The courage of Hippocrates

in ARTICOLI

““Knowledge is research for truth – research for clarifying, objectively true theories. It is not research for certainty…””
K. Popper           

“ Your roots are deep in your land and they keep you in your country even though you are far in space and time. Don’t forget your roots. Without roots you have no nourishment, without roots you can’t live, without roots you don’t grow, without roots you don’t recognize yourself, without roots you have no culture, without roots you don’t...fly ”
I wrote this aphorism in a moment of particular awareness and gratitude towards what has helped me grow and succeed as a doctor and, above all, as a man throughout my long existence. It is weird to talk about myself, especially with reference to the past, to the projects conceived and then achieved often going against the current theories and the academic teachings. Still today, despite my age, I like to look ahead and think of innovative solutions that might change the destiny of many people suffering from diseases related to the locomotive apparatus. I love challenges, I have always loved them. Just like when, just after my graduation, I worked on the hand lesions which were very frequent then (the post-war years when factories prospered everywhere without any protection or prevention from accidents at work) and generally left to the last and least prepared assistant. The fine, diagnostic and surgical techniques which would later distinguish hand surgery had not been invented yet. So I started to travel abroad to learn as much as possible from those few European and American pioneers who devoted themselves to the hand, an extremely complex structure anatomically and functionally but, above all, an important organ for relations. The hand strokes, prays, asks, speaks, points, helps, hears and sees. And it operates…
The hand, an amazing organ to all intents and purposes, is to be known and respected. The Italian Hand Surgery Association was set up in Italy on 8 December 1962; we were eight founder members and now there are 500 members. It was just my interest in the hand, with its fine vascular and nervous structures, which led me to microsurgery. It was the 1960s then and the nerves were unknown structures to be looked at from a distance and, above all, not to be touched when you came across them in surgical operations. Therefore, I started, the first in Italy, using the surgical microscope, to study thoroughly with fine dissections and intraoperative electric stimulations the peripheral nerves in order to identify the position inside them of the bands of fibers with different functions; this in order to face the motor and sensitive fibers properly to obtain a correct function again. I have drawn tens of maps of the various nerves for my personal use, which have been further enhanced and have represented a guide to young surgeons undertaking the difficult art of nervous microsurgery for decades. To work properly on nerves and vessels particular surgical instruments which didn’t exist at the time were required. I made some of them myself by changing, for example, women’s hairpins to be used as  clamps to temporarily stop the blood flow while vessels with a short diameter (2-3 mm or less) were being repaired, others were already available like the small pincers used by the watchmakers. I got some more from companies which made surgical instruments after discussing the “microscopic” characteristics of the same instruments with their engineers. Indeed the set of microsurgical instruments consisted of few specific and extremely delicate tools like: straight and curved clippers, approximators, straight and curved pincers, needle holders. In addition, needles and threads were so thin that they could be seen only under the microscope. So started in Italy and around the world the great adventure of microsurgery which made possible interventions never imagined until then. Several fields of general and specialized surgery were swept away by the microsurgery cyclone, thus widening considerably their possibilities to operate and therefore to cure a lot of diseases which were still without solutions.
Soon the field of orthopedics was enhanced by very particular and effective interventions. Like the ones to the brachial plexus (tangled network of nerves running from the neck to the arms passing under the collarbone and then  the armpit). It was the 1970s and my friend Algimantas  Narakas in Lausanne started to operate the palsies of the brachial plexus, which had become more and more frequent due to motorbike accidents, using the technique of microsurgery.

I decided to go and see his interventions and, back in Italy, I started this complex and difficult surgery. In that period, at the Department of Orthopedics and Traumatology of the Spedali Civili in Brescia, we operated over 1000 people afflicted with palsy of the upper limb caused by a lesion to the plexus with very satisfactory results as regards the functional recovery of the arm which practically means that hundreds of people have regained an active and working life. It took courage both because the intervention was difficult technically and because success was not always certain. Many variables came into play.
The good thing was that then the patient put their full trust in the surgeon who operated according to science, conscience and indeed courage.
Another intervention made possible by microsurgery I carried out with extreme trepidation was the full reimplantation of a severed organ. It was 1973. My first reimplantation (and first in Europe) had the sweet face of  Luciano, a 13-year old boy who had lost his arm in the industrial laundry of the company run by his family. I remember that he got to the hospital an evening in July. Luisa and I received him. His arm was not with him. I immediately requested to fetch it, wherever it was. I was ready, technically, thanks to the experimental microsurgery I practiced every day in my research laboratory.
Luciano was the first of countless reimplantations carried out successfully by my team and myself. In a short period  Brescia became a center of reference for the reimplantations coming from all over Italy and abroad, but it also became a training center for several surgeons attending the 37 theoretical and practical courses of microsurgery. The way was paved and various Centers of Microsurgery started to be set up throughout Italy, but not only! One day an Italian doctor, Antonio Salafia, came to attend the course; he had been living in India for years working as a surgeon at the leper colony “ Vimala Dermatological Center “in Mumbai. He wanted to learn the microsurgical techniques to operate better on his patients affected by leprosy. So we went to India to bring our theoretical and practical course (Zeiss provided, free of charge, 40 surgical microscopes). We trained people there too and today the head of the department of reconstructive microsurgery at the Tata Memorial Hospital of the University in Mumbai is Dr.Prabha Yadav who learned microsurgery back then, she got fascinated by it and has been applying it successfully ever since, especially in the oncological field, saving hundreds of lives every day.
At this stage, I would like to take a step back in time, to the period between the 1950s and the 1960s when I was a young head physician at the Ospedale Civile in Chieti and I often examined people suffering from severe arthrosis to the hips. Therefore, I went to the masters to learn. My first destination was Paris, working with the great Merle D’ Aubignè who taught  the “ head-neck resection “ which removed the pain but left a serious disability; the second destination was England  where, at the beginning of the 1960s, Mckee and Charnley had started to carry out full prostheses to the hip. Back in Chieti I decided to put into practice what I had witnessed and learned.
I will never forget the sleepless night and the prayers in the hospital chapel at 5 a.m. before entering the operating theatre to carry out my first full hip prosthesis. It was the first in Italy and I had already received the blessing from well-known professors threatening to take legal action in case a removal of the prosthesis would be necessary. It was 1963 and for two years I was the only Italian surgeon to apply this kind of surgery, and I was criticized by nearly all my colleagues. It took some courage at that time to implant a metallic hip prosthesis cementing it in the bone! A real conceptual and cultural revolution made possible by technology.
As for me, I have always believed in progress and in research and then…..watching people previously stuck to a wheelchair walk again was the greatest gratification and the most beautiful reward to my dedication and my sacrifices.
Several surgeons came to Chieti and later to Brescia to learn the surgical technique in order to apply it in their workplaces and the full hip prosthesis is today a routine operation whichs provide a huge satisfaction to patients, surgeons and, not least, hospitals! At the end of the 1970s, the numerous patients afflicted with hip arthrosis had as many orthopedic surgeons capable of performing operations to solve their problem successfully. In Brescia we had reached a level of excellence in that field as well and people kept coming, especially from southern Italy. Those were the years when the ward didn’t exist anymore, as it couldn’t contain the patients who were admitted to hospitals hoping to be included in a waiting list for the operation as soon as possible.
There were several young paraplegics who turned up at my ward hoping to find a solution for their legs like the one we had found for the palsy of the brachial plexus but all the experiments I had carried out until then on animal models had shown that the spinal cord was not permissive to receive the axons coming from the brain. I didn’t lose heart and, convinced more than ever that it was necessary to continue the research on spinal cord repair, I took up the challenge. After years of experimental interventions with different operating protocols performed by myself in Italy and abroad, I came up with the idea of connecting, through a nervous graft, the extensions of the nervous cells of the brain to the nerves of some leg muscles, excluding the spinal cord underneath the injury. Using this technique we operated, among others, a young woman who, following a car crash, suffered the total spinal cord injury on the eighth thoracic vertebra. Gigliola, this is her name, after the operation and a long period of rehabilitation, started to take the first steps, even if basic ones, with a walker first and then with a tetrapod. This is because the extensions of the cerebral cells reaching the muscles have formed some new motor end plates capable of responding to the glutamate neurotransmitter typical of the Central Nervous System and not to the acetylcholine anymore, a peripheral neurotransmitter. This response to the glutamate was unpredictable and urged us to carry on with the research which, thanks also to the precious guidance of Prof. Rita Levi Montalcini, became a real multidisciplinary basic research involving the scientists of the University of Brescia. Through these studies, we have shown the capacity   of the muscle to turn its normal acetylcholine receptors into receptors capable of responding to the glutamate, which is the neurotransmitter of the cerebral neurons. On June 14, 2005 the prestigious official journal of the American National Academy of Sciences P.N.A.S. (P.N.A.S., 2005, 102, 24, 8752-8757 ) published the results of our research.
Another prestigious American journal “ Current opinion in Neurobiology 2006 “  also had an article about the work with the title “ A lost paradigm“ with a clear reference to the result obtained by this research which lost a paradigm but found a new truth never revealed or thought up by a human being.
I can’t help thinking about Prof. Rita Levi Montalcini and her thought about free and independent research. I heard her more than once urge young researchers to do even risky research in the firm belief that the solution to many diseases could be found in the future just by all those who were bold enough to dare.
I wish to add that, among the brave actions a physician and researcher of today is asked to take, one is of fundamental importance: the courage not to take possession of the diseases and the needs of other people! Especially in the current globalized society where different stories, religions, cultures, colors intertwine, we need to take different parameters into consideration. We need to get close to each single individual very discreetly according to his or her actual requirements. Patients have to be involved in first person in the treatment submitted and, above all, they have to be free to accept them as well as to turn them down.

Giorgio Brunelli

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