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The First Writings
of Heart Failure
Hector O. Ventura, MD
Section Head,
Heart Failure & Transplantation
Chairman, Graduate Medical Education
Ochsner Heart & Vascular Institute
New Orleans, Louisiana
T.S. Elliot
“The historical sense involves
a perception, not only of the
pastness of the past, but its
presence.”
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.
Hydropsy or “Dropsy”
Generalized swelling due to
accumulation of excess water
The Concept
of Heart Failure
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. 1997;3:319-34.
Paradigms in the Evolution of Our
Understanding of Heart Failure
Cardiac Hemodynamics
Pressure and flow
abnormalities in the
failing heart
Cell Biochemistry
and Biophysics
Abnormal contraction,
relaxation and energetics
microscopy pathology
Molecular Biology
Growth abnormalities
Katz AM. J Card Fail. 1997;3:319-34.
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. 2005;11:247-52.
Egyptians
(4000 BC - 2000 BC)
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.”
Contribution to the Knowledge
of 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).
“When thou examinest the obstruction
in his abdomen and thou findest that he
is 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. 2006;12:416-21.
“Do thou cause an emptying by means
of a medical remedy. Make him therefore:
Wormwood 1/8, Elderberries 1/16,
Sebester 1/8, Sasa-chips 1/8…
Cook in beer that has been brewed
from many ingredients, strain into one
thoroughly, and let the patient drink.”
Saba MM et al. J Card Failure. 2006;12:416-21.
The main and most common word
utilized to indicate "weakness or
feebleness" of the heart is “wegeg.”
Saba MM et al. J Card Failure. 2006;12:416-21.
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. 2006;12:416-21.
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. 2006;12:416-21.
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. 2006;12:416-21.
Ancient Greeks
(2000 BC - 100 BC)
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.
Contribution to the
Knowledge of Medicine
Hippocrates (460-370 BC)
First ethical code
Rational scientific
Clinical observation
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}
Hippocrates
“Should [phlegm coming from the brain]
make its way to the heart, palpitation
and difficulty breathing supervene…
for the phlegm descends cold to
the lungs and heart, the blood is chilled;
the veins…beat 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}
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}
Romans
(100 BC - 476 AD)
Contribution to the
Knowledge of Medicine
Progress in:
Public health
Sanitation
Founded first hospitals
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…”
The Circulation
According to
Galen
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.
The Middle Ages
(476 AD - 1450 AD)
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.
Contribution to the
Knowledge of Medicine
Galenic Theories
The Christian church
controlled Europe and
repressive regimes
prevented further advances
in scientific knowledge.
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)
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.
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
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
Alexius I
Irene
Anna Comnena
The Alexiad
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 patient’s 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. 1988;61:494-5.
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. 1988;61:494-5.
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. 1988;61:494-5.
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. 1988;61:494-5.
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. 1988;61:494-5.
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. 1988;61:494-5.
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
Transfer 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
“…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.”