Friday, June 26, 2009

In our journey into the History of Pediatric Cardiology, we have reached till the contributions of Greek. Lets move to the other parts of Europe now.

The Renaissance in the continent of Europe, more so in Italy in 15th and 16th centuries brought the birth of modern art and science. The architects of the period wanted to reconstruct the knowledge base by scrutinizing the ancient forms carefully. Hence, many ancient works, of those such as Hippocrates and Galen were translated and re-read. Galen's views were unquestionable till then. The Renaissance architects of science decided to study human anatomy by dissection (mostly in secrecy). It was well known that Galen's doctrines were based on animal studies, as human dissection was considered unthinkable in his times. This step helped to understand the real facts of human body better and widened horizons of anatomy to give rise to the concept of pathoanatomy.

The most quotable name of the era was a genius born in AD1452. This multifaceted person, who was probably much ahead of his times even by Renaissance standards, is considered as the one of the most famous artists the world has ever seen. In AD 1513, he described a case of atrial septal defect was sets of brilliant drawings, accurate to present day standards.
He also described the nature and possible functions of the heart. His name was Leonardo da Vinci. His notebooks were studied after his death in AD 1519. Not much was made out of his notebook data, as they seemed to be written in an unknown funny language. Much later, the “da Vinci code” was deciphered! The notebooks had the same language of the Renaissance era, but were, for some reasons, written backwards or in mirror image forms! So much was for the eccentricities of genius, that lesser men took the credit for what he had written centuries back. The recognition of Leonardo da Vinci’s contribution to human anatomy got delayed by few centuries, but nevertheless, credited. Even today, the credit for the accurate description of any congenital heart disease should go to Leonardo da Vinci.

(Ref: Thiene G. The discovery of cirulation and the origin of modern medicine during the Italian Renaissance.Cardiol Young 1996;6:109-119)

If somebody really dared at human dissection, it was Andreas Vesalius. Born in AD 1514, Andreas Vesalius was perplexed at the differences in Galenic hypotheses and real life situations. He decided to look at truth himself and did human body dissections in secrecy. Once he was convinced about the flaws of Galenic hypotheses, he challenged them in open and convinced others to look out for truth by human dissections. In AD 1543, a just 29-year-old Vesalius published the first complete textbook of human anatomy titled De Humani Corporis Fabrica, which liberated the world of age-old shackles of Galen. Vesalius was the first person to scientifically propose the role of heart as the center of the entire vascular network of body. But, he strongly believed that the pulmonary veins carried air from the lungs to the left atrium. This concept was later challenged and disproved by Realdus Colombus few years later. Vesalius taught the scientific anatomy to generations of medical students until his death in AD 1564. This led to a leash of fresh thinking and opened the doors for further refinement of subject. His treatise stands as a medical monument even today.

(Ref: Vesalius A. De Humani Corporis Fabrica. Basel, 1543

Not everything of these changes from ancient acceptance was smooth. Few men of greater ability were not only active in medical front, but also in the issues of Church. One such ill-fated person was a Spanish physician Michel de Villeneuve. He was born in AD 1511 as Michael Servetus, but his religious beliefs and views on the Holy Trinity brought widespread condemnation from Roman Church, forcing him to change his name and flee to Paris. He was famed for his medical abilities, especially his dissection skills. He was first to point that the blood circulated through lungs also. His fame probably prompted him to circulate his views on non-medical issues and he disastrously ended up publishing his views against the doctrine of Trinity. The Church conducted a trail with men as famous as Martin Luther, John Calvin, and Sir Thomas More, who approved his execution. He was burnt to death. The world tragically lost another brilliant man for Godsake!

Next time, I shall dwell upon the other parts of Europe, to see how the science got new turns with each contributor.

On personal note, Dr Pankaj and Dr Ritesh are appearing for their fellowship exit exam. Theory papers are on 1st July and practical on 6th July 2009. Hearty good wishes for their success.

Also, congrats to Mrs Harini, our beloved Echo lab technician!

Our surgeons literally created a record when they operated three neonates with TAPVC (two among them were Infracardiac) in 24 hours duration! A charming visitor from Boston Childrens Hospital was taken aback when she witnessed our PITU, whose capacity is almost 80 beds with more than 80% occupancy on an average. Our volumes must be one of the highest in the World. Any data from other Pediatric Cardiac centers across the globe, anyone? Please mail me.

We came across two infants with DOLV with DORV, one with PS and other with PAH. One infant had DIRV with DORV. Another infant of right isomerism had IVC entering LA; hepatic veins and RSVC entering RA. Few lesions do not seem to have an obvious embryological basis. We had an interesting session of impromptu questions. Dr Shweta spoke on concept of Conus tissue and Dr Amol on embryological basis of DILV and DORV. I had an opportunity to explain the cardiac embryology on the lines of Heckle's biogenetic law (Ontogeny recapitulates Phylogeny). It was quite refreshing to stray away from didactic teaching and to hear the views of budding Pediatric Cardiologists. We hope to have some sessions like this in future.

Please send in your inputs. Let me hear if non-didactic sessions with forums for open discussion need to be increased in number.

Regards

Kiran

Friday, June 19, 2009

Lets continue our voyage with History of Pediatric Cardiology.

In the last post we saw some fantastic facts. Lets see few more now.

Herophilus of Chalcedon (BC 280)

One of the most famous Roman authors of an encyclopedic natural history, Pliny, considers Herophilus of Chalcedon as “the first physician who searched into the causes of disease". The diagnostic value of the pulse, which is relevant even today, was the most important contribution of Herophilus' to clinical medicine. He lived in a period when measurement of time depended on movement of Sun and Moon/planets. Precision time measurement could be in hours, forget minutes and seconds.
Herophilus used his innovation to count pulse, using the water clock. He made subtle analyses of pulse rate and rhythm. As per the norms of time, a gentleman had to attach music for almost everything! Herophilus was no different. Aristoxenus of Tarentum, who was famed for his musical theories of the period, had his influence on Herophilus to build the famous rhythmical pulse lore that continued in medicine until late 19th century.
Herophilus described the pulse as not just an innate faculty of the arteries, but that it also derived from the heart itself, a concept that is groundbreaking in present standards. He was not the one to just count the pulse and feel the rhythm, but he also linked them to palpitations, tremors and spasms, which are indeed muscular in origin. Unfortunately, for the rest of the world, this pulse doctrine was based on too much musical tenants. It got sequentially more complicated for each subsequent generation, that only a skilled musician could possibly understand it in later centuries! The theory failed to gain ground, thanks to its complexity and failure of the future “Gentlemen” to bank on as much music as their predecessors!

Erasistratos of Iulis (BC 250)

Erasistratos of Iulis was another celebrated figure of his times. He elaborated the view of the pneuma. This theory said that the inspired air passed to the left side of the heart and to the arteries of the body to cause the heartbeat. The theory explained the absence of any fluids in arteries postmortem. This erroneous view was maintained for almost four centuries, with each generation cutting open the arteries of dead animals to show the emptiness and praise Erasistratos for this!

(Ref: Osler W. The evolution of modern medicine. Yale; Yale University Press:1921)

Claudius Galenus (AD 129-201)

It took almost 400 years for Erasistratos to get disproved. Claudius Galenus (popularly known as Galen), who was considered as the “Genius of the era” used several experiments to prove that the arteries carried blood and not air.
Galen studied the actions of the heart, its valves and the pulse. He noted the structural differences between arteries and veins, wondered why they were different, but fell short to realise that blood circulated. He hypothesized that blood was produced by liver and sent to the periphery of the body to form flesh. He not only noticed, but also attempted to explain the function of the arterial duct and the foramen ovale, probably for the first time in human history. Galen strongly believed in the relationship between food, blood and air. He was so prolific and accurate for his times, that medical and church authorities considered Galen’s work could not happen without divine inspiration, thereby calling him Divinus Galenus. Galen’s extraordinary brilliance provided more recognition to Divinity, but his hypotheses got sustained for ages, as the church solidly backed him up and bashed anyone who dared question him, for almost 13 centuries after his death!

(Ref: Osler W. The evolution of modern medicine. Yale; Yale University Press:1921 and Thiene G. The discovery of cirulation and the origin of modern medicine during the Italian Renaissance.Cardiol Young 1996;6:109-119)

We shall see how the knowledge of these brilliant Greeks led to further unfolding of secrets of heart in next post.

On the personal note, Dr Sunita and yours sincerely had a publication in the current issue of Annals in Pediatric Cardiology. The article is an invited one under “Point of view” and titled, “Cardiac Care for the Economically Challenged: What are the options?” It is freely available from www.annalspc.com. For anyone interested, please see issue 1, Volume 2, 2009, page 91-94.

The wonderful surgical team of our institute did very well this week. They not only saved a couple of infracardiac obstructed TAPVCs by urgent surgeries, they also did a stage one Norwood for HLHS newborn successfully. None of them had enough finances to cover their surgical expenses, but it did not come in the way of surgery. Bravo!

How common is Ebstein’s anomaly of Tricuspid valve with bicuspid aortic valve and coarctation of aorta in the same child? We came across one this week. I shall map progress of this next time.

Please send in your inputs. Let me hear something about the history if any particular aspect is to be dealt with.

Regards

Kiran

Saturday, June 13, 2009

Lets begin our voyage with History of Pediatric Cardiology from now on:

What do you think of the earliest reference to the heart? Many have told me about Leonardo da Vinci, few mentioned “Greek physicians”; few had the idea of Egyptians, not to forget our own Charaka and Sushrutha.

The answer lies in the prehistoric times, which probably did not even have a word for Heart!!

About 30,000 years ago even the primitive man was aware of existence of heart, at least in animals. Abbe` Breuil, who is considered as the father of the study of prehistoric art, discovered something fascinating to all of us in AD 1908. The prehistoric figure was sketched in red chalk inside a mammoth (prehistoric animal, larger than the present day African elephant) drawn by Aurignacian man (someone who had firmish jaws) in the cave of a place called Pindal in Northern Spain. It was a 16.75 x 17.5 inch drawing, which had "A broad, almost heart-shaped spot, placed in the middle of the body". Breuil first believed this to indicate the flap of the ear, but the crimson hue was not corroborating. Breuil later described this filling as "A broad red spot covers the place where the heart should be situated". Assumed to be a depiction of the site of the heart located within this huge animal, which the hunter had to aim for. Otherwise probably, it was impossible to hunt for the sheer size and raw power. The Aurignacian drawings also indicate primitive man's knowledge of the vital role of this central organ in sustaining life of the giant animal.

(Ref: Pollak K, Ashworth Underwood E. The healers. The Doctor, then and now. London; Nelson: 1968)

Even if we set aside the hypothesis of prehistoric art, the heart dates back to the origin of great civilizations.

Around the year 700 BC, the Assyrian King Asshurbanipal assembled clay tablets, which were believed to have been passed down from Babylon from the Royal Library of Nineveh. These tablets, which are said to date back to 4000 BC, can be considered as the earliest written records of congenital malformations. This included a list of sixty-two human malformations with their associated prophetic implications. For example, Ectopia cordis, which was included in this list, comes with a description, “when a woman gives birth to an infant ... that has the heart open and that has no skin over it, the country will suffer from calamities”.

(Ref: Brodsky I. Congenital abnormalities, teratology and embryology: Some evidence of primitive man’s knowledge as expressed in art and lore in Oceania. Med. J. Australia 1943;1:417)

The Greeks were to provide further history. Largely because their records are well kept while that of others perished with time.

Aristotle (384-322 BC) ascribed the power of thought to the heart, which he contended also contained the soul. He also is credited with the earliest observations of normal cardiovascular function by describing the fetal pulsations in a chick embryo.

We shall see the development of written account of heart in the next post.

On the personal note, our team had a good week. There was some time to relax at last! Dr Karunakar presented a boy who had all the four valves of the heart involved by Rheumatic disease. Involvement of pulmonary valve is considered as “never possible” in western literature, but often described by Indian physicians and journals. Any inputs?

We had our “Publication meet” with our boss! As usual, few tittered, few were cajoled and few escaped! Kudos to Dr Sunita, who consistently peps us up to do something creative. I can imagine our efforts if she were not push us at all!

Please send in your inputs, especially for the history. Also, if anyone has any data on the knowledge of ancient Indians on heart, please pass on the note and reference to me. After all, Indology is hot nowadays!

We have one more follower, but this time it is a person out of our NH team. Please welcome, Prashanth Mishra. I dont seem to recall any friend by that name. Can you please identify yourself, Sir? Please send me an email if you find it difficult to use comments tool of blog.

Regards

Kiran

Friday, June 5, 2009

Philosophy of science without history of science is empty; History of science without philosophy of science is blind

Lakatos I
History of Science and Rational Reconstructions

If something is not given enough attention in any medical specialty, it must be the history of the field. I am surprised to see how naive students are to the historical aspects of science. Whether it is a sign that is eulogized or a procedure that carries a name, the historical details are as fascinating as the scientific fact. However, one cannot blame the students. For, they have to keep abreast with the latest happenings of the field along with meeting their requirements of the course. Most often, questions on the historical aspects are asked to the students during academic sessions when they answer all other difficult ones, just to make sure they still don’t know everything!

Many of the senior consultants of Pediatric Cardiology have actually worked with the pioneers of this field. In our hospital (Narayana Hrudayalaya, Bangalore), the HOD of Pediatric Cardiology, Dr Sunita Maheshwari had been a student of Dr Ruth Whitmore, who was trained under Dr Helen Taussig and started Pediatric Cardiology at Yale. Our senior Pediatric Cardiothoracic surgeon, Dr Shekar Rao has worked with giants of filed like Dr Danielson. Ours is such a young branch, that we are at a transitional period in the development of this fascination. The current generations of students have all the possibilities of being big names in few years from now. I certainly feel that the knowledge of Historical aspects of science would make us feel more humble and proud at the same time. Aren’t theirs the same shoulder on which we are standing to witness wider horizons today?

From now on, I shall put up few posts on the historical aspects of Pediatric Cardiology, which I have followed fervently over past years. I shall also give the references for future studies for those interested. Believe me, with some imagination, you can relive those moments.

On the personal note, thanks to Dr Shweta Nathani for being the “first lady” follower of blog! Of course, I would be happier if my team can contribute more academic data and ideas to blog. I hope this would be met with in future.

We witnessed a 5-month-old baby with Aortico Pulmonary tunnel this week. Dr Sejal Shah diagnosed this on echo within no time! But, many of us saw the echo of this rare condition for the first time.

Is there any data on “How to define Right Atrium?” Is the uninterrupted IVC entry the most formidable clue? Aren’t cases of Total Anomalous Systemic Venous Connection described in history? At Narayana Hrudayalaya, we had a couple of children in whom the surgeons had actually witnessed the entry of IVC into LA on the table. One child at Narayana Hrudayalaya who came from Nigeria showed this last week. Even CT confirmed it. Surgery is not an option in him due to very complicated anatomy and extremely high risk. Dr Shweta showed us a quote from Moss and Adams textbook that virtually no instance in the world is described wherein IVC enters LA. Any difference of opinion from anyone? Please come up with your take in it with proof.

Any suggestions for improving the blog are welcome. Please come up with your contributions for the historical aspects of Pediatric Cardiology. Also, please let me know if you have any specific needs on the historical aspects.

Regards,

Kiran