The Eraly History of Neurosurgery in Brazil
THE EARLY HISTORY OF NEUROSURGERY IN BRAZIL
Sebastião Silva Gusmão
Professor of Neurosurgery
Universidade Federal de Minas Gerais – Brasil
José Gilberto de Souza
Professor of Neurosurgery
Faculdade de Ciências Medicas de Minas Gerais - Brasil
Rua Padre Rolim, 921- Apt. 21
30130-090 Belo Horizonte
Tel: 31-32222547; 31-32730511
This work presents the professional lives of the pioneers who founded neurological surgery in Brazil and the Brazilian Society of Neurosurgery. The first steps were taken by Brandão Filho, the first general surgeon to try brain surgery in Brazil, and by José Ribe Portugal and Elyseu Paglioli, the pioneers and creators of the first two neurosurgical schools in Brazil. The Brazilian Society of Neurosurgery was founded in Brussels, Belgium, on July 26, 1957, during the First International Congress of Neurological Surgery, by the initiative of José Ribe Portugal and José Geraldo Albernaz.
History of neurosurgery, Brazil
Surgical interventions on the skull carried out before the appearance of modern medicine in the middle of the 19th century were almost totally limited to the treatment of fractures of the skull and the drainage of possible extra cerebral hematomas and associated festering collections 1,12.
The essential technological innovations that provided for the first significant developments in modern neurosurgery were the evolutionary progression of general surgery, especially the introduction of anesthesia (Morton, 1846), antisepsis (Lister, 1867), and the theory of the cerebral localization (Broca, 1861)10. These were established only in the last two decades of the 19th century and in the first decades of the 20th century, due in large part to the pioneering work of Victor Horsley (1857-1916) and Harvey Cushing (1864-1939)1,12. In Brazil, modern neurosurgery began at the end of the 1920’s thanks to the work of devoted practitioners and pioneers.11
But the recorded history of neurological surgery in Brazil began with the publication of Erário Mineral (Mineral Treasury), written by Luís Gomes Ferreyra, who practiced medicine in the cities of Sabará and Vila Rica (today Ouro Preto), in Minas Gerais, with the description of Brazil first neurosurgical procedure18,13,17. It was a case of head trauma, a compound depressed fracture of the skull caused by a falling tree branch on a slave's head in the vicinity of Sabará village in 1710. Ferreyra removed the bone fragments, achieved hemostasis, covered the bone defect and applied spirit (alcohol from sugar cane) to the wound, until healing was complete. After recovery, the patient returned to work.
In the first three decades of the 20th century, cases of head injury and cerebral abscess were operated on by general surgeons in the principal medical centers of Brazil. In 1922, Augusto Paulino Soares de Souza and Américo Gonçalves Valério presented at the Second Brazilian Congress of Neurology, Psychiatry and Forensic Medicine a report entitled A cirurgia nervosa no Brasil (Nervous System Surgery in Brasil)16. The majority of the cases described were of traumas and abscesses.
The official teaching of neurology was begun in 1912 when the discipline of neurology was created as distinct from psychiatry in the Faculty of Medicine of Rio de Janeiro. Antônio Austregésilo Rodrigues Lima (1876 - 1961), the director of the Neurology Service of Santa Casa de Misericórdia Hospital of Rio de Janeiro15 at that time, was appointed as discipline coordinator.
In the late 1920s, conditions were favorable for the introduction of neurosurgery in Brazil. Neurology and general surgery were already well established, especially in Rio de Janeiro, allowing for neurosurgery to become a fully established independent specialty. The first steps were already in place with the work of Brandão Filho, one of the first general surgeons to attempt brain surgery in Brazil, and by José Ribe Portugal and Elyseu Paglioli, both pioneers and founders of the first two neurosurgical schools in Brazil.
Augusto Brandão Filho
Augusto Brandão Filho (1881 - 1957) was a teacher in the Surgical Clinic of the National Faculty of Medicine at the University of Brazil. He practiced surgery at the Hospital da Misericórdia in Rio de Janeiro and was one of the most skilled surgeons of his time with a fine scientific disposition.
He was the first Brazilian to go beyond trauma surgery to undertake the surgical treatment of cerebral tumors. He was also the pioneer of neuroradiological investigation in Brazil and the first to perform ventriculography (1924) and cerebral angiography (1928). In these landmark studies, he was assisted by two remarkable medical doctors. In ventriculography he was associated with Manoel de Abreu (1894–1962), who later in 1936 invented the fluoroscopic image known in Brazil as abreugrafia3. In cerebral angiography, he worked with the inventor of the technique himself, Egas Moniz (figures 1, 2) 7,2. This was the first cerebral angiography performed on the American continent, just one year after its invention.
In the book written by Brandão Filho, Tumores do Encéfalo: algumas observações comentadas (Brain Tumors: Some Observations and Commentaries)5, there were accounts of six interventions on the cranium during the period from 1927 to 1931. A seventh case was published in 19243. All seven patients suffered from advanced intracranial hypertension and all died. Surgical localization was based only on neurological examination and simple skull x-ray, except in one case in which ventriculography was performed.
Brandão Filho’s book included a detailed case-by-case commentary on the causes of the mistakes in diagnosis and localization and of the failure of subsequent treatment. This analysis was based exclusively on the teachings of the great neurosurgeon from the beginning of the 20th century. In the book’s final remarks, he concluded that the treatment of intracranial tumors would only be possible with the creation of neurosurgery as a specialty. The work was truly prophetic in its conclusions.
In addition to the surgery of cerebral tumors, Brandão Filho also performed the surgical treatment of trigeminal neuralgia. He reported two cases, one of which was operated on in 1922 and the other in 1923 by sectioning the sensory root of the trigeminal nerve4.
José Ribe Portugal
Antônio Austregésilo (1876 - 1960), truly one of the pioneers in Brazilian neurology, introduced José Ribe Portugal (1901 – 1992) (figure 3) to the field of neurosurgery. In 1928, Austregésilo visited the surgical services of Cushing and Frazier in the United States. He was very impressed by American neurosurgery, particularly with its precise methods of diagnosis in ventriculography and pneumoencephalography as introduced by Dandy in 1918.
Immediately after his return to Brazil, Austregésilo created the Neurosurgerical Service at Hospital da Misericórdia. In 1928, Alfredo Monteiro, in association with Portugal, initiated neurosurgery in Rio de Janeiro. Monteiro was appointed to the recently created Chair of Neurosurgery of the National Faculty of Medicine in Rio de Janeiro four years later. However, he progressively lost interest in the specialty and in 1935 moved to the Chair of Surgical Techniques and Experimental Surgery, leaving Portugal in charge.
José Ribeiro Portugal had graduated from the Faculty of Medicine of the University of Rio de Janeiro in 1927 and, in the following year, was appointed Lecturer in Anatomy of the same faculty.
In 1929 at the age of 28, he underwent the examination for full professorship in the discipline of Surgical Techniques and Experimental Surgery at the Faculty of Medicine of Rio de Janeiro by presenting a thesis entitled Contribuição à neurectomia retrogasseriana (Contribution to Retrogasserian
Neurectomy). The treatment of trigeminal neuralgia remained his primary interest throughout his carreer as a neurosurgeon (figure 4).
Neurectomy). The treatment of trigeminal neuralgia remained his primary interest throughout his carreer as a neurosurgeon (figure 4).
In the beginning, Portugal was self-taught. His medical practice was guided by the neurosurgical literature of the time and by his correspondence with the great masters of neurosurgery: Cushing, Frazier and Adson. His technical competence matured as a result of his being surrounded by new equipment and modern facilities. He educated a body of assistants, taught courses and led conferences.
In 1930, Portugal visited the neurosurgical service of Manuel Belado (1897 - 1942) in Buenos Aires and in 1945 several other similarly specialized neurosurgical services, including those of Scarff, Ingraham, Matson, Grant, Gross and Dandy. After the Neurosurgery World Congress in Paris, he in turn visited the neurosurgical services of Olivecrona, Sjoqvist, Norman Dott and Jefferson.
Continuing in his outstanding career, Portugal later occupied the Neurosurgery Chair at the Faculty of Medical Sciences of Rio de Janeiro. In 1965, he worked at the Hospital das Clínicas, retiring in 1970.
Portugal was titular member and founder of the most important Brazilian neurological societies: the Brazilian Academy of Neurology, the Brazilian Society of Neurosurgery and the Brazilian Academy of Neurosurgery. He held the title of Emeritus Member in the National Academy of Medicine.
Portugal published several neurosurgical papers of which those concerning trigeminal neuralgia and meningiomas are of preeminent importance in the neurosurgical literature. As attested to by all the currently available history, testimonies and commentary, to say nothing of the sheer volume and quality of his own published works, Portugal was clearly an extraordinary surgeon gifted with impressive technical abilities6,11.
A recognized master of the classroom and his subject as well as a lecturer of incomparable renown, Portugal trained many disciples who also became great masters in their own right: Santos Machado, Jaime Viana, Renato Tavares Barbosa, Mário Coutinho, Pedro Sampaio, Francisco Guerra, Otoide Pinheiro, Feliciano Pinto, Gianni Maurélio Temponi and Mário Brock.
He influenced Brazilian neurosurgery deeply through his disciples and for his intense activity in congress and scientific activities. All of his students are unanimous in exalting his accomplishments in surgical technique. Aging didn't keeps him from neurosurgery. To the brink of death, he influenced the development of the profession and was a constant participant in the Congress of Neurosurgery. He kept a young, enthusiastic spirit by developing projects and by learning constantly while being concerned with neurosurgery’s future. His last lecture on cystic meningiomas was given two weeks before his death during the Congress of the Brazilian Academy of Neurosurgery at the age of 91.
Portugal was a man of simple means and of positive disposition. He liked to be surrounded by friends, sharing with them his ability on the guitar. He is recognized as the most important Brazilian neurosurgeon.
Elyseu Paglioli (1898--1985) (figure 5) graduated from the Faculty of Medicine of Porto Alegre in 1923 obtaining his doctorate by presenting a thesis entitled: Relações anatômicas do ouvido médio com o ápice do rochedo, gânglio Gasser e sexto par, com deduções clínicas (Anatomical Relationships of the Middle Ear with the Apex of the Petrous Bone, Gasser Ganglia and Sixth Nerve, with Clinical Conclusions). He was interested in neuroanatomy, being nominated only a year later in 1924 as coordinator to the Chair of Anatomy.
Paglioli decided to return to São Francisco de Paula, where he had grown up and where he had also performed his first neurosurgical procedures, to work there for a short period. He returned to Porto Alegre in 1928 after securing the Anatomy Chair position with a thesis entitled: Circulação venosa dos núcleos centrais do cérebro (Venous Circulation of the Central Nucleus of the Brain). He began to perform neurosurgical interventions, but with great difficulty due to scarcity of resources.
In 1930, Paglioli spent eight months in Paris as assistant to De Martel (1875–1940), the eminent pioneer neurosurgeon in France. After his return, he acquired the necessary equipment and began the practice of neurosurgery at the Hospital Alemão (today Hospital Moinhos de Vento), in the late 1930s.
Paglioli began an intense period of activity with the publication in 1932 of an article on tumors of the cerebellopontine angle, which had been operated on successfully. In 1933 at the National Academy of Medicine, he presented a monograph entitled Cirurgia crânio-encefálica (Brain surgery) in which he reported 11 cases of successfully treated of cerebral tumors. Until that time, surgical interventions were made only with the patient in the seated position and exclusively under local anesthesia. In 1938, in order to obtain the Chair of Surgical Clinic, he presented a thesis entitled Ventriculografia (Ventriculography), one of the first and most complete works on the subject. De Martel himself wrote its foreword.
Elyseu Paglioli later realized his ambition of founding the Latin-American Neurosurgery Society. Together with Alejandro Schroeder from Montevidéo, Uruguay, and Rafael Babini from Rosário, Argentina, he organized the first congress of the specialty in Latin America in 1945 (figure 6).
In 1946, he founded the Institute of Neurosurgery of Santa Casa with 112 beds, and it was from here that he started to develop neurosurgery under better conditions and also where he trained several young associates, among them João Alberto Martins Dahne, Eduardo Beck Paglioli, Mário Schinini Cademartori, Nelson Pires Ferreira, Nelson Aspesi, Ricardo Gavenski, Carlos Ferrari, Zaluar Campos, Manoel Krimberg, Antônio Mazzaferro, Frederico Kliemann and Djacir Figueiredo.
Besides his work in neurosurgery, Paglioli was also engaged in politics and administration. In 1950, he was nominated mayor of Porto Alegre by his friend, the president of the Brazilian republic, Getúlio Vargas. He occupied city hall for just one year, leaving to undertake the Rectory of the University of Rio Grande do Sul, where he remained for twelve years. In 1961, he left the Rectory to become Minister of Health during the government of the Brazilian president João Goulart.
Elyseu Paglioli was founder of several organizations, the most important of which were the Brazilian Society of Neurosurgery, the Latin-American Society of Neurosurgery and the Brazilian Academy of Neurosurgery11. His marked surgical activity and skill along with his leadership and affective temper trained and influenced for several years a large group of neurosurgeons. He positively affected the field of Brazilian neurosurgery and many neurosurgeons. His relationship with the pioneer neurosurgeons in the countries of South America contributed to the creation of the Congress of Latin American Neurosurgery and the future Latin American Federation of Neurosurgery (FLANC). His restless temper impelled him to the administrative life as mayor of Porto Alegre and rector of the Federal University of Rio Grande do Sul and Minister of the Health. In all these positions he accomplished significant achievements on behalf of education and health in Brazil.
The Brazilian Society of Neurosurgery
As the records show and to give credit where it is due, it was from the initiative of both José Ribe Portugal and José Geraldo Albernaz that the Brazilian Society of Neurosurgery was founded on July 26, 1957, in Brussels, Belgium, during the First International Congress of Neurological Surgery. The founders were José Ribe Portugal, J. L. Brito e Cunha, Renato Tavares Barbosa, Paulo Niemeyer, Henrique Austregésilo, Aloysio Mattos Pimenta, Carlos Sacramento, Elyseu Paglioli, Zaluar Campos, Manoel Caetano of Barros, Moacir Bernardes, and José Geraldo Albernaz. Portugal was chosen as president and Albernaz as both the interim secretary of the new society and as editor of the statutes and regulations.
Finally, marking one more event in Brazilian neurosurgical history, the First Congress of the Brazilian Society of Neurosurgery was held in Petrópolis at the Hotel Quitandinha from 18 to 20 July,1958 (figure 7). More significant still, the following year, the young Brazilian Society of Neurosurgery became part of the World Federation of Neurosurgical Societies.
01. Ballance SC: A glimpse into the history of surgery of the brain. Lancet 22:111-116; 165-172, 1922.
02. Brandão Filho A: Primeira encefalografia arterial no Brasil, In Clínica cirúrgica . Rio de Janeiro, Editora Scientífica, 1930, Vol 4, pp 271-293.
03. Brandão Filho A: Quisto da hipófise; ventriculografia e intervenção cirúrgica por via frontal [in Portuguese]. Jornal dos Clínicos 16: 224 – 251,1924.
04. Brandão Filho A: Tique doloroso da face; secção da raiz sensitiva do trigêmeo, In Clínica cirúrgica. Rio de Janeiro, Editora Scientífica, 1923, Vol 2, pp 251-314.
05. Brandão Filho A: Tumores do encéfalo: algumas observações comentadas. Rio de Janeiro, Pimenta de Mello, 1931.
06. Brock M: José Ribeiro Portugal – pai da neurocirurgia brasileira [in Portuguese]. Arq. Neuropsiquiatria 52: 118-122, 1994.
07. Egas Moniz: Confidências de um investigador científico. Lisboa, Edições Ática, 1949 pp. 129-136.
08. Ferreyra LG: Erário Mineral. Lisboa, Oficina de Miguel Rodrigues, 1735, pp 345-347.
09. Gomes MM: Marcos históricos da Neurologia. Rio de Janeiro, Editora Científica Nacional, 1997, pp 61-65.
10. Greenblatt SH: A History of Neurosurgery. The American Association of Neurological Surgeons, 1997, pp 3-9.
11. Gusmão SS, Souza JG: História da Neurocirurgia no Brasil [in Portuguese]. Joinville, Letra d’agua, 2000, pp 120-128.
12. Horrax G: Neurosurgery: A Historical Sketch. Springfield, Charles C. Thomas, 1952, pp 10-15.
13. Niemeyer P: Erário Mineral: primeira intervenção neurocirúrgica realizada em Minas Gerais [in Portuguese]. Medicina de Hoje 2: 566-568, 1976.
14. Reimão R: História da neurologia no Brasil. São Paulo, Lemos-Editorial, 1999, pp 43-51.
15. Ribeiro L: Medicina no Brasil. Rio de Janeiro, Imprensa Nacional, 1940, pp 53-59.
16. Souza APS, Valério AG. A cirurgia nervosa no Brasil. Anais do segundo congresso brasileiro de neurologia, psychiatria e medicina legal [in Portuguese]. Arch Neurol Psiq e med legal 6: 30-67, 1922.
17. Souza JGA, Gusmão SS. A primeira intervenção neurocirúrgica relatada no Brasil [in Portuguese]. Arq Bras Neuroc 12: 11-14, 1994.
Fig. 1 – Egas Moniz in São Paulo. “Prof. Ovídio Pires de Campos, Prof. Pedro Dias da Silva, dr. Ayres Neto, Prof. Rafael de Barros, dr. Osvaldo Portugal, Prof. Cantídio de Moura Campos, dr. Synésio Rangel Pestana, Prof. Antônio Camargo, Prof. Enjolras Vampré, Prof. Paulino Longo, etc.”7
Fig. 2 – Lateral veiw of the first cerebral angiography performed in Brazil by Brandão Filho and Egas Moniz, on 6 August,1928.
Fig. 3 – José Ribe Portugal (1901 – 1992).
Fig. 4 – Retrogasserian neurotomy performed in August, 1938, in the Neurosurgical Clinic of the Universidade do Brasil, in Rio de Janeiro. The surgical procedure was performed by José Ribe Portugal (1), observed by Leriche (2) and assisted by Renato Tavares Barbosa (3).
Fig. 5 – Elyseu Paglioli (1898 - 1985).
Fig. 6 – The First South American Congress of Neurosurgery held in Montevideo, Uruguay, on May 1,1945. Seated, from left to right: Portugal, Asenjo, President of
Uruguai, Paglioli and Babini. Standing, from left to right: Arana, Rocca Schroeder and Ghersi.
Fig. 7 –First Congress of the Brazilian Society of Neurosurgery held in Petrópolis in 1958. From left to right:: Lélio Gomes, Paulo Niemeyer, Rolando Tenuto, José
Geraldo Albernaz, José Ribe Portugal, Mattos Pimenta, Manoel Caetano de Barros, Renato Tavares Barbosa and Francisco Rocha.