Italian contribution to the origin of neurosurgery

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Special A r t i c l e

Italian Contribution to the Origin of Neurosurgery Beniamine Guidetti, M.D., Renato Giuffr~, M.D., and Vinicio Valente, M.D. Institutes of Neurosurgery, First and Second Universities of Rome, Italy

Guidetti B, Giuffr& R, Valente V. Italian contribution to the origin of neurosurgery. Surg Neurol 1983;20:335-46. KEY WORDS: Birth o f neurosurgery; History; Early operations;

Italian contribution

According to the historians of neurosurgery [52,85, 103,104], between the remote origins (going back to millenia before Christ, to the paleolithic and neolithic ages) and the era of the pioneers (the end o f the 19th century) that preceded the true birth of neurosurgery as an autonomous branch o f the medical sciences lies a gap of many centuries of "obscurantism." Wertheimer and David [104] assert that neither Greco-Roman nor Arab medicine nor the great medieval and renaissance universities made contributions of significance. Thus, the work of the pioneers in the last two decades of the 19th century [4,29,51,53,58,59] appears to be isolated, unconnected with any recognizable surgical tradition. The present study, based on a survey of surgical texts of several Italian centers, shows--logically e n o u g h - that the pioneering operations (the oft-quoted procedure of Durante, for example) were not isolated innovations but form part of a centuries-old tradition, slowly evolving since 1200, in the context of a practice common to many schools of surgery of their time.

Review It was in the 13th century that Guglielmo da Saliceto [50] wrested the surgery of the nervous system from the hands of quacks and mystics and placed it on a scientific basis. The distinction between surgical practice and science is extraordinarily clear in his own words: "A surgical operation is not surgery but merely stems from Paper submitted as poster at the Seventh European Congress of Neurosurgery, Brussels, August 28-September 9, 1983. Address reprint requests to: Dr. Renato Giuffr~, Institute of Neurosurgery, viale dell'Universitfi 30/A 1-00185 Rome, Italy.

it. Surgery is a boundless science demanding infinite knowledge. Those who operate without the necessary scientific knowledge may succeed by chance in a few operations. This does not alter the fact that they are unreasoning and ignorant men." The master from Saliceto (province of Piacenza) may not have performed major operations on the skull, but we do know that he protected wounds with a small pad so that air would not penetrate, that he used the rasp in fractures, and that he laid down rules for operating on external hydrocephalus. However, his principal merit was the training of pupils such as Guido Lanfranchi [56] from Milan (1250-1306?). Banished by Matteo Visconti, Lanfranchi settled in France, first in Lyon and later in Paris, where he founded (1295) a flourishing school of surgery and completed his Chirurgia magna. H e once saw two soldiers recover after loss of tissue from the anterior part of the brain, which left them with poor memories and dull wits thereafter; the seat of thought was therefore accessible to the surgeon's hand. This report was not the first, as Carbondula da Vercelli, Ruggero da Parma [83], surgeon of the Salerno school and author of Practica (ca. 1180), and later Rolando da Parma, surgeon of Bologna, had reported cases of recovery after extensive traumatic or surgical lacerations of the brain. In addition to the schools of Salerno and Bologna, which never ceased to teach medicine and surgery contemporaneously, other schools arose and flourished in Italy in the 13th and 14th centuries. Those of Padua, Pavia, Pisa, and Milan produced the greatest anatomists and surgeons [106]. Anatomy and surgery continued to evolve in parallel in later centuries, the fortunate 16th century producing anatomists such as Vesalius, Eustachio, and Falloppio and surgeons such as Mariano Santo da Barletta, Berengario da Carpi, and Giovan Battista Carcano Leone. At the beginning of the 16th century the book De abditis nonnullis et mirandi morborum was written by Antonio Benivieni [3], who said that medicine and surgery were branches of one and the same trunk, both requiring

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the study of anatomy enhanced by experimental physiology and scrupulous observation. Subsequently, Giovanni Vigo da Rapallo [46], also known as Giovanni Vigo, the Genoese, produced the work Practica copiosa i n arte chirurgica a d f i l i u m A l o i s i u m . In the passages dealing with diseases and lesions of the head, he was such a strenuous upholder of trephining that he has been described as "the first to propound trephining in Italy." To the same period belongs the C o m p e n d i u m i n C h i r u r g i a u t i l i s s i m u m volentibus i p s a m exercere Mariano Santo da Barletta [87], a collection of many close, wise, and valuable observations. For example, "head wounds must be kept warm, for cold is harmful to the nerves, bones, brain and spinal cord"; and "the signs of broken bone are vomiting, scotoma, giddiness, blindness and collapse, all of which occur at the time of the blow; in some cases apoplexy, stupor and fever with shivering ensue". Against the prejudice of his time, which attached importance to the meteorologic conditions of the city in which one operated, Mariano Santo called for safety in medication; he taught a new and simple, if dangerous, way of medicating wounds, simply using fresh, clear water Cnovum m o d o m medendi vulnera, quanvis periculosa, sola aqua dulci, clara, viva"). The author once examined a skull in which the drilled gap had reossified (Figure 1), from which he deduced that "perhaps the physician through fear had left in situ the part that had uncovered the dura mater," that is, the bone chip Cfortasse medicus reliquerat prae timore partem illam qua duram matrem detexerat"). A foreshadowing of osteoplastic craniotomy! Another very learned and skillful surgeon, Giacomo Berengario da Carpi [5] of the province of Modena, after practicing his profession in Pavia, was called to Bologna as professor of anatomy and surgery. In the end he withdrew to Ferrara to escape persecution by the Inquisition for some opinions he had expressed on the subject of generation. In his T r a c t a t u s p e r u t i l i s et completus de f r a c t u r a cranei, he dwelt at length on the timing of craniectomy in head injury, commenting with clinical acumen on the opposing trends of medical opinion of the time: immediate operation in any case or operation only at the onset of symptoms. The treatise contains drawings of surgical instruments, including various types of drill bits. Some even see Berengario as a forerunner of Lister, because he advised aromatic fomentation in the operating room. H e sounds a topical note when he shrewdly criticizes medical men who, not having studied surgery, rashly want to try their hand at it for gain: When confronted with an operation they do not know how to do, they pretend to be tenderhearted to conceal their ignorance and cunningly suggest surgeons of little account who will comply with their wishes; and thus, to the detriment of poor mankind, "the blind

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Figure 1. Top:PictureofMarianoSanto(1488?)fromthePublicLibrary of Barletta. Bottom: Extract from the Latin "Forte fortuna caluaria . . . os veru cap#is," translated as follows: "By goodfortune I noticed the skull of a man who in life had been wounded in the/eft side of the head and an incision had been made with section of the bone. The incised part had been opened with such a large hole that a small finger could have been put into it. The physician had probably left the part that had uncovered the dura mater either out of fear or because he knew that this part, which nature regenerated so well with a sarcoid channel as it had been before, would reach us. And I tested it with scalpels to see whether it was hard or soft and I found that it was harder than the true bone of the head." (From Santo's De Fractura Capitis, Rome, 1521: reprinted with permission of Vallicelliana Library, Rome.)

Italian Contribution to Neurosurgery

leads the blind and both fall into the ditch" Ccoecus coecum ducit, et ambo in foveam cadunt"). A champion of simplicity in medication (dressing every 2 - 3 days with very simple remedies) was Leonardo Fioravanti [33], who worked in Naples. Paolo Giuliaro [47] of Verona (De vulnerum capitis curatione libellus . . . . Venice, 1549) and later Giovanni Passero [75] of Bergamo (De causis mortis in vulneribus capitis . . . , 1590) proposed trephining when the symptoms indicated extravasation o f blood under the skull. The dominating figure of the end of the century was Giovan Battista Carcano Leone [13]. A Milanese nobleman, pupil of Falloppio, he was only 25 years of age when he was judged to be the most suitable to substitute for his teacher in lectures on anatomy and surgery at the University o f Padua. On Falloppio's death, however, despite his recommendations to the senate of Venice, Carcano Leone found himself without support and had to withdraw to Pavia. T h e r e his worth was recognized, and he obtained the chair o f anatomy and surgery. In Milan in 1583 he published De vulneribus capitis . . . . a comprehensive treatise on cranial traumatology in which he discusses simple and compound, penetrating and blunt wounds, with and without contusion. H e sets forth examples o f all the kinds of wounds that can be inflicted on the head, which are bound to be fatal, and which symptoms should prompt trephining. It is asserted that trephining must not be performed on the sutures or on the squamous part of the temporal bone. If the first drilling fails, Carcano Leone suggests performing one at another site and even opening the dura mater if signs of underlying extravasation persist. H e gives good descriptions of the symptoms o f brain contusion, o f deep hemorrhage without cranial injury, and of epidural bleeding with phenomena accompanying fracture o f the skull. Referring to the observation o f Mariano Santo, he shows that cranial bone flaps become reattached in situ. H e inveighs against the prejudices o f the "meteorologists," asserting that in the bad weather conditions of Milan, in unheated hovels in the depth of winter, he had cured about 100 poor people with severe head wounds, shunning ointments and poultices and using medication rarely and simply. Surgery of the peripheral nerves, o f which there is timid anticipation in the works o f Guglielmo da Saliceto and Guido Lanfranchi, reappears in the work of Gabriele Ferrara [32]. H e supplied the first lucid, succinct description of the suture o f the stumps o f a transected nerve: Gentle traction on the retracted stumps; suture using a special needle with an eye (after immersion in a decoction of red wine, rosemary, and roses; alcoholic disinfection?); and finally insulation of the sutured segment with a mixture of oils.

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To crown the glorious 16th century, several Italians (for example, Mariano Santo da Barletta, Michelangelo Biondo, and Alfonso Ferri from Naples) were associated with the Parisian Ambroise Pard on the Thesaurus chirurgiae [98]. Pard, by following the armies, gained experience with gunshot wounds and published a book on them (1546). In Italy with the army of King H e n r y II for the war on Modena (1560), he probably met Bartolomeo Maggi [61] of Bologna, who had been making observations since 1518 as well as conducting experiments on the same subject (of which Berengario speaks in his treatise on fractures); at that time, Maggi had been called to Bologna to treat the wounds sustained by the Pope's nephew. According to Zannetti [106], in the second edition of his Study on Gunshot Wounds Pard probably added in all honesty that he was the first "of the French" ("inter Gallos primus"), as he was preceded among the Italians by Maggi. At the turn of the century we have Girolamo Fabrizio da Acquapendente [31] (in Lazio). Trained at Bologna and later a pupil of Falloppio at Padua, he succeeded his teacher at that university. In 1582 in Frankfurt he published his surgical work Pentateucum et operationes distincta, and in 1617 in Padua, Opera chirurgica. A man o f fine clinical perception, he opposed procrastination in surgery but was also prudent in advising against trephining on the sutures and over the venous sinuses. All of his work bears the imprint of a rigorous knowledge o f anatomy. The debate on the best way to treat wounds continued in the 17th century [60]; trephining of the skull was extended to cases of syphilitic headache, to epilepsy of any origin, and to melancholia [91,92]. Magati [60], who practiced as a surgeon in Rome, Naples, and Bologna and later became professor at Ferrara, provided important observations in the field of cranial traumatology: Intuition told him that in injuries without fracture, contusion of the underlying soft tissues is likely; he gave sound precepts on the subject of the margins of skull fractures; he distinguished between depressed skull fractures that have a compressive effect and those that have no repercussions on the brain; and he emphasized the uselessness of topical remedies in severe injuries, preferring to trephine even in cases in which fracture was doubtful. Marco Aurelio Severino [91,92], an able and daring surgeon who sought to reinstill into surgery a more energetic and resolute approach during an interval of decadence, was criticized by some for being unduly bold. Pietro Marchetti [62] of Padua, author of Sylloge observationum medico-chirurgicorum rariarum, was of the same mind as Severino on the advisability of trephining in epilepsy and in venereal headache. A remarkable figure of the second half of the 17th century was Giovanni Andrea della Croce [45]. A sur-

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geon who practiced with great distinction in Venice, he published his Cirugia universale eperfetta, which covered the whole range of surgical theory and practice in seven volumes. Each of the first six volumes is divided into several (2-12) treatises; of particular interest to the neurosurgeon are the first three in the second volume, which discuss head wounds, facial wounds, and wounds of the nerves, tendons, and ligaments, respectively. The seventh volume, on a single theme, is called Officina, or workshop; here he writes about surgical instruments, describing the evolution and use of each, and concludes with a depiction of an operating room and surgical procedure. These pictures, like those of the various drills and of the bone hook (for raising depressed cranial bones), are among the most widely reproduced of all classic surgical illustrations [52,103,105] (Figure 2). Whereas in France, after Pard and his first pupils, trephining fell into disrepute until it was abandoned altogether as irrational and lethal, in Italy the tradition was maintained unbroken by a series of surgeons. Its

rare opponents were not so much against the procedure as against its abuse (for example, Cappelletti da Lucca, pupil of Cecchini, of the Magati school). Within its rational limits, however, the practice was upheld throughout the 18th century at several Italian schools of surgery, first at the Ospedale Santa Maria Nuova in Florence, where Antonio Benevoli was succeeded by Angiolo Nannoni [67], then by Nannoni's son, Lorenzo [68] and then by Giuntini, Uccelli, Andreini, and others. Trephining of the skull was performed systematically at Turin by Giovanni Ambrogio Bertrandi [6,7] [see his "Trattato delle operazioni chirurgiche" (Turin 1763) and above all the monumental work in fourteen volumes

"Anatomical and surgical works of Ambrogio Bertrandi"

Figure 2. Giovanni Andrea della Croce's Universal and Perfect Surgery. Left: Title page. Right: Surgical instruments (top, center) and three

methods of incising the skin and the pericranium (bottom). (Reprinted with permission of the Institute of History of Medicine, Rome University.)

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Italian Contribution to Neurosurgery

published in Turin between 1786 and 1802 by his pupils Penchienati and Brugnone]. At Turin University Bertrandi succeeded the French teacher Pietro Simone Rouhault, who had published his Treatise on Head Wounds in 1720. The neurosurgical tradition of Bertrandi was carried on by his successors Malacarne, Reyneri, Rossi (Trattato di operazioni chirurgiche, Turin, 1806), and Riberi (Elements of Surgical Therapeutics, Turin, 1839). Another great school of surgery with neurosurgical overtones was flourishing at that time in Bologna; it included Anton Maria Valsalva (1666-1723), Pietro Molinelli (1702-1764), upholder of cranial trephining, and Gaetano Tacconi [95], author of De non nullis cranii ossiumque fracturis ( 1751). Morgagni, pupil of Valsalva, also taught at Bologna before going on to Padua. The two schools of the Veneto, Padua and Venice, were ancient and already great before the pathologist's authority shone upon them: Sebastiano Melli (La pratica chirurgica, Venice, 1713) and Giovanni Menini at Venice, and Camillo Bonioli (On Gunshot Wounds, 1789) at Padua. Over all spread the great sweep of Giovan Battista Morgagni's (1682-1771) learning. His foremost work, De sedibus et causis morborum per anatomen indagatis (Venice, 1762), which after the works of Hippocrates is the classic monument of medical knowledge, henceforth characterized and stimulated every study and every surgical investigation. The Lombard schools of surgery were more recent institutions: Antonio Scarpa (1747-1832) was the first professor of surgery at Pavia, and Giovan Battista Monteggia [64] (1762-1815) was the first public demonstrator of surgery at Milan. Sponsor of surgical studies in Lombardy and patron of the University of Pavia, Giovanni Alessandro Brambilla [9] (1728-1800) was also founder of the Medico-Surgical Academy Josephina of Vienna (named for its patron, Emperor Joseph II) and author of History of Physico-medico-anatomico-surgical Discoveries (Milan, 1777). In 1765 Francesco Biumi [8,86] of Milan reported the first case of bleeding intracranial aneurysm (parasellar aneurysm of the carotid siphon) and clearly correlated the clinical pattern with the postmortem findings. The teaching of surgery in the Lombard schools was to pave the way for Panizza, Signoroni, Porta, and others. More modest in its contribution to the surgery of the nervous system was the Rome school of surgery. To it belonged Carlo Guattani [49] (1707-73), known for his interest in the treatment of aneurysms, and Giuseppe Flajani [34,35] (1741-1808), whose experience included cases of hydrocephalus. The indications for neurosurgical treatment multiplied during the 19th century, and the various subspecialties into which neurosurgery was to divide began to be delineated.

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Neurotraumatology emancipated itself and shook off its ancient constraints. Even in the days of Bertrandi and Riberi, the old rules not to drill the skull except above a circle that passes ideally through the nasion and inion and to avoid the sutures, temporal muscle, sinuses, and meningeal artery were becoming outdated. Hemorrhage from the sinuses, stated Ghersi [36] responds to simple packing and bleeding of the meningeal artery, to occlusion of the bony channels in which it runs, or to cautery. Signoroni [93] still recommended ligature of the sinuses and forceful pressure on the meningeal artery. Vacc~ Berlinghieri [44], noting that the site of intracranial extravasation need not depend on the external lesion, warned surgeons not to assume that the law of crossed hemiplegias, till then an article of faith, holds in every case. Ranzi [80], his successor at Pisa University, and Rizzoli [81] at Bologna, reversing the ancient precept, advocated the temporal region as the zone of choice for trephining. Both emphasized the importance of a progressive, rather than immediate, onset of signs of compression. A typical case was that of Rizzoli [81]: A man who was wounded at the anterior angle of the left parietal bone fell, got up at once, walked along the road a bit, then staggered and fell unconscious. The surgeon argued that blood leaking from the damaged vessel drop by drop had formed a hematoma. After trephining of the skull and removal of the hematoma, the patient regained consciousness. Later, however, a fresh collection of blood formed under the skin and the symptoms of compression recurred. The patient was finally cured after a second operation for removal of the bloody fluid. Cavara [15] (1838 and 1849) saved two patients with closed epidural hematomas by trephining. Tacconi [95] diagnosed and treated a lesion of the middle meningeal artery. Asson [1] was also in favor of trephining for lesions of the meningeal artery. Consolini [119] found that intermittent pressure on the common carotid artery in the neck was helpful for a false aneurysm of the middle meningeal artery. Italian surgeons were definitely more interventionist than their French colleagues in cases of head injury. Vacc~ Berlinghieri at Pisa and Palasciano at Naples rejected the adverse impression they had gained in Paris, "where for the past 200 years no trephined patient has been cured," and, while admitting that trephining is not free of risk, considered its indications to be valid when based on sound clinical judgment. Both criticized Desault, who would not trephine even for depressed fractures. It was Ferdinando Palasciano [74 ] (1815-1891 ), professor of surgery at Naples, who first had the idea of an International Red Cross. In a speech at the Accademia

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Pontaniana, Naples, on April 21, 1861, he proclaimed the inviolability and neutrality o f the wounded (and physicians) in war, although his proposal was not considered officially at the G e n e v a Convention (1864), which set up the institution. The surgery o f space-occupying lesions o f the central nervous system became better defined and more complex in the 19th century. Even in the previous century (for example, the studies of Nannoni and Bertrandi), the view that tumors should be removed as promptly and completely as possible was gaining ground. In the early 19th century we find the first document to consider this area o f pathology: Trattato di Chirurgia Teorico Pratico di Andrea VaccA Berlinghieri, a 488-page manuscript treatise with the date 1813 on the title page. N e v e r printed, it was discovered by chance years later by Davide Giordano, chief surgeon in Venice. It appears to have been dictated to a pupil by the Pisan surgeon (1772-1825) during the years 1810-1813. Organized in chapters rather than lectures, each on the pathology of an organ "from head to foot," as the ancients used to say, the treatise reports the daring procedure of Berlinghieri in the treatment of"sarcomas" of the dura mater (evidently meningiomas). His statement that it is uncertain whether these tumors can develop 10-12 years after an injury is reminiscent (as we are still in doubt today). H e considered cautery, supradural removal, and ligature, the procedures o f his day, inadequate. His procedure was as follows: "After craniectomy with five or six burr holes, to cut out the tumor together with the dura mater from which it arose with a knife and tie the cut vessels. If the meningeal artery is damaged during cranial resection, occlude it by bending onto the edge of the bone a lead plate coated with rosin or agaric or keep a small feather pad over the mouth of the vessel." In 1835, Pecchioli [76] devised a similar procedure for removing a "fungus o f the dura mater" (meningioma) and used it at Siena. This technique became the chosen procedure in the competition for the chair of surgery in Paris in 1840. The lesion was a large ulcerated cranial outgrowth at the level of the right sinciput, which at operation proved to originate from the dura mater and to be eroding the bone. The surgeon drilled three widely separated holes and then joined them to form a large triangular flap; he removed the mass with the dural insertion, "thus leaving the underlying arachnoid exposed in two large zones." Oddly enough, healing of this extensive area, which was protected with cambric soaked in sweet almond oil, was "by second intention." The patient, who recovered in 4 months and attended for subsequent observations several times in the course of 30 months, was always fit and showed no sign of recurrence.

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In 1847, Pecchioli [77] included in his surgical material, which spanned 16 years of activity, 16 operations involving "trephining o f the skull for fractures, caries, exostosis, necrosis and osteo-sarcomatous fungi of the skull and dura mater." In 1844, the Venetian Tito Vanzetti [100] ( 1 8 0 9 1888), then professor of surgery at Kharkov, Russia, published Quelques observations pratiques recueillies ~ la

Clinique Chirurgicale de l'Universit~ Imp~riale de Kharcoff (Russie) in Paris. This work includes "a case of a bone cyst on the right side of the head that had destroyed the base of the skull without affecting cerebral function" (pp. 13-24 plus three drawings) (Figure 3). It was a large conical outgrowth on the right side of the skull on which the author, in the mistaken conviction that it was a cyst in the bone, operated on N o v e m b e r 26, 1841; the lesion proved to be a massive, solid, intracranial growth. The patient died of sepsis on the 32nd day. Necropsy confirmed the enormous size of the lesion and showed that the base of the skull, which it had invaded, was grossly malformed. The Memorie ed Osservazioni del Prof. Ferdinando Palasciano [74], published posthumously (1896-1899), includes a "successful case of trephining for hydatid cyst of the skull, shown eleven years later in the Department of Surgery, Faculty of Naples, on May 29, 1865." The operation, performed on N o v e m b e r 19, 1853, was necessitated by a pulsating growth on the vertex, which some thought might be an aneurysm. At operation the lesion proved to be very large ("the fluid discharged by the cyst was over 6 ounces") with considerable intracranial development (the lesion "inside the skull had caused such compression between the two hemispheres as to produce a depression centered on the falciform process o f the dura m a t e r . . , such that the space it left could have contained a small fist"). The patient recovered and was in good health 11½ years later. In the last two decades of the century the case series carried an increasing number of operations for intracranial tumor. This phenomenon, at least initially, seems to have occurred independent of news from the across the Alps. In Turin in 1883, Giacomo Filippo Novaro [71] (18431934) operated on a parasagittal frontal hyperostosing meningioma. Once again, as in the cases o f Vanzetti and Palasciano, the diagnosis was based on irregularities of bone apparent from the outside that were associated with epileptic seizures. The surgeon resected the superior sagittal sinus, which was clearly infiltrated. The patient died 1 hour after the operation. In Rome in 1883 (August ?), Francesco Durante [28] (1845-1934) removed a "fibroma of the base of the skull" that extended into the nasal fossae and caused

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Figure 3. Vanzetti's Quelques observations pratiques recueillies/* la Clinique Chirurgicale de l'Universit~ Imp~riale de Kharcoff (Russie). Left: Title page. Right: Illustration of "a case of a bone cyst on the right side of the head that had destroyed the base of the skull without affecting cerebralfunction." {Reprinted with permission of the Vatican City Library.)

respiratory problems. H e used an original approach, the transpalatine. Again in R o m e , on January 25, 1885, Mazzoni and Tomassoni p e r f o r m e d an exploratory craniectomy on a patient in w h o m the neurologist Sciamanna [90] had diagnosed a cerebral corticosubcortical space-occupying lesion, either an abscess or a glioma, based on the clinical evidence (focal convulsions). Exploration did not reveal the tumor, which was discovered at approximately the site postulated at necropsy: it was a glioma with "at several points a somewhat sarcomatous structure" ("gliosarcoma" according to the pathologist Marchiafava). O n J u n e 1, 1885,* Durante [29] operated on a 35year-old w o m a n with a meningioma of the left olfactory

groove. This procedure, m o r e than any other so far cited, is the Italian operation most widely known abroad, because it was reported outside Italy (at the surgical section of the International Medical Congress in Washington in September 1887) and published in T h e Lancet the same year (article reproduced in J N e u r o s u r g 1962;19:804-5). It was remarkable a m o n g intracranial operations of the period for several reasons: (a) It was performed on the surgeon's own diagnosis, based on the clinical evidence (hyposmia, m e m o r y deficit) rather than on external signs (exophthalmos); (b) it was a lesion of the base of the skull rather than o f the convexity; and (c) the operation was sufficiently radical, as it afforded the patient over 11 years of good survival. She was operated on again by Durante [26] in March 1896, with a confirmed diagnosis of fibrosarcoma of the dura mater, and she was still living in 1905 [26,27]. *An unexplained oddity is that on several occasions both Durante and some of his contemporaries cited the date as June 1, 1884.

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Not only was Durante's operation widely commented on in Italian surgical circles, but news began to reach Italy of the operations of Macewen and Godlee. Consequently, in the years that followed the Proceedings of the Italian Society of Surgery included many reports of intracranial operations. In 1886 alone, Azzio Caselli [14] of Genoa reported a successful operation on a "myelogenic sarcoma" of the bregma with dural involvement, Andrea Ceccherelli [16] of Parma operated on two cases of carcinoma of a frontal sinus that had eroded its walls and infiltrated the dura mater, and Antonio Ceci [17] of Pisa, struck by the progression of symptoms that had appeared 2 months after an injury, performed a successful operation in a country house on a chronic subdural hematoma. In the years that followed case reports became increasingly numerous, too numerous to mention. Instead, we will discuss the commencement in Italy of surgery on tumors of the spine and cerebellopontine angle. In Turin in June 1890, Caponotto and Pescarolo [ 12] performed a successful removal, with functional recovery, of a thoracic intradural meningioma. In Bologna in February 1895, Bendandi [2] operated on a tumor of the cerebeUopontine angle (the brilliant diagnosis and referral for operation were made by Augusto Murri, the professor of medicine at Bologna [65]). The patient recovered from a partial removal, but died 4 months later after a reoperation. In our discussion of intracranial space-occupying lesions we have thus far mentioned only tumors. It is evident, however, that intracranial suppuration received equal, if not greater, attention. All of the authors cited previously, from Vacc~ Berlinghieri to Palasciano, Novaro, Durante, Ceccherelli, and many others, worked on purulent collections. Examples include Nannotti's [69] experimental work on suppuration in the dog (1895) and Gradenigo's [48] procedure for operating on otitic cerebral and cerebeUar abscesses (1897). Essential to the surgeon when planning an operation, apart from neurological knowledge, is of course familiarity with the topography of the skull and brain. In Turin in 1878, Giacomini [37 ] published his monograph on the topography of the central sulcus of the cerebrum which immediately became the subject of study and comment. The outcome of patient research, inspired by the work of Broca and Ferrier, the monograph rightly depicts the sulcus as the linchpin of craniocerebral topography. Many important personal contributions of surgical technique were made, including the osteoplastic flap [26,27,30,78,79,88]. The obstetrician Leonardo Gigli [38] (1863-1908) invented a twisted wire saw for cutting the symphysis pubis, which Obalinski [73] (1897) used in craniotomy and which Gigli [39] (1898) himself

Guidetti et al

Figure 4. Rizzoli's enterotome, squeezing an encephalocele [81].

improved for neurosurgical purposes by supplying a metal guide to protect the dura mater. Meanwhile, Alessandro Codivilla [18] (1891) and Ercole Sacchi [84] (1893) were working on repairing losses of cranial and dural substance. Davide Giordano [43] (1898) at Venice, working on cadavers, devised a transnasofrontoethmoidal approach to the hypophysis. Later, Francesco n u t ante (1909) proposed the transpalatine route. Hypophysectomy had been performed experimentally by Giulio Vassale and Ercole Sacchi [ 102] (1892); the connections between the hypophysis and acromegaly had, according to Marie, been worked out by Tamburini [96] (189495). All of these examples still give an incomplete picture of neurosurgical developments in Italy in the latter half of the 19th century. In 1855, Palasciano [74] applied his own method to the treatment of cases of spina bifida cystica and later (1856-1857) of cases of encephalocele. The method consisted of emptying the sac of fluid, concentric compression to approximate the cranial or vertebral margins of the cleft, and sclerosing injections of iodine into the sac. Later, Rizzoli [81] (1869) considered it more prudent to avoid exposing the spinal cord to iodine or other irritants and preferred gradual squeezing of the hernial sac at the base with a special enterotome (Figure 4). In 1856 Giannantonio Gioppi [40], professor of oculistics at the University of Padua, cured a carotid cavernous fistula by intermittent digital compression of the carotid artery in the neck. The compression method, proposed by Genga and Guattani, had been recommended by Vanzetti in 1846 as the only method of treating any aneurysm with an afferent artery accessible to the hand. In 1858 Vanzetti [101], then professor of surgery at Padua University, treated another case of carotid cavernous fistula in the same way at Verona Hos-

Surg Neurol 1983;20:335-46

Italian Contribution to Neurosurgery

pital. Both Gioppi and Vanzetti classified their cases as "aneurysm of the ophthalmic artery." Surgeons had long been wrestling with the problems of functional neurosurgery, at least those problems (epilepsy, pain) for which the appeal for help from patients was most pressing. We have seen that from the mid-17th century (for example, in the work of Severino and Marchetti), attempts had been made to free the brain from the epileptogenic irritation caused by injury through deformation of the skull and scarring. The discussion on indications and methods continued throughout the 18th century (for example, in the studies of Bertrandi and Nannoni) and in the 19th century engaged the efforts of many of the surgeons who performed craniotomies, such as Pecchioli, Giordano, Caselli, Postempski, and Ranzi. Noteworthy figures in this field were Francesco Rizzoli [81] of Bologna (1809-1880) and Antonio D'Antona [21,23] of Naples (1842-1914). The neurologists Luciani and Tamburini [57], studying the guenon, found that the paralysis that immediately follows removal of motor gyri gradually resolves; this finding encouraged surgeons to think in terms of topectomy. The doubt however, arose, that the operation might itself be epileptogenic, one scar replacing another in time. Remedies were proposed. Sacchi [84] (1893), for example, suggested that postoperative adhesions could be avoided by placing heterologous cartilage grafts between the dural gap and the scalp or even by turning the bone disk upside down to oppose the periosteum to the cortical surface. Negro [70] (1891), on the other hand, proposed liquefying the epileptic foci with the negative pole of a galvanic current. The Italian schools of surgery also tackled the problem of intractable pain, such as trigeminal neuralgia. Gasserectomy was performed first by Caponotto [11] (1891), then by Novaro [72] (1891), and by D'Antona [22] (1893) via a basal approach to the ganglion from the foramen ovale. Each contributed a personal variant to the method of the British surgeon Rose, the alternative to the subtemporal route of Horsley and Krause. There was also controversy in the field of functional neurosurgery regarding the value of craniectomy in microcephaly. D'Antona and Padula were in favor of it, whereas Novaro, Durante, Postempski, Giordano [42], and Isnardi [54] were skeptical. As we will not discuss other, minor fields of neurosurgery, such as infantile hydrocephalus [82], let us now examine how neurosurgical literature was faring toward the end of the 19th century. In addition to the monographs on trephining of the skull [106] and on the topography of the central sulcus of the cerebrum [37] cited previously, there was the

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two-volume treatise by D'Antona [21], La Nuova Chirurgia del Sistema Nervoso Centrale (Naples, 1893-1894). The periodical Rivista Sperimentale di Freniatria e di Medicina Legale which began publication in Reggio Emilia in 1875 (and is still flourishing) with Livi as editor and Tamburini and Morselli on the editorial staff, accepted articles of neurosurgical interest as well as those on the basic neurological sciences (for example, papers by Camillo Golgi on neurocytology).

Discussion In Italy, as in other countries, neurosurgery developed out of general surgery. It is clear that this phenomenon was not isolated in one or two cities or individuals, but developed at all clinical centers of some standing. It is also evident that proper schools of surgery at Florence, Pisa, Turin, Bologna, and Padua-Venice, and later at Pavia, Milan, Rome, and Naples, handed down science and art from generation to generation. In the last decades of the 19th century, neurology gathered momentum and neurologists consulted with surgeons regarding diagnoses and indications for surgical treatment. This approach was the practice of Luciani, Sciamanna, and Mingazzini in Rome, Tamburini in Reggio Emilia, Besta in Milan, and Murri [65,66], professor of medicine at Bologna with a special interest in neurology. During the same period, investigators in neurosurgery were working closely with those in ophthalmology (for example, Vanzetti and Gioppi at Padua) and in otology (such as Gradenigo). Our review is only indicative; it has no claim to completeness. It is derived from publications and hence from cases that the authors thought worthy of reporting. It would have been far closer to complete had it been based on the notes of operations in individual institutions. For example, the reports of operations by Dr. Landi [55] for 1843-1848 at the hospital in Montepulciano, a small town in the province of Siena, include the removal of a cystic tumor of the right temporal fossa, apparently successful. Evidently, however, the author did not think it was worthy of reporting. The relative shortage of data in the literature on operations on peripheral nerves can probably be explained in this way: it was regarded as routine, not worth publishing. These circumstances did not obtain in Italy alone, of course. It is reasonable to suppose that the same was happening in o~her countries; indeed, several times in the publications to which we have referred we found references to cases operated on or surgical methods used in other countries, especially in Europe. In conclusion, the aims of our study are twofold: (a) To stimulate the search in other countries for inter-

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mediate links in the chain--in the 16th, 17th, and 18th centuries--between medieval and modern surgery; and (b) to further the appreciation that the surgical activity of the last two decades of the 19th century was the arrival, not the starting point, of modern neurosurgery. Naturally, we share the oft-repeated view that the various factors that led to the final establishment of neurosurgery (the development of clinical neurology and of the basic neurological sciences, neuropathology and neurophysiology; the development of anesthesiology; and the achievement of asepsis in surgery) all came to fruition in the latter half of the 19th century. It is equally true, however, that at least 50 years earlier a vast body of knowledge and skills existed in all fields of neurosurgical interest and that operations, some of them major, were performed with success.

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