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Vol 1 - Nยบ 1

November 2014

CULTURE&M EDICINE

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


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STAFF Editor in Chief

Design:

Alfredo E. Buzzi

Soulbranding Marketing Studio

Editorial Board

Printing:

Isabel Del Valle

Printerra SRL

Martín Dotta Santana Sonia Lesyk

Santa Elena 938 (Barracas) Buenos Aires, Argentina

Juan Enrique Perea María Victoria Suárez Martín Valdez Advisory Editorial Board Arpan Banerjee (Birmingham, UK) Elizabeth Beckmann (Worthing, UK) Uwe Busch (Remscheid, Germany) Davide Caramella (Pisa, Italy) César Gotta (Buenos Aires, Argentina) Jean-Pierre Martin (Sarlat-la-Canéda, France) Federico Pérgola (Buenos Aires, Argentina) Florentino Sanguinetti (Buenos Aires, Argentina) Eric Stern (Seattle, USA) Adrian Thomas (Bromley, UK) Adolfo Venturini (Buenos Aires, Argentina)

ALMA - Culture & Medicine is an international quarterly concerned with topics of interest shared between culture and the medical sciences. Diseases, with its symptoms and signs, its diagnosis, prognosis, and treatments, are full of aspects that are not strictly medical: the story of the disease itself, its name, the story of those who have described diseases, the vicissitudes of patients that suffered them, its onset on literature, art, music and movies. It may be of interest to learn about the life of physicians that have contributed to medical knowledge, to know about their interests beyond medicine (many physicians have been poets, musicians, politicians, sportsmen, cooks…) and also about the way we remember them today (their names are present in streets, buildings, squares, cities, hospitals etc.). They have written books that became classics. It may also be of interest to learn about contemporary physicians’ interests beyond medicine. A space used to recommend a book, a movie, a drink, a touristic destiny, a museum, a play or how to cook fish. The journal maintains academic standards. All approaches to culture and medicine are recognized, with the emphasis on marshalling new material and on creative thinking. It is intended the journal should serve a wide readership in both medical and non-medical communities. Information for contributors All contributions submitted for publication should be sent to Prof Dr Alfredo E. Buzzi, Editor, ALMA- Culture & Medicine, alfredo@editorialalfredobuzzi.com. Manuscripts should be prepared in accordance with the Guidance for Authors published in the web page (www.editorialalfredobuzzi.com)

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


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SUMARY Editorial

Page 4 Prof. Dr. Alfredo E. Buzzi

Atropine (Atropa belladonna) ETYMOLOGY AND MEDICINE

Page 5

Prof. Dr. Alfredo E. Buzzi

Page 9 The Anatomy Lesson of Dr. Nicolaes Tulp (Rembrandt, 1632) ART AND MEDICINE

Prof. Dr. Alfredo E. Buzzi

Page 26 Theodor Billroth (1829-1894): A new concept in abdominal surgery MEDICAL EPONYMS

Prof. Dr. Alfredo E. Buzzi Dr. Martín Dotta

Franz Kafka’s Case History FAMOUS PATIENTS

Page 52

Dr. Juan Enrique Perea

Illness & Identity

Page 57

MEDICINE & LITERATURE

BA Isabel del Valle

Ivan the Terrible FAMOUS PATIENTS

Page 61 Prof. Dr. Alfredo E. Buzzi

Basil ETYMOLOGY AND MEDICINE

Page 76 Prof. Dr. Alfredo E. Buzzi

Garibaldi and Nélaton THE HISTORY OF MEDICINE IN A PICTURE

Page 105 Prof. Dr. Alfredo E. Buzzi

Alexis Carrel: cet inconnu GALLERY OF NOBEL PRICES IN MEDICINE

Page 107

Prof. Dr. Alfredo E. Buzzi

A talk given to the Osler Society of Buenos Aires on 14 September 2010 CLUB WILLIAM OSLER

Page 114

Prof. Dr. Adrian Thomas

Larry Fink, the intuition as a creative engine PHOTOGRAPHIC WINDOW

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com

Page 119

Dr. Martín Valdez


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Editorial Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Our projects are like virgin wood: it needs to be carved

story of those who have described diseases, the vicissitudes of

to become a real object. The consolidation of such projects

patients that suffered them; its onset on literature, art, music

depends on the quality of the wood and also on the efforts,

and movies.

perseverance and skills with which we perform our work. Some projects have stopped or have not progressed in line

It may be of interest to learn about the life of physicians

with the expectations either because of the wood’s poor

that have contributed to medical knowledge, to know about

quality or because our inability to perform the work. There is no solution to a poor quality wood. But if the failure was ours, then the solution is within us. The future is there to be carved, and if we do not project ourselves into it, we will never get it and thus our dreams will never come true. Only the fear of failure stops us from reaching our goals. We do not dare to change our everyday routine because of fear and because of fear we do not value the strength and power of our capabilities to create and change our future. This journal is a project conceived with the idea of doing something different: a space for physicians to express themselves and find out more about the concerns, passions, pleasures and skills that are outside the merely scientific or

their interests beyond medicine (many physicians have been poets, musicians, politicians, sportsmen, cooks…) and also about the way in which we remember them today (their names are present in streets, cities, hospitals etc.). They have written books that became classics. It may also be of interest to learn about contemporary physicians’ interests beyond medicine, that is to say our own interests. A space used to recommend a book, a movie, a drink, a touristic destiny, a museum, a play or how to cook fish. Due to its own essence, this Project needs to grow with everyone’s contribution. This means that “the wood” is of good quality. The efforts, perseverance and skills need to be accompanied by the pleasure of doing it. This is a space to share our concerns with everyone.

technological sphere of medicine. A goal should not be the end of the road, as success (and Diseases, with its symptoms and signs, its diagnosis,

happiness) is a process and not a destination…

prognosis, and treatments, are full of aspects that are not strictly medical: the story of the disease itself, its name, the

We invite you to walk this path together.

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


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ETYMOLOGY AND MEDICINE

ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Atropine (Atropa belladonna) Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Atropine is an anticholinergic drug extracted from deadly nightshade and from other plants of the Solanaceae family, used in medicine to diminish the muscarinic effects of acetylcholinesterase inhibitors. This drug is named after the way Carlo Linneo, the Swedish botanist, physician, and zoologist who laid the foundations for the modern biological naming scheme of binomial nomenclature, named the plant from which is extracted: Atropa belladonna. Atropine is an anticholinergic drug extracted from deadly nightshade (Atropa belladonna) and from other plants of

and asystole. It is also used to diminish gastrointestinal motility and as mydriatic.

the Solanaceae family. This large family comprises almost 98 genders and 2700 species and includes herbs, trees, sub-

Furthermore, it is widely used as antidote in the case of

shrubs, shrubs or lianas. Some of them contain other types of

organophosphate poisonings as it relaxes smooth muscles

alkaloids, such as the scopolamine, hyoscyamine and nicotine,

and avoids death by suffocation produced by these substances

which are found in plants such as the henbane (Hyoscyamus

since organophosphates induce the antagonist effect to

albus), the jimson weed (Datura stramonium), the mandrake

atropine: they possess acetylcholinesterase  inhibitors and

(Mandragora autumnalis), the tobacco, etc. Some edible

therefore perpetuate the effect off acetylcholine.

species are also solanaceaes like for example potato (Solanum tuberosum),

tomato

(Solanum

lycopersicum),

eggplant

I still remember the mnemothecnical rule we were taught in Pharmacology lessons to be able to remember symptoms

(Solanum melongena) and bell pepper (Capsicum).

and signs of atropine poisoning: ROSECATAMILO (Spanish Atropine is an anticholinergic drug extracted from deadly nightshade (Atropa belladonna) and from other plants of

letters for RED, DRY, HOT, TACHYCARDIA, MYDRIATIC AND MAD).

the Solanaceae family. This large family comprises almost 98 genders and 2700 species and includes herbs, trees, sub-

Ancient Indians knew the belladonna preparations and

shrubs, shrubs or lianas. Some of them contain other types of

Indian physicians used it for many centuries. It was also used

alkaloids, such as the scopolamine, hyoscyamine and nicotine,

in Ancient Egypt as narcotic and afterwards by Syrian to “push

which are found in plants such as the henbane (Hyoscyamus

aside sad thoughts”. During Roman Empire times, and also in

albus), the jimson weed (Datura stramonium), the mandrake

Middle Age, the shrub was frequently used to produce gradual

(Mandragora autumnalis), the tobacco, etc. Some edible

progression poisoning.

species are also solanaceaes like for example potato (Solanum tuberosum),

tomato

(Solanum

lycopersicum),

eggplant

(Solanum melongena) and bell pepper (Capsicum).

This resulted in Swedish physician Carl Nilsson Linneo (1707-1778), founder of modern taxonomy and creator of the binominal system, naming the plant Atropa Belladonna, in

It’s English, French and German name refers to aspects and dangerousness of its fruit (“poison black cherry” or “deadly

reference to Atropos, the oldest of the three Moiras (Romans used to call them Parkas).

nightshade”, “morelle furieuse” and schwarze tollkirsche”). In

Greek

Mythology

Atropos

(in

Greek

Ἄτροπος,

Atropine is a competitive antagonist of muscarinic

“inexorable” or “inevitable”), chose mortals’ mechanism of

acetylcholine receptor and thus it is used in medicine to diminish

death and finished with them by cutting the thread of life

the muscarinic effects of acetylcholinesterase inhibitors, as pre

with his scissors. Atropos used to work with Cloto (in charge

anesthesia medication and for the treatment of bradycardia

of spinning the thread) and Laquesis (measuring its length).

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Fig. 1 - Carlo Linneo. Swizz natural scientist, botanist and zoologist who gave the name Atropa belladonna

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


Page _ 7 Fig. 4 - Nefertiti, another Egyptian Queen, with her pupil dilated and accentuated eyes.

observations recorded have shown that pupil dilates in a state Fig. 2 - Giaconda’s pupil.

of sexual excitement. Respondents were more attracted by the woman who they perceived more sexually stimulated. Women have somewhat perceived that a long time ago. Cleopatra, 50 years before Crist, used henbane and mandrake (other solanaceae plants) to dilate her pupils and thus being more attractive. During XVI to XVII centuries, women of Italian courts were devout to the use of atropine which they use before attending at to nobility balls to provoke mydriasis (usually by rubbing the

Fig. 3 - Atropa Belladonna.

fruit in the eyelids) and thus being a “belle donne”. Leonardo Da Vinci (1452-1519) Giaconda’s eyes have some degree for

Its equivalent in roman mythology was Morta (from where it derives the word muerte (death in Spanish). The second part of the name “Belladonna” (“beautiful woman”, in Italian) derives from another interesting fact. In recently performed research which was published on the internet, participants (all men), had to observe two

mydriasis, and this has been proposed as one the reasons off her charm. Such practice was reused in Paris by the end of XIX century. The mydriatic effect of atropine has been studied, among others, by German chemist Friedrich Ferdinand Runge (17951867) who also identified caffeine in coffee.

photographs of a woman’s face, entirely equal except for a

Atropine was first synthesized by German chemist Richard

tiny detail: in one of them pupils were much more dilated.

Willstätter in 1901 who, in the year 1915, won the Nobel Prize

Afterwards, they were asked which was the more beautiful

for Chemistry for his chlorophyll discovery.

of the two. An overwhelming majority chose the image of the woman with dilated pupils but not knowing consciously

For many centuries, women’s search for beauty stimulated

the difference in both images. Ever since last century, the

many inventions that have influenced on other words, some of

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BIBLIOGRAPHY

them unexpected.

Asimov I.:Historia de los egipcios. Alianza Editorial, Madrid, Female habit of blackening eyelids was already present

1993

in Ancient Egypt (Nefertiti and Cleopatra) as well as in the

El Castellano. La página del idioma español. http://www.elcas-

aesthetic model of Middle Age Mediterranean countries

tellano.org/ (Accessed January 17th, 2011)

(again Italians) and they did it by means of a dust made from

Goodman E., Ketchum J.S., Kirby R.D.: Historical Contribu-

antimony. Such dust was named “alcohol” by some Spanish

tions to the Human Toxicology of Atropine. Exymdine Publi-

authors of the XIII century and the term came from the vulgar

shers, Missouri, 2010.

Arab “al kohól”, which meant, precisely, “antimony”.

Graves R.: Greek Myths. Ed. Ariel, 2007. Holzman R.S.: The Legacy of Atropos. Anesthesiology 1998,

Antinomy was heavily grinded until obtaining such dust,

89:241–249.

and by the year 1500 the word was already used to refer to

PLANTS. Profile for Atropa bella-donna (belladonna). United

“any essence obtained by grinding, sublimation or distillation”.

States department of Agriculture. http://plants.usda.gov/java/ profile?symbol=ATBE Accessed January 17th, 2011.

Paracelsus (1493-1591), the Swiss multifaceted physician

Vallejo, J.J.: The Secrets of Ancient Egypt. Ed. Nowtilus SRL,

was the first one to call “alcohol” to wine spirit. Hence the

2002.

category of “spiritual”, applied to alcoholic beverages. Let’s

Vaughan J.G, Judd P.A., Bellamy D.: The Oxford Book of Heal-

drink to that.

th Foods. Oxford University Press, 2003.

Fig. 5 - Las Parcas (Giovanni Antonio Bazzi, c. 1525). Atropa is in the middle, just about to cut the thread with her scissor is Atropa.

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

The Anatomy Lesson of Dr. Nicolaes Tulp (Rembrandt, 1632) Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Very few physicians attain immortality by virtue of their views instead of their actions. Such was the weird destination of Nicolaes Tulp, a man that is remembered as the demonstrator in the famous “Anatomy Lesson” painting by Rembrandt. Unfortunately we have overlooked his significant medical achievements. The life of Nicolaes Tulp

After his death, Aelius Vorstius became the Professor of Botany and Medicine but his interests and writings were

Nicolaes Tulp was born Claes Pieter or Nicolaus Petrus in

extraordinarily diverse. He studied history, archaeology,

Amsterdam (figure 1) on October 11th, 1593. He adopted the

marine life, heraldry and numismatic. Of great imagination, he

name “Tulp”, which in Dutch means tulip, at some moment

was one of the first men that suggested enlarging coastal lands

before his 38 birthday. The tulip became his emblem and

through pumping.

th

the shape of this flower was carved on the stone façade of his mansion.

Tulp was undoubtedly stimulated by talented teachers. After graduating, he practiced surgery and general medicine

Nicolaes was the youngest of four children in a well-off family. His father, Pieter Dirks, was a prosperous merchant active in civic affairs. There is not much information about Tulp’s childhood. He joined the Leyden Lyceum (figure 2) where he later studied medicine (from 1611 to 1614). His great lecture about the relation between body and soul was praiseworthy. In 1614, he presented the 24 propositions derived from a thesis name “The Cholera Humida”. Some of his professors at the School of Medicine of the

in Amsterdam. Soon after, and in order to meet the huge demand of consultations, he started using a small carriage to visit his patients. He became the first physician in the city using a carriage. Never had he denied visiting a patient, and he used to do it free of charge. His opinion was very well respected. In 1617 he married Aafge Van der Voegh. He had a happy and productive marriage but his wife died eleven years later. With five young children, Tulp married his second wife, the daughter of the Major of Outshoorn, and she bore him three children.

University of Leyden (figure 3) were Reinier Bontius (figure 4), Pieter Paauw (figure 5) and Aelius Vorstius (figure 6). Reinier

Due to his interests, skills and opulence, Tulp had a strong

Bontius, son of a famous physician, was a philosophy and

participation in the city’s civic affairs. In 1622, he was appointed

medicine professor and physician of Prince Frederick Hendrik

judge and member of the City Council.

and Prince Maurits’ Court. Unfortunately, his writings have not survived. Paauw, who was a distinguished botanist and

The practice of anatomical public demonstrations was

anatomist, wanted to convert Leyden into an anatomy center

established in Amsterdam in 1550. In 1555, Phillip II, King of

and he obtained a Royal permission to dissect criminal’s

Spain and Count of Holland, decided to concede the Surgeons

corpses (another form of punishing criminals’ actions). Paauw influenced on the construction of an amphitheater, which he used for over nineteen years to dissect male corpses and animals. Dutch anatomists had to wait until 1720 to be able to use female corpses. He designed the botanical gardens of Leyden and was a prosperous writer.

Guild one corpse per year. Due to the complexity of both the process for obtaining corpses and the relationship among judges, such demonstrations were left under the control of the city’s Major and the judges who also had to assign a “Prelector” (dissector). Dissectors are qualified anatomists and recognized municipal figures. Dr. Maarten Jansz Koster (Aeditus) was the

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ART AND MEDICINE


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Figure 1: Amsterdam in the 17ยบ century

Figure 2: The city of Leyden in 1610

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Page _ 11 Figure 3: Leyden’s University seal (founded in 1575)

Figure 6: Aelius Vorstius (1565-1624)

Figure 4: Reinier Bontius (1576-1623)

Figure 7: Anatomical Theatre of Leyden

first dissector, a position that he occupied until his death. He was succeeded by Dr. Sebastian Egbertsz (1599-1621), Dr. Joan Fonteyn (1621-1628), and lastly by Tulp who held office from 1621 to 1628 when he resigned adducing other responsibilities. As he expressed with a plate tulip full of wine: “I will drink this glass of wine to your health, to the teachers and supervisors, in thankfulness for the unity we have maintained. The plate glass is my gift to the guild by virtue of the charming relationship we have had and as proof of my gratitude”. During twenty-four years, Dr. Tulp was a diligent and distinctive demonstrator. He followed the rules of anatomy Figure 5: Pieter Paauw (1564-1617)

public lessons strictly (figure 8). According to their availability,

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Figure 10: The city of Leyden (Jan Beerstraten, 1635) Figure 8: Anatomical Dissection in Leyden

Figure 11: The city of The Hague (Sybrand van Beest, 1650)

Using sharp instruments and describing the process, the expert performed the dissection carefully and methodically. Dissection usually started in the abdomen to show internal organs under the watchful eyes of spectators. The complete lesson used to last four to five days. In order to document and commemorate a public anatomy lesson, a painting representing the first demonstration of the Figure 9: Self-portrait of Rembrandt painted on the same year as “The Anatomy Lesson of Dr. Tulp” (1632)

year was formally commissioned. The painting had to portrait the dissector, the spectators and the cadaver.

corpses were dissected in wintertime, generally Tuesdays or

Normally, spectators would pay for the portraits in which

Fridays at one o’clock with the presence of physicians, surgeons,

they appeared and which were afterwards hung in a room of

judges, other important figures and even some women. All members of the Guild had to assist, or otherwise they were charged with a fine. Members had to pay an entrance fee and

the Surgeon Guild’s head office. Only very important artists had access to the guild’s commission. The circumstances under which young artist Rembrandt

with the money collected the Guild paid annual banquets.

Harmensz van Rijn (figure 9) painted Nicolaes Tulp in 1632

“Neither children or individuals without incumbency” were

are still uncertain. Most probably the Surgeons’ Guild

allowed to attend. It was prohibited to walk, talk or laugh and

commissioned Rembrandt to do the painting in order to

only by the end of the demonstration people were allowed to

commemorate its activities. Other recognized “Anatomy

make questions. Its main objective was to stimulate curiosity

Lessons” paintings already existed in other cities. In fact,

and educate participants. However, it was also performed as a social event.

Rembrandt painted another canvas in 1656 representing Tulp’s successor, Jan Deyman. Unfortunately a fire damaged

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understand his fear, I tried not to oppose his idea; I did not want to bring down his belief (product of his imagination) with direct actions but instead I wanted to do it in a veiled way. In six days with the help of suggestions and cathartics the painter was cured without either suspecting or perceiving it. He was a very smart person and in his art he was unbeatable”. There is no evidence that this patient was Rembrandt. He was famous enough as portrait painter to obtain the commission of the Guild by the usual means. There is little information available about Tulp’s last years and they mainly relate to civic honors. In 1649 and in 1660, he was appointed Orphanage Supervisor. From 1645 and 1672 he was appointed City Major four times and eight times City Treasurer. From 1663 to 1665 and from 1673 to 1674 he was a member of the Netherlands Executive Committee and of the West Friesland regarding Amsterdam. Those were difficult times for Amsterdam as in 1672 Louis XIV had declared war against The Netherlands. Holding office in said Committee, Tulp died in The Hague on September 12th, 1674 at the age of 81. Figure 12: Nicolaes Tulp: “Ailiis insirviendo consumor” (Nicolaes Eliaszoon Pickenoy)

the painting and only a small part survived. An “appropriate” commission could certainly increase powerful individuals’ awareness of an artist’s work if the expectations of the patron were satisfied. In fact, this painting helped the Dutch painter, 25 years old by then, to consolidate his reputation as a brilliant painter.

There is a well accomplished yet less famous painting of Tulp. Nicolaes Eliasz (1591-1656) painted him in gratitude for curing his daughter free of charge. Tulp is painted pointing at a burning candle and with the following phrase under the painting: “Ailiis insirviendo consumor” (“I burn with the desire to serve others”) (figure 12). Tulp was also portrayed in marble and copper (figure 13). Tulp´s opera medica.

Rembrandt was born and lived in Leyden (figure 10) where

Nicolaes Tulp had an outstanding career both as a doctor

he was a well-recognized artist. He had an upward career but

and as a politician. In 1635 a terrible plague killed 17.000 people

he was looking for a positive change. Since in Leyden patronage

in Amsterdam. Tulp, opposing the prevailing public opinion,

was quite limited, Rembrandt decided to move to Amsterdam

proposed quarantine to control plague propagation. Despite

(figure 1) during 1631, soon after the death of his father and

all efforts, both wise and unwise, 1.300 people died within a

elder brother, Gerrick. In Amsterdam, Rembrandt changed his

week. The plague and the increasing suspicion of negligence

painting technique by abandoning small formats and focusing

on the part of pharmacists, made Tulp suggest that the 66

on” larger size paintings such as the “The Anatomy Lesson of

apothecaries of Amsterdam be left under supervision of the 70

Dr. Tulp”, the first official commission he took in 1632 and

physicians of the city. In 1636 appeared the “Dispensatorium”,

which gave him a tremendous success and established him as

the first Dutch pharmacopoeia and all pharmacists were

the most important painter of the moment.

legally bound to prepare compounds following its instructions.

Some believe that Rembrandt and Tulp were friends since

He became a famous doctor mainly after publishing

Rembrandt had been Tulp’s patient. The belief came up after

his impressive book “Observationvm medicarvm” (figure 14),

Tulp presented a clinical case: “Distinguished painter, afflicted

written in 1637 originally as a practical guide for his son Pieter

with the black bile disease for a certain period of time, he had the

who had recently graduated from the School of Medicine of

hilarious idea that all his bones had softened to the extent that

the University of Leyden. Some later editions appeared in

they would collapse like wax with a minimum weight. Anchored in

the years 1652, 1672, 1685 and 1716. The second edition was

this belief, he stayed in bed for a whole winter. Once I was able to

dedicated to his son who precipitately died soon after the first

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impression. The book of “Observations” is written with simplicity and, even some observations are not correct, never are they pretentious. He wrote it in Latin to avoid non-expert people from reading and interpreting it wrongly. Tulp was the first to describe the ileocecal valve, the vasa lacteal of the small bowel, the Diphyllobothrium latum, the pulsation of the spleen, the importance of cauda equina and the human qualities of orangutan (figure 15). He much contributed to primatology. He believed in the benefits of blood letting. For empyema, he proposed an early drainage. Within his book “Observations”, Tulp registered the adverse effects of gallbladder, kidney and bladder stones. He described three ways of eliminating urethral stones: by using a scalpel, a hook or by suction. Most parts of the clinical material is presented as clinical cases; some of them though are somewhat fantastic. Observation 43, for example, is about a young damsel who lost her skin after ingesting sulfuric acid she was given to relieve

Figure 13: Nicolaes Tulp.

a toothache. She managed to survive, although disfigured ever after. It also includes the description of a seven years evolution hyperhidrosis case: “A poor young seamstress with an abnormally increased sweating condition. She had to change her underclothes at least four or five times a day”. Unfortunately we never got to know how she was cured. The following is probably one of Tulp’s most interesting stories: “The son of Peter Wit was injured by a heavy window that fell over his head. The injury affected the left side of the skull but the paralysis occurred in the right side. Then…¿why the injury affected the opposite side?” Tulp evidently ignored the pyramidal decussation that had been shown centuries before. Head injuries were quite common among his patients. In one occasion he took out a piece of skull that was pressing the brain of one his patients. Furthermore, he described epilepsy, hydrocephaly and hysterical aphasia, the latter cured by a thunderbolt.

Figure 14: “Observationvm medicarvm” (Nicolaes Tulp, 1641)

He was one of the first European doctors to describe beriberi in detail. He treated it with petroleum. He was frankly against tobacco and talked about the benefits of tea which was still unknown in his country. He strongly recommended brandy and hare urine to cure deafness. However, as most men, he was chained to his time. For

Figure 15: “Observationvm medicarvm” (Nicolaes Tulp, 1641)

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Page _ 15 Figure 16: The “Anatomy Lesson of Dr. Sebastian Egbertsz” (Nicolaes Eliaszoon Pickenoy, 1619)

Figure 17: The “Anatomy Lesson of Dr. Willem van der Meer” (Michiel Jansz van Mierevelt, 1617.)

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Figure 18: The “Anatomy Lesson of Dr. Frederik Ruysch” (Jan van Neck, 1683).

example, he suggested oysters to cure tuberculosis and

One of the characters is holding a list of names and numbers

herring to eliminate dyspepsia. On the other side, he could

that correspond to a number placed above each spectator’s

precisely explain volvulus, intestinal obstruction, gangrene,

head. We can identify this group as: 1.Tulp, 2. Jacob Blok, 3.

hydrocele, ascitis, incisional hernia and torticollis.

Hartman Hartman, 4. Adriaan Slabren, 5. Jacob de UIT, 6. Mathys Kalkoen, 7. Jacob Koolvelt y 8. Francis van Loenen.

Reading his “Observations” it can be inferred that Tulp

Later, Rembrandt painted portraits of Kalkoen and Hartman.

was a humble person that used to recognize the limits of his knowledge and the need of finding other truths. He was also

Rembrandt chose not to paint the exact image of the

a compassionate man, a real physician who was aware of the

lesson. Instead of capturing the moment when the expert

responsibility he was assuming when dealing with mental

is opening the cadaver’s abdomen (normally the first part

problems and other disorders. It seems appropriate that Tulp

dissected during a public demonstration) Rembrandt painted

and Rembrandt have been joined in history forever..

the dissection of the cadaver’s left hand and arm. The rest of the body is intact, something not common in a dissection as we

“The Anatomy Lesson of Dr. Nicolaes Tulp” (Rembrandt,

can see in other “Anatomy Lessons” paintings such as that of

1632)

Michiel Jansz van Mierevelt (figure 17), Jan van Neck (figure 18), and Cornelis Troost (figure 19) and in many other engravings

Rembrandt had probably seen the “Anatomy Lesson of

(figures 20 y 21). Twenty-five years later Rembrandt painted

Dr. Sebastian Egbertsz”, painted in Leyden in 1619 by Nicolaes

a similar scene, “The anatomy lesson of Dr. Jan Deyman” (figure

Eliaszoon Pickenoy (figure 16). Compared with this painting,

22) where it is observed the usual order of dissection: first the

Rembrandt’s work is clearly improved, with a unit, seriousness

abdomen and the thorax, then the brain and finally the arms

and dignity not perceived in the other “Anatomy Lesson”.

and legs.

The characters in Rembrandt´s painting were outstanding people in his time but none, except Tulp, had a medical degree.

It is worth mentioning the dynamism of the composition and the way the artist painted his main characters.

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It is an oil painting on canvas, 169 centimeters tall and

paleness of the cadaver. Tulp, who was 39 years old at that

219 centimeters wide (figure 23). The painting, housed in the

time, is the only character with a hat to depict his importance in

Mauritshuis Museum in The Hague (The Netherlands), portraits

the painting. Also, the tiny white collar distinguishes him from

Dr. Tulp making a public dissection on January 31st, 1632.

the seven members of the Guild who are observing his master lesson. Tulp is sat with his back straight, his hand lifted and his

The spectator’s attention is directed towards the lower

finger whirling while he is explaining the dissection. With his

part of the painting (center), where a pale cadaver is laying in

right hand he is holding a clamp with which he separates the

a narrow worktable. The corpse is that of the criminal Adriaan

tendons he is dissecting.

Adriaanszoon who was convicted for armed robbery and

sentenced to  death  by  hanging. He was executed earlier on

The seven spectators are grouped in the left half of the

the same day of the scene. The face of the corpse is partially

composition, behind and very close to the corpse and forming

shaded. It is the shadow of death (umbra mortis), a technique

a sort of pyramid so that everyone can see the cadaver (figure

that Rembrandt started using frequently.

26). Each of the characters is pictured in different positions and with different expressions. The use of the light is to highlight

A white cloth covers the criminal’s private parts. His right

a specific face or part of the body. The contrast between light

arm is alongside the torso and the doctor is analyzing his

and darkness increases with the black typical costume used

left hand and arm with its tendons exposed to analysis. The

in those days and the smooth brush stroke technique used to

dissected arm is longer than the right arm, perhaps because

produce an airy texture.

the model belongs to other “patient”. Also the left hand has a different color, which suggests that it was painted afterwards

The painting focuses on the diagonal formed by the four

from other model (perhaps Adriaan Adriaans’ right hand

characters located in direction to the clamp of the doctor

had been amputated before his execution as part of the

(figure 27). To avoid diverting the spectator’s attention, the

punishment). The cadaver’s navel has an “R” in uppercase

background is neutral and hardly defined. The year and

and that is related to the fact that Rembrandt was working

signature are in the upper part of the wall at the back. This may

intensely with his signature. During that time he used three

be the first time Rembrandt signed a painting with his name

different consecutive types of signatures and in 1633 he finally

and not with his monogram “RHL” (Rembrant Harmenszoon de

decided to use his first name only.

Leiden), an indication of his increasing artistic confidence.

To the right and behind the cadaver is Dr. Nicolaes Tulp

The three characters that are closer to the corpse’s head

(Figure 25), dressed with dark clothes that contrast with the

forming another triangle (figure 29) were the most enthusiastic

Figure 19: The “Anatomy Lesson of Dr. Willem Röell” (Cornelis Troost, 1728).

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Figure 20: Detail of “Anatomical Theatre of Leyden”.

Figure 21: Detail of “The Reward of Cruelty” (William Hogarth, 1751).

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Page _ 19 Figure 22: The “Anatomy Lesson of Dr. Jan Deyman” (Rembrandt, 1656). Due a fire the art work was significantly damaged and in the 17º century had to be trimmed

Figure 23: The “Anatomy Lesson of Dr. Nicolaes Tulp” (Rembrandt, 1632).

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spectators. Two of them (at the bottom) are bending over

Notwithstanding, the movement is quite complex: the wrist

to get a better perspective of the dissection and follow the

is extended; the metatarsophalangeal joints are extended

explanation with great attention. The figure at the top of the

while proximal interphalangeal joints are bent. The result is an

group is staring at the doctor (figure 30).

unnatural position of the hand and fingers. Tulp’s left hand is essential to interpret the meaning of this “Anatomy Lesson”:

To the left of this triangle formed by the three enthusiast

with the position of his left hand he tries to show that the

spectators, there are two more spectators (figure 31). The man

contraction of the muscle he is lifting with the clamp will also

at the left has a more relaxed attitude while his colleague’s

bend in the proximal interphalangeal joints of the corpse.

attention is directed towards something else at the lower-right area.

In other words, Tulp is displaying the action of the fingers’ superficial flexor muscle by combining a voluntary movement

The man situated at the top of the composition seems to direct his gaze towards the painting’s spectator (figure 32). The other man is holding a list with the names of the attendants (figure 33).

of the hand and a demonstration of the cadaver’s muscles action. However, if this is true ¿why does Rembrandt not display the cadafer’s fingers flexed?. Obviously, that would have been the most obvious

On the lower right area, alongside the cadaver’s feet, there is an open book of medicine (figure 34), probably “De Humani Corporis Fabrica” of Andrés Vesalio. Rembrandt composed the scene situating it near the spectator; probably his intention was to make the spectator participate of the anatomy lesson just as another attendant. This is not a common anatomy lesson. As we already

scenario. However, the painting would have been deprived of Rembrandt’s mark: the suggestion of movement. If both actions had occurred simultaneously (the flexion of both Tulp’s left hand fingers and the cadaver’s left hand fingers) the scene’s dynamic would have been ruined. From the scene, it may be deduced that Tulp is displaying the phenomenon of flexion of the interphalangeal joint with his left hand while he is preparing to pull out the muscle in the corpse in order to explain how the voluntary movement is produced. There is evidence supporting this hypothesis, and such is detected

mentioned, dissections almost always start with an exploration

in the characters in the front row who seem to be the most

of the chest and abdominal cavities (the parts of the human

interested in Dr. Tulp’s lesson. The man to the left, whose face

body most likely to decompose first) and only later does the

is seen from the side, is staring at the cadaver’s forearm. The

procedure move onwards to the limbs.  In this Rembrandt’s

man to the right is staring at Tulp’s left hand (figure 35). The

painting, the dissector starts with the superior right limb. The

way in which these two characters are looking at two different

artist does not focus on all the stages of an usual dissection

objects indicates what will happen next, once the image has

but on something specific. Tulp is holding the clamp with his

been captured and fixed in Rembrandt’s time: the cadaver’s

right hand and his left hand is lifted in an odd way. Some have

fingers will move at the time the muscle is pulled out with

suggested he is emphasizing something.

the clamp. Therefore, by making two people stare in different

Figure 24: Detail: Cadaver

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directions, Rembrandt suggests not only a point in time but

The painting then assumes a different dimension: this

also something that engages a period of time. A final track is

is not a static descriptive anatomy lesson. It is a functional

suggested by the man staring at Tulp’s left hand and holding

anatomy lesson, a physiology lesson. It displays one of the

his chest with his fingers flexed as if reflecting the gesture of

essential qualities of the brilliant painter: the representation

the doctor (figure 36).

of movement. It embodies one of the central concepts of the European thought in the 17 century: the movement, both the movement of the body (as it is shown by Tulp in the painting), the movement of planets (Galileo was being prosecuted in Italy) and the movement of the soul (Descartes was already in exile in The Netherlands). A lot has been written about anatomical errors in “The anatomy lesson”. In the painting, the flexor digitorum superficialis tendon appears inserted in the lateral epicondyle instead of the medial epicondyle. It is unlikely that this had been an anatomical variant. Some suggest that Rembrandt misunderstood an image of Vesalio and confused the right arm anatomy with the left arm anatomy. Many assure that it is impossible that Rembrandt (a good anatomist) had painted this anomaly by mistake. Others, think that the brilliant painter changed it intentionally to give the painting a larger artistic unit. Furthermore, Tulp, who was a famous anatomist, must have recognized the error and had a reason to accept it. Maybe he was more interested in the representation than in the function. Then we may say that in fact “The Anatomy Lesson” is

Figure 25: Detail: Dr. Tulp.

Figure 26: Detail: The pyramid formed by spectators.

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Figure 27: Detail: Diagonal that directs the attention to Tulp’s right hand.

not a lesson of anatomy. The famous painting has been restored in several occasions and while the painter was still alive it underwent changes that can be observed by means of x rays. This canvas from 1632 might have implied a drastic change

Figure 28: Detail: Signature of Rembrandt and year.

in the artistic career of Rembrandt as it was the first artwork unanimously praised by patrons and the public and its success was immediate. Rembrandt, 26 years old at that moment, became a celebrity (figure 37). From 1632 to 1634 he received forty commissions, whereas in 1631 he had painted only three portraits in addition to that of his own and of his family. With “The Anatomy Lesson of Dr. Tulp” Rembrandt not only became very famous but he also met his future very good friend and patron, Jan Six (Dr. Tulp’s son in law) and Arnout Tholinx (also Dr. Tulp’s son in law), of whom Rembrandt painted and engraved a portrait. The painting far exceeded the pictorial representations of anatomy lessons traditionally painted by Italian and Dutch painters and provided truly amazing innovations. The Dutch paintings performed before to commemorate public dissections such as “The Anatomy Lesson of Dr. Sebastiaen Egbertsz” (figure 15) were merely portraits that appeared

Figure 29: Detail: The “Lower triangle”.

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Page _ 23 Figure 30: Detail: The “Lower triangle�

Figure 31: Detail: The most distant spectators..

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Figure 32: Detail: The one staring at spectator.

Figure 33: Detail: The one with the list.

symmetrically aligned in several parallel planes around the cadaver. The pyramidal composition with its solid and complex conception, the powerful diagonal conformed by the corpse, the faces carefully illuminated, Dr. Tulp’s delicate hands and the cadaver (the contrast of light and shadow that afterwards made him famous), bring the painting to life in the three dimensions. Rembrandt’s anatomy lesson painting is both a plastic document and a portrait of the epoch. It has unintentionally Figure 34: Detail: The book.

constituted an impressive tribute to 17 century’s physicians that despite superstition and obscurantism, managed to keep the prestige of a profession and of a science serving mankind. BIBLIOGRAPHY Afek A, Friedman T, Kugel C, Barshack I, Lurie DJ. Dr. Tulp’s Anatomy Lesson by Rembrandt: the third day hypothesis. Isr Med Assoc J. 2009,11:389-92. Bankl HC, Bankl H. Dr. Nicolaas Tulp. A critical view of Rembrandt’s Anatomy Lesson. Wien Klin Wochenschr. 2000, 112:368-371.

Figure 35: Detail: Those observing the hands.

Burkart, F. Rembrandt und sein Anatomie. Medizinische Klinik, I906, II, 762-763. Clark K. An Introduction to Rembrandt. John Murray/ Readers Union, London, 1978 Contreras J. Rembrandt. Editorial Sol 90 S.L., Barcelona, 2008

Figure 36: Detail: Imitation of fingers flexion.

Glazenburg J. Rembrandt’s anatomy of Dr. Nicolaas Tulp.

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


Page _ 25 Figure 37: Rembrandt’s Statue in Amsterdam.

Arch Chir Neerl. 1977,29:83-91.

Major R. A History of Medicine. Charles C. Thomas,

Goldwyn R. Nicolaas Tulp (1593-1674). Med Hist. 1961,5:270-

Springfield, 1954.

276

Masquelet AC. Rembrandt’s Anatomy Lesson of Professor

Gombrich, E.H., The Story of Art, Phaidon, London, 1995

Nicolaes Tulp (1632). Bull Acad Natl Med. 2011,195:773-783.

Heckscher WS. Rembrandt’s Anatomy Lesson of Dr. Nicolaas Tulp. New York University Press, Nueva York, 1958. Hove LM, Young S, Schrama JC. Dr. Nicolaes Tulp’s anatomy lecture Tidsskr Nor Laegeforen. 2008, 128:716-719.

Rachlin H. Tras las obras maestros. Robinbook Editions, Barcelona, 2008 Rosler R., Young P. La lección de anatomía del doctor

Jackowe DJ, Moore MK, Bruner AE, Fredieu JR. New insight

Nicolaes Tulp: el comienzo de una utopía médica. Rev Med

into the enigmatic white cord in Rembrandt’s The Anatomy

Chile 2011; 139: 535-541

Lesson of Dr. Nicolaes Tulp (1632). J Hand Surg Am. 2007,

Thyssen, E. H. M. Nicolaas Tulp. Medical Life, 1932, XXXIX,

32:1471-476.

317-28.

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MEDICAL EPONYMS

ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Theodor Billroth (1829-1894): A new concept in abdominal surgery Prof. Dr. Alfredo E. Buzzi

Dr. Martín Dotta

Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Chief of the Imaging Department Sanatorio Dupuytren Buenos Aires, Argentina

Associated Eponyms BILLROTH’S CORDS: The splenic cords found in the red pulp between the sinusoids, consisting of fibrils and connective tissue cells with a large population of monocytes and macrophages. BILLROTH’S DISEASE I: Accumulation of cerebrospinal fluid under the scalp in children, generally caused by skull fracture. BILLROTH’S DISEASE II: A malignant lymphoma BILLROTH GASTRECTOMY TYPE I: Also called “Rydigier’s resection”, removal of the lower portion of the stomach (pylorus) with end-to-end anastomosis of the remaining stomach with the duodenum. BILLROTH’S GASTRECTOMY TYPE II: Gastrojejunal anastomosis with duodenal closure. Subtotal excision of the stomach with closure of the proximal end of the duodenum and side-to-side anastomosis of the jejunum to the remaining portion of the stomach. BILLROTH VENAE CAVERNOSAE: Small tributaries of the splenic vein in the pulp of the spleen. BILLROTH-WINIWARTER DISEASE: Also known as Endarteritis obliterans, Buerger’s disease, Miniwarter-Buerger’s disease and Miniwarter-Manteuffell-Buerger’s syndrome. A chronic inflammatory disease of the peripheral vessels, forming blood clots that results in reduced blood flow, possible ulceration and gangrene and affecting mainly radial and ulnar arteries. It was first described by the German pathologist and bacteriologist Carl Friedländer (1847-1887) as Endarteritis obliterans. In 1879, Felix von Winiwarter described the disease in a 57 year- old male patient. Buerger depicted it in 1908, and in 1924 published a monograph with information on a number of 500 patients.

In the 19th century, thanks to the extraordinary technical

suture, conceived to prevent skin tears and some anatomic

innovations that enabled to start controlling pain, hemorrhage

parts and diseases such as splenic cords (cords of Billroth) and

and infection, surgery developed a different intention which was deliberately functional and restorative instead of just dealing with the removal of the diseased parts. Theodor Billroth established himself within this scenario, in the model of modern scientific surgery. He introduced histological,

bacteriological,

experimental

and

statistical

methods in his activity. Through him, the process of the conversion of surgery into science was brilliantly achieved. Considered the founder of modern abdominal surgery, his name lives on many instruments, techniques and operations conceived and regulated at that time. Such is the case of gastrectomy operations known as Billroth operation I and II. Billroth’s operation is also used to describe a tongues’ removal process. Furthermore, the eponym is used to name the button

Figure 1: Widow Johanna Christina Billroth with her five sons. Theodor is standing behind her.

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spurious meningocele (Billroth’s disease).

on the Baltic coast. He was the first of five children in a family of Swedish origin. His father was Carl Theodor Billroth, a priest

Early life and career

Christian Albert Theodor Billroth was born on 26th April 1829 at Bergen, on the island of Rugen (Germany’s largest isle),

in the Lutheran Church and his mother was Johanna Christina. At the age of three, his family moved from the fishing village of Bergen, on the isle of Rugen, to Reinberg, on the German coast of the Pomeranian region. His father died when he was five years old and his mother moved to live with his grandfather in the neighbor city of Greifswald, at the northeast of Germany, where Billroth completed secondary school. Theodor was an indifferent student but he was musically inclined. Although he expressed himself with some difficulty and had a speech impediment, finally he was able to complete his studies (figure 1). His mother and professors of Greifswald, surgeon Wilhelm Baum (figure 2) who later on developed new surgical options to treat polyps, and the pharmacology professor Philip

Figure 2: The surgeon Wilhelm Baum (1799-1883), who had a great influence on Billroth.

Figure 3: The physician Philipp Magnus Seifert (1800-1845).

Figure 4: The University of Gottingen in 1820 (above) and in 2006 (below).

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Magnus Seifert (figure 3) who later on became the Rector of

learned experimental pathology from Langenbeck, his surgery

the Greifswald University, induced Billroth to study medicine

professor. In Berlin he also completed his training, based on

for financial reasons. He then abandoned his vocation as a

experimental histology and physiology (that had initiated with

musician and enrolled for medicine. However, he maintained

Wagner in Gottingen) along with Johannes Muller (figure 12).

his passion for music which, throughout his life, was his source of energy and of great help in moments of depression,

Traub encouraged him to write the thesis “De natura et

which were frequent. He even said: “Though I am married to medicine, music has always been my mistress”. He started his medical career in Greifswald, but then followed his professor Wilhelm Baum to Gottingen University where he completed his studies (figure 4). Later on, in 1872, they would both work together at the recently created German Society of Surgery (figure 5). From that moment onwards, Billroth studied and worked with tremendous energy and self-discipline but without sacrificing his passion for music: “…in Gottingen sciences changed my attitude to life, as if by a miracle”. In Gottingen, Billroth established a lasting friendship with the anatomist Georg Meissner (figure 6). Meissner, also interested in music, was pupil of physiologist Rudolph Wagner (figure 7) who taught him microscopy. Along with Wagner and Meissner, Billroth went to Trieste on study tour where they visited other universities, including the University of Vienna. He became very fond of travelling; he especially enjoyed the north of Italy and the Adriatic Sea coast. In 1851, he continued his studies in Berlin, with Bernhard Rudolf Konrad von Langenbeck (figure 8), Johann Lukas Schonlein (figure 9), Moritz Heinrich Romberf (figure 10) and Ludwig Traube (figure 11). Along with Romberg and Traub, he

Figure 6: The anatomist Georg Meissner (1829-1905). His study on the skin structure led him to describe tactile corpuscles located in the papillary region of the dermis ( “Meissnerís corpuscles”).

Figure 5: Founders of the German Society of Surgery (1872).

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Page _ 29 Figure 7: The physiologist Rudolph Wagner (1805-1864). He discovered human oocyte.

Figure 9: The German physician Johann Schonlein (1793-1864), personal physician of Frederick William IV of Prussia. He gave a definite name and a unified clinical entity to tuberculosis. He described thrombopenic purpura named after him as Schonlein’s disease.

After obtaining his doctorate, he worked some time at the Albrecht von Graefe Ophthalmologic Clinic (figure 14). In 1853, he moved to Vienna to receive a training in dermatology with Ferdinand von Hebra (1816-1880), in pathology with August Henschel (1790-1856) and in internal medicine with Johann von Oppolzer (1808-1871). He also completed his training in Paris. Surgical Training By the end of 1853, he tried in vain to start his own clinic as a family practitioner in Berlin (no patients consulted him) and became greatly concerned about his future. A few months later, he was appointed assistant to Langenbeck (considered the most prominent surgeon of his time) at the Charite, the Figure 8: The German surgeon Bernhard von Langenbeck (1810-1887), remembered as “the father of the surgery residency”, in 1859. He was teacher of Billroth.

causa pulmonum affectionis quae nervio vago utroque dissectro

University of Berlin’s hospital until 1860. This was another inflexion point in Billroth’s career. He regained enthusiasm for his work and study. He spent many hours looking through a microscope. As a result he became an authority in histology and pathology which he applied to his surgical practice. He

exoritur” (in Latin), where he described the effects of vagotomy

later on manifested he had spent so much time behind the

and the value of tracheotomy. On September 30th, 1852,

microscope as standing next to the surgical table.

Billroth completed his doctorate studies from the University of Berlin (figure 13).

In 1856 he was appointed “Privatdozent” (lecturer) in

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Surgery and Pathological Anatomy. In Berlin, still ignoring which branch he would finally choose, Billroth applied to fill a vacancy in Pathology. He was disappointed for not getting the position but had to admit the defeat since he was competing with Rudolf Virchow (figure 15). As a matter of fact, he considered this event as an omen to choose surgery as his vocation. During his training in Berlin, he wrote eleven articles, most of them about normal and pathologic histology. In 1855, he produced his first monograph on polyps and concluded that benign and malign polypoid tumors of the colon were related, and suggested its early treatment. He published several works on cystic tumors of the testis, on the development of blood vessels and on compared anatomy of the spleen. It was in Berlin that Billroth met his wife Christine, daughter of the court physician Heinrich Sabatier Michaelis (1791-1857) and of Karoline Eunike. They married in 1858 (figure 16) and, of

Figure 10: Moritz Romberg (1795-1873), one of the few neurology innovators of Europe during the period 1820-1850. He described his famous maneuver to test proprioception in tabes dorsalis.

their four daughters and a son, only three daughters survived. In 1859, the Department of Surgery in Zurich became vacant, and Theodor Billroth applied for the job. This time he was full of hope, despite the fact that the surgeon of Munich Johann von Nussbaum (1829-1890), also a disciple of Langebeck, was initially the favorite candidate. However, under the pressure of the University of Munich, Nussbaum was forced to retire from the competition and Billroth was appointed to the chair. With the connivance of Langenbeck, Billroth was given the news in a closed envelope that was discretely placed under his Christmas tree. Zurich When Billroth arrived to Zurich in the year 1860 he was only 31 years old. It was in Zurich that he gained his vast surgical experience and conceived his ideas about the formation of a surgeon. He created both the Department of Pathology and

Figure 11: German physician Ludwig Traube (1818-1876), co-founder with Rudolf Virchow of German experimental pathology.

of Ophthalmology, and was in charge of the construction and organization of the hospital, including the training of nurses. In Zurich he published several books that became world famous: In 1862, he published “Beobachtungsstudiën Uber Wundfieber und accidentelle Wundkrankheiten” about “wound fever” and, in 1863 “Die allgemeine Chirurgische Pathologie und Therapie” (“General Surgical Pathology and Therapy”) (figure 18). His most impressive work was the documentation of all of his surgical work to the date: published in 1869, “Chirurgische Klinik Zürich 1860-1867” was a complete and honest audit of his complete surgical work in Zurich. He stated: “those surgeons who cannot honestly inform of their results are like charlatans”. This publication was soon admired by the surgical world and

Figure 12: The German anatomist and physiologist Johannes M¸ller (1801-1858), who made important contributions in the physiology, neurobiology, embryology and zoology fields.

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Page _ 31 Figure 13: Billroth in times of his doctorate.

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provided greater legitimacy to the discussions on morbidity, mortality and techniques, with resulting improvement in patient selection. A new edition of the compilation, along with his subsequent experiences from Vienna, was published in 1879. Billroth was also dedicated to teaching and writing on history of surgery. He approached many surgery traditional problems such as healing and treatment of wounds, inflammation and hemorrhage, both from the clinical and anatomical pathology perspective. He is also remembered for his contribution to a better understanding of febrile syndrome in wounds. In 1865, he had the fortune to meet the brilliant musician Johannes Brahms (figure 19) with whom he established a life lasting friendship. Brahms was born in Hamburg in a humble context, but his exceptional musical talent compensated for his poor education and knowledge. Although Billroth came from an intellectual background, both friends got along very well (Later, they had some disputes) Billroth was so musically talented that sometimes he was invited to direct the Zurich Symphony Orchestra. In 1862 and 1864, respectively, he refused Rostock’s and Heidelberg’s Surgery Chairs, however he felt Zurich was not his last challenge. Once he jokingly told one of his colleagues in

Figure 14: Albrecht von Graefe (1828-1870), pioneer of German ophthalmology. He was the first to use the ophthalmoscopy (invented by his compatriot Ludwig von Helmholtz) on a daily basis.

pathology: !“If I stay here much longer I am going to develop a fatty degeneration!” During his seven years stay as director in Zurich, Billroth notably increased his fame and helped further develop the institution. Vienna When professor Franz Schuh (figure 20) retired from the Second Surgery Clinic at the Vienna General Hospital (the famous “Allgemeines Krankenhaus”), Billroth applied to occupy his position (figure 21). Fortunately for him and for Vienna he was appointed Chief of the Service and professor of Surgery at the University of Vienna. His appointment was somewhat surprising since Billroth was of German origin and the two countries were somewhat opposed. He called the best possible assistants and obtained major support from his new colleagues. Additionally, he became an Austrian citizen. Billroth had a special way of teaching: he tried to inspire his assistants by challenging them to solve problems on their own, instead of teaching them didactically. He explored, developed

Figure 15: Rudolf Virchow (1821-1902), pioneer of the pathological processí modern concept through his “cellular theory”. He is considered the father of modern pathological anatomy.

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and invented, but, at the same time, inspired his students to be

of assistant for the role of professor and vice versa, as he had

original and to act independently. He compared himself with

done before in Zurich.

a miner who shows his assistants the way after the dynamite

At times, after these scientific discussions occurred, they

exploits. He fostered debates and discussions among his

amused themselves having dinner and listening to music

subordinates, and sometimes he made them change the role

until late at night. His assistants loved him like a father and he

Figure 16: Christel Michaelis and Theodor Billroth (aged 29) at the time of their marriage.

Figure 17: Theodor Billroth and Johann Nussbaum, both candidates for the Surgery Chair of Zurich (1859).

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referred to them as “my sons”. Billroth’s musical talent came from both sides of his family. He played piano, viola and violin. In Zurich, he had been a music critic for local newspapers. He really enjoyed his music with Brahms, who had also moved to Vienna (figure 22). Eduard Hanslick (figure 23), a very well-known music critic of that time, joined them to form a highly-talented trio (figure 24). Most of Brahms’s manuscripts were first tested at Billroth’s home in Vienna. This tradition was rightly named “noctis primae ius” by Hanslick. Brahms dedicated his first two strings quartets (opus 51, I and II) to Billroth. Billroth himself composed several music pieces, but he was so much dissatisfied that burned most of them in his last years. Billroth and Brahms wrote each other a vast number of letters (331) that were published in 1933. In Vienna, Billroth worked long hours. He started with his clinical surgical work, continued with his music and wrote scientific articles and letters very late at night. Evidently he needed few hours of sleep. He later on recognized he had used the life’s energy as a lit candle on both sides.

Figure 18: “Die allgemeine Chirurgische Pathologie und Therapie” (Billroth, 1863).

Figure 19: German musician and compositor Johann Brahms (18331897) in 1862.

Figure 20: Franz Schuh (1804-1865), who made important progresses in surgical practice in Vienna. He was the first Austrian physician to use ether as anesthetic.

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In 1870, when the war between France and Germany broke out (“Franco-Prussian War”), conflict that emerged from tensions caused by German unification, Billroth felt the need to gain more experience in war surgery. In 1859, he had published a historical treaty with literature review on the treatment of bullet wounds, though in 1870 he noticed that

Vincenz von Czerny (figure 25), he volunteered for the war, working in hospitals in Weissenberg and Mannheim. 

Basic care of the war-wounded turned out to be poor (figure 26). Billroth assured “The impossibility of providing shelter

the practice was inadequate. Thus, together with his assistant

or food to patients makes the surgeon also become useless”.

Figure 23: The musician critic Eduard Hanslick (1825-1904)

Figure 24: Hanslick, Brahms and Billroth (ca. 1890).

Figure 22: Brahmsí Statue in Vienna (photograph A. Buzzi, 2012).

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Figure 21: Billroth in 1867, when he arrived to Vienna.

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of

weekly Clinical Journal of Berlin”) and in the famous monograph

humanitarian, surgical and nursing standards. He covered

He

contributed

greatly

to

the

improvement

“Briefe aus den Chirurgische Kriegs-Lazaretten in Weissenberg

the whole organization of military hospitals, surgical services

und Mannheim” (“Letters from Surgical War Hospitals in

provision and military transport of the wounded. He organized

Weissenberg and Mannheim”), published in Berlin in 1874.

the writing of case stories and published his experiences in letters directed to the Berliner klinische Wochenschrift (“the

In the end, he felt deeply affected by the terrible war and wrote to his wife assuring that he had definitely seen bullet wounds in each and every square centimeter of the body.  Having returned after the war, Billroth focused completely on developing his surgery. He was one of the first European surgeons that insisted on the need of asepsis during operations. Also, he started using chloroform as anesthesia during his surgeries. He is very well regarded for being concerned with his patients’ well-being. He was a pioneer in the study of bacterial causes of wound fever, as evidenced by “Untersuchungen über die Vegetationsformen von Cocobacteria septica” (“About researches on septic vegetation of cocobacterias) in 1874. In this study, he depicted, for the first time, the bacteria which he named streptococcus. Although he failed to understand the correct causal relation, the German physician Robert Koch (figure 27), who described the bacterial etiology of infections, later on declared having based his investigation on the work of Billroth. Yet, Billroth had informed fifty years before the Scottish Alexander Fleming that penicillin fungus had an influence on bacterial growth.

Figure 25: Vincenz von Czerny (1842-1916) accompanied Billroth to the Prussian War. He was a pioneer of oncologic surgery.

Initially, Billroth was not a great believer of British physician

Figure 26: “Battle scene of Franco-Prussian War” (W. Beauquesne, 1896). Billroth was very affected by the wounds of this war.

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Joseph Lister’s work (figure 28) on antisepsis with carbolic acid. He reported having seen adverse effects attributable to the use of the acid (fenal) and thus he used several alternatives for his bandages and sponges (thymol, alcohol, lead acetate solutions and camphorated wine) Later on, convinced of the progresses achieved by the asepsis, Billroth said: “with clean hands and conscience, less experienced surgeons achieve better results than the most famous surgery professors of long ago”. It is worth noting that Hungarian Ignaz Semmelweis’ achievement (figure 29), twenty years before Lister’, in reducing the infections’ rate with antiseptic measures such as hand washing, was completely ignored by his colleagues at the hospital of Vienna where he worked. With the threat of surgical infections nearly eradicated, Billroth proceeded to operate on organs that had hitherto been considered inaccessible. In 1871, he was the first to perform an esophagus resection and, in 1873 he performed his first laryngectomy. Later on, he continued performing many other similar operations of the stomach, intestine and pancreas to remove malignant tumors. He was the first surgeon to excise a rectal cancer and, by 1876 he had performed 33 such operations. These operations were both difficult and hazardous for the patient. However, Figure 27: Robert Koch (1843-1910) in 1900. He discovered cholera and tuberculosis bacilli. He established his famous “postulates” to determine the causal agent of an infectious disease.

Figure 29: The Hungarian physician Ignaz Semmelweis (1818-1865) in 1860. He also worked at the General Hospital of Vienna where he advocated the hand washing to prevent puerperal fever, reducing diseaseís mortality, many years before Louis Pasteur published the microbial hypothesis and Joseph Lister expanded the idea of sterile surgery to the remaining medical specialties.

Figure 28: The English surgeon Joseph Lister (1827-1912), in 1902. He was the pioneer of surgical asepsis and antisepsis, introducing the use of carbolic acid (today known as phenol).

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taking into account the conditions in which he worked, most of Billroth’s operations were successful. With the six ovary removals performed by him before adopting the antisepsis (which did not use systematically until 1875), Billroth demonstrated his outstanding technical skills as a surgeon. His methods of resection, although modified, remained in use for many years. Plastic surgery, especially of the face, was another of his specialties. The success of gastric surgery By 1881 Billroth had made intestinal surgery seem almost commonplace and was ready to attempt what appeared in his time as the most formidable abdominal operation conceivable: excision of a cancerous pylorus (the lower end of the stomach). Since the middle of the century and until 1880’s, some surgeons performed occasional stomach operations Figure 30: Karl Gussenbauer (1842-1903), Billrothís disciple, in 1902. By this time, he had already succeeded his teacher in the “2nd Surgical Clinic of Vienna”, and he was the Rector of the University of Vienna.

that had mostly failed and resulted in the patient’s death.  His successful execution of the operation caused a great sensation and initiated the modern era of surgery. It was an adequate, effective and perfectly regulated surgical procedure, and therefore subject to immediate dissemination: partial or subtotal gastrectomy with gastroduodenal anastomosis, today known as “Billroth’s operation I”. By 1885 he had created the modification with gastrojejunal anastomosis, which we call “Billroth’s operation II”. For many years, Billroth and his assistants had been preparing and studying the viability of pilorectomy in dogs. His disciples Karl Gussenbauer (figure 30) and Alexander von Winiwatter (1848-1917) detected an opportunity to resect

Figure 31: Austrian stamp with the image of the Czech physician Karls von Rokitansky (1804-1878), founder of modern pathologic anatomy. Virchow called him “The Linnaeus of pathologic anatomy”

pyloric carcinoma from the prolific material of autopsies performed by the brilliant pathologist Karl von Rokitansky (figure 31), Professor of Pathological Anatomy in the University of Vienna and Chief of Service in the General Hospital: 903 cases of this carcinoma were found out of 61.000 autopsy protocols, and more than one third of the total was not with metastasis. Thus, both resection and healing were theoretically possible. The first resection for gastric cancer was performed in Paris by Jules Emile Pean (1830-1898) in the year 1879, while the second one took place in Kulm (Poland) and was performed by Ludwik Rydigier (1850-1920) in 1880. The patient operated

Figure 32: The General Pathologic Anatomy Institute of Vienna, where Rokitansky performed more than 100.000 autopsies (photograph A. Buzzi, 2012).

by Pean died five days after surgery while Rydigier’s in just 12 hours. Billroth’s first operation took place on the 29th of January, 1881. The patient was Therese Heller, a 43 years old woman, with pyloric syndrome. She was operated under chloroform anesthesia, prepared by Barbieri, which enabled Billroth and his team to concentrate on the surgical technique only. The

Figure 33: Surgical technique of the first gastrectomy (Billroth, 1881).

surgery room’s temperature was maintained at 25 ºC and

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precautions as regards modified listerian antisepsis were

Therese Heller recovered with no complications; except

taken (no carbolic acid used). A transversal incision was made

for the discomfort of a sacral eschar which she already had on

above the palpable tumor, which was mobile enough to be

the day of the operation. She started eating normally and was

extracted through the 11 cm incision. After ligature of blood

released from hospital 22 days after the operation.

vessels, Billroth proceeded to resolve the expected diameter divergence between the two resection margins. First, he closed

Billroth, who was aware of the importance of the operation,

up most of the greater curvature, with 21 Lembert stitches,

had already written, within that historical period of time, to Dr.

and then he performed the anastomosis with 33 interrupted

Wittelshofer, editor of the”Wiener medizinische Wochenschrift”

stitches (figure 33). All stitches were done with the carbolized

(“Vienna Weekly Journal”), saying that the operation had been

silk devised by von Czerny (figure 25). While operating, Billroth

a success. His article was published seven days after the

identified and removed several pathological lymph nodes.

intervention and the news spread quickly around the world.

Figure 34: Pathologic anatomy specimens from the first gastrectomy and autopsy.

Figure 35: The Josephinum, where the Museum for the History of Medicine of the University of Vienna is hosted (photograph A. Buzzi, 2013).

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Three months after the surgery, the symptoms of a recurrent disease appeared and the patient died a month later. The autopsy was carried out by pathologist Zemann at the patient’s domicile. Both, the stomach operated on and the surgical piece removed four months before, are still exhibited at the Josephinum (figure 34), the Museum for History of Medicine of the University of Vienna, housed at the building where Emperor Joseph II had commanded the construction of the “Medizinisch-Chirurgische Militärakademie” (“MedicalSurgical Academy”) in 1785. His second and third patients with similar tumors died after the resection. The twisting of the recently anastomosed Figure 36: Scheme of “Billroth I” and “Billroth II” operations.

duodenum

and

the

invasion

of

the

pancreas

were,

respectively, the recognized causes. Wolfer, another Billroth’s assistant, successfully performed the fourth operation, while his instructor was abroad. He fully depicted his

Figure 38: Current view of the Old General Hospital of Vienna (photo A. Buzzi, 2012)

Figure 37: The Czech surgeon Anton Wölfler (1850-1917), disciple of Billroth, who afterwards became Professor of Surgery of the University of Prague.

Figure 39: Since 1988 the Old General Hospital of Vienna is the campus of the University of Vienna (photo A. Buzzi, 2012).

Figure 41: The “1st Courtyard” (“Hof 1”) of the Old General Hospital of Vienna (now the university campus). Billrothís statue is placed there.

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experience in “Über die von Herrn Profesora Billroth ausgeführte

Initially, the mortality and morbidity rates of these

Resectionen des carcinomatöse píloro”. This type of resection

operations were too high. Even in Billroth’s clinic, those rates

and gastroduodenal anastomosis was afterwards known as

were around 50%, though by improving both the experience

“Billroth’s operation I” (figure 36)

and the indications, the results also improved.

On that same historical year, his disciple Anton Wölfler

In 1890, Billroth had already performed 41 gastric

(figure 37) performed the first gastroenteric anastomosis

resections; 19 of them were successful. His work contributed

(antecolic) for an inoperable pyloric carcinoma. This procedure

to significantly incrementing the available information of

was the basis for the operation that Billroth and his disciple

gastrointestinal tissues related to cancer, its origin and

Viktor von Hacker carried out in January, 1885 for a similar

physiology.

carcinoma. Since the patient was too weak, the procedure was planned in successive phases: first, a gastrojejunal

Several physicians from abroad visited Billroth, and he was

anastomosis in order to bypass the obstruction and second, the

consulted with increasing frequency by the most important

tumor resection. However, during the operation the patient’s

European personalities.

condition improved so much, they decided to continue. After the tumor resection, the opposite sides of the duodenum and

Nowadays, the “Old General Hospital of Vienna” (figure 38)

the stomach were closed up. Later on, this type of procedure

is home to the University of Vienna campus (figure 39). A walk

(resection, duodenum closing and gastrojejunal anastomosis)

along the building is a journey through 200 years of Viennese

was to be called “Billroth’s operation II (figure 36).

history of medicine: its courtyards and gardens are full of monuments, busts and plaques recalling important medical

Several variations have been introduced to these two procedures, which are named after numerous eponyms.

achievements (figure 40). There is a life-size statue of Billroth (figure 42) in the first courtyard (figure 41), and his “Second

Figure 40: Campus of the University of Vienna, where the Old General Hospital of Vienna used to operate (photo A. Buzzi, 2012).

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Surgical Clinic” in one of the corners above the passage that

created, organized and partly funded the “Rudolfinerhaus”

leads to the second courtyard (figure 43) is where Billroth made

(figure 46), a training center for nurses, which has continued to

history: In 1871, he performed the first esophagectomy, in

this day and was named in honor of Archduke Rudolf of Austria

1873 the first laryngectomy, and in 1881, the first gastrectomy.

and Crown Prince of Austria (figure 47), son of Emperor Franz Joseph I and Empress Elisabeth (“Sissi”).

This 2000-bed hospital opened its doors on August 16th, 1784 at the initiative of Emperor Joseph II (figure 44). Only 20

Billroth was concerned about the huge number of poorly

physicians and surgeons and 140 assistants were necessary

educated people in Eastern Europe which moved to Vienna

for the full assistance operation of these 2000 hospitalization

to be trained as surgeons and physicians. As many of them

beds and for urgencies.

were Jews, Billroth was sometimes unjustly accused of antiSemitism.

The School In Billroth’s own mind, the greatest accomplishment he could make would be the creation of a high quality Surgery School to continue his work for the benefit of the whole population. He wrote: «The greatest happiness of my life was founding a school that conveys my scientific and humanitarian goals and aspirations, thus ensuring a legacy for the future” Many of his disciples held the surgery chairs in several European countries (figure 45), spreading Billlroth’s approach to clinical research, treatment and monitoring of patients. Some of them held more than one Chair, successively: Karl Gussenbauer and Alexander Winiwarter in Lüttich (Belgium), Friedrich Salzer, Albert Narath and Anton Eiselsberg in Utrecht,

In his clinic, Billroth organized the work in order for surgeons to get familiar with all the scientific surgery issues, surpassing the mere technical training. With the objective of performing regulated operations suitable for learning, they developed anatomopathological and experimental studies aimed at clarifying the physiopathology and the pathological anatomy of both gastric injuries and of new situations created by experimental surgical methods, in corpses and animals. Billroth’s teaching covered surgery of almost all areas of the human body and he managed to establish a long lasting school that spread all through Europe and became the driving force of scientific surgery in the last third of the 19th century.

(The Netherlands), Vincenz Czerny in Freiburg (Germany), Vincenz Czemy and Albert Narath in Heidelberg (Germany), Anton Eiselsberg in Königsberg (Prussia), Johann Mikulicz in Cracow (Poland today), Karl Gussenbauer, Anton Wölfler, Hermann Schloffer and Karl Maydl in Prague (Czech Republic today), Viktor Hacker and Schloffer in Innsbruck, Anton Wölfler and Viktor Hacker in Graz (Austria). Billroth introduced the careful medical history taking, record keeping and temperature measuring, as well as the discussion and follow up of all his patients’ results, including failures and mistakes. In 1876, he published his famous book: “Über das Lehren und Lernen der medizinischeWissenschaften an die Universitäten der Deutsche Nation, nebst allgemeine Bemerkungen über Universitäten” (“About the teaching and learning of medical sciences in German universities along with general comments on the universities”). Several editions were published and translated into many languages. His methods and educational schemes have been copied all over the world. He was not only concerned about the training of his assistants, but also about the training of general practitioners and nurses. The book “Die Krankenpflege en Hause und Hospitale” (“Home and Hospital”) of 1883, covered all aspects of nursing both at home and in the hospital. He

Figure 44: Statue of Emperor Joseph II at the Old General Hospital of Vienna, which he founded in 1784 (photo A. Buzzi, 2012).

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Figure 42: Billroth’s statue in the “1st Courtyard“ of the Old General Hospital of Vienna (now the university campus).

Figure 43: Billrothís “2nd Surgical Clinic” was on the first floor, above the passage that leads to the “2nd Courtyard”, where he performed the first esophagectomy in 1871, the first laryngectomy in 1873, and the first gastrectomy in 1881 (photo A. Buzzi, 2012).

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His surgical school remained open after his death until 1938.

This painting is of huge historical importance as it depicts with precision a surgical operation of late 19th century.

In a painting of 1889 by Adalbert Seligmann (1862-1945),

Seligmann also evidences the leadership of a renowned

titled “Billroth in the operating theatre” (figure 48), Billroth is

surgeon and educator. Today, the artwork is housed in the

represented when he was sixty, at the top of his professional

“Belvedere Museum” of Vienna.

career. He turns his head away from the patient, perhaps to give some explanation to the audience, while one of the seven

We owe his surgical achievements, which he attained with

assistants that surrounds him and the patient gives him a

thorough attention to each and every scientific and technical

clamp. The patient is in a semi-seated, supine position. His head

detail, to caution and not to risk: “One may perform surgical

has been shaved. According to the artist’s notes, the painting is

procedures only if there is a chance of success. To operate without

about a neurotomy to treat a trigeminal neuralgia. The patient

having a chance means to prostitute the beautiful art and science

is administered general anesthesia by the open-drop method:

of surgery and make it suspicious before colleagues and non-

a volatile liquid anesthetic agent is dripped, one drop at a

colleagues. But, how can one measure the chance of success?

time, onto a porous cloth or mask held over the patient’s face.

Through the tireless study of our science, the severe critic of our

Billroth preferred a mixture of chloroform, alcohol and ether,

and other’s observations, the most accurate investigation in

anticipating the modern trend of administering several agents

each particular case and through the critical evaluation of our

within the anesthesia. Billroth is also using Lister’s method of

experiments”.

sterilization and asepsis. Rubber gloves were not being worn Above successes, he appraised the development of solid

in surgery.

methods for typical operations, so that surgery not be effective The light from a huge window at the right of the surgeon

only in few hands. “The greatest happiness of my life was founding

illuminates the room. There are many people in the

a school that conveys my scientific and humanitarian goals and

grandstand witnessing the operation, including the artist, that

aspirations.”  He achieved this aspiration in an exceptional

painted himself sat on the first row’s right side, and the Duke of

manner and some well-known disciples such as Czerny,

Bavaria, who used to assist to operations and conferences to

Gussenbauer, Winiwarter, Wölfler, Eiselsberg, Mikulicz or

keep himself entertained, sat in on the opposite side.

Riedel, among others (figure 49), joined the already mentioned

Figure 45: Billroth with his assistants (1871), from left to right: Robert Gersuny, Vincenz Czerny, Billroth, Menzel and Steiner. Standing, from left to right: Karl Gussenbauer, Lobmayer, Satller, Vladan GjorgjeviÁ, Pernitza and Pfleger.

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ones in their efforts to develop modern surgery across Europe. He is regarded by many as the leading German surgeon of late 19th century, as well as an outstanding surgical technician who was able to bring experimental medicine into clinical practice. For that time, he had radical ideas on surgical training. He proposed prolonged surgical training upon completion of medical studies consisting of preliminary work in hospitals followed by performing operations on cadavers and experimental animals. This should be followed by a 2-3 year assistantship in a surgical department with studies of surgical literature and the acquisition of advanced practical skills. His ideas were adopted by many. Billroth founded the House of the Society of Physicians in Vienna or “Ärztenhaus” (“The House of Physicians”); today called “Billroth-haus” (The house of Billroth) (figure 50). The house’s large meeting room was designed by Billroth himself (figure 51). Figure 46: The “Rudolfinerhaus”, with Billrothís bust.

Billroth was a member of the Academy of Sciences in Vienna and honorary member of thirty-two scientific societies. He was also honored with sixteen decorations, among them the one granted by the Austrian government, rarely conceded to physicians. He published several books and articles on surgery and pathology, nearly 150 publications. During his years in Vienna he was offered several Chairs in several famous institutions, but he did not accept. The most difficult one was in 1882, when his respected teacher, Bernhard von Langenbec, retired from Berlin (figure 6) at the age of 73. Although very honored by the offer, Billroth felt so much at ease in Vienna that he refused. Von Langenbeck was surprised and tried again: “You cannot refuse to the imperial city of Berlin”, to which Billroth answered: “There is only one imperial city, and that is Vienna”. In the end, Ernst von Bergmann, the father of asepsis, became the successor of von Langenbeck in Berlin. The decline In 1887, a severe lung infection threatened Billroth’s life and resulted in a cardiac weakness that worsened during his last years. He never recovered his previous good health and his physical strength diminished. He had often suffered from melancholy and depressive states and therefore he concentrated more on philosophy, psychology, ethics and sociological problems. Figure 47: Rudolf, Crown Prince of Austria. Billroth named the Institution for training nurses in his honor. In 1889, he died (according to the official version) as part of a suicide pact with his mistress, Baroness Marie Vetsera, in the hunting lodge of Mayerling. The scandal became international news and continued to be motive of speculation a century after.

During his summer holidays, Billroth rested at his house in St. Gilgen, a city near Salzburg (figure 52), and in winter, at a hotel in Abbazia, part of the Austro-Hungarian empire, on the Istria peninsula (now Opatije, in Croatia). Usually he would

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Page _ 47 Figure 48: Famous canvas by Adalbert Seligmann titled “Billroth in the operation theatre� (1889).

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return to Vienna looking younger. However, he considered work the best medicine to fight depression and his impetus to achieve goals never abandoned him. Once he wrote: “My strength is leaving me, although the demand of people for which I can still give increases”. While his health fluctuated, 1892 was the year of his 25th anniversary in Vienna. His pupils wrote a publication titled “Tribute” which included some of his original scientific contributions. Some of them thought that would be the last time they saw the great man. The last thing he could create was the institution for nursing training (“Rudolfinerhaus”) and the building for the Royal Society of Physicians in Vienna (now “Billroth-haus”). It was here that he gave his last lecture on aneurysms. One month before his death he planned his retirement, during which he expected to lay the cornerstone for his new surgical clinic. Prophetically, during his last vacation in Abbazia, in early 1894, he suspected he would soon be dead. In fact, in several occasions he dreamt about doing his own post-mortem examination. After that, shortness of breath, sleep disorders and Figure 49: Billroth with his assistants from 1867 to 1889.

arrhythmias followed. Digitalis he had used for many years no longer seemed to help. His wife was by his side when he died suddenly on February 6th 1894. He prepared a letter in which he thanked his wife and family for their love and loyalty and apologized for his mistakes. Vienna massively grieved for the death of such a giant, who was not only known as a medical and scientific genius, but also for his artistic, cultural and political contributions. He was buried as if he was a king at the central cemetery of Vienna (figure 54), close to Beethoven and Schubert’s graves and to the golden statue of Mozart, whose grave is unknown. However, despite his fame, Billroth was always a modest man. He always gave full credit to his teachers. A phrase of Goethe became one of his favorites: “Everything that one achieves is owed to others”. On November 7th, 1897 Billroth’s statue was inaugurated at one of the arcaded courtyard of the University of Vienna (figures 55 and 56). He was the first surgeon whose image appeared on bill

Figure 50: The “Billroth-haus” or “Billroth house” (photo A. Buzzi, 2012).

notes (figures 57 and 58) to commemorate his one hundredth

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birth anniversary (1929). He also appeared on coins (figure 57) and stamps (figure 59). He was succeeded by his disciple Carl Gussenbauer, a pioneer of modern pancreatic surgery, in the Second Surgical Clinic. Epilogue Christian Albert Theodor Billroth was a human and competent doctor, a surgical artisan. He was a conscientious scientist: he first tested the new surgical procedures on corpses and animals before applying them to patients. He informed the results of his operations in a completely honest manner and wanted to learn from his failures and errors and for the benefit of others. He was a prolific writer. He maintained correspondences throughout his entire life. His system for training surgeons was emulated everywhere, as well as his organization in hospitals and in war circumstances. He was an artist, mainly as a musician. In his opinion, science and art derive from the same source: fantasy and imagination. He was an initiator: he created the institution for nursing training (“Rudolfinerhaus”) and the Royal Society

Figure 52: Billroth in St. Gilgen (September, 1892).

Figure 51: Meeting room of “Billroth-haus”.

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“Only the man who is familiar with the art and science of the past is competent to aid in its progress in the future.” «A person may have learned a lot and be an exceedingly skilled physician, but aroused little confidence in his powers... The way of dealing with patients, to win their confidence, the art of listening to them (the patient is always more anxious to talk than to listen), of soothing and consoling them or of drawing their attention to serious matters, - all this cannot be learned from books. The student can learn these things only from immediate contact with the teacher, whom he will unconsciously imitate ... Patients long for Figure 53: Billroth in 1892.

the doctor’s daily visit; it is the event upon which all his thoughts and emotions turn. The physician can do all he has to do with speed and precision, but he must never appear to be in a hurry, and never absent-minded. » «He who combines the knowledge of physiology and surgery, in addition to the artistic side of his subject, reaches the highest ideal in medicine. » «The pleasure of a physician is little, the gratitude of patients is rare, and even rarer is material reward, but these things will never deter the student who feels the call within him. » «The principle, method and the goal of investigations is recognition of truth, even though the truth may be in conflict with our social, ethical and political circumstances. »

Figure 54: Billrothís grave at the Central Cemetery of Vienna.

«He who cannot quote his therapeutic experience in numbers is a charlatan; be truthful for clarity’s sake, do not hesitate to admit failures, as they must show the way and place of improvement.» Bibliography Absolon KB. Theodor Billroth’s formative years (1829-1894)- a study in memory of the subject’s 150th birthday. Am J Surg 1979;137:394-407. Absolon KB. The surgical school of Theodor Billroth. Surgery

Figure 55: One the courtyardís hall of the University of Vienna with commemorative busts, statues and plaques of famous personalities, among them, Billroth (photo A. Buzzi, 2012).

of Physicians (“Ärztenhaus”). He was an innovator: he was the first surgeon to perform a gastrectomy, a laryngectomy, and a

1961,50: 697-715 Aguirre Marco CP. Instituto de Historia de la Ciencia y Documentación, Universidad de Valencia-CSIC, Abril 1999. Allgower M, Trohler U. Biographical note on Theodor Billroth. Br J Surg 1981;68:678-9

oesophagectomy. His vast technical experience with intestinal

Androutsos G. Theodor Billroth (1829-1894) and other

anastomosis and thyroid, liver, spleen, uterus, kidneys, urinary

protagonists of gastric surgery for cancer. J Buon 2004, 9:215-

bladder and prostate operations, established him as an icon

20.

on whose shoulders all of surgery stands.

Billroth T. La patología quirúrgica general y su terapéutica en 50 lecciones trad. de la quinta edición alemana por L.

Billroth left the following phrases to his colleagues and they denote his position and thoughts towards medical sciences.

Góngora y R. Tuñón. Seville, La Andalucía, 1871. Browne H. Theodor Billroth – surgical pioneer. Ir Med J 1981;74:2

«The future of a school is based on the work of the pupils, as the future of a country on the work of its citizens. » 

Brunschwig A, Simandl E. First successful pylorectomy for cancer. Surg. Gynaecol. Obstet 1951, 92: 375-379.

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Busman DC. Theodor Billroth (1829-1894). Acta chir belg 2006, 106:743-752. Cormanm L. Classic articles in colonic and rectal surgery: Christian Albert Theodor Billroth 1829-1894. Dis. Col. Rect 1986,29: 284-287. Ellis H. A history of surgery. Cambridge University Press, 2001. Kazi RA, Peter RE. Christian Albert Theodor Billroth: Master of surgery. J Postgrad Med 2004;50:82-83 Kwan H, Mclaren R, Peterson T. The life and times of a great surgeon: Theodor Billroth (1829-1894). J Invest Surg 2001;14:191-4. Lesky, E. Billroth als Mensch und Arzt. Dtsch. Med. J., 1966,17:739-743. Lesky, E. La cirugía austriaca. En: Laín Entralgo P. Historia Universal de la Medicina. Ed Salvat, Barcelona, 1974. Lewis JM, O’Leary JP. Theodor Billroth: surgeon and musician. Am Surg 2001;67:605-6. Majno G, Joris I. Billroth and Penicillium. Rev Infect Dis. 1979, 1:880-4.

Figure 56: Tribute to Billroth in one of the courtyardís hall of the University of Vienna (photo A. Buzzi, 2012).

Mclaren N, Thorbeck RV. Little known aspect of Theodor Billroth’s work: His contribution to musical theory. World J Surg 1997;21:569-71. Miehlke A. Theodor Billroth, 1829-1894. Arch Otolaryngol 1966;84:354-8. Roses DF. On the sesquicentennial of Theodore Billroth. Am. J. Surg 1979,138: 704-709.

Figure 57: Billroth in an Austrian 2 shillingsí coin.

Rutledge RH. Theodor Billroth : A century later. Surgery 1995,118: 36-43. Rutledge RH. In commemoration of Theodor Billroth on the 150th anniversary of his birth. Billroth l: His surgical and professional accomplishments. Billroth ll: His personal life, ideas and musical friendships. Surgery 1979;86:672-93 Schein CJ, Koch E. Autobiographic sketch of himself by T. A. Billroth. Am. J. Surg 1978, 135: 696-699.

Figure 58: Billroth in a 50 eurosí coin.

Schein CJ, Koch E. Mikulicz’s obituary of Theodor Billroth. Surg. Gynaecol. Obstet 1979, 148: 252-258 Schwartz AW. Dr. Theodor Billroth and the first laryngectomy. Ann Plast Surg. 1978, 1:513-6. Sigerist HE. Los grandes médicos. Historia biográfica de la medicina. Barcelona, 1949. Strohl E. L. The unique friendship of Theodor Billroth and Johannes Brahms. Surg. Gynaecol. Obstet 1970, 131: 757-761 Wayand W, Feil W, Skopec M. Surgery in Austria. Arch Surg 2002, 137:217-220 Weil PH, Buchberger R. From Billroth to PCV: A century of gastric surgery. World J Surg 1999;23:736-42. Wölfler A. Resection of the cancerous pylorus performed by professor Billroth. Rev Surg 1968, 25: 381-408 Zimmermann L, Veith I. Great ideas in the history of surgery, Baltimore, 1961.

Figure 59: Billroth in an Austrian stamp of 1994.

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FAMOUS PATIENTS

ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Franz Kafka’s Case History Dr. Juan Enrique Perea Assistant Professor of Internal Medicine. School of Medicine, University of Buenos Aires

Kafka’s literary productivity moved forward in different steps. Peaks of creativity and writing were followed by a vast remission. Did his unstable health have any influence over these cycles? Did he write in spite of his illness and distress? From his family history, we know that his maternal great-grandfather died young, when Kafka’s mother was just six years old. His maternal grandmother also died young, after suffering from typhus, and his great-grandmother committed suicide by throwing herself into the Moldova River, in Prague. His paternal grandfather did not reach his elderly years. Kafka’s father suffered from heart disease, which led to his death at the age of seventy-nine. His mother, Julie Löwy, died when she was seventy-eight years old. One of Kafka’s brothers died at the age of two of measles and another of his brothers died when he was six months of meningitis. Kafka’s three sisters died in a concentration camp. Franz Kafka was born on July 3rd, 1883 by natural home birth. He did not suffer from any diseases during his childhood and adolescence. He enjoyed practicing sports such as gymnastics, race walking, rowing and swimming in the Moldava River. As a young boy, he practiced naturism and vegetarianism. He used to eat yoghurt, nuts, chestnuts, dates, figs, grapes, almonds, raisins, bananas, oranges and wholegrain bread. He did not smoke nor drink alcohol, coffee or tea. He was a tall, thin young man. At the age of twenty-four –according to the medical examination he went through to start working for the company Assicurazioni Generali–, Kafka was 1.85 meters (6 feet) tall and weighed about 70 kilos (154 lbs).

Figure 1: Max Brod (left) y Franz Kafka (right)

ted by insomnia, is associated with phonophobia. On October 4th, 1911, he writes: “A tension type sensation over my left eye has become natural”. Headaches gave rise to uncertainty. At the age of twenty-eight, he writes: “I will hardly reach forty, as it is shown by the tension I normally feel in the left half of my cranium. I feel

Somewhere between 1900 and 1905, Kafka started to ex-

it as a leprosy that comes from within, as if I was witnessing an al-

perience the symptoms that would torment him for the rest

most painless necrotomy in which the knife is cutting membranes

of his life. In 1903, he commenced his long road of sickness

as thin as paper very close to those areas of my brain that are acti-

with a visit to Dr. Lahmann’s clinic –Weisser Hirsh–, near Dres-

ve”. He also senses a bilateral headache. The pain is growing in

den. Around 1905, during Kafka’s university years, he mentions

both temples. He believes he will never be able to free himself

suffering from headaches in one of his letters: “Such sense of

from pain. However, in times of euphoria and good sleep, pain

discomfort ought to have a pane of glass when it explodes”. He

wears off.

suffered from a constant, severe unilateral headache. Pain, which lasted for several days and was activated and exacerba-

Between January and June, 1910, he experiences a wides-

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In his diary, he mentions he frequently suffers pains in his chest, particularly when he runs. In 1911, he visits the Erlenbach Clinic, in Switzerland. This is how Kafka describes his feelings while the doctor was carrying out a precordial examination: “The doctor listened over and over again to my heart, kept asking me to change my position, and couldn’t make up his mind. He tapped the area around my heart for an especially long time; it lasted so long he seemed almost absent-minded”. Kafka’s irregular heart rhythm or the presence of a heart murmur may have captured the doctor’s attention. Kafka is afraid of becoming disabled due to heart failure, probably a supraventricular dysrhythmia. He reckons his heart is not healthy. On October 24th, 1911, he writes: “It has been a long time since I am complaining about feeling sick all the time. Yet, I do not have a specific disease”. That year, he records: “At the beautiful age of twenty-eight, I lie here watching for sleep that refuses to come and will only graze me when it does, my joints ache with fatigue, my dried-up body trembles toward its own destruction in turmoils. Nothing can be accomplished with such a body”. Kafka suffers frequent and diverse digestive disorders. This is how he describes his esophageal motility disorders: “The connection between stomach and mouth is partly disturbed, a lid the size of a gulden moves up or down, or stays down below from Figure 2: Kafka and Felice Bauer

where it exerts an expanding effect of light pressure that spreads upward over my chest”. Digestive disorders prevent him from

pread musculoskeletal pain. He writes to his friend Max Brod:

having an adequate diet. He suffers from gastric indigestion

“Lately, I have been experiencing pains in my shoulders, then they

and constipation, which he describes as “blocked intestines”.

slid down to my back, then into my legs, but instead of going on

He is very interested in using a laxative to feel better. With that

into the ground as you might expect, they went up into my arms.

purpose, at the age of twenty-eight he starts treating his cons-

I am nothing but a mass of spikes going through me: if I try to

tipation with a seaweed-based laxative. He rejoices when his

defend myself and use force, the spikes only press in the deeper”.

digestion goes back to normal. “When my stomach is healthy,

Frequently, musculoskeletal pain forces him to remain in bed

I cram myself with herrings, pickles, and all the bad, old, sharp

during the day. He suffers from strong pains in his lower limbs. Between 1911 and 1917, Kafka is daily exposed to asbestos fibers in a factory that was opened by his paternal family and the Hermann family. Chronic insomnia tortures him. He experiences difficulties with the duration and quality of sleep. Waking up constantly, he cannot have a restful sleep. He wakes up exhausted. “Sleeping, waking up, sleeping, waking up… what a life”. This is how he describes his night of insomnia on October 2nd, 1911: “Sleepless night. The third in a row. I fall asleep soundly, but after an hour I wake up. I am completely awake, have the feeling that I have not slept at all or only under a thin skin, have before me anew the labor of falling asleep and feel myself rejected by sleep”. Sleeping

foods. I enjoy in this way not only my healthy condition but also a suffering that is without pain and can pass at once”. He suffers from abdominal distress. In 1912, he looks more and more sick. On June 11th, he is granted a license on the base of the following health certificate signed by Dr. Siegmund Kohn: “I confirm that it is urgently necessary for J.U. Dr. Franz Kafka, clerk for the Workmen’s Accident Institute for Bohemia, Prague, to undergo at least a one-week systematic cure at a well-run institution because of digestive problems, weight loss, and a range of nervous complaints, and to this end he needs to be given at least a one-month holiday”. Following the doctor’s indication, Kafka visits Jungborn (Source of Youth), Rudolf Just’s Therapeutic Institute of natural medicine. In July, he suffered an ankle sprain.

interruptions lead to the deterioration in his daily functioning. He lives with a severe fatigue: “Three nights without sleep. When

He is twenty-nine years old and his weakness torments

I try to do the minimum effort, my strength immediately falls to

him: “The totality of my strengths was so slight that only collectively

the lowest point”.

could they even half-way serve the purpose of my writing”. He pe-

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sleep for the first time. And it stopped and I slept the rest of the night. I felt better than usual”. The following afternoon, he visited a doctor. The doctor examined him and performed a radiological examination. On September 4th, Kafka seeks advice with Friedl Pick, a professor at the Faculty of Medicine at the German University in Prague. The doctor, who was a laryngologist, diagnosed Kafka with tuberculosis in both apexes of the lung. He writes Felice saying his insomnia and headaches had invited this illness. He says that, after the hemoptysis, he still coughs, runs a slight temperature, sweats at night; feels a little short of breath, headaches leave him and he sleeps better than before. Bleeding and tuberculosis have made headaches disappear. It seems that, some time before, he had started spitting something reddish more and more frequently. In 1914, he narrated in his diary the beginning of a pulmonary disease: “It began with a heavy cough. The fits of coughing were so severe that I had to double up when I coughed. They called it the wolf’s cough. I waited until the bursting of some vital blood vessel. But nothing of the kind happened”. Hemoptysis marked the end of the uncertainty that surrounded him since 1910. He was desperate due to his body and his future in that body: “The brain could no longer endure Figura 3: Mílena Jesenska

the burden of worry and suffering heaped upon it. Then the lung spoke up, picked up the burden and alleviated it”.

riodically suffers fainting episodes. Despite everything he goes through, he has hope. Feeling sick, he writes: “Don’t despair. Just

In November 1918, he became ill with the Spanish flu. He

when everything seems over with, new forces come marching up,

travelled to the mountain village of Schelesen, where he stayed

and precisely that means that you are alive. And if they don’t, then

for a month in an inn. In 1920, he goes through periods of total

everything is over with here, once and for all”.

insomnia that extend to more than fifteen days, which make him heavy as a log. He refers to the night as his old enemy.

Tired and without strength, he feels beaten by depression when he reaches his thirty years of age. Even though he does

According to Max Brod, Kafka’s very dark hair had become gray due to insomnia.

not try to commit suicide, he considers this possibility. He is convinced he would be happy on his deathbed, as long as his

By the end of 1920, Kafka was hospitalized. In that clinic,

pains are not excessive, and he would be content to die with

he met the medical student Robert Klopstock. The clinical pat-

someone that dies. In Riva, he visits the clinic of Dr. Hartungen,

tern is characterized by cough, temperature and dyspnea. He

where he spends several months.

experienced prolonged coughing fits. “I am coughing from 9:45 to about 11 without stopping. I then fall asleep but toss about in

In 1915, when he is thirty-one, he writes about an apparent

bed and around 12 I again start coughing and continue till 1:00”.

progressive tuberculosis. A year later, he thinks he might be

He describes the tyranny of cough. He could not recite me-

suffering from a provable organic disease. On August 9th, 1917,

dium-length congratulations without coughing. He suffers acu-

he suffers from his first hemoptysis. This is how he describes it

te episodes of dyspnea. He spends several days in bed with

on September 9th, 1917 in a letter to Felice Bauer: “Precisely four

acute febrile syndrome, which he calls his “rack”. He had trem-

weeks ago, at about 5.00 a.m., I had a hemorrhage of the lung. For

bling attacks. At night, he runs temperatures reaching 38°C

ten minutes or more it gushed out of my throat; I thought it would

(100.4° F).

never stop”. Three years later, in a letter to Mílena Jesenska, he gives sense to this episode: “It began in the middle of the night

In his late thirties, asthenia and fatigue are exacerbated,

with a hemorrhage. I got up, perturbed as one is by everything

and Kafka feels terribly ill. His lassitude overcomes human for-

new. Continual blood. At the same time I was not unhappy, becau-

ce. “I have to work hard just to crouch and lift the corpse a little bit

se it dawned on me for a specific reason that after 3, 4 sleepless

above me”. He loses weight. At his thirty-eight years of age, he

years – assuming that the bleeding stopped – I would be able to

weighs 55 kilograms (121lb). He senses his decay and comp-

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lains about his lack of strength to recover. In his diary, he refers to his heart trepidation. He writes to Mílena Jesenska saying the cause of his pulmonary tuberculosis is just an overflow of his mental illness. He rejects the idea of dying, and he waits until he is diagnosed with a pulmonary engorgement. He describes death as a force of gravity haunting and dragging him. He believes that, given him little strength, he ought to be dead already. He says he will die by suffocation. “For each invalid his household god, for the tubercular the god of suffocation”. He speaks of the lungs as proud, strong, tortured and unmoved creatures. He is afraid of pain, not death. He fights to flee the toxic atmosphere of insomnia, which has worsened, and thinks of suicide. “How would it be if one were to choke to death on oneself?” His doctor confirms the disease is still located in the apex of his left lung and suggests he leaves Prague and visits a clinic specialized in pulmonary diseases.

Figure 4: First row, at the left is Robert Klopstock, and at right, Franz Kafka

pread musculoskeletal pain, where other causes of pain, such

Kafka suffers the devastation of disease. Writing to Max Brod, he says: “How much is it necessary to wait until you have been squeezed so much that, when reduced, you can fill the last hole?” In December, 1923 he suffers attacks of high fever. His health weakens even more. In April, 1924 Kafka is diagnosed with laryngeal tuberculosis and is transferred to the Kierling Sanitarium, in Klosterneuburg. On May 3rd, 1924 Dr. Oscar Beck described Kafka’s condition: “Dr.Kafka feels acute pains in his larynx, especially when he coughs. When he eats, the pain exacerbates so much it is almost impossible for him to swallow food. I could see a tuberculous process in the larynx affecting the epiglottis. I administered an alcohol injection in the superior laryngeal nerve. Dr.Kafka’s lungs and larynx are in such bad a state that no specialist could help him. It is only possible to mitigate his pains with morphine”. Robert Klopstock opposed to the idea of administering morphine. With the torment of laryngeal pain, Kafka pleads: “Kill me, or else you are a murderer”. On the night of June 2 he felt better. He had some fruit and water. He died nd

in the early morning of June 3 , assisted by Klopstock. rd

Clinical comments:

as inflammatory processes or tissue damage, are not found. The dominant finding of fibromyalgia is musculoskeletal pain of variable intensity. It has been characterized as a chronic widespread allodynia. Allodynia is defined as the perception of pain resulting from a stimulus that is normally not painful. In the case of fibromyalgia, pain would be the consequence of a dysfunction in the central control process of pain (nociceptive control), secondary to over expression of pathways that promote the feeling of pain (pronociceptive pathways). It has been shown that a variety of stressors, such as physical traumas, infections and psychological stress, are able to trigger or exacerbate the symptoms of fibromyalgia. Many patients experiencing fibromyalgia report that a severe stressor has preceded the appearance of symptoms. In a group of patients with fibromyalgia, 57% of them presented significant levels of post traumatic stress disorder symptoms, showing a significant overlapping of stress and fibromyalgia. On the other hand, the hypersensitivity of the nervous system would occur as a consequence of loss of the modulating functions in pain sensitivity (antinociceptive), which is normally exercised by the central nervous system. The loss of antinociceptive functions

Since he was twenty, Frank Kafka suffered a number of sy-

would be a consequence of deficiency of neurotransmitters in-

ndromes that –as we will soon explain– are part of the Central

volved in the antinociception, such as serotinin, noradrenaline

Sensitivity Syndrome, aggravated by tuberculosis, which led to

and dopamine. Irritable bowel syndrome and chronic low-back

his death. Since this age, the main symptoms in Kafka’s clinical

pain –which is highly frequent in patients suffering fibromyal-

condition were widespread musculoskeletal pain, headaches,

gia–, seem to reflect deficiencies in the serotonergic and nora-

insomnia, fatigue and weakness, precordial pain, functional

drenergic transmission.

gastrointestinal disorders, cognitive pendularity and depression. When he was thirty-three years old, he suffered his first

It has recently been suggested that fibromyalgia should be

hemoptysis, being diagnosed with pulmonary tuberculosis. He

included within Central Sensitivity Syndrome –which include,

dies seven years later, diagnosed with laryngeal tuberculosis.

among other entities, chronic fatigue syndrome, chronic lowback pain, tension headache and migraine. Clinical patterns

Fibromyalgia is the diagnosis given to patients with wides-

will depend on the specific overlapping of these entities in each

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subject. Thus, for instance, 77% of patients with fibromyalgia

cranium, the duration and recurrence of headaches, which is

have suffered irritable bowel syndrome; 80% of them have su-

associated with phonophobia, the activation of insomnia, as

ffered chronic fatigue and 76% experienced headaches. In this

well as deactivation causes, enable us to believe Kafka suffe-

last case, the clinical impact of headaches is severe. A clear overlapping of diverse psychiatric entities that are part of Central Sensitivity Syndrome has been observed, particularly in a comorbid relationship with fibromyalgia. Patients

red migraine occurring without an aura. He also experienced headaches that affected both temples. The bilateralism of these episodes leads us to infer that he suffered from migraine combined with tension headaches. The clinical impact heada-

can suffer disorders such as depression and anxiety disorders,

ches exercised over Kafka was so important that when he was

with the possibility of fibromyalgia sharing physiopatholo-

twenty-eight he thought he would hardly reach forty.

gical links underlying these psychiatric entities. Up to 79% of patients sense that sleeping badly is an aggravating factor for

On the basis of our analysis, it is possible to conclude that,

fibromyalgia symptoms. Sleep disorders and pain and fatigue

since he was twenty years old –and during his whole adult life–,

are the most common symptoms in patients with fibromyalgia.

Franz Kafka experienced a group of syndromes that today are

What is more, sleep disorders, along emotional distress and

included within Central Sensitivity Syndrome, later aggravated

health problems, are independent predictors of widespread

by tuberculosis. His symptoms – particularly the unbearable

chronic pain. On the other hand, the increase in sleep disturbances results in an increase of pain, disabilities and depression. It should be pointed out that non-restorative sleep is so prevailing in fibromyalgia that it has been set as a parameter to evaluate the result of the treatment for patients with fibromyalgia. Trouble sleeping promotes allodynia, widespread pain, hypersensitivity and chronic fatigue. Patients with fibromylagia frequently complain about cog-

headaches, insomnia, fatigue and extreme weakness, widespread musculoskeletal pain, digestive difficulties and depression– tormented Kafka’s adult life and exerted an influence over the irregular rhythm of the fiction author’s literary work. Suggested readings: 1. Kafka, Franz. The diaries (1910-1923). New York: Schocken

nitive difficulties, which have been called “fibrofog” –the cog-

Books, 1988

nitive haze in fibromyalgia. Clinical features include a slowed

2. Wagenbach, Klaus. Franz Kafka: Pictures of a Life. Random

processing of information, trouble to perform multiple tasks,

House Inc, 1984

memory failure, poor concentration and clarity of thought, and

3. Stach, Reiner. Kafka: The Decisive Years. Harcourt Books,

a deficiency in the executive function. Cognitive dysfunction is

2005

more correlated to pain than depression. Kafka’s depiction of pain leads us to infer the existence of allodynia: “If I try to defend myself and use force, the spikes only

4. Murray, Nicholas. Kafka. Little, Brown, London, 2004 5. Brod, Max. Kafka, a biography. New York, Da Capo Press, 1995

press in the deeper”. Chronic widespread musculoskeletal pain

6. Kafka, Franz. Letters to Felice. New York, Schocken Books.

with allodynia, without any evidence of musculoskeletal disea-

1973

se, leads us to suspect Kafka suffered from fibromyalgia. The

7. Kafka, Franz. Letters to Felice. New York, Schocken Books.

intensity of his headaches, the damage to the left half of the

1990

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Illness & Identity BA Isabel del Valle Medical Humanities Developer of the Literature & Medicine Program in Argentina Partner of Maine Humanities Council

“… not only my body had changed, but I, that other person behind my body, behind my memories, was no longer the same”. Sandor Marai Illness is a complex vital experience that takes place inside each organism but emerges to the surface of a particular existence. It is a disorder for the body and an obstacle for life. Life is a process of personal construction from integrity and imaginary continuity assumptions. However, illness breaks such conviction by questioning the image and the identity. Being ill goes beyond what happens to the affected body; perhaps the worst is what it comes out of it. Perhaps, this is why in the novel Pabellon de reposo, by Jose C. Cela, one of the “patients with tuberculosis” said with conviction that, “…rheumatism is not a disease, pain is welltolerated”. Although, in the interpretative approach of an illness, traditional medical training gives supremacy to the biologic

fragmentation feeling. The body is a constitutive factor of

aspects, the existential ones constitutes the experience-based

the personal identity. During the illness, the body changes

nucleus where subjective, affective, emotional, cultural and

its aspect, gets slower, sets its own pace, takes lucidity away

social factors constitute the experience of being ill.

from conscience,…it separates from the man, to become, sometimes, a stranger.

Being ill is experienced as an internal fragmentation where not only the body is broken but also the self-image,

When the illness affects the man-body relationship, identity

the vital projection and the daily world. Reality begins to be

is also affected. The impaired body reflects a fragmented self-

experienced as different. The world of the sick person suffers

image

threat of dissolution. So felt Hadrian once the illness established in his life. Perhaps, dispossession is the main experience of those Respiratory failure turned him heavy, slow, weighty.

who are ill. The relation with the body is the initial step of this

But illness was impious not only with his body but also with

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MEDICINE & LITERATURE


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his social investiture. He would not be able to walk like before or remain standing as required by Roman ceremonies. Perhaps, Hadrian was better able to tolerate illness than its social and political consequences. Hadrian would no longer be the man he had been used to be. “…this morning, for the first time I came up with the idea that the body, that loyal companion known better than my soul, is but a mangy monster that will end up devouring his lord.”(Memoirs of Hadrian, Margarite Yourcenar) Sometimes personal identity may be affected to the point that it hurts more than the body, the sense of not being any more. Certainly, illness brings along the threat of dissolution of the identity. One of the biggest challenges for those who are ill is to continue to be themselves. The comfortable routine in which Paul Rayment spent his days disappeared along with his amputated leg. This healthy old man of Coetzee’s novel Slow Man, could never imagine the twist his life would take. Metallic noises, screams, pain, more pain, dream… A car that came out of nowhere dragged his bicycle and took, in an instant, part of his body, and with it, his living habits and his identity. The car not only broke his leg, it also broke his self-image. Paul Rayment could never again find himself in that newbody-old.

Susan Sontag, who lived in this shadowy territory, experienced her illness as a change of citizenship. To leave one’s home ground is to detach ourselves from smells, costumes and language. A sort of emotional and experiential exile “Illness is the dark side of life, a more expensive citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a while, to identify ourselves as citizens of that other

On the other hand, medical management can make its contribution to this process of dissolution of identity. Becoming a “patient”, redefinition of social spaces, the role in the relation with the physician, the labelling process that implies the diagnosis, the repositioning before the chronic disease… are just some of the situations in which medical management itself affects personal identity. “…suddenly, by simply climbing the stairs and saying good bye

place” According to Gabriel García Márquez, “…there are times when the person is obliged to be born more than once during his lifetime”. Perhaps, illness is an opportunity to be born in a new way of existence. But the citizenship acquired during illness is not precisely the desired one

to his family, Rusanov had lost everything: position, prestige and

Hence, more than once, the sick is eager to exchange his

even future plans; he had become just another tumor in Ward 13th

identity for that of anyone else. It no longer matters age or

….” Solzhenitsyn

sex; the sole condition is health.

Undoubtedly, illness is a solitary lonely experience.

Therefore in Everyman by Philip Roth, successful New Yorker publicist, tormented by a heart disease, began to

Strangeness and uncertainty accompany the first steps of the ill person that wanders about the corridors of disease with

hate his dear brother. He could not accept the mystery of the inequity between them:

the uneasiness of those who walk through an unfamiliar city. Illness settles the man in the abandonment level.

His body stubbornly cut with the scalpel; while his brother

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Marai’s famous pianist was convinced that “…all this has to do with my life, with music, with my relation with E…” Throughout his life, and especially in the last part, man is faced to make decisions. A person deprived of information is also deprived of the possibility of making a correct choice. When one chooses, the whole previous life is jeopardized. Information protects subject’s identity allowing him to choose according to who he is. In the face of a silence wall, Ilich was deprived of his last choice: choosing how to live his own death. But illness affects not only the personal identity but also the social one. In Anne Fadiman’s novel, The Spirit Catches you and You Fall Down, different interpretation models of disease are confronted. That cultural incomprehension / misunderstanding determines the result of medical management. People live, become sick, suffer and die as marked by the body, nature and culture. lived in the blind ignorance of health. Many literary characters express the conflict of living with an excised identity. The sick is torn between two scenarios: the real one, among bushes and weeds, and the imaginary one, where the person wanders with his integrated identity. People with tuberculosis were expert nomads between two worlds: the upper one, the mountain hospital, and the bottom

The imposition of the western health care system paradigm ignored the system of values, beliefs and ideas that constitute the social identity of the Hmong community. Few steps separate illness from stigmatization. It was never easy to go through life carrying certain illnesses. On the other hand, some patients have been touched by the

one, where life runs without restrictions. Illness and health,

magic wand of social praise, thanks to which the ill was able to

exclusion and acceptance.

build his identity with a greater environment’s complacency.

Illness makes the man to look back at the self. From there,

The stigma is an indelible mark for the person’s identity.

with his macerated conscience, in the hell of illness, looks at his

Stigma & illness & identity: one of the history’s most

life and wonders who he is, who he has been or who he would

dangerous alliances.

have liked to be. Stigmatization debilitates personal identity, emptying it of its This takes him to question the authenticity of his steps and

singularity until it becomes a collective, standardized category, where the specific features are fused in a homogenous whole.

choices. Is illness the punishment for not having lived a genuine life?

The stigma builds collective identities, without name or surname, without personal biography.

The better way to understand the own disease is to look back at our own life story.

In Henry Barbusse’s short story The Eleventh in the first day of each month, a long line of homeless, patiently inclined

Only oneself can find the meaning of what we have to live.

against the grey wall of the hospice, waited to be admitted into

That is what Ivan Ilich, Tolstoy’s dull official, did when the first

the hospital. They resembled one another. That stubborn line

symptoms expelled him from his obstinate routine. Sandor

of faceless human beings turned into an endless line. Simple

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inert masks with an empty look. An anonymous mass, without a voice and without a self-story. Cognitive and insane disorders also represent a threat to identity; memory contains much more than data on our lives; memory holds the matrix of our social and personal identity. In some point, to forget is to stop being. First of all, to forget is, forgetting, letting go the own memories and from that onwards, letting it roll without a name. The limits of oblivion are not precise. Its mist confuses,

And although it is difficult to retrace the walked steps,

distorts the contours of reality. That is why living with the

disease gave him the possibility of choosing who he would

presence of oblivion is also difficult for the caregiver.

have liked to be.

In the blurred identity of the sick, part of one’s own identity also becomes blurred. The other stops being the mirror in which we could recognize ourselves. In the lack of knowledge and ignorance of the other, we feel the threat of our own disintegration. An example of that is Mary Gordon’s Mrs. Cassidy’s last year. But there are circumstances in which illness is a factor of consolidation of the identity. Do hereditary diseases become, perhaps, a family mark? Isn’t it a unifying factor among generations? Sometimes, we recognize ourselves in our antecessor’s disease. Patrimony: A True Story by Philip Roth is a testimony to that. Roth accompanied his father through the process of his illness and, during the hours spent together, he was able to acknowledge the tenacity, values and convictions that had nurtured his family. In Sender Roth’s disease, Philip strengthened his own

One cannot always choose how to live, though it is possible to choose how to die. The trip to the South was the key to encounter his postponed and desired destination. Dahlman would die part of the writer’s disavowed life and would live the chosen death, the death Borges would have liked to die. Man is never as owner of himself as when he can take over his dying. The disease gave Borges the possibility of reencountering with the self and thus redeeming part of his life. “…Why do bodies break into pieces to allow death to come? Why does death take us as entire as we offer ourselves? J.C. Cela All that illness brings is exchanged by a part of the self. The body breaks like dry leather and life cracks like porcelain. Perhaps Cela’s character wonders why the sick has to pay the painful price of personal disintegration, where physical pain is just a metaphor of the existential drama that means living with a disease.

identity and found the family legacy: the symbolic and affective

Literature undresses flesh and blood sick life. Its pages

patrimony that was being transmitted from generation to

contain these thematic recurrences that reveal that illness

generation.

establishes a vital shared field of problematization among men.

For Jorge Luis Borges, septicemia was the possibility of recognition of his identity.

All sick persons feel that their identity is jeopardized.

In his short story El Sur (The South) Borges, transmuted into

Such questioning of self-identity confers upon the biologic

Dahlmann’s skin, narrates that key moment of his life: a trivial

process its existential depth. And although illness devours

accident and the hospitalization that made him familiar with

its prey ignoring its singular features, it is in that suffering

the intimacy of disease and the experience of being close to

experience dimension where illness recovers the sufferer’s

death.

proper name.

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ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Ivan the Terrible Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Ivan the Terrible evokes one of the most fascinating and terrifying characters of history. A man of complex personality: he was described as a killer, insane, intelligent, intellectual, devout, reformist, eccentric etc. The story of his life was distorted by the propaganda both for and against him. Of all Russian Tsars, Ivan’s reign was the longest one. He developed the first modern absolutist state (he wanted to engage and learn from western countries). Today Ivan is considered a Russian national hero. Apparently, his dementia deepened after treating his syphilis with mercury salts. Eastern Europe’s plains comprise enormous large land

after his father’s death (Basil III) (figure 1). Due to Ivan being

areas which extend from the White to the Baltic seas in the

only three years old, her mother Elena acted as regent until

North, and from the Black to the Caspian seas in the south.

her death. During five long years, she had to face the Tatars,

Slavs populated those lands as from the 6º century and

the Lithuanians, and above all, the boyars, the powerful

founded cities like Novgorod, Kiev and Smolensk. Vikings

aristocracy willing to retain their power.

and Scandinavian gave origin to “Rus”, a medieval state and princedom around Kiev.

He was orphaned at the age of 8 when his mother Elena died (apparently the boyars were involved in her death) and,

Vladimir, who had been baptized by the Eastern Christian Church, started the unification and spreading of Christian faith throughout the Rus’ territories. Later on, the Tatars invasions and the fall of Constantinople changed the destiny of Kiev and of other states. Mongols provoked a population displacement and established a tax system that weakened Russian dukedoms. In the meantime, Moscow, negotiating with the Tatars, obtained the primacy and became more powerful. By that time, the empire had a six million people population and was reigned by Ivan III, also known as Ivan the Great. It was him who renovated the Moscow Kremlin and gave it a similar appearance to that of today.

along with his deaf and dumb younger brother Yuri, had to suffer the constant humiliation and manipulation of the boyars. Shortly after her death, the new regents got rid of both Ivan’s governess and of her mother’s former helpers. He finally escaped from the boyars’ oppression with the help of his religious tutors. By those years, probably due to the constant fear and danger situations, he began to show signs of mental illness and sadism. However, and with the support of the Orthodox Church, he soon became a strong and astute leader. Profoundly distrusting, Ivan soon understood that his future as a monarch was subject to defeating the boyars. At

This Ivan was Ivan IV’s grandfather, via his son Basil III, who continued the unifying movement and, supported by the

the age of 13, in an outburst of authority, he sentenced one of the leaders of the group to death (Andrei Shuinsky) and had

church, conducted an autocracy that conceived Moscow as the

him killed by a pack of hungry dogs. The monk Macarius (figure

new Constantinople, under the name of “Moscow as the third

3), afterwards appointed Bishop of Moscow (and subsequently

Rome”.

canonized as Saint Macarius of Moscow) was one the most influential members of the clergy during Ivan’s reign.

Turbulent childhood. He transmitted him a profound religiosity and the sense Ivan was born in 1530 and became Grand Duke of Moscow

of having been summoned to develop a divine mission. And

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FAMOUS PATIENTS


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Figure 1: Dying Basil III blesses his son Ivan

Figure 2: Russian boyars. The height of the hat indicates the social status (Andrei Ryabushkin, 1901)

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that was also due to the fact that Russia, or rather Moscow, after the fall of Constantinople, was the most Christian eastern territory, the barrier against the Turks and Tatars that were stalking from east and south. The cleric convinced him that he was a descendant of Rome’s Caesars, reinforced by the fact that his grandmother, Sofia Paleologo, had been a byzantine princess, nephew of the last emperor. This was rapidly and successfully spread within the reign. Such would be the reason for which, in 1547, he was crowned as Ivan IV as the first Russian Tsar (from the Slavic word, derived from Caesar), and not only as prince of Moscow but he claimed to be the success of the Eastern Roman Empire (figures 4 and 5). Moscow would be a third Rome and the church would accompany him in the enterprise. This union between Crown and Church, with all of it magnificence and ceremonial, would last up to the revolution of 1917. Two weeks after he was crowned Tsar of Russia, Ivan married Anastasia Romanova (figure 6), a sensitive and intelligent woman, who had a positive influence on him. In October 1552, Anastasia gave birth to a son, Dimitri, who died six months later, to Ivan, only nine months after Dimitri’s death and to Feodor in 1558. Dimitri apparently died affected by a congenital syphilis. Feodor was a simple minded man with little interest in politics. He was described as physically inactive, of overweight and short or medium height. Due to some illness in his legs he was unsteady on his feet. Though from a distance and with little information it is not possible to make an accurate diagnosis, Feodor probably also suffered from the congenital syphilis. Figure 3: Saint Macarius of Moscow

The Reformist Tsar Taking into account today’s parameters, Ivan was a cruel tyrant. However for the Russia of that time and for European practices, he was a wise and humanitarian governor. From 1551 to 1560 he played a significant role in the decisions of his council, allowing freedom of speech and opinion and accepting the requests of all his subjects. According to legend, it was the first and sole time in the history of Russia when the country’s poor people had access to their Sovereign. After taking back power from his uncles, he created the “Rada” or private council in which his religious mentors had particular influence. He managed to fulfill almost all of his objectives: reconstructed Moscow, centralized and modernized the administration, updated legislation and for the first time summoned a group of general states to present petitions and complaints, strengthened the relationship with

Figure 4: Ivan IV of Russia’s seal

the Church, founded schools etc.

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Figure 5: Ivan IV of Russia’s coat of arms

Ivan also created units of guardsmen, the embryo of the future Russian military units. The “streltsi” (figure 7) was a group of three thousand men absolutely loyal to the Tsar, armed with axes and harquebuses (almost unknown in Russia at that moment) and whose services were paid with lands. All of these reforms had a common end: to reduce the influence of the hatred boyars and to push them away from the spheres of power. The external affairs policy’s objective was to eliminate the permanent Tatar threat. They decided to conquer large

Figure 6: Anastasia Romanova, first wife of Ivan

territories of Kazan in 1552 (figure 8), Astrakhan in 1556 and other territories of the Volga valley extending even to Siberia (figure 9). To this end, a strict policy of extermination and deportation of all Tatar population (all of them Muslims who were replaced by Russian settlers) was followed. The Orthodox Church compared Ivan with Alejandro Magnus, and to commemorate his conquers they built the Saint Basil Cathedral (figure 10), near the Kremlin. It is said that Ivan had the architects blinded to prevent them from building anything like it elsewhere. He failed to accomplish his second objective: establishing a stable port outlet to the Baltic. His goal was to come into contact with Western Europe scientific and cultural progresses. But he entered into conflict with Polish, Lithuanian and other Scandinavian countries’ interests that blocked the path because they feared the power the new Russian State could achieve. The constant wars throughout his reign produced limited results. Instead, they generated a tremendous economic cost and social discontent, of which opponents tried to take advantage. The only tangible successes were the introduction of printing and the creation of sporadic commercial ties with England (figure 11). The Insane Tsar In the year 1560 his life took a dramatic turn. His mental problems increased notably, boosted by his excessive alcohol

Figure 7: A ”streltzi” (XVII century)

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Page _ 65 Figure 8: “Ivan IV capturing Kazan� (Grigori Ugryumov, 1800)

consumption, after his beloved wife Anastasia died.

Rada and their families and against any boyar considered a suspect.

The authoritarianism, his rages and outbreaks, and his hilarious religious fanaticism took over his character and marked the future political events. He blamed the boyars for having poisoned Anastasia (they had already poisoned his mother) and on his counselors and friends for their lack of

The death of both his brother Yuri and his old mentor Macarius, head of the Orthodox Church, deteriorated the situation further. Macarius was replaced by Afanasy who dared to ask him to moderate cruelty and despotism.

compassion towards her. Devoted to sadism, he embarked

A year later, a new setback affected him: Prince Andrei

on a campaign of killings against his formers councilors of the

Kurbsky, hero of the war against the Tatars and one of Ivan’s

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main advisors, more and more afraid of Ivan`s dangerous outbreaks, defected to the Polish- Lithuanians’ side. In 1564, in the middle of an attack perpetuated by the traitor Kurbsky, fearing a general rebellion on behalf of the boyars, Ivan left Moscow with his family, treasures and followers (supported by some sectors within the Church) and settled in Alexandrovskaya. From there (figure 12), at 120 km away from the capital city, he wrote letters to Bishop Afanasy, to the nobility and to the people of Moscow. In those letters he accused noblemen of corruption and abuse of power and he explained the reasons for which he wanted to abdicate. The reaction was immediate: the population called for his return fearing both social upheaval and Polish invasion. Both the boyars and the church urged him to come back.

  Ivan

agreed to come back but on his own terms, demanding absolute power to punish anyone he believed disloyal. As soon as he came back he divided the realm in two: a part that maintained the old administration, where boyars still had a significant influence, and the Oprichnina (Russian word that means “separate”) an area in the northeast of Russia. In those territories he had unlimited power, thus boyars were obliged to emigrate. The system called the “oprichnik” (figure 13) was a police force composed by soldiers and members of the church that acted with extreme cruelty, torturing and killing all those accused of disloyalty. They dressed in total black with golden touches and rode black steeds. Their caps’ flagship was the cadaver of a dog and a broom: bit betrayal, be loyal and sweep Russia. For seven years, the police force accumulated over six thousand men Figure 10: Saint Basil Cathedral, located at the southeast of Moscow’s Red Square, declared World Heritage in 1990.

that operated with total immunity. Thousands of boyars, churchmen, soldiers and anyone suspected of treason were

Figure 9: “Conquest of Siberia” (Vasilis Ivanovich Surikov, 1895)

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Page _ 67 Figure 11: “Ivan the Terrible showing his treasures to Jerome Horsey”, the English Ambassador (Alexander Litovchenko, 1875)

exterminated. It was precisely this repression what prevented a powerful feudalism was implemented in Russia like in other parts of Europe. Since then, the country would remain in the hands of an absolute monarchy, strongly centralized, which very few states dared to defy. It was evident that with the unleashed oppression the power of the nobility had considerably reduced. Meanwhile, the everlasting wars against Polish and Lithuanians were generating a progressive deterioration. In 1570 he headed for Novgorod, suspecting the city’s authorities had been cooperating with Lithuania. The killing of more than 15.000 people lasted five weeks (figure 15). In Moscow, the evil oprichnik continued bringing death and massacres against boyars and sacking the city arbitrarily. The state of terror and

Figure 12: Alexandrovskaya’s Kremlin

the poor harvests affected the collection of taxes, weakening the state even further. Crimean Tatars took advantage of this situation and leaped on to Moscow while Polish and Lithuanians recovered the territories previously lost. Ivan’s dementia took him to believe the Oprichnik had also betrayed him and blamed them for poisoning his third wife and for conspiring with the enemy. He even ordered the execution of several generals. The Oprichnik was abolished within a short period of time. The killer Tsar

Figure 13: An Oprichniki

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Ivan IV’s dementia became visible during the last decade of

Subsequently he confined himself for days in churches and

his reign (figure 16) and it was accompanied by his progressive

monasteries to purge his sins, though before long he returned

tendency to alcoholism.

to the old ways (figure 18).

He lived in religious mysticism outbursts, devoting

Obviously, Polish historians greatly boosted his criminal

countless hours to praying, hitting and chastising himself at the

actions, and invented many others. However, due to the

altars (figure 17), and ordering all sort of killings and sadistic

murderous insanity condition in which he was, all of them were

perversions which, occasionally, he himself perpetuated. The

credible, and the reason for which Western Europe forged a

execution of noblemen suspected of treason was followed by

very repulsive image of the Tsar (figure 19). In those years, he

the killings of their widows and children, after they had been

became known by the name of Grozny, “The Terrible”, though

subject to tortures and sexual abuses.

some say the correct translation would be “the Severe” or “the

Apparently, after each criminal action he committed in anger, he was assaulted by a deep feeling of remorse.

Feared” (figures 20 and 21). History tells that in a trip to England he became interested in visiting the Tower of London to learn from its torture instruments. When shown “the wheel”, he was explained that he would not be able to witness the use of the torture device as no criminal had been sentenced to death. He responded: “Use one of my men. I want to see the demonstration”. Legend claims that the Tsar had an insatiable sexual appetite. True or not, and apart from possible and sporadic mistresses, eight wives are documented. The first one was Anastasia (herein before mentioned) with whom he had three children: the first one died very young, he killed his second son by striking him in the head, and the third one survived and succeeded him. His second wife was Maria Temryukovna (figure

Figure 15: The atrocities of the Russian army in Livonia.

22) whom he poisoned. The third one was Marta Vasilyevna Sobakina who was found dead two weeks after they wed. His fourth wife, Ivanovna Koltovskaya, was lucky enough to be sent to a convent almost two years after their wedding. His fifth wife was Ana Grigorievna Vasilchikova, who was also locked up in a monastery. His sixth wife, Vasilis Melentyeva (figure 23) was discovered having an affair. She saved her life by being confined in a cloister (figure 25) and her lover was impaled (figure 24). Maria Dolgorukaya, his seventh wife, was accused by the Tsar

Figure 16: Facial Forensic Reconstruction of Tsar Ivan IV (M.Gerasimov, 1963)

Figure 17: Ivan’s cilice. A cilice was originally a garment or undergarment made of coarse cloth or animal skin worn close to the skin to induce discomfort or pain as sign of repentance and atonement.

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Page _ 69 Figure 14: The Oprichniki (Nikolai Nevrev, 1870). The painting shows the moment in which the boyar Feodorov is arrested for treason.

Figure 18: “Ivan’s repentance” (Grigori Ugryumov, 1800) Ivan IV asks the Father Superior of the Pskov- Perchorsky Monastery to let him take the tonsure at his monastery (Klavdiy Lebedev, 1898)

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Figure 19: “Ivan the Terrible�

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of not being a virgin and she was asphyxiated the day after the wedding. His last wife, Maria Feodorovna Nagaya, had the merit to survive him. In 1580, in an outburst of anger, Ivan struck with his iron staff the head of his son and heir, Ivan, who finally died after three agonizing days (figure 26). In deep sorrow and regret, Ivan IV pulled out his beard and hair, peeled off his nails against walls and spent night after night howling in the halls. As penance, he decided to write personally a list of the thousands of men he had ordered to execute. The idea was to send it to all churches and monasteries along with large sums of money to be invoked in prayers and mass for their soul salvation. His health deteriorated the same as his limited lucidity. In that period he became obsessed with marrying Isabel I, or any princess of England, to reinforce ties with the sole western reign that showed him a certain interest. Queen Elizabeth I of course ignored his proposition. His last months were hilarious: surrounded by wizards who predicted the date of his death; stroking his jewels which he believed had mystic healing powers and being more and more delirious. The only event worth mentioning was the expansion up the Obi river basin: Cossacks occupied the Khanate of Sibir, then to Figure 20: “Ivan IV” (Viktor Vasnetsov, 1897)

Figure 21: “Ivan IV”. This image, which shows him full of kindness, contrasts with figures 19 and 20 and shows another conception of him.

Figure 22: Maria Temryukovna

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Figure 23: “Tsar Ivan admires his sixth wife Vasilis Melentyeva” (Grigori Semyonovich Sedov, 1875)

Figure 24: An impalement

Figure 25: “Vasilis Melentyeva” (Nikolai Vasilyevich Nevrev, 1883). Ivan is at the back of the scene.

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Page _ 73 Figure 26: “Ivan the Terrible and his son Ivan on December 16th, 1581” (Ilya Repin, 1885)

Ivan’s vassals believed that the Tsar was the physical presence of God on earth and thus did not conceive the idea of a disease affecting him. On the contrary, they interpreted his atrocities as God’s punishment for the “multiplication of sins within Orthodox Christians”. With the same conception, they later on interpreted that God became angry with Ivan and that, through Feodor (his successor), had sent mercy to the people. Feodor was considered a “sacred fool”. Many diagnoses have been tried to explain Ivan the Terrible’s personality. From the psychological point of view, periods of dysphoria might represent a pure depressive disorder; religiousness and philosophic worries, paranoia; verbosity, neurosis; emotional changes, hysteria or borderline Figure 27: “Ivan the Terrible with the body of his son, who he has murdered” (Nikolay Shustov, 1860)

be called Siberia.

personality disorderf we consider his violence and suicide attempts. Anger outbursts and sudden emotional changes, hyper religiosity and a certain sense of “personal destiny” gave

Ivan died in March, 1584 while playing chess (figure 29). He

origin to the controversial temporal lobe personality that has

was buried in the Kremlin, in the Archangel’s Cathedral. He was

been related to temporal lobe syndrome as it is associated to

succeeded by his son Feodor I (figure 30) who died childless

temporal lobe epilepsy.

in 1598. Feodor’s death marked the end of the Rurik dynasty (Muscovite line) that descended from Ivan I of Russia (Ivan

The truth is that the syphilis and its treatment based on

Kalita). As from then onwards Russia was ushered in the so

mercury salts, conspired against the Tsar’s insanity. During the

called Times of Trouble.

soviet regime Ivan’s remains were exhumed in the Kremlin. It was demonstrated that they had the typical bone lesions

The cause of his disorder

produced by such disease. At the age of 23, Ivan had been

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Figure 28: “The tsar meditating at the deathbed of his son� (Viacheslav Schwarz, 1861)

Figure 29: The last chess play

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seriously ill with high fever and that could have been the onset of his syphilis, which he transmitted on to all his descendants. The syphilis lesions were combined with the damage produced by the treatment used in that period: mercury salts. There was a classic saying:” One night with Venus a lifetime with Mercury”. The damage produced by mercury was even more severe than the disease itself, with symptoms such as sudden mood changes, anger outburst and psychotic manias. Therefore, the progressive deterioration of his personality was the result of both the evolution of the disease and the ongoing treatment with mercury salts. The high mortality within his children and the defects within those that survived only reinforce the theory. Apparently, his heir Feodor, had also been born with the disease (congenital syphilis), and his physical aspect and countenance clearly denoted he was mentally retarded. Due to his lack of interest in politics he left Boris Godunov, a former boyar and member of the oprichnik, to rule in his name.

Figure 30: Facial forensic reconstruction of Tsar Feodor I (M.Gerasimov, 1963)

Apparently, Feodor’s sole interest included praying and ringing bells at churches and that is why he is sometimes called the “Bellringer”. The death of his only daughter maddened him in sorrow. His failure to sire other children brought an end to Rurik dynasty that had been ruling Russia since the year 862. He was succeeded as tsar by Godunov (figure 31)

Bibliography Appleby J. Ivan the Terrible to Peter the Great: British formative influence on Russia’s medico-apothecary system. Medical History, 1983, 27: 289-304 Cartwright F., Biddiss M. Grandes pestes de la historia. Editorial El Ateneo, Buenos Aires, 2005 De Madariaga I., Ivan the Terrible: First Tsar of Russia. Yale University Press, London, 2005 Dewey H. Some perceptions of mental disorder in pre-petrine Russia. Medical History, 1987, 31: 84-99. Dickson Wright A. Venereal disease and the great. Brit J Vener Dis 1971, 47: 295-306 Espinoza R., Benavides E. Ivan IV, el Terrible, ¿padeció de un síndrome del lóbulo temporal? Rev Méd Chile 2006; 134: 1465-1469 Hellmann M, Goehrke C, Scheibert P, Lorenz R. Historia Universal. Siglo XXI Editores. Mexico, 1975 Ibáñez Fos M.C. Ivan “El Terrible” en la historiografía rusa y soviética. Revista de Historia Medieval 1993, 4:275-290 Newell R. Pain and Cruelty. California Medicine 1965, 103: Figure 31: Boris Godunov

208-211

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ETYMOLOGY AND MEDICINE

ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Basil Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

With more than 150 crop varieties around the world, basil is well known for its distinctive flavor, fragrance, essential oil and healing properties. The species most commonly used is sweet basil, also known as Ocimum Basilicum and is very popular in the kitchen. Basil (figure 1) is an annual aromatic herb of the family of the lamiaceae, to which also belong the mint, oregano, thyme and rosemary. The original name of this family was “labiated”, due to the peculiar shape of the flower, with 5 petals fused in the form of a mouth with an upper lip, generally bilabiated and shorter, and one inferior, trilabiated (figure 2) It is an annual herbaceous plant of about 30 cm in height, very fragrant, of very small green leaves (figure 3) and white flowers, a little purple, that has being cultivated for many millenniums. Its essence contains methyl clavicol (estragole), linalool, linalyl acetate and camphor. Its leaves also have tannin. Like other aromatic herbs, such as rosemary or sage, it is very appropriate to cultivate the basil around other vegetables that are attacked by insect pests, since it has the property of scaring them off. The basil pots are usually placed in the windows to protect the entry of insects. It is native of Iran, India and other tropical regions of Southeast Asia and warm regions of Africa. From there, it would spread throughout Europe thanks to the Greek and Roman cultures. In ancient civilizations, such as the Egyptian, it had a high value, even being one of the elements used in mummification. Like many words that begin with al-, the word “albahaca” in Spanish comes from Arabic (“al-habaga”), name to which the Arabs gave to the aromatic plants used in cooking and in medicine. In addition, “babagah” comes from “veheca” which means “penetrate to the brain with soft smell”. Its generic name, Ocimum basilicum (figure 4) derives from

Figure 1: Plant of Basil.

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the Greek words “okimon” which means “ fragrant” (which was given by the fragrance of its leaves) and “ basilikohn” which means “ king”, “ real” or” royal” and reflects the attitude of the ancient cultures toward this herb that considered noble and sacred: “ the queen of herbs”. This last Greek word is the derivation of its name in English (basil), German (basilikum), Dutch (basilicum), French (basilic), Icelandic (basilíka), Polish (bazylia),

Romanian

(busuioc),

Slovak(bazalka),

Slovenian

(bazilika), Hungarian (bazsalikom) and Italian (basilico). Even, the expression in Neapolitan dialect is similar: vasenicola

Figure 4: Ocimum basilicum.

Figure 5: Carlos Linneo (1707-1778), Swedish scientist, naturalistst, botanistc and zoologist who established the foundations for the modern scheme of the binomial system of nomenclature. He is considered the founder of modern taxonomy

Figure 2: “Labiated” flowers of basil.

Figure 3: Basil leaves.

Figure 7a: Basil seeds bought in Naples by the author.

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Figure 6: “Species Plantarum” (Linneo, 1753).

Figure 9: Dioscorides (40-90), Greek physician and botanist, who practiced medicine in Rome at the time of the emperor Nero.

Figure 7b: Basil seeds. Figure 10: “De Materia Medica” (Dioscorides, Byzantine edition of the 15th century).

The name Basilio comes from the same Greek root (Basileus= “King”). With the word “basilica” (“royal” or “real”), the Greeks referred to a large rectangular room in the palaces of the Asian kings and that was the throne hall where court hearings were held. The Romans referred to a civil building that was used to hold open to the assistance of the general public and also as business meeting center and financial transactions, running at times as “stock exchange”. In the fourth century, with the rise of Christianity, these Roman buildings were taken as example and temples were built in the form of a simple basilica, with a rectangular nave, two rows of columns and an apse in the chancel. The Ocimum basilicum was described by the Swedish Scientist Carlos Linneo(figure 5) in his work “Species Plantarum” (figure 6) in 1753, and is considered the starting point for the botanical nomenclature which is used nowadays. There are around 160 species of the genus Ocimum. In the region of Murcia, Spain, it is known as “Alhabega” Figure 8: Basil in the form of bunch, with its roots

and in Catalan it is called “Alfàbrega”

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This plant is very sensitive to frost. It is grown only by seeds (figure 7a and 7b), which can be sown in seedbeds or pots in a greenhouse in early or mid spring. It requires a sun position, although in climates of very hot summer, it appreciates some shade and fertile soils, permeable and wet. Usually in grocery stores, it can be found in the form of a bunch, with its root (figure 8). Many times, although it is left in water, we do not get the plant to survive more than a few days. One way to accomplish this is the following: prepare a pot with fertile soil converted into mud. Remove all the leaves of the basil purchased in the grocery store and plant the root in the prepared pot. Put it in a place with moderate but regular sun and light. Irrigate it so it is always wet. Medical uses Dioscorides, the Greek doctor and botanist (figure 9), author of “De Materia Medica� (figure 10), the main pharmacopoeia manual throughout the Middle Ages and the Renaissance, recommended basil to combat bloating, promote diuresis and increase the secretion of milk. During the Middle Ages, it was very frequent to make pillows with aromatic herbs, including basil, to be protected from the plague. A variety that grows in India which was considered sacred, is widely used in religious

Figure 11: Plant of purple basil (Ocimum sanctus).

Figure 12: Caprese salad.

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ceremonies and it is believed to protect the houses where it

prepare lotions, soaps and cosmetics, and also in distillery.

is grown. The orientin and the vicenin are two water-soluble Many cultures have widely used purple basil or Ocimum

flavonoids present in basil that protect cellular structures and

sanctus (figure 11) for its medicinal value. Chinese medicine

chromosomes of radiation and the damage caused by oxygen.

uses it to treat stomach cramps, kidney disorders, and snakes and insects´ bites and to promote blood circulation.

In addition, basil provides protection against the growth

In the past, the dried leaves reduced to powder were used as

of unwanted bacteria. These antibacterial properties of basil

snuff. It is believed that the Arabs were the first to cultivate it

are associated with their volatile oils, which contain estragole,

in an orderly way and to also spread it in the countries they

linalool, cineole, eugenol, sabinene, myrcene, and limonene.

conquered.

Laboratory studies demonstrate the efficacy of basil in restricting the growth of many bacteria, including: Listeria

Multiple medicinal uses have been described: it fights

monocytogenes, Staphylococcus aureus, Escherichia coli, Yersinia

depression, exhaustion, insomnia, migraine, loss of appetite,

enterocolitica, Shigella dysenteriae and Pseudomonas aeruginosa.

nerve dyspepsia and some intestinal parasitosis. It is digestive,

Based on this, the scientists are trying to develop natural

antispasmodic, diuretic and reduces fever. It can increase

preservatives for food with basil. Adding fresh basil to salads

mothers’ secretion of milk. It also soothes skin irritations. It is

not only will enhance the flavor of fresh vegetables but will also

a cough suppressant and very conducive against pharyngitis

ensure that fresh products which we consume are safe to eat.

and laryngitis. It activates the immune system and increases the antibodies. It combats acne. Some aphrodisiac properties

The eugenol of volatile oils of basil blocks the activity of an

are attributed to it. It is healing, analgesic and antiseptic. It is

enzyme of the body called cyclooxygenase. Many commonly

used in infusions, poultices, ointments, dyes, balms, lotions,

used non-steroidal anti-inflammatory drugs (NSAIDs), including

compresses, syrups, soaps, creams, fresh and dry, and

aspirin and ibuprofen, work by inhibiting the same enzyme.

powdered. Basil is a very good source of vitamin A thanks to its high It is also used in aromatic potpourris, in perfumery to

concentration of carotenoids, such as beta- carotene, called

Figure 13: “Caprese appetizers” (Vicky’s style)

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Page _ 81 Figure 14: Location of the island of Capri in the Gulf of Naples.

Figure 15: Buffalo Mozzarella manufactured in Argentina.

“pro-vitamin A� because it is transformed into vitamin A. Betacarotene is a powerful anti-oxidant and not only protects the epithelial cells from free radical damage, but also helps to prevent free radicals from the oxidation of cholesterol in the blood stream. Cholesterol builds up on the walls of the blood vessel only after undergoing the process of oxidation, thereby initiating the development of atherosclerosis. The damage caused by the free radicals is evident in

Figure 16: Water buffaloes.

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and potatoes) and in pastas, breads and pizzas. Given that basil’s oils are very volatile, the best thing to do is to add the herb near the end of the cooking process, to maintain its maximum essence and flavor, and all its beneficial properties. Here I have taken the opportunity, I would like to share some of my favorite preparations with basil: Caprese salad, Margherita pizza, pesto, mussels with tomato, garlic and basil, spaghetti with tomato sauce, garlic, basil, black olives and capers, and basil daiquiri. Caprese salad The Caprese salad, or simply caprese, is a typical Italian salad of the Neapolitan cuisine, specifically from the Capri Island. It is made of tomato slices and fresh mozzarella (the original recipe requires buffalo mozzarella), and fresh basil leaves seasoned with olive oil (figure 12). There are several ways to combine the ingredients (figure 13).

Figure 17: Bartolomeo Scappi (1500-1577), Chef of the Popes Pius IV and Pope Pius V.

Ground peppercorn in any of its varieties or a mixture of them can be added to the salad.

many other conditions, such as asthma, osteoarthritis and rheumatoid arthritis. Beta-carotene found in basil can help slow the progression of these diseases. Basil is also a good source of magnesium, which promotes cardiovascular health, and of vitamin K, manganese, copper, vitamin C, calcium, iron, folic acid and omega-3 fatty acids.

Some people add oregano, black olives, grated cheese and/ or icing sugar to the salad. I do not. Its colors (the red of the tomato, the green of the basil and the white of the mozzarella) are reminiscent of the Italian flag (also called “insalata tricolore” or tricolored salad) In Italy, unlike most of the salads, it is generally served as

Culinary use

an “antipasto” (starter), and not as a “contorno” (side dish).

Whenever possible, choose fresh basil over dry basil as it is superior in flavor. The leaves of fresh basil should be deep green in color without stains or yellowing. The fresh herb can be stored in a plastic bag in the refrigerator during short periods of time, or in the freezer during longer periods, if it is quickly blanched in boiling water.

The key ingredient in this salad is the “mozzarella di bufala campana” (“buffalo mozzarella from Campania”)  made with buffalo milk and typical of the region of Campania, where the Island of Capri is placed, in the gulf of Naples (figure 14). It is also easily available in many countries, like Argentina (figure 15)

Also, fresh leaves can be stored in a jar with a pinch of salt

The mozzarella made from buffalo milk is originally from

and covered with olive oil. To avoid clumping when they are

Italy. These water buffaloes, so called for their preference of

chopped, they should be washed before being stored in the

watery and swampy areas (figure 16) are native to Southeast

refrigerator.

Asia. The history of the water buffalo in Italy is not clearly established. One theory is that a water buffalo was brought to

It is highly appreciated in culinary art. It can be used in

Italy by the Goths during the migrations from Asia during the

soups (fish and tomato soups), sauces (tomato, herbs and

early medieval period. However, the most accepted hypothesis

barbecue sauces), salads (tomato and cucumber salads),

is that they were brought by the Normans of Sicily in the

eggs (scrambled and omelets), fish (fried and boiled fish and

year 1000, where the Arabs had introduced these animals.

lobster cocktail), meats (roasted veal, lamb and pork, and

Another theory states that the water buffaloes were brought

hamburgers), poultry (grilled chicken), vegetables (tomatoes

from Mesopotamia to the Near East by the Arabs and then

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introduced into Europe by pilgrims and crusaders.

In 1993, the buffalo mozzarella from Campania was granted the status of Denominazione di origine controllata (DOC

The name “mozzarella” has its origin in the verb “mozzare”

– “Controlled designation of origin (CDO).

which refers to the manual cutting and separation of the kneaded curd cheese, done with the forefinger and the thumb.

Pizza Margherita

The first historical documents of the term date back to the twelfth century and bear witness to the monks of the Monastery

The history of the pizza starts with the history of bread. The

of San Lorenzo in Capua on how they used to offer a cheese

flat breads and all the preparations based on them, like pizza,

called “mozza” with a piece of bread to the pilgrims. Already in

are typical of the Mediterranean cuisines.

the twelfth century, the presence of buffaloes in the coastal plains of Volturno and Sele was common and appreciated. In the fourteenth century, there are different testimonies proving the commercialization of buffalo dairy products, intended for the prosperous market of Naples and Salerno. In 1570, the term “mozzarella” appears for the first time in the famous cookbook of Bartolomeo Scappi (figure 17), chef at the Papal court, entitled “The work of the art of cooking” (figure 18). This book has more than a thousand recipes of the Renaissance cuisine and describes the cooking techniques and tools.

The Etruscan dressed their flat breads with various ingredients (olives, raisins, aromatic herbs, etc). The Greeks made a flat bread called “plakuntos” that consumed with herbs, species, garlic and onion. At the time of Darius I the Great (521-486 B.C.), the Persian soldiers ate a flat bread with melted cheese and dates on the top. The Roman poet Virgil (70 B.C-19 B.C.) mentions a similar dish in “The Aeneid”. Other Roman authors describe similar foods, such as Cato the Elder (234 B.C-149 B.C.) who describes the food of the average Roman in the form of a flat bread flavored with various condiments. This flat bread was called “Placenta” and

At the end of the eighteenth century, the mozzarellas became a product of wide consumption thanks in part to the realization by the Bourbons of a large space devoted to the breeding of buffaloes with an attached experimental cheese

because of the similarity in its shape, from here derives the name of the intermediary body between the mother and the fetus during pregnancy, which adheres to the inside surface of the uterus and from which the umbilical cord is born.

factory for the transformation of the milk obtained. This was

In the same way, Marcus Gavius Apicius, who wrote in the

located in the Royal Site of Carditello (figure 19), the royal

first century the only book of Roman cuisine that has survived,

property of the Spanish Dynasty in the province of Caserta

“De re coquinaria”, mentions the making of numerous flat

(mozzarella´s birth place).

breads sprinkled with olive oil, parsley, oregano, etc. It is quite possible that they were served as open and subsequently

The production in the region of Naples (figure 20) was

folded on themselves to give rise to “calzone”.

briefly interrupted during the Second World War when the Nazis ruined the area of the herds, but was resumed a few years after the end of the war.

The nearest precursor of the pizza is probably a flat bread known by the Romans as “panis facacius” and known today as

Figure 19: The Royal Site of Carditello, owned by the Bourbons when they ruled Naples and Sicily.

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“focaccia” (figure 22), topped with some ingredients. The term “pizza” first appeared in a Latin text of the Southern Italian city of Gaeta in the year 997, which states that a tenant of certain goods must give to the bishop of Gaeta “duodecim pizze” (“twelve pizzas”) every Christmas Day, and another twelve every Easter Sunday. The origins of the word are uncertain and debatable. The etymologies suggested include: a) the    ancient Greek word “pikte” meaning “fermented pastry”, that step into Latin as “picta”, and in Late Latin “pitta” and from there to “ pizzas”; b) from the Ancient Greek  word “pissa” meaning “bran bread”;

Figure 18: “L’Opera dell’arte del cucinare” (Scappi, 1570).

c) from the Latin word  “ pinsa” meaning “to crush”, which supposedly refers to pizza dough being flattened; d) from the Latin word “picea” describing the blackening of the bread in the oven; e) from the Italian word “pizzicare” meaning “to pluck” which supposedly refers to pizza being “plucked” quickly from the oven; f) from the  Old High German  word  “bizzo”  or “pizzo” meaning “mouthful” which was brought to Italy in the middle of the sixth century by the invasion of the Lombards. Before the arrival of tomato to Italy, the Neapolitans prepared what today is called “white pizza”, made with garlic, parsley and olive oil. Very occasionally a cheese called “caciocavallo” was used, at that time made with mare milk and today with buffalo milk or with a small fish called cecenielli (“pizza with i cecenielli”). Tomato was carried to Europe after the discovery of America from the regions of present-day Peru. In spite of the fact that it was present at the European plantations, it was not eaten by the belief that was poisonous (as well as other fruits of the family of the Solanaceae, like aubergine).

Figure 20: In red, the province of Naples.

Figure 22: Focaccia.

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Page _ 85 Figure 23: Vincenzo Corrado (1736-1836), Italian Chef, philosopher and literary. A man of great culture, was a symbol of his time and one of the great chefs distinguished in the nobility of Naples.

Figure 25: “Port’Alba”, the first pizzeria of the world.

In Italy, where it was called “pomi d’oro” (´golden apple´), tomato began to be used as food in 1544. However, by the end of the eighteenth century, in the poor areas in the suburbs of Naples, tomato was added to a flat bread made with yeast (either by the desire for innovation or of simple need) and thus was born the pizza. The first references preserved on Neapolitan pizza date from 1715 to 1725. In 1773, Vincenzo Corrado (figure 23) wrote a valuable treatise called “Il Cuoco Galante” (“The Courteous Cook”-figure 24), about the eating habits of the city of Naples, in which he observed that people used to garnish pizza and pasta with tomato. The combination of these products and his comments have given rise to the gastronomic reputation of Naples and attributed to Corrado an important role in the history of gastronomy. Some say that the appearance of tomato in pizza is due to the competition with the sellers of spaghetti (that already added tomato in their dishes). Pizza gained popularity and soon became an attraction to people who came from outside to visit the city and who dared to enter in the poor areas to try out this local specialty. The former pizzeria “Port’Alba” (´white door’), in Naples, is regarded as the first pizzeria of the world. In 1738, they began Figure 24: “Il cuoco galante” (Corrado, 1773)

to produce pizzas for pilgrims and in 1830 they expanded to a

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kind of pizzeria-restaurant with tables and waiters. It remains open at the Via Port’Alba 18 (figure 25). In 1830, the French writer Alexandre Dumas (father) described pizza in the court of Naples in his novel “Le corricolo”. Dumas describes the poverty of the people who live in the city, to whom he called lazzaroni (as a remainder to the poor Lazarus, the biblical character) and describes how these humble people have as breakfast, lunch and dinner, a piece of flat bread to which they add several ingredients: “In Naples it was made with olive oil, bacon, cheese, tomato and anchovies

Figure 26: Pizza marinara.

in salting “. Neapolitan cuisine is very strict with the elaboration of its pizza. The purists believe that in there, only the two “real” pizzas should be served: the marinara and the Margherita. The marinara is the oldest (dating from 1734) and has a topping of tomato sauce, oregano, garlic and olive oil (figure 26). The name “marinara” is not due to the inclusion of fish or seafood (this is the “frutti di mare”), but to be the meal of fishermen when they were returning from their activities in the bay of Naples. According to others, it owes its name to the fact that its ingredients are preserved a long time, so that they could easily be transported and fishermen could prepare it on their long journeys. Pizza “Margherita” is attributed to one Raffaele Esposito who worked at the pizzeria “Pietro... e basta così” (literally “Peter … and that is enough”), which was founded in 1780 and today is Figure 27: Interior of “Pizzería Brandi”

Figure 28: “Pizzería Brandi”

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Page _ 87 Figure 31: “Pizza Margherita”.

Figure 29: Umberto I (1844-1900), King of Italy between 1878 and 1900, when he was killed. A street in Buenos Aires bears his name. Figure 32: Plaque commemorating the centenary of the creation of “pizza Margherita”.

Figure 33: Version of “pizza Margherita” made in the pizzeria Brandi during the celebrations for the 150th anniversary of the unification of Italy (2011).

still open under the name of “Pizzeria Brandi” (figure 27), which is located in the hill S.Anna di Palazzo across the street Chiaia (figure 28). In June 1889, to celebrate the visit of King Umberto I (figure 29), and his wife (and first cousin), the queen Margarita Teresa of Savoy (figure 30), Esposito invented three different types of pizza: one with pork fat, cheese and basil, another with garlic, oil and tomato and a third one with mozzarella, basil and tomatoes. The Queen chose the pizza which reminded Figure 30: Margarita Teresa de Saboy (1851-1926), Queen of Italy.

her of the colors of the Italian flag: green (basil leaves), white

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Figure 34: “Usi e costumi di Napoli” (Bouchard, 1866)

Figure 37: Parmigiano Reagiano cheese.

fable for to that historical moment: the pizza chosen by the queen would show the acceptance on the part of Italian monarchy of the South and its traditions. The tri-colored pizza is the final acceptance of the unification of the South to the kingdom of Italy (figure 33). Some more indiscreet tell another story: the queen hated the garlic and refused to receive her husband in the marital bed after he ate the classic pizza. Because of this, the king asked the chef Raffaele Esposito to prepare a tasty pizza, but without garlic. In fact, the one that now is called “pizza Margherita” had already been prepared prior to its dedication to the queen of Italy. Francesco de Bouchard described in his book in 1866 “Uses and customs of Naples” (figure 34) the main types of pizza, and included one with tomato, cheese and basil. And before him, in 1830, Riccio had already described in the book “Napoli, contorni e dintorni” a pizza with tomato, mozzarella and basil. Figure 35: In red, the province of Genoa.

Although traditionally only “marinara” and “Margherita” (or “Neapolitan”) pizzas are considered as real pizzas, there abound many other types that are elaborated with different ingredients. It is not possible to list the countless varieties of pizzas which have gradually been created, since each pizzeria acts according to its own judgment. And it is already known that on tastes, there is nothing to comment. The culinary regions and their habits are very marked in Italy. Contrary to what happens in Rome, whose local residents Figure 36: Marble mortar with its wooden pestle.

hardly think of a pizza for lunch (“it is a thing of tourists”,

(mozzarella cheese) and red (tomatoes). In honor of the queen,

they say), in Naples it is a usual lunch. Such is the devotion

this pizza was then named as “Pizza Margherita” (figure 31). It

of the Neapolitans for this product that the elaboration and

was the first recipe to incorporate cheese as an important

the ingredients of the “verace pizza napoletana artigianale”

ingredient (figure 32).

are defined in a standard prepared by the “Associazione Verace Pizza Napoletana”, that since 1984 promotes the

Many do not accept this story and consider it a convenient

authentic Neapolitan traditional pizza. For that reason, it

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is pointless to ask in Naples for “a Neapolitan pizza”; all the pizzas sold in Naples are Neapolitan. In fact, what the Romans call “Neapolitan pizza” (with mozzarella, tomato, basil and anchovies), in Naples it is known as “Roman pizza”. In 2010, Neapolitan pizza was recognized in the European Union with the brand of Traditional Specialty Guaranteed. My country, Argentina, has important Italian roots. Here, pizza was transformed and has its own personality, different from the Italian. The mixture of Neapolitan, Sicilian and Genoese customs gave form to the Argentinean pizza, resulting in the thick-crust pizza, the fugazza, the faina and even the habit of eating it standing. Figure 38: Pecorino Fiore Sardo cheese.

The first pizza of Argentina was made by the Neapolitan Nicola Vaccarezza in 1882, who rented a bread oven in the neighborhood of La Boca. At that time the pizza was austere without cheese. It was food of the poor. In 1893, Agustin Banchero came from Genoa to Argentina. He opened a bakery and created the fugazza (“focaccia” in Genoese) with cheese. Only in 1930 did the “ pizzerias” begin to proliferate. Banchero opened his pizzeria in 1932. Toward the 1940s pizza was not only part of the urban landscape but also a deep-rooted habit that is still preserved in the thousands of pizzerias of Buenos Aires. In Argentina, there are three types of dough: “stone pizza” Figure 39: Pliny the Elder (23-79). He died as a result of the eruption of Vesuvius.

(thin and crispy), “thick-crust pizza”(thicker, very leavened and not too crispy) and the “middle dough” which is also sold in bakeries and supermarkets as a “pre-pizza”, a pizza crust to be completed at home with different ingredients according to individual taste, creating countless varieties. The pizza menu seems not to have an end. Our sauces have more ingredients and much more cheese than the Italian. Argentineans fill up pizza with mozzarella (until dripping) making it heavier. In Italy, an entire pizza is served per person, while here, we share a pizza of eight portions and sometimes we add faina (variety made only with chickpea flour, pepper and water). Hence the traditional combination of “moscato, pizza and faina” (immortalized in a song by Adrian Otero and Memphis La Blusera in 1982), custom that has been disappearing and that only exists in traditional pizzerias. Pizza in Buenos Aires is an experience with a particular folcklore, and there are varieties for all the tastes. In his book, “On heroes and tombs”, the Argentinean writer Ernesto

Sabato

(1911-2011)

assures:

“There

are

more

pizzerias in Buenos Aires than in Naples and Rome together”. Figure 40: “Natural History” (Pliny the Elder, Spanish edition of 1629).His writings came to occupy 160 volumes.

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Genoese Pesto Pesto is a typical seasoning originating from Liguria (Italy) whose capital is Genoa (figure 35). Basil is its main ingredient. Also it has pine nuts and garlic, all dressed with Parmesan cheese and sheep´s cheese (depending on the local traditions) and olive oil. The word “pesto” comes from the Genoese “pestare” that means to crush or grind in a mortar (figure 36), that is the way in which traditionally this sauce is prepared. The Ancient Romans ate a paste called “moretum” made with cheese, garlic and herbs, all crushed in a mortar. The first mention of the recipe for pesto as it is known today is contained in the book “La Cuciniera Genovese” written in 1863 by Giovanni Battista Ratto. The recipe handed down by the “Consorzio del Pesto Genovese” says that for 600 grams of pasta, should be used: 50 grams of basil leaves, 6 tablespoons of grated Parmigiano

Figure 41: In rojo, the province of Savona.

Reagiano cheese, 6 tablespoons of Pecorino cheese, 2 garlic cloves, 1 tablespoon of pine nuts, and a few grains of coarse salt. Everything must be crushed in a marble mortar with a wooden pestle. The Parmigiano Reggiano cheese (figure 37), also known as “Parmesan”, is a famous Italian hard crust, whose production is regulated by a PDO (“Protected Designation of Origin”). According to a legend, Parmigiano-Reggiano was born in the Middle Ages in the province of Reggio Emilia, under the diocese of Parma (hence the name). It is possible that the recipe is similar to that of a cheese that is mentioned in sources dating back to Roman times.  Pecorino is a cured Italian cheese made from sheep´s milk, also regulated by a PDO. Of the four accepted varieties, the one used for the Genoese pesto is the Pecorino Fiore Sardo (figure 38), produced in the island of  Sardinia, whose manufacture was already mentioned by the Roman writer Pliny Segundus, known as Pliny the Elder (figure 39) in his encyclopedia “Natural History” (figure 40). This is the way my grandfather Eugenio Lamberti, son of Mr. Paolo Lamberti, did it. He was born in Ceriale, in the province of Savona (Figure 41), neighboring to Geneva. Occasionally he replaced the pine nuts by walnuts when he couldn´t find them. My mum keeps the family tradition. It is necessary to wash basil leaves with cold water and to dry them with a piece of cloth without crushing them. It is

Figure 42: Paolo Lamberti.

added and mashed with a smooth rotary motion of the pestle in the mortar walls. To get the best from the essential oils of basil, it is important to tear but not cut the leaves. When basil releases a bright green liquid, the ground pine nuts are added. Then, the cheeses are added and finally the olive oil to amalgamate all the ingredients. This whole operation should be made with all the ingredients at room temperature, and as quickly as possible to avoid oxidation.

necessary to crush garlic cloves with coarse salt in the mortar until reduced to a creamy consistency. Then basil leaves are

Of course you can also use a food processor, but is not the

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Page _ 91 Figure 43: “Mafaldine” pasta.

Figure 46: Matilde (Nené) Lamberti de Buzzi.

same: the satisfaction of eating a pesto born of our effort is lost. Our version from the region of the River Plate, already classic, has definitely adopted the walnut instead of the pine nuts and has only parmesan cheese. One of the best known variants is the “red pesto” (pesto rosso) or “Sicilian pesto”, with the addition of sundried tomatoes, and red peppers. If it were not for the basil, these pestos of the south of Italy would be similar to some Catalan sauces, as the “romesco sauce”. In the region of Provence (France), near Genoa, there is a sauce similar to Genoese pesto, called “pistou”, which carries olive oil, garlic and basil, but not pine nuts nor cheese. Pesto is a condiment valid for all types of recipes. It goes Figure 44: The princess Mafalda of Savoy (1902-1944). He was killed by the Nazis in the Buchenwald concentration camp (Germany)

very well accompanying meat, both roasted, grilled, or breaded. It also goes very well with fish, especially those of strong flavors such as salmon. Though, the queen of the recipes for pesto is the pasta. My great-grandfather Paolo (figure 42) and his wife Ana preferred to have the pesto with “mafaldine”, to which they added green beans or turnip green (a vegetable with flowers similar to those of the broccoli) and potato. The “mafaldine”, are a type of long and flat pasta, with “curly” edges (figure 43), which means that the type of sauce for this pasta can be much more dense, since it is better adhered and concentrated on its waves. It is one of the classic pastas, originating in the region of Campania, which owes its name to the Princess Mafalda of Savoy (figure 44), daughter of King of Italy Vittorio Emanuelle III (died in a Nazi concentration camp). The shape of this pasta

Figure 45: Eugenio Lamberti.

comes from the hems of a skirt of this Italian princess. It is also

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Figure 47: NenÊ’s Pesto, which maintains, by third generation, the family tradition.

Figure 48: Parmigiana di melanzane.

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known as “reginette”, which means “queens”. Pesto was also added to minestrone, a soup made with onion, garlic, carrot, chard, leek, green beans, potato, sweet potato, beans, noodles and bacon. My grandfather Eugenio (figure 45) preferred to accompany pesto with flat and thin noodles which he himself kneaded. My mother (figure 46) remembers how her grandmother asked her to crush the preparation when she was a child until a homogeneous cream was formed, so any of all the ingredients were noticed (figure 47) Parmigiana di melanzane The parmigiana di melanzane (figure 48) is a typical dish of the region of Campania, in Italy. The protagonist and main ingredient is the “melanzana” (eggplant or aubergine), accompanied by grated Parmigiano Reggiano, (Parmesan cheese -figure 37), tomato sauce and basil leaves. The Neapolitan version of this dish usually has also

Figure 49: Vicky´s vegetarian “musaka”.

Mozzarella cheese, whereas Sicilian and Apulian versions often have Pecorino cheese (figure 38). This dish is very typical in the families of the South of Italy. It is usually served hot, although it is also very appreciated at room temperature. In my version, eggplants are cut lengthways in slices and are grilled or baked (this version is less caloric than the deep fried one). The slices are arranged in different layers, as it was a lasagna, alternating cheese, tomato sauce and basil leaves. Some people cut the eggplants in big chunks and mix all the ingredients. Others finish the dish grilled in the oven. Its name may be due to the favorite (Parmesan) cheese or to the way of cooking the vegetables in layers in the city of Parma. Another version says that “Parmesan” is the Italian version of the word “parmiciana” that in Sicilian dialect refers to the wood strips that make up the central part of a shutter, which overlap in the same way as the eggplant slices on the plate. When I was a child, my mom made me a version that she called “eggplant pizza”. The origin of this dish is not clear, and it is disputed by many regions of Italy. Most probably it was born in Sicily, which had great Arab influence in the Middles Ages. Were the Arabs who brought eggplant from Asia to Europe and spread its use. In fact, this dish has a very similar version in the Arab world, in Greece and in the Balkans, the so called “moussaka” that includes meat, preferably lamb. My wife makes a vegetarian

Figure 50: Ceres, the goddess of agriculture and grain crops.

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version of “moussaka” which she covers with mozzarella, and

volcano, between the flames and the steams, then he sprayed

it is a delight (figure 49). Probably from Sicily the parmigiana di

with olive juice and ate his result: a plate of pasta.

melanzane has spread for the whole Kingdom of Naples and then to the rest of the Italian peninsula.

The

Etruscans

(figure

51),

ancient

people

whose

geographical core was Tuscany, developed pasta through the Spaghetti with tomato, garlic and basil The history of pasta is long and complex, full of myths and contradictions. There are many theories that have been elaborated around its origin. An ancient Roman legend says that it all happened as a consequence of a fight between Vulcan, the god of fire, and Ceres, the goddess of agriculture and grain crops (figure 50). Vulcan enraged so much that he tore out the wheat grains in the ground and crushed them with his huge mass of iron. The flour obtained, was introduced to the mouth of the Vesuvius

crushing or grinding of various cereals and grains mixed with water, which then cooked. When the Greeks founded Naples (“Neapolis”, which means “new city”), they adopted a dish prepared by the natives consisting of pasta made of barley flour and water, that then dried in the sun, they called it “makaria” for its similarity to a barley broth soup that they consumed in their land and that they considered a delicacy, of the same name. “MaccarronesMaccaroni” derives from “makaria”, a term that is found in the Roman writings of the first centuries of our era and that was used for any type and format of pasta, that is to say, it was a synonym of “pastas”. Another version says that “macaroni” derived from the term “maccare”, which in Latin means “crush to knead”. A librarian of the Vatican called Bartolomeo Platina (figure 52) wrote in the twelfth century that macaroni and cheese were a legacy from the Genoa and Naples cuisines, and that their inhabitants ate them every day. In ancient Rome, there are also references of pasta dishes that date from the third century before Christ. In fact, the emperor Cicero himself speaks of his passion for long strips of pasta in the shape of sheets named “lagana”, plular of “laganum”, wherefrom derives “lasagna”.

Figure 51: The Etruscans (painting of the year 480 B.C. in the “Tomb of Triclinio”).

Figure 53: In red, the province of Udine.

Figure 52: Pope Sixtus IV appointed to Bartolomeo Platina prefect of the Vatican Library (1477).

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The “lagana” are also found in the already mentioned book “De re coquinaria” by Marcus Gavius Apicius (figure 21). In a Codex of the thirteenth century entitled “Cooking pot”, located in the University of Bologna, the description of how to make lasagnas is included. Around the year 1000, there is the first documented recipe of pasta in the book “De arte Coquinaria per vermicelli e macaroni siciliani” (The Art of Cooking Sicilian Macaroni and Vermicelli), written by Martino da Como, chef of the powerful homeland of Aquileia, in the province of Udine (figure 53). In the eleventh and twelfth centuries, dry pasta appears for the first time in Italy brought by the Arabs of Sicily, then under their domain. It was a long strip of thin pasta called “itrya”, that in Persian means “shoes´ laces “in Persian. This pasta is still made in Sicily under the name of “trii”. Apparently the Arabs took the idea from some nomadic people of the Middle East. Originally, it had to be dough strips rolled around to threads of straw or similar that were

Figure 54: Preparation of pasta in an Italian family (fourteenth century)

left to dry. The hollow served to reduce the possibility of mold formation. Possibly, this food had a practical purpose: lightweight and easily transportable but perishable, it allowed a quick preparation and was particularly useful for the troops which frequently moved. All these references refute the anecdotal introduction of pasta in Italy by Marco Polo in the thirteenth century, who would have brought it back from one of his trips to China in 1271. Fresh pasta, then, was used and appreciated in Italy since the Etruscan and Roman times. Through the centuries, pasta continued to appear in the tables of Italy with different names. In 1400, pasta was called “lasagna” and pasta makers “lasagnare”. In 1800 they changed their name and were called “vermicellai” (“vermi” means “worm”). But between 1400 and 1800 (that is, between “lasagne” and “vermicelli”) “fidelli” were born, which were threads of pasta with cylindrical shape. In

Figure 55: Preparing the pasta (engraving of the 19th century)

this way pasta makers also were called “fidellai”. Between 1400 and 1500, “fidei” (pasta in the local dialect) production spread widely to Liguria (figure 54) according to what the foundation in Naples of the Pasta Makers Corporation in 1546 demonstrated. In 1574, a similar association was founded in Genoa and in 1577 in Savone, the “Regolazione dell’Arte dei Maestri Fidelari” (Rules of the art and the masters of the pasta) was written. In the mid-sixteenth century pastas were taken to France by the chefs of Catherine de Medici and recommended by the medical practitioner of the Royal Court, Paul Jacques

Figure 56: A factory of Maccaroni in Naples (1900).

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Figure 57: Another pasta factory in Naples (1900).

Figure 58: In front of a spaghetti factory of Apulia, people trying to eat them with the hands (1909).

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In 1740, in Venice, Paolo Adami received the license to open the first pasta factory. One hundred years later, in Amalfi, they began to use water mills and stone grinders, where the semolina flour was separated from the wheat bran. Machines brought market development, competition and exports across the ocean. During the nineteenth century, consumption of dry pasta spread rapidly among the whole Italian society (figures 55, 56 and 57). Little by little its use became a gastronomic habit among the upper classes. The consumption of dry pasta quickly Figure 59: Neapolitan Family eating pasta with the hands.

spread among the whole Italian society and its offer to the guests became a sign of social distinction. Until then, pasta was eaten with the hands (figure 58 and 59) because the forks of that time had only two tines not suitable to roll the pasta and the adding of sauces made this way of eating it not the most appropriate. So an additional instrument started to appear in the high class tables: the fork of four tines. Its use started being an element to impress the guests rather than to help them eat. Delightful events of the Neapolitan life are described, giving details on the work of the “maccheronari”, who practically in every corner were very busy making “maccheron”, especially on days of meat fasting, using their pots filled with boiling water. Their product sold so incredibly well that hundreds of people took them in pieces of paper”(figure 60). In the creation of the different types of pasta legends are

Figure 60: Seller of Neapolitan pasta of the 19th century.

inexhaustible. According to an old tradition, the “tortellini” was created by a Bolognese innkeeper who fell in love with

Malouin, member of the Academy of Sciences. In the second half of the eighteenth century, a new profession appeared in France, the “vermicelliers”, who by using a device with holes they transformed pasta in thin threads similar to worms. As already mentioned, “vermi” means “worm” and hence comes the term “vermicelli”, whose synonym in Neapolitan dialect is “spaghetti”, a word that newly appeared in the middle of the nineteenth century.

Venus´ navel the night that the goddess slept in his inn. All his determination was to reproduce the fascinating shape of the goddess in the perishable pasta. In the same way, the “tagliatelle” arose from the reproduction of the hairs of the beautiful daughter of Pope Alexandre VI, by Zafiran, chef of John II, during the wedding of Lucrecia Borgia. The dough was made by a process similar to the pressing of grape to make wine. The mixture of the semolina with water was done by the feet. This method was used until King

At the beginning of the seventeenth century it was in

Ferdinand II of Sicily (figure 61) visited a pasta factory and,

Naples where the first and rudimentary machinery for its

very surprised by what he saw, he asked Engineer Cesare

production was born. This led to the highest level of perfection

Spadaccini to develop a machine. Thus was invented the

in its production, specifically in Gragnano, where the way was found to dry and keep it and keep it thanks to the special weather created by the alternation of the Ponentino (dry) wind

mechanical press, made of bronze, and the process was progressively mechanized. The pasta industry grew rapidly at the end of the nineteenth

with the Vesuvian (warm and humid) wind. The extension of

century and at the beginning of the twentieth century, when

the kneading machine and the invention of the press machine

deliveries were done all over the world. Taganrog was the

made possible the production of pasta at a low price. And thus

variety of wheat most appreciated by pasta manufacturers. It

became the food of the common people.

was a high quality durum wheat imported from Russia.

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The great development of Italian pasta at the turn of the century was also related to exportation, which in 1913 reached a record. In 1917, Fereol Sandragne patented the largest continuous system of pasta production. Meanwhile, the Bolshevik Revolution had cut off the imports of Russian wheat. Italian pasta producers used first French or American wheat, but nowadays most of the wheat used for Italian pasta production is grown in Italy, with some imports from Australia. In 1933, the first continuous fully automated press machine came into action. It was designed and built by two Engineers of Parma, Mario and Giuseppe Braibanti. Around 1800, pasta met tomato. Until then, it had been eaten plain or with cheese. Tomato sauce, boiled in a pot with a pinch of salt and a few basil leaves, began to be used by the outdoor sellers of the South of Italy to spice up macaroni.

Figure 61: Ferdinand II (1810-1859), of the Bourbon dynasty, King of the Two Sicilies between 1830 and 1859.

There is a variation of this sauce, which I and my wife like best. In a frying pan with olive oil, stir fry for a minute (not more) chopped garlic and then add the tomatoes (peeled and seeded) cut into not very small pieces (figure 62). When the tomatoeshave just started to cook, add chopped black olives and capers (figure 63), and cook it for a few minutes more (be careful not to add too much salt because the olives are already salty) (figure 64). Cook the pasta until it is “al dente” and dump it into the sauce. Finally, add chopped basil. Put it in the pan for a while and then serve (figure 65). Do not add grated cheese. The pasta that is best suitable for this recipe (to our taste)

Figure 62: Tomatoes ready, peeled and seeded.

are the flat and long noodles, such as linguini (3 mm wide) or fettuccini (6 mm wide). Mussels with tomato, garlic, White wine and basil Mytilidae, commonly known as mussels, are a  family  of marine bivalve mollusks, which live exclusively both in intertidal areas  such as areas of shallow subtidal coastlines across the world (figure 66). They are some of the most abundant shellfish and are known both in North and South hemispheres. Like

other

bivalves,

they

are

filter

feeders

Figure 63: Chopped capers and black olives give the sauce a special touch. Of course, they can be avoided.

(they

feed on phytoplankton and organic matter in suspension) that live attached to the substrate (figure 67). As most bivalves, the mussels have a large organ that acts as a foot, similar in shape to a tongue, with a furrow through which ejects a viscous secretion that hardens gradually when it comes in contact with sea water. There is a highly resistant ”byssus” near the hinge and with that the mussel is fixed to its substrate. The outer shell of the mussel is composed of two hinged valves (“bivalves“). It has several functions, from support for the soft tissues to protection against predators and drying (figure 66).

Figure 64: The sauce waiting the pasta (never the reverse).

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Page _ 99 Figure 65: Vicky´s favorite dish of pasta, finished.

They are widely used in gastronomy and there is much archeological evidence that humans have used mussels as a food source for thousands of years. It is one of the foods that brings most iron to the body, much more than many kinds of meat and fish. In addition, they are very rich in proteins, vitamins A, B1 and B2, calcium, iodine and phosphorus. They have fats of the Omega 3 group. Although mussels are valued as a food, the poisoning due to toxic organisms contained in the mussels can be a potential danger. Most of the mussels from the market come from the mussel

Figure 66: A mussel.

Figure 67: Mussels attached to the sea water substrate.

Figure 68: Mussels with debris in their shells.

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Figure 69: Mussels ready to cook.

Figure 71: The ones that do not open should be discarded.

Figure 70: Cooking of the mussels.

farming (controlled breeding in trays) so that it is possible to get this product fresh all year round. If they are bought fresh, they need to be purged to remove debris (figure 68). They are

Figure 72: Finished dish.

also found frozen (with or without the shell). Each region has its typical preparation. Mussels can be smoked, boiled, steamed, fried or grated. Our favorite recipe includes basil, and that is why I include it here. It is ideal that the mussels are alive just prior to being cooked (figure 69). Frozen mussels that are bought in supermarkets can also be used. In the event that they are still alive, they are cooked in a pot with water and a little salt to a high heat, and should be removed from the pot as they start to open (figure 70). We must discard those that do not open (figure 71) To make the preparation, add chopped garlic in a pan with olive oil and after a few minutes add tomatoes (peeled and seeded) cut in cubes and season with salt and pepper. Before they become a sauce, add the mussels and immediately some white wine. When the alcohol evaporates, add plenty of chopped basil and remove them immediately. If the mussels were cooked with their shells, the sauce is served within each one on a plate (figure 72). If cooked without a shell, you can serve the mussels with the sauce in small pots. Some slices of toasted bread sprayed with olive oil is the ideal side dish.

Figure 73: Jenning Cox.

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Basil daiquiri Daiquiri is a type of cocktail made from white rum and lemon juice. It has its origins in the Cuban beaches, specifically in Santiago de Cuba, so it should be prepared with Cuban rum. There are different stories about its origin. The most accepted recognizes the engineer Jenning Cox as its creator Figure 75: American troops landing on the beaches of Daiquiri (June 26th, 1898)

(figure 73). Cox, who was the manager of the then Spanish American Iron Company, worked in an iron mine in a village called Daiquiri, located 30 km east of the city of Santiago de Cuba (figure 74). Its beach was the scene of an major landing of the North American army during the Spanish-American War of 1898 (figure 75) which determined the occupation of Cuba by  the  United States  of  America and the loss, on the part of Spain, of their island colonies in America and Asia (Puerto Rico, The Philippines and Guam), which were transferred to the United States, which, in turn, was to become a colonial power. One day, Jenning Cox received visits from his country and as he did not find the gin, he added to rum a bit of lemon juice

Figure 76: The original recipe by Jenning Cox´s own hand.

and a bit of sugar, so it was not too strong. It was the Italian engineer Giacomo Pagliuchi, colleague of Cox, the people who gave it the name of “daiquiri” in honor of the place. They were who took his drink to the bar of the (later disappeared) Venus hotel, known as the “American Bar”. There they showed it to the bartender who immediately began to prepare it (figure 76) Daiquiri was moved from Santiago de Cuba to Havana in Emilio Gonzales’s mind, the great and popular Maragato, bartender of Spanish origin, who worked in the Plaza hotel. Maragato, in turn, introduced it to his friend Constantine Ribalaigua (figure 76), the owner in those days of the legendary bar La Floridita (figure 78). Ribalaigua got excited and began

Figure 77: Caricature of Constantine Ribalaigua (1937).

to transform the cocktail until he created Daiquiri Frappe or

Figure 74: In orange, the Province of Santiago de Cuba.

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Figure 78: The Bar “La Floridita” in Havana (Cuba).

Figure 79: The “Floridita Daiquiri” in a T-shirt.

Daiquiri Floridita, adding maraschino liqueur and replacing

and doubling the quantity of rum. Thus was born the “Daiquiri

lemon with lime (figure 79).

Savage” which later was called “Daiquirí to the Pope”. This variety became such a source of inspiration for the winner of the

This cocktail became famous some years later, in 1909, when admiral Lucius W. Johnson, who had tried the cocktail

Nobel Prize for Literature that sometimes he carried a thermos flask to be filled religiously with his favorite beverage.

in Cuba, took it to the Club of the Army and Navy in the city of Washington, USA.

It is said that there are more than 20 kinds of daiquiri cocktails, by varying the fruit: strawberry, peach, pineapple,

The famous American writer Ernest Hemingway (1899-

apricot, melon, coconut milk, etc. Fredo Corleona (played by

1961), a frequent visitor of the bar La Floridita (figure 80)

the American actor John Cazale) in “The Godfather II” movie,

mentions the daiquiri cocktail in one of his novels. Thanks

asks for a banana daiquiri.

to him, this cocktail acquired international fame (figure 81). Later, the famous American writer, obsessed by not eating

A little known variety is basil daiquiri, which I prepare like

sugar, modified the Daiquirí frappé, eliminating the sweetness

this: blend a coffee cup of rum, 6 basil leaves, sugar to taste, a

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Page _ 103 Figure 80: Statue of Hemingway in the Bar “La Floridita”.

dash of lemon juice and about a cup of crushed ice, garnished with a basil leave. I suggest a wide - mouth glass

Basil has religious connotations. After the resurrection of Christ, basil grew around his tomb, and in memory of that, in some Greek Orthodox churches, some containers with basil

Cultural aspects of basil In ancient Egypt, basil was employed as one of the elements of the balsam used in mummification process. It has generally been described as poisonous. While the African traditions claim that it protects from the scorpions, the European tales assert that it is a symbol of Satan.

leaves are located under the altars. It is also used to make holy water. In Bolaños of Calatrava (Spain), basil is the symbol of their patron saint festivals, which are also called “Basil festivities”. People grow this plant throughout the summer to carry in September as an offering to the Christ of the column, the patron saint of Bolaños. In addition, on the patron saint´s day (14th September), during the procession of the Christ of the column, the people cast chopped basil as an offering to Christ.

Currently, in Italy it is a sign of love, but in the Ancient Greek it embodied the hatred, the misery and poverty.

All this means that Christ is also known by the nickname “The Christ of the Basil”.

In some Caribbean cultures it is related with natural powers

In the Valencian town of Betera, specimens of more than

to repel the bad spiritual influences and attract the positive

two meters in height and between 2.5 and 4 meters in width

impact of the good spirits.

are cultivated to the offering dedicated to the Virgin of the Assumption, in the traditional feast of Les Alfàbegues. The

In Cuba it is greatly used in spiritual ceremonies and it is

technique used to achieve this magnitude is kept under secret.

a tradition to pass a fresh bouquet by the head and the body of the medium. Among spiritualists and mediums, basil is the most recommended herb to believers.

In certain regions of Central Mexico, basil is used to attract good fortune, by placing a pot with the herb on the door or in any window of a store or business. The development of the

It is also called the “herb of the witch”, and it is attributed multiple magic virtues, many related to love as, for example,

plant is a sign of bonanza in the business, since it shows how careful the owner of the business is.

to predict, by putting some basil in someone’s hand, if it is promiscuous or unfaithful. According to tradition, if the plant is wilted immediately, it is best to change the partner. On the

Basil is part of the food and traditions from time immemorial. Glory to the Queen of Herbs.

contrary, if it sprinkled on the beloved person while sleeping, it is said it ensures fidelity.

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Figure 81: Commemorative plaque of “The cradle of the Daiquiri”.

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Fortin, Francois, Editorial Director. The Visual Foods Encyclopedia. Macmillan, New York. 1996. Hoekstra D. World’s best pizza. Chicago Sun-Times, 27 July 2008.

estragol, linalool and p-cymene towards Shigella sonnei andS.

International Pasta Organization. Historia de la pasta.

flexneri. Food Microbio 2004 Feb;21:33-42.

http://www.internationalpasta.org/ (Accessed 21 January

Barroso JL. Recante registrazione di una denominazione

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nel registro delle specialità tradizionali garantite [Pizza

Lamberti M. Personal communication (January 2014)

Napoletana (STG)]. Gazzetta ufficiale dell’Unione europea, 4

Made in Italy. The Food and Cuisine of Liguria.

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http://www.made-in-italy.com/italian-food/regions/liguria

BBC Food. Was margherita pizza really named after Italy’s

(Accessed 21st January 2014)

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Muniesa J., Gavilán M. Melanzane alla parmigiana. http://

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Calucci L, Pinzino C, Zandomeneghi M et al. Effects of

Opalchenova G, Obreshkova D. Comparative studies on

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L.--against multidrug resistant clinical isolates of the genera

2003 Feb 12; 51:927-34.

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Consorzio del Pesto Genovese. http://www.

Microbiol Methods 2003 Jul;54:105-110.

mangiareinliguria.it/consorziopestogenovese/pestogenovese.

Orafidiya LO, Oyedele AO, Shittu AO, Elujoba AA. The

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formulation of an effective topical antibacterial product

Corato N. History of pizza Margherita.

containing Ocimum gratissimum leaf essential oil. Int J Pharm

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Curioni A. y Arizio O. Plantas Aromáticas y Medicinales –

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D’Agostino A. La vera storia della pizza napoletana.

Stradley L. History & Legends of Pizza.

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ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com


ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Garibaldi and Nélaton Prof. Dr. Alfredo E. Buzzi Full Professor of Radiology. School of Medicine, University of Buenos Aires.

Portrait of Dr. Auguste Nélaton and Giuseppe Garibaldi who are shaking hands (note also that Nélaton is checking Garibaldi’s arterial pulse with his left index and middle fingers). Garibaldi, wounded, lying on a bed, is told the news that his leg does not need to be amputated (Photo by DeAgostini/Getty Images)

ALMA Culture&Medicine - Editorial Alfredo Buzzi - www.editorialalfredobuzzi.com

Page _ 105

THE HISTORY OF MEDICINE IN A PICTURE


Page _ 106

The aim of unifying Italy was partly fulfilled in 1860 with the

no improvement and his attendants decided to invite Auguste

annexation of southern Italy to the Kingdom of Piedmont and

Nélaton (1807-1873), Professor of Surgery in Paris, to give his

the creation of the Kingdom of Italy, since Venice and, most

advice.

importantly, Rome and the Papal States did not form part of Nelaton, having introduced an ordinary stilet into the

the new political entity.

wound, was convinced that the bullet was still there. He The Italian government was reluctant to launch a military

advised against amputation, and was of the opinion that

campaign against the Pope, but Giuseppe Garibaldi (1807-

either an abscess would form that would indicate the site of

1882), was the hero of the unification of Italy, because despite

the bullet, or that it would emerge without interference and

the fact that he had previously pledged loyalty to the King of

the wound would then heal. He suggested that to facilitate

Italy (Victor Emmanuel II), he crossed the Strait of Messina

the ejection of the bullet, the diameter of the wound might be

(with help from the British Royal Navy) in August 1862, and

enlarged by the insertion of sponges.

marched north to reach Rome. Three days later, Partridge again arrived in Spezia, and Unwilling to risk war with France, whose army protected

accompanied by Nicolai Pirogoff, Professor of Surgery in

the Pope, the Italian government hastily dispatched troops to

Moscow, again saw Garibaldi. He was convinced by this second

stop his advance, and the two armies came face to face in the

examination that the bullet was still in the ankle. During these

Aspromonte Mountains in Calabria. Garibaldi could not bring

few days, no less than seventeen surgeons examined the

himself to shoot at fellow Italians and ordered a cease-fire. In

patient, who is said to “have suffered great agony” as a result

the ensuing confusion he received three gunshot wounds, only

of their investigations.

one of which gave cause for concern. A bullet had penetrated his right ankle a little above and in front of the medial

Nélaton had not convinced his Italian colleagues and on

malleolus and, despite the efforts of the attending surgeon,

his return to Paris immediately applied himself to finding

Enrico Albanese, it could not be found.

some means of proving that the bullet was still in the ankle. His solution was achieved by the construction of a probe with

Garibaldi was taken to Spezia, in Liguria, on board the

an unglazed porcelain head. Mere rubbing of the instrument

steamer Duc de Gêne, where he was imprisoned on a charge

against lead was sufficient to mark the porcelain. Meanwhile,

of treason. Two days later he was examined by Professor Porta

Professor Zannetti had been attempting, unsuccessfully, to

of Pavia in the presence of Professors Rizzoli (Bologna) and

confirm the presence of the bullet by means of a galvanic

Zanetti (Florence) and the surgeons Prandina (Chiavari), Negri

current. When he received the probes from Paris, however, he

(Genoa) and Ripari (Turin). With one exception, all were of the

was able to prove to his own and his colleagues’ satisfaction,

opinion that the bullet was no longer lodged in the ankle.

that Nelaton’s diagnosis was correct. On November 22nd, Zannetti successfully removed the bullet with the use of an

The detection of a bullet was particularly difficult before

expandable stent. It seems probable that James Marion Sims,

the discovery of X-rays (it would be another 30 years before

the well-known American gynaecologist, supplied tents of the

radiology was available to medicine).

seaweed Laminaria digitata through Nélaton, to open up the wound and allow easy extraction of the bullet.

Delicate questions of medical etiquette arose against the backdrop of nationalistic interests, as physicians from four

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countries (Italy, Russia, Britain, and France) became involved.

Dall’osso, E. Ferdinando Guidicini and Francesco Rizzoli are about to depart in order to cure Garibaldi’s wounds. Chir

Supporters of Garibaldi’s ideals in England formed a

Organi Mov 1956; 43(3):250-4

committee, and Professor Richard Partridge of King’s College

Dobson, J. A surgical problem of the last century: Garibaldi’s

(London): proceeded to Spezia to give his opinion on the

bullet and Nelaton’s probe. Ann R Coll Surg Engl 1953; 13(4):

wound. He was received most courteously by Garibaldi’s

266–269.

medical attendants, and his opinion was that “the bullet did not

Dobson , J. A supplementary note on Nélaton’s probe. Ann R

enter the joint nor effect a lodgment elsewhere.” But there were

Coll Surg Engl 1954;14(5):430-1.

certain Italian practitioners who still maintain that the bullet

Lippi, D., Donell S. Gynaecologists and the treatment of

was in Garibaldi’s foot. Meanwhile, Garibaldi’s wound did not

Garibaldi’s ankle wound. Eur J Obstet Gynecol Reprod Biol

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2013;170(2):315-7

serious and amputation might be inevitable.

Moscucci, O. Garibaldi and the surgeons. R Soc Med 2001; 94: 248-252.

Five weeks later, however, Garibaldi’s condition showed

Sabbatani, S. Garibaldi’s wounds. Infez Med 2010;18(4):27488.

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ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Alexis Carrel: cet inconnu Prof. Dr. Alfredo Buzzi Professor Emeritus and Dean of the Faculty of Medicine of the University of Buenos Aires

Alexis Carrel was a French physician awarded with the Nobel Prize in Medicine in 1912. The originality of his works still amazes us today. He wrote a book in French titled L h ́ omme, cet inconnu (Man, the unknown), which became a best-seller, and contains his own social prescriptions. Almost a century after, this French scientist has been almost forgotten. For those of us who started our medical studies in the late 1940s, the scientific and humanist French doctor Alexis Carrel (1873-1944) was familiar to us for his contributions to vascular surgery, organ transplantation and the culture of cells and tissues –for which he was granted The Nobel Prize in Physiology or Medicine in 1912– as well as for the development of antiseptic solution containing sodium hypochlorite along with the English biochemist Henry Drysdale Dakin (81880-1952). This solution, known as Dakin-Carrel, was used efficiently as an antiseptic solution in the continuous blood supply to wounds during the First World War (1914-1918). In addition to his scientific writings –whose originality still amazes us today, almost a century after their publication–, Carrel wrote a book in French titled “L´homme, cet inconnu”, 400 pages long, which was translated as “Man, the unknown”. In this volume, which is divided into eight chapters, Carrel expressed his philosophical point of view regarding a number of issues: the need to know ourselves, the science of men, the body and physiological activities, mental activities, internal time, adaptive functions, the individual and the reconstruction of men. These themes awakened the interest of young minds at the time, as much as the paramedical and cultural writings of the Spanish sage Santiago Ramón y Cajal (1852-1934),

Pétain (1856-1951), and was prescribed with an adequate

who shared the 1906 Nobel Prize with the Italian histologist

medical assistance– his wife Madame Carrel decided to travel

Camilo Golgi (1844-1926), for his studies on the structure of

to Argentina and settle in the province of Córdoba. Thanks

the nervous system.

to my beloved friend Dr. Guy Feune de Colombi, have held in my hands a number of sections of Dr. Carrel’s scientific

The figure of Carrel sustained the interest for Argentine

publications.

doctors, whether because of Argentina’s similarity to French culture in general and its medicine in particular or for the

Accustomed to following the medical method of Canadian

fortuitous event that –after his death in Paris in 1944 under

doctor William Osler (1849-1919) to arouse the interest of young

painful circumstances, as he was accused of collaborating

medical students of the time, I used to intersperse questions in

with Vichy’s administration, headed by marshal Philippe

my classes at Hospital de Clínicas of the University of Buenos

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GALLERY OF NOBEL PRICES IN MEDICINE


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Aires about historical personalities that were recognized for their scientific contributions. This was how, when seeing a patient suffering from a cardiovascular condition, I would ask my students: “Who was William Harvey and what did he do?” When faced with a physiological issue, I would say: “Who was Claude Bernard and what did he discover?” Once, when I asked the same question about Alexis Carrel, I was met, to my surprise, with absolute silence. None of the students that attended my class knew or had heard of the works of this remarkable French researcher. Then, I decided to carry out an anonymous survey among the students of the annual rotating internship at Hospital de Clínicas of the University of Buenos Aires who were in the last year of their medical career or aspiring to become medical professors who were studying at the Faculty of Medicine of the University of Buenos Aires. The purpose of the survey was to objectively establish how much they knew about the life and work of Alexis Carrel. The survey consisted of three questions that were meant to be answered briefly: Who was Alexis Carrel? - In what time did he live? - What were his contributions? 1 One hundred doctors and twenty-four students answered the survey, which revealed the following results: out of the twenty-four students, six men and eight women did not answer the questions and, thus, were ignorant of the life and work of Alexis Carrel. Out of the hundred doctors, two answered Carrel

1

I would like to thank professors Raúl de los Santos and Federico Pérgola for their collaboration in carrying out the survey.

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was recognized for his work in vascular sutures and another

There was an incoercible hemorrhage to a section of the

two recognized his work in cell cultures. Another two doctors

portal vein, and the doctors that assisted him were helpless.

mistakenly attributed Carrel studies on blood clotting. One

This assassination deeply impressed the young mind of Alexis

doctor wrongly mentioned Carrel’s contributions to neurology

Carrel, who correctly theorized that, if the blood vessels had

and, only one doctor correctly mentioned his book “Man, the

been stitched, Sadi-Carnot would have survived.

unknown”. That is to say, only five among one hundred doctors with academic aspirations (5%) were familiar with partial

Two years later, familiarized with the work of Mathieu

aspects of his contributions. None of them mentioned Carrel’s

Jaboulay (1860-1913) on vascular sutures, Carrel was devoted

original contributions to limb transplantation and organ

to studying this subject. Not finding the materials he needed

transplantation –such as heart, kidney and thyroids– and the

at manufacturers of surgical instruments, Carrel visited a “lace

use of veins to replace carotid, coronary and aorta arteries,

woman” that provided him with the needles he needed.

among others. At the same time as he practiced his experiments on a Alexis Carrel was born on June 28th, 1873 in a village near

dog, Carrel publicised his findings along with his partner Louis

Lyon. He was baptized the following day by Marie Joseph

Gallavardin (1875-1957), who would later become a world-

Auguste. His father, Alexis Carrel Billiard, died when he was

renowned cardiologist. Among Carrel’s listeners was René

thirty-two years old after suffering from pneumonia. His first-

Leriche (1879-1955), a man with whom he would start a sincere

born son was of robust health. He started his first studies with

and long-lasting friendship.

Jesuit priests, finishing his Baccalaureates in Letters in 1889 and in Science in 1890.

Young Carrel, who was baptized with the name of his grandfather Augusto, changed his name to that of his father

He attended the Faculty of Medicine of Lyon, where he

Alexis, which indicates a clear paternal affinity.

finished his four years of internship. In 1898, he was appointed an assistant lecturer of Anatomy to the renowned professor

In 1903, he eye-witnessed a miraculous cure at the

Jean León Testut (1849-1925). Among other important

Sanctuary of Our Lady of Lourdes, an event that marked the

personalities that influenced his scientific personality were

beginning of a progressive change in his life taking him from

Louis Farabeuf (1841-1910) and Antonin Poncet (1845-1913).

skepticism to faith. Today, he is considered one of the most famous converts in Lourdes.

In June 1894 there was an attack against the fourth President of the French Republic, Francois Sadi-Carnot (1837-

One of his doctor colleagues was unable to escort sick

1894). The President was stabbed to the heart by an anarchist.

people to the train for the sick that were making a pilgrimage

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to the shrine at Lourdes and asked Carrel to replace him. Among the wagons filled with sick people, he saw a girl over an extended mattress whose face was emaciated. Examining the abdomen of Marie Bailly, he diagnosed a very advanced stage of tubercular peritonitis. Both of her parents had succumbed to the white plague. At the last minute, he decided to transport her and to bathe her in the pools and performed an ablution over her abdomen with the fountain’s water. Carrel, who could not take his eyes away from the dying woman, noted that her face changed its aspect. Palpating her stomach, he felt it was smooth and depressible. When he asked her how she was feeling, Marie answered: “I feel I have been healed”. She recovered her health and, on December 6th, 1903 she took the vows to become a nun with the Saint-Vincent-dePaul’s Daughters of Charity. She died without having a relapse until her death at the age of fifty-one on February 22nd, 1937. With full conviction, Carrel signed a medical report testifying the woman’s cure, and allowed the press to publish his point of view –which generated loud objections. He was attacked simultaneously by a member of the clergy because of his restrained tone and by an anticlerical man, who tried to refute him. He was in the crossfire. One of his bosses, who thought highly of him, suggested he quitted tenders, assuring him he would never be successful. His 1902 publication “La technique opératoire des anastomoses vasculaires et la transplantation de viscères” (“The Operative Technique of Vascular Anastomoses and the Transplantation of Viscera”) in the journal Lyon Médicale marked the beginning of his influential original contributions –although he had already published twenty-four works, including two on popliteal aneurysm. Given it was impossible for him to pursue an academic career in Lyon, he decided to emigrate to Canada, where there were multiple opportunities for young entrepreneurs like him. After a short stay in Paris, on May 15th, 1904 he set out to North America. He arrived in Montreal, where in July he presented a paper on vascular anastomosis at the Second Medical Congress of the French Language of North America. Dr. Carl Beck, a well-known surgeon from Chicago, who was in the audience, immediately recognized Carrel’s talent. In November 1904 Carrel was offered a position at the Department of Physiology at the University of Chicago, where he worked along with Dr. Charles Claude Guthrie, a young physiologist seven years Carrel’s junior. Carrel and Guthrie worked together between November 1904 and August 1906. During that time, they jointly published twenty-eight papers –Carrel additionally wrote five papers on his own and, Guthrie, two. During this productive collaboration, arteries, veins, kidneys, thyroid glands, ovaries and a thigh were transplanted or re-implanted. On May 1906 Carrel was invited as a fellow by Dr. Simon Flexner, Director of the Rockefeller Institute of Medical

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Research from New York, who, after Carrel’s death, expressed in a biographical essay: “He drew my attention in an interview published in the journal Science on October 13th, 1905. He was describing a kidney transplant to a dog, with the renal artery being sutured to the carotid artery, the renal vein being sutured to the jugular vein and the ureter to the esophagus. The kidney was still functioning. Carrel was little-known in North America at that time. Invited by me, he came to New York for a conversation that led to a fellowship in the recently opened Rockefeller Institute. He joined us in October 1906, precisely when the Institute was moving from its provisional headquarters to the first building of laboratories, based in the East River bay. This circumstance made it possible to grant him a space where he could work following his own ideas, a clear advantage, given that his surgical work required the strictest asepsis conditions”. Carrel was awarded the 1912 Nobel Prize in Physiology or Medicine “in recognition of his work on vascular suture and the transplantation of blood vessels and organs”. Between 1901 and 1910, using experimental animals, he developed techniques that are currently known by cardiovascular surgeons –except for using a dissection microscope and tubes made of synthetic materials. He reunited vessels, inner lining to inner lining; he sutured artery to artery, vein to vein, artery to vein, and did this end to end, side to side, and side to end. He used patch grafts, autografts, homografts, rubber tubes, glasstubes, metal tubes, and absorbable magnesium tubes. He devised his own atraumatic needles, clamps and sutures. He performed coronary bypass surgery on a dog using a carotid artery segment as a bridge, which took him only five minutes. He could preserve vessels, tissues and organs by refrigerating them in Locke’s solution. He suggested using a segment of a patient’s vein to replace a damaged vein. He transplanted

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the thyroid gland, spleen, ovaries, limbs, kidneys, and even a heart and so proved that, surgically, it was possible and easy to transplant organs. But he recognized that a homotransplant vessel served only as a framework for new cell growth. Carrel could suture efficiently almost any vessel, even those that were a match-stick in diameter. Part of his success was due to a new technical resource: triangulation. His technique consisted of sewing around three straight lines instead of doing it around a circumference. In order to do it, he placed three sutures placed 120° apart. Part of his success was also based on his unusual manual dexterity and on his insistence on unheard-of gentleness to tissues (he used fine, round, polished atraumatic needles and extremely fine, vaselined thread), and practiced aseptic techniques that went far beyond those practiced by contemporary surgeons. His laboratory rooms, necessarily guarded against bacterial contamination, acquired the aura of a sanctuary where masked acolytes clad in black gowns and caps performed the aseptic mysteries of experimental surgery and tissue culture. Early in his career Carrel adopted black surgical gowns and drapes for his operating table to cut down glare and give better visibility to the tissues upon which he performed his extremely delicate operations. It is obvious that in the early 1900s, Carrel was approaching the modern germ-free atmosphere required for survival of patients who had few or no mechanisms for defense against bacteria. Carrel recognized the importance of preserving blood vessels in vitro so that they would be immediately available when needed, preserving vessels in cold storage in special saline solutions or in the animal’s own serum or defibrinated blood. Thus, metabolism could be completely stopped, by placing them in a condition of latent or potential life, in an indefinite period of preservation. The first reimplantation of a human limb was performed in 1962 at Massachusetts General Hospital in Boston when the arm of a 12-year-old boy was successfully sewn back after being accidentally amputated by a train, using the techniques employed in animals by Carrel and Guthrie in 1905 and 1907. During those years, Carrel showed that, once the techniques of joining artery to artery and vein to vein were mastered, the reimplantation or transplants of organs was technically simple. He also acknowledged the problems of antigen-antibody reactions and the phenomenon of rejection of foreign tissues. Even though Christian Barnard was the first to transplant the heart of one man to another in 1968, Carrel described the technique for the transplantation of both the heart and the lung in 1907. In the final paragraphs of his work, we can see that he acknowledged the phenomenon of rejection on

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of the artery a segment of the neighboring vein, or of some other vein like the saphenous vein or the external jugular vein. In 1910, Carrel detailed that in some cases of angina pectoris, when the ostium of the coronary arteries is calcified, it could be useful to establish a complementary circulation for the lower part of the arteries. One time, he implanted one end of a long carotid artery, preserved in cold storage, on the descending aorta. The other end was passed through the pericardium and anastomosed to the peripheral end of the coronary artery, near the pulmonary artery. Unfortunately, the operation was too slow. Three minutes after the interruption of the circulation, fibrillary contractions appeared, but the anastomosis took five minutes. By massage of the heart, the dog was kept alive. But he died less than two hours afterwards, showing that anastomosis must be done in less than three minutes. In 1910, Carrel established that certain cardiac lesions could be corrected surgically if the operation could be performed quickly, before brain damage occurred. Alone, and also along with Théodore Tuffier (1857-1929), he performed several types of interventions on the pulmonary artery of dogs and predicted the use of commissurotomy in man. Carrel spent many years working on tissue culture and organ perfusion. He kept a chicken’s heart pulsating in vitro for months, maintained a strait of connective tissue alive in vitro for decades and cultivated human sarcoma cells outside the body. In 1930, he Carrel met the famous aviator Charles Lindbergh (1902-1974), with whom he developed an apparatus suitable for the perfusion of tissues and organs –which has in modified form served to maintain and preserve human kidneys until they can be transplanted. Carrel died in Paris on November 5th, 1944, when he was seventy-one. One must wonder why Carrel’s work was lost or totally ignored. A number of reasons may be argued, whether political –such as the accusation that he collaborated with Vichy’s administration– or personal –as he was somewhat undiplomatic and hypercritical and had little tolerance for human flaws. However, he worked in institutions such as the Rockefeller Institute for Medical Research, which is highly recognized by scientists. Carrel was a prolific publisher, and his works on experimental vascular surgery were published in journals such as the Journal of the American Medical Association (18 articles), Journal of Experimental Medicine (25 the part of the recipient: “The technique of transplanting the

articles), Science (7 articles), Surgery, Gynecology and Obstetrics

heart of one animal into the neck of another is now providing

(5 articles), Annals of Surgery (3 articles), Transactions of the

a valuable technique for those who are today scientifically

American Surgical Society (3 articles), as well as the Bulletin of the

investigating the process of rejection of cardiac tissue and

Johns Hopkins Hospital and British Medical Journal.

what to do to prevent it”. It is possible that, when writing “Man, the unknown” in 1935, Carrel also established that, after having extirpated an aneurism, it was possible to interpose between the cut ends

Carrel would never have imagined that he himself, in the near future, would be the unknown.

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LITERATURA & MEDICINA

ALMA Culture&Medicine - Vol 1. N1 - November 2014 Sir William Osler and the Osler Club of London

A talk given to the Osler Society of Buenos Aires on 14 September 2010 Prof. Dr. Adrian Thomas Past-President of the Osler Club of London http://www.osler.org.uk/

On the visit to the newly formed Osler Society of Buenos Aires by the President of the Osler Club of London a postcard, written by Sir William Osler, was presented to the new society. The card depicts the statue of the Elizabethan physician Sir Thomas Browne whose statue is in the square next to the Church of St. Peter Mancroft in Norwich. Sir Thomas Browne (born October 19, 1605 in London, England and died October 19, 1682 in Norwich, Norfolk) was a British physician and author. While practicing as a doctor he wrote several books with his best-known work being the Religio Medici of 1642. Religio Medici is a book of reflections on the mysteries of nature, man and God. Sir William Osler (1849–1919)(figure 1) was deeply influenced by Browne and this continued throughout his life. A similar card (figures 2a&b) was sent in 1908 to Dr Birnie of Taneytown, Maryland and reads: “Dear Birnie, Xmas greetings, ever yours, Wm Osler.” Osler had a selection of such postcards which he used as his contemporary equivalent of modern e-mail. When he was sixteen Osler went to school at Weston, and he was introduced to many books including scientific manuals of geology, botany, and microscopy. The Warden and the Founder of this school was the Revd. W. A. Johnson, who was affectionately known by the boys as Father Johnson, was an excellent field botanist, an active microscopist, and a competent artist. It was Father Johnson’s habit to read to the young people at the parsonage and to illustrate the beauty and depth of the English language by reading selections from the Religio Medici. At Christmas 1867 Osler’s eldest brother gave him a copy of Friswell’s Varia: Readings from Rare Books, published in 1866. This book included an essay on Sir Thomas Browne. The first book Osler bought for himself was the Globe edition of William Shakespeare, and then, in 1868 Osler purchased the 1862 Boston edition of the Religio Medici.

Fig 1. Sir William Osler (1849–1919).

rising expectations. Many things are much better than they were, but few things are as good as people have been led to expect. What

The image of the doctor has changes somewhat since

patients expect is what they can understand and often amounts to

Osler’s time and Halligan (Halligan, 2008) stated that it

a perception of attitude. Ironically, in the mid-20th century, when

“continues to be an idealized model that reflects people’s

medicine could do a great deal less than it can now, much more

aspirations rather than their actual experience. While medical

attention was given to attitudes because, in practice, that was all

practice is continuously improving, it has not kept up with patients’

doctors had to offer patients.” The role of the doctor is difficult

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Page _ 115 Fig 2b. Postcard used by Sir William Osler in 1908, sent to Dr Birnie.

ministry and therefore he entered Trinity College, Toronto in the autumn of 1867. However, his interests changed to medicine and he enrolled in the School of Medicine in Toronto. After two years he went to McGill University in Montreal and he obtained his first medical degree in 1872. After post-graduate training in Europe, Osler returned to McGill as a professor in 1874. Figure 3 illustrates a certificate of attendance for the Summer Session at the Faulty of Medicine for 1882 at McGill University and is signed by Osler. Osler’s medical career is varied and he worked in various medical centres (table 1). In 1884 he was appointed Chair of Clinical Medicine at the University of Pennsylvania. In 1885 he Fig 2a. Postcard used by Sir William Osler in 1908: “Monument to Sir Thomas Browne, Norwich.”

was appointed Visiting Physician to the Philadelphia General Hospital and in 1887 he was appointed Physician to the Philadelphia Orthopaedic Hospital and Infirmary for Nervous

and Osler in a well-known quotation says that: “No class of men

Diseases.  In 1889 he became the first Physician-in-Chief at

needs friction so much as physicians; no class gets less. The daily

Johns Hopkins Hospital, and in 1893 one of the first professors

round of a busy practitioner tends to develop into an egoism of

of medicine at Johns Hopkins University School of Medicine in

a most intense kind, to which there is no antidote. The few set-

Baltimore. Osler’s reputation as clinician, humanitarian and

backs are forgotten, the mistakes are often buried, and ten years of

teacher steadily increased.

successful work tends to make a man touchy, dogmatic, intolerant of correction, and abominably self-centred.” In Osler’s view this

After arriving at Baltimore, Osler insisted that medical

will emphasise the value of medical societies such as the Osler

students should be at the patient’s bedside early in their

Society of Buenos Aires, and he says in another well known

career and that by their third year they should be taking

quotation: “To this mental attitude the Medical Society is the best

clinical histories, performing physical examinations and doing

corrective, and a man misses a good part of his education who

laboratory investigations, instead of sitting in a lecture hall

does not get knocked about a bit by his colleagues in discussion

and taking notes. Indeed, it could be maintained that William

and criticisms.”

Osler’s greatest contribution to medical practice, aside from his clinical observations (table 2) was his insistence that medical

Sir William Osler, has been called the Father of Modern

students should learn by seeing and talking to patients. Osler

Medicine, and called one of the greatest icons of modern

reduced the dominant position of formal lectures and said: “I

medicine. Osler himself thought that this honour was due to

desire no other epitaph … than the statement that I taught medical

Avicenna. His life has been well reviewed in a recent biography

students in the wards, as I regard this as by far the most useful and

(Bliss, 1999). Osler was born in Bond Head, Canada West (now

important work I have been called upon to do.”

Ontario), and after 1857 lived in Dundas, Ontario. His parents were the Rev. Featherstone Lake Osler and Ellen Free Picton,

Osler promoted the establishment of medical residency

and he had two older brothers: Britton Bath Osler (1839-1901),

programs, and this idea subsequently spread throughout the

and Edmund Boyd Osler (1845-1924). As a young person, his

English-speaking world and still remains today in a modified

desire was to follow his father into the Anglican (Episcopalian)

form most teaching hospitals. Through this system, doctors in

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training make up much of a hospital’s medical staff, although this is currently changing with a consultant-led service and the physician-of-the-day with an increased senior involvement in the management of the acutely ill. The success of his residency system depended on a hierarchical structure involving many interns, fewer assistant residents and a single chief resident, who originally would occupy position for a number of years. While at Johns Hopkins, Osler also established the full-time, sleep-in residency system whereby staff physicians lived in the Administration Building of the Hospital. Osler’s contribution to medical education of which he was proudest was his idea of clinical clerkships - having third and fourth year students work with patients on the wards. He pioneered the practice of Fig 3. Certificate of attendance for the Summer Session at the Faulty of

bedside teaching making rounds with a handful of students,

Medicine for 1882 at McGill University signed by Osler.

demonstrating what one student referred to as his method of “incomparably thorough physical examination.” He himself liked to say, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” He is also remembered for saying, “If you listen carefully to the patient they will tell you the diagnosis” which emphasises the importance of taking a good history. Osler combined the science and the humanity of medicine. Fish & de Cossart (Fish & de Cossart, 2007)(table 3) contrasts two models of professional practice and their values as The Technical Rational view and The Professional Artistry view. So as an example, “Follows rules, laws, routines and prescriptions” is contrasted with “Starts where rules fade, sees patterns and frameworks.” Osler transcends this dualistic either/or paradigm and replaces it with a both/and approach. It is apparent that a technical rational view is as important as a professional artistry view for an integrated and humanistic approach to life and this is exemplified in Osler’s ethos. In 1905 he was appointed to the Regius Chair of Medicine at Oxford, a position which he held until his death. Osler was created a baronet in 1911 for his many contributions to the field of medicine. His house in Oxford, 13 Norham Gardens, was one of the finest houses in Oxford when Sir William Osler had it built in 1907 (figure 4), and became the home of one of the greatest physicians in the history of medicine. The house is currently the location of the Osler-McGovern Centre. His desk is still intact and can be visited (figure 5). The house has been the residence of two other Regius Professors: Sir George Pickering and Sir Richard Doll, the last Regius Professor to reside there. Green College have purchased 13 Norham Gardens and have made a major internal refurbishment and have set up the Osler-McGovern Centre, thanks to contributions from the McGovern Fund in Houston, Texas, Dr John P McGovern, and the Patrick Trust. Sir William Osler made 13 Norham Gardens a meeting place for students, physicians, scientists and visitors from all over the world, and it became known as “The Open

Fig 4. The entrance to 13 Norham Gardens today.

Arms” for the warm welcome given. The Centre promotes

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the integration of the art and science of medicine and offers

Club has recently offered free membership for four years

programmes

from election to all interested medical students. The members

involving

lectures,

seminars,

workshops,

conferences, for visiting students and post-doctoral Fellows.

of the Club, either medical or those engaged in some activity related to medicine, are devoted to the humanistic approach

Osler was a prolific writer and speaker. Osler’s first

to medicine, as exemplified in the life and works of Sir William

published paper was entitled “Christmas and the Microscope” and was published in 1869. His great textbook “The Principles and Practice of Medicine” was published in 1892 when Osler was aged 43, and rapidly became an essential reference for medical students and physicians. All told, Osler wrote over

Table 1. Osler’s Medical Career 1868-1870 Toronto School of Medicine. 1870-1872 McGill Medical School.

1,200 papers and books. Of these 200 on were on neurological

1872-1874 Further medical studies in Europe.

topics, and 100 publications were on paediatric topics.

1874-1884 Montreal. 1884-1889 Philadelphia.

Sir William Osler died, at the age of 70, in 1919, during the Spanish influenza epidemic. His wife, Grace, survived him by another nine years. The Osler Club of London (http://www.osler.org.uk/) was founded in 1928, which was the year of Lady Osler’s death. Figure 6 illustrates the Presidential badge of office. The club has two primary objectives: to encourage the study of medical history among medical students and practitioners and to keep alive the memory of Sir William Osler. The Club believes that the study of medical history should take place during the forming, moulding influences of the learning years and as a stimulus to the growing minds of the young rather than as a relaxation for the retired, ageing and old. For this reason the

1889-1904 Baltimore. 1905-1919 Oxford. Table 2. Osler’s eponymous diseases. Osler’s sign. An artificially high blood pressure caused by calcification of atherosclerotic arteries. Osler’s nodes. Raised tender nodules in the pulp spaces of the digits seen in sub acute bacterial endocarditis. Rendu-Osler-Weber disease. This is also known as hereditary haemorrhagic telangiectasia, and is a condition of multiple vascular malformations. Osler-Vaquez disease. This is also known as Polycythemia Rubra Vera.

Table 3. Two models of professional practice and their values. Fish &Twinn (1997) in Fish & de Cossart (2007)

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Fig 5. Osler’s writing desk at Norham Gardens today.

Fig 6. The Presidential Badge of the Osler Club of London.

Fig 7. Prof Alfredo Buzzi, Orator 2011, and the portrait of Thomas Linacre.

Osler. The Club has seven meetings each year and meets at

“Throw away all ambition beyond that of doing the day’s work well.

the Royal College of Physicians in London. Each year there

The travelers on the road to success live in the present, heedless of

is a prestigious Oration which, in 2011 was delivered by Prof

taking thought for the morrow. Live neither in the past nor in the

Alfredo Buzzi, the President of the Osler Club of Buenos Aires,

future, but let each day’s work absorb your entire energies, and

Argentina*. Figure 7 illustrated Prof Buzzi with a portrait of Thomas Linacre, the founder of the Royal College of Physicians, and the subject of a short biography by Osler. The principles that guided Osler are as relevant today as they were in Osler’s lifetime. As Aidan Halligan says: “Time spent with a patient, a hand held, a small kindness, a caring act, honesty – any of these seemingly inconsequential actions have a

satisfy your wildest ambition.” REFERENCES. Bliss, M. William Osler: A Life in Medicine. (USA: Oxford University Press, 1999). Fish, D & De Cossart, L. Developing the Wise Doctor: A

critical impact well beyond their stand-alone worth” (Halligan,

Resource for Trainers and Trainees (In Practice). (London:

2008). We need to defend these values and as Martin Luther

RSM Books, 2007).

King states “Our lives begin to end the day we become silent about

Halligan, A. The importance of values in healthcare. J R Soc

things that matter.” We can end with the words of Sir William:

Med 2008 (101): 480–481. DOI 10.1258/jrsm.08k019

*

Prof. Buzzi died on June 2nd, 2013.

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PHOTOGRAPHIC WINDOW

ALMA Culture&Medicine - Vol 1. N1 - November 2014 -

Larry Fink, the intuition as a creative engine Dr. Martín Valdez Chief of the Radiology Department. Centro Médico Luis Pasteur. Buenos Aires, Argentina

In October 2010, Larry Fink, the master of social photography and photojournalism, presented and discussed his work in a series of exhibitions and conferences organized at the photogallery of General San Martin Theater of Buenos Aires, Argentina. I had then the unique opportunity to interview this great photographer and deepen my understanding of his original conception of this art. As soon as the conversation started, it became clear for me

Undoubtedly, this intuition -which he strongly highlighted

why this artist is considered one of the best photographers

when I asked him about the qualities necessary for a good

of the twentieth century. His photography goes beyond the merely aesthetic effect to reveal the essence of the situations and people he photographs. A frowning face, a drop of sweat on a cheek, or an elusive look, Fink´s photos are always committed to human attributes and their context. His incredible intuition allows him to capture the synergy of

photographer- is intrinsically linked to the spontaneity and simplicity in the way he communicates his ideas. In fact, when one of the photographers present at the exhibition asked him about his inspiration for his famous series on the jazz world, another of his interest and talents (Fig. 1), Fink, without saying

gesture and circumstance at the right time, something he

a word, pulled out an harmonica from one of the pockets

learned well from the French photographer Henry Cartier-

of his worn vest, and improvised some jazz, surprising his

Bresson, one of his main influences.

interlocutor and the people around them (Fig 2).

Fig. 1

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Fig. 2

Fig. 3

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Page _ 121 Fig. 4

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Fig. 5

Fig. 6

But Fink´s work implies not only his innate ability to

at the Museum of Modern Art in New York (MOMA) and his

capture the “decisive moment” (something sought by every

subsequent book “Social Graces,” which gained him a place in

photographer, but masterfully achieved only by a few), but

the pantheon of great figures in the history of photography

also technical perfection, sometimes rebellious to formalisms

(Fig. 5).

(a clear example of this would be the memorable photographic series for the presidential campaign of Barack Obama, Fig. 3),

There is much more that can be said about his work,

and a poetic and almost theatrical vision of reality, which often

especially after understanding the how and why of such

reminds the gorgeous Parisian images of Brassaï. Another remarkable aspect of his oeuvre is a profound social conscience (inherited from his parents), usually depicted from unconventional perspectives, and sometimes assuming an ironic undertone. A clear example of this, is the refined sensibility with which he portrayed the rural working class of Pennsylvania that greatly contrasts with the images taken

production. But, as he said in one of the moments of the talk: “one must be guided by what one feels, observes, and achieve empathy with the person in front, that´s how the best results arise.” In my opinion, that unprejudiced, shy yet bold attitude, rather close to an “innocent search” -as himself defines it-

at the most lavish parties of the New York elite, memorable

than a cold and rational approach to reality, is one of the main

shots that evidence sensuality, pictorialism, and visual

factors that make Fink one of the most important artists to

forcefulness (Fig. 4). Precisely, this series of photographs were

follow for every individual interested not only in photography,

the protagonists of his celebrated solo exhibition held in 1979

but in the vast and diverse world of the visual arts.

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The International Society for the History of Radiology The story began in 1895, when a German physicist discovered a new kind of rays. The development of diagnostic imaging has been the result of a fruitful relationship between doctors, radiographers, physicists and equipment manufacturers.

New

apparatus

has

stimulated

the

introduction of new techniques and medical needs have in their turn stimulated new developments in equipment. Many new techniques have been introduced in recent years. The principles of CT scanning were first described by Godfrey Hounsfield and the first prototype EMI scanner was installed in 1972 at Atkinson Morley’s Hospital. Work was progressing on Magnetic Resonance Imaging (MRI) in the 1970s and the first human image was obtained at Aberdeen in 1977. Nuclear Magnetic Resonance can be used to either to produce planar images of anatomy or as Magnetic Resonance Spectroscopy can provide biochemical information. Ultrasound started in the 1950s and gained popularity in the 1960s. „Realtime“ ultrasound machines were introduced in the late1970s and ultrasound is now the most commonly used examination after plain radiographs. The use in the last 10 years of Doppler technology has enabled flow to be assessed as well as anatomy. These new techniques have displaced many of the older X-ray techniques and this process will continue. In modern radiological practice it is not possible to

Until the 1980s the techniques needed to store

consider techniques in isolation. An integrated approach is

reports and films had changed little since the 1920s. Modern

needed with the various techniques used as appropriate.

technology is transforming departments with the introduction

Often it is better for a complex procedure to be used early in

of computer management systems and digital image storage.

an investigation since a diagnosis may be reached quickly with

This last technique will dramatically alter the use of images

minimal inconvenience and risk to the patient. In recent years

with studies being transferred via links between different

the widespread use of percutaneous biopsy techniques and ultrasound and CT scanning have considerably reduced the need for exploratory surgery.

institutions and offices. The last 100 years have produced many changes and

There have been many changes in medicine which influence radiological practice and for example, the increasing use of endoscopy has considerably reduced the need for

the next 100 will be even more dramatic. To stimulate the study and conservation of radiological history, the International Society of History of Radiology was founded in 2011.

barium meals. The recent developments in diagnostic imaging have considerably facilitated the recent trend to investigate and

To stimulate the study and conservation of radiological

treat patients as day cases or as outpatients with considerably

history, the International Society of History of Radiology was

less disruption to the patient’s life.

founded in 2011.

ISHRAD - c./o. Deutsches Roentgen-Museum Schwelmer Str. 41 - D-42897 Remscheid Website: www.ishrad.org Email: info@ishrad.org


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