Year : 2020 | Volume
: 7 | Issue : 1 | Page : 1--12
Footprints on the sands of time: From the doyens of our specialty
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. Footprints on the sands of time: From the doyens of our specialty.Indian J Vasc Endovasc Surg 2020;7:1-12
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. Footprints on the sands of time: From the doyens of our specialty. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jun 5 ];7:1-12
Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/1/280661
The art and science of medicine has evolved over thousands of years and vascular diseases are no exception. These ancient pioneers deduced disease patterns by keen observations and examinations. Even more recently, in last three to four centuries, most of the medical diagnosis and perpetrated therapies were from these astute observations and remarkable application of this knowledge to provide best care to their patients, with limited diagnostic modalities. Some of these might seem archaic now and appear obvious to us – this is because the pioneers bequeathed us this knowledge.
”Reading the history of science and medicine provides good basis for teaching or learning what has happened in the past – how people with keen curiosities were led to important discoveries. Gastone Matioli, however, warns readers “Validate the historical background upon which the experts base their views. Reviews sometimes distort original intentions or at least phrase them poorly. Doctors often ignore history and thus miss the opportunity to identify the source of inherited errors and misunderstandings”. Sit William Osler advised physicians “read the original descriptions of the master who, with crude methods of study, saw so clearly”(1) (2)
I have attempted to provide an illustration of the works of some of these great men from the days of yore, with sepia toned images from the copies of their originals; some unintelligible, but indubitably convey their epoch-making thoughts, methods and techniques without any ambiguity. I hope some of the readers will make it their pastime to study these historic writings.
I. Circulation – Galen and Sir William Harvey:
Circulation has been studied for many centuries, but Galen provided the hypothesis of the arterial and venous blood flow, though erroneous, as discovered later.
The writings of Galen were never questioned, or more aptly nobody dared to question, till landmark discovery and lecture by Sir William Harvey in 1616, that the blood actually circulates.
”The first fundamental facts outlined by him, which paved the way for discovery of circulation (3)
The heart is erect and raises itself up in to an apex; it strikes against the chest wall and the pulse is felt externallyThat it is contracted ever way, but more so at sidesThat grasped with the hand it is felt to become harder at the time of contractionFrom these observation he came to natural conclusion that the activity of the heart consisted of contraction of its fibres by which it expelled the blood from the ventricles
Then he proceeded to study the action of the arteries and showed their diastole (expansion) corresponded with the systole (contraction) of the heart, and the arterial pulse follows the force, frequency and rhythm of the ventricle and in fact dependent on it. Remarkably accurate and vivid description of the motion of the heart and generation of peripheral pulse!”
II. Definition & Description of Gangrene – Sir Astley Cooper
He describes the symptoms of gangrene in incredible details with his astute observation in a series of outstanding and pathbreaking lectures, captured by Frederick Tyrrell in1825!
He continues to detail the symptoms and various types of gangrene
He further goes on to describe the “.. separation of nerves, separation of bones, separation of skin, separation of cellular tissue … as the gangrene progresses”. But he stated “… in general principle inflammation is the cause of gangrene. But there are few exceptions to this general principle …”. This appears obviously erroneous now, but his next section really paved the way for recognition of arterial occlusive disease as cause of gangrene, through his seminal statement on popliteal aneurysm:
III. Aneurysms and Aortic Wall Structure – Giovanni Maria Lancisi
He contributed extensively to vascular diseases around 1700s; his first essay contributing to the dilatation of the heart and the next about aneurysms. He pointed to heredity, mechanical, obstructive, syphilitic and even violent emotions causing these dilatations.
In the next chapter, Lancisi describes the structure and function of the arteries. He states “… let us take the aorta and let it be wetted several times in boiling water, after inserting a wooden tube that fits in…slice with slender knife and probe gradually from external parts to internal and we shall discover that the arteries are compacted with four skins….
The first is made entirely of villi interwoven like fine cotton threads --- some around tiny blood vessels and some around nerves – Vasa vesorum and nervorum penetrating the adventitia?Second and thicker skin which offers more resistance – believed to be glandular seems like pleura or pericardiumThird coat is the thickest of them all – resembles muscles of the stomach, but not of one pattern but many … spiral and longitudinal in a marvellous craftmanship of wickerwork…it means crosswise of the fibres that the momentum in any direction and the capacity to propel the fluid actively forwards…. Obviously smooth muscle layer!The fourth and the last membrane is strong and transparent … in this membrane two things are seen. Inner surface glazed with sort oily glue which makes the flowing fluid friction free. Second thing seen at large branches are fatty follicles … so the arteries may be lubricated
Further Lancisi describes extensively the various aspects of aneurysms in many parts of the body. Amazing observations nearly 400 years back!
IV. System of Surgery – Samuel David Gross
Samuel Gross spent early years translating classic French and German surgical manuals and realized there was a paucity of an original English text book. In 1859 he published two-volume “System of Surgery”, perhaps the first comprehensive surgical text book in English. It had 2360 pages and 936 wood engravings! Figs.10 & 11
V. Operative Surgery – Theodor Kocher
He was the preeminent surgeon of Europe during his time and his contribution to all aspects of surgery, including vascular surgery, are well recognized. He was first to resect and anastomose the intestines and inventor of numerous surgical instruments (including Kocher's clamp). But his Nobel Prize in 1909 was for “Physiology, Pathology and Surgery of the Thyroid Gland”
He defined the need for precise incisions for surgical exposure, virtually of every organ in the body, including arterial and venous systems. The incisions he recommended, or more precisely ordained, continue to be used today. Also “contents” of his book shows the extent of his skills in surgical exposures. Figs. 17, 18, 19
Are these relevant to modern practice? Many, if not most, present day students in vascular surgery may not be aware of the contributions of these colossuses from the past, who left an indelible mark on our specialty. And the question asked, “how this knowledge benefit our practice today”. The mark we leave today will likely be antiquated tomorrow, but the historical cycle needs to continue! This is captured in sublime form by the great poet Henry Wadsworth Longfellow in “Psalm of Life”
But let us also disagree with H W Longfellow in a part of his above poem where he states “Let The Dead Past Bury Its Dead” – let us keep these ancient lights burning eternally so that the present and future generations can continue to learn from them!
Kalkunte R. Suresh
Chief Editor – IJVES
Director – JIVAS, Bengaluru
Suggested Reading: Above mentioned books and many more! ,,
|1||Medicine – Preserving the passion in 21st century, page 69 – Phil Manning, Lois DeBakey https://www.springer.com/gp/book/9780387004266|
|2||Osler W. In Bean WB ed. Sir William Osler: Aphorisms from his bedside teachings and learnings; Springfield, Illinois; Charles C Thomas; 1968:79|
|3||The Evolution of Modern Medicine – Sir William Osler; 1921, Yale University Press|