Galen on “syncope”
Niki Papavramidou*, Dimitrios Tziakas**
* Lecturer, PhD, History of Medicine, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
** Assist. Professor, MD, PhD, FESC, FAHA, FCCP, FACC, University Cardiology Department, School of Medicine, Democritus University of Thrace, Alexandroupolis,
Greece
Corresponding author Niki Papavramidou History of Medicine Dragana area, 68100 Alexandroupolis, Greece Tel: +306976910508
E-mail: papavramidou@hotmail.com
Word count: 2204
Abstract
This paper studies the Galenic views on syncope. According to Galen, syncope is a sudden prostration of the vital powers, without suspension of the
respiration and it is usually a sign or complication of fever. He believed that “cardiac syncope” was a primary illness of the mouth of the oesophagus or of the stomach that affected the heart “by sympathy”, meaning secondarily. The aetiology, the clinical manifestations and the treatment are presented, along with a special section referring to the connection between “marasmus”, which was supposed to be a wasting of the organism of the elders due to “dryness”, and syncope. Numerous authors before and after Galen treated the subject of the famous “cardiac affection”: Hippocrates (4th-5th century BC), Asclepiades (2nd-1st century BC), Celsus (1st century AD), Aretaeus (2nd century AD), Soranus of Ephesus (2nd century AD), and Caelius Aurelianus (5th century AD) all see cardiac syncope as a distinct disease. Based on the Galenic
descriptions, several modern medical conditions may be identified, such as congestive heart failure, hypertrophic cardimyopathy, arrhythmogenic right ventricular dysplasia, congenital long QT syndrome or anomalies of the coronary arteries.
Keywords: syncope, history of medicine, history of cardiology
INRODUCTION
Galen, the most prolific author of antiquity, often refers to a condition called
“syncope” (συγκοπή). According to him, it is an affection of both the heart and the stomach that produces what is called a “heart condition.” Since many people believed that the illness begins in the heart, they attached the term “cardiac,” thus producing the term “cardiac syncope.”[ 1] Others called it “gastric syncope” because they believed that the condition was a symptom of a disease of the opening of oesophagus or of oesophagus itself (that the Greeks named “cardia”), just as are also the
heartburns.[2] According to Siegel (1970), Galen believed that this irritation of the stomach was associated with the heart , and especially with the left ventricle, through humors and connecting vagal fibres.[3]
CLINICAL MANIFESTATIONS
Sweats always occur in syncope, because the person suffering always has a
“dissolved” nature, given that the stomach, just as the bladder, retains more superfluities and delays their separation. In view of the fact that the abundance of sweat is either due to the thinness of the body or due to the amount of superfluities, the abundance of the later provoke profuse sweating.[2] It is then reasonable to read that many people have died from syncope during the summer, because they were not evacuated properly, meaning that the combination of heat with the inability to release the superfluities provoke syncope.[4] Fainting is another symptom that always
precedes syncope.[4] Furthermore, the patient is weak to move, he stretches his limps trying to find a position that is not painful and cannot lift any weight.[5] Frequent pulses are always present in those wasting away from infections and subsequently, in
those being in risk of suffering from gastric syncopes,[6] because frequency of the pulses is the result of weak function.[7] Nevertheless, extreme frequency of the pulse may also be the cause of syncope [6] because it is inseparable from fainting.[8] A sign that heart syncope may occur is the appearance of palpitations of the heart, which usually means accumulation of humor in the pericardium that prevents dilation.
Dyspnoea may also be another symptom and especially the type of dysnoea that makes respiration bigger and more frequent.[9] Finally, heart syncopes are usually accompanied by formicating pulses.[6]
ETIOLOGY
Syncope may arise due to a diseased condition of the heart itself. It usually occurs due to “dyscrasia”, which is the unhealthy temperament of a person, or due to an inflammation or due to a tumor or due to “erysipelas,”[10] which is any disease that reddens the skins with diffuse purulent inflammations of internal organs, but also due to a sympathetic affection of the heart. Other causes are extreme pain,[11]
insomnia, extreme exercise and extreme evacuation of the stomach.[11] Furthermore, when the veins are excessively full, there is the danger of decreasing the innate heat, resulting in heart syncope.[12] Starvation, baths after eating,[12] the application of the so-called “loosening” diet for the treatment of liver infections,[13] are also factors that may cause syncope. Galen refers to many cases of people suffering from heart syncope. He enumerates gladiators that have died after being injured in the heart; this injury provoked the appearance of an inflammation of the organ that caused syncope.
He also refers to healthy people of different ages struck by sudden palpitations without any other visible symptom. He treated them with venesection, with
appropriate medicaments and with what he calls “thinning diet”, treatments that were proved to be life-saving for those of them that had this affection for the first time.[9]
Marasmus and syncope
Marasmus was for Galen the wasting of the organism of older people due to excessive “dryness”. According to the texts, there is a specific type of marasmus that is accompanied by syncope: the pulse is frequent and weak and it occurs in people who suffered syncope before and survived but the danger remained. This type of marasmus demands a mixed type of treatment because the condition is an
intermediate state of disease, since the innate moisture of the parts is wasted. The food taken should neither be cold not warm; so, the mother-milk or the milk of a donkey, barley soup and gruels are appropriate for this diseased condition. An average
consumption of wine is helpful as well. All the abovementioned foods and drinks are used in order to constrict and condense the body.[14]
TREATMENT
If a mild syncope is expected, based on the mildness of the symptoms appearing, the patient should not drink wine but it suffices to eat pomegranates or pears or apples or any other fruit that is acrid. If the syncope is sudden, the patient should drink warm wine and gruel, but moderately, because a larger amount of wine accompanied by difficult-to-digest gruels provokes not only syncope but also
choking.[4] The reason why wine should be warm is because there is necessity for quick digestion of the food and not remaining of it in the stomach. Furthermore, the wine should be white, thin and preferably old but not bitter, and nice-smelling. For those that syncope occurs because of excess of raw humors existing in the stomach,
the thick wines and the watery ones should be avoided because they are harmful.[11]
If the wine is cold and the patient eats other inappropriate foods, the obstruction and the dryness already existing in the stomach will aggravate and sepsis will occur, provoking fever as well. Melikrat, which is a mixture of honey and water that
dissolves thick humors and cleans the viscid ones, is an excellent aid against dryness and sepsis. But it is harmful as well because it increases the fever. If the fever is already high, avoid melikrat and use barley soup instead. If the physician has reasons to believe that the obstructions in the stomach are hard to get rid of, he also has to administer oxymel, which is a mixture of vinegar and honey. But even oxymel, if used badly, may scratch the intestine, may produce cough and harm the nervous parts.
Consequently, it is obvious that it is very difficult to find a treatment that does no harm at all.[11]
DISCUSSION
Syncope is nowadays defined as the sudden, transient loss of consciousness accompanied by loss of postural tone.[15] According to Galen, syncope is a sudden prostration of the vital powers, without suspension of the respiration and it is usually a sign or complication of fever. He believed that “cardiac syncope” was a primary illness of the mouth of the oesophagus or of the stomach, that affected the heart “by sympathy”, meaning secondarily. Numerous authors before and after Galen treated the subject of the famous “cardiac affection”. Hippocrates (4th-5th century B.C), Asclepiades (2nd-1st century B.C.), Celsus (1st century A.D.), Aretaeus (2nd century A.D.), Soranus of Ephesus (2nd century AD) and Caelius Aurelianus (5th century A.D.) all see cardiac syncope as a distinct disease. The Hippocratic Corpus has
attacks cause sudden death without obvious cause”[16] that Mirchandani and Phoon believe it possibly refers to Long QT syndrome.[17] Asclepiades seek to differentiate the signs of the heart disease from those of the stomachic troubles. According to him, the differentiating symptom was that in the heart disease, once the attack had
occurred, palpitations of the heart appeared, along with pain in the area of the left nipple.[18] Celsus thought that heart syncope was the result of great weakness of the body; owing to the languid state of the stomach, the body is melted by immoderate sweating. The symptoms he described were: small and weak pulse, immoderate sweats, breaking out of the chest and neck, while the feet and legs alone were dry and cold.[19] Aretaeus believed that “cardiac syncope” was a disease of the heart and dismisses the idea that it has something to do with the stomach or the oesophagus. He describes small and weak pulse, noisy heart-beat, fainting, coldness of the body, paralysis of the limbs, sweating, and loss of sensation.[20] According to Soranus and Caelius Aurelianus, gastric syncope was different from cardiac syncope, the latter being an acute swift dissolution of the body through all its passages and pores. The symptoms were acute fever, frequent pulse, difficulty in moving, hallucinations, depression, insomnia, sweating, difficult breathing, pain in the chest, and fainting.[18]
Siegel considers Soranus’ account as an exact description of atrial fibrillation portending imminent vascular collapse.[21]
From the above descriptions it is apparent that the subject of syncope was tormenting the authors of Antiquity. Based on the Galenic descriptions, numerous modern medical conditions may be identified, such as congestive heart failure, hypertrophic cardimyopathy, arrhythmogenic right ventricular dysplasia, congenital long QT syndrome or anomalies of the coronary arteries. In general, given that the means for a correct diagnosis were inexistent, even the association made by the
ancient authors between the symptoms and the heart is admirable. Even if Galen often erred on whether the heart suffered primarily or by sympathy to the stomach or the oesophagus, the description of the clinical manifestations of a heart condition is extremely detailed and quite accurate.
REFERENCES
1. Galen. Definitiones medicae. In Kuhn CG, ed. Opera Omnia. Volume 19. Lipsiae:
Libraria Car. Cnoblochii 1830: 421.
2. Galen. De symptomatum causis libri iii. In Kuhn CG, ed. Opera Omnia. Volume 7.
Lipsiae: Libraria Car. Cnoblochii 1824: 128, 252-3.
3. Siegel R. Galen on sense perception; his doctrines, observations and experiments on vision, hearing, smell, taste, touch and pain, and their historical sources.
New York: Basel 1970:457-52.
4. Galen. Ad Glauconem de medendi methodo libri ii. In Kuhn CG, ed. Opera Omnia.
Volume 11. Lipsiae: Libraria Car. Cnoblochii 1826: 44, 58.
5. Galen. De motu musculorum libri ii. In Kuhn CG, ed. Opera Omnia. Volume 4.
Lipsiae: Libraria Car. Cnoblochii 1822: 420.
6. Galen. De pulsibus libellus ad tirones. In Kuhn CG, ed. Opera Omnia. Volume 8.
Lipsiae: Libraria Car. Cnoblochii 1824: 473, 480, 484.
7. Galen. De causis pulsuum libri iv. In Kuhn CG, ed. Opera Omnia. Volume 9.
Lipsiae: Libraria Car. Cnoblochii 1825: 186-7.
8. Galen. De praesagitione ex pulsibus libri iv. In Kuhn CG, ed. Opera Omnia.
Volume 9. Lipsiae: Libraria Car. Cnoblochii 1825: 290.
9. Galen. De locis affectis libri vi. In Kuhn CG, ed. Opera Omnia. Volume 8. Lipsiae:
Libraria Car. Cnoblochii 1824: 433.
10. Grmek MD. Diseases in the Ancient Greek world. Baltimore: The Johns Hopkins University Press 1991: 129.
11. Galen. De methodo medendi libri xiv. In Kuhn CG, ed. Opera Omnia. Volume 10.
Lipsiae: Libraria Car. Cnoblochii 1822: 765-7, 815, 830-7, 850.
12. Galen. In Hippocratis de victu acutorum commentaria iv. In Kuhn CG, ed. Opera Omnia. Volume 15. Lipsiae: Libraria Car. Cnoblochii 1828: 600, 722, 775.
13. Galen. De compositione medicamentorum secundum locos libri x. In Kuhn CG, ed. Opera Omnia. Volume 13. Lipsiae: Libraria Car. Cnoblochii 1827: 117.
14. Galen. De marcore liber. In Kuhn CG, ed. Opera Omnia. Volume 7. Lipsiae:
Libraria Car. Cnoblochii 1824: 686-8, 701-3.
15. Linzer M, Yang E, Estes M, et al. Diagnostic syncope, part 1: value of history, physical mexamination and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Int Med 1997;126:989-96.
16. Littré E. Oeuvres complètes d’Hippocrate. Volume 4. Paris: Baillière 1844: 483.
17. Mirchandani S, Phoon C. Sudden cardiac death: a 2400-year-old diagnosis? Int J Cardiol 2003;90:41-8.
18. Caelius Aurelianus. De morbis acutis II. In Dalechamp J, ed. Caelii Aureliani Siccensis De acutis morbis lib. III. Lugduni: Guliel, Rovillium 1567: 129-138.
19. Védrènes A. Traité de médecine de A. C. Celse. Paris: Masson 1876: 182.
20. Rénaud ML. Ouvrage d’Aretée. Paris: Lagny 1834: 40.
21. Siegel R. Descriptions of circulatory collapse and coronary thrombosis in the fifth century A.D. by Caelius Aurelianus. Am J Cardiol 1961;427.
22. Coats AJ: Ethical authorship and publishing. Int J Cardiol 2009;131:149-50.
ACKNOWLEDGMENT
The author of this manuscript has certified that he complies with the Principles of Ethical Publishing in the International Journal of Cardiology
