Chapter 49 Clinical neurology in Latin America

Chapter 49 Clinical neurology in Latin America

Handbook of Clinical Neurology, Vol. 95 (3rd series) History of Neurology S. Finger, F. Boller, K.L. Tyler, Editors # 2010 Elsevier B.V. All rights re...

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Handbook of Clinical Neurology, Vol. 95 (3rd series) History of Neurology S. Finger, F. Boller, K.L. Tyler, Editors # 2010 Elsevier B.V. All rights reserved

Chapter 49

Clinical neurology in Latin America RICARDO F. ALLEGRI * Services of Neurology & Neuropsychology (SIREN), Instituto Universitario CEMIC (Centro de Estudios Médicos e Investigaciones Clínicas); CONICET (Consejo Nacional de Investigaciones Científicas y Tecnológicas); Department of Neurology, Hospital Abel Zubizarreta, Gobierno de la Ciudad de Buenos Aires, Argentina

INTRODUCTION The history of neurology in Latin America developed in parallel with the leading European centers, most importantly in France and Germany, where most prominent Latin American neurologists were trained. Nevertheless, it is difficult to follow this puzzle of country-specific scattered data, which have hardly been included in international publications or were included in local journals without being referenced in bibliography indices. In fact, given lost records and the difficulties of publishing in Spanish in most international journals (Gibbs, 1995; Famulari, 2003) there are only limited data available on the history of neurology in some of these Latin American countries. Neurology in Latin America emerged toward the end of the 19th century, following the origin of the specialty in Europe and its official baptism with Charcot at the Salpeˆtrie`re Hospital in Paris. The first steps took place almost simultaneously in five countries: Argentina, Brazil, Uruguay, Chile, and Peru. In the other countries, the development of neurology took place later in the 20th century. In all cases, one can discern three fundamental stages: 1. Stage of neurology as part of internal medicine: doctoral theses and publications about neurological topics are found early in the history of medicine, but only within internal medicine. 2. Foundation stage of clinical neurology: under the typical European influence, mainly French, the first neurologists appear. With the founding of chairs of neurology, the birth of scientific societies, and specialized journals, clinical neurology consolidated. *

3. Stage of neurological sub-specialties: in the more recent North American-influenced years, there is a new paradigm favoring the atomization of the sciences. Specialists in epilepsy, headache, stroke, dementia, among others, appear.

SOUTH AMERICA Argentina The history of neurology in Argentina began in 1827 at the University of Buenos Aires School of Medicine (university names will be given in English throughout this chapter) with a doctoral thesis about epilepsy (Epilepsia: su naturaleza y curación) submitted by Martı´n Garcı´a (Bardeci, 1948). The foundation stage started in 1885, with the creation of the Hospital San Roque de Buenos Aires’ first nervous diseases ward. Its first chair, Jose´ Marı´a Ramos Mejı´a, had a solid humanistic education; he was a writer, a sociologist, a person of science, and an outstanding public man. His thesis was Apuntes clínicos sobre el traumatismo cerebral (Clinical Notes on Traumatic Brain Injury), including two reports on cranial trepanations. In 1887, only 5 years after Charcot was awarded the chair of neurology in Paris, Ramos Mejı´a became the first professor of neurology in South America, this being at the University of Buenos Aires. In his double capacity as chair and professor, he was a pioneer of neurology in Argentina (Somoza and Gualtieri, 1998). Ramos Mejı´a was the most important positivist in Argentina. His classical articles, more sociological and psychiatric than neurological, were La neurosis en los hombres públicos de la historia argentina

Correspondence to: Ricardo F. Allegri, MD, PhD, Servicios de Neurologı´a & Neuropsicologı´a (SIREN), CEMIC (Centro de Estudios Me´dicos e Investigaciones Clı´nicas), Galva´n 4102 (1431FWO), Buenos Aires, Argentina. E-mail: [email protected], Tel: +54-11-4546-8227, Fax: +54-11-4546-8293.

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(Neurosis in Public Men in the History of Argentina), Las multitudes argentinas (The Argentinian Masses) and Estudios clínicos sobre las enfermedades nerviosas y mentales (Clinical Studies on Mental and Nervous Diseases). In 1888, Federico Papi, an Italian neurologist and neuropathologist, took over the Department of Neurology at the University of Co´rdoba School of Medicine, which he headed until 1890, when he returned to Italy (Brunetti and Palacio, 1998). Three assistants collaborated with Ramos Mejı´a at the University of Buenos Aires and were essential for the development of neurology in Argentina. Christofredo Jakob specialized in neuropathology. He trained in Germany with Strumpell and published an atlas of the nervous system with him. Jakob is considered the founder of neuropathology in Argentina and was important in the systematization of brain slicing and for efforts to study the myelin sheath (Hano´n, 1956). Jose´ A. Este´vez, in contrast, favored a clinical approach. He was hired in 1913 and became known for his bedside clinical acumen. He published articles about facial progressive hemiatrophy, epidemic meningitis, Sydenham’s chorea, and hydatid cysts. Hydatid disease, endemic in South America, is a parasitic infestation caused by Echinococcus. Symptoms depend upon where hydatid cysts form in the brain. Seizures and headaches are common symptoms. The third important assistant was Jose´ Ingenieros, who made sociological contributions. In 1924, Mariano Alurralde succeeded Este´vez, and he gave his lectures an anatomo-pathologic orientation (Somoza and Gualtieri, 1998). Alurralde wrote articles about neurosyphilis. In Este´vez, Jakob and Alurralde’s times, the focus was on anatomy and histopathology; unsubstantiated opinions not backed by hard data were no longer as important as they had been in Ramos Mejı´a’s era (Somoza and Gualtieri, 1998). In 1941, Vicente Dimitri was designated professor of neurology at the University of Buenos Aires. Dimitri was the first physician with neuropathological and neurological training, which he acquired with Jakob and by visiting European hospitals. With Dimitri, neurology par excellence began (Figini, 1964). He greatly influenced those who surrounded him, including Jose´ Pereyra Ka¨fer, who became chairman of the Hospital Ramos Mejı´a Neurology Service (formerly Hospital San Roque) and then took over as professor of neurology at the University of Buenos Aires. In 1952, he founded the Sociedad Neurolo´gica de Buenos Aires, which later became the Sociedad Neurolo´gica Argentina (SNA), a part of the World Federation of Neurology (WFN). During the 1970s, the stage of neurological sub-specialties began, reflecting a greater North American influence (Somoza and Gualtieri, 1998). The new era

at the University of Buenos Aires Department of Neurology began with Roberto E.P. Sica, neurologist and neurophysiologist, whose most important articles were on motor neuron disease and on Chagas’ disease (also called American trypanosomiasis). The latter is a mammalian disease occurring only in the Americas. It is caused by the protozoan Trypanosoma cruzi, transmitted to humans in most cases by insects of the Triatominae subfamily, known in Argentina as “vinchuca.” Sica became chairman of the Hospital Ramos Mejı´a Neurology Service, the most recognized department of neurology in Argentina. FLENI (Fundacio´n para la Lucha contra las Enfermedades Neurolo´gicas de la Infancia) Neurological Institute in Buenos Aires dates back to 1959, when the creator Rau´l Carrea (a neurosurgeon) returned after several years in the US. The Centre for Neurological Research was the first scientific research laboratory to open in 1968 in the “Ricardo Gutierrez” children’s hospital, but it was closed in 1976. In 1978, Carrea opened the first Computed Tomography Center in Latin America at FLENI. At that point, he invited Ramo´n Leiguarda (a neurologist trained in London) to join him. In 1978 Carrea passed away unexpectedly and Leiguarda followed his work in maintaining and developing FLENI. Nowadays it is the most important non-profit neurological organization in Latin America, delivering preventive medicine, diagnostics, health care services, and research on neurological disease (www. fleni.org.ar). The first journal in Argentina was the Revista Neurológica de Buenos Aires created by Dimitri in 1936 (Fig. 49.1). In 1972, Pereyra Ka¨fer renamed it the Revista Neurológica Argentina with He´ctor Figini as its first editor. This journal is still published. Among the reviews and case studies in the early period of the journal, we find (in Spanish) Jakob’s “Contribution to pituitary neoplasm histogenesis” (Jakob, 1936), Dimitri’s “Retinal telangiectasis, angioma of the protuberance and cerebellum glioma” (Dimitri et al., 1936), and notices and summaries of international congresses and lectures. These notices and summaries were very important, since few physicians had a good command of non-Spanish languages and even fewer had access to international journals.

Brazil The history of neurology in Brazil centered on developments in Rio de Janeiro and Sa˜o Paulo, and each will be treated in turn. Neurology in Rio de Janeiro has been considered the foundation of Brazilian neurology. In 1878, Joa˜o Vicente de Torres Homem wrote the first Brazilian book exclusively devoted to neurology, Lições Sobre as

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Fig. 49.1. The first journal in South America was the Revista Neurológica de Buenos Aires created by Dimitri in 1936 (Volume 1, issue 3, 1936).

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Fig. 49.2. The Austrege´silo and Esposel sign. It is obtained by stimulating the thigh and, like Babinski’s sign, it is manifested by the upturning of the big toe and also by fanning of the other toes. It is a sign of a pyramidal tract disorder (from Austrege´silo and Esposel, 1912).

Molestias do Sistema Nervoso (Lessons about Nervous System Diseases) (Gomes, 1999a). The University of Rio de Janeiro School of Medicine created the first Brazilian department of neurology in 1912. Its first full professor was Anto˜nio Austrege´silo Rodrı´gues Lima, a politician, a writer, and a skilled physician, now considered Pai da Neurología Brasileira (the father of Brazilian neurology). He was the first to study movement disorders in Brazil, publishing several works on this subject, primarily in Revue Neurologique and L’Encéphale, including an alternate to the Babinski sign (Fig. 49.2), and the first description of a post-traumatic dystonia (Teive et al., 1999). In 1944, Deolindo Augusto de Nunes Couto took over as chairman and consolidated Brazilian neurology. In 1946 he founded the Instituto de Neurologı´a da Universidade Federal do Rio de Janeiro, with extensive research activity in neurology, neurophysiology, and neurosurgery. This institute, later renamed Instituto de Neurologı´a Deolindo Couto da Universidade Federal do Rio de Janeiro, became the international face of Brazilian neurology. His first assistants were Antoˆnio Rodrı´gues de Mello, Ismar Fernandes, and A´lvaro Jose´ de Lima Costa, who published a book on neuroparasitosis in 1967. Neuropathology was further developed by Paulo Elejalde, followed by Alexandre

Alencar, both known for Chagas’ disease research. Bernardo Henrique de Nunes Couto headed the Institute and was followed by Clo´vis Oliveira, He´lcio Alvarenga, and Gianni Temponi (Gomes, 1999a). In 1925, Enjolras Vampre´ was appointed by the School of Medicine of the University of Sa˜o Paulo to take over the Department of Psychiatry and Neurology. Vampre´, through his training at the Salpeˆtrie`re, introduced the fundamentals of French neurology to Sa˜o Paulo and is considered the founder of the Sa˜o Paulo School of Neurology (Reima˜o and Alonso Nieto, 1996; Morato-Leite, 1999). In 1935, the Department was divided into Psychiatry and Neurology. Successive generations of neurologists and neurosurgeons at the Sa˜o Paulo school were associated with Vampre´. They include Adherbal Tolosa, Paulino Watt Longo, Oswaldo Lange, and Carlos Gama (MoratoLeite, 1999). Following a competitive examination, Tolosa was appointed chair of neurology at the University of Sa˜o Paulo. He wrote several semiotic articles (including studies on the cremasteric reflex) that were published in local journals. Longo became the chair of the Paulista School of Medicine, and Lange remained clinical chief of the University of Sa˜o Paulo School of Medicine until 1969. Lange was known outside Brazil for his activity as director of the Arquivos

CLINICAL NEUROLOGY IN LATIN AMERICA 805 Jacinto de Leo´n aspired to be appointed to the Neurology Department of the University of Montevideo, although this never happened (Wilson, 1991, 1992). Jose´ Verocay, another important physician at this time, provided a good neuropathological description of neurofibromatosis or von Reckinghausen’s disease, now also known as Verocay neurinoma (Verocay, 1910). In 1925, the creation of the Department of Neurological Diseases was approved in the School of Medicine of Montevideo, with Ame´rico Ricaldoni as its chairman. Ricaldoni’s acceptance was conditional on financial assistance and the creation of a teaching and research facility. Subsequently, the government created the Instituto de Neurologı´a de Montevideo (in 1927; Fig. 49.3), and Ricaldoni was designated Director of the Institute and Professor of Neurological Disease. This was the first neurological institute in Latin America – preceding the Montreal Neurological Institute by several years. Ricaldoni published articles in journals from Uruguay and Argentina, wrote about Landry’s palsy in Archives Générales de Médicine de Paris, and bilateral cranial nerve VI and VII palsies in the Revue Neurologique. He died in 1928. The creation and abrupt growth of his institute, however, did not mean the birth of neurology as a specialty in Uruguay; the practice of neurology, other than for Jacinto de Leo´n, continued within internal medicine. At the beginning of 1937, Alejandro Schroeder, a neurologist and neurosurgeon, was appointed university professor and institute director. In 1925, he traveled to Germany to work with Jakob and Nonne in Hamburg, and Fo¨rster in Breslau. He then wrote the first book of neurology in Uruguay. Since Schroeder took over, the Institute – renamed Instituto de NeuroUruguay logı´a Prof. Dr. Ame´rico Ricaldoni – has been ranked Neurology in Uruguay started with Francisco Soca, very highly in South America. who graduated in Paris at the end of 1888 with his docThe Institute’s third director, Roma´n Arana In˜iguez, toral thesis Étude clinique sur la maladie de Friedtook over in 1957 and was moved to the second floor of reich (Clinical Study of Friedreich’s Disease) the Hospital de Clı´nicas (Wilson, 1991, 1992). Arana supported by Charcot himself (Soca, 1888). This thesis started his neurosurgical training at the Institute and was important for extending fundamental knowledge then went to the United States. After 1957, different about this disease, and Pierre Marie referred to the role scientific interest sections were created in the Institute. of age in this disorder as “Soca’s law.” After his return Scientific contributions increased in number and quality to Montevideo, Soca gradually left neurology to in the different sections of the Institute. devote himself to internal medicine. From 1945, the Neuropathology Laboratory was Jacinto de Leo´n, who treated patients with neurolodirected by Juan Medoc, who was known for his work gical diseases, is often considered the first neurologist on brain tumors (craniopharingiomas). The Neuropsyin Uruguay. In 1894, he started to teach neurology in chology Laboratory started in 1958 with Carlos internal medicine at the School of Medicine of MonteviMendilaharsu and Selika Acevedo de Mendilaharsu, deo. His works usually consisted of case reports or clinwho had worked in France with He´caen and Ajuriaical reviews, but without new concepts. “Contribution a guerra. These individuals published several papers l’e´tude de la paralyse myastenique,” the most widely and five textbooks (Estudios Neuropsicológicos), and are regarded as “the parents of the Latin known of his reports, was published in the Nouvelle IcoAmerican Neuropsychology.” nographie de la Salpêtrière.

de Neuropsiquiatria journal, and for his research on cerebrospinal fluid and infectious diseases, including syphilis and cysticercosis. Antoˆnio Branco Lefe`vre, Hora´cio Martins Canelas, Antoˆnio Spina Franc¸a Netto, and Gilberto Scaff continued this school (Reima˜o and Alonso Nieto, 1996; Morato-Leite, 1999). Antoˆnio Branco Lefe`vre was recognized as the father of child neurology and neuropsychology for his research and articles (Lefe`vre, 1999). Martins Canelas, who did research on Wilson’s disease, wrote articles in Brazilian journals and in international journals, such as Journal of Neurology, Neurosurgery and Psychiatry and Acta Neurologica Scandinavica. The Academia Brasileira de Neurologia was created in 1962, and Deolindo Couto was its first president. The first neurological journal published in Brazil was Neurobiologia, created in 1938 by Ulysses Pernambucano in northern Brazil (Recife). The first articles included not only theory; they incorporated clinical research in psychology, neurology, and psychiatry (Codeceira, 1999). In 1943, Tolosa, Longo, and Lange created – under Oswaldo Lange’s direction – the Arquivos de Neuropsiquiatria in Sa˜o Paulo. This is the most important journal of neurosciences in Latin America and it is found in Index Medicus, WHO, Bireme, Lilacs, and Latindex (Spina Franc¸a, 1999). In 1949, in Rio de Janeiro, Deolindo Couto created the third neurological journal to come out of Brazil, Jornal Brasileiro de Neurologia, renamed Revista Brasileira de Neurologia in 1983 (Gomes, 1999b).

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Fig. 49.3. Members of the Instituto de Neurologı´a de Montevideo in 1927 (Wilson, 1991, with permission).

Arana retired in 1974, the year he decided to separate neurology from neurosurgery. He´ctor Deffe´minis was appointed professor of neurology. After his retirement, he was succeeded by Marı´a A. Rebollo and, in 1987, by Carlos Chouza (Wilson, 1991, 1992). The Sociedad de Neurologı´a y Neurocirugia de Montevideo was set up in 1939 with Schroeder as its first president. In 1951, the Acta Neurológica Latinamericana was created. The objective was to have a common Latin American neurological journal, preserving the language and making it easier for Spanish-speaking neurologists to publish their work (Wilson, 1991).

Peru Neurology in Peru took its first steps with Carlos Krumdieck, who in 1928 spent a year at the Salpeˆtrie`re. When he returned from Paris, he taught neurology until 1930, but increasingly devoted himself to pediatrics. Juan B. Lastres, who was chief of clinical neurology between 1931 and 1934, later became professor of the history of medicine. The first true neurologist was Oscar Trelles Montes, considered the “father of neurology of Peru.” He worked in Paris from 1930 to 1935, where he acquired neurological training under Jean Lhermitte. He published 35 scientific

papers in collaboration with Lhermitte. He also published a notable book, Précis d’Anatomophysiologie Normale et Pathologique du Système Nerveux, with Franc¸ois Masquin (Cubas, 2002; Escalante Sa´nchez, 2004). In 1935, he returned to Peru and in a few years he joined the elite of doctors in Latin America. In 1940, he was recognized as professor of neuropathology at the Universidad Nacional Mayor de San Marcos School of Medicine (Escalante Sa´nchez, 2004). By this time, he was attending the Refugio de Incurables, a ward under the administration of the Beneficencia Pública of Lima (Escalante Sa´nchez, 2004). The “Refugio” was renamed Hospital Santo Toribio de Mogrovejo thanks to his efforts (Escalante Gavancho, 2004). During the 30-year leadership of Trelles, almost all neurologists in Peru had this hospital as their alma mater. In 1941, Trelles co-authored (with Lazartes) a book titled Cisticercosis Cerebral. Brain cysticercosis is an endemic infection in Latin America caused by the pork tapeworm, Taenia solium (Escalante Gavancho, 2004). Infection occurs when the tapeworm larvae enter the body and form cyst cerci. Neurological symptoms of cysticercosis depend upon where and how many cyst cerci are found in the brain. In 1963, the Hospital Santo Toribio was recognized as Hospital Neurolo´gico and in 1981 it became the

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Instituto de Ciencias Neurolo´gicas (Institute of Neurological Sciences) of Peru, headed by Silvio Escalante Sa´nchez, Ernesto Rı´os Montenegro, and then Luis Trelles Montero (son of Oscar Trelles Montes) (Cubas, 2002). The Sociedad de Neuropsiquiatrı´a y Medicina Legal of Peru was created in 1938 by Honorio Delgado, a prominent psychiatrist, and Oscar Trelles Montes. In 1945, it was renamed the Sociedad Peruana de Psiquiatrı´a, Neurologı´a y Neurocirugı´a. As time went by, the Sociedad Peruana de Neurocirugı´a and the Sociedad Peruana de Psiquiatrı´a were divided, so the Sociedad Peruana de Psiquiatrı´a, Neurologı´a y Neurocirugı´a consisted largely of neurologists. In 1990, it became the Sociedad Peruana de Neurologı´a. In 1937 Honorio Delgado and Oscar Trelles cofounded the Revista de Neuropsiquiatría, which continues to publish quality scientific articles. The Revista Peruana de Neurología was created in 1995 under Jose´ del Carmen’s direction, and it is the official journal of the Sociedad Peruana de Neurología.

Chile Neurology in Chile goes back to 1869, with Jose´ Ramo´n Elguero del Campo, the first professor of mental diseases of the University of Chile. Three years later, however, he devoted himself to medical pathology (Escobar, 2000). The chair remained unoccupied until 1882, when Carlos Sazie´ Heredia took over. Sazie´’s neurological training started when he won a government scholarship to specialize with Magnan, Voisin and Charcot in France (from 1874 to 1879). Fe´lix Vulpian sponsored his doctoral thesis on intellectual problems of aphasics. Sazie´ taught neuropsychiatry at the Hospital San Juan de Dios and then at the Hospital San Vicente de Paul until he was dismissed in 1891, following political problems (Escobar, 2001). In 1892, his disciple Augusto Orrego Luco (Fig. 49.4) took over as professor of nervous diseases at the University of Chile. Orrego Luco graduated in 1873 with a thesis on Alucinaciones mentales (Mental Hallucinations). Trained in France by Charcot, he published in the Iconographie de la Salpêtrière. In 1902 he wrote the book (translated as) Hysterical Hemiplegia and Organic Hemiplegia, in which differences between hysterical and organic symptoms were discussed. He was the most prominent figure in Chilean neurology during the second half of the 19th century, and was nicknamed the “Charcot of America” (Escobar, 2002a). In 1907, Orrego Luco retired and his chair was taken over by his disciple, Joaquı´n Luco Arriagada. The school decided to divide the department, and psychia-

Fig. 49.4. Augusto Orrego Luco, “the Charcot of America” (1902).

try and neurology were coordinated by his assistants, Oscar Fontecilla and Hugo Lea Plaza, respectively. Luco Arriagada was also trained in Europe, in his case by Babinski, showing once again the influence from the French school. In 1925, he created the Hospital del Salvador Neurology Service. He began to serve as clinical chief at the Manicomio Nacional (Neuropsychiatric Hospital) in 1931. When Luco Arriagada retired, Lea Plaza was made chair of neurology at the University of Chile and Jorge Oyarzun became chief of neurology at the Hospital del Salvador (Escobar, 2002b). In 1929, the Hospital San Vicente de Paul’s Neurology Service was created in Santiago, and Oscar Fontecilla took over as chairman. Lea Plaza was succeeded by Guillermo Brinck, Emilio Morales (a neurosurgeon) and then Archibaldo Donoso. At the Hospital del Salvador, he was followed by Jorge Gonza´lez Cruchaga. Later on, the teaching and clinical care sections separated. Alfonso Asenjo Go´mez, trained in the United States by Walter Dandy and in Germany by Toennis, stimulated the creation of the Chilean Service of Neurosurgery. Asenjo worked with He´ctor Valladares, Carlos Villavicencio, Mario Contreras and A. Lepe. In 1953, the Instituto de

808 R.F. ALLEGRI Neurocirugı´a e Investigaciones Cerebrales (Institute of of the new University of Venezuela’s Neurology Neurosurgery and Brain Research) of Chile opened, and Department. The Hospital Clı´nico de la Ciudad it was directed by Asenjo for 34 years. The Institute is Universitaria de Caracas Department of Neurology currently named after Asenjo, is known internationally, and Neurosurgery was also founded that year, with and is sponsored by the University of Chile. Juan Fierro, the collaboration of Enrique Garcia Maldonado Reynaldo Pobrete, Pablo Donoso and Jaime Lavados were (trained at the National Hospital, Queen Square in its directors after Asenjo (Uribe Barreto, 2003). London) and Julio Borges Iturriza (trained at the Neurological teaching at the Catholic University University of Michigan hospitals). School of Medicine started in 1946 at the Instituto de The Cuban neurosurgeon Leo´n Mir, who in 1945 Neurocirugı´a Alfonso Asenjo under Enrique Uiberall, founded the Hospital Vargas Neurosurgery Service, an Austrian neurologist who moved to Chile because was another important figure in Venezuelan neurology. of World War II. The Hospital Clı´nico of the Catholic Hugo Izaba Stevenson (trained in neurology at the University had no staff neurologists until 1961, when National Hospital, Queen Square in London), Pedro Luis Oscar Marin – trained under Derek Denny Brown – Ponce Ducharne (electroencephalography, Hospital joined it. Marin performed teaching and clinical activReina Mercedes, Havana, Cuba), and Frank Risquez ities at the Hospital Clı´nico, and founded the Hospital Cotton (clinical neurology, Salpeˆtrie`re, Paris, France) Barros Luco-Trudeau Neurology Service. In 1964, he were his collaborators. In 1952, Celina Leo´n de Ponce decided to continue his academic activities in the and Jaime Boet joined them (Ponce Ducharne, 2004a). recently created Universidad Austral School of MediGustavo Leal Aldazoro, a pediatrician, traveled to cine in Valdivia. North Carolina in 1950 to attend courses at the Child Between 1964 and 1970, Camilo Arriagada, chairBehavior Clinic in Durham, and then to Boston to man of the Neurology Service at the Hospital Barros broaden his epilepsy and electroencephalography Luco, was in charge of neurology teaching. In 1971, (EEG) training under William Lennox’s guidance. He the Catholic University decided to move the teaching returned to Venezuela in 1953 and settled in the Disactivity to Hospital Dr. Sotero del Rı´o, under Jaime pensario Central de Higiene Mental. He also devoted Court. In 1974, as part of an academic reorganization himself to teaching in the Hospital Universitario de of the School of Medicine, the Department of NeuroloCaracas (HUC) Neurology Service. In 1963, Alberto gical and Neurosurgical Disease was created. It was Abadi (trained in Boston) joined the HUC Department staffed by neurologists from the Hospital Dr. Sotero of Pediatrics (Dı´az Carvajal, 2004) and, in 1959, Izaba del Rı´o and neurosurgeons from the Hospital Clı´nico. and Risquez moved to the Hospital Clı´nico de la In 1971, the Hospital Trudeau Neurology Service Ciudad Universitaria de Caracas. Pedro Luis Ponce became one of the three University of Chile neurology Ducharne continued at the Hospital Vargas, and in units (the others being at the Hospital Clı´nico and at 1959 founded the Neurology Service (Ponce Ducharne, the Hospital del Salvador). Arriagada remained chief 2004a, b). until 1994, training over a hundred specialists. In The study of a Venezuelan family from the Lake 1995, when Jorge Nogales-Gaete became chairman Maracaibo region led to the discovery of a polyand full professor, he wrote the first Chilean textbook morphic DNA marker genetically linked to Huntingof neurology. ton’s disease. This important discovery represented an The Sociedad de Neurologı´a, Psiquiatrı´a y Neurocirinternational collaboration between multiple groups ugı´a de Chile was founded in 1932 and the Revista of clinical and basic scientists (Gusella et al., 1983). Chilena de Neuropsiquiatría has been in circulation In 1942 the Sociedad Venezolana de Psiquiatrı´a was since 1947. created and it grouped all nervous system-related disciplines. It was chaired by Pedro B. Castro and Pedro Luis Ponce Ducharne. A group of neurologists Venezuela met in early 1969 to create another society, the SocieThe history of neurology in Venezuela started with dad Venezolana de Neurologı´a. This organization was Pedro B. Castro’s return from Paris in 1936, where he presided over by, among others, Pedro B. Castro, had trained with Guillain at the Salpeˆtrie`re. In 1938, CasPedro Luis Ponce Ducharne, and Celina de Ponce tro took over as a neurology consultant at the Hospital (Ponce Ducharne, 2004b). Vargas, where he stayed until 1959. In 1940, the Central The Archivos Venezolanos de Otorrinolaringología, University of Venezuela’s Department of Neurology Oftalmología y Neurología was circulated in the 1930s and Psychiatry was created with Castro as chairman. and 1940s. In 1953, the Archivos Venezolanos de PsiIn 1959 neurology and psychiatry became indepenquiatría y Neurología became the official organ of dent, and Castro became the first chairman and founder the two societies. When they separated, the Boletín

CLINICAL NEUROLOGY IN LATIN AMERICA Informativo de la Sociedad Venezolana de Neurología appeared. It was published between 1976 and 1983, and was followed (in 1987) by the Revista Venezolana de Neurología y Neurocirugía, which was published until December 1991 (Ponce Ducharne, 2004b).

Colombia Miguel Jime´nez Lo´pez, who specialized in psychiatry and internal medicine in France, was the first to lead the National University’s Department of Mental and Nervous Diseases (Rosselli and Otero, 2000). By this time, Luis Lo´pez de Mesa, who would become Professor, had trained in neurology, psychopathology and neuropsychology at Harvard (Rosselli, 1985). In the first half of the 20th century, several professors of the National University were showing an interest in neurological diseases, among them Pablo A. Llina´s, Alfonso Uribe Uribe, and Edmundo Rico Tejada (Rosselli and Otero, 2000). The true foundation stage of neurology started with Andre´s Rosselli Quijano (Fig. 49.5), who in 1954 traveled to the Massachusetts General Hospital to study neurology. In 1956, he collaborated in the foundation of a neurology unit annexed to the Neurosurgery Department at Hospital Militar Central de Bogota´ (Rosselli, 1985; Rosselli and Otero, 2000). In 1961, Ignacio Vergara founded the Hospital San Juan de Dios Neurology Service and Jaime Potes founded the Hospital Universitario Del Valle Neurology Service. The first Hospital San Vicente de Paul Department of Neurosurgery and Neurology was created by the neurosurgeon Ernesto Bustamante. Jorge Holguı´n, who trained in France, created the first neuropediatrics service in Medellı´n in 1965 (Rosselli and Otero, 2000). The Sociedad Neurolo´gica de Colombia, which included both neurosurgeons and neurologists, was created in 1963. Neurologists decided to become independent in 1982, creating the Asociacio´n Colombiana de Neurologı´a. In 1985 the journal Acta Colombiana de Neurología was founded (Rosselli and Otero, 2000).

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Bolivia Neurology in Bolivia had largely been the domain of neurosurgeons, and it was not until the second half of the 20th century that neurologists took a more active role. In 1966, the Sociedad de Psiquiatrı´a, Neurologı´a y Neurocirugı´a de Bolivia was at its height, with formal and regular meetings. There were three groups that catalyzed these institution activities, and they were led by Jose´ Marı´a Alvarado, from psychiatry, and Mario Michel Zamora and Hugo Rodrı´guez Serrano, two neurosurgeons who covered neurology and neurosurgery. The only two neurologists then in the city of La Paz had neither independent services nor society affiliations (Trigosso, 2003). In 1975, the Sociedad Boliviana de Neurologı´a was created. The board of directors was constituted by Mario Barraga´n and Adria´n Trigo (Trigosso, 2003). Inactivity led to the creation of a new leadership with Harry Trigosso as president, Luis Fernando Zegada as vice-president, and Humberto Molina as general secretary (Trigosso, 2003). After the Hospital de Clı´nicas and Hospital Obrero neurology and neurophysiology services were created, more neurologists began to be trained in Bolivia (Zegada, 2003). The Sociedad Boliviana de Neurologı´a was itself created in 1975.

Ecuador In 1960 the Sociedad Ecuatoriana de Neurologı´a, Neurocirugı´a y Ciencias Afines was created in Ecuador. Its founding president was Alfonso Martı´nez Arago´n. Until 1967, neurology in Ecuador was practiced within internal medicine and neurosurgery. Rafael Vargas Ortiz, the first neurologist, returned to the country that year, after being trained at the Centro Me´dico Nacional de Me´xico. In 1974 Toma´s Alarco´n, who founded the Hospital Regional de Guayaquil’s Neurology Service, returned from Mexico, and in 1975 Marcelo Cruz, who developed the Hospital Carlos Andrada Marı´n’s Neurology Service, returned from the USA. In 1982 the Sociedad Ecuatoriana de Neurologı´a became a WFN member (Leo´n de Ponce, 1988).

CENTRAL AMERICA Panama

Fig. 49.5. Andre´s Rosselli Quijano, the founder of neurology in Colombia.

The first neurosurgery and neurology service was founded in Panama at the Hospital Santo Tomas de la Ciudad de Panama´ in 1947. Neurosurgeon Antonio Gonza´lez Revilla was first chairman. In 1968, the Sociedad Panamen˜a de Neurocirugı´a y Neurologı´a was created and Gonza´lez Revilla was its first president (Leo´n de Ponce, 1988). From 1990, studies

810 R.F. ALLEGRI revealed that Guaymi Indians residing in Bocas del In 1960, the first Neurology Service was created at Toro (Panama´) had HTLV-II (retrovirus) infections the Hospital de La Raza of the Instituto Mexicano de without typical risk factors, suggesting that it is an Seguro Social (IMSS). It was headed by J. Herna´ndez endemic disease in Panama (Lairmore et al., 1990). Peniche. One year later, clinical neurology groups were established at the Hospital General de la Ciudad de Me´xico by Luis Saez Arroyo, and later, in 1962, at Guatemala the Hospital General del Centro Me´dico Nacional del The history of neurology in Guatemala began with IMSS by Luis Lombardo. Miguel Molina, who did his postgraduate studies at At the beginning of the 1960s, the creation of the the Salpeˆtrie`re with Pierre Marie and returned in 1922 Direction of Neurology, Mental Health and Rehabilitaas chairman of neuroanatomy and neurophysiology. tion was approved by the Secretary of Health, with In 1953, Ricardo Ponce Ramı´rez took over the chair Manuel Velasco Sua´rez (a neurosurgeon) as its direcof neurology at the University of San Carlos. Six years tor. Later, he became chairman of the newly created later, Roberto Rendon, trained in Michigan, founded Service of Neurology and Neurosurgery at the Hospital the Instituto Neurolo´gico de Guatemala; Roberto Jua´rez. The first attending physicians were Francisco Ibarra followed in 1962 and Luis Salguero in 1969. Escobedo, Sergio Go´mez Llata, Enrique Ibarra, and In 1970, the Asociacio´n Guatemalteca de Neurologı´a Jesu´s Sa´nchez Burciaga. was founded. In 1987, the Asociacio´n Guatemalteca de In 1964, the Instituto Nacional de Neurologı´a y NeuCiencias Neurolo´gicas became a WFN member (Leo´n rocirugı´a de Mejico (INNN) was inaugurated (Fig. 49.6), de Ponce, 1988). and Velasco Sua´rez appointed its first director. The INNN was initially conceived as an institution where El Salvador the three main divisions of clinical neurosciences would coexist with equal academic pre-eminence: neurology, In El Salvador, Mario Romero Alvergue was the first neurosurgery, and psychiatry. neurologist, having returned in 1952 after studying in The true neurological consolidation stage started in Vienna. In 1956, he founded the National University 1967, when Francisco Rubio Donadieu, a neurologist of Salvador School of Medicine’s Department of Neutrained at the National Hospital, Queen Square in rology. He died in 1998. The first department of neuLondon, arrived. Velasco Sua´rez would be succeeded rology was founded in 1963 at the Hospital General by Francisco Escobedo (a neurosurgeon). In 1983, Rubio del Seguro Social by the neurosurgeon Julio Bottari. Donadieu was appointed Institute Director and Enrique Otero, Gustavo Vega, Fernando Barinagarrementerı´a, Honduras Carlos Ma´rquez, Sergio Co´rdoba, Vicente Guerrero, Francisco Leo´n Go´mez was the first neurologist in Luis Da´vila, Carlos Cantu´, and Teresa Corona were his Honduras, having done his postgraduate studies in collaborators. the United States. He served as director of the NeuroThe Consejo Mexicano de Neurologı´a was created psychiatric Hospital Mario Mendoza in Tegucigalpa. in 1972, and Rubio Donadieu was its first president. The first service of neurology was founded in 1978 in Rubio Donadieu would be succeeded by Jesus Rodrithe Hospital Escuela from Tegucigalpa. In 1995 the guez Carbajal and Julio Sotelo. In the academic field, Asociacio´n Honduren˜a de Neurologı´a was created the INNN is the largest training center for specialists and it became a WFN member. In 1998, Marcos Tulio in Latin America. In its 40 years, it has graduated Medina developed a neurology training program at almost 1000 specialists in the neurological sciences the Universidad Auto´noma de Honduras. and more than 250 MSc and PhD researchers. The major research contributions from Mexico CARIBBEAN AND LATIN have thus far been those related to regional endemic NORTH AMERICA diseases like cysticercosis. The discovery of the gene for myoclonic epilepsy represented an international Mexico collaboration between Mexico, Japan and the USA In 1880, Miguel Alvarado taught neurology at the School (Elisa Alonso, Adriana Ochoa, Aurelio Jara, Astrid of Medicine of Mexico City. In 1929, when the UniverRasmussen, Jaime Ramos Peek, Sergio Co´rdova, sidad Auto´noma was consolidated, Manuel Guevara Francisco Rubio, Marco Tulio Medina) (Escobedo Oropeza became one of its first professors of neuroland Corona, 2004; Instituto Nacional de Neurologı´a ogy. In the first half of the 20th century, several profesy Neurocirugı´a, 2006). sors showed interest in neurological diseases, but all In 1937, the Sociedad Mexicana de Neurologı´a y were primarily associated with internal medicine. Psiquiatrı´a was founded. In 1976, clinical neurologists

CLINICAL NEUROLOGY IN LATIN AMERICA

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Fig. 49.6. Photograph of the Instituto Nacional de Neurologı´a y Neurocirugı´a (Mexico, 2006, with permission).

broke away to start a separate organization, the Academia Mexicana de Neurologı´a (http://www.neurologia. com.mx). The first journal published at the INNN was the Revista del Instituto Nacional de Neurología y Neurocirugía, created in 1966, with Gu¨ido Belsasso and Francisco Escobedo as its first editors. In 1980, it was renamed Archivos del Instituto Nacional de Neurología y Neurocirugía and, in 1996, it was further renamed Archivos de Neurociencias (Escobedo and Corona, 2004). The Revista Mexicana de Neurociencias was created in 2000 under Lilia Nun˜ez Orosco’s direction and is the official journal of the Academia Mexicana de Neurologı´a (2006).

Puerto Rico The formal history of neurology started in Puerto Rico in 1958, when Luis Sanchez Longo was hired by the School of Medicine of Puerto Rico to start training in clinical neurology. Rosa Fiol, Iva´n Pe´rez Nazario, and Judith Roman were among his collaborators. In 1968 the Academia Portorriquen˜a de Neurologı´a was founded (Leo´n de Ponce, 1988).

Dominican Republic The Instituto Dominicano de Seguros Sociales Neurology Service was taken over by Mario Tolentino upon

his return from France in 1957. In 1965, the Hospital Moscoso Puello Neurology Service started under Juan Santoni. A year later, the Sociedad Dominicana de Psiquiatrı´a, Neurologı´a y Neurocirugı´a was created. In 1982 Psychiatry became independent, resulting in the Sociedad Dominicana de Neurologı´a y Neurocirugı´a (Leo´n de Ponce, 1988).

Cuba Neurology started in 1925 in Cuba, with the creation of the University of Havana Department of Neurology and Psychiatry and the birth of the Sociedad Cubana de Neurologı´a. But despite advances in neurology and neurosurgery, these disciplines were not officially recognized as specialties for many years. In 1960, when the University of Havana School of Medicine’s Department of Functional Neuroanatomy was created, there were only three neurologists practicing the specialty. With the aim of regrouping existing resources, the Department of Public Health created the Hospital de Neurologı´a, which opened in 1962. This institution provided nationwide neurological care and allowed Cuba to start a postgraduate teaching program. Five years later, it was renamed Instituto de Investigacio´n de Neurologı´a (Severa Ortega and Lo´pez Espinosa, 1997).

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PAN AMERICAN CONGRESSES The idea of organizing a Pan American congress that would meet every 4 years was initially conceived within the framework of the World Federation of Neurology. The first Pan American Congress of Neurology was held in October 1963, in Lima, chaired by J. Oscar Trelles Montes (Fig. 49.7), who was then the Prime Minister of Peru. Official languages were Spanish and English. A.E. Walker, P. Bailey, R. Garcin, and F. Lhermitte were given the decoration Comendador El Sol del Peru by the President of the Republic, Belaonde Terry. The Second Pan American Congress was held in October 1967 in San Juan de Puerto Rico under the direction of Luis P. Sanchez Longo (Culebras, 1998). Subsequent congresses have since been held in Sa˜o Paulo (1971), Mexico City (1975), Caracas (1979), Buenos Aires (1983), San Juan, Puerto Rico (1987), Montevideo (1991), Guatemala City (1995), Cartagena, Colombia (1999), and Santiago, Chile (2003).

CONCLUSION The consistent and long-standing admiration for European training led to the birth of neurology as a discipline in some South American countries, namely Argentina, Chile, Uruguay, Brazil and Peru (Fraiman, 2000). This was followed by greater interest in North American training, which led to further developments in these countries and the start of the specialty in others. Among the most significant landmarks are: ●

The first neurology service in South America, which was created in 1885 at the Hospital San Roque de Buenos Aires and headed by Jose´ Marı´a

Ramos Mejı´a, who took over as professor of neurology at the University of Buenos Aires School of Medicine in 1887. ● The first institute of neurology in Latin America, the Instituto Neurolo´gico de Montevideo, created in 1926 under Ame´rico Ricaldoni’s direction. ● The creation of the most important Latin American journal, the Arquivos de Neuropsiquiatria from San Pablo, started in 1943 and it is still in existence. Unfortunately, the lack of access to scientific, Englishwritten and indexed publications has limited what has come out of Latin America, as have clinical demands and additional responsibilities of neurologists in official positions. Even today, articles written in Spanish are not considered by many international journals, most of which will only accept articles in English (Famulari, 2003). In a recent article published in Scientific American, which is appropriately titled “Lost Science in the Third World,” Gibbs (1995) wrote that investigators who want to become known outside of their own countries are strongly advised to publish in English, despite the fact that Spanish is spoken by more than 400 000 000 individuals worldwide (Famulari, 2003). The major research contributions from Latin America have thus far been those related to regional endemic diseases. From Brazil and Argentina, there have been important studies on Chagas’ disease; neurologists from Peru, Ecuador, Mexico and Colombia have researched cysticercosis; Venezuela stands out for genetic studies of Huntington’s disease; while retrovirus-induced neurological diseases have been studied in Panama. In the last 10 years, “globalization” has been positive for Latin American countries, as cooperative projects among them, as well as with first world countries, are now resulting in a more rapid development of Latin American neurology. This review was aimed at giving an overview of the initial stages of neurology in the Latin American world, highlighting the setting in which it was developed, who its pioneers were, how it was perceived locally and elsewhere, and developments in care, teaching, communications, and research. Given the space constraints, interested readers are encouraged to explore this subject further, possibly beginning with the references that follow.

ACKNOWLEDGMENTS Fig. 49.7. Oscar Trelles Montes, father of neurology in Peru and first Pan American Congress of Neurology chair.

This chapter was supported by a grant from the Research Council of the Secretary of Health of Buenos Aires Government, Argentina.

CLINICAL NEUROLOGY IN LATIN AMERICA The author wishes to specially thank Professors Franc¸ois Boller, Stanley Finger, Roberto E. Sica and Leopoldo Tamaroff for their helpful comments on this chapter and those who provided information on the history of neurology in their respective countries (Argentina: Leopoldo Tamaroff; Brazil: Rubens Reima˜o; Chile: Jorge Nogales Gaete; Colombia: Diego Roselli; Cuba: Calixto Machado; El Salvador: Carlos Diaz Manzano; Guatemala: Luis F. Salguero; Honduras: Marcos Tulio Medina; Mexico: Guillermo Albert; Peru: Carlos Escalante and Oscar Gonzales; Uruguay: Eduardo Wilson and Jorge Lorenzo; Venezuela: Celina Leo´n de Ponce).

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