Giulio Nicita
Florence, Italy

 

A view of Villa Monna Tessa. From the author’s archive.

We were in the middle of the 1970s in Florence, Italy. We had concluded the long, tedious years of university study. Real work awaited us in Villa Monna Tessa, a large early 1900s four-story building. It housed several departments of Medicine as well as Urology. The edifice, once an elegant patrician residence, had become the city hospital and was used as temporary site while the definitive quarters were being remodeled. Since modernization took years, the “transitory” accommodation was hardly temporary.

Urology, with 70 beds, operating theaters and rooms for out-patients (ambulatori) filled the entire second floor. Because Monna Tessa was a renowned Urology center, it attracted patients from across the country—despite the “temporary” and decrepit character of the wards—the alberghieri (hotel).

The male wards comprised four large halls, each with fourteen beds ringed around the walls, all feet toward the center of the hall. There were few bathrooms. The female ward was more “comfortable,” each room housing four or six patients. Nevertheless, we realized that, thanks to the optimal level of care, the structural and alberghieri deficits were of little importance.

Our department, part of Florence University, was a division of the main city hospital of Florence, Careggi (named after a Medici villa on the site).

The director, our professor, a man of about fifty, was fat, short, wider than taller, his head neckless above the body, his round face topped off with a thick shock of curly white hair. His chubby hands bore stubby fingers. Despite this aspect of a jovial “salumiere” (the guy behind the delicatessen counter), he handled surgical instruments with great skill. In sum, he was the epitome of our saying “the monk’s clothing does not make the monk” (“l’abito non fa il Monaco”); in his ordinary persona lodged a distinguished doctor. He was the idol of us residents for his extraordinary clinical capabilities. By contrast, when he became angry, he erupted abrasively. The congenial, good-humored man vanished when, in his opinion, somebody erred. He then castigated blatantly, without restraint.

Hardly the stereotypical figure of a surgeon, our head could not have been more of a contrast with his own mentor. The latter, founder of our school of Urology, left for Rome University at the apex of his career—one rich in talent, new thinking, and innovation. On his departure, our professor became departmental head. For as much as our professor was the archetype of vivacity and plebian attributes, his predecessor had been a prototypical aristocrat. Tall and thin, his constant demeanor was of detached reserve. He was known for the signature white tie he wore in perpetual mourning for the son he had lost.

We thought that our professor, not tender with his assistants, mistreated us because he had suffered similar treatment in his training. Both men were charismatic, demanding, and like many masters were surrounded by a flock of followers.

Our professor’s team members were mostly younger: his right-hand man, the aiuto (assistant), was nearly 40; six other assistants were approaching 40; the three of us were under 30. We residents lived in blind enthusiasm for our chosen profession. We wanted the most out of the stimulating environment, full as it was of opportunities for learning and research.

Our days were hectic. In the ward of a university clinic there were duties beyond the care of patients. The department was responsible for parts the course work for the medical degree, and we offered students-in-training opportunities in the wards as well as with outpatients. We also conducted and published research. All told, there was never a minute of free time.

One of us studied the anatomy of the bladder’s lymphatic vessels,¹ and wished to show the pathways of lymph during surgical operations. Because these structures are normally colorless, he injected the wall of the bladder with methylene blue, a biological dye,² the dose based on the patient’s weight. Within minutes, bluish tracks appeared around the bladder. The dyed lymphatic paths were photographed. The methylene blue passed from the lymphatic circulation into that of the blood and within a few hours was eliminated in the urine.

The aim of my colleague’s study was to document anatomical variations in the lymphatic system. Because he had to build up several cases, he injected methylene blue when our various bladder operations were completed.

In those years, patients’ right to full information had not been regulated. We did not ask for permission in such innocuous procedures, and we did not even tell patients of their participation in research. The injections had nothing to do with their healthcare, but would be useful for others.

One bright summer morning, an extremely thin patient about to undergo an operation for bladder stones was chosen for the research. He was operated under full anesthesia, the stones were removed, and the presumably appropriate quantity of methylene injected into his bladder wall. Within a few minutes, the lymphatic pathways stood out fully in a blue we had never seen before. Many photographs were taken, the operation concluded, and the patient returned to the ward.

About half an hour later, while we residents were having coffee in the lounge, a nurse abruptly interrupted: “Doctors! Rush to that patient’s bed!” Our nurses, then, were mostly scantly educated rural people who had taken brief courses to prepare them for hospital work. The majority were dedicated and had become expert through on-the-job training. One reason for our department’s renown was the quality of the staff. Behind their sometimes unpolished or even rough manners were individuals with professional bravura. We knew, therefore, that if a nurse searched us out urgently, there was a serious problem.

We hurried to the ward, now in the splendid full light of late morning. Before us was a surreal scene. Absolute silence reigned as the other thirteen patients focused on the patient in question. Under the white sheets and against the candid pillow-case calmly rested a head of intense blue. The agitated nurse asked anxiously, “Doctors, what do we do now?” The colleague who had given the injection thought for a moment. He then came up with a genial response: “Do not give him a mirror!”

Could such a thing happen today, almost fifty years later? Certainly, an error waits behind every corner in the practice of medicine. But between then and now, there is a difference in dealing with mistakes. Now, before starting any research, the project must be approved by an ethics committee. Then, patients must give explicit consent, after being fully informed of every possible adverse eventuality. Finally, once the study begins, if a patient turned blue, an audit would ascertain the cause and identify the party or parties responsible. Appropriate procedures would be proposed, together with controls to guarantee no repeat event. In our time, the experience of the man tinged with blue was resolved by an outburst from our professor. Calling us into his office, he tore us apart for a good ten minutes. From that time on, there were no further excessive administrations of methylene blue.

 

References

1. Saenz, J.M. Fazio. Anatomy of the bladder lymphatic system. Rev. Argent. Urol. Nefrol. Sep-Dec 3, 1966;5(9):248-54.
2. Cwalinski T. et al. Methylene Blue—Current Knowledge, Fluorescent Properties, and Its Future Use. J. Clin. Med. Nov 2, 2020;9(11):3538.

 

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GIULIO NICITA, MD, held the Chair of Full Professor of Urology at the University of Florence from 2002 until 2016 after a career begun there as resident in 1972. His fields of clinical study were urological oncology, female urology, and kidney transplantation. He is the author of numerous articles published in Italian and international journals.

 

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