Friday, July 24, 2009

Welcome back to the wonderful voyage called History of Pediatric cardiology. Last time we saw the saga of Laennec and stethoscope. We shall continue with this further

There was no dearth of critics for Laennec. He concentrated so much on stethoscopic findings that he ignored the traditional percussion and auscultation techniques, which earned him the title of “Cylindromaniac”! It is true that his concepts of origin of heart sounds were complete mismatch, but we should understand that we are talking about the inception of the science. It is very easy to comment about past without having to undergo the trouble of pain involved in the labour. Saintington, Laennec’s biographer in AD 1904 gets severely critical of Laennec’s cardiology concepts. Probably, one should get soft in criticism of past, for, we are standing on the same shoulders whom we are talking about!

(Ref: Saintignon, H. (1904). Laennec, sa Vie et Son Oeuvre. J. B. Bailliere, Paris)

Irrespective of the fundamentals, stethoscopy had earned a great demand in Europe, as each patient wanted their doctor to use them. Gradually, physicians used stethoscope for heart and direct auscultation for lungs.

Claude Bernard had prophetically told once about the light of scientific truth dispelling the obscurities and discovery of new paths. A new era of physical diagnosis was laid on be Laennec’s stethoscope. Auscultation of heart got into new straits with many physicians exploring the vista and scaling new heights. The wooden stethoscope did not come in the way of Bouillaud to study his own heart sounds when he decided to attach a rubber tube to its end. This innovation helped in the flexibility of the device and paved the way for present day design. He was also the first to favour a valvar origin of heart sounds, by correctly attributing the S1 to AV valves and S2 to semilunar valves.

(Ref: Flint, Austin (1876). A Manual of Percussion and Auscultation, of the Physical Diagnosis of Diseases of the Lungs and Heart. Churchill, London)

Laennec was not the only one to get the origin of heart sounds incorrect. To-be Giants of field also erred at this level! Majendie attributed the S1 to ventricular diastole against the chest wall and S2 to impulse impelling the base of the heart against the chest. Pigeaux regarded the S1 as diastolic and Corrigan attributed S1 to atrial systole and S2 to ventricular systole. Despite the big names making huge wrong sounds, Bouillaud stuck to his decision and won at the end. Further experiments in this regard in AD 1832 by Rouanet, 1839 by Hope, in AD 1840 by C. J. B. Williams, in AD 1860 by Halford and many others gradually established the view held up by Bouillaud. Scores of textbooks were written on auscultation. In AD 1858, Hamernik, a physician of regard in University of Prague assigned himself as the professor of auscultation! Many signs were brought up via auscultation later. Duroziez gave the signs of mitral stenosis, its presystolic murmur and snapping first sound, second sound, opening snap, and diastolic rumble. Potain described splitting of sounds and gallop rhythm. The development of phonocardiography further refined this science.

(Ref: Halford, G. B. (186o). The Action and Sounds of the Heart; A Physiological Essay. Churchill, London.

Hamernik, J. (1858). Das Herz und seine Bewegung. Dominicus, Prague.

Hope, J. (1839). A Treatise on the Diseases of the Heart and Great Vessels, 3rd ed. Churchill, London)

Leannec’s contribution to Cardiology is unparalleled in history, in league with that of William Harvey. It looks daringly evident in the everyday life of any physician!

Next time, we shall see further progress of clinical cardiology.

On a personal note, this week saw few heartbreaks. I had seen an infant with Ebsteins anomaly with ASD and communication between LV and atrialised RV. (What should we call such defects?) This baby had a turbulent post-operative course after complete correction and succumbed. I had not seen this variant of Ebsteins earlier. Any inputs?

We saw a couple of adolescent girls with infective endocarditis. It is very painful experience when we see the multiple vegetations hanging on to the valves and are set to get into the circulation any time. One among them already had a probable systemic embolization, as right radial pulses were feeble. The other had developed severe regurgitation and was in multiorgan failure. Can we see a time when such a happening be prevented in India?

Not everything was bad. Our surgeons operated on sever MR in an infant very successfully. Also, a symptomatic newborn with TAPVC and restrictive PFO was taken for emergency surgery and saved. The numbers of device closures are increasing gradually. It is very heartening to see the success in front of our eyes.

Thanks to Mr Praveen Kumar, our beloved Echo technician for following the blog. Believe me, he knows a lot of computer stuff. I look forward to his inputs.

I think the field of Pediatric Cardiology and Surgery is going through a major polarization in India. The arrival of Five-star hospitals in metros is drawing the best brains from charitable institutions into them. Whether it is the indifferent behaviour of such institutions that prompt the hard working souls to move away or the perceived need of a decent life for a doctor and his family which mandate such a step is a matter of debate. I have seen world-class doctors working for peanuts at many institutions. After a while, the institute takes them for granted and neglects their services. This happens when the hospital management shifts from Doctors to MBAs. For a non-medical administrator, every doctor is a file on his table. He would not have worked with the doctor skin-to-skin to appreciate their subtle value and prodigal skills. Consequently, they fail to see the reason from the point-of-view of the doctor. The loss of a brilliant medical brain to another institute bleeds the colleagues from within, but the administrator does not even feel the loss in short term. They would put in their efforts to rope in another name to get the work done, without analyzing the causes that prompted the previous person to leave. How much can it serve the team spirit, how much would it affect the overall efficiency, how much would it translate to losses on a long run is probably never thought, as the administrator himself is not considering a long-term prospect in the said hospital. For them, any place is as good as the other. However, a hospital is much more than a financial institute. A non-medical person can possibly never understand it.

All this was written in the context of a major Pediatric Cardiology center at Kerala losing out both its fantastic surgeons to Five-star hospitals at Mumbai. What was carefully built over a decade with lot of care, love and passion collapsed in short time due to myopic vision of non-medical administrators. I bet neither of the surgeons would have left if somebody more empathic had run the show. It is probably the beginning of the downfall of such “charitable” institutes. The overall effect is really bad for the country. But, who would tell the “practical” administrators who cannot see beyond balance sheets? How would you put the entire picture to a person who has his eyes fixed to a narrow tube?
It pains to write such stuff, but it is time to ponder over such issues. Time is the most crucial factor; hope the best prevails at right time. Please let me know your views on this issue of “braindrain” from places where it is badly required.




  1. material is nice. delighted to see my name being mentioned . u can comment on people from other dept as well as general public events or national event etc.
    whats new in medical or other subjects. anamika

  2. can add our dept photo on blog. am