Friday, August 21, 2009

Before we start this session of our Voyage into History of Pediatric cardiology, I have a small disclaimer to make!

I had some criticism from some readers that the details on Dr Thomas Peacock were too exhaustive. Few argued that brevity is the soul of interesting writing. So, I felt I should make this clarification.

I was interested in giving some details on works of Dr Peacock, more than as a passing reference. When I searched Wikipedia for some details, there was no write up on this person who contributed so much to the science of Congenital Cardiology. It was painful.

I would like to quote Dr Miguel A. Chiong of Queen's University Kingston, Ont. “We don't remember our medical heroes, but, as everyone knows, most of us mortals need to be reminded of most things most of the time. Since medical history is at the bottom of the medical curriculum, there is no curiosity or incentive to find our medical roots, and the young grow woefully unaware of those on whose shoulders they now stand…. Perhaps it should be the task of departments of medical history across the country to remind the medical profession of its forgotten or almost forgotten heroes so we can pay our respects on time!” I felt Dr Peacock is one such forgotten hero.

(Ref: CAN MED ASSOC J 1990;143 (10) 995)

The history of a period happens by references of the era and the persons who made the era memorable. However, old times have to be gauged by works, as reliable biographies of the people who made them are not available. But, in case of living memory, a biographical sketch of a person adds up to the work of the period. As Booker Washington once quoted, it is not only the achievement of a person that carries importance, but the circumstances through which the person had to pass to achieve the glory. So was my decision to write some extra stuff on Dr Peacock. I intend to follow this style for future references too. If the readership feels that the details are asynchronous with the spirit of flow, then I shall cut short.

With this, lets continue our journey!

The publications of Dr Thomas Peacock arouse a great deal of interest in the professional circles and prompted more physicians to look for congenital heart diseases. The blue babies aroused interest but no one kept a sustained interest, as no available treatment was effective. Even then few sustained their interest. One among them was a big name then and a bigger name now! He is Etienne-Louis Arthur Fallot, the same person on whom the tetralogy is eulogized.

Fallot taught pathological anatomy to students. In AD 1888, he coined the term “tetralogy” and clarifies the concept of a cardiovascular malformation with four distinctive characteristics that today is universally known as the tetralogy of Fallot. He had no wish for this lesion-complex to be named after him; nor he made any statement about him ‘discovering’ this entity. He studies 3 cases personally and exclaimed that it was a ‘happy hazard’ for him to have witnessed this rare and curious lesion thrice over few years duration. After a description of his findings in Part 1 of his article, Fallot reviewed the available literature on this lesion in Parts 2 to 6 of his work. Apart from 3 cases seen by himself, Fallot nicely reviewed and summarized 68 other cases of blue disease, whether or not they had tetralogy. Fallot referred to and summarized the first known case of Stenson (Steno) in AD 1671, the second known case of Sandifort in AD 1777, the cases of Hunter in AD 1784 and many more.

In his own words, “Blue disease had hardly been described clinically when the cardiac alterations which caused it were simultaneously established. Knowledge of the symptoms and lesions have, one might say, marched together. It is sufficient to go over the observations of Hunter, Sandifort, Duncan, and Pallois, etc to find indicated here in a fashion most clear and detailed, our pathologic anatomic tetralogy: stenosis of the pulmonary artery, interventricular communication, hypertrophy of the right ventricle, and deviation of the aorta to the right. One asks oneself why a group of facts so numerous and of such demonstrable value has not already become established in science. Above all, one has trouble in comprehending how, despite the opinion of Gintrac, Senior, and of Cruveilhier, it has been possible for this belief, so profoundly erroneous, to be born, to grow, and to develop to the point of becoming almost universal: the belief that blue disease is linked to failure of the hole of Botallo to close (the foramen ovale)”

Fallot never applied his name to tetralogy. He never wished to, as he knew he was not the first to describe it. He wanted to call this condition la maladie bleue, i.e., the blue disease, or morbus caeruleus (in Latin). Till his death in AD 1911, the lesion-complex did not bear his name. It is to the credit of Maude E. Abbott, who coined the diagnosis “tetralogy of Fallot” in AD 1924, probably for the sake of convenience!

(Ref: Fallot A (1888) Contribution a l’anatomie pathologique de la maladie bleue. Marseille-Medical 25:77-93, 138- 158, 207-223, 270-286, 341-354, 403-420 (in 6 parts)
Abbott ME, Dawson WT (1924) The clinical classification of congenital cardiac disease, with remarks upon its pathological anatomy, diagnosis and treatment. Int Clin 4: 156-188
Allwork SP (1988) Tetralogy of Fallot: the centenary of the name, a new translation of the first of Fallot’s papers Em J Cardio-thorac Surg 2:386-392)

Next time we shall see further developments of end of 19th century and beginning of 20th century.

On a personal note, it was a pleasant experience for me to have delivered a talk at Hassan, a town located about 200 km from Bangalore. It was a satellite CME, in collaboration with ISRO at their Master Control Facility auditorium. The CME was uplinked using the Edusat (Indian satellite dedicated for educational purposes) facility. It could be downlinked by any person or institute who has a small dish antenna to capture Edusat signals, totally free of cost. The CME also had star speakers like Dr Krishnakumar and Dr Zulfikar Ahmed. An added incentive was our visit to the world-famous temples at Belur and Halebid. After visiting the temples and witnessing the splendor of architecture, we wondered if these are any less than Taj Mahal. Yet, it pains to see the neglect of them by our system. Tourism has so much potential in India. Why is that the private sector still not attending to such things? Few “good for nothing” rock formations at west are given such a hype that we travel across continents to see them. But, we forget the million times more magnificence at our backyard, just because we care a damn for our own culture! I feel few entrepreneurs should put their hands together to glamorize our own symbols of splendor to draw our own folks to it! I bet it would be reaping them the moolah in no time.

I should mention a word about the Pediatric fraternity at Hassan. For a small branch of around 20 members, Hassan branch of IAP has been awarded “Best IAP branch of country” for 3 years in succession! Their way of conducting the satellite CME was amazing. They are showing how to integrate the technology to spread good among the masses through out the country. They do not see the audience directly during CME, as it is beamed through satellite. Yet, their impetus does not wither. There are no applause or “pats on back”. But they don’t care for the acknowledgement. They conduct the CMEs for the greater benefit of Doctors across country, with no expectations. I think, they exemplify the social commitment of our fraternity, with no returns. In fact, they spend money on transport, accommodation and hospitality of all speakers, all at their own cost. Kudos to Dr Dinesh, Dr Sudhir Bangalore, Dr Lakshmikanth and others for their service to Medical community of India. I wish many more years of “Best IAP branch of the country” award for them in future.

Situs ambiguous never cease to surprise a Pediatric Cardiologist! How many variants are possible? I think there is no such number. We saw common AV valve with TAPVC with pulmonary atresia with Situs ambiguous. We had recently seen cTGA with d-malposed great vessels with ambiguous situs. Another combination was criss-cross ventricles with VSD with situs ambiguous. It is fascinating to deduct them sequentially and make the defect unravel and managable. I wonder how anyone would have managed these before the “Sequential Analysis” pattern of van Praagh!

In any criss-cross ventricle, should the patch closing a VSD pass though the axis of AV valves? In that case, does every VSD of criss-cross ventricle not closable? What does the literature say? Any inputs? Please let me know.

In a sequential lesion, how to assess the relative importance of individual lesions? We had an infant with multiple VSDs with Supramitral membrane and closely placed papillary muscles. The MS gets overestimated and VSDs get underestimated. Our surgeons felt that the mitral valve may be unmanageable and closing VSDs alone may not be fruitful. It was the sheer logical approach of Dr Sejal Shah, which prompted them to open up the supramitral membrane and correction of VSDs, without touching the mitral valve per-se. The infant is recovering well, with minimal gradient across the mitral valve. Great go indeed!

Has anyone had any experience with spontaneous closure of a mild LV to RA jet in a postoperative VSD closure? How do these lesions behave? If anyone has any data or reference, please let me know.

Our PITU team is interested in posting their experiences in this blog. We have perhaps the largest Cardiac PITU in the world, with atleast 80 beds and equally massive and varied challenges! The inputs might be very informative for all interested in Pediatric Cardiac care. I welcome the move with all earnestness. This would definitely enhance the gravity of content in the blog. May be, from next few posts, one can read a substantial amount of our PITU experiences too. I would certainly invite our surgical team also to share this platform for posting their views. But as of now, they are not finding enough time to do so. May be, sometime in future.

Please send in your inputs. If anyone has anything interesting to share, either post a reply or send the info to my mail I shall post the content on your behalf.



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