De motu cordis, November 6, 1991

Dr. John Martin: Threaten me with a hook if I overrun, but I'm going to take this time off of some precious moments to put in a little lick here for the collection. We have all the important works that are available in various additions of both Vesalius and William Harvey, the two greatest figures, the two most important, meaningful men in the history of medicine and the story of the development of medicine. We're in a different lead so far as collections and libraries are concerned when we have especially the first edition of the de Motu Cordis, the book I'm going to talk about. Now it's nice to follow Vesalius with this talk about Harvey because the two were poles a part in personality, even in physical physic. Their mentalities were completely different, but in many ways, they were alike. They worked individually, independently, hands on method. They didn't care what Galen said. They did care, but they didn't dare declare themselves. They had to pretend in their teaching, particularly Harvey, that the old tenants of Galen dating from around 150 AD which were written so authoritatively, so extensively and with such absolute apparent veracity that the rules of Galen were not unfrozen until the people in the Vesalius time and particularly Vesalius and more particularly Harvey cracked those old rules forever. These are two very important people. Harvey was born in 1578 in Folkestone 14 years after Vesalius died. He lived to 1668 or thereabouts, 1678. 79 years old anyway. You see, that covered the ... Historically, that covers that last period of Elizabeth's reign, the whole reign of James I to whom he was appointed king's physician as well as to Charles I during his disastrous reign. He remained a royalist and therefore was in bad with Cromwell's reign. He suffered insults and losses at the hands of Cromwell and he lived on into the reign of Charles II. He was a shy, reticent, secretive man who didn't ... I suspect he was very thin skinned and perhaps very sensitive to personal criticism. My own feeling in reading his biography is that he might have been just a little bit paranoid. He is said to at times maybe out of fashion or to impress people, carry a dagger in his belt. He has to history of ever having stabbed anybody that I know of. He married, had no children, lived a long life, came early in his childhood to the neighborhood of Cambridge, was educated early at Canterbury, later got his BA from Cambridge is 1597 and thereafter went to Padua which of course was the mecca of all medical education, particularly anatomy in those days, and studied there for four years with the great anatomist at the time at Padua who had the mellifluous name of Hieronymus Fabricius ab Aquapendente. That's quite a mouthful. We usually call him Fabricius. While there, Fabricius was doing some work on the veins. He pointed out the valves in the veins. The veins of the extremities as you know have valves with the cusps pointing upward to prevent the downward flow of blood, the backward flow, so that the pools in the foot and the hand of the extremities are dependent. He didn't know what they meant however. He just pointed them out and wrote an article about it. Harvey was studying with him there at the time. That's probably where Harvey's first interest in the cardiovascular system arose. He went back to England as I said after that and married and had no children, but they had a parrot that lived with them all their married life and finally this parrot died. Harvey, ever the scientist did an autopsy on the parrot and decided that the parrot died of old age. Harvey was, as you see in this picture which is a strange picture, this is a colored portrait in the royal college of physicians in London. It apparently was repaired and repainted after damage. Look at those strange, lobster claw like hands. Really objectionable, kind of creepy. He's past middle age in this picture. He was at that time still lecturing in anatomy at the royal college of medicine in London where he was connected all his professional life as well as at St. Bartholomew's hospital. Lectured all that time on Anatomy. All that time was collecting data, bit by bit by bit until he had a tremendous amount of first hand independently collected data. He was never influenced by anybody else's opinion. He was an independent thinker. He didn't care what Galen said. He was forced by the college to teach Galen's principles, but he came to completely disagree with Galen on practically completely on all of Galen's rules. This is Harvey then after middle age, a rather sad, pallid looking old man. He suffered from gout. He had his manuscripts and much of his equipment and records were destroyed by Cromwell's men. His wife died, his parrot died and he lived to an old age. You can imagine what a snowy, cold evening like this was in his quarters in London without any central heating. Next slide please. Where is it, Dave? This one? This button? This is the title page from the book about which I'm going to talk. Exercitatio Anatomica de Motu Cordis, but de Motu Cordis is usually the name we use for short for this world famous, perhaps the most famous in all of medicine. et Sanguinis in Animalibus William Harvey, English, royal doctor in the royal college. Professor of medicine at the royal college of medicine in London. This is the overdone printers device of William Fitzer the young printer in Frankfort who printed this book badly. This is the only illustration in any of the editions of de Motu Cordis. It simply ... It was lifted practically in tact from Fabricius work on the veins. As far as I know, Harvey did not acknowledge the source of this plate. It is ordered somewhat, but that, to me, is a bad mark on Harvey. He was a very proud man and probably didn't want to do it. Now you see all this is doing is showing what the veins look like in the forearm with a tourniquet applied. These little blobs are valves in the veins. Here he shows you if you press on the vein, central word there is no flow of blood. Therefore, venous flow is toward the heart. Galen didn't say that. These are the three illustrations I can show you relative to Harvey. There isn't much to show by way of pictures. Before we go on, I want to just tell you briefly the circumstances under which this man had to teach. He was sort of teaching a lie he thought. Galen, I won't tell you all about Galen's rules of general physiology and anatomy, but only so far as a cardiovascular system is concerned. Galen said this. It sounds like utter nonsense now. I think it must have to Harvey after he had done some of his research. Galen said that the air is suffused everywhere in the universe with a certain anima or nuema. We breath that in and it pervades our entire body just like the soul pervades our whole body. You can't measure, you can't see, taste, smell or hear the nuema, but it's there and it's essential to life. It is throughout all parts of the body. As far as the blood is concerned, food taken in reaches the intestine, is turned into nutrients which are absorbed into the portal system, goes through the protal vein to the liver. There it is immediately and continuously turned into a large quantity of blood, made into blood by the liver. While in the liver, it is infused with a natural spirit which is also manufactured by the liver. Something else that wasn't measurable. The blood then went on from the inferior venacaval to the right side of the heart. Meantime, blood was coming down from the brain having circulated up there through the superior venacaval to the right side of the heart. In the brain, it had picked up animal spirit. By mere going out in the body, the blood had become very overheated. When the blood finally reached the lungs as Galen realized it did, it was cooled. The blood went from the right side of the heart to the lungs. Nobody knew what happened there. Then it came back to the left side of the heart and some of the blood, however, had gone through the holes in the interventricular septum. There were big holes, big pores through which part of the blood poured, not all of it went through the pulmonary artery to the lungs, just part of it. It got back to the left side of the heart and there it was mixed up and shot out through the aorta. It wasn't the aorta and the arterial system wasn't too clearly defined from the veins. The venous system was the important part of the vascular system. This blood went out and sort of ebbed and flowed like a tide all through the tissues. The impurities picked up in the body were accuted through pores in the skin as vapors, whatever that was. Here was this blood ebbing and flowing back and forth and being absorbed as rapidly as it was rapidly manufactured by the liver, great quantities therefore. It all sounds pretty far fetched. In the heart, by the way, the blood had been given a fourth spirit. The vital spirit. It had the nema, the natural from the liver, the animal from the vein, and the vital from the heart. It was a pretty well endowed batch of blood that finally got out and ebbed and flowed through the tissues. Anyway, Harvey in his teaching kept notes. He had two rooms in the back of his house which he turned into a laboratory. There, he really in secret and alone, he was a loner. He did these bit by bit experiments, Vivisection. he tied the dogs and cats and worms and the birds and everything he could get his hands on to dissect alive. He wanted to see ... He also studied the emiological development of the cardiovascular system at the same time, but he wanted to see the living beating heart. He wanted to see the coursing blood. He did that. Then of course he did many human anatomies and was able to see fresh hearts right after the strangulation or the hanging or whatever of this conveniently murdered criminal. He had an extensive first hand view of the cardiovascular system, but he did this all himself alone, almost in secret. He kept extensive, very accurate notes. He was an excessively almost compulsively honest man and very independent. He was teaching Galen, but putting down all these other contrary facts which he found. It must have been a very difficult 13 years, up to 1627 when he was finally induced to publish a book. He, for instance, he decapitated dogs and tied off the vessels in the neck, put a bellows to the trachea, kept the lungs inflated and watched the heart through the open chest and saw that that heart continued to beat just like a dog who's head was intact and who's chest was open. It looked just the same. He was the automaticity therefore of the heart muscle. He saw this rhythmic pulsation. He saw that it was in synchrony with the pulse. It was in synchrony with the spurt of blood from an artery. He recognized that an artery was a thick walled muscular structure with the blood flowing peripheral ward. He recognized that the veins were thin walled and the veins only had valves and the blood flowed slowly central ward. If you cut a vessel in a dog or you cut your own arm, or any accident you might see, blood spurts from an artery and it oozes from a vein and in a small enough vein, it finally stops and clots. That's not true with an artery of a certain size. He exsanguinate dogs and watched the heart stop. He looked at the various valves in the heart. The valve between the atria and the ventricles, the valves to the pulmonary artery and vein, the aortic valves and noticed the direction of the cusps up or down so placed as to prevent regurgitation of the blood back where it came from when the heart pulsated. It was always a forward motion of the blood. He said, "I don't see any holes in the ventricle. There aren't any. The blood all goes through the lungs." He said, "These veins in the valves, valves in the veins are there for a purpose." He showed this very simple picture the direction of the flow and what happens, how these valves activate when there's a little pressure on them as there is when the extremity is dependent. He said something much more telling and with much greater finality. He said, "Look, the liver could not possibly absorb that much material and make blood out of it. You isolate an animal or a human being for 24 hours without food or drink. At the end of that time, they weight the same. They've got the same pulse. The same color, the same respiration. They are unchanged without having taken in any food or fluid. Where would all this come from if Galen were true?" He said, "No, there is about ... If you figure it out yourself." He called it grandma. If you figure out that it's anywhere from 60-65 Ccs of blood in one ventricul at a time, there are about 6300 liters of blood go through each ventricle in 24 hours. There are only about 11 pints of blood or plus or minus five liters of blood in the average size human being. He computed that. He said, "Well, there's 72 beats a minute, three gram per thrust, 60 minutes in an hour, 24 hours in a day, and you come out with this tremendous amount of blood." He said, "This blood isn't just ebbing and flowing and going around and exerting acidic vapors. I can see it. I can see it passing through this vessel to the lungs. I can see it coming back from the lungs. I can see it going out into the aorta. There's a motion here. This blood is in motion." He finally was induced to have this book published. He was very shy. [Inaudible 00:19:37] physician friend of his, a rather strange fellow said, "Let's take it over to Frankfurt on the QT and have this book published." They unfortunately chose this rather inexperienced young man who saw this little manuscript and probably thought it wasn't worth very much trouble. He produced a cheap, little book that printed on highly acidic paper, probably only about 250 copies all together. That's one reason why this book is so accessibly rare. There were not very many printed, and it was very destructible because of the nature of the paper. The book was only 68 pages of printed text in Latin with many typographical errors. The sort of thing which now a days if you got through the mail from the [inaudible 00:20:38] drug company, you would say this is junk mail and you would throw it in the waste basket. The book was badly received. Harvey lost a lot of practice. His colleagues turned on him. He was criticized all the way from Scotland to the continent. He finally was vindicated, but he died a rather unhappy man. This book has come to mean two important things which I want to point out to you as my last statement. I want to read you the 14th chapter. It sounds like I'm reading out of the Bible. This is out of de Motu Cordis. Here are 215 words. Every word has to be listened to and considered because this is terse, un padded, simple, effective prose. This is where he wraps it up. This is where he says the whole thing. "Conclusion of my description of the circuit of the blood. That's the key word, circuit. May I now be permitted to summarize my views about the circuit of the blood and make it generally known! Since calculations and visual demonstrations have confirmed all my suppositions to with that the blood is passed through the heart and the lungs by pulsations of the ventricles, is forcibly ejected to all parts of the body, therein steals into the veins and porosities of the flesh, flows back everywhere through these very veins from the circumference to the center, from small veins into larger ones, and thence comes at last into the venacaval and the oracle of the heart. All this too in such an amount and with such large flux and reflux from the heart out to the periphery and back from the periphery to the heart, that it cannot be supplied by the ingesta and is all so much greater in bulk than would suffice for nutrition. I am obliged to conclude that in animals, the blood is driven round in a circle with an unceasing, circular sort of movement and that this is an activity or function of the heart which it carries out by virtue of its pulsation and that in some it constitutes the sole reason for the hearts pulsital movement." Therefore he said in another place, the heart acts like a pump. That is one of the most telling and important paragraphs in all medical history. The importance, the primary importance of this historic work is not that he proved the circulation of the blood. The blood had been known to move before this as Dick pointed out in some of his remarks. Anyway, he didn't discover anything. This wasn't a matter of serendipity. He worked this out bit by bit by bit. There is the important part. This was the beginning of experimental investigation, independent of any previous views or any outside influences. This was the beginning of the experimental message, this was the beginning of physiology as we know it. That's the important part of the de Motu Cordis. The secondary important is the fact that we say he discovered the circulation of the blood. As a matter of fact, he didn't describe the whole circulation. He didn't know what happened in the lung. He knew nothing about gaseous exchanges. He knew nothing about capillaries. They were discovered in 1660 by Malpighi and reported in '61. He didn't know how out in the periphery the blood got from the arteries to the veins. He thought there were certainly fine connections out there, but he didn't know about capillaries. He knew that this blood in very limited quantity was used over and over and over and never stopped moving. When you stop to think about this little structure about the size of your fist, puts out this tremendous quantity of blood in 24 hours, day after day after day, you can see the importance to modern therapy, modern surgery of, of the proper knowledge of really what's going on in your heart. Up to that time, all this nonsense had been believed. Form this time on, physiology was established as a separate entity. Pathology became a little longer. First you have anatomy, then you had functional anatomy or physiology. Later we had pathology. This book is important. His work is important. It was only one of two. He only published one other book on embryology and midwifery. This book is primarily important because it is the beginning of the experimental method done personally independent of previous conceptions. Secondly, he showed that a limited definite amount of blood circulated over and over and over. Thank you very much. Moderator: Any questions? Does anyone have any questions for Dr. Martin?