One should realize, that in those times when
the elaborations on the heart and on circulatory organs first appeared in Poland,
the traditional, rational medicine lived its own life, acknowledging the importance
of blood circulation for the maintenance of life. It existed far from and in
spite of the metaphysical, ritual practices, affected strongly by the powerful
Catholic Church. These first, timid elaborations mentioned above, appeared in
Poland as early as in the Middle Ages to boldly catch up with the pace of world
medicine in the Renaissance and Baroque and then, in the XIXth
century, to gain international recognition for original ideas.
The knowledge of human physiology based on the great achievements of the ancients such as Aristotle, Hippocrates, Praksogoras, Alkmeon, Erasistratos, Herofilos, Celsus and Galen on the top of the list, did not have a chance to develop in the times of either Polish or European Middle Ages. What is known to us about the physiology in the early Middle Ages before Christianization, and so before writing was introduced? Indeed, just nothing. At that time in Europe there was no corresponding period of transition to that created by such medieval Arabian physicians, such as Avicenna, Rhases, Avenzoar or Ibn-an-Nafis.
The schools of medicine did not exist - only Salerno and Montpellier, with the most eminent minds of the Middle Ages can be considered significant. Christianisation of the country gradually introduced the Western ways of life, and with it appeared the scientific method. However, the teaching was based on the works of ancient doctors, and the most prominent teachers were foreigners, so the scope of the knowledge of physiology was contained. It was spiced with a pinch of mysticism, which was completely dominated by the church dogma created in the ancient times. This blend of scientific and theological dogma swerved far from the standards of rational thinking.
The achievements of Thomas of Wrocław
(1297-1378), a titular bishop of
Sarepta, operating the region of Lower Silesia, were the exception to the ocean
of medieval dogmatism (1). He was thoroughly educated in Western Europe, in
Montpellier, Salerno, Padua and Bologna. Once recognized as a scientist, he
was repeatedly invited as a lecturer to the universities of Paris, Montpellier
and Oxford. He treated pope John XXIInd
of Wrocław, and the Czech kings - John
Luxemburger and Charles IVth
, the Holy Roman Emperor.
In 1360-1363 he published the work "Mihi Competit", which was a form of medical
encyclopaedia, known as "Kanon Biskupa Tomasza
" ("The Bishop Thomas'
") or "Śląski Kanon Avicenny
" ("Silesian Cannon of
") and "Practica Medicinalis", a collection of edicts referring
to the art of medicine and pharmacy. The achievements of Bishop Thomas are linked
to the history of cardiology by his work entitled "De syncopi et debilitate
cordis", a text on the palpitations and syncope. This was probably the first
work dealing with the heart to point to the relationship between slowing of
the heart rate and syncope to appear in Polish lands, and one of the first in
the world. Thomas claimed that the palpitations (i.e. "trembling") would reflect
imperfection of the heart, and it may very often result in syncope. In his opinion,
syncope is serious and may lead to death. Can we notice here the beginning of
the Polish way of thinking on physiology of circulation? Maybe yes, we can,
as it seems that the basis of that kind of ideas could be the considerations
referring to the regular versus irregular heart rate, and the resulting syncope.
It is not out of place to mention that the observation on the irregularities
in the heart rate (changes in the heart rate including slowing down) could be
the first observation related to the loss of consciousness as a result of serious
decrease of the heart rate, remaining well ahead of the other such reports (on
so called Morgagni-Adams-Stokes' syndrome) by more than three centuries. M.
Gerbezius made such a statement in 1691, before Morgagni's description in 1760.
The author claims that the reason for these disturbances could be the damage
to the "whiff within the heart", or its excessive excretion and he writes about
the imbalance between the cold and the hot matter. Maybe in the Thomas' works
we could detect some absence of balance in the proper perfusion of the cardiac
muscle (deficiency in influx of nutritional substances). Thomas' recommendations
concerning the application of ligatures on extremities were very intriguing,
indeed, as if the author was foreseeing the role of redistribution of blood
in the circulation (2).
The Akademia Krakowska
) that was open in 1364,
and then reformed in 1400, had the Medical Faculty, but it was not showing progress
in the quality of the scientific and educational activities in the XIVth
and the XVth
century. Not till the Renaissance
this faculty showed some interest in the practical medicine. Young students
of the Academy, eager to learn, showed more and more ambitions to catch up with
the outstanding European leaders in medicine. That is why, after completing
their studies in Kraków, they frequently travelled to the best-known scientific
centres - most often choosing Italy. There they studied those subjects, which
were not available at their alma mater
. In the XVIIIth
century the level of medical sciences in Kraków was still rather low. The physiological
interpretation of Hippocrates, Galen and Avicenna was still respected. The second
university centre, opened in Zamość, did not pursue medical sciences. The situation
in the Western regions of the country was somewhat different. However, despite
the fact that there was no university there, the doctors from that region were
in constant and lively contact with Western European scientists in the field
of biology and medicine. Nevertheless, we can start discussing the beginnings
of Polish contribution to the disciplines of anatomy and physiology. Numerous
works dealing with the relations of the heart and blood vessels written by Polish
authors started appearing during this period. One should mention the work of
obstetrics, with a chapter: "O biciu serca y omdlewaniu brzemiennych" ("On the
heartbeat and syncope of the pregnant women"). A rather clumsy explanation of
the reasons for the physical weakness and syncope appears in this chapter, ascribed
by the author to the disturbances of the performance of the heart.
Adalbert (Wojciech) Nowopolski
(1505-1559), the author of the first Polish
manual on anatomy "Fabricatio hominis", quotes a variety of works, with the
one by Andreas Vesalius among them. Nowopolski's work contains numerous fragments
on the heart and blood vessels and presents ideas on the physiology of circulation
The only Polish physician of that era to became famous abroad in his lifetime
and still remembered by historians of medicine, was Joseph Struś
the outstanding physician of the Renaissance. He became famous for his publication
of the brilliant work "Sphigmicae artis mille ducentos annos perditae et
desideratae libri V
" (4). We can proudly claim that work to be the first
Polish genuinely scientific dissertation on the physiology of circulation. Struś,
born in Poznań, after completing his studies in Cracovian Academy went to Padova
(Padua) to continue his education. At the age of 26 (1536) he became a professor
of University of Padova. To honour his outstanding pedagogical skills and extraordinary
knowledge the University community granted him a position of a prorector of
the University. In 1537 he decided to go back to Poland. Struś started lecturing
in Kraków on the 29th
of October 1537. Unfortunately,
he decided to stop lecturing next year. He took the position of a mansion physician
of Starosta of Wielkopolska. Very soon he was offered a position of a court
physician of queen Isabella - daughter of king Sigismund the Old, and a wife
of John Zapoly (king of Hungary), to get yet another proposition of a post of
a court physician of the king Sigismund August. He was also treating the Spanish
king Philip II and Turkish sultan Suleiman II (the Magnificent) (2, 3).
Now let us get back to the great work of Struś
, "Sphigmicae artis...
Soon after being completed, the book was published in Basel almost on the spot
(1555), in approximately 1000 copies and doctors and medical students, greedy
for knowledge, literally fought to get it. According to the records, 300 copies
of the book were sold on the first day of its appearance in Padova! (5). The
work of Struś, although based on the ideas of Galen, was genuine on nature.
It took under consideration the most current achievements of the medical art.
He suspected the existence of vasomotor nerves; he would agree that body temperature
could affect the pulse. He classified pulse into five different types: high,
frequent, accelerated, strong and soft, and many subordinate subtypes. He compared
the pulse to the rhythm of music. It well could be that he was the first to
depict the pulse graphically, so he can easily being considered the inventor,
(pioneer) of sphygmography (Fig.1
). He indicated that the changes of
pulse could reflect the emotions, including sexual reactions and love (2, 4).
||Fig. 1. The first attempting of the diagrammatic record of the human pulse - J. Struś - 1555 r.
In 1628 appeared the fundamental work "Exercitatio anatomica de motu cordis
et sangunis in animalibus
" of Sir William Harvey
(6). The same year
(1673) was promoted to Baccalaureate at the Cracovian
Academy, on the grounds of his thesis entitled "Questio de motu cordis
The question whether the sensational discovery of William Harvey arrived that
quickly to Kraków, remains unanswered. Was it an echo of the lectures attended
(or the word passed by the third party?), or the Ochocki's work is coincidentally
convergent with Sir William's work? It seems that Ochocki's short elaboration
containing four conclusions was a result of his own speculations and, simply,
of common sense - but it lacked the sharp wit and modern expressions one could
find in Sir William Harvey's work. Moreover, there was no background of the
original experimental verification for the theory in animal material performed
by the great discoverer, Sir William. Nevertheless, it appeared original, as
Ochocki at the time immediately before completing his writing was unlikely to
have travelled abroad. All four "Ochocki's conclusions" were presented briefly
and concisely as the evidence of his understanding of the blood flow in a human
body. On the top of that he attempted to solve the dilemma of whether the heart
moves "in a natural way". The expressions and notions applied still held the
deep medieval appearance and they bore the scholasticism of his times, remote
from the brilliance of Sir William Harvey. But still, the description of blood
flow and the directions of that flow were reported properly, all of it contradictory
to the ideas of Galen (2, 3).
The Polish physicians studying and perfecting their skills in the Italian universities
of the XVIIth
century must have known the work
of the brilliant English scientist. Unfortunately, the Harvey's work did not
receive the adequate appreciation for a long time. It should be stressed then,
that apart from Ochocki, another young physician, John Toński
, was in
the group of medics of the Cracovian Academy, who presented the original dissertation
"De motu sanguinis
" (1647) in order to get incorporated into the Medical
Faculty after he completed his studies in the foreign universities (in Padova,
among the others). Unfortunately, his dissertation was in a form of manuscript,
as during those times publishing in print could compromise author's professional
and scientific career of the highly unpopular Harvey's theses. Toński could
differentiate the adult circulation from the foetal one; he described the role
of foramen ovalae
and ductus arteriosus
. Despite few mistakes
resulting mainly from the incomplete knowledge or wrong interpretation of the
Harvey's work, his elaboration was the first Polish open promotion of the new
theory on the circulation of blood. Moreover, Toński was probably the first
Polish author aware of the distinct physiology of foetal circulation (2).
The studies of Adam Christian Thebesius
(1686-1732), a physician from
Lower Silesia had the inestimable value for the understanding of circulatory
). He was one of the most famous scientists studying
the anatomy of the heart, and the pioneer in studies on the coronary circulation
(2, 7). He was not a Pole, he did not speak Polish, he spent almost all his
life in Silesia - his native country - and he worked there, but we refer to
that man with a satisfaction, recalling his links with our country. In 1708
he published the work "Disputatio medica inauguralis de circulo sanquinis
" in Leiden. After his return to Silesia for 20 years he performed
the important function of a city "physicist" in Jelenia Góra. He was a consultant
to the Habsburg court and a fellow of the Leopoldian-Carolian Academy of Nature
Researchers in Wrocław (7). He was the first to describe in details the physiology
of coronary circulation: venae cardiacae minimae, the coronary sinus valve,
and some congenital anomalies of coronary arteries. The first out of these descriptions
refers to the small veins collecting venous blood directly into the ventricles,
being the element that complements the coronary venous return. Thebesius' veins
gain the importance in pathology, e.g. in the congenital defects with total
deficit of coronary sinus. Thebesius' valve is a small endocardial fold closing
the outlet of the coronary sinus in a right atrium of the heart; sometimes it
is only a residual film. It is a relic (similarly to the Eustachian valve) of
a foetal valve of the right venous sinus. Moreover, as one of the first, Thebesius
described the "ossification" of coronary arteries. However, it was his mistake
to claim that the leaflets of aortic valve were closing the outlets of coronary
arteries during the outflow of blood from the left ventricle.
||Fig. 2. Adam Christian Thebesius (1686-1732)
In the XVIIIth
century brilliant elaborations
on the circulation and physiology of the heart were scarce in our country. Those
who wanted to get educated in the medical arts had to study in Western Europe
because of stagnation in the Cracovian Academy. Foreigners took positions of
medical doctors, and even they did not represent any interesting personalities.
The only exceptions in this situation were few elaborations that could serve
as some sort of briefing on matters concerning the anatomy or physiology of
circulation. Also some descriptions of the peripheral organ perfusion and the
role of particular blood and lymphatic vessels appeared. The elaborations mentioned
below were obviously based, to great extent, on the works of foreign masters,
but they were prepared thoroughly, and since the eventual appearance of medical
bibliography in Polish, the stage of creating a Polish medical nomenclature
in the literature started. An altogether good elaboration of John Adamus
, a physician from Wrocław, appears in 1718. He was probably born
and educated in this city. After completing his medical education and achieving
the rank of a physician in the West (he was H. Boerheve's student) he came to
Gdańsk where he wrote two very interesting works: "De sanguine ejusque circulatione
(1718) and "De circulatione sanquinis medicina universali
" (1744). The
works mentioned were based on Harvey's theory of blood circulation, so they
were not his genuine invention, but he earned recognition after publishing them
in the Eastern Europe. That was the first scientific, carefully elaborated presentation
based on a profound understanding of physiology in this part of the continent,
a presentation of a theory that at that time was not very popular. In 1722 he
published "Tabulae anatomicae
" - a large atlas of anatomy, translated
into seven languages, including Japanese. And so Kulmus gained international
In 1786 a small booklet entitled "Stan człowieka zdrowego naturalny" ("A natural
condition of a healthy man") of Felix Xavier Ryszkowski
in Polish (Fig. 3
). The book was published in Kraków in 1786 (8). It
was possibly written for laymen curious about the medical arts. The descriptions
of blood circulation contained in the book, which, by the way, are quite often
cited in historical elaborations, are light and easy and they are written in
a beautiful old-fashioned Polish. The author presented the theory of blood flow
through the pulmonary capillaries and explained the idea of gas diffusion through
the alveolar-capillary membrane, quoting M. Malpighi's discoveries.
||Fig. 3. Stan człowieka
zdrowego naturalny..., by Feliks Ksawery Ryszkowski, Kraków, 1786
The same year (1786) an army physician, Theodore Weichardt
similar but slightly more professional description of physiology of blood circulation
and of heart and blood vessel anatomy (Fig. 4
). He published a very thoroughly
elaborated small work, "Anatomy", in Polish (9). A fragment referring to a foetal
circulation reflects the perfect knowledge of the topic and excellent theoretical
background of the author. If not for the old-fashioned language, some of the
Weinhardt's descriptions could easily be incorporated into the contemporary
manuals for the students.
POLISH CONTRIBUTION TO THE UNDERSTANDING OF
THE CIRCULATION OF BLOOD IN THE XIXth CENTURY
||Fig. 4. Anatomia... by
Theodore Weichardt, 1786
The turn of the XVIIIth
century coincided with the loss of independence as a result of partitions of
Poland. Polish lands were annexed to Russia, Prussia and Austria. Socially underdeveloped,
pushed to the level of uncivilised and economically neglected province, submitted
to the process of denationalization, the country sank into anarchy. All that
would strongly affect the fate of the development of science in Poland. Two
Polish regions were granted a sort of a semiautonomy. One was the Polish Kingdom,
remaining within the Russian occupational zone and the other was Kraków with
a small piece of the adjacent land, which became a miniature "Republic" under
the control of all three occupants. In those regions some residual freedoms
allowed for promotion of development of science and the reform of the national
education. The great progress in medical sciences that took place at the same
time (the beginning of the XIXth
century) in Western
Europe had a substantial impact on Polish medicine. The experience and new discoveries
flowing from the West very soon led to initiation of an interest in the circulatory
system, its structure and pathology. The beginnings of the Polish involvement
in this matter are mainly linked to the medical colleges and to the newly set
medical associations. The scientific analyses of the etiology of diseases of
the circulatory system and the application of increasingly more rational treatment
began. It is obvious that the foundation is physiology, in which the physicians
of the XIXth
century naturally had to develop
a more profound interest. It opens up the road to a better understanding of
all irregularities of the human system, which needed to be treated more effectively.
Physiology as a separate branch of science first appears in the first half of
century and blooms by the end of it.
A department of physiology, the first in the world, was founded in Wrocław,
initiated by John Evangelist Purkinyě
(1787-1869), a great Czech scientist
who was one of the founders of experimental physiology. His discovery of fibres
of the conductive system in the heart (later called "Purkinye's fibres") (6)
was one of his many major achievements in physiology. Obviously, we do not attempt
to include the great scientist in the Areopagus of Polish fathers of medicine.
Purkinyě worked in Wrocław, which presently is a Polish city; he made all his
exquisite discoveries in Wrocław, and we recall this outstanding researcher
and his substantial contribution to the studies on the heart only for the clarity
One of the centres of Polish science was the Vilnius Academy
in which there appeared a chance for a progress in the studies on circulatory
system. It was founded in 1579 as the Jesuit Academy, but it did not undertake
teaching of medical sciences until the end of the XVIIIth
century. The Medical Faculty was finally founded on April 4th
1803. The Vilnius University was transformed into the Szkoła Medyko-Chirurgiczna
) in 1832, but unfortunately, 10 years
later it was closed and moved to Kijów (10). Vilnius Academy was the leading
Polish centre of development of medicine including cardiology in the first half
of the XIXth
century. This centre was also recognized
as a part of European scientific community thanks to such scientists as Joseph
, Jędrzej (Andrew) Śniadecki
, Vincent Herberski
(3, 10). Polish medical terminology in theoretical sciences was
also created in this Academy, including cardiological terms. In 1804 Joseph
(1771-1842) from Vienna became a chair of the Department of Pathology.
He chaired the Department of Detailed Therapy and Medical Department since 1806.
He was an outstanding practitioner and a shrewd observer of the human physiology.
As an author of voluminous medical work he presented the most current achievements
in medicine in a monograph on the heart and circulation. The school created
by Frank had profound influence on the development of Polish cardiology, and
his students (with W. Herberski, J. Oczapowski or F. Rymkiewicz among them)
became renowned leaders of the modern cardiologic diagnostics far beyond their
country (10). Jędrzej Śniadecki (1768-1838) is considered to be a co-creator
of modern resuscitation (11). He recommended the application of mouth-to-mouth
method of artificial ventilation (in 1805). In selected cases he suggested tracheotomy.
Among his very innovative methods was the application of electric current to
the chest in order to initiate breathing during resuscitation.
Jakub (James) Szymkiewicz
(1775-1818), the author of the first Polish
case report on a cyanotic heart defect (1806), very accurately describes the
physiological state of systemic cyanosis pointing to the disturbances in saturation
of blood with oxygen, either caused by anatomical conditions (such as narrowing
of pulmonary arteries), pulmonary embolism, or decrease in the area of oxygen
exchange due to the tuberculous lesions in the lungs (10).
The first manual of physiology in Polish by Hyacinth J. Dziarkowski
"Fizjologia czyli fizyka ciała ludzkiego dla lekarzów i przyjaciół antropologii
("Physiology, i.e. the physics of a human body for physicians and friends
") appeared in 1809. This manual was based on the work
of G.W.Ch. Consbruch containing the information on blood and lymph circulation.
Another book published in Warszawa in 1816 by Franciszek (Francis) Brandt, "Angiology"
on the blood and lymphatic vessels, was based on the work of G.F. Hildebrandt.
Very good descriptions of the pulmonic and systemic blood circulation could
be found there (10).
The reform of Cracovian Academy at the turn of XIXth
century was a major breakthrough for
Polish medicine and cardiology as well. There appeared numerous publications
of Cracovian physicians (Joseph Lewicki, Alexander Kremer, John Cenner, John
A. Klecki, Onuphrius Dzianott, John B. Bobrzyński) referring to the circulatory
system (5, 12, 13). The work of Klecki
(1833) on oedemas appearing in
the course of circulatory failure is worth mentioning. The author explained
that the misbalance between the fluid escape through the capillaries and its
reabsorption was the reason for the oedema. Alexander Kremer
) in his manual on the percussion and auscultation (1841) presented his
opinions pertaining to the physical basis of generation of tones and murmurs
in the heart (10). In his doctorate in 1820 ("De angore pectoris
Cenner summarized the contemporary state of art in angina pectoris (Fig.
). Along with the information on the essence of disease (some of it based
on wrong assumptions) the author gave quite precise recommendations as to the
conditions favouring the occurrence of the disease and the methods of prevention.
He presented the hygienic and nutritional instructions pointing to the proper
diet versus improper one, and he drew our attention to the need for proper care
as far as the balance in the delivery of fluids was concerned ("large volumes
of liquids, tea or coffee are contraindicated...") and recommended refraining
from alcoholic beverages or other stimulants (12).
||Fig. 5. Alexander Kremer (1813-1880)
||Fig. 6. Dissertatio inauguralis
medica de angore pectoris, by Jan Cenner, Kraków, 1820
A dozen or so years later, in his doctoral dissertation (Fig. 7
) in 1836,
came back to sphygmology, the knowledge of pulse,
which for ages has been of interest for physicians (5). We know that physicians
of those times did not know how to examine the pulse, nor could they make anything
out of it, as did the physicians earlier. They assumed that palpation lacked
precision required to make it useful and led to mistakes. However, the new methods
and means of percussion and auscultation came into use at that time, and application
of these methods made evaluation of the conditions of the circulatory system
incomparably simpler. The old ways were not abandoned quickly, but after a period
of backwardness in the Cracovian medicine, which also included simply neglecting
the thorough clinical examination of a patient, the examination of pulse was
restored. The above mentioned work did not contain any brilliant discoveries
nor was it the first Polish work on human pulse as almost three centuries earlier
our great countryman, already mentioned Joseph Struś, wrote his magnificent
work on this matter. Nevertheless, it was a thorough "review" of the earlier
achievements and of the ways the thinking of medicine was shaping as far as
the interpretation of pulse was concerned (5). Next, in 1837, there appeared
the doctoral dissertation "De asphyxia in genere
" (Fig. 8
John B. Bobrzyński
, dealing with the conditions of circulatory system.
The author attempted the description of causes of dyspnea in different types
of diseases and tried to find the relationship between these conditions and
the congenital anomalies of the heart and compromised pulmonary circulation
or the corrupted function of the left ventricle. He also pointed out to the
necessity of restoration of circulatory system function in the course of resuscitation
||Fig. 7. Sphygmologia seu
doctrina de pulsu
, by Onufry Dzianott, Kraków, 1836
||Fig. 8. De asphyxia in
genere commentatio inauguralis, by Jan B. Bobrzyński, Kraków, 1837
The Varsovian physician, Ferdinand Dworzaczek
was an excellent observer
of physiological events in cardiovascular system. In the 1840's he was occupied
with the problem of fetal circulation, the causes of cyanosis in congenital
defects of the heart and intracardiac shunts. He was a promoter of the modern
physical examination in clinical medicine and associated the physical symptoms
with the physiology of circulation (10).
(1813-1868) from Poznań was professionally active at
the same time. He completed his studies and defended his dissertation "De
muscularu cordis structura
" (1839) in Wrocław. He wrote his thesis under
the supervision of Purkinyě who advised him as to "the entire clarification
of the complex structure of the heart
" (10). The author performed the detailed
review of the literature on the macroscopic image of the cardiac muscle and
of the studies performed thus far. He used animal hearts for his experiments.
It never was an investigation of the physiology of this organ, but rather so
called functional morphology. As far as the character of the description was
concerned, it was the synthesis of all the contemporary scientific approaches
and one of the broadest works on the subject on international scale (6). Robert
was another scientist of Polish origin from Poznań, but very often
is mistaken for a German. He performed studies on the neurogenic theory of cardiac
automatism. This great scientist spoke Polish and kept confirming his relations
with Poland. Later, after living for years in Germany, he published his papers
only in German. He made numerous discoveries in histology, and his leading achievements
pertained to the neuron. He described the neurons without the myelin sheath.
Remak was the first to observe the neural ganglia in the heart. These localised
in the neural plexuses in the area of the junction of main veins and subendocardially
in the interventricular septum and in papillary muscles (2, 6). Some outstanding
clinical doctors, who ran their own departments, such as Joseph Dietl
(1804-1878), Edward Sas-Korczyński
(1844-1905) from Kraków, Oscar
(1830-1900) from Lwów, Henry Łuczkiewicz
(1833-1919), Theodore Dunin
(1854-1909) from Warszawa,
were equally interested in physiology of circulation. Joseph Dietl, the chair
of the Medical Department in Krakow, attempted to introduce the scientific principles
in diagnostics and treatment of heart diseases, based on a profound analysis
of physical and physiological phenomena. That kind of analysis was also promoted
in Warszawa by Łuczkiewicz
(10). E. Korczyński
) was familiar with the physiological issues related to the heart
and blood vessels. He performed advanced clinical studies pertaining to the
vasomotor reactions and the influence of nitroglycerine on the circulatory and
nervous system. Among phenomena reported were the feeling of warmth in the head,
the feeling of fullness, and problems with concentration. Korczyński is believed
to be the second in the world to recognize myocardial infarction in a live patient
in 1887 (6, 10).
||Fig. 9. Edward Sas Korczyński (1844-1905)
) was an experienced investigator. He made attempts
to elucidate the mechanism of initiation of hypertension in the course of atherosclerosis.
Basing on about one thousand experiments performed he concluded that the increased
blood pressure was related to disturbances in lipid metabolism. He also performed
studies on so-called functional hypertension. In 1893 he analysed the causes
of degenerative lesions of the heart, called "ungluing" of the myocardiocytes.
||Fig. 10. Theodore Dunin (1854-1909)
The papers of O. Widmann
from Lwów contained a vast knowledge of pathophysiology
of congenital anomalies of the heart. His manuals concerning the diseases of
the heart and the blood vessels (1879 and 1884) were the first publications
on those topics in Poland (Fig. 11
||Fig. 11. Choroby serca
i wielkich pni naczyniowych, by Oskar Widmann, Warszawa, 1884
The studies of the Cracovian scientist, Napoleon Cybulski
) made significant contribution to the development of Polish
physiology and cardiology. He set up a centre of physiological studies, which
became well known throughout Europe, and a major part of his research contributed
substantially to the development of sciences related to the circulatory system
in the world. One of his most significant achievements was his discovery (together
with Władysław Szymonowicz
) (1895) of a substance contained in the adrenal
glands that strongly constricted blood vessels and increased blood pressure.
That discovery had a great impact on the understanding of hypertension and it
further affected the progress in clinical studies. The scientist named this
substance "nadnerczyna", which was then translated into "adrenaline". Then Cybulski's
invention of photohaemotachometre (1885) (i.e., a device for measurement of
blood flow in vessels) also had a great influence on the progress in research
on hemodynamics (3, 10, 14). Cybulski, being fascinated by the discoveries of
W. Einthoven, was the first in Poland to obtain the records of electric activity
of the heart. Therefore, he was a pioneer of electrocardiography in our country.
Cybulski's numerous students and followers, such as physiologists Adolph
(1863-1942), Andrew Klisiecki
(1895-1975), and Francis Czubalski
(1884-1965), and histologists Stanisław Maziarski (1873-1956) and Władysław
Szymonowicz (1869-1939) further continued his studies. For instance, Adolph
(1894) dissertation entitled: "On the changes of blood pressure in
veins" qualifying him for an associate professor referred to the physiology
of the circulatory system (10, 14, 16). The experimental scientist, John Prus
(1859-1926), the chair of the Department of General and Experimental Pathology
in Lwów, performed the studies on the resuscitation of people in clinical death.
He was the first in the world (January 19th
to perform a direct massage of the heart after surgical opening of a chest (suicidal
hanging), with simultaneous artificial ventilation through a tracheostomy tube.
Two hours after death he restored the action of the heart within 15 minutes.
Thus Prus became one of the pioneers of reanimation. He tried to prove in his
works that it was possible to restore activity of the heart after sudden cardiac
arrest, using mechanical stimuli. He analysed the bibliography of the other
authors in different countries (1901-1910), who also applied his method of reanimation.
He found 11 case reports of successfully performed reanimation in patients with
cardiac arrest during surgical procedures (3, 14).
|Fig. 12. Adolph
Beck (1863-1942) with Napoleon Cybulski (1854-1919), from left to right
(Museum of History of Medicine, Kraków)
We may also mention the book, which was published in 1899 by Wilhelm Pisek
a physician from the Public Hospital in Lwów (an ex-assistant to Korczyński).
That book entitled "The therapy of diseases of heart and blood vessels
had quite different character, which swerved from the trends of rapid progress
in medical science concerning studies on circulation and the heart. However,
it was connected with cardiology, as the author tried to "complement the principles
of treatment of valve dysfunction and degeneration of the cardiac muscle" in
his own way. In fact, in order to treat these diseases he recommended, among
the others, massage and Swedish gymnastics and physiotherapy and climatic therapy.
But that was not all. He attempted to define acceptable limits for the physical
exertion and the capability of procreation of patients with heart diseases (15).
The second half of the XIXth
century brings the
development of theoretical specialisations in medicine, including physiology.
In particular, the great progress was made in the physiology of circulation.
(1834-1907), an embryologist from Warszawa and the author
of the first Polish manual on histology, left behind numerous papers of great
importance referring to these matters. He discovered native arterio-venous anastomoses.
Felix Nawrocki, a professor of physiology, worked at the same time in Warszawa.
He was a student of both Rudolph Heidenhein at the acclaimed Institute of Physiology
in Wrocław and of Claude Bernard in Paris. Nawrocki made several interesting
observations on the relationship between the blood pressure and heart function
THE END OF THE XIXth
CENTURY AND THE FIRST HALF OF THE XXth CENTURY
Physiology had already crystallised into a separate branch of science, but still
valuable contributions from the borderline between theory and practice were
made by a group of clinicians - practitioners, interested in the essence of
events in cardiovascular system. An outstanding scientist, Edmund Faustyn
(1866-1911), published a series of articles referring to the physiology
and pathology of the heart. Joseph Pawiński
(1851-1925), who became famous
as a genuine creator of cardiology in Poland (Fig. 13
), noticed that
heart disease led to disturbances in physiology of the entire organism of the
patient (10, 16). His numerous papers referred to heart failure in the course
of organic anomalies; he also studied cardiac dysrhythmias and introduced the
term of so-called incomplete contraction. He wrote about the influence of disturbances
in the nervous system on the cardiovascular diseases, about the impact of emotions
and mental overburden, nicotine and some cardiac drugs. Working with Anthony
Hołowiński, he performed creative experiments that allowed for graphic recording
of circulatory system function and obtaining tracings of heart sounds, thus
becoming a pioneer in the field of phonocardiography. In 1883 Pawiński, independently
from Graham Steele, reported and proved the existence of diastolic murmur in
a case of mitral stenosis, resulting from the partial insufficiency of the pulmonary
artery valve. Physiology of circulation was also the major field of interest
for the other outstanding clinician from Warszawa Kazimierz (Casimir) Rzętkowski
(1870-1924) (Fig. 14
). He studied the physiology of cardiac function
in different heart diseases, heart failure and chemical changes in the cardiac
muscle. Some 10 years before H. Eppinger he reported the chemical changes as
the cause of disturbances in cardiac function (16). He found the decrease in
protein content, the increase in sodium chloride concentration and claimed that
ionic imbalance was responsible for the loss of ability of cardiac muscle to
use the energy resources for contraction. In 1904 Rzętkowski performed the experiments
on rabbits treating them with intravenous injections of adrenaline, which raised
their blood pressure and, subsequently, led to the development of atherosclerosis
of aorta. He addressed the issue whether adrenaline damaged the vessel wall
by the increase of blood pressure or whether adrenaline could trigger atherosclerosis
through its direct detrimental action on the vessel wall. Edwin Mięsowicz
(1875-1914) and Zenon Orłowski
(1871-1948) continued Rzętkowski's investigations
in 1906, and W. Nowicki with Joseph S. Hornowski did so in 1907 (3, 16). The
authors concluded that chronic arterial hypertension dependent on adrenaline
was the trigger for atherosclerosis and similar condition could occur in humans
through the stimulation of nervous system. They tried to elucidate the mechanism
of hypertension and concluded that the increase of vascular tone and the vasoconstrictor
reactions played an important role. They associated hypertension and atherosclerosis
with improper diet, especially with high content of meat and animal fat (16).
Another investigator who had contributed much to the development of clinical
medicine in Poland, Władysław Biegański
(1856-1917), worked in Częstochowa.
In 1881, basing his conclusions on clinical studies, he found that atherosclerosis
was a process secondary to chronic hypertension.
||Fig. 13. Joseph Pawiński (1851-1925)
||Fig. 14. Casimir Rzętkowski (1870-1924)
The studies performed by a group led by L. Popielski
a significant contribution to the progress in physiology of circulation. In
1909 Popielski's team discovered a compound that could be found in every tissue,
which could lower blood pressure in physiological conditions; it was histamine.
Popielski produced in the stomach is most powerful stimulant of gastric acid
secretion. He found also a compound coming from disrupted erythrocytes, which
was capable to efficiently lower blood pressure; he named it "wazodylatyna
"). He also showed that intravenous atropine and morphine
lowered blood pressure because they hemolysed erythrocytes, which, in turn,
released vasodilatine. Unfortunately, Popielski never tried to use his observations
in the treatment of hypertension (10, 16).
During the interwar period, Polish investigators working in the field of physiology
of the cardiovascular system published important new clinical findings. One
of those clinicians is Tadeusz Tempka
(1885-1974) showed in 1923 in Kraków
the powerful influence of calcium ions on the cardiac muscle and pointed to
the necessity of monitoring of these ions in the course of treatment with digitalis
(17). An internist, Alexander Oszacki
, working in diabetology and endocrinology
in Kraków, performed interesting studies in clinical physiology. Eventually,
he published a paper in 1920 entitled "Energetyczne wskaźniki sprawności
" ("Energy indicators of efficiency of circulation
paper presented the principles of evaluation of the general state of circulation
and pointed to the relation between the size of the heart during systole and
diastole and its anatomical and physiological condition. Strong research centres
appeared in Lwów. Marian Franke
(1877-1944) created an excellent experimental
centre in the Department of General and Experimental Pathology of the University
of Lwów, which he chaired. Next, the Department of Experimental Pharmacology,
chaired by Włodzimierz Koskowski
, became famous for its studies on the
action of vasoactive drugs and on histamine-induced hypotension, in particular.
In his paper of 1920 Koskowski reported that histamine-induced hypotension resulted
from the inhibitory action of this amine on the sympathetic nerve endings or
on a hypothetical neuromuscular mediator, which mediated the action of catecholamines.
He also made an assumption that "the site of action of a-imidazolylethanolamine
was the same as that for adrenaline" (16). This way he explained the interaction
of these two amines in their action on blood vessels. In the USA, half a century
later, W.G. Richards and C.R. Gannelin obtained the same results (18). In 1920
Koskowski also showed that nicotine affected the heart through the ganglia but
not through the vagal nerve endings (19). The Koskowski's studies on plant extracts
allowed for introduction of a new hypotensive drug, "Myostratol", into the clinic.
The scientists from the Koskowski's group (J. Dadlez, P. Kubikowski and J. Teuchmann),
who worked on the activity of biogenic amines, obtained surprisingly interesting
results and their papers were highly valued among their peers, pharmacologists
of cardiovascular system (16).
In the 1920's, in the Veterinary Medical College in Lwów, a young scientist,
(1895-1975) performed his studies (Fig. 15
in continuation of the research run by his mentor, Napoleon Cybulski from Kraków.
Having modified the device, he started studies on the speed of blood flow using
the photohaemotachometer. Klisiecki worked out the equation for the speed of
blood flow in a cannula: V=R-g (R - a difference in pressures, g - gravitation
coefficient) (20). In his dissertation for getting qualified as an associate
professor, he presented the evidence for the presence of systolic and dicrotic
speed waves in the aorta, of breath waves, which thus far were known to occur
only in the peripheral arteries, and the third order speed waves analogous to
the so called Traube's and Hering's waves in the tracings of arterial blood
pressure. He also analysed the dynamics of blood flow in arteries corrupted
by calcifications resulting in a loss of elasticity (1929-1935). In the thirties,
Klisiecki and his very talented student, Wiesław Hołobut
the etiopathogenesis of histamine shock. The results were presented in a classical
paper (1937) on the disturbances of function of the left ventricle, resulting
in a fall in arterial blood pressure in the course of histamine shock (21).
After the war Klisiecki lived and continued his studies in Wrocław.
||Fig. 15. Andrew Klisiecki (1895-1975)
A very interesting body of research, done by Jerzy (George) Kaulbersz
(1891-1986), an outstanding Cracovian physiologist (Fig. 16
) and the
head of the Department of Physiology, was started in the 1920's and referred,
to some extent, to the cardiovascular system (22). These studies related to
the high mountain medicine and the reaction of the human body to high altitude
(the Alpes and Peruvian and Bolivian Andes) and received worldwide recognition.
After World War II, one of his major interests was high mountain physiology
extended to aviation and space medicine. He also investigated physiology of
physical exercise, e.g. adaptation of the circulatory system to the prolonged
physical effort in skiers during international ski competition in Zakopane.
Part of these studies was done in collaboration with Andrew Ogiński
(1913-1985) (Fig. 17
). Research into the physiology
of circulation made up the majority of Wcisło's professional activity, and his
hard work and ingenuity assured his impact on the development of experimental
techniques in the world of experimental cardiology (23). The first work that
started his contribution to the world science was his doctor's dissertation
(1945), entitled: "The influence of gas masks on the breathing and cardiac output
per minute". During very hard times following World War II he (with Kaulbersz)
studied the functional reserve of the heart in humans during rapid changes of
the volume of flowing blood (during work or physical training). He also started
experimenting with the circulatory systems of animals. He was the first to measure
and record in a single living animal the following circulatory system parameters
simultaneously: blood pressure in the aorta and the vena cava, the output of
right and the left heart, the coronary and total systemic blood flow (22, 23).
||Fig. 16. George Kaulbersz (1891-1986) [reproduced with permission of J. Grochowski]
||Fig. 17. Vincent Wcisło (1913-1985) [reproduced with permission of J. Grochowski]
He measured cardiac output using Fick's and plethysmographic methods along with
the determination of pulmonary artery blood flow. He measured the blood flows
using Cybulski's photohaemotachometre, which he himself modified. For the measurement
of the changes in volume of the organs he used a plethysmograph he had constructed.
After he had perfected the experimental methodology he started his studies on
the performance of the heart during an episode of acute circulatory failure.
In his paper on the pathogenesis of histamine shock (1959) he described several
interesting original hemodynamic tests, which he applied to prove that both
cardiac and vascular factors contributed to the development of histamine shock.
One of Wcisło's most brilliant contributions was the introduction of a new
method of evaluation of coronary blood flow
in dogs (along with the measurement
of the outflow from the coronary sinus), without the necessity of opening of
the animal's chest. He could make it by using a set of cannulas and external
tubings in the femoral artery, carotid artery and coronary artery, as well as
the coronary sinus. At the same time he continued his studies on the physiology
of work and sports, investigating the metabolism of cardiac muscle. In 1967-68
he elaborated a new method of experimental provocation of an acute coronary
failure by means of a small cannula introduced into the coronary artery. His
methods were internationally recognised by physiologists [presentations at conferences
in Washington (1968) and in Munich (1971)]. He was the creator of educational
films on physiology and pathophysiology of the circulatory system. His films
became famous worldwide after their presentation at festivals of educational
films [Cannes (1958 and 1959), Padua (1963), Varna (1966), Venice (1977), and
The issues pertaining to the physiology and pathophysiology of the circulatory
system remained in the scope of interest of the Department of Physiology of
Medical College in Kraków (at present Collegium Medicum of Jagiellonian University)
for a long time. At the moment it is a very influential centre of modern physiological
studies and it is difficult to cite all the spectacular achievements related
to the circulatory system in works led by Stanisław Konturek
In Warszawa, Bohdan Lewartowski
made remarkable achievements in the range
of basic sciences related to the heart. His studies, which fundamentally clarified
the problem of calcium ion flow in the intracellular compartments, are known
worldwide. Polish cardiologists received and still do receive acknowledgement
due to their studies, which are very often cited in the prestigious literature
on cardiology, as for example, the paper of L. Ceremużyński
and his collaborators
in 1969, on the dysrhythmias in experimental ischemia of cardiac muscle (24).
The last quarter of the XXth
century brought several
achievements in this matter in a number of scientific centres in Poland. In
fact, there is no room for offering them here, so we finish presenting our "short
historical outline" of Polish studies on physiology of circulation at end of
POLISH INTERESTS IN THE PATHOPHYSIOLOGY OF CORONARY ISCHEMIC DISEASE
Early in the Renaissance Polish scientists contributed to the elaboration of
diagnosis of the diseases of the heart (coronary ischemic disease in particular)
and their etiopathogenesis. The descriptions of the coronary ischemic disease
were known in the ancient times. Lucius Seneca (the Younger) suffered from this
disease, as we learned from his letters to his friend Licilius. He described
in them the symptoms of his dramatic illness, which could not be anything else
but angina pectoris. The "numbness" of coronary vessels drew the attention of
Giovanni M. Lancisi (1654-1720), who attempted to find the reason for angina
pectoris by investigating the details of heart anatomy. Both A. Ch. Thebesius
a physician from Lower Silesia, in 1708, and J.B. Morgagni
in 1760, followed suit. But it was only in 1768, when W. Heberden
presented a complete description of angina pectoris that was close to today's
The first descriptions of angina pectoris from Polish sources appeared in the
first half of the XIXth
century. They were contained
the works of J. Chrzczonowicz (1812), J. Cenner (1820), A. Janikowski (1844)
and J. Rompalski (1850) (25-28).
Two eminent clinicians, Joseph Pawiński and Mściwój Semerau-Siemianowski, greatly
advanced the understanding of ischemic heart disease in the first half of the
century by characterizing sign and symptom
patterns with stages of advancement of coronary artery disease.
Pawiński pointed out the significance of factors such as atherosclerosis, smoking
and emotional stress and their effects on the etiopathogenesis of angina pectoris.
The majority of Semerau-Siemianowski's
activities took place in the 1920's
and concentrated on etiopathogenesis and diagnostics of angina pectoris (29).
The increasing incidence of angina pectoris just after the World War II resulted
in a rapid progress in studies on etiopathogenesis of this illness. The new
name for the disease was accepted, a literal expression from English, i.e. ischemic
heart disease. It was firmly stated that atherosclerosis was the main culprit
in the ischemic heart disease and myocardial infarction in particular. The disturbances
in homeostasis of the organism, such as incorrect lipid metabolism, became the
major targets of the studies, although the other less common causes of myocardial
infarction, such as bacterial infection and resulting inflammation of the coronary
vessels or influenza (30) were also investigated. Detailed studies of hormonal
and immunological reactivity in the ischemic heart disease were performed in
Poland during the 1970's. L. Ceremużyński
, W. Januszewicz
found profound endocrine disturbances in the course of
a fresh myocardial infarction (31-33). The authors emphasised a marked increase
in catecholamine and a significant drop in glucocorticosteroid concentration
in the plasma during the acute phase of myocardial infarction, in particular.
Numerous studies performed later in other cardiology centres confirmed these
observations. The understanding of these processes became a prerequisite for
rational action in the therapy of myocardial infarction, based on the blockade
of excessive reactivity of the adrenergic system.
The autoimmune reactions are another important issue in the cardiac muscle diseases.
The first paper in the world on immunological problems in the heart diseases
appeared in 1937; it was a paper of the Polish scientist, H. Brokman. It started
the period of investigations on the contribution of immunological reactions
to the etiopathogenesis of the heart diseases (34). M. Gamski
was the first in Poland to study the immunological reactions in ischemic heart
disease. J. Kuch and T. Chorzelski
performed a comprehensive evaluation
of the autoimmunological phenomenon in myocardial infarction using immunofluorescence
IF test and immunofluorescence IF staining (35, 36). Screening a significant
cohort of 60 patients with acute myocardial infarction they detected the presence
of anti-cardiac antibodies (IgG) in blood serum in a quite high percentage of
patients tested (19 patients). The increase in concentration of the antibodies
could be detected for several weeks after the myocardial infarction. Moreover,
using indirect - IF staining, the authors established the presence of antigen
- antibody complexes (muscle cells - IgG) in the scrapes of muscles taken from
the area of post myocardial scar from patients post mortem. Later A. Żebrowski
obtained similar results, using the same method (37).
The Progress in Non-invasive Diagnostics
In the past 10 years (1994-2004) we witnessed a great progress in cardiology. Even though from a historical perspective a decade is a rather short time, there happened a tremendous advances in diagnostics and treatment of cardiovascular diseases. Polish cardiology and cardiosurgery kept pace with the rest of the world.
Both in a non-invasive (tissue Doppler's echocardiography, three-dimensional echocardiography, magnetic resonance) as well as in invasive diagnostics (intravascular echocardiography, coronarography) many diagnostic centres in Poland meet the standards of the most experienced European centres.
Echocardiography as the Basic Diagnostic Method
Since 1954 echocardiography has been one of the basic diagnostic methods. First
echocardiographic recording in Poland was performed in the Institute of Cardiology
of Medical Academy in Warszawa in 1966. The work of Christine Ilmużyńska
led to a broad acceptance of one-dimensional echocardiography in cardiology
clinics throughout the country. Nevertheless, there was an obvious delay in
introduction of the method as compared to the Western European centres.
The introduction of two-dimensional echocardiography into the clinics was a
major breakthrough in the cardiologic diagnostics. It allowed for the imaging
of the anatomical structures of the heart and the evaluation of the heart in
motion, i.e. of its action in a real time. Introduction of other methods made
possible the assessment of flow using Doppler's method and allowed new options
for visualisation of the heart and the great vessels. In 1987 W. Rydlewska-Sadowska
published the first broad and complex dissertation on the evaluation of flow
by Doppler's technique (38). The author presented the first discussion of colour
visualisation of flow in a monograph "Clinical Echocardiography", published
by the Institute of Cardiology in Warszawa. In 1988 Wojciech (Adalbert) Braksator
and his team from the Department of Cardiology of the II Faculty of Medicine
of Medical Academy in Warszawa performed the first echocardiographic intraesophageal
examination in Poland (39). It was few years after publications of Hisnaga,
Matsumoto and Hanrath, who introduced this method as a routine procedure into
the clinical practice at the turn of seventies and eighties. This method turned
out to be very useful in the evaluation of structure of the heart, especially
of valvular insufficiency and isolated disturbances in contractility after myocardial
infarction in those cases, which were difficult to diagnose by the transthoracic
The end of the eighties and the beginning of the nineties of the XXth
century meant the continuous and rapid progress in echocardiography; in a way,
the progress was a step ahead of the possibilities of application of this method
in practice. The intravascular echocardiography became the most sophisticated
technique of echocardiographic examination. Due to the miniaturisation of the
echocardiographic probe of the frequency of 20 MHz it was possible to evaluate
the coronary blood vessels, to "look inside" these vessels. W. Rużyłło with
his group presented the first paper on this topic in Poland at the Congress
on Cardiology in Gdańsk in 1992. At present this technique is used for qualification
of patients for surgery and monitoring of procedures during interventional cardiology:
angioplasty, rotablation and implantation of intravascular stents. It should
be mentioned, that it was a Polish physician, Tomasz Cieszyński
Medical Academy in Wrocław, who was the first in the world to introduce the
echocardiographic probe into the heart in order to examine its structure. His
original was patented in Poland on October 19th
in 1956 (40).
During the mid 1990's two new echocardiographic techniques were introduced into clinical use. The first one, colour kinesis is based on the automatic detection of endocardium in consecutive images during contraction. The motion of the endocardium is encoded with different colours depending on the phase of contraction. It allows for an evaluation of the kinetics of motion with accuracy on the order of tens of milliseconds.
The second method, the tissue Doppler echocardiography consists of an analysis
of motion of cardiac tissues. In this method the ultrasonographic signal reflected
from the cardiac tissue undergoes Doppler analysis; the speed of the motion
of the tissue is presented in the form of a colour map superimposed on a conventional
black and white echocardiographic image. It becomes possible to differentiate
the moving fragments of cardiac tissue, encoded with colour, from immobile,
non-coloured pericardial tissue. In the echocardiographic diagnostics this method
offers better visualisation of the borders of endocardium and enables the evaluation
of the speed of the cardiac motion at any phase of cardiac cycle. J. Drożdż
of the Cardiology Department of the Medical Academy in Łódź performed first
studies on this new diagnostic imaging technique in Poland. He started his work
on the subject during his stay in Essen in 1993, in a group with R. Erbel and
H. J. Nesser, and continued it in Poland. The results were presented at cardiologic
congresses and published in scientific journals (41, 42). They were the basis
for the first monograph on this subject. It was published in 1995 (R. Erbel,
H. J. Nesser, J. Drożdż "Atlas of Tissue Doppler Echocardiography").
At present, three-dimensional echocardiography is considered the best among
the non-invasive techniques for evaluation of the morphology of the heart. The
studies of Wallschlager (and his team) and the resulting papers from the late
1980's provided the rationale for the introduction of this method into clinical
diagnostics. J. Kasprzak
from the Department of Cardiology at the Medical
Academy in Łódź was the first in Poland to apply this technique. He learned
it during his training abroad and investigated it in Thoraxcentre in Rotterdam.
He published his results together with J.R.T. Roelandt (42, 43). He is a co-author
of a series of experimental investigations, performed in an animal model. These
pioneer studies related to the measurement of the area of ischemia by means
of the three-dimensional echocardiography after application of contrast. The
value of three-dimensional echocardiography in determining the mapping of the
ischemia in cardiac muscle has been proven. The size and the mass of the region
prone to necrosis resulting from the occlusion of coronary arteries in pigs
were evaluated. If this technique is available it may become a useful and important
method for the assessment of the pathological lesions in acute coronary episodes
in humans in the future. Moreover, three-dimensional echocardiography is useful
for the evaluation of heart structure, and, especially, of the thoracic aorta
and its valve during three-dimensional reconstruction.
The Application of Magnetic Resonance in Coronary Angiography
An American physicist, I.I. Rabi
, discovered the phenomenon of magnetic
in 1939. He was awarded the Nobel Prize for his discovery.
Then, P.C. Lanterbur
from the New York University published his first
images made by means of magnetic resonance, in Nature in 1963. Not until 20
years later, in 1982, the first equipment enabling the imaging of the entire
body by MRI was presented.
Coronary angiography with the use of magnetic resonance offers the possibilities
of the non-invasive imaging of epicardial coronary arteries in the majority
of patients (44). J. Walecki
and T. Zaleska
and her group from
the Central Railway Hospital in Warszawa presented first papers on the heart
structure and function in the primary cardiomyopathy at the International Cardiologic
Symposium in 1993 (45). Later, in 1998, the results of studies on the evaluation
of the myocardial infarction size were presented at the Congress of International
Magnetic Resonance Association (ISMRM). The group of T. Zaleska, J. Walecki
and A.Torbicki presented very interesting studies on the evaluation of the chronic
thrombosis in the main pulmonary arteries with the use of magnetic resonance.
The method proved to be very useful in diagnosing, determining the progress
of the illness, and evaluating the effectiveness of treatment.
Out-patient ECG Monitoring
Out-patient ECG monitoring in Poland started when first records using radio waves (radioelectrocardiography) were registered in the Institute of Cardiology of Medical Academy in Warszawa in the 1960's. The first recorders were constructed in 1969 in the Clinical Laboratory of Medical Electronics, using magnetic tape for registration of the tracings of ECG in non-hospitalised patients. They were some of the first recorders in the world and anticipated what would become the Holter monitor.
The demonstrated success in the studies gained numerous followers and several clinical centres appeared. The Polish version of the recorder, Oxford-Medilog system, obviously promoted broad availability of the method and became standard equipment at many newly established centres. The establishment of the Holter Section in 1993 (the Section of Non-invasive Electrocardiography of the Polish Society of Cardiology at present) was a very important event as it led the way in research and education.
The well-received papers on the diagnostic value and clinical relevance of parameters evaluated by the Holter system were published in 2001 (46). The unique system of standard values for the parameters evaluated for both the adults and children were discussed. The Holter system was used for the first time in the world for complex analysis of the sinus node function with the simultaneous evaluation of the dynamics of the sino-atrial timing (World Report 1988).
The vivid activity of the Polish research centres on the international scene resulted in the significant role of Polish cardiologists in functioning of the International Society for Holter and Non-invasive Electrocardiology. W. Zaręba is the president-elect; R. Piotrowicz is a member of the Board and R. Baranowski is a member of the extended Board.
Invasive Cardiologic Diagnostics and Intervention Cardiology
Hemodynamic heart diagnostics is the system of investigation based on the analysis of data obtained directly from the heart chambers and great vessels. There are several methods that serve this purpose, and the most important one is the cannulation of the heart and angiography. The first method yields the information on the blood flow and the other one reflects the morphological structure of the heart.
The first cannulation of the right half of the heart was performed in Poland
in 1948 (I. Krzemińska-Ławkowicz
, Warszawa). In 1962, T. Hryniewiecki
(Warszawa) performed the first cannulation of the left half of the heart using
intra-arterial and interseptal technique (47).
In 1948, A. Jakubowski
and L. Zgliczyński
a simple seriograph to perform the first angiography. The method of direct examination
of the coronary arteries by means of a selective coronarography was introduced
in 1967. W. Rużyłło
pioneered this work in 1967-68 (the Department of
Cardiology, Warszawa). Coronarography became the method of special significance
when the era of the coronary surgery started in the late sixties.
Soon after A. Gruentzig's announcement of first experiments using transcutaneous intravascular coronaroplasty (PTCA) in 1977, W. Rużyłło went through the training in his laboratory and in 1981 he performed the first procedures of widening the narrowed coronary arteries. During the late 1980's one might say that the Polish school of invasive cardiology was established. Since the introduction of percutaneous intravascular coronaroplasty, a dynamic progress of therapeutic techniques based on the cannulation of the heart could be observed. In the mid eighties the methods of non-surgical treatment of the congenital and acquired defects of the heart based on the balloon technique became more and more common. Those were the first procedures of pulmonary and aortic valvuloplasty, angioplasty of aortic coarctation and percutaneous mitral comisurotomy in our country (47).
The first procedure of pulmonary valvuloplasty in Poland was performed in 1984,
two years after the first world publication. A regression of the right ventricle
outflow tract obstruction was observed after completion of balloon pulmonary
valvuloplasty procedure (48). At the end of the eighties percutaneous mitral
comisurotomy became an alternative to surgery in treatment of the stenotic mitral
valve in some cardiology centers in the world. It was introduced in Poland in
1987 as the method of treatment of the mitral valve stenosis without the need
for thoracotomy. In 1994 the new techniques of non-surgical closure of patent
ductus arteriosus (Rużyłło et al.
), Rashkind's double umbrella (1994),
"detached coils" (1996) and Amplatz's cork (1997) were introduced in Poland.
Detached coils and Amplatz's cork became the methods of choice in the treatment
of patients with patent ductus arteriosus
, both in the world and in Poland.
In 1997 the procedures of non-surgical closure of atrial septal defects of II
type were introduced in Poland simultaneously in three cardiology centers (W.
Rużyłło, M. Demkow, Warszawa; J. Białkowski, Zabrze; G. Brzezińska-Rajszys,
Warszawa). Those were the first clinical trials with a new type of an occluder,
which were also performed in other cardiologic centres in the world at that
time. It also became the method of choice in the treatment of large group of
patients with the same type of defect (49). In December 1999, W. Rużyłło and
M. Demkow performed for the first time in Poland, and perhaps in the world,
a successful non-surgical procedure of closure, by stages, of the two postinfarction
ventricular septal defects, using the Amplatz's occluder (50). The introduction
of stent implantation in the narrowed sections of the coronary arteries during
the 1980's was quite revolutionary. In 1989, H. Bonnier
performed the first procedure of the coronary stent implantation during Workshops
on Hemodynamics in the Silesian Centre for Heart Diseases in Zabrze. A team
of Polish physicians (M. Dąbrowski, A. Witkowski - Institute of Cardiology in
Warszawa) implanted for the first time two Palmatz-Schatz stents into the right
coronary artery in 1992. The Institute of Cardiology coordinated the first multicentre
national programme "Angioplasty or stent?" which compared the results of stent
implantation with balloon angioplasty in patients suffering from ischemic heart
disease. A programme of primary angioplasty in the acute myocardial infarction
with hemodynamic laboratory being on duty 24 hours a day was initiated in Poland
in the Silesian Centre for Heart Diseases
in the middle of 1987. The
period of rapid increase in the availability of primary angioplasty lasted from
2000-2001, until now. In 2003, the number of patients treated with primary angioplasty
in Poland reached the level of 20 thousand, and the number of centres with a
hemodynamic laboratory on duty 24 hours a day increased up to 40. In April 2002
in two centres in Poland (the Institute of Cardiology in Warszawa and Collegium
Medicum of Jagiellonian University in Kraków) gene therapy was used in the treatment
of patients with ischemic heart disease who were disqualified from classical
revascularisation procedures. The gene encoding the vascular endothelial growth
factor (VEGF) was administered percutaneously directly into the myocardium of
the left ventricle using NOGA system as a part of the international research
programme EUROINJEST ONE. In 2003, for the first time in Poland, I. Siminiak
(Medical Academy in Poznań) injected myoblasts through the cardiac veins into
the myocardium of a patient with damaged left ventricle, while monitoring with
intravascular ultrasonography (IVUS) (47).
POLISH CARDIAC SURGERY: THERAPY AND CARDIOVASCULAR PATHOPHYSIOLOGY RESEARCH PROGRAMMES
While briefly summarising the history of studies on the cardiovascular system
in Poland, starting from the distant past up to the present, and placing it
in the international context, one cannot forget about cardiac surgery. Very
often it was surgery that was the inspiration for the pursuit of the knowledge
and better understanding of biology of the myocardium and the blood vessels,
the energy processes, the complex mechanisms of ischemia and possibilities of
cardiac muscle protection, mediators, enzyme systems and all the other intriguing
and mysterious issues related to the human body. Continuing progress in cardiac
surgery is inevitably linked to contemporary research programmes in physiology
of the circulatory system and contemporary cardiology. Polish cardiac surgery
has its own tradition that has begun more than a century ago. In 1898 (hardly
2 years after a famous operation of suturing of the heart wound performed by
Louis Rehn) Witold Horodyński and a few months later Wacław Maliszewski performed
the operations of puncture wound repair of the heart; unfortunately without
success. Jan Borzymowski in the Holy Spirit Hospital (Szpital św. Ducha) in
Warszawa performed a similar operation on April 23rd 1902, and then, in 1904,
reported three such cases, out of which one (on February 28th 1903) turned out
to be a full success (52). Borzymowski's
patient was one the first such
patients in the world saved that way. The beginnings of cardiac surgery of congenital
heart defects in Poland had some delay; it was not until after World War II.
Nevertheless, Polish surgeons tried hard to catch up with the progress in medicine,
in spite of post-war problems and a huge gap in the possibilities of therapy
between the West and our country, harassed first by the war and then the post-war
communist anarchy. In the 1940's and 1950's Polish surgeons followed the progress
of cardiac surgery in the West (especially in the USA). One only can to imagine
how in the face of scarcity of diagnostic and technical means for surgery, yet
presented with desperate need of the operation in patients with cardiac defects
they bravely performed these difficult tasks. Poland may be proud of the group
of great and talented surgeons, who became part of history of world medicine.
Among them, Leon Szoege-Manteuffel
, who earned the reputation of a pioneer
in paediatric cardiac surgery when he performed the first mitral comisurotomy
in Poland in 1953. He ligated the ductus arteriosus
in 1948, 10 years
after the first operation of that kind in the world performed in Boston by R.
Gross in 1938. In 1950 Manteuffel made the Blalock-Taussig shunt for the first
time in Poland, and in 1958, together with Jan Kossakowski
the first correction of aortic coarctation, not to mention the first Polish
open heart operation (closure of the atrial septal defect in hypothermia) performed
by Victor Bross in Wrocław in 1958 (hardly 6 years after the first operations
of that kind, in the USA) (53). In the 1990's the results of Polish cardiac
surgeons were equal to those, whose achievements were published by the leading
centres in the West. Their numbers also approached the level of satisfying the
needs for treatment of children with cardiac defects. Consequently our paediatric
cardiac surgery has reached a stage similar to that of the most developed and
richest European countries. Moreover, since in the present paper we attempt
to evaluate the contribution of Polish physicians to the world science in the
field of physiology of circulation, let us recall that in the last two decades
of the XXth
century there occurred a breakthrough
in the approach that surgeons make to the physiology of circulation of a newborn
with a severe defect. This breakthrough consists of a novel surgical procedure,
which resulted in a spectacular improvement in the outcome. Polish cardiac surgeons
substantially contributed to this progress, when they succeeded in the treatment
of the transposition of the great arteries (Jacek Moll, Łódź
) or the
hypoplastic left heart syndrome (Edward Malec, Kraków
) with results no
worse than those obtained by the most renowned cardiologic centres in the world,
if not better.
The routine introduction of the surgical procedure of cavo-pulmonary connection in cases of a heart with a single ventricle morphology (according to "Fontan's principles") made necessary certain revolutionary changes in postsurgical therapy, ones based on the special hemodynamics of a new pattern of pulmonary flow that is entirely different from the physiological one (56).
The centres such as Warszawa (B. Maruszewski
), Kraków (E. Malec
and Zabrze (J. Skalski
) are the most experienced in the treatment of
this group of patients. In 1997 the programme of mini-invasive and cosmetic
treatment of congenital heart defects was introduced (J. Skalski with his team,
Zabrze). The experience of Polish paediatric cardiac surgeons is not without
an impact on the development of science in this field of medicine. An immense
progress in the adult cardiac surgery and surgical treatment of ischemic heart
disease in particular occurred in Poland. The first by-pass operation for ischemic
heart disease with use the saphenous vein (CABG) was performed in Poland by
Jan Moll in 1970. Then in 1984 in Łódź, Richard Jaszewski
thoracic artery for the same purpose. The programme for surgical treatment of
recent myocardial infarction, introduced into Zabrze in 1985 by Zbigniew Religa,
brought positive results. It was further extended by Marian Zembala, in cooperation
with invasive cardiologists, to a group of patients operated during myocardial
infarction and cardiogenic shock and was presented at numerous international
congresses (57). In 1985, 16 years after the first unsuccessful attempt of heart
transplantation by J. Moll in 1969 in Łódź, Zbigniew Religa
, as the first
in Poland, performed the operation successfully (53).
and his team were the first to successfully perform the heart
and lung transplantation in Poland, in Zabrze in 2001 (54, 55). In 1987 M. Zembala
and P. Buszman introduced for the first time in our country, in Zabrze, a surgical
treatment of ventricular paroxysmal tachycardia using the Harken's technique
(endocardial peeling) with a concomitant intraoperative epi- and endocardial
mapping. Kazimierz Suwalski further developed this treatment in Warszawa. The
first procedure of epicardial ablation with the use of microwave technique on
a beating heart without extracorporeal circulation was performed in Zabrze in
2001. For patients who were not qualified for by-pass surgery, transmyocardial
laser revascularisation (TMLR) was performed for the first time in Poland by
Marian Śliwiński in 1996. At the beginning of the 1990's some cardiac surgical
centres in Poland (Katowice, Zabrze, Warszawa, Szczecin, Gdańsk) introduced
operations on a beating heart without application of extracorporeal circulation.
Stanisław Woś's team in Katowice successfully performed the first mini-invasive
operation (MIDCAB) in 1996. One of the newest of the less invasive treatment
methods for ischemic heart disease is hybrid revascularisation. It consists
of a combination of percutaneous angioplasty, very often combined with arterial
stenting, and by-passing of the coronary arteries through a small access on
a working heart. In Poland the majority of such procedures were performed in
Szczecin (K. Filipiak, R. Gil), in Katowice (R. Bachowski, M. Cisowski, P. Buszman)
and in Zabrze (R. Przybylski, T. Hrapkowicz, J. Pacholewicz, M. Gąsior). In
1998 Andrzej Bochenek and Marek Cisowski introduced a videoscopic technique
of harvesting the internal thoracic artery using the surgical robot (AESOP).
Romuald Cichoń, a surgeon from Zabrze, working in Dresden, was the first to
perform the operation on the heart using an operational robot of the Da Vinci
type without thoracotomy and circulatory arrest (57).
The progress in Polish cardiology and cardiac surgery in the recent times in performing research studies on the complex matters of myocardial physiology and pathology, with postinfarction cardiomyopathy in particular, cardiogenic shock, cardiac protection, remodelling, angiogenesis and, eventually, the transplantation of stem cells, is outstanding, indeed. The character of this article and its rather narrow range destined for presentation of the outcome of discussion on the history of physiological studies on the circulation in Poland do not allow for touching, even in a nutshell, of all the scientific trends of the recent times. Then we kindly request the forgiveness in case we did not give a rightful chance to some very important issues to get included in this paper. We also ask for your leniency if, without ill will, we contained in our work too much of the subjectivism which is probably always present in historical elaborations, anyway.
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