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Through the Cardiac Centuries in a Heartbeat

Push one of epi, charge to 200, clear is the line every Greys Anatomy doctor uses to revive a

patient undergoing ventricular fibrillation. Sleepless Sunday nights were dedicated to curling up in a

ball next to my mother as I watched doctors in perfectly pressed scrubs layered with white coats

running around the hospital to save patients, adrenaline rushing through their veins, hearts beating

faster and faster with each step as their eyes bulge out with excitement and fear. Medical jargon such

as encephalocele, Moyamoya disease, aortoenteric fistula, and much more were commonly thrown

around in every episode. My younger self never understood what any of those terms meant, but I

enjoyed watching the doctors struggle in unveiling the underlying problem, taking pride in their

diagnoses as if I had solved it myself. From their initial contact with the patient to examining a panel

of tests run on said patient to standing in an operating room to watching the illness be alleviated, I felt

as though I were in the doctors impeccable minds; no, I felt as though I were the doctor.

Every awe-inspiring case made me want to be that very physician working furiously at a

complex case with furrowed eyebrows, racking my brain to figure out how these symptoms correlate

to an illness. As I grew older I began watching new episodes as well as reruns to gain a better

understanding of these diseases and illnesses, those that can be treated as well as those that cannot,

and how such remedies are applied (as far as a fictitious show could broadcast to a public audience).

It is the application of knowledge to creating ideas that caught my attention. Equally important to the

medical cases were the doctors made up of both human and god-like traits.

As I watched the characters grow and progress in their careers as surgical residents, I was

convinced I was a member of Dr. Greys hardworking and talented circle of flair. I wanted to be the

Dr. Cristina Yang, exceptional cardiothoracic surgeon of my generation-- dedicated, crafty, resilient,

coveted, and most importantly, brilliant. Although esteemed for her skilled expertise in surgery, she

could not be standing in an operating room, holding the life of a patient in her hands without first

properly diagnosing the illness causing the chief complaint. Her knowledge of solving these cases

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came from what could only be years of studying and training to become an aficionado in medicine. A

combination of various tests and a well-rounded comprehension of symptoms allows for successful

diagnoses. However, unlike a simple television show, such abilities to solve convoluted ailments did

not appear all at once. Just as how Rome was not built in a day, it took centuries of mistakes,

accidental discoveries, and straying from convention to turn the obscure clear. It is for this reason I

decided to ask the question: How has diagnosing cardiac patients changed over time?

Despite warnings and prevention made readily available to the public, heart diseases still lead

the United States in annual deaths. According to the Centers for Disease Control and Prevention, each

year approximately 610,000 deaths occur from cardiac related ailments in the United States alone

(Heart Disease Fact Sheet). Such deaths can be prevented with medication, treatment, and therapies,

but in order to do so, accurate diagnoses must be made to offer a proper prognosis. With the

advancement of technological availabilities, cardiac diagnoses have progressed immensely over time.

In particular, outburst of discoveries in chemistry and physics has allowed for the myriad of

equipments cardiologists utilize to deduce the problem at hand. More importantly, applying the

anatomical and physiological processes gathered over the centuries have prompted improvements to

be made. We often take advantage of the diagnostic tools easily available at hand in a doctors office

without acknowledging how they came to be. Over time, cardiac diagnoses have changed due to

mythological beliefs, religion, political aspects, technological advancements, and atypical ideas.

Long before physicians used reason and rationality to diagnose cardiac patients was a time

when medicine was based on mythology and theocracy. Without dissecting a human body, a clear

visual was not readily made available rendering improper assumptions to be made. For example,

Acierno notes, Against a background of magic, religious beliefs, idolatry, and satanism, the

Babylonian practitioners of this epoch had very confused conception of cardiovascular anatomy

(Acierno, 4). Though Babylonians marked arteries as blood of the day and veins as blood of the

night, no logical conclusion was made in regards to their physiological functions. Discovered

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Egyptian medical papyri dating as far back as 3000 B.C. indicate written works of magic, spells, and

incantations in reference to their gods, with sparse evidence of actual medicine. In the far east,

Chinese lore placed pulse-taking to a new level which relied on environmental circumstances,

necromancy, and divinity. Outside of erroneous suppositions, religion played an important role in the

discouragement of human dissection. Autopsies were not encouraged under Islamic purview as it was

tradition to bury bodies within the first two days of passing and was vital for organs to be intact along

with the dead. In fact, the prophet of Muhammad stated that "To break the bone of a dead person is

like breaking the bone of a living person," further hindered progress to be made in the early centuries.

(Burton) Likewise to Muslim prejudice towards disembowelment of the human body was Catholic

concerns, Following 200 AD, religious and legal laws made autopsies unlawful. In 1153 AD, the

Church banned mutilation of dead bodies during the Council of Tours in France. This was aimed at

preventing the common practice of eviscerating Crusaders' body parts for transport back to Europe,

but it contained implications for anatomists (Burton). Long before the separation of church and

medicine and capability of discerning nature from myths crucially inhibited cardiac progress from

being made earlier.

Through time, medicine was able to detach itself from sacerdotal monopoly, drifting greatly

towards observations and justifications through logic. Since the beginning of mankind, asking

questions in regards to pain and illnesses has always been the premier in diagnosing cardiac ailments.

Although Greeks have been praised for being the first in utilizing rationale, Egypt, Crete, and

Babylon had long built the foundation for clinical medicine. According to Dr. Boisaubin, Taking an

accurate history of the patient was an essential component of Egyptian medicine observations that

certain events presaged other events gave a reasonable foundation for inquiry (Boisaubin, 83). It is

because of their prevailing influence that physicians such as Hippocrates used physical diagnoses

1,000 years later, He should mark, particularly, the first day on which the patient became ill,

considering when and whence the disease commenced, for this is of primary importance to know

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(On Regimen). Deemed as the father of medicine, Hippocrates essentially became the first

recognized individual to take patients history into consideration as a primary component in

diagnosis. Asking questions was an important element in ensuring the physician can get the most out

of the patient given their understanding of cardiac anatomy and physiology was incomplete. Even

today, Dr. Romfh of Pediatrics Cardiology at Stanford Hospital goes through a patients history

before proceeding to diagnostic tests. After centuries, such preliminary practice is still used to this

day.

Following the introduction of doctor-patient communication, primitive means of diagnosing

patients through physicality of the five senses, particularly sight, touch, and hear (commonly

described as inspection, palpation, percussion, and auscultation) became incorporated as vital factors

in diagnosing cardiac patients. As components of natural human bodies, such tools were readily

available at every physicians dispense. Visual observation was the foremost source out of the five

senses used in the expanse of all civilizations as it was an easy indirect diagnostic application. The

Chinese paid special attention to color in the face and tongue for those are reportedly parts that stand

in relation to organ(s) at question. The tongue was believed to have been the window into the heart

thus, black tongue meant impending heart failure. Observation was not limited to the patient, but

included the bodily fluids and excreta expelled by the illed-- urine, feces, mucus, blood, and much

more. Aciernos gathering from translated Alexandrian text, ... And there is a difference of the

discharge, whether it be brought up from an artery or a vein. For if it is black, thick and readily

coagulates, if from a vein; it is less dangerous, and more speedily stopped; but if from an artery, it is

of a bright yellow colour and thin, does not readily coagulate, the danger is more imminent, and to

stop it is not easy (Acierno, 448). Visual observations continued to be utilized well into the 19th

century during which time technological advancements in palpation, percussion, and auscultation

were made. In early times Dr. Bings research found that, Palpation was not all diagnostic, the touch

of the hands was also healing touching the patient is the oldest and most effective act of

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physicians (Bing, 336). Palpation of the chest was quickly ruled as an inaccurate tool as physicians

took into consideration obesity and thickness of chest walls. With the aforementioned elements

hampering on palpation of the heart, physicians used their knowledge of blood vessels correlation to

the heart to resort to the secondary site-- radial pulse. The Egyptians were first to record abnormal

pulse to indicate cardiac irregularities in the Ebers and Edwin Smith papyri:

Everywhere the motion of the heart touches him, coursing through the vessels to all the
members. When the heart is diseased its work is imperfectly performed; the vessels
proceeding from the heart become inactive, so you cannot feel them. If the heart trembles, has
little power and sinks, the disease is advancing. (Acierno, 450).
Hippocrates may have counted pulse and Praxagoras of Cos may have been the first to describe

tachycardia (abnormally fast heart rate) and bradycardia (abnormally slow heart rate), but the

Egyptians were the first to design a water clock to count pulse rate. As one of the first medically

related instruments designed for cardiac purposes, a hole was designed at the bottom of a vase in

which drops of water may escape. Pulse rate was then compared to the speed at which water droplets

fell, advancing physicians understanding of pulses relativity to the heart. In Greece, Hippocrates

contemporaries furthered pulse concept, particularly Galen, giving it five characteristics: rate,

rhythm, compressibility, condition of arterial wall, and size and shape of pulse wave. Despite the

effectiveness of observation and palpation, auscultation sparked the most intrigue and progress in

relation to cardiac diagnoses. In ancient times, physicians simply leaned their ears against the

patients chest to listen to the heart beating, noting irregularities. Such rudimentary practice was

highly inaccurate that which Dr. Hajar stated, Hippocrates advocated for the search of practical

instruments to improve medicine in 350 BC. He discussed a procedure for shaking a patient by the

shoulders (succussion) and listening for sounds evoked by the chest. Hippocrates also used the

method of applying the ear directly to the chest and found it useful in order to detect the

accumulation of fluid within the chest (Hajar). Over time, physicians and inventors fulfilled

Hippocrates suggestion of designing instruments, enhancing mans perception of cardiology. During

the Middle Ages, continuous fall and rise of civilizations, plagues, and feuds stagnated cardiac

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advancements. It was not until the 15th century when Ottoman expansion began did the revival of

spurring medicine occur. According to Ranhel and Mesquita, Gradually, the Western world renewed

its knowledge in different fields, particularly in medicine, as a result of the scientific and cultural

splendor happening in the Islamic world coming to Europe through the knowledge generated by

the Arabs, in the reading of Greek texts and new ways to conduct medical training and patient care

(Ranhel and Mesquita). Revered Arab physician, Avicennas identification of blood vessels spreading

illness throughout the body and distinguishing several circulatory maladies in conjunction with

patients history revolutionized cardiac diagnoses. It was the revival and redefinement of Greek

medical treatises by Arabs into Europe again that brought about the pioneering era of the

Renaissance. Works of Leonardo Da Vinci (precise anatomical drawings of heart and circulatory

system), Andreas Vesalius (determined heart as center of vascular framework), William Harvey

(explained how blood circulation operates) and many more primarily built a sturdy foundation of

knowledge for later physicians to model ideas off of; progress made into the late centuries of the

Renaissance bled into iconic advancements made forth in the 17th and 18th centuries as physicians

readily used anatomical and physiological rapport to design tools dedicated to supplement mans

noninvasive understanding of the heart.

Together Leopold Auenbrugger, Jean Corvisart and Ren-Thophile-HyacintheThephile

Lannec respectively forged a new chapter in percussive cardiology. In the mid-18th century,

Auenbruggers practice of direct percussion on the lungs required fingertips enclosed in gloves to

strike against the patients chest, taking note of irregular sound pattern as an indication of

abnormality. Moving from the lungs to the heart, Various gradations of percussion sounds in

different parts of the chest, he noted a dull percussion note (sonus carnis) when tapping over the

space occupied by the heart itself it marked an important transition point in the physical

examination (Acierno, 463). Corvisart identified a series of cardiac afflictions, but more importantly,

his translation of Auenbruggers disregarded monograph into a 400-page book, ultimately introduced

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Lannec to become the founding father of stethoscopes. Lannec fashioned a cylindrical tube, placing

it against the patients chest to receive more pronounced heartbeats, bettering percussion techniques.

Over decades, the stethoscope has been modified to provide the most enhanced means of listening to

cardiac muscle contract and relax. These three physicians radical ideas brought together percussion

and auscultation, serving as the stepping stone between ancient primitive cardiac diagnoses to those

involving technology.

Cardiac instrumental legacy could not be where it is now without Stephen Hales experiments

on animals, discovering blood pressure and prompting future physicians to develop increasingly

accurate sphygmometers. Hales cleverly determined how to calculate cardiac output that which has a

direct relationship to blood pressure as vessels dilate and constrict under different circumstances. The

first blood pressure related machine to have been developed was the kymograph by Carl Ludwig.

According to Ghasemzadeh and Zafari, This device was able for the rst time to graphically record

hemodynamic measures (Ghasemzadeh), serving as the initial instrument from which

sphygmometers were based on. The first few sphygmometers invented were too invasive, requiring

direct cannulation-- insertion of a tube into a blood vessel. Years of adjustment was required for

Scipione Riva-Rocci in 1896 to finally create a minimally invasive equipment used to measure

arterial blood pressure. Building off of Riva-Roccis work was Nicolai Korotkoff in which he

combined auscultatory methods to take arterial blood pressure. Today, a refined means of Korotkoffs

distinction of diastolic and systolic pressure is still used as a simple preliminary diagnostic approach.

During the 19th and 20th century, great burst of technological invention was introduced as

diagnostic tools in cardiology. Revolutionary discoveries in physics and chemistry played a crucial

role in ensuring the road was paved in developing the instruments available now. Acierno finds, The

various physiological parameters whether normal or abnormal can be delineated by means of

mechanical, sound, or electrical tracings and by the usage of radiation methods. Sphygmography

refined the extension of palpation; phonography enhanced auscultation; electrocardiography served

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as means of evaluating the electrical forces underlying cardiac function (Acierno, 501).

Modifications of the electrocardiogram (ECG or EKG), echocardiogram (echo), Positron Emission

Tomography (PET) scan, Magnetic Resonance Imaging (MRI), chest x-ray, coronary angiogram, and

Cardiac Computed Tomography (CT) scan are still put to use today in getting the most detailed

picture of the heart. With the progress made thus far, Dr. Romfh of Stanford Hospital finds that,

Even though there have been technological advances that have supplanted diagnostic testing, Im

still a believer in physical examination. Such a statement proves that technology and rudimentary

methods can be interwoven in the practice of diagnosing cardiac patients.

Walking up to the dismal grey parking lot in an attempt to traverse through and find my way

to Dr. Deuses office, I distinctly remember seeing the exact mundane slab of concrete years ago. As a

child, I used to ride N Judah metro inbound with my sister on Saturday afternoons after Chinese

school, in which one of the stops was in front of this very parking structure. During those times,

never had I once seen a streak of light shine down on it nor did I believe life could be found within.

In my younger days, I was convinced the blue UCSF letters stood for United Committee of Scary

Findings. Having only seen the exterior of this mundane slab, my juvenility had no proper proof to

support this naive conjecture.

Fast forward ten years later, I finally have a reason to get off at that very stop-- UCSF

Parnassus. Nostalgically descending those three steep steps, I look around and see that not much has

changed. Walking into that grey parking lot, I did not expect to find ghosts gliding by to greet me, but

knew I must find the elevator to reach the top level. I got in an elevator, reached my initial

destination, and found myself entering another street. Before me were seemingly interesting

characters in varied colored scrubs, while others were in formal outfits with a tie and women in high

heels, some carrying backpacks while their peers chose briefcases. The sun was showering down on

the hospital, on the streets, and on my face. The fast-paced atmosphere of people rushing by with

faces that seemed puzzled while their swagger contradicted it made my heart beat faster. Lost in

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wonderment of being in a professional environment, I quickly snapped back into reality and recalled

my purpose. To my right were directional signs pointing this way and that, providing information for

every location, all but mine. Looking down at my watch and realizing I had no allotted time for

hopeless wanderings, I quickly walked across the street to the UCSF Medical Center and promptly

asked for directions to room MUW-405 in the Adult Cardiology sector. I received a hasty response to

walk across the street into what looked like the back entrance of the actual building, into the elevator

and made my way up to Dr. Deuses office.

Despite the ever-changing methods of diagnosing patients illed with cardiac ailments, one

standing remains true-- sharing and discussing knowledge has fueled much in-depth understanding of

such maladies. Dating as far back as ancient Mesopotamia, the sick were often brought to market

centers in hopes of spurring ideas is regards to maladies. Such discussion is still practiced today as

Dr. Deuse, member of Division of Cardiothoracic Surgery at UCSF states, We have conferences and

meetings where cardiologists and radiologists meet. This is a great forum to talk about these patients.

Somebody presents this patient and we discuss what diagnostic we would need to confirm a diagnosis

and which diagnostic steps would help us determine which treatment option would work best.

Spread of ideas not only verbally, but textually has always been the primordial means of

advancement. However, as Dr. Deuse noted, the ability to distinguish amongst rational and irrational

works through reading, talking, and exchanging of ideas puts one in the advantage of seeing the

truth.

William Faulkner once said, The past is never dead. Its not even past. This concept applies

in the advancement of cardiac diagnoses as present physicians use knowledge of the past to build the

future. Long before application of reason were non-secular forces obstructing cardiac diagnoses to be

achieved. Nevertheless as physicians began to break ties with secular ideas, spur of logical, altering

ideas were able to be made. Factors including religious hindrances, political changes, mythological

beliefs, unorthodox ideas, and technological progress have all influenced the change in diagnosing

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cardiac patients over time. As a field requiring constant flow, constant outside-the-box ideas, and

constant reconsideration of the accepted, diagnosing cardiac ailments follow this trail.

I began this project with the idea that technology was the sole factor influencing means of

diagnosing cardiac patients. I had completely disregarded culture, religion, and politics as contributes

in how this evolution has altered over time. Although I knew about the strong influence the church

had over the public especially in regards to their authority and credibility, I did not realize the extent

to which cardiology was influenced. I also expected technology to play the most impactful role, but it

was the exchange of ideas and thoughts that ultimately allowed for cardiac diagnoses to be as

advanced as it is today.

Works Cited

Books

Acierno, Louis J. Physical Examination. The History of Cardiology, The Parthenon

Publishing Group, London, 1994, pp. 1-40, 447697.

Bing, Richard J. History of Cardiology at the Bedside. Cardiology: the Evolution of the

Science and the Art, 2nd ed., Rutgers University Press, New Brunswick, NJ, 1999, pp. 328

345.

Electronic Sources

Boisaubin, Eugene V. Cardiology in Ancient Egypt. Vol. 15, 2 Nov. 1988, pp. 8085.,

www.ncbi.nlm.nih.gov/pmc/articles/PMC324796/pdf/thij00061-0013.pdf. Accessed 18 Mar.

2017.

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Burton, Elizabeth C. Religions and the Autopsy. Edited by Kim A. Collins, Overview,

Islam, Judaism, Medscape, 21 Sept. 2016, emedicine.medscape.com/article/1705993-

overview#a6. Accessed 18 Mar. 2017.

Ghasemzadeh, Nima, and A Maziar Zafari. A Brief Journey into the History of the Arterial

Pulse. Edited by Julian Halcox, Cardiology Research and Practice, Hindawi Publishing

Corporation, 28 July 2011, www.hindawi.com/journals/crp/2011/164832/. Accessed 18 Mar.

2017.

Heart Disease Fact Sheet. Centers for Disease Control and Prevention, Centers for Disease

Control and Prevention, 16 June 2016,

www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm. Accessed 17 Mar. 2017.

Hajar, Rachel. The Art of Listening. Heart Views : The Official Journal of the Gulf Heart

Association, Medknow Publications & Media Pvt Ltd, 2012,

www.ncbi.nlm.nih.gov/pmc/articles/PMC3385195/. Accessed 18 Mar. 2017.

Hindawi. A Brief Journey into the History of the Arterial Pulse. Cardiology Research and

Practice, Hindawi Publishing Corporation, 28 July 2011,

www.hindawi.com/journals/crp/2011/164832/. Accessed 16 Mar. 2017.

Musso, Carlos G. Auenbrugger, Corvisart and Laennec: Three Generations That Forged the

Basis of Chest Examination . Auenbrugger, Corvisart and Laennec: Three Generations That

Forged the Basis of Chest Examination, vol. 5, no. 1, 2005,

hekint.org/documents/AuenbruggerCorvisartandLaennec.pdf. Accessed 18 Mar. 2017.

On Regimen in Acute Diseases by Hippocrates. The Internet Classics Archive | On

Regimen in Acute Diseases by Hippocrates, The Internet Classics Archive ,

classics.mit.edu/Hippocrates/acutedis.27.appendix9.html. Accessed 18 Mar. 2017.

Ranhel, Andr Silva, and Evandro Tinoco Mesquita. The Middle Ages Contributions to

Cardiovascular Medicine. Brazilian Journal of Cardiovascular Surgery, Sociedade Brasileira

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De Cirurgia Cardiovascular, 2016, www.ncbi.nlm.nih.gov/pmc/articles/PMC5062728/.

Accessed 19 Mar. 2017.

Walker, H. Kenneth. The Origins of the History and Physical Examination. Clinical

Methods: The History, Physical, and Laboratory Examinations. 3rd Edition., U.S. National

Library of Medicine, 1 Jan. 1990, www.ncbi.nlm.nih.gov/books/NBK458/. Accessed 18 Mar.

2017.

Primary Sources

Deuse, Tobias, member of Division of Cardiothoracic Surgery and Director of Minimally

Invasive Cardiac Surgery, University of California San Francisco, San Francisco CA. Personal

Interview. 10 March 2016.

Romfh, Anita, Pediatrics Cardiologist, Stanford Hospital CA. Personal Interview. 17 March 2016.

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