A Paradigm Shift of the Seventeenth Century

Brian J. Morrison, MD, FACCSouthern Oregon Cardiology

� A fundamental change in approach or underlying assumptions

� A time when the usual and accepted way of doing or thinking about something changes completely

� first used by Thomas Kuhn, The Structure of Scientific Revolutions, 1962

� The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia� Alfred Blalock, Helen B. Taussig

� JAMA, 1945

� Nonoperative dilatation of coronary artery stenosis� Gruentzig, et al

� NEJM, 1979

� Effects of enalapril on mortality in severe congestive heart failure (CONSENSUS)

� NEJM, 1987

� Copernicus� De Revolutionibus OrbiumCoelestium, 1543

� Vesalius� De humani corporis fabrica libriseptem, 1543

� Newton� Philosophiae Naturalis Principia Mathematica, 1687

� Darwin� On the Origin of Species, 1859

� Einstein� Theory of general relativity, a

series of papers published 1915

� Copernicus� De Revolutionibus OrbiumCoelestium, 1543

� Vesalius� De humani corporis fabricalibri septem, 1543

� Newton� Philosophiae Naturalis Principia Mathematica, 1687

� Darwin� On the Origin of Species, 1859

� Einstein� Theory of general relativity, a

series of papers published 1915

� Copernicus� De Revolutionibus OrbiumCoelestium, 1543

� Vesalius� De humani corporis fabrica libriseptem, 1543

� Newton� Philosophiae NaturalisPrincipia Mathematica, 1687

� Darwin� On the Origin of Species, 1859

� Einstein� Theory of general relativity, a

series of papers published 1915

� Copernicus� De Revolutionibus OrbiumCoelestium, 1543

� Vesalius� De humani corporis fabrica libriseptem, 1543

� Newton� Philosophiae Naturalis Principia Mathematica, 1687

� Darwin� On the Origin of Species, 1859

� Einstein� Theory of general relativity, a

series of papers published 1915

� Copernicus� De Revolutionibus OrbiumCoelestium, 1543

� Vesalius� De humani corporis fabrica libriseptem, 1543

� Newton� Philosophiae Naturalis Principia Mathematica, 1687

� Darwin� On the Origin of Species, 1859

� Einstein� Theory of general relativity, a

series of papers published 1915

Discovery consists of seeing what everyone has seen and thinking what nobody has thought

� Albert Gyorgyi, Nobel Laureate Medicine, 1937

A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.

� Max Planck, Nobel Laureate Physics, 1918

Galen and the Heart

Galen on the blood

…venous blood nourishes the body following transformation of the blood in the liver….this venous blood reaches the heart where a portion of it passes through the pores of the septum where it would mix with the pneuma from the lungs and the very center of the innate heat, leading to the formation of the arterial blood…which is responsible for distributing the vital heat to the body..

Breaking with Galen

Vesalius on the pores of the septum, 1543

“…the septum is formed from the very densest substance of the heart. It abounds on both sides with pits. Of these none, so far as the senses can perceive, penetrate from the right to the left ventricle. We wonder at the art of the Creator which causes blood to pass from right to left ventricle through invisible pores..”

The Lesser Circulation

� “…blood from the right chamber of the heart must arrive at the left chamber, but there is no direct pathway between them…the blood from the right chamber must flow through the vena arteriosato the lungs…be mingled there with air, pass through the arteria venosato reach the left chamber…”

Manuscript, Commentary on Anatomy in Avicenna’s Canon, c.1270

…Now this communication is not made through the Septum of the Heart, as is commonly believed, but the subtil Blood is very artificially agitated by a long passage through the Lungs from the right Ventricle of the Heart, and is prepared, made florid by the Lungs, and transfused out of the Arterious Vein into the Venous Artery, and at last in the Venous Artery is self it is mixed with the inspired Air…And thus at length the whole Mixture is attracted, by the Diastole of the Heart, into the left Ventricle…

� Christianismi Restitutio, 1553

…air is carried by means of the trachea through the whole lung, but the lung mixed the air together with that blood which is carried from the right ventricle of the heart through the pulmonary artery…mixed blood and air are taken up at the same time through the pulmonary vein…to the left ventricle of the heart…

� De re anatomica, 1559

Discovery of the Venous Valves

The Final Piece of the Puzzle

� Gian Battista Canano of Ferrara

� Described valves in the azygous vein

� Musculorum humani corporis picturala dissectio, 1551

� Charles Estienne of Paris

� Described valves in the mouth of the hepatic veins

� De dissectione partium corporis humani libri tres, 1545

� Jacobus Sylvius of Paris

� Described valves in the azygous, jugular and brachial veins

� Isagogue in libras Hippocratis et Galeni anatomicos, 1555

Hieronymus Fabricius abAcquapendente

…Who, indeed would have thought of finding membranes and ostiola within the cavities of the veins of all places else, when their office of carrying blood to the several parts of the body is taken into account?..

De venarum ostiolis liber, 1603

� Born in Folkestone, England, eldest of seven sons

� Educated at Caius College, Cambridge

� MD degree at Padua, 1602, mentored by Fabricius

� Elected to RCP 1604

� Named LumleianLecturer 1615

Lumelian Lectures, c 1616

Harvey demonstrates the circulation to Charles I

Painting by Robert Hannah, 1848

The Paradigm Shift Begins

ROBERT FLUDDMEDICINA CATHOLICA, 1629

JAMES PRIMROSEEXERCITATIONES ER ANIMADVERSIONESIN LIBRUM DE MOTU CORDIS…, 1630

OLE WORMCONTROVERSIARUM MEDICARUMEXERCITATIO SEXTA, 1632

CASPAR HOFMANCORRESPONDENCE WITH HARVEY, 1636

JOHANN VESLINGLETTER TO HARVEY, 1637

JAN VAN BEVERWIJCKLETTERS TO HARVEY, 1637, 1638

JAN DE WALAEUSEPISTOLAE DUAE: DE MOTU CHYLI ET SANGUINIS, 1640

SIR KENELM DIGBYTWO TREATISES…, 1644

Harvey and Jean Riolan

“It is now many years ago, learned Riolan, since with the assistance of the press I published a part of my work. Since that birthday of the circuit of the blood there has of a truth been scarcely a day, or even the smallest interval of time passing, in which I have not heard both good and ill report of the circulation which I discovered. Some tear the as yet tender infant to bits with their wranglings, as underserving of birth; others by contrast consider that the offspring ought to be nurtured, and cherish it and protect it by their writings…”

Retirement and Death

Memorials of Harvey

“…He had led his life with the utmost temperance and according to the strict rule of medicine.”

Dr. Edmund Wilson, Harveian Oration, c.1660

“Ah! My old friend Dr. Harvey, I knew him right well, he made me sitt by him 2 or 3 hours together discoursing. Why! Had he been stiffe, proud, starcht & retired, as other formal Doctors are, he would had known no more than they…”

John Aubrey, Brief Lives, c.1690

“What was left for Harvey to discover was nothing less than the circulation itself. His predecessors had but impinged, and that by guesswork, upon different segments of the circle, and then gone off at a tangent into outer darkness, whilst he worked and proved and demonstrated round its entire periphery.”

George Rolleston, Harveian Oration, 1873

“…he is the only man, perhaps, that ever lived to see his owne doctrine established in his life time…”

Thomas Hobbes, 1650

Results of the New Paradigm

Jean PecquetExperimenta nova anatomica, 1651

Pecquet describes the thoracic duct and therefore joins the lymphatics(Aselli, 1622) to the systemic circulation

Marcello MalpighiDe pulmonibus, 1661

Malpighi demonstrates the capillaries in frog lung, utilizing an early microscope.

“…here it lies revealed to the senses that, as the blood passes out through these twisting divided vessels, it is not poured into spaces, but is always passed through tubules and is distributed by the many windings of the vessels..”

Richard LowerTractatus de corde item de motu& colore sanguinis, 1669

Lower described the scroll-like structure of the ventricles, showed how the heart would beat even devoid of blood, and demonstrated the color change of arterial blood “…was entirely due to the penetration of particles of air into the blood.”

He also demonstrated the feasibility of blood transfusion