 1950s at a “memorable time in medicine” [11]–[13]. To depict how the medical landscape was at that time, let’s pick few interesting points:

On a medical point of view

- Insulin was introduced to the US in 1922.

- Jonas Salk developed a polio vaccine, administered by injection. Later, Albert Sabin developed a more advanced vaccine that could be taken orally. With this medical achievement, the polio disease, which was a devastating one back then, was slowly eradicated from west countries. Nowadays it is still mandatory for public health administrations to give children polio vaccine.

- Autopsies were common and medical malpractice suits were virtually nonexistent.

- Patients with strokeswere managed without MRI nor CT-scan (invented in 1990 and in 1970 respectively [14]). They performed skull X-rays, lumbar punctures, and regularly examined the patients to detect any symptoms or signs that could suggest a worsening of the clinical state. Technology was not as developed as nowadays, so doctors had to rely on their clinical experience.

On a surgical point of view

- Anesthesia in surgery was performed since 1846.

- Open heart surgeries using an extra-cardiac machine was first performed in 1956.

- Brain surgery exhibited high mortality due to lack of tools and skills in neuro-anesthesia [14]. Indeed, the only procedure of surgery was to directly open the skull upon the disease.

- Endovascular procedures for brain surgery have only been developed around 1980-1990.

On lab tests, imaging and other explorations

- Directly viewing heart arteries (coronary arteries) by angiography using X-rays was discovered accidentally in 1958 by F. Mason Sones MD. Indeed, people thought at that time that injecting contrast dye into patient’s vein would kill them. But he accidentally injected the dye… however not only the patient did not die, but he could perfectly see the coronary arteries like never before!

- The electrocardiograph to record heart electric activity was introduced to the US in 1914

- Daily-basis blood samplesanalysis were performed by medical students and interns in a small “student lab” where they followed-up blood counts but also urine analysis, stool tests, and investigated under microscopy all the liquids extracted from patients.

- There was no echographyand no computer for everyone (the “computer” was that big machine that spanned the size of your house!)

On healthcare accessibility

- It seems that healthcare was affordable and that health insurance was easy to obtain

Of course, this list is extremely minimalist and only depicts few medical breakthroughs of that time. But I hope you can perceive the medical general mood and landscape of that time. I highly recommend you to go check this article [11] to have more insights about how it used to be a doctor back in 1950.

How is the medical care in Mario’s world?

Medical staff in Mario’s world

When someone is sick in Mario’s world, he can go to… Dr. Mario and Dr. Luigi (Figure 7).

The first thing that strikes me is: “Hey, Mario is be a plumber and a doctor as well?”. There could be two Mario which are twins! Are there many different Mario in Mario’s World? Does he have a family? Apparently, Luigi is Mario’s twin brother according to his biography [15] and to Super Mario World 2: Yoshi’s Island game in 1995.

We don’t know how long it took Mario and Luigi to obtain their MD diploma. Mario first appeared in 1981, and practices as a physician since 1990 in Dr. Mario. We can assume it took as least 9 years to obtain his MD diploma, which is reasonable. Luigi first appeared in 1983 in Mario Bros. game on Game & Watch console, and first appeared practicing medicine in 2013 in Dr. Luigi game on Wii U console. That took at least 30 years to obtain his MD diploma, which is a bit long…

I would say that if Mario and Luigi are the only physician in the entire world, the healthcare system is going to last long… I won’t be surprised if they regularly burn out and choose to become plumber again (well, they are the only plumbers in the Mario’s universe…)!

Displayed diseases in Mario’s world

The main disease represented in Mario’s World is infectious disease (and especially, viral infections) and Dr. Mario and Dr. Luigi treat them with different colored-drugs (Figure 7, [16]). There are three kinds of viruses: red viruses, yellow viruses and blue viruses. The pathogenicity of these different viruses remains unknown (Figure 8).

It seems that these viruses do not proliferate and their only way to kill the patient is by doctor’s malpractice when choosing the wrong drug to cure the illness. I really hope Mario and Luigi have a very good malpractice insurance… By the way, YOU are controlling Dr. Mario so YOU better have a damn good malpractice insurance!

However, when you beat the game it means that all viruses have been eradicated. So, it is fair to claim that in Mario’s world, all viral infections can be cured! How wonderful is that! In comparison to our modern world, HIV treatments cannot yet completely eradicate the disease from our body (because it integrates its genetic material right inside our cells genome and use cell’s machinery to replicate) [17]; C hepatitis is a deadly viral disease and new therapies only started to be very efficient since few years from now only (however it is very encouraging, and a noble price in Medicine was awarded to three researchers in 2020 for their work in C hepatitis virus [18]) ; the SARS-CoV2 (Covid19) virus, which is named after the respiratory failure syndrome “severe acute respiratory syndrome”, does not have yet an efficient treatment. PAXLOVID® drug is used in some severe cases, demonstrating a 89% reduction in risk of COVID19-related hospitalization or death when compared to a placebo drug (which is a drug with no active compounds inside) [19].

Dr. Mario and Dr. Luigi then do an astonishing medical job!

What are the non-displayed diseases that Mario could be affected of?

Hand and wrist injuries

At first, I thought Mario destroys blocks with his head by jumping underneath them. By looking closer, Mario actually hits the block with his hand (Figure 9).

Assuming these blocks are made of bricks/concrete, the force of the impact must be enormous to destroy the block! This can be compared to boxing athletes, fighting with a stone golem, or to volleyball athletes playing with a stone ball.

Mario is exposed to hand and wrist injuries in the same way professional athletes are [20]. This includes metacarpal fractures, phalangeal fractures, thumb ligament injuries, scaphoid fractures Figure 10).

Hand and wrist injuries actually represent up to 25% of athlete’s injuries [20] so there is good chance Mario is affected by that also. Management greatly depends on the type of injury, of the doctor’s practice and the athlete expectations [21]. As an example for scaphoid fractures, it has been reported in a survey that about 50% of doctors allowed athletes to return practicing with a protection (such as splinting) after 4 to 6 weeks of treatment if the fracture is non-displaced ; about 30% of doctors allowed athlete to return practicing with a protection immediately [21]. It also depended on the expertise, as baseball players doctors were more inclined to allow practicing without protection than non-baseball players doctors.

Since Mario does it every single day of his life and never seems to complain about having pain, we can assume he manages his effort very well! Either the gloves he is wearing are ultra-protectives, either between each stage he rests accordingly. Indeed, we don’t know how much time has past when we finish one level, and go to another one. Mario has the right to have some intimacy. Lesson from Mario here: self-care is important to go far in life and save the princess!

Vertical impact injuries

Don’t you think that Mario jumps very high (Figure 11)?

In-game, small Mario is able to jump 4 times his height, and big Mario can jump approximately 2,5 times his height. According to many Nintendo fans, Mario’s height is 5,1 ft (1,55 m) [22]. Using an image analysis software (ImageJ-Fiji, available here), we can extract the height of big Mario which is 7,4 ft (2,24 m). It means small Mario falls down from 20,4 ft (6,2 m) and big Mario from 18,4 ft (5,6 m).

In the US, the average height of a house is 8 ft (2,4 m) from the floor to the ceiling ([23], Figure 11C). Therefore, it is as if Mario falls down from the top of a 2 floors-house! Have you ever tried to jump from the top of your house? Hold on, you don’t need to. Emergency medicine has already dealt with injuries from patients who fall and land on their feet from various heights [24]. In this report, patients fell from 20 to 100 ft (6,1 m to 30,5 m) and all landed on hard surfaces. On admission to the emergency department, many were hypotensive, respiratory distress and low level of consciousness. One patient died from intracerebral hemorrhage. A lot of different injuries occurred in these patients, such as: rib fractures, renal artery transection, renal contusion, spinal fractures, bladder hematoma, pneumothorax, hemothorax, lower extremities fractures, pelvic fractures and cranial fractures. Surprisingly, the patient who fell from 100 ft (30,5 m) survived.

Fun fact
In the article [24], one paragraph says: “Cats, it is often said, almost always land on their feet. However, the same may not be said for human victims of falls. During five-year study period, the paramedics […] responded to 312 cases involving jumps of fall; only 3,8% had landed on one or both feet”.

To have an idea of impact's energy, let’s consider that Mario is 70 kg and is falling vertically without air friction from 6,1 m. Simple physics show that Mario will hit the ground at a velocity of 10,93 m/s with a kinetic energy of 4185 Joules.

As a comparison, 1 grams of TNT releases 4184 Joules [25] and a hand grenade is filled with 52 grams of TNT [26], thus releasing about 217 570 Joules of energy, which is 52 times more than Mario’s impact on the ground.

Even tough surgery had well developed with anesthesia in 1950, since it appears there is no surgeon in Mario’s world, that would be difficult for Mario to recover from vertical impact injuries. He would probably die from internal hemorrhage or would be no more able to walk.

Again, Mario does not complain about it AT ALL. That means he must have some damn good shock-damping shoes! To my knowledge, such technology does not currently exist in our society, at least a technology that is so tiny that it would fit inside regular shoes like Mario has. For sure, it has something to do with the anti-gravity and levitating platform thing…

PTSD (post-traumatic stress disorder)

Each time Mario touches an enemy, he instantly loses a life… Assuming this is a traumatizing experience (which can be assessed by Mario’s face on Figure 12), and that he suffers from it many times through his life, chances are that he is highly exposed to PTSD!

Indeed, PTSD is defined by the American Psychiatric Association and includes 8 criterion [27]. Briefly, PTSD involves (among other things) exposure to death, threatened death, serious injury either directly or by witnessing; re-experiencing the traumatic event in absence of the event (memories etc.); avoidance of trauma-related cues; negative thoughts; behavioral disorders; during more than 1 month; impairing life; not due to another illness. Such stress disorder has been first described in 1871 by a physician treating people who endured the American Civil War. But it has only been named PTSD in 1980. The work resulting in the description of PTSD mainly came from treating American soldiers who endured wars [28].

It is never mentioned that Mario “dies” when he touches an enemy, but we see he clearly loses one life. After losing every life, it is “game over”. However, Mario’s face obviously show it is an unpleasant experience! Almost a traumatizing one. Nevertheless, Mario does not seem to exhibit all the other criterion of PTSD according to the definition. And this is all the contrary, push the START button and he is always ready to fight again and to save the Princess! Mario only lives for the Princess, doesn’t he?

Conclusion

In Mario’s world, there is no viral diseases anymore if doctors don’t make error in drug administration. But there are only 2 doctors, and there is probably not enough medical coverage for all the people. Being the solely physician in their world, Mario and Luigi are highly exposed to PTSD. They not only have tons of work, but also daily experience near-death event! Luckily, they succeeded in managing their own mental health. Maybe some of their colored-pills have some unsuspected effect on the brain. When not working as doctors (to earn a living maybe?), their objective is to save the princess and they disguised as plumbers! They casually have some hand and wrist injuries which are well managed by self-care and rest. They also found how to use the anti-gravity technology to avoid vertical impact injuries. Mario, what a hero!

Glossary

NES: Nintendo Entertainment System

SNES: Super Nintendo Entertainment System, also known as “Super Famicom” in Japan.

References

[1]         Youtube, “Mario Myths with Mr Miyamoto,” [Online]. Available: https://www.youtube.com/watch?v=uu2DnTd3dEo&ab_channel=NintendoUK.

[2]         Wikipedia, “Mario Segale,” [Online]. Available: https://en.wikipedia.org/wiki/Mario_Segale.

[3]         Wikipedia, “List of best-selling video game franchises,” [Online]. Available: https://en.wikipedia.org/wiki/List_of_best-selling_video_game_franchises.

[4]         VGSales, “Best selling game franchises,” [Online]. Available: https://vgsales.fandom.com/wiki/Best_selling_game_franchises.

[5]         Wikipedia, “Gold coin,” [Online]. Available: https://en.wikipedia.org/wiki/Gold_coin.

[6]         L. Strauss, “The History of Denim,” [Online]. Available: https://www.levistrauss.com/2019/07/04/the-history-of-denim/#:~:text=May 20%2C 1873 marked an,for the very first time.

[7]         Wikipedia, “Plumbing,” [Online]. Available: https://en.wikipedia.org/wiki/Plumbing.

[8]         Wikipedia, “Kart racing,” [Online]. Available: https://en.wikipedia.org/wiki/Kart_racing.

[9]         W. D. of P. I. (DPI), “Banana,” [Online]. Available: https://dpi.wi.gov/sites/default/files/imce/school-nutrition/pdf/fact-sheet-banana.pdf.

[10]      “Cleveland Clinic History: 1950s - The Golden Age of Medical Innovation.” https://my.clevelandclinic.org/about/history/1950s#learnmore (accessed Feb. 07, 2023).

[11]      H. L. Fred, “The Late Forties and Early Fifties: A Memorable Time in Medicine,” Texas Hear. Inst. J., vol. 40, no. 5, p. 508, 2013, Accessed: Feb. 07, 2023. [Online]. Available: /pmc/articles/PMC3853817/.

[12]      “The 1950s Medicine and Health: Overview | Encyclopedia.com.” https://www.encyclopedia.com/social-sciences/culture-magazines/1950s-medicine-and-health-overview (accessed Feb. 07, 2023).

[13]      “Timeline of Discovery | Harvard Medical School.” https://hms.harvard.edu/about-hms/history-hms/timeline-discovery (accessed Feb. 07, 2023).

[14]      D. Muzumdar, “Neurosurgery in the Past and Future. An Appraisal,” Ann. Med. Surg., vol. 1, p. 13, 2012, doi: 10.1016/S2049-0801(12)70004-3.

[15]      “IGN: Luigi Biography.” https://web.archive.org/web/20090817041854/http://stars.ign.com/objects/924/924288_biography.html (accessed Feb. 07, 2023).

[16]      Wikipedia, “Dr. Mario,” [Online]. Available: https://en.wikipedia.org/wiki/Dr._Mario.

[17]      T. Cihlar and M. Fordyce, “Current status and prospects of HIV treatment,” Curr. Opin. Virol., vol. 18, pp. 50–56, Jun. 2016, doi: 10.1016/J.COVIRO.2016.03.004.

[18]      M. P. Manns and B. Maasoumy, “Breakthroughs in hepatitis C research: from discovery to cure,” Nat. Rev. Gastroenterol. Hepatol. 2022 198, vol. 19, no. 8, pp. 533–550, May 2022, doi: 10.1038/s41575-022-00608-8.

[19]      S. Drożdżal et al., “An update on drugs with therapeutic potential for SARS-CoV-2 (COVID-19) treatment,” Drug Resist. Updat., vol. 59, p. 100794, Dec. 2021, doi: 10.1016/J.DRUP.2021.100794.

[20]      J. D. Lehman, K. R. Krishnan, J. G. Stepan, and B. U. Nwachukwu, “Prevalence and Treatment Outcomes of Hand and Wrist Injuries in Professional Athletes: A Systematic Review,” https://doi.org/10.1007/s11420-020-09760-w, vol. 16, no. 3, pp. 280–287, Jan. 2021, doi: 10.1007/S11420-020-09760-W.

[21]      C. J. Dy, E. Khmelnitskaya, K. A. Hearns, and M. G. Carlson, “Opinions regarding the management of hand and wrist injuries in elite athletes,” Orthopedics, vol. 36, no. 6, pp. 815–819, Jun. 2013, doi: 10.3928/01477447-20130523-30.

[22]      “What are the main (and some side) character’s heights and weights in the Mario universe? : Mario.” https://www.reddit.com/r/Mario/comments/8iwuvv/what_are_the_main_and_some_side_characters/ (accessed Feb. 08, 2023).

[23]      “Ceiling Heights in Homes and Offices — Zell/Lurie Real Estate Center.” https://realestate.wharton.upenn.edu/working-papers/ceiling-heights-in-homes-and-offices/ (accessed Feb. 08, 2023).

[24]      S. R. Lowenstein, M. Yaron, R. Carrero, D. Devereux, and L. M. Jacobs, “Vertical trauma: Injuries to patients who fall and land on their feet,” Ann. Emerg. Med., vol. 18, no. 2, pp. 161–165, Feb. 1989, doi: 10.1016/S0196-0644(89)80107-6.

[25]      Wikipedia, “TNT equivalent,” [Online]. Available: https://en.wikipedia.org/wiki/TNT_equivalent.

[26]      Wikipedia, “Mk 2 grenade,” [Online]. Available: https://en.wikipedia.org/wiki/Mk_2_grenade#:~:text=The original Mk 2 grenade,a 50%2F50 amatol%2Fnitrostarch.

[27]      “PTSD and DSM-5 - PTSD: National Center for PTSD.” https://www.ptsd.va.gov/professional/treat/essentials/dsm5_ptsd.asp#one (accessed Feb. 08, 2023).

[28]      P. A. Saigh and J. Douglas Bremner, “History of posttraumatic stress disorder Noninvasive Vagal Nerve Stimulation View project Internet Gaming Disorder View project,” Accessed: Feb. 08, 2023. [Online]. Available: https://www.researchgate.net/publication/269463647.