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May 27, 2017
18th Century Raymond Vieussens

Raymond Vieussens (1641-1715)

Traite nouveau de la structure et des causes du mouvement naturel du Coeur. In ceuvres Francaises de M. Vieussens dediees a nosseigneurs des etats de la province de Languedoc, Toulouse, 1715

Raymond Vieussens
Portrait of Raymond Vieussens
Portrait of Raymond Vieussens


Cesalpino Andrea
  Cesalpino Andrea

Raymond Vieussens was a leading French physician and anatomist of the 17th century. He was professor at the University of Montpellier, one of the major centers of medical knowledge in Europe during the 17th and 18th centuries. He is celebrated for his anatomic studies of the brain and his pioneering work in the field of cardiology.  

He described several neuro-anatomic structures including the anterior medullary velum between the cerebelar pedoncules, the mass of white matter within the cerebral hemispheres, a small space called fifth ventricle beneath the corpus callosum, the celiac ganglia. His neurologic discoveries were published in "Novum vasorum corpris humani systema" in 1705.

Raymond Vieussens was one of the greatest early contributors to the field of cardiology. His historic monograph, "Traite nouveau de la structure et des causes du mouvement naturel du Coeur,"  which was published in 1715, the year of his death, is considered the earliest work focusing entirely on cardiac anatomy and pathology. One of the unique features of this outstanding work is Vieussens' permanent attempt to establish the relationship between anatomic structures and their physiologic function.

The table of contents of Vieussens' monograph is displayed here.

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  Cesalpino Andrea

Regarding the anatomy of the heart, He was the first to describe precisely the course of the coronary arteries and the coronary sinus. He also described collateral vessels connecting the left anterior descending artery and the right coronary artery (circle of Vieussens), the valve Vieussens situated at the junction of the great cardiac vein and coronary sinus ostium and finally a depression at the margin of the fossa ovalis called Vieussens' annulus.  In his monograph, he provided several historical illustrations demonstrating the arterial and venous coronary circulation. These engravings on coronary artery anatomy were very detailed and precise and probably the best ever published in the history until that time (plates 1 to 6). He also described in detail the organization of myocardial fibers of the right and left ventricles (plates 7 to 9).

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From pathologic perspective, similar to Lower, he reported cases of pericardial effusion and restrictive pericarditis ("symphyse pericardique"). He presented in detail the clinical manifestations associated with these diseases. He described one of the first cases of aortic regurgitation.

Raymond Vieussens was also the first to provide a comprehensive description of mitral stenosis with extreme precision in the report of clinical symptoms and autopsy findings. In the introduction of this section of his monograph, he first discussed the structural and functional anatomy of the mitral valve. He then gave an account of a case of  "bony transformation of the mitral valve" which was referred to him in 1705.  Vieussens described a 30 year old male who initially presented with low grade fever, dyspnea and lower extremities edema. As his condition did not improve despite "medical treatment", the patient was referred to Vieussens who wrote in his assessment:

"He was lying on his bed, his head quite high; his respiration seemed to me very difficult, his heart was working with a very violent palpitation; his pulse appeared small, feeble & quite unequal, his lips were the color of lead and his eyes sunken; his legs and his hips were swollen; & rather cold than hot."

Vieussens thought the prognosis of this patient was extremely poor. He then added that the violence of the palpitation of the heart and the nature of the symptoms associated with it were such as to convince him that the disease of this young patient was due to an actual change, the nature of which eluded him, in the tissues of this organ.

The clinical situation of this patient deteriorated rapidly and he expired within a week. At postmortem examination, Vieussens remarked:

"...The entire cavity of the chest was filled with a yellow serous fluid; the lungs were extraordinarily large & soft, because all of its tissue was soaked with an aqueous lymph its size [heart] was so extraordinary that it approached that of a beef's heart: the coronary veins & all of their branches were very much dilated; the cavity of the right ventricle & the right auricle were very large (See figure on the twelfth plate).

When I had opened the right ventricle...I noticed in the first place that the size of the columnae carneae & the trabeculae carnea... surpassed a great deal their natural size... I observed in the second place that the usual openings of this ventricle had been so markedly dilated, that they had become very evident, & that the membrane which covered them, had been so distended, that it allowed the blood which came from it to pass freely... the usual openings of the right auricle had become markedly dilated...

Great as was the dilatation of the part of the vena cava where the two trunks join; it was not as remarkable as that of the pulmonary vein, which one can see in the first figure of the thirteenth plate. In proportion as the trunk of this vein was excessively dilated, the common openings became larger, & the left auricle was also dilated in such a manner that finally the fossa disappeared, if you will except a few of those at the tip....I perceived that the mouth of the left ventricle appeared very small, and that it had an oval oblong shape; & in searching for the cause of such a surprising fact, I discovered that the mitral valves of this ventricle were really bony, & realized that as they became hardened, they would become thickened and rough enough to cause a marked narrowing of the lumen, & give a picture such as is represented in the figures of the plate indicated below [plates 13].

...I opened the left ventricle, & I discovered here first that which I have just pointed out: namely, that the substance of the mitral valves has become bony, & that it had very markedly diminished, & indeed changed the natural appearance of its lumen: I observed in the second place that the bundles of the columnae carneae which formed the sides of the fossa of this ventricle, had lost, some of them, much of their natural size, because they did not receive as much blood as they had accustomed to receive before the mitral valves were changed into a bony substance, & others not receiving any at all, had become pale, & had taken the form of small tendinous ligaments very little like those of the mitral valve. (See the second figure of the thirteenth plate.)

The lumen of the left ventricle being markedly narrowed, & its margin having lost all of its natural suppleness, blood could no more enter freely & as abundantly as it should have into the cavity of this ventricle: so that in the beginning the circulation was impaired, it commenced to dilate extraordinarily the pulmonary vein, because the blood remained  too long & accumulated  in too large an amount. The blood had no longer commenced to make too long a stay in the trunk of this vein, than it retarded the course of that in all the blood-vessels of the lungs: so that the branches of the pulmonary artery and pulmonary vein extending throughout all the tissue of this organ , were always too full of blood, & consequently so dilated that they compressed the vesicles, interfered with the free entrance of air or prevented it from leaving freely; that is why the patient always breathed with a great deal of difficulty. As the blood thickened considerably in the lung because of its stay in the blood vessels, its serous portion separated little by little & fell into the cavity of the chest."

The entire Vieussens' historical text on mitral stenosis is displayed in the original French version (pages 101-106). Raymond Vieussens illustrated this case  with two magnificent engravings (plates 12 and 13). The drawings were made by Lason at the time of dissection in Montpellier. They were taken to Paris to be engraved by Simmoneau who was one of the most brilliant engravers of his time.

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In his treatise,  Vieussens also discussed "the structure of the internal surface of the right ventricle." He provided a detailed description of the structural and functional anatomy of the tricuspid and pulmonic valves (pages 98-101). Here again, he illustrated his observations with outstanding engravings (plates 10 and 11).

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Vieussens skillfully provided one of the most comprehensive early descriptions of mitral valve stenosis in the history of medicine. He remarkably presented the clinical manifestations and the autopsy findings and used this information to explain the pathophysiology of this condition. He correctly recognized the hemodynamic consequences of mitral stenosis with dilatation of the left atrium and the right-sided chambers, pulmonary congestion and impairment of the blood circulation.

Vieussens' achievement is credit to his ability as a great physician and his observation is one of the most remarkable early accounts of disease in the history of cardiology.

REFERENCES

Major RH. Classic descriptions of disease. 3rd ed. Springfield Ill, CC Thomas,1945

Jarcho S. The concept of heart failure, From Avicenna to Albertini. Cambridge, Harvard University Press,1980


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Giovanni Maria Lancisi


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