Michele Augusto Riva

Sleepwalking in Italian Operas: A Window on Popular and Scientific Knowledge on Sleep Disorders in the 19th Century

There is little knowledge on sleepwalking in ancient times even though it is a very common condition. The aim of this report is to describe the backgrounds of medical knowledge on somnambulism in the 19th century, a key period in the development of neurosciences, by analysing its representation in two famous Italian operas: La Sonnambula by Vincenzo Bellini and Macbeth by Giuseppe Verdi. The 19th-century operas may be considered as a crossing point between the popular and intellectual world because they mirror popular answers to phenomena that were still awaiting scientific explanations. Shakespeare’s play Macbeth was also considered. In Shakespeare’s play and in Verdi’s Macbeth, sleepwalking is looked upon as a neuropsychiatric disorder, a manifestation of internal anxiety. In La Sonnambula by Bellini, this condition is considered as common disorder that anticipates scientific theories. The analysed Italian operas provide two different views on sleepwalking, probably because they are based on texts belonging to different periods. Their examination allows one to understand the gradual evolution of theories on sleepwalking, from demoniac possession to mental disorder and sleep disease. At the same time, this analysis throws some light on the history of psychological illnesses.

The disease of the moon: the linguistic and pathological evolution of the English term "lunatic".

The public opinion and the scientific community incorrectly believe that the English term “lunatic” was originally related only to insanity, but it also referred to epileptic people. The aim of this article is to clarify the original meaning of the English word “lunatic” by analyzing the evolution of the relationship between psychiatric and neurological diseases and by pointing out the influence of the moon in the history of medicine, in popular traditions, and in English literature. The article also contains a detailed and accurate review of the modern scientific literature on the relationship between moon and epilepsy/psychiatric disorders.

Social status and cardiovascular disease: a Mediterranean case. Results from the Italian Progetto CUORE cohort study.

BackgroundSocial factors could offer useful information for planning prevention strategy for cardiovascular diseases. This analysis aims to explore the relationship between education, marital status and major cardiovascular risk factors and to evaluate the role of social status indicators in predicting cardiovascular events and deaths in several Italian cohorts.MethodsThe population is representative of Italy, where the incidence of the disease is low. Data from the Progetto CUORE, a prospective study of cohorts enrolled between 1983-1997, were used; 7520 men and 13127 women aged 35-69 years free of previous cardiovascular events and followed for an average of 11 years. Educational level and marital status were used as the main indicators of social status.ResultsAbout 70% of the studied population had a low or medium level of education (less than high school) and more than 80% was married or cohabitating. There was an inverse relationship between educational level and major cardiovascular risk factors in both genders. Significantly higher major cardiovascular risk factors were detected in married or cohabitating women, with the exception of smoking. Cardiovascular risk score was lower in married or cohabitating men. No relationship between incidence of cardiac events and the two social status indicators was observed. Cardiovascular case-fatality was significantly higher in men who were not married and not cohabitating (HR 3.20, 95%CI: 2.21-4.64). The higher cardiovascular risk observed in those with a low level of education deserves careful attention even if during the follow-up it did not seem to determine an increase of cardiac events.ConclusionsPreventive interventions on cardiovascular risk should be addressed mostly to people with less education. Cardiovascular risk score and case-fatality resulted higher in men living alone while cardiovascular factors were higher in women married or cohabitating. Such gender differences seem peculiar of our population and require further research on unexpected cultural and behavioural influences.

Dante and cardiology: Physiopathology and clinical features of cardiovascular diseases in the Middle Ages

Ancient non-medical texts can unexpectedly provide useful information on the development of knowledge about the heart and its diseases throughout history. The 750th anniversary of the birth of the Italian poet Dante Alighieri (1265-1321) provides a timely opportunity to analyze medical references in his works, in particular, focusing on literary descriptions that may be attributed to cardiovascular disorders. Dantes high level of medical knowledge, probably derived from his academic studies, is testified by his affiliation to the Florentine Guild of physicians and pharmacists. In all his works, the poet shows a deep interest for the heart. However, his anatomical and physiological knowledge of the circulatory system appears to be poor, probably due to it being based on theories and concepts brought forth by Aristotle and Galen, which were taught in medieval universities. Despite this, accurate descriptions of some symptoms (emotional syncope, orthopnea, dyspnea on exertion) and signs (ascites, paleness), which may be attributed to cardiovascular disorders, can be easily found in Dantes works, particularly in his masterpiece, the Divine Comedy. The literary and historical analysis of cardiovascular signs and symptoms allows us to assume that clinical features due to alterations of heart function were probably known by medieval physicians, but their etiology and pathophysiological mechanisms were not completely understood in that period. Historians of cardiology and clinicians should consider analysis of non-medical texts (including poetry) as an opportunity to better investigate the evolution of their discipline throughout the ages.

Workers’ Health Conditions in the Greco-Roman World: The Contribution of Non-Medical Sources

M edical texts of the classical period do not provide us with relevant information regarding workers’ health conditions, even where the patient’s occupation is often cited in descriptions of clinical cases.1 Limited interest by ancient physicians regarding this subject is likely explained by the different conceptions of work in the GrecoRoman world, further highlighted by the terminology used to define the workers of antiquity. Referring to working men, ancient Romans used the word “operaii” or the periphrasis “qui opus faciunt”, indicating “those who produce”. These terms excluded some groups, such as physicians and merchants, who were not considered as workers since they did not produce anything. A strong relationship with production, demonstrates that, in Greco-Roman thought, work encompassed only “manual work”. Therefore, since “manual workers” were likely to be slaves and prisoners, their health was little considered.1 According to the historian Xenophon (ca. 430–355 BC), “in some cities, especially the warlike ones”, it’s not legal for a citizen to ply a “mechanical trade”, or undertake “manual work”.2 The Greek writer added that “what are called the mechanical arts, carry a social stigma and are rightly dishonoured in our cities” and “the workers at these trades simply have not got the time to perform the offices of friendship or of citizenship. Consequently, they are looked upon as bad friends and bad patriots” (Oeconomicus, IV). Greek physicians, as citizens, were therefore expected to only treat other citizens, rather than workers or slaves. Thus, according to Hunter, “this social division was so deep

Positive signs of functional weakness

Functional (conversion) neurological symptoms represent as one of the most common situations faced by neurologists in their everyday practice. Among them, acute or subacute functional weakness may mimic very prevalent conditions such as stroke or traumatic injury. Hence, accurate and reliable positive signs of functional weakness are valuable for obtaining timely diagnosis and treatment, making it possible to avoid unnecessary or invasive tests and procedures up to thrombolysis. We therefore present here a brief overview of the positive neurological signs of functional weakness available, both in the lower and in the upper limbs, moving from a historical perspective to their relevance in current clinical practice.

Cesare Vigna (1819–1892)

The year 2013 marks the bicentennial anniversary of the birth of the Italian Romantic composer Giuseppe Verdi (1813–1902). In his operas neurological and psychiatric disorders (e.g., acute delirium/psychosis in ‘‘Nabucco’’, madness in ‘‘Giovanna d’Arco’’, insane jealously in ‘‘Otello’’, sleepwalking in ‘‘Macbeth’’) are prominently performed on stage [5]. Probably this has some relation to the personal experience of Verdi, who often suffered from depression during his long life. It is however less known that during these depressive episodes the composer was cared for by his close friend and personal physician Cesare Vigna, who also in other respects deserves to be recalled as an Italian pioneer in the field of neurology, psychiatry and music therapy. Vigna (Fig. 1) was born in Viadana, near Mantua, on October 24, 1819, the son of Giuseppe and Lucia Pirini. He was a brilliant student and finished his medical studies at the University of Padua in 1842, when he was only 23 years old. Immediately afterwards he was appointed lecturer in Forensic Pathology at the same university [3]. Two years later, Vigna moved to Venice, where he was politically involved in the revolutionary movements of 1848–1849 against Austrian domination; also he actively participated on the battlefield as ‘‘battalion physician’’ [3]. After the failure of the revolts and the re-conquest of Venice by Habsburg troops, Vigna returned to his medical career, mainly in the field of nervous and mental disease. He also cultivated his interests in music, as shown by some essays on the influence of music on mental health, which appeared in a musical bulletin of the time, the ‘Gazzetta musicale di Milano’, between 1852 and 1856. In particular, Vigna tried to explore the neurophysiological events through which music produces emotional responses in the brain and influences the body as well as the moral sense of any individual [6–8]. In those years Vigna met Verdi, with whom he established a deep and lasting friendship. As demonstrated by their regular correspondence, he was often called by the soprano Giuseppina Strepponi (1815–1897), Verdi’s second wife, to care for the Maestro during his frequent depressive episodes. An example of his influence on the Italian composer is Vigna’s decisive role in the creation of the character of Violetta Valéry, the courtesan suffering from tuberculosis in ‘‘La Traviata’’ (1852); because of his contribution, the musical editor Tito Ricordi (1811–1888) dedicated the orchestral score of that opera to Vigna [1]. From 1856 onwards, Vigna worked as medical consultant at the psychiatric hospital on the island of San Servolo in the Venetian lagoon, under the direction of the alienist Prosdocimo Salerio (1815–1877) [3]. There, and on the island of San Clemente, where he was appointed as director of a new psychiatric hospital for women in 1873, Vigna investigated the positive effects of music on his patients, who could freely listen to music in a dedicated room in the hospital. The treatment of ‘insane’ patients by means of music had originated in France in the 1820s–1830s, when Jean-Étienne Dominique Esquirol (1772–1840) used to organize performances by orchestras for his patients at the Salpêtrière, while his pupil François Leuret (1797–1851) M. A. Riva (&) V. A. Sironi Research Centre on the History of Biomedical Thought (Centro Studi sulla Storia del Pensiero Biomedico, CESPEB), University of Milano Bicocca, Villa Serena, via Pergolesi 33, 20900 Monza, Italy e-mail: michele.riva@unimib.it

Administrative databases as a tool for identifying healthcare demand and costs in an over-one million population

Background: the aim of this study was to assess healthcare demand of specific groups of population and their costs borne by Italian Health System, using healthcare administrative databases. Methods: demographic, clinical and economic data were obtained from datasets available at the Regional Health System, combined into a data warehouse (DENALI), using a probabilistic record linkage to optimize the data matching process. The study population consisted of more than 1 million people registered in 2005 at one Local Healthcare Unit of Lombardy. Eight different segments were identified. Costs occurring in 2005 for hospital admissions, drug prescriptions, outpatient medical specialist visits were quantified in each segment. Results: healthy people accounted for 53% of the population and cost € 180 per-capita. Subjects with only one chronic disease made up 16% of the population and cost € 916 per-capita, those affected by several chronic diseases accounted for 13% and cost € 3 457 per-capita. Hospitalizations were the cost driver in five segments, ranging from 42% to 89% of total expenditures. Outpatient visits were the cost driver among healthy subjects (54%) and those with a possible chronic disease (42%), while drug costs ranged between 4% (“acute event”) and 32% (“one chronic disease”). Overall, healthcare cost was € 809 per-capita. Conclusions: healthcare costs were mainly determined by people affected by chronic conditions, even if “healthy people” ranked third for total expenditure. These costs need an appropriate identification of healthcare demand, that could be efficiently monitored through the use of administrative databases.

Arsenic eaters and altitude sickness: an epigenetic strategy for improving fitness in a hostile environment?

(f) Bell CL, Watson B, Waring WS. Acute psychosis caused by co-amoxiclav. BMJ 2008;337:996. [2] Abouesh A, Stone C, Hobbs WR. Antimicrobial-induced mania (Antibiomania): a review of spontaneous reports. J Clin Psychopharmacol 2002;22:71–81. [3] Fisher GH, D’Aniello A, Vetere A, et al. Free D-aspartate and D-alanine in normal and Alzheimer brain. Brain Res Bull 1991;26:983–5. [4] Nagata Y, Akino T. D-amino acids in mouse tissues are not of microbial origin. Experientia 1990;46:466–8. [5] Konno R, Owada T, Ozaki A, et al. Origin of D-alanine present in urine of mutant mice lacking D-amino acid oxidase activity. Am J Physiol 1993;265:G699–703. [6] Konno R, Niwa A, Yasumura Y. Intestinal bacterial origin of D-alanine in urine of mutant mice lacking D-amino acid oxidase. J Biochem 1990;268:263–5. [7] Kleckner NW, Dingledine R. Requirement for glycine in activation of NMDAreceptors expressed in Xenopus oocytes. Science 1988;241:835–7. [8] Tsai GE, Yang P, Yue-Cune C, et al. D-alanine added to antipsychotics for the treatment of schizophrenia. Biol Psychiatry 2006;59:230–4.

Somnambulism in Verdi's Macbeth and Bellini's La Sonnambula: opera, sleepwalking, and medicine

The arts can provide unique ways for determining how people not directly involved in medicine were viewing and informing others about physical and mental disorders. With operas, one need only think about how various perturbations of madness have been portrayed. Somnambulism has long been a particularly perplexing disorder, both to physicians and the laity, and it features in a number of operas. Two mid-nineteenth-century masterpieces are examined in detail in this contribution: Verdis Macbeth and Bellinis La Sonnambula. In the former, the sleepwalking scene is faithful to what Shakespeares had written early in the seventeenth century, a time of witchcraft, superstition, and the belief that nocturnal wanderings might be caused by guilt. In Bellinis opera, in contrast, the victim is an innocent girl who suffers from a quirk of nature, hence eliciting sympathy and compassion. By examining the early literature on somnambulism and comparing this disorder in these operas, we can see how thinking about this condition has changed and, more generally, how music was helping to generate new ways of thinking about specific diseases and medicine.