The First Writings of Heart Failure

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The First Writings of Heart Failure
Hector O. Ventura, MD Section Head, Heart
Failure TransplantationChairman, Graduate
Medical EducationOchsner Heart Vascular
InstituteNew Orleans, Louisiana
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T.S. Elliot

• The historical sense involves a perception,
  not only of the pastness of the past, but its
  presence.

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Frank Luttmer
There is another reason to study history it is
FUN. History combines the excitement of
exploration and discovery with the sense of
reward born of successfully confronting and
making sense of complex and challenging problems.
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Hydropsy or Dropsy
Generalized swelling due to accumulation of
excess water
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The Concept of Heart Failure
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Paradigms in the Evolution of Our Understanding
of Heart Failure
Clinical Observation Case reports describing
signs and symptoms Anatomic Pathology
Autopsy correlations with clinical findings,
microscopy pathology Circulatory Physiology
Abnormalities in the circulation of the blood
Katz AM. J Card Fail. 19973319-34.
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Paradigms in the Evolution of Our Understanding
of Heart Failure
Cardiac Hemodynamics Pressure and flow
abnormalities in the failing heart Cell
Biochemistry Abnormal contraction, and
Biophysics relaxation and energetics microscopy
pathology Molecular Biology Growth
abnormalities
Katz AM. J Card Fail. 19973319-34.
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Bloodletting
It is the least equivocal of remedies its good
effects, when properly administered, are, in
most cases, so immediate and striking... In
short, bloodletting is a remedy which, when
judiciously employed, it is hardly possible to
estimate too highly."
Ventura HO Mehra MR. J Card Fail.
200511247-52.
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Egyptians
(4000 BC - 2000 BC)
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Ebers Papyrus
The heart is the centre, its vessels lead
to all members, whether the doctor lays his
fingers in the forehead, on the back of
the neck, on the hands, everywhere he
meets with the heart, because its vessels
lead to all members.
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Contribution to the Knowledgeof Heart Failure
The Egyptians were able to count the pulse and
used it as means of assessing the function of
the heart. Dyspnea was due to the blockage of
the flow of blood and employed venesection
(bleeding).
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When thou examinest the obstruction in his
abdomen and thou findest that heis not in a
condition to leap the Nile, his stomach is
swollen and chest asthmatic, then say thou to
him it is blood that got itself fixed and does
not circulate.
Saba MM et al. J Card Failure. 200612416-21.
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Do thou cause an emptying by means of a
medical remedy. Make him therefore
Cook in beer that has been brewed from many
ingredients, strain into one thoroughly, and
let the patient drink.
Wormwood 1/8, Elderberries 1/16, Sebester
1/8, Sasa-chips 1/8
Saba MM et al. J Card Failure. 200612416-21.
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The main and most common word utilized to
indicate "weakness or feebleness" of the heart is
wegeg.
Saba MM et al. J Card Failure. 200612416-21.
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855m. Weakness due to old age. These are
pain-matters have fallen on his heart. 855f.
His heart is bored. This means that his heart
is weak because of heat of the anus. 855x.
His flesh is entirely hot, as the heart of a
man tires, exhausted by the road. This means
that his flesh is tired as a result, like the
flesh of a man because he has gone very far.
Saba MM et al. J Card Failure. 200612416-21.
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855l. The heart kneels down because of
pain-matter. This means that his heart becomes
small inside of his belly. Pain matters have
fallen on his heart and it becomes and kneels
down. 855e. The heart weakens. This means that
the heart does not speak or that the vessels of
the heart are dumb. Its information under your
hands which normally appears because of the air
with which they are filled is missing.
Saba MM et al. J Card Failure. 200612416-21.
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• 855c. The heart is weak. A vessel called "the
  receiver" is the one that causes it. It is this
  vessel that gives water to the heart.
• 855d. Debility that has arisen in the heart.
  This means it is arching out as far as the
  borders of the lung and liver. It happens there
  from to him that his vessels become deaf, having
  fallen down as a result of their heat.

Saba MM et al. J Card Failure. 200612416-21.
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Ancient Greeks
(2000 BC - 100 BC)
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Contribution to the Knowledge of Medicine
The major contribution of the Greeks was to
separate the practice of medicine from the
disciplines of philosophy and theology. This
allowed medicine to develop as a separate craft
based on knowledge gained by careful observation
of patients.
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Contribution to the Knowledge of Medicine
Hippocrates (460-370 BC) First ethical
code Rational scientific Clinical observation
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Hippocrates
When the ear is held to the chest, and one
listens for some time, it may be heard to
seethe inside like a boiling of vinegar.
Diseases II, LXI
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Hippocrates
Should phlegm coming from the brain make its
way to the heart, palpitation and difficulty
breathing supervenefor the phlegm descends cold
to the lungs and heart, the blood is chilled
the veinsbeat forcefully against the lungs and
heart, and the heart palpates, so that under this
compulsion difficulty of breathing and orthopnea
results. The Sacred Disease IX
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Hippocrates
Dropsy is usually produced when the patient
remains for a long time with impurities of the
body following a long illness. The flesh is
consumed and becomes water the abdomen fills
with water, the feet and legs swell, the
shoulders, clavicles, chest and thighs melts
away.
Affections XXII
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Romans
(100 BC - 476 AD)
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Contribution to the Knowledge of Medicine
Progress in Public health Sanitation Founded
first hospitals
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Celsus
when moderate and without any choking, it is
called dyspnea when more severe, so that the
patient cannot breathe without making a noise
and gasping, asthma but when in addition the
patient can hardly draw in his breath unless
with the neck outstretched, orthopnea. Of these
the first can last a long while, the two
following as a rule acute blood letting is the
remedy unless anything prohibits it. Moreover
even in bed the head is to be kept raised
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The Circulation According to Galen
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Galen (130 - c 200 CE)
. . . in the heart there must be warmth in
plenty, for it both moves itself and the other
parts at the same time as with its pulse, and it
also warms them . . . The heart must always be
on the boil . . . the heat flows from the heart
to the members not only through the arteries but
also through the veins . . . On the Use of the
Pulse I, 5-7.
. . . we breathe for regulation of heat. This
then is the principal use of breathing which
is brought about by both parts of of breathing,
both in breathing and out to the one belong
cooling and fanning, and to the other evacuation
of the smoky vapor. On the Use of Breathing
5,8.
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The Middle Ages
(476 AD - 1450 AD)
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Contribution to the Knowledge of Medicine
Decline of the Roman Empire Europe was
devastated by wars, famines, epidemics and
social upheaval which greatly inhibited further
progress in medicine.
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Contribution to the Knowledge of Medicine
Galenic Theories The Christian church controlled
Europe and repressive regimes prevented further
advances in scientific knowledge.
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Contribution to the Knowledge of Medicine

• Existing knowledge of medicine was preserved
  through the early part of this period by Arabic
  speaking people of North Africa and the Middle
  East.
• Rhazes (865-925)
• Avicenna (980-1037)

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Contribution to the Knowledge of Medicine
Avicenna (980-1037)
Canon of Medicine compiled the medical
knowledge of the Greeks and Egyptians,
perpetuating many Galenic and Hippocratic
theories. This was the standard textbook in
many European Medical Schools until the
seventeen century.
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Avicenna
pernicious suffocation hastens to stop the
breathing when the patient lies down, his
breathing is hindered completely, and when is not
recumbent his breathing is difficult also. In
addition, he himself keeps extending his neck in
contriving to breathe. He is restless and wants
to stand erect and cannot lie down. Canon
of Medicine iii.11.1.9
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Avicenna
For fluids are very often found between the
bulk of the heart and its membrane. And it is
known that when they are abundant they restrain
the heart from diastole. Canon of Medicine
iii.11.1.2
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Alexius I
Irene
Anna Comnena
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The Alexiad
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Alexius I Rule of the Byzantine Empire
Most of the doctors had no idea at all of the
danger with which we were threatened. But
Nicolas Kallicles predicted fearful troubles he
told us that he was afraid the humours, having
abandoned the extremities, might move to other
direction and so endanger the patients life
Kallicles foresaw what would happen and told them
emphatically, For the time being the matter has
left the extremities and attacked the shoulder
and neck, but if we do not get rid of it by
purging, it will move again, to some vital organ,
or even the heart itself. If that happens the
damage will be irremediable.
Lutz JE. Am J Cardiol. 198861494-5.
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Alexius I Rule of the Byzantine Empire
He was greatly affected by the pressure of
daily business and the many cares of government.
I often heard him telling the empress about it
in a way he was accusing the disease. What on
earth is this trouble that affects my breathing?
I want to take a deep, full breath and be rid of
this anxiety that troubles me, but however often
I try I can't lift even once a small fraction of
the load that oppresses me. For the rest it's
like a dead weight of stone lying on my heart
and cutting short my breathing. I can't
understand the reason for it nor why such pain
afflicts me.
Lutz JE. Am J Cardiol. 198861494-5.
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Alexius I Rule of the Byzantine Empire
They felt his pulse and admitted that they found
all kinds of irregularities, but they were
altogether unable to give a reason for this.
They knew that the emperor's diet was not rich
it was indeed the sort of food athletes or
soldiers have, so that the question of an
accumulation of humours from too rich a diet was
ruled out they attributed the difficulty in
breathing to some other cause and said the main
reason for his illness was overwork and the
constant pressure of his worries. His heart
they said, was inflamed and was attracting all
the superfluous matter from the rest of the
body
Lutz JE. Am J Cardiol. 198861494-5.
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Alexius I Rule of the Byzantine Empire
Every day it grew worse.... He was unable to
lie on either side so weak that every breath
involved great effort.... He was forced to sit
upright to breathe at all... but when his stomach
was visibly enlarged and his feet also swelled up
and fever laid him low, some doctors, with scant
regard for the fever, has recourse to
cauterization
Lutz JE. Am J Cardiol. 198861494-5.
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Alexius I Rule of the Byzantine Empire
He was forced to sit upright in order to breathe
at all if by chance he did lie on his back or
side, the suffocation was awful to breathe in
or exhale even a tiny stream of air became
impossible. When sleep in pity overcame him,
there was a danger of asphyxia, so that at all
times, asleep or awake, he was menaced by
suffocation. As purgatives were not allowed, the
doctors tried phlebotomy and made an incision at
the elbow, but that also proved fruitless. He
was just as breathless as before and there was a
constant danger that he might expire in our
arms."
Lutz JE. Am J Cardiol. 198861494-5.
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Alexius I Rule of the Byzantine Empire
She kept nudging me, urging me to tell her about
the pulse, but when I touched it again and
recognized that all his strength was going and
the circulation of blood in the arteries had
finally stopped, then I turned away, exhausted
and cold, my head bowed and both hands covering
my eyes."
Lutz JE. Am J Cardiol. 198861494-5.
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Contribution to the Knowledge of Medicine
Later period of the Middle Ages
University of Salerno became for 200 years the
outstanding center for medical education Transfe
r the practice of medicine from the ecclesiastics
to the laity Frederick I introduced a system
to licensing physicians and encouraged the
dissection of human cadavers
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It is shown by an application of a ligature
that the passage of blood is from the arteries to
the veins. Whence it follows that the movement
of the blood is constantly in a circle, and is
brought about by the beat of the heart.