Thursday, August 27, 2009

Welcome back to our wonderful journey into History of Pediatric Cardiology.

How many of us can understand the term, “cor biatriatum triloculare”? I think all of us should be indebted to this term. For, it started the scientific journey of Pediatric cardiology in the dawn of 20th century. One such heart was cooling in the shades of dilapidated museum of McGill Medical school at Canada in the turn of 19th to 20th Century. This specimen of heart dated back to AD 1824 and was there only because it was donated to the collection by the first dean of McGill Medical School, Dr Andrew Holmes. The story of how this specimen led to the development of the science of congenital cardiology is quite exciting. Read on..

By the end of 19th century, after much controversy, McGill medical school took its first women candidate for studying Medicine. This lady, despite having had a brilliant academic career till then, was flatly refused admission due to her gender. She fought for her admission and finally made it to become the first lady doctor from McGill. When she applied for a position in the same medical school, she was appointed as the assistant curator of medical museum in AD 1898, largely because nobody else wanted this job. The museum was a disorganized collection of huge number of specimens collected over 75 years. Although some medical data always accompanied the specimen, it was usually stocked with some rubble, quite away from the specimen itself. It would have been maddening and thankless job. No one cared how the museum was.

Kudos to this gutsy lady, she started cataloging the specimens carefully and did a wonderful job. One specimen titled “cor biatriatum triloculare” confused her. She decided to consult Dr William Osler, the ‘Chief’ of McGill. Dr Osler was a phenomenal figure and was knighted by the Queen. On the description of the said specimen by the assistant curator, he immediately identified it and ranted out some history of the specimen. This specimen belonged to a man who died at the age of 22 years in AD 1824, collected to the museum by the first Dean of McGill medical school and reported in Edinburgh Medical Journal. It had two atriae but both AV valves drained into the same ventricle. The other ventricle was reduced to a “nonentity” at the upper right end. The posteriorly located aorta sprung from the main ventricle and the anteriorly located Pulmonary Artery from the diminutive cavity representing the other ventricle.

Either taken away from the charm of Sir Osler, or due to a spring of inspiration from her own innate brilliance, the assistant curator searched for the original article and re-did the article along with her etchings in the McGill Medical Journal in AD 1901. She did an extraordinary cataloging of the specimens of museum, making it a place worth a visit for all the students and faculty. In AD 1904, Sir Osler visited McGill museum and was spellbound by the beauty with which it had metamorphosed in the hands of its assistant curator. He told the Dean of McGill that the museum was “the best that McGill had done to date…there was no collection in North America or Britain that came close to it”. So impressed Sir Osler was, that he asked the young lady doctor to write a chapter for his Magnum Opus, “Systems of Modern Medicine”. She was the only woman contributor in the list of 104 authors. And what a work she did! In a 100-page chapter, she had evaluated 400 cases and correlated the clinical findings with the autopsy reports. Sir Osler wrote a thank you note to her, saying… “It is by far the best thing ever written on the subject in English – possibly any language… For years it will be the standard work on the subject…” She returned the compliments by naming her McGill museum catalogue as ‘The Osler Catalogue’. Although her biographers differ, this was possibly the moment of inspiration for her monumental Atlas.

Her “Atlas of Congenital Cardiac Disease” was published by American Heart Association in AD 1936. The Atlas described 1000 hearts with their pathophysiological and statistical analysis of the clinical and anatomical abnormalities. The frontpiece of the Atlas had Portraits of Senac, Morgagni, Peacock, Rokitansky, and Sir Arthur Keith, demonstrating her gratitude towards the history of the field.

She wrote the following note in the introduction of the Atlas: “This volume presents, in a somewhat unusual form, a pictorial retrospect of the author’s personal experience in what may be considered a specialized field of clinicopathological research. A first-hand knowledge of the exact morphology of a large range of cardiac anomalies obtained in the first place through an intensive study of the rich material accumulated under the author’s care as Curator of the Medical Museum of McGill University, has been continuously applied and amplified through more than three decades of activity, by observations of congenital heart disease in the wards and autopsy rooms of many great hospitals both at home and abroad.”

In bringing order to what had previously been a disorganized array of fascinating, but poorly understood, congenital malformations of the heart, she divided these patients into three groups: Those with no abnormal communications, those with a left-to-right shunt (acyanotic), including patients with shunt reversal later in life (cyanose tardive), and those with permanent right-to-left shunt (Morbus coeruleus). For each she developed a diagram of the circulation.

Recognizing the importance of preventing these malformations, she developed the following 6 “ever-pertinent” questions to learn their etiology.
1. Did the abnormality result from a fault in the germ plasm?
2. Was the abnormality inherited?
3. Did the abnormality occur because of a change in the environment of the embryo in utero?
4. Was the abnormality a result of maternal disease?
5. Was the abnormality due to fetal trauma or a uterine disorder?
6. Did a disease affecting the early embryo cause the abnormality?

It is probably the time to remember the person who provided an impetus for our modern understanding of the etiologies of congenital heart disease. Called by various names as “The beneficent Tornado”, “The Saint”, “The big chief of Heart” etc, but I personally prefer to call her the “God-Mother” of Congenital heart diseases. We are referring to Dr Maude Elizabeth Abbott. The “cor biatriatum triloculare” that we spoke of at the start of this session is today known as the “Holmes’ Heart”. It is probably very important for every student of Congenital Cardiology to know the background, which this heart has provided for this science and the person who made it possible for all of us.

The coming 2nd of September commemorates the 69th death anniversary of Dr Maude Abbott. In view of many authorities on the subject, if we have to name one keystone person for the development of Congenital Cardiology, it would be Dr Abbott. Please vote your views after reading today’s piece again!

March 18th happens to be the birthday of Dr Maude Abbott. I personally wish to see every hospital delivering Congenital Heart care to celebrate this day meaningfully.

(Ref: Abbott ME. Atlas of Congenital Heart Disease. New York, NY: American Heart Association; 1936

MacDermot HE. Maude Abbott. A Memoir. Toronto, Canada: Macmillan; 1941

Wiglesworth FW. Maude E. Abbott.Perspect Pediatr Pathol. 1984;8:291-294)

Next time, lets see the history of Pediatric Cardiology in the first half of 20th century.

On a personal note, we at Narayana Hrudayalaya are witnessing a change in the state of affairs. New branches are coming up. The Health city is progressing. New cases of Novel H1N1 are getting diagnosed! In next few weeks we shall come with new developments and their repercussions.

Hearty congrats to our chairman, Dr Devi Prasad Shetty, for having named as a member of National Human Resource Commission, led by the Prime Minister himself. It is another feather in the cap of Dr Shetty, who can do wonders given the right position at any level – National or International. Many states of India now are trying to replicate our Yeshaswini scheme and getting advice from him.

We never cease to learn; all that is required is to keep the senses open. Our weekly Cath meetings are always filled with new outlooks, new discussions and learnings. It is wonderful to be a part of such illuminating brains that can think laterally so well.

How to proceed in a case of {S,L,L} dextrocardia, Ebsteins anomaly, juxtaposed atrial appendages, Severe PAH in a 9 month old child? Though the ventricles are of good size, juxtaposed appendages are an impediment for double switch. Can we consider PA banding? Would it be final palliation? Is Senning/Mustard cannot be done in any case of juxtaposed atrial appendages? Let me know your views on it.

What to do if a clot gets totally organized to an atrial wall? On echo, it does not show any sign of movement. How to make sure that patient would have no problem with this at home? How does such things generally behave?

When we are balloon opening a tight aortic valve, should we start with 80% balloon size to begin with? Or should we start with a smaller balloon and progressively dilate the valve? Any comparative trails or personal experiences?

Is there a role of DC Cardioversion in cases of chronic tachycardia induced cardiomyopathy? We saw a 10-year-old girl, who was diagnosed as Dilated Cardiomyopathy and referred. We saw 6-month old ECG traces showing a ventricular rate of around 300/min with SVT pattern. This girl hardly has any LV contraction. She is currently on life support measures. Is it terminal? Can the situation be improved? This girl emphasized the need for a good training of physicians in the peripheries in identifying simple problems and timely advice. Lest, this is what we would witness time and again.

Dr Amol Morey, who was with us for a 6-month training has gone back to Australia. He shared an interesting case scenario with us. I would like him to be a part of our team from that distance to contribute his overseas experience. Thanks Dr Amol, for that update.

I am off to a medical camp at Ranibennur, a small town about 7 hours from Bangalore. I shall narrate my experiences next time.

Let me know your comments. I am yet to receive any response from our PITU team on their postings. I hope to get it soon and let you know about it.



1 comment:

  1. Welcome to our new follower, who calls himself docspike.
    He operates a blog by name Yukon Ho! (An obvious Calvin and Hobbes lover)
    He is Dr Ravichandra Karkal, from a small town called Ilakal in Karnataka. Ilakal is famous for its typical traditional sarees.
    Welcome aboard, Dr Ravichandra. We hope to see your contributions in our blog soon.