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History of Neurology | February 2003

Syncope and the History of Nervous Influences on the Heart

Frederick Nahm, MD, PhD; Roy Freeman, MD

Arch Neurol. 2003;60(2):282-287. doi:10.1001/archneur.60.2.282.

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The vertige larynge of Charcot,¹ the tussis convulsiva of Heberden,² and other variants of syncopal states have been described throughout the history of medicine. It has even been suggested that death by crucifixion may be a form of fatal syncope.³ Early clinical observations during the practice of bloodletting suggested that a decrease in both heart rate and blood pressure occurred during syncopal attacks. The relative contribution of the nervous system to bradycardia and hypotension still remains controversial despite the almost 2 centuries of investigations into nervous influences on the heart. Central to this debate is the concept of an inhibitory reflex arc among the heart, brain, and circulatory system. The goals of this article are 3-fold: to trace the contributions of bloodletting to our understanding of syncope, to articulate the experimental and conceptual history of this reflex arc with special attention to cardiac innervation, and to show that an overemphasis on vagally mediated bradycardia led to a delay in recognizing the importance of sympathetic effector systems in the production of hypotension.

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Figure 1.

The vagus nerve and sympathetic trunk according to Sir Thomas Willis, 1664. This figure appeared in Cerebri Anatome, Cui Accessit Nervorum Descriptio et Usus.⁵ Figure reprinted courtesy of Harvard Medical School, Francis A. Countway Library of Medicine, Boston, Mass.

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Detail from woodcut by Hieronymus Brunschwig (Strassburg, 1500) showing seated woman being bled by a barber surgeon. A stream of blood flows from her left arm as she looks away as though about to faint. This figure appeared in Hieronymus Brunschwig [Strassburg], Johann (Reinhard) Grüninger, Pestbuch, August 19, 1500. Figure reprinted courtesy of the National Library of Medicine.

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Title page of Caleb Hillier Parry's text on syncope anginosa. Figure reprinted courtesy of Harvard Medical School, Francis A. Countway Library of Medicine, Boston, Mass.

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Depressor nerve according to Jarisch and Zotterman, 1948. Abbreviations: aod and aos indicate right respiratory and left aortic depressor nerve; Gla, aortic bodies; Glsp, supracardiac aortic ganglion; Kn, ventricular fibers; V, vagus; Vao, vagal branch to aorta; Vl, vagal branches to lungs; and Vt, lower vagal branches to the heart. Reprinted with permission from Acta Physiol Scand.²⁸ Copyright 1949, The Scandinavian Physiological Society.

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Nahm F, Freeman R. Syncope and the History of Nervous Influences on the Heart. Arch Neurol. 2003;60(2):282-287. doi:10.1001/archneur.60.2.282.

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