Ethical disputes still beset Italian medicine 150 years after Count Cavour's death

Abstract

The year 2011 marks the 150th anniversary of the reunifi cation of Italy. The struggle for unifi cation—or the Risorgimento as it is now remembered—had been long and hard. It began in 1815, after the Congress of Vienna, which followed the Revolutionary and Napoleonic wars, and it culminated in the declaration of the Kingdom of Italy on March 17, 1861. But even that was not the end: it took another 10 years of wars and diplomatic manoeuvrings for Venice and Rome, capital of the sovereign Papal States for more than 1000 years, to be incorporated into the new kingdom. The process involved the meeting and often the clash of contrasting political ideologies and traditions—liberalism, proto-socialism, republicanism, monarchism, clericalism, and anti-clericalism—and its cultural and social eff ects were profound. Four iconic fi gures embody the Risorgimento, their names familiar to every Italian schoolchild: Vittorio Emanuele II (1820–78) was the fi rst king of Italy; Giuseppe Garibaldi (1807–82) was the fearless fi ghter for unifi cation; Giuseppe Mazzini (1805–72) represented idealistic republicanism; and Camillo Benso (1810–61), Count Cavour and Prime Minister of Piedmont, was the diplomatic and political driving force (fi gure 1). Count Cavour was known not only in Italy, but also in political and diplomatic circles and to the newspaper-reading public throughout Europe, so the announcement of his death on June 6, 1861, barely 3 months after the declaration of unifi cation, came as a shock. The English-language medical press lamented the loss of a statesman, as did many others. The Lancet mourned a “sagacious intellect” whose “political vision embraced the preservation of personal liberty, freedom of thought and speech and the advancement of the arts and sciences”. But as the fi rst accounts of Count Cavour’s last illness and death emerged, grief gave way to consternation and then to horror. He had been, The Lancet declared, a victim of the “antiquated practices of Italian physicians”. The Boston Medical and Surgical Journal, parent of the New England Journal of Medicine, reported on June 4, 1861, that “the enemies of Italy must erect a statue to Sangrado. But it is diffi cult for us to read the accounts transmitted to us of the disease and treatment of Count Cavour with patience”. On July 13, 1861, Robert Wollaston framed his accusations in the British Medical Journal in even starker terms: “On perusing the statements in the public journals of the death of that great patriot and most enlightened statesman, Count Cavour, it must strike every English physician that he was killed by having been bled no less than seven times”. Of the actual events, the detailed testimony of Count Cavour’s niece, Giuseppina Alfi eri, was reported by historians. She recalled that her uncle, Prime Minister of the newly united country, returned home on May 29, 1861, tired and worried after a long and turbulent session in Parliament. During the night he woke up shaking with fever, vomiting, and complaining of abdominal pain. His physician, Francesco Rossi, was summoned and immediately prescribed bloodletting. Second and third bloodlettings followed within a few hours. The next day, the patient felt tired but slightly better and even received several members of his cabinet. However, on Friday May 31, another bout of fever and rigor left him prostrate. Quinine was prescribed but he was unable to retain it. Then two more bloodlettings were done, leaving the Count in what would be recognised today as hypovolaemic shock. He was “pale, continuously dozing off and his hands were as cold as marble”. Cavour then became delirious, his breathing fast and shallow, muttering about continuous thirst. Rossi requested a consultation with colleagues. Their diagnosis of congestion with a risk of cerebral oedema confi rmed Rossi’s own. The treatment was to be more bloodletting and quinine. The bloodletting was