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Congestive Heart
Failure and Cardiac
Transplantation
Clinical, Pathology, Imaging
and Molecular Profiles

Daniel J. Garry
Robert F. Wilson
Zeev Vlodaver
Editors

123
Congestive Heart Failure and Cardiac Transplantation
Daniel J. Garry • Robert F. Wilson • Zeev Vlodaver
Editors

Congestive Heart
Failure and Cardiac
Transplantation
Clinical, Pathology, Imaging and Molecular Profiles
Editors
Daniel J. Garry, MD, PhD Robert F. Wilson, MD
Lillehei Heart Institute University of Minnesota
Department of Medicine Division of Cardiovascular Medicine
University of Minnesota Medical Center Minneapolis, MN, USA
University of Minnesota
Minneapolis, MN, USA

Zeev Vlodaver, MD
University of Minnesota
Division of Cardiovascular Medicine
Minneapolis, MN, USA

ISBN 978-3-319-44575-5    ISBN 978-3-319-44577-9 (eBook)

DOI 10.1007/978-3-319-44577-9

Library of Congress Control Number: 2017935486

© Springer International Publishing AG 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically
the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the
absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for
general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and
accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to
the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
 v

This book is dedicated to our wives:

Mary Grace Garry
Betsy Wilson
Dalia P. Vlodaver
For their encouragement, support, and inspiration
 vii

Preface

This book is a comprehensive overview of heart Chap. 23 highlights the state-of-the-art research
failure and the only curative therapy for this dis- strategies and their potential clinical impact for this
ease, heart transplantation. Since heart failure is field. Part V addresses the field of cardiac transplan-
so prevalent in our society and has such a pro- tation. These chapters detail the rich history of surgi-
found impact in our healthcare system, we have cal, immunobiological, and therapeutic discoveries
targeted a diverse audience ranging from the stu- that are the signature for this field and target the
dent to the clinical trainee as well as the research clinical management of the heart transplant recipi-
investigator and the practicing clinical expert. As ent. Topics include the cardiac transplant procedure,
the title and table of contents outline, a unique the early and late management of the post-transplant
feature of this book is its breadth. The intent is to patient, allograft rejection, heart-lung transplanta-
produce a single book that comprehensively tion, and xenotransplantation.
examines the field of heart failure and the thera- A unique feature of this compendium is the
peutic strategies, including cardiac transplanta- authors’ expertise and national and international
tion, that would be of interest to the molecular reputations. Many of the authors direct research
biologist, the pathologist, the practicing clinician, programs focused on heart failure and cardiac
the radiologist, and the surgeon. transplantation and these initiatives complement
Introductory chapters are provided as a platform their outstanding clinical expertise in the field.
for the depth of the subsequent chapters. Chapter 1, They have further distinguished themselves as
which presents an extensive historical perspective, founders or leaders of institutes, cardiovascular
provides a unique beginning to the book. Subse- programs, pulmonary hypertension programs,
quent chapters in Part I explore the basic concepts in neuromuscular programs, physiology depart-
the physiology, molecular biology, pathology, and ments, robotic surgical and transplant programs,
epidemiology of the normal and failing heart and adult congenital heart programs, structural heart
also highlight emerging research discoveries that are disease programs, regenerative medicine pro-
having a significant impact on the field. Part II grams, and start-up cardiovascular companies.
addresses the known causes of heart failure, such as The expertise of the authors and the comprehen-
right heart failure, valvular cardiomyopathy, molecu- sive nature of this book serve as an important
lar mechanisms of sarcomeric cardiomyopathies, resource both for the practicing clinician in her/his
and neuromuscular cardiomyopathy. These chapters daily practice and for trainees and research investi-
serve as an outstanding resource for the practicing gators. Importantly, it is the editors’ hope that this
clinician and the research investigator. In Part III, the scholarly effort inspires the next generation to pur-
progression of heart failure is outlined, with chapters sue innovations and discoveries that will bend the
devoted to cardiorenal syndrome, neurohormonal path of heart failure and cardiac transplantation
activation, remodeling, and arrhythmias in cardio- and lead to cures for these diseases.
myopathy. Advanced therapies for the heart failure
patient are discussed in Part IV, including cardiac
resynchronization, ventricular assist devices, and
cellular strategies for structural and hemodynamic Minneapolis, MN, USA Daniel J. Garry
improvement of the failing heart. An area of intense Robert F. Wilson
interest is the field of regenerative medicine and Zeev Vlodaver
 ix

Acknowledgements

The editors are grateful for all the efforts and and education with a central theme of sound sci-
insights provided by the authors of the respective entific evidence were hallmarks of Dr. Burchell’s
chapters in this book. The research and clinical career. Drs. Garry and Wilson pay special acknowl-
expertise of the authors is unparalleled and serve edgement to Dr. Burchell as they led the Cardio-
to distinguish this book. vascular Division at the University of Minnesota
The editors recognize the foundational impact in the same spirit of innovation, discovery, and the
of the innovative contributions to cardiovascular delivery of outstanding cardiovascular care.
medicine that is reflected in our book by the fol- Jay N. Cohn, MD, Professor of Medicine at the
lowing pioneers. University of Minnesota, discovered much of the
C. Walton Lillehei, MD, internationally renowned basic physiology of heart failure and its relation-
as the “Father of Open-Heart Surgery,” was professor ship to afterload and vascular tone. Dr. Cohn cre-
of surgery at the University of Minnesota under Dr. ated an integrative conceptual framework for
Owen Wangensteen. In 1952, Lillehei participated in understanding heart failure that shaped our
the world’s first successful open-heart surgical pro- understanding of the pathophysiology and guided
cedure using hypothermia, which was performed at a revolution in therapy. Today, he is widely recog-
the University of Minnesota. In 1954, he performed nized as the Father of Heart Failure as he founded
the world’s first open-­heart surgery using cross-cir- the Heart Failure Society of America and served as
culation and these procedures provided the platform the inaugural editor-in-chief for the Journal of
for use of the heart lung machine. In 1958, Dr. Lille- Cardiac Failure. Dr. Cohn also served as the chief
hei was responsible for the implantation of the of cardiology for 22 years and established one of
world’s first small, portable, battery-powered pace- the world’s leading heart failure programs in the
maker; he also developed and implanted the world’s world. Dr. Wilson pays special acknowledgement
first prosthetic heart valve in 1966. Thousands of to Dr. Cohn who recruited him to the University of
cardiac surgeons across the world were trained by Minnesota and was supportive in his studies of
Dr. Lillehei and his colleagues at the University of sympathetic reinnervation after transplantation.
Minnesota and revolutionized the field of cardiovas- The editors wish to acknowledge all the train-
cular surgery. Dr. Garry pays special acknowledge- ees that they have worked with throughout their
ment to the late Dr. Lillehei who together with his careers. It is our hope that the discoveries and dis-
late spouse, Kaye Lillehei, established the Lillehei cussions we shared together will serve as a plat-
Heart Institute, which is led by Dr. Garry. form to inspire you to further impact the field.
Jesse E. Edwards, MD, was a world-renowned We acknowledge and thank Jane Hutchins-­
pioneering cardiovascular pathologist. He was Peterson for her outstanding assistance and for
professor of pathology at the Mayo Clinic in Roch- handling the flow of material from the writers to
ester, Minn., and at the University of Minnesota, the publisher.
Minneapolis. He taught many medical students, We recognize with deep appreciation Barb
pathologists, cardiologists, cardiac surgeons, and Umberger for her dedication in the editing of the
visiting medical experts from around the world. manuscript in the minutest detail to ensure the
Dr. Edwards housed an enormous collection of high quality of this project.
autopsied hearts at United Hospital, St. Paul, We acknowledge and thank Erik Munson and
Minn., known as the Dr. Edwards’ Cardiovascular Cynthia DeKay for their assistance with the illus-
Registry that became a principal resource for his trations and artwork that appear in this book.
illustrated reference books: An Atlas of Acquired We extend our gratitude to Michael Griffin,
Diseases of the Heart and Great Vessels (1961), and Development Editor for Springer Publishing, for
Congenital Heart Disease (1965). He also coau- his outstanding efforts, support, and attention to
thored nearly 800 journal articles and 14 books. the details needed for publication of this book.
Dr. Vlodaver pays special acknowledgment to Dr. We wish to acknowledge the support of Janet Fol-
Edwards who was his teacher, mentor and “inspi- tin, Senior Editor of Clinical Medicine, at Springer,
rational force in his medical life.” for her encouragement for this project and all her
Howard B. Burchell, MD, cardiologist, profes- efforts to help bring the project to reality.
sor of medicine at the Mayo Clinic in Rochester,
and the inaugural chief of cardiology at the Uni- Minneapolis, MN Daniel J. Garry, MD, PhD
versity of Minnesota. He was editor-in-chief of the Robert F. Wilson, MD
journal Circulation from 1965 to 1970. Scholarship Zeev Vlodaver, MD
 xi

Contents

I History and Basic Mechanisms of Heart Failure

1 A Historical Overview of Cardiovascular Medicine and Heart Failure.......................................... 3
Cyprian V. Weaver and Daniel J. Garry

2 Physiology of the Normal and Failing Heart.................................................................................................. 21

M. Chadi Alraies, Daniel J. Garry, and Mary G. Garry

3 Molecular Biology of the Normal and Failing Heart................................................................................. 39

Forum Kamdar, Mary G. Garry, and Daniel J. Garry

4 Pathology of Ischemic Heart Disease................................................................................................................. 59

Zeev Vlodaver, Richard W. Asinger, and John R. Lesser

5 The Pathology of Cardiomyopathies.................................................................................................................. 81

Zeev Vlodaver, James H. Moller, Shannon M. Mackey-Bojack, and K. P. Madhu

6 Epidemiology of Heart Failure................................................................................................................................ 93

Russell V. Luepker

II Etiology of Heart Failure

7 Acute Heart Failure......................................................................................................................................................... 105
Pradeep P.A. Mammen, William K. Cornwell III, Mark P. Birkenbach, and Daniel J. Garry

8 Ischemic Cardiomyopathy.......................................................................................................................................... 119

Robert F. Wilson

9 Valvular Cardiomyopathy........................................................................................................................................... 135

Robert F. Wilson

10 Molecular Mechanism of Sarcomeric Cardiomyopathies...................................................................... 151

Brian R. Thompson, Michelle L. Asp, and Joseph M. Metzger

11 Right Heart Failure.......................................................................................................................................................... 161

Thenappan Thenappan and Daniel J. Garry

12 Neuromuscular Cardiomyopathies...................................................................................................................... 175

Forum Kamdar, Pradeep P.A. Mammen, and Daniel J. Garry

13 Heart Failure with Preserved Ejection Fraction (HFpEF)........................................................................ 197

Gary S. Francis, M. Chadi Alraies, and Marc R. Pritzker
xii Contents

14 Myocardial Viability and Imaging in the Failing Heart........................................................................... 211

Prabhjot S. Nijjar, Ashenafi M. Tamene, and Chetan Shenoy

III Heart Failure Disease Progression

15 Cardiorenal Syndrome and Heart Failure........................................................................................................ 227
Maria Patarroyo-Aponte and Peter M. Eckman

16 Neurohormonal Activation and the Management of Heart Failure............................................... 239

Jay N. Cohn

17 Structural Remodeling in the Development of Chronic Systolic Heart Failure:

Implication for Treatment.......................................................................................................................................... 247
Inder S. Anand and Viorel G. Florea

18 Heart Failure Prevention............................................................................................................................................. 267

Ziad Taimeh, Daniel Duprez, and Daniel J. Garry

19 Arrhythmias in Cardiomyopathy........................................................................................................................... 285

Henri Roukoz, Wayne Adkisson, Baris Akdemir, Balaji Krishnan, Scott Sakaguchi,
and David G. Benditt

20 Peripartum Cardiomyopathy................................................................................................................................... 323

Alan Berger and Daniel J. Garry

IV Advanced Therapies for Heart Failure

21 Advanced Therapies: Cardiac Resynchronization Therapy for Heart Failure........................... 341
Scott Sakaguchi, Henri Roukoz, and David G. Benditt

22 Ventricular Assist Devices for Advanced Heart Failure........................................................................... 361

Ziad Taimeh and Daniel J. Garry

23 Regenerative Mechanisms of the Adult Injured and Failing Heart................................................. 377

Jop H. van Berlo, Mary G. Garry, and Daniel J. Garry

24 Cell Therapy and Heart Failure................................................................................................................................ 401

Glynnis A. Garry and Daniel J. Garry

V Cardiac Transplantation
25 History of Cardiac Transplantation: Research, Discoveries, and Pioneers................................. 417
Sara J. Shumway and Daniel J. Garry

26 Orthotopic Heart Transplantation........................................................................................................................ 431

Kenneth K. Liao, Ranjit John, and Sara J. Shumway

27 Cardiac Transplantation: Immunobiology and Immunotherapy..................................................... 449

Ziad Taimeh and Daniel J. Garry
 xiii
Contents

28 Cardiac Transplantation Pathology..................................................................................................................... 469

Priti Lal

29 Management of the Posttransplant Cardiac Patient................................................................................ 479

Sirtaz Adatya, Monica M. Colvin, and Daniel J. Garry

30 Adult Orthotopic Heart Transplantation: Early Complications......................................................... 493

John R. Spratt, Ziad Taimeh, Thenappan Thenappan, and Ranjit John

31 Late Complications Following Heart Transplant......................................................................................... 505

Khalil Murad and Monica M. Colvin

32 Heart Transplantation and Antibody-Mediated Rejection................................................................... 517

Monica M. Colvin, Ziad Taimeh, and Daniel J. Garry

33 Heart and Heart–Lung Transplantation in Adults with Congenital Heart Disease.............. 539
Cindy M. Martin and James H. Moller

34 Cardiac Xenotransplantation................................................................................................................................... 549

Jeffrey L. Platt and Marilia Cascalho

Index............................................................................................................................................................................................ 563
 xv

Contributors

Sirtaz Adatya Department of Medicine/Cardiol- Daniel Duprez, MD, PhD Cardiovascular Divi-
ogy, University of Chicago Medicine, Chicago, IL, sion, Department of Medicine, University of Min-
USA nesota, Minneapolis, MN, USA
Wayne Adkisson, MD Medicine/Cardiology, Peter M. Eckman, MD Minneapolis Heart Insti-
University of Minnesota Fairview Medical Center, tute at Abbott Northwestern Hospital, Minneapo-
Minneapolis, MN, USA lis, MN, USA
Baris Akdemir, MD Medicine/Cardiology, Uni- Viorel G. Florea, MD, PhD, DSc, FACC,
versity of Minnesota Fairview Medical Center, FAHA Cardiology, University of Minnesota Med-
Minneapolis, MN, USA ical School, Minneapolis, MN, USA
M. Chadi Alraies, MD, FACP University of Min- Gary S. Francis, MD Cardiovascular Division,
nesota, Minneapolis, MN, USA University of Minnesota Medical Center/Fairview,
Minneapolis, MN, USA
Inder S. Anand, MD, FRCP, D Phil (Oxon.) Car-
diology Section, VA Medical Center, University of Glynnis A. Garry, MD Department of Internal
Minnesota, Minneapolis, MN, USA Medicine, University of Texas Southwestern Medi-
cal Center, Dallas, TX, USA
Richard W. Asinger, MD Cardiology, Hennepin
County Medical Center, University of Medicine, Daniel J. Garry, MD, PhD Lillehei Heart Insti-
Minneapolis, MN, USA tute, Department of Medicine, University of Min-
nesota Medical Center, University of Minnesota,
Michelle L. Asp, PhD Integrative Biology and Minneapolis, MN, USA
Physiology, University of Minnesota, Minneapolis,
MN, USA Mary G. Garry, PhD Lillehei Heart Institute,
Department of Medicine, University of Minnesota,
David G.Benditt, MD Medicine/Cardiology, Uni- Minneapolis, MN, USA
versity of Minnesota Fairview Medical Center,
Ranjit John, MD Cardiothoracic Surgery, Uni-
Minneapolis, MN, USA
versity of Minnesota Medical Center, Fairview,
Alan Berger Lillehei Heart Institute, Department Minneapolis, MN, USA
of Medicine, University of Minnesota Medical Cen-
Forum Kamdar, MD, PhD Cardiovascular Divi-
ter, University of Minnesota, Minneapolis, MN,
sion, University of Minnesota, Minneapolis, MN,
USA
USA
Jop H. van Berlo, MD, PhD Division of Cardiol- Balaji Krishnan, MD Medicine/Cardiology, Uni-
ogy, Lillehei Heart Institute, University of Minne- versity of Minnesota Fairview Medical Center,
sota, Minneapolis, MN, USA
Minneapolis, MN, USA
Mark P. Birkenbach, MD Lab Medicine and Priti Lal, MD, FCAP Perelman School of Medi-
Pathology, University of Minnesota Medical Cen- cine, Hospital of the University of Pennsylvania,
ter, Minneapolis, MN, USA Philadelphia, PA, USA
Marilia Cascalho, MD, PhD Surgery; Microbiol- John R. Lesser, MD Department of Cardiology,
ogy and Immunology, University of Michigan, Abbott Northwestern Hospital, Minneapolis, MN,
Ann Arbor, MI, USA USA
Jay N. Cohn, MD Department of Medicine— Kenneth K. Liao, MD, PhD Cardiothoracic Surgery,
Cardiology, University of Minnesota Medical University of Minnesota, Minneapolis, MN, USA
School, Minneapolis, MN, USA
Russell V. Luepker, MD, MS Division of Epidemiol-
Monica M. Colvin, MD, MS Cardiovascular Divi- ogy and Community Health, School of Public Health,
sion, University of Michigan, Ann Arbor, MI, USA University of Minnesota, Minneapolis, MN, USA
William K. Cornwell III, MD Internal Medicine, Shannon M. Mackey-Bojack, MD Jesse E Edwards
University of Colorado Anschutz Medical Cam- Registry of Cardiovascular Disease, United Hospi-
pus, Aurora, CO, USA tal, St. Paul, MN, USA
xvi Contributors

K.P. Madhu, MD Department of Cardiology, Scott Sakaguchi, MD Medicine/Cardiology, Uni-

University of Minnesota Medical Center, Minne- versity of Minnesota Fairview Medical Center,
apolis, MN, USA Minneapolis, MN, USA
Pradeep P.A. Mammen Division of Cardiology, Chetan Shenoy, MBBS Cardiovascular Division,
UT Southwestern Medical Center, Dallas, TX, USA Department of Medicine, University of Minnesota
Medical Center, Minneapolis, MN, USA
Cindy M. Martin Department of Medicine-­
Cardiology, University of Minnesota, Minneapolis, Sara J. Shumway, MD University of Minnesota,
MN, USA Minneapolis, MN, USA
Joseph M. Metzger, PhD Integrative Biology and John R. Spratt, MD, MA Department of Surgery,
Physiology, University of Minnesota, Minneapolis, University of Minnesota, Minneapolis, MN, USA
MN, USA
Ziad Taimeh, MD Department of Cardiology,
James H. Moller, MD Department of Medicine— Baylor St Luke Medical Center, Baylor College of
Cardiology, University of Minnesota, Minneapolis, Medicine, Houston, TX, USA
MN, USA
Ashenafi M. Tamene, MD Cardiovascular Divi-
Khalil Murad, MD, MS Section of Cardiology, sion, Department of Medicine, University of Min-
Department of Medicine, University of Minnesota, nesota Medical Center, Minneapolis, MN, USA
Minneapolis, MN, USA
Thenappan Thenappan, MD Department of
Prabhjot S. Nijjar, MD Cardiovascular Division, Medicine—Cardiology, University of Minnesota,
Department of Medicine, University of Minnesota Minneapolis, MN, USA
Medical Center, Minneapolis, MN, USA
Brian R. Thompson, PhD Integrative Biology
Maria Patarroyo-Aponte, MD Allegheny General
and Physiology, University of Minnesota, Minne-
Hospital McGinnis Cardiovascular Institute, Pitts-
apolis, MN, USA
burgh, PA, USA
Zeev Vlodaver, MD Division of Cardiovascular
Jeffrey L. Platt, MD Surgery; Microbiology &
Medicine, University of Minnesota, Minnesota,
Immunology, University of Michigan, Ann Arbor,
MN, USA
MI, USA
Cyprian V. Weaver, PhD Department of Medi-
Marc R. Pritzker, MD Department of Medi-
cine, Lillehei Heart Institute, University of Minne-
cine—Cardiovascular, University of Minnesota,
sota, Minneapolis, MN, USA
Minneapolis, MN, USA
Henri Roukoz, MD Medicine/Cardiology, Uni- Robert F. Wilson, MD Cardiovascular Divi-
versity of Minnesota Fairview Medical Center, sion, University of Minnesota, Minneapolis,
Minneapolis, MN, USA MN, USA
 1 I

History and Basic

Mechanisms of Heart
Failure
 3 1

A Historical Overview
of Cardiovascular Medicine
and Heart Failure
Cyprian V. Weaver and Daniel J. Garry

Introduction – 4

A Brief History of the Heart and Cardiovascular System – 4

 ncient Egyptians – 4
A
Ancient Greece – 5
Galen and Erasistratus – 5
Italy – 8
William Harvey – 15

A History of Heart Failure – 15

 iuretics – 15
D
Pump Failure – 16
Drug Therapies – 16
Targeted Therapies – 17

Summary – 17

References – 17

C.V. Weaver, PhD

Department of Medicine, Lillehei Heart Institute, University of Minnesota, 2231, 6th Street SE,
Cancer and Cardiovascular Research Building, Minneapolis, MN 55455, USA
e-mail: [email protected]
D.J. Garry, MD, PhD (*)
Lillehei Heart Institute, Department of Medicine, University of Minnesota Medical Center,
University of Minnesota, 2231, 6th Street SE, 4-146 Cancer and Cardiovascular Research Building,
Minneapolis, MN 55455, USA
e-mail: [email protected]

© Springer International Publishing AG 2017

D.J. Garry et al. (eds.), Congestive Heart Failure and Cardiac Transplantation, DOI 10.1007/978-3-319-44577-9_1
 4 C.V. Weaver and D.J. Garry

Introduction described throughout the remainder of this textbook. As Sir

1 Winston Churchill stated, “Those who fail to learn from his-
»» For as long as we have been self-aware, we have been in tory are doomed to repeat it.”
awe of the fact that there is something so vital, so alive,
within our bodies: a relentlessly active core with a will of
its own. An animating essence that does not obey our  Brief History of the Heart
A
commands the way our hands do, or our eyelids, or even and Cardiovascular System
our lungs. A link to the universal motion surrounding us,
the tides and stars and winds, with their puzzling Recent research into Ardèche cave dwellings in France from
rhythms and unseen sources. Once this awareness the Aurignacian and Late Magdalenian cultures of the
dawned, it would have been impossible for us ever again Paleolithic Era (35,000–10,000 B.C.) has shown that, among
to look at ourselves or the world the same way. S. and the wall etchings and paintings of hunting parties and the
T. Amidon [1] hunted, of spirits that lurk in the forces of nature, a vocabu-
lary of symbols may exist literally. Among these is a surpris-
These lines from The Sublime Engine are a good place to ingly unmistakable outline of a heart or cordiform shape
begin any historical excursion into the heart’s role in the his- [2]—an almost childlike rendition of a valentine (. Fig. 1.1).
tory of medicine. They remind us that, from the earliest Whatever this may reflect in symbolic value, it could reason-
moments of self-awareness at the dawn of humanity, the ably signify the organ so often seen in a butchered catch, a
heart has been a constant companion of motion within us. horrifically injured hunter, or in any accident that rendered
Whatever that may have meant for our early ancestors is any- the heart bare and exposed to the unsparing milieu of pre-
one’s conjecture, but we do know that it was on people’s history.
minds from the very outset of our human journey. While the
study of the heart has a rich and dynamic history, it also pro-
vides a platform for research that would focus on the patho- Ancient Egyptians
physiology of the failing heart and the discovery of therapies
that would impact the course of this disease. Here, we pro- As we move forward in time to the ancient Egyptians, we find
vide a historical overview of the studies of the heart and heart a culture that fully embraced the heart not only medically and
failure as a foundation for the emerging technologies that are physiologically but psychologically as well. Although there is

..Fig. 1.1 Twenty-six signs all drawn in the same style but compiled from 146 prehistoric sites in France covering 25,000 years—from 35,000 to
10,000 B.C. These symbols may represent a written form of code transmitting information. While the cordiform symbol is heart-shaped, its
symbolic meaning remains open to interpretation. Source: www.ancient-wisdom.co.uk/caveart.htm
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
5 1
Nevertheless, much of Egypt’s religion-based medicine was
largely abandoned by the Greeks for a more rational approach
to disease and medicine.

Ancient Greece

In Greece’s Homeric period (1100–750 B.C.), aspects of car-

diovascular anatomy were largely known in the traumatic
..Fig. 1.2 The hieroglyphic characters from the Edwin Smith context of battle wounds and lesions, including the well-­
Papyrus, ca. 1700 B.C., portrays the “counting” or “measuring” of the known account in Homer’s Iliad (760–710 B.C.) about the
pulse. The symbol on the right is a depiction of counting seeds or dying Alcathous and his still-pulsating heart: “… while fight-
beads from a container. These characters represent the first account of
ing Idomeneus stabbed at the middle of his chest with the spear,
tabulating the rate of the pulse and would later be replaced by water
vessels in which incremental loss of water could be correlated with the and broke the bronze armor about him which in time before
pulse and a reference to time. Source: Brewer LA 3rd. Sphygmology had guarded his body from destruction. He cried out then, a
through the centuries. Historical notes. Am J Surg. great cry, broken, the spear in him, and fell, thunderously, and
1983;145(6):696–702 the spear in his heart was stuck fast but the heart was panting
still and beating to shake the butt end of the spear” [5].
no defined structure of a circulatory system proper, the Although later in the Archaic period, Hippocrates (460–
Edwin Smith Surgical Papyrus (c.1600 B.C.) does record its 355 B.C.) would hold a prestigious position within Greek
author’s awareness that the status of the heart can be assessed medicine because of his compendium of medical practice
by the pulse. It also records the first written observation of the which sought a rational basis for disease. Actual knowledge
heartbeat (. Fig. 1.2). From the beginning, the papyrus’ text of the cardiovascular system within the Hippocratic Corpus
suggests that: The counting of anything with the fingers [is was limited and, in many cases, erroneous, including its
done] to recognize the way the heart goes. There are vessels in it description of the heart as “a firm thick mass so richly sup-
leading to every part of the body. When a Sekhmet priest, any plied with fluid that it does not suffer harm or manifest pain
sinw doctor…puts his fingers to the head…to the two hands, to [6].” Nevertheless, anatomical detail was not only useful but
the place of the heart…it speaks…in every vessel, every part of would historically help to define the organ with greater preci-
the body [3]. Furthermore, it was believed that all the “inner sion, including the heart’s description as four-chambered.
juices of the body” (e.g, blood, air, mucous, urine, semen, and Other details included its unidirectional flow of blood
feces) flowed through channels that extended from the heart through the aortic valve, the shape of the pulmonary valve,
and were distributed peripherally throughout the body in and the pericardial sac and fluid.
harmony and collected at the anus and recirculated [3]. Any In the Classical Period (480–323 B.C.), Greek contribution
disruption of the flow resulted in illness. to cardiology was modest, as reflected in the work of Diocles
References to the anatomy and physiology of the heart of Carystus (400 B.C.), who is attributed with distinguishing
are also evident in the Ebers Papyrus (circa 1550 B.C.). the aorta from vena cava, and Aristotle (384–322 B.C.), who
Aside from its biology, the papyrus described the heart as took a cardiocentric position regarding the heart. He noted it
bearing the ponderous role as the center of emotion, mem- as three-chambered and the seat of the soul. He also described
ory, thought, will, and personality. As such, it was the final the heart and great vessels as the source of all vessels.
arbitrator in the afterlife by which one’s integrity and even- Paraxagoras (ca. 340 B.C.) proposed a distinction between
tual fate were determined. In this final judgment, unlike the arteries and veins, with the former arising from the heart,
other organs that were removed during mummification transporting air, and the latter arising from the liver and
and placed in canopic jars to be buried with the body, the transporting the blood. While Herophilus (335–280 B.C.)
heart remained in the body. And according to the prescrip- would further characterize and distinguish arteries and veins,
tions of the Egyptian Book of the Dead, it was weighed in a noting that the arterial wall was thicker and pulsated, it was
balance against an ostrich feather, called the feather of his colleague Erasistratus (304–250 B.C.) who championed
Ma’at (. Fig. 1.3). If found worthy, one would join the gods the Greek contribution to cardiology with his observations
in the Fields of Peace. If the heart of the deceased weighed on the nature of vessels, the valves of the heart, and his con-
more than the feather—that is, more evil than good—the ceptualization of the vascular angioarchitecture.
heart was immediately devoured by the chimeric demon
Ammit. In effect, this condemned the bearer to dying a sec-
ond death that signaled complete ­annihilation. Galen and Erasistratus
Egyptian medical knowledge of the heart would diffuse
through time and eventually influence the early Greeks, Most of what has been preserved about circulation theories
including Praxagoras, the Cnidians, and the Sicilians in seeing comes by way of Galen. Judging from Galen’s references
the primacy of the heart, even as the seat of intelligence [4]. to Erasistratus’ works, Erasistratus was not far from an
 6 C.V. Weaver and D.J. Garry

..Fig. 1.3 A hieroglyphic and graphic representation of the ritual of the weighing of the heart from the Papyrus of Hunefer. Anubis, the
jackal-headed god associated with mummification and the afterlife, takes Hunefer, dressed in white, by the hand to lead him to the ritual. Anubis
is shown a second time checking the scale to assure its accuracy, while Ammit stands below the scale awaiting the results. The Ibis-headed god
Thoth, the record-keeper and arbiter of godly disputes, stands on the right ready to record the outcome. Hunefer’s heart is placed on one side of
the balance and Ma’at’s feather on the other. If the heart weighs less, reflecting the good life that Hunefer embraced while alive, he will join the
gods in the Fields of Peace. If it weighs more, indicative of an evil life, the heart will be consumed by an anxious and hungry Ammit. This action
condemns the lost to dying a second time, signaling complete annihilation. Fortunately, Hunefer’s heart weighed less and will be presented to
Osiris for admission into the afterlife and granted eternal life in Aaru

understanding of circulation—and, certainly, a more contig- Galen (129–216 A.D.), whose name and theories alike
uous relationship between arteries and veins, both of which would come to cement medical knowledge for thirteen cen-
he believed arose from the heart: The vein (pulmonary artery) turies, was a Greek physician born in Pergamon. His seem-
arises from the part where the arteries, that are distributed to ingly unlimited knowledge of medical science likely was
the whole body, have their origin, and penetrates to the san- derived from his firsthand knowledge as court physician to
guineous [or right] ventricle; and the artery [or pulmonary several Roman emperors, surgeon to the gladiators, and avid
vein] arises from the part where the veins have their origin, dissector of numerous animal species including the Barbary
and penetrates to the pneumatic [or left] ventricle of the heart ape and pigs. His cardiological work builds on a refinement
[7]. Furthermore, he held that arteries contained exclusively of Greek physiology that relied heavily on the four bodily
air and, when punctured, the air escaped. Blood seeped in humors (blood, black and yellow bile, and phlegm). The
from arteries to fill the space which was observed to spill underlying principle is that, although the heart is the source
from the cut vessel. Like Herophilus, Erasistratus believed of innate heat that gives life and soul to the body, it must be
that veins contained and transported blood only. cooled. In Aristotle’s interpretation, cooling was the brain’s
As Aird (2011) points out in his elegant analysis, the focus task, while Galen held the novel idea that the lungs provided
of the Greek school of cardiovascular thought was under- this activity. Galen provided an open-ended theory of the
standing how nourishment is disseminated to all parts of the vascular system that expanded upon Erasistratus’ scheme—
body [8]. Erasistratus described an open-ended vascular sys- providing an innovative way the blood flowing in both arter-
tem (. Fig. 1.4a) where absorbed nutrients were converted in ies and veins (. Fig. 1.4b).
the liver into blood that flowed via the hepatic vein to the In Galen’s scheme, the heart and arteries stood in parallel
vena cava, and from there, to the rest of the body. A portion with the liver and veins, and the brain and nerves to form a
of the blood was directed to the right ventricle and, ulti- tripartite system of governance. Each provided a functional
mately, to nourish the lungs. Conversely, he said the pulmo- component of the living system: brain and nerves brought
nary veins take up air and transport it to the left ventricle and sensation and thought, the heart and arteries replenished
ultimately carry it to the tissues by arteries. Although flawed, life-­giving energy, and the liver and veins provided nutrition
such a system explained what he thought he observed in his and growth. Each also generated a pneuma (πνεΰμα, an
dissections and would continue to influence cardiology until ancient Greek word for “breath”) or spiritual substance that
the time of Galen. animated and nourished the body. He believed the heart
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
7 1
­ roduced vital pneuma, the liver a natural pneuma, and the
p
brain an animal pneuma.
The actual flow of blood via the Galenic system has not
been without debate due to translation and the interpretation
that comes with translation. Foibles also arise from Galen’s
own ambiguities which can be found in his descriptions. As
Henri de Mondeville (1260–1320) would later note, “God did
not exhaust all his creative power in making Galen [9].” That
said, the following is a simple and generalized scheme of the
Galenic system.
His scheme begins with the intake of food. Once digested,
it is transported from the intestines to the liver via the portal
vein (. Fig. 1.5). In the liver, the nutrients were changed to
blood which was suffused with natural pneuma that endowed
it with the power of growth and nutrition—signaled by the
dark red color of the newly formed blood. From the liver, the
vitalized blood passed to several destinations. One portion
flowed through the vena cava and downstream veins and
throughout the body to bring the nutrient potential to mus-
cles and organs. Some blood, however, diverted from the
inferior vena cava to the right ventricle of the heart. Here,
some flow continued to the lungs via pulmonary arteries
(arteria venialis), while a portion of the flow filling the right
ventricle passed through invisible pores located within the
interventricular septum and into the left ventricle. Here, the
blood mixed with air transported from the lung via arteria
venialis and pulmonary vein by ebb and flow motion and
infused with the vital spirit. The imbued blood, now bright
red, was transported via pulsatile arteries to the rest of the
body where it was consumed by the tissues and a portion of
flow to the brain. The latter blood diverted to the brain was
further vitalized by the animal pneuma, a rarefied pneuma
that vitalized the brain and flowed peripherally via nerves to
bring power to the muscles and perception via the senses.
Finally, as to pulsation, while Erasistratus saw the heart as
a suction-and-force “bellows” that produced a passive disten-
tion of the artery due to the expulsive force of pneuma from
the left ventricle during its contraction [10], Galen believed
the pulse was generated by the active contraction and dila-
tion of the muscular coats within the arterial wall. The stimu-
lus arose in the heart and propagated down the wall [11].
Both were incorrect. For Erasistratus, the pulse arose from
the action of the heart, but it was pneuma, not blood, that
pulsed through the arteries. For Galen, it was blood that
..Fig. 1.4 A schematic of the circulatory system, comparing major flowed through the arteries—but due to the pulse produced
advances in the conception of the cardiovascular system. (a) The work by the arterial wall.
of Erasistratus illustrates his belief that the arterial and venous systems
were separate. The venous system transported blood, while the
Many clinicians today have asked why Galen, a scientist
arteries carried air. Food absorbed from the intestines was transported of discerning and incisive insight, failed to deduce the obvi-
via the portal veins to the liver where the nutrients were transformed ous role of the heart within a circulatory scheme. Many have
into blood that was delivered to the rest of the body via the vena cava.
(b) Galen’s scheme was designed around the arteries that carried
blood—derived from venous blood that passed through pores of the
interventricular septa. (c) Colombo’s scheme provided for an accurate ..Fig. 1.4 (continued) blood passing from the lung is pumped to
pulmonary circulation but maintained the Galenic distribution of most the rest of the body. Although no direct evidence existed in William
venous blood passing directly to the tissues of the body and only a Harvey’s time for capillary beds to link the closed system, Marcello
portion to the right ventricle. (d) Harvey’s system expanded the Malpighi later wrote of a porous transfer between the two. Source: Aird
pulmonary route to include the entire body whereby all venous blood WC. Discovery of the cardiovascular system: from Galen to William
passes from the tissues and lungs to the right ventricle, and arterial Harvey. J Thromb Haemost. 2011;9(Suppl 1):118–29
 8 C.V. Weaver and D.J. Garry

..Fig. 1.5 A schematic representation of

1 Galen’s concept of circulation. Nutrients
passing by way of the portal veins were
carried to the liver (1) where, mixed with the
natural pneuma, formed blood was
distributed to the entire body by the vena
cava (2) and a small portion to the right
ventricle (3) by the ebb and flow motion from
the liver. Some blood in the heart flows to the
lungs to emit “sooty vapors,” while some flows
through pores of the interventricular septum
where it is suffused with “vital spirits” from the
pneuma and transported via the trachea.
Blood flowing further into the brain was
imbued with animal spirits before being
distributed to the body via nerves considered
to be hollow. Source: Singer C. A Short History
of Anatomy and Physiology from the Greeks
to Harvey. New York: Dover; 1957

also proposed answers to this puzzling question. An increas- exception to the existence of invisible pores within the inter-
ing number support the thesis that Galen became consumed ventricular septum that enabled blood passage from right to
and distracted by his ongoing dispute with the Stoics [12]. left ventricle and, furthermore, provided an accurate basis of
His agenda became a polemical dialectic to discredit the pulmonary circulation. While the West continued to embrace
Stoics’ concept of an indivisible soul while maintaining his and teach Galenic principles, new developments in the
own allegiance to the Platonic concept of the tripartite soul. twelfth century would eventually lead to a reevaluation of
The intensity of the debate allowed little option of moving Galen’s all-pervasive influence.
beyond this defensive position. The Galenic system would
become the predominant paradigm that would influence and
guide medical practice and education down through the sub- Italy
sequent ages as it was further emulated and canonized dur-
ing the Middle Ages. Although it has been referred to as a “Civitas Hippocratica,”
The Galenic system would eventually be challenged in the the School of Salerno represented a fresh and integrated
thirteenth century by physicians of the Islamic world who approach to medicine and medical education in an other-
had greater familiarity with the ancient Greeks. This included wise unresponsive era. Beginning the in the tenth century
the Arab physician Ibn al-Nafis (1210–1288), who took clear and arising in the context of Benedictine monasticism,
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
9 1
including Monte Cassino, it became the first medical school f­our-­ chambered with atria distinct in configuration and
in the world and, subsequently, an outstanding secular insti- function as they contracted to fill the ventricles. He also ele-
tution. It returned to the earlier historical practice of animal gantly traced and defined the course of the coronary arteries
dissection as one of its chief merits. As Castiglioni points as those that supplied the muscle of the heart itself and
out, “up to that time anatomy had been taught simply sicut ­provided cogent demonstrations of the bronchial arteries
asserit Galenis (‘thus does Galen declare’)” [13]. At Salerno’s (. Fig. 1.8). Nevertheless, all this wealth of knowledge issued
peak in the twelfth century, anatomic dissection, particu- from the pen and drawings of da Vinci would never see the
larly of the pig, was systematically undertaken, and although light of his age. With his death, his rich insights into the anat-
still steeped in Galenic perspective, faculty members were omy and function of the heart would be lost for almost
beginning to embrace the importance of independent 400 years.
­observation. During the century of Leonardo’s death, several distin-
The first public dissection of the human body for medical guished anatomists would prove essential to the continuing
instruction was performed by Mondino de Luzzi (1275– evolution of cardiology. Perhaps the most well known of
1326) at the University of Bologna in 1315. Dissection of the these would be the Flemish anatomist Andreas Vesalius
body was evident as well in the work of the great Italian (1514–1564) who would publish his De Humani Corporis
Renaissance artists who were less confined by the ideas of Fabrica and Epitome in 1543. This was a startling collection
Galen or even Aristotle or Hippocrates. They sought to of dissected images of the human body illustrated by Jan van
examine firsthand what the visually impoverished medical Calcar, his friend and pupil of the artist Titian, and unlike
texts of the period failed to relay. Human dissections, includ- anything published to date. Despite the exquisite drawings,
ing those of da Vinci, provided the anatomic and mechanical including those of the vascular system, his heart images
basis that conferred dynamics of motion and function to the remained modest and illustrated the interventricular pores of
body in life. Leonardo da Vinci (1452–1519) has only recently Galen (. Fig. 1.9). On the other hand, the sentiment
been properly acknowledged for his impressive knowledge of expressed in his text would indicate otherwise:
the heart, both in terms of function and anatomical features.
Our temptation is to regard Leonardo exclusively as an »» The septum of the ventricles, composed of the thickest
substance of the heart abounds on both sides with little
artist or illustrator, but he was much more. He was a scientist
pits impressed in it. Of these pits, none, so far as least as
at heart, driven by an inquisitive nature, open to novel ideas
can be perceived by the senses, penetrate through from
and explanations, and heavily dependent on firsthand obser-
the right to the left ventricle, so we are driven to marvel
vation and experimentation. From age 14, he apprenticed in
at the handiwork of the Almighty, by means of which the
art and art history in the workshop of Andrea del Verrocchio
blood sweats form the right to the left ventricle through
and at the age of 33 was appointed director of the Academy of
passages which escape human vision. [15]
Science and Art in Milan. For 17 years, da Vinci undertook
numerous engineering and architectural projects for the Whether the sarcasm was deliberate or unintentional, da
Duke of Milan. He explored and studied the elements of city Vinci simply had nothing else to substitute for Galen’s expla-
planning, military engineering, mathematics, hydrodynam- nation. Nevertheless, his instincts as a precise and careful sci-
ics, and the physics of optics and motion. entist led him to conclude otherwise. In his second edition of
The principles applied in these studies and projects were the Fabrica (1555), he does assert no evidence for the pores.
ultimately focused on his abiding interest in anatomy— “Not long ago I would not have dared to turn aside even a
dynamic anatomy—and recorded in his notebooks anatomi- hair’s breadth from Galen. But it seems to me that the septum
cal dissections which he had planned to publish. His of the heart is as thick, dense and compact as the rest of the
anatomical works spanned two intervals: 1480–1497 and heart. I do not see, therefore, how even the smallest particle can
1506–1509. Of his 5000 known pages of notes and illustra- be transferred from the right to the left ventricle through the
tions largely on mechanics, 190 recorded the anatomy of septum” [15].
autopsied human subjects and animals, of which 50 were In addition to the work of Vesalius, others would provide
devoted exclusively to the heart [14]. Aside from the amaz- strategic insights in moving forward the study of the heart.
ingly detailed surface features of the heart (. Figs. 1.6 and Michael Servetus (1511–1553), a Spanish physician, sug-
1.7), Leonardo explored the inner aspects of the chambers gested evidence of a pulmonary circulation. While this was
and conduits, noting the architecture of the valves, papillary new to the West, it had been firmly articulated earlier by the
­muscles—even the moderator band obvious in the ox heart Arab physician, Ibnal-Nafis, who clearly described the flow
and more difficult to distinguish in the human that he cor- of blood from the right ventricle via the pulmonary artery to
rectly identified as a muscular bridge stabilizing the right the lung and from the lung via the pulmonary veins to the
ventricle from over-distention. His drawings astutely record heart and through the aorta to the rest of the body. Unlike
and analyze the physics of motion through the trileaflets of Ibn al-Nafis’ observations that were based on autopsies and
the aortic and pulmonary valves. human dissections [16, 17], the thesis proposed by Servetus
Aside from the intricacies of the heart itself, Leonardo was mainly based on his observations—primarily on the
regarded the heart as a muscle, not flesh, as stated by Galen. color of the blood and ventricular and pulmonary dimen-
He clearly characterized for the first time the heart as sions. Furthermore, his work was largely unknown because it
 10 C.V. Weaver and D.J. Garry

..Fig. 1.6 A comparison of heart drawings

1 by Leonardo da Vinci and contemporaries.
(a) Leonardo’s drawing of the ox heart,
showing detailed images of the coronary
arteries, the atria, as well as the great vessels.
(b) An enlarged image showing the posterior
facet of the base of the aorta with the
pulmonary trunk cut away (1511–13).
(c) The graphic representation of dissected
hearts drawn by Mondino di Luzzi (1541)
and (d) Berengario da Carpi (1523)

was found within his theological treatise, Christianismi flow in the veins, he became the first to publish such experi-
Restitutio. He wrote it to clarify the origins of the Holy Spirit mental data and the first to have used the term circulation in
in the air-blood interface of the heart, “Ab aere inducit Deus print. His exact meaning of the term, however, is still debated.
anima” [From the air, it induces the soul]. Some believe it referred exclusively to the cooling of blood in
Andrea Cesalpino (1519–1603), an Italian physician and the heart [18] or that is was chemical (distillation) rather
contemporary, was interested in the dynamics of blood flow than physical in nature [19]. Others, taking a de novo transla-
within the veins. For the most part, he understood that blood tion and analysis of the original Latin text, concluded that “it
in veins flow in a single direction, and the distinctive differ- is inescapable that this author, several decades before William
ences between pulmonary artery and vein, and aorta and Harvey, had a clear general understanding of the circulation
vena cava. He demonstrated in his Quaestionum Peripateticum of the blood [20].”
(1593) the disposition of the blood above and below the point It would come as no surprise that the latter opinion could
of a ligature placed on the arm. In showing the dilation below be true because Cesalpino was a student of the next major
and the collapse above the ligature and, thus, a centripetal figure of this era. Realdo Colombo (1516–1559), a surgeon
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
11 1

..Fig. 1.7 Da Vinci’s drawings of the human heart—both surface features and a study of the open and closed aortic valves—shown in the
lower right margin of his notebook. Harvey asserted that the pulse was felt throughout the body and correlated with the heartbeat. As he stated,
“And the same thing happens in the bodies of animals by means of the beating of the heart which generates a wave of blood through all the
vessels, which continually dilate and contract. And dilatation occurs on the reception of superabundant blood, and diminution occurs on the
departure of the superabundance of the blood received. This, the beating of the pulse, teaches us when we touch the aforesaid vessels with our
fingers in any part of the living body”

and professor of anatomy, was a student and then colleague Colombo would prove to be a sentinel, signaling that the full
of Vesalius and, later, his successor at Padua. Later in understanding of systemic circulation was at hand. Unlike
Colombo’s career, he would criticize Vesalius who, reacting his contemporaries, Colombo clearly presented his observa-
strongly to the critique, ended their relationship [21]. tions in a straightforward and scientific manner, which is
 12 C.V. Weaver and D.J. Garry

..Fig. 1.8 Da Vinci’s drawings of the bronchial arterial blood supply. Leonardo’s views indicated an awareness of a perfusion of blood within
the bodily organs for normal function. This included the size and the function of the organ

apparent in his De Re Anatomica (1559), published shortly He dismisses the pulmonary vein as the conduit of air and fulig-
after his death. inous vapors and, given the true function of the cardiac valves,
For example, much of Servetus’ work, obfuscated by theo- denies access of arterial blood retrogradely to the lungs:
logical interests, was clearly articulated in Colombo’s scheme of
circulation, although he makes no mention of his name or work. »» Between these ventricles there is a septum through which
Much of Colombo’s scheme is Galenic, with veins arising from most everyone believes there opens a pathway for the
the liver, but no pores present in the interventricular s­eptum. blood from the right ventricle to the left, and that the
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
13 1
..Fig. 1.9 The illustration of the heart
dissected free of the chest and presented to
show its various facets. In the first edition of
Fabrica, the small pits were shown within the
interventricular septum across which the blood
passed from the right to left ventricle. This
Galenic version of blood flow was omitted in this
later edition (1566) of Andreas Vesalius’ work

blood is rendered this so that this may be done more easily Servetus. Colombo did not know of either man and arrived at
for the generation of vital spirits. But they are in great error, his conclusions independently.
for the blood is carried through the pulmonary artery to Colombo’s successor at Padua was Girolamo Fabrizio
the lung and is there attenuated; then it is carried, along (1537–1619), Italian anatomist and surgeon, also known as
with air, through the pulmonary vein to the left ventricle of Fabricius. In addition to making remarkable discoveries, he
the heart. Hitherto no one has noticed or left in writing, taught a generation of notable anatomists and physicians
and it especially should be observed by all [22]. including William Harvey, who succeeded Colombo at
Padua. Fabricius was interested in circulation as well but
Colombo’s schema gave rise to both an open and closed focused his work on the valves present in walls of large veins.
system circulatory schema—open in the lungs but closed As shown in his De venarum ostiolis [On the Valves of the
elsewhere in the body (. Fig. 1.4c). Such a proposal clearly Veins], he proposed the hemodynamic feature of valves in
stood in contrast to but did not dismantle the Galenic system facilitating the progressive flow of blood through a vessel and
and was not unlike that proposed earlier by Ibn al-Nafis and preventing retrogressive movement. Much of his work on the
 14 C.V. Weaver and D.J. Garry

tricuspid valves had already been described in da Vinci’s Many have suggested that Cesalpino discovered systemic
1 work but went unknown to contemporaries. circulation because of his comprehensive understanding of the
All of these sixteenth-century physicians, anatomists, and circulation of blood based on careful empirical observations
professors contributed to a formative and fomenting period presented in his Quaestionum peripateticarum (1571) and
for cardiology. Their work led to the definitive moment when Quaestionum medicarum (1593) [25]. He was the first to use
the undisputed center, the heart, would be ultimately under- the expression “circulatio sanguinis” in a hemodynamic sense.
stood as the source of motion that propelled the blood His physiological demonstrations with ligatures on the arm
throughout a closed cardiovascular system. If we ask who present in a compelling way as progenitors of Bauhin’s iconic
discovered the pulmonary circulation, the reply would have presentation of valves later used by Frabricus and still later by
to be all three: Ibn al-Nafis, Michael Servetus, and Realdo Harvey as the only illustration in his De Motu (. Fig. 1.10).
Colombo. Although followers have long favored their own But like many of his contemporaries, Cesalpino’s work
candidate, the work of Meyerhof [23] and Temkin [24] in the was a crucial footstep toward a definitive understanding of
1940s spurred a general agreement that all three arrived at systemic circulation. That understanding would arrive very
their conclusions independently, largely based on a compari- shortly with a work that struck literally at the very heart of
son of their own commentaries. Later, Wilson [17] would the issue: De Motu Cordis. The very title, On the Motion of the
concur due to all three sharing a common knowledge of Heart, cut to the chase. The heart was the source of the
Galenic physiology, but each using different evidence to sup- motion that systemically circulates the blood within a closed
port their observations and conclusions. system.

..Fig. 1.10 The illustration used by Harvey in

his De Motu Cordis, showing ligatures placed on
the arm for the collection of blood. The original
appeared in Bauhin’s anatomical textbook
(Theatrum Anatomicum, 1605) and later used by
Fabricius. Before Harvey’s use of the illustration,
no one noted or addressed the obvious conflict. If
the blood flowed centrifugally from the liver to
the extremities, as it was held from the time of
Galen, then the vein on the proximal side of the
ligature should have showed swelling
Chapter 1 · A Historical Overview of Cardiovascular Medicine and Heart Failure
15 1
William Harvey but even as a scorned “circulator” (traveling quack) by his
most vitriolic of opponents, Jean Riolan (1577–1657), who
Between 1597 and 1602, William Harvey (1578–1657) stud- could not forgive Harvey’s disrespect for Galen. Even more
ied at and received his doctorate of medicine from the outspoken was Guy Patin (1601–1672) who stated that
University of Padua. While a student there, he studied under Harvey’s theory was “paradoxical, useless, false, impossible,
Fabricus of Aquapendente. Fabricus would have a lasting absurd, and harmful” [27]. Despite these and other vocal
influence on Harvey and, in particular, his appreciation of critics, Harvey had his supporters, including many eminent
the venous valves. Harvey later intimated to Robert Boyle colleagues like Richard Lower (1621–1691) who, in his own
that this appreciation formed the basis of his interest in circu- work, demonstrated Harvey’s system to be empirically sound.
lation [26]. In addition to the negative reaction to his work, Harvey’s
After his return to England in 1602, Harvey was appointed troubles did not end in academic contention alone. He had
Lumleian lecturer at the Royal College of Physicians. The served as court physician to King Charles I, who had kindly
gradual synthesis of his lecture notes and numerous experi- provided Harvey with deer from the royal parks for his
ments led him in his understanding of veins and blood flow. experiments. Because he remained loyal to Charles even after
He may have initially shared his theory of circulation with his his beheading in 1649, Harvey’s residence was ransacked
students between 1617 and 1619 when he most likely began during the Cromwellian Civil War [Third English Civil War
to write. Experimental work including ligature experiments, (1649–1651)], and many of his notes and papers were
jugular experiments, and heart dissections of deer and other destroyed. Although Harvey died of a stroke in 1657, his leg-
animals to quantify flow-rate dynamics and intrinsic move- acy formed much of the basis for modern cardiology and its
ment of heart muscle ensued for nearly another 10 years. continuing evolution into modern times.
Finally, the publication of his Exercitatio Anatomica de Motu
Cordis et Sanguinis Animalibus in 1628, generally known
simply as De Motu Cordis, made his theory of circulation A History of Heart Failure
known to all. Harvey began his work with a preface acknowl-
edging his teacher Fabricus as “a venerable old man” and Heart failure was a recognized disease from ancient Greece,
acknowledged his work, De Respiratione (1615). India, and Egypt, but mechanistic insights were limited until
Harvey maintained some of Colombo’s ideas, including Harvey’s description of the circulation, Rontgen’s discovery of
the assertion that the primary motion of the heart is contrac- x-rays (1895), Einthoven’s development of the electrocardio-
tion (systole), which propels blood into the arteries, which gram (1903), the discovery of echocardiography by Inge Edler
dilate (pulse) in response to the contraction of the heart and (1953), the discovery of cardiac catheterization by Werner
propulsion of blood. The pulse as demonstrated by Harvey Forssmann (1929), and other medical interventions. These
was not blood being pulled into the heart but rather the interventions initially used leeches for bloodletting (by the
blood being propelled by the heart into the arteries. Harvey “barber-surgeons” of the day; . Fig. 1.11) and later used
had no role for interventricular septal pores since the blood Southey’s tubes (established by Dr. Reginald S. Southey in
of the right ventricle is propelled into the lungs by the pulmo- 1877) to drain peripheral fluid from the patient with heart fail-
nary artery and from the left chamber into systemic circula- ure [28]. The practice of bloodletting continued up to the mid-
tion. Completing this circuit during diastole, blood flows dle of the twentieth century when diuretics became available.
from the great veins into the atria and ventricles. Unlike
those who had gone before, Harvey believed the arteries
transported nutrients throughout the body and, although Diuretics
undefined within the periphery of the tissues, blood passed
from artery to vein, providing a circular basis of flow In addition to bloodletting, paracentesis was also used to
(. Fig. 1.4d) where the flow of venous blood is essentially remove fluid from the abdominal cavity. Dr. William
centrifugal. Thus, the blood was not consumed by the tissues, Withering introduced the use of Digitalis purpurea in 1785,
as conjectured by the Galenists, nor by the liver, per genera- as outlined in his book, An Account of the Foxglove. Toward
tion de novo. The anatomical design of the veins with their the end stage of the disease, patients were noted to be inca-
valves is oriented toward the heart, with the heart as the pable of lying flat and were reclining in a semi-upright state.
source of the blood’s movement, not the liver. Heart failure patients were typically described as having
It has been suggested that this circular pattern came to dropsy (from the Greek word for water) which reflected the
Harvey because of his admiration of Aristotle who regarded edematous state of the patient [28]. Various therapies were
circular motion as a symbol of perfection, perpetuity, and implemented including mercury (i.e., Mercupurin,
embodied qualities of preservation [8]. It was still remarkable Thiomerin, Mercuhydrin, Salyrgan), which served as a
that the definition of the circulatory system had so long diuretic as outlined by Dr. John Blackall (1771–1860) in his
eluded even the most skilled of physicians and the most book, The Nature and Cure of Dropsies [28]. During this time
astute of philosophers. Yet controversy arose as soon as De period, patients were primarily managed with bed rest, fluid
motu cordis was published. Harvey was not hailed as a hero restriction, and diuretic therapy.
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Switzerland, and he was committed to a resultless warfare in the
high mountains, with an army which was a mere detachment jarij^r
and in the hope of co-operating with two other dctach•rtftrvrfto
ments far away on the other side of Switzerland. As *•'**•*'• for the
reasons which led to the issue of such an order, it can only be said
that the bad feeling known to exist between the Austrians and
Russians induced England to recommend, as the first essential of
further operations, the separate concentration of the troops of each
nationality under their own generals. Still stranger was the reason
which induced the tsar to give his consent. It was alleged that the
Russians would be healthier in Switzerland than the men of the
southern plains! From such premises as these the Allied diplomats
evolved a new plan of campaign, by which the Anglo- Russians
under the duke of York were to reconquer Holland and Belgium, the
Archduke Charles to operate on the Middle Rhine, Suvirov in
Switzerland and Melas in Piedmont — a plan destitute of every merit
but that of simplicity. It is often said that it is the duty of a
commander to resign rather than undertake an operation which he
believes to be faulty. So, however, Suvirov did not understand it. In
the simplicity of his loyalty to the formal order of his sovereign be
prepared to carry out his instructions to the letter. Massena's
command (77,000 men) was distributed, at the beginning of
September, along an enormous S, from the Simplon, through the St
Gothard and Giants, and along the Linth, the ZUricher See and the
Limmat to Basel. Opposite the lower point of this S, Suv&rov (
28,000) was about to advance. Hotze 's corps ( 2 5,000 Austrians) ,
extending from Utznach by Chur to Disentis, formed a thin line
roughly parallel to the lower curve of the S, Korsakov's Russians
(30,000) were opposite the centre at Zurich, while Nauendorff with a
small Austrian corps at Waldshut faced the extreme upper point.
Thus the only completely safe way in which Suv&rov could reach the
Zurich region was by skirting the lower curve of the S, under
protection of Hotze. But this detour would be long and painful, and
the ardent old man preferred to cross the mountains once for all at
the St Gothard, and to follow the valley of the ReuM to Altdorf and
Schwyz — i*. to strike vertically upward to the centre of the S— and
to force his way through the French cordon to Zurich, and if events,
so far as concerned his own corps, belied his optimism, they at any
rate justified his choice of the shortest route. For, aware of the
danger gathering in his rear, Massena gathered up all his forces
within reach towards his centre, leaving Lecourbe to defend the St
Gothard and the Reuss valley and Soult on the Linth. On the 34th he
forced the passage of the Limmat at Dietikon. On the 25th, in the
second battle of Zurich, he completely ztirkh°' routed Kors&kov, who
lost 8000 killed and wounded, large numbers of prisoners and 100
guns. All along the line the Allies fell back, one corps after another,
at the moment when Suv&rov was approaching the foot of the St
Gothard. On the 2ist the field marshal's headquarters were at
Bellinzona, where he made the final preparations. Expecting to be
four days en route before he could reach the nearest friendly
magazine, he took his trains with him, which inevitably augmented
the difficulties of the expedition. On the 24th Airolo was taken, but
when the far greater task of storming the pass itself presented itself
before them, even the stolid Russians were terrified, and only the
passionate protests of the old man, who reproached his " children "
with deserting their father in his extremity, induced them to face the
danger. At last after twelve hours' fighting, the summit was reached.
The same evening Suv&rov pushed on to Hospenthal, while a
flanking column from Disentis made its way towards Amsteg over
the Crispalt. Lecourbe was threatened in rear and pressed in front,
and his engineers, to hold off the Disentis column, had broken the
Devil's Bridge. Discovering this, he left the road, threw his guns into
the river and made his way by fords and water-meadows to
Goschenen, where by a furious attack he cleared the Disentis troops
off his line of retreat. His rearguard meantime held the ruined Devil's
Bridge. This point and the tunnel leading to it, called the Urner Loch,
the Russians attempted to force, with the most terrible losses,
battalion after battalion crowding into the tunnel and pushing the
foremost ranks into the chasm left by the broken bridge. But at last
a ford was discovered and the bridge, cleared by a turning
movement, was repaired. More broken bridges lay beyond, but at
last Suv&rov joined the Disentis column near Goschenen. When
Altdorf was reached, however, Suv&rov found not only Lecourbe in a
threatening position, but an entire absence of boats on the Lake of
the Four Cantons. It was impossible (in those days the Axenstrasse
did not exist) to take an army along the precipitous eastern shore,
and thus passing through one trial after another, each more severe
than the last, the Russians, men and horses and pack animals in an
interminable single file, ventured on the path leading over the Kinzig
pass into the Muotta Thai. The passage lasted three days, the
leading troops losing men and horses over the precipices, the
rearguard from the fire of the enemy, now in pursuit. And at last, on
arrival in the Muotta Thai, the field marshal received definite
information that Kors&kov's army was no longer in existence. Yet
even so it was long before he could make up his mind to retreat, and
the pursuers gathered on all sides. Fighting, sometimes severe, and
never altogether ceasing, went on day after day as the Allied
column, now reduced to 15,000 men, struggled on over one pass
after another, but at last it reached Ilanz on the Vorder Rhine
(October 8). The Archduke Charles meanwhile had, on hearing of
the disaster of Zurich, brought over a corps from the Neckar, and for
some time negotiations were made for a fresh combined operation
against Mass^na. But these came to nothing, for the archduke and
Suv&rov could not agree, either as to their own relations or as to the
plan to be pursued. Practically, Suv&rov's retreat from Altdorf to
Ilanz closed the campaign. It was his last active service, and formed
a gloomy but grand climax to the career of the greatest soldier who
ever wore the Russian uniform. MARENGO AND HOHENUNDEN The
disasters of 1799 sealed the fate of the Directory, and placed
Bonaparte, who returned from Egypt with the prestige of a recent
victory, in his natural place as civil and military
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198 FRENCH REVOLUTIONARY WARS [HOHENLINDEN

head of France. In the course of the campaign the field strength of
the French had been gradually augmented, and in spite of losses
now numbered 227,000 at the front. These were divided into the
Army of Batavia, Brune (25,000), the Army of the Rhine, Moreau
(146,000), the Army of Italy, Massena (56,000), and, in addition,
there were some 100,000 in garrisons and depots in France. Most of
these field armies were in a miserable condition owing to the losses
and fatigues of the last campaign. The treasury was empty and
credit exhausted, and worse still — for spirit and enthusiasm, as in
1794, would have remedied material deficiencies— the conscripts
obtained under Jourdan's law of 1798 (see CONSCRIPTION) came to
their regiments most unwillingly. Most of them, indeed, deserted on
the way to join the colours. A large draft sent to the Army of Italy
arrived with 310 men instead of 10,250, and after a few such
experiences, the First Consul decided that the untrained men were
to be assembled in the fortresses of the interior and afterwards sent
to the active battalions in numerous small drafts, which they could
more easily assimilate. Besides accomplishing the immense task of
reorganizing existing forces, he created new ones, including the
Consular Guard, and carried out at this moment of crisis two such
far-reaching reforms as the replacement of the civilian drivers of the
artillery by soldiers, and of the hired teams by horses belonging to
the state, and the permanent grouping of divisions in army corps. As
early as the 25th of January 1800 the First Consul provided for the
assembly of all available forces in the interior in an The Arm "
•^Tmv °^ Reserve." He reserved to himself the of Reserve,
command of this army,1 which gradually came into being as the
pacification of Vendee and the return of some of Brune's troops from
Holland set free the necessary nucleus troops. The conscription law
was stringently reenforced, and impassioned calls were made for
volunteers (the latter, be it said, did not produce five hundred useful
men). The district of Dijon, partly as being central with respect to
the Rhine and Italian Armies, partly as being convenient for supply
purposes, was selected as the zone of assembly. Chabran's division
was formed from some depleted corps of the Army of Italy and from
the depots of those in Egypt. Chambarlhac's, chiefly of young
soldiers, lost 5 % of its numbers on the way to Dijon from desertion
— a loss which appeared slight and even satisfactory after the
wholesale dSbandade of the winter months. Lechi's Italian legion
was newly formed from Italian refugees. Boudet's division was
originally assembled from some of the southern garrison towns, but
the units composing it were frequently changed up to the beginning
of May. The cavalry was deficient in saddles, and many of its units
were new formations. The Consular Guard of course was a corps
d'flite, and this and two and a half infantry divisions and a cavalry
brigade coming from the veteran " Army of the West " formed the
real backbone of the army. Most of the newer units were not even
armed till they had left Dijon for the front. Such was the first
constitution of the Army of Reserve. We can scarcely imagine one
which required more accurate and detailed staff work to assemble it
— correspondence with the district commanders, with the adjutant-
generals of the various armies, and orders to the civil authorities on
the lines of march, to the troops themselves and to the arsenals and
magazines. No one but Napoleon, even aided by a Berthier, could
have achieved so great a task in six weeks, and the great captain,
himself doing the work that nowadays is apportioned amongst a
crowd of administrative staff officers, still found time to administer
France's affairs at home and abroad, and to think out a general plan
of campaign that embraced Moreau's.Massena's and his own armies.
The Army of the Rhine, by far the strongest and best equipped, lay
on the upper Rhine. The small and worn-out Army of Italy was
watching the Alps and the Apennines from Mont Blanc to 1 He
afterwards appointed Berthier to command the Army of Reserve, but
himself accompanied it and directed it, using Berthier as chief of
staff. Genoa. Between them Switzerland, secured by the victory of
Zurich, offered a starting-point for a turning movement on either
side — this year the advantage of the flank position was recognized
and acted upon. The Army of Reserve was assembling around Dijon,
within 200 m. of either theatre of war. The general plan was that the
Army of Reserve should march through Switzerland to close on the
right wing of the Army of the Rhine. Thus supported to whatever
degree might prove to be necessary, Moreau was to force the
passage of the Rhine about Schaff hausen, to push back the
Austrians rapidly beyond the Lech, and then, if they took the
offensive in turn, to hold them in check for ten or twelve days.
During this period of guaranteed freedom the decisive movement
was to be made. The Army of Reserve, augmented by one large
corps of the Army of the Rhine, was to descend by the Splugen
(alternatively by the St Gothard and even by Tirol) into the plains of
Lombardy. Magazines were to be established at Zurich and Lucerne
(not at Chur, lest the plan should become obvious from the
beginning), and all likely routes reconnoitred in advance. The Army
of Italy was at first ^ ITALIAN CAMPAIGNS 1794-1800 Scale. 1 :3.
ooo ,000 Publish Miles o 10 m 3f> 40 St to maintain a strict
defensive, then to occupy the Austrians until the entry of the
Reserve Army into Italy was assured, and finally to manoeuvre to
join it. Moreau, however, owing to want of horses for his pontoon
train and also because of the character of the Rhine above Basel,
preferred to cross below that place, especially as in Alsace there
were considerably greater supply facilities than in a country which
had already been fought over and stripped bare. With the greatest
reluctance Bonaparte let him have his way, and giving up the idea of
using the Splugen and the St Gothard, began to turn his attention to
the more westerly passes, the St Bernard and the Simplon. It was
not merely Moreau's scruples that led to this essential modification in
the scheme. At the beginning of April the enemy took the offensive
against Mass6na. On the 8th Melas's right wing dislodged the French
from the Mont Cenis, and most of the troops that had then reached
Dijon were shifted southward to be ready for emergencies. By the
25th Berthier reported that Mass6na was seriously attacked and that
he might have to be supported by the shortest route. Bonaparte's
resolution was already taken. He waited no longer for Moreau
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HOHENL1NDEN] FRENCH REVOLUTIONARY WARS 199 (

who indeed so far from volunteering assistance, act ually demanded
it (or himself). Convinced from thepaucityof ncwsthat Massena's
army was closely pressed and probably severed from France, and
feeling also that the Austrian* were deeply committed to their
struggle with the Army of Italy, he told Berthier to inarch with
40,000 men at once by way of the St Bernard unless otherwise
advised. Berthier protested that he had only 25,000 effectives, and
the equipment and armament was still far from complete — as
indeed it remained to the end — but the troops inarched, though
their very means of existence were precarious from the time of
leaving Geneva to the time of reaching Milan, for nothing could
extort supplies and money from the sullen At the beginning of May
the First Consul learned of the serious plight of the Army of Italy.
Massena with his right wing was shut up in Genoa, Suchet with the
left wing '*• driven back to the Yar. Meanwhile Morcau had won a
preliminary victory at Stokach, and the Army of Reserve had begun
its movement to Geneva. With these data the plan of campaign took
a clear shape at last — Massena to resist as long as possible; Suchet
to resume the offensive, if he could do so, towards Turin; the Army
of Reserve to pass the Alps and to debouch into Piedmont by Aosta;
the Army of the Rhine to send a strong force into Italy by the St
Gothard. The First Consul left Paris on the 6th of May. Berthier went
forward to Geneva, and still farther on the route magazines were
established at Villeneuve and St-Pierre. Gradually, and with immense
efforts, the leading troops of the long column' were passed over the
St Bernard, drawing their artillery on sledges, on the isth and
succeeding days. Driving away small posts of the Austrian army, the
advance guard entered Aosta on the i6th and Chatillon on the iSth
and the alarm was given. Melas, committed as he was to his Riviera
campaign, began to look to his right rear, but he was far from
suspecting the seriousness of his opponent's purpose. Infinitely
more dangerous for the French than the small detachment that
Melas opposed to them, or even the actual crossing of the pass, was
the unexpected stopping power of the little fort of Bard. The
advanced guard of the French appeared before it on the ipth, and
after three wasted days the infantry managed to find a difficult
mountain by-way and to pass round the obstacle. Ivrea was
occupied on the ijrd, and Napoleon hoped to assemble the whole
army there by the 27th. But except for a few guns that with infinite
precautions were smuggled one by one through the streets of Bard,
the whole of the artillery, as well as a detachment (under Chabran)
to besiege the fort, had to be left behind. Bard surrendered on the
2nd of June, having delayed the infantry of the French army for four
days and the artillery for a fortnight. The military situation in the last
week of May, as it presented itself to the First Consul at Ivrea, was
this. The Army of Italy under Masslna was closely besieged in
Genoa, where provisions were running short, and the population so
hostile that the French general placed his field artillery to sweep the
streets. But Masslna was no ordinary general, and the First Consul
knew that while Massena lived the garrison would resist to the last
extremity. Suchet was defending Nice and the Var by vigorous minor
operations. The Army of Reserve, the centre of which had reached at
Ivrea the edge of the Italian plains, consisted of four weak army
corps under Victor, Duhesme, Lannes and Murat. There were still to
be added to this small army of 34,000 effectives, Turreau's division,
which had passed over the Mont Cenis and was now in the valley of
the Dora Riparia, Moncey's corps of the Army of the Rhine, which
had at last been extorted from Moreau and was due to pass the St
Gothard before the end of May, Chabran's division left to besiege
Bard, and a small force under Bethencourt, which was to cross the
Simplon and to descend by Arona (this place proved in the event a
second Bard and immobilized Bethencourt until after the decisive
battle). Thus it was only the simplest part of Napoleon's task to
concentrate half of bis army at Ivrea, and he had yet to bring 1 Only
one division of the main body uwd the Little St Bernard. in the rest.
The problem was to reconcile the necessity for time, which he
wanted to ensure the maximum force being brought over the Alps,
with the necessity for haste, in view of the impending fall of Genoa
and the probability that once this conquest was achieved, Melas
would bring back his 100,000 men into the Milanese to deal with the
Army of Reserve. As early as the i ,|i h of May he had informed
Moncey that from Ivrea the Army of Reserve would move on Milan.
On the 2$th of May, in response to Berthier's request for guidance,
the First Consul ordered Lannes (advanced guard) to push out on
the Turin road, " in order to deceive the enemy and to obtain news
of Turreau," and Duhesme's and Murat's corps to proceed along the
Milan road. On the 27th, after Lannes had on the 26th defeated an
Austrian column near Chivasso, the main body was already
advancing on Vercelli. Very few of Napoleon|s acts of generalship
have been more criticized than this resolution to march on Milan,
which abandoned Genoa to its fate and gave Melas a week's leisure
to assemble his scattered forces. The account of his motives " he
dictated at St Helena (Nap. Correspondence, v. 30, toM"aapp. 375-
377), in itself an unconvincing appeal to the rules of strategy as laid
down by the theorists — which rules his own practice througnout
transcended — gives, when closely examined, some at least of the
necessary clues. He says in effect that by advancing directly on Turin
he would have " risked a battle against equal forces without an
assured line of retreat, Bard being stilluncaptured." It is indeed
strange to find Napoleon shrinking before equal forces of the enemy,
even if we admit without comment that it was more difficult to pass
Bard the second time than the first. The only incentive to go towards
Turin was the chance of partial victories over the disconnected
Austrian corps that would be met in that direction, and this he
deliberately set aside. Having done so, for reasons that will appear in
the sequel, he could only defend it by saying in effect that he might
have been defeated — which was true, but not the Napoleonic
principle of war. Of the alternatives, one was to hasten to Genoa ;
this in Napoleon's eyes would have been playing the enemy's game,
for they would have concentrated at Alessandria, facing west " in
their natural position." It is equally obvious that thus the enemy
would have played his game, supposing that this was to relieve
Genoa, and the implication is that it was not. The third course, which
Napoleon took, and in this memorandum defended, gave his army
the enemy's depots at Milan, of which it unquestionably stood in
sore need, and the reinforcement of Moncey's 15,000 men from the
Rhine, while at the same time Moncey's route offered an " assured
line of retreat " by the Simplon* and the St Gothard. He would in
fact make for himself there a " natural position " without forfeiting
the advantage of being in Melas's rear. Once possessed of Milan,
Napoleon says, he could have engaged Melas with a light heart and
with confidence in the greatest possible results of a victory, whether
the Austrians sought to force their way back to the east by the right
or the left bank of the Po, and he adds that if the French passed on
and concentrated south of the Po there would be no danger to the
MilanSt Gothard line of retreat, as this was secured by the rivers
Tjcino and Sesia. In this last, as we shall see, he is shielding an
undeniable mistake, but considering for the moment only the
movement to Milan, we are justified in assuming that his object was
not the relief of Genoa, but the most thorough defeat of Mclas's field
army, to which end, putting all sentiment aside, he treated the hard-
pressed Massena as a " containing force " to keep Melas occupied
during the strategical deployment of the Army of Reserve. In the
beginning he had told Massena that he would " disengage " him,
even if he had to go as far east as Trent to find a way into Italy.
From the first, then, no direct relief was intended, and when, on
hearing bad news from the Riviera, he altered his route to the more
westerly passes, it was probably because he felt that Massena's
containing power was almost exhausted, and that the passage and
reassembly of the Reserve Army must be brought about in the
minimum time and by the shortest way. But the object was still the
defeat of Melas, and for this, as the Austrians possessed an
enormous numerical superiority, the assembly of all forces, including
Moncey's, was indispensable. One essential condition of this was
that the points of passage used should be out of reach of the enemy.
The more westerly the passes chosen, the more dangerous was the
whole operation — in fact the Mont Cenis column never reached him
at all — and though his expressed objections to the St Bernard line
seem, as we have said, to be written after the event, to disarm his
critics, there is no doubt that at the time he disliked it. It was a pis
alter forced upon him by Moreau's delay and Ma»sena'g extremity,
and from the moment at which he arrived at Milan he did, as a fact,
abandon it altogether in favour of theSt Gothard. Lastly, so strongly
was he impressed with the necessity of completing the deployment
of all his forces, that though he found the Austrian* on the Turin
side much scattered and could justifiably expect a aeries of rapid *
When he made his decision he was unaware that Bethencourt had
been held up at Arona.
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2OO FRENCH REVOLUTIONARY WARS [HOHENLINDEN

partial victories, Napoleon let them go, and devoted his whole
energy to creating for himself a " natural " position about Milan. If
he sinned, at any rate he sinned handsomely, and except that he
went to Milan by Vercelli instead of by Lausanne and Domodossola *
(on the safe side of the mountains), his march is logistically beyond
cavil. Napoleon's immediate purpose, then, was to reassemble the
Army of Reserve in a zone of manoeuvre about Milan. This was
carried out in the first days of June. Lannes at Chivasso stood ready
to ward off a flank attack until the main army had filed past on the
Vercelli road, then leaving a small force to combine with Turreau
(whose column had not been able to advance into the plain) in
demonstrations towards Turin, he moved off, still acting as right
flank guard to the army, in the direction of Pavia. The main body
meanwhile, headed by Murat, advanced on Milan by way of Vercelli
and Magenta, forcing the passage of the Ticino on the 3ist of May at
Turbigo and Buffalora. On the same day the other divisions closed up
to the Ticino,2 and faithful to his principles Napoleon had an
examination made of the little fortress of Novara, intending to
occupy it as a place du moment to help in securing his zone of
manoeuvre. On the morning of the 2nd of June Murat occupied
Milan, and in the evening of the same day the headquarters entered
the great city, the Austrian detachment under Vukassovich (the
flying right wing of Melas's general cordon system in Piedmont)
retiring to the Adda. Duhesme's corps forced that river at Lodi, and
pressed on with orders to organize Crema and if possible Orzinovi as
temporary fortresses. Lechi's Italians were sent towards Bergamo
and Brescia. Lannes meantime had passed Vercelli, and on the
evening of the 2nd his cavalry reached Pavia, where, as at Milan,
immense stores of food, equipment and warlike stores were seized.
Napoleon was now safe in his " natural " position, and barred one of
the two main lines of retreat open to the Austrians. But his
ambitions went further, and he intended to cross the Po and to
establish himself on the other likewise, thus establishing across the
plain a complete barrage between Melas and Mantua. Here his end
outranged his means, as we shall see. But he gave himself every
chance that rapidity could afford him, and the moment that some
sort of a " zone of manoeuvre " had been secured between the
Ticino and the Ogh'o, he pushed on his main body — or rather what
was left after the protective system had been provided for — to the
Po. He would not wait even for his guns, which had at last emerged
from the Bard defile and were ordered to come to Milan by a safe
and circuitous route along the foot of the Alps. At this point the
action of the enemy began to make itself felt. Melas had not gained
the successes that he had expected in Piedmont and on the Riviera,
thanks to Massena's mo'"-'* obstinacy and to Suchet 's brilliant
defence of the Var. meats. These operations had led him very far
afield, and the protection of his over-long line of communications
had caused him to weaken his large army by throwing off many
detachments to watch the Alpine valleys on his right rear. One of
these successfully opposed Turreau in the valley of the Dora Riparia,
but another had been severely handled by Lannes at Chivasso, and a
third (Vukassovich) found itself, as we know, directly in the path of
the French as they moved from Ivrea to Milan, and was driven far to
the eastward. He was further handicapped by the necessity of
supporting Ott before Genoa and Elsnitz on the Var, and hearing of
Lannes's bold advance on Chivasso and of the presence of a French
column with artillery (Turreau) west of Turin, he assumed that the
latter represented the main body of the Army of Reserve — in so far
indeed as he believed in the existence of that army at all.3 Next,
when 1 This may be accounted for by the fact that Napoleon's mind
was not yet definitively madeup when his advanced guard had
already begun to climb the St Bernard (izth). Napoleon s instructions
for Moncey were written on the I4th. The magazines, too, had to be
provided and placed before it was known whether Moreau's
detachment would be forthcoming. * Six guns had by now passed
Fort Bard and four of these were with Murat and Duhesme, two with
Lannes. ' It is supposed that the foreign spies at Dijon sent word to
their various employers that the Army was a bogy. In fact a great
part of it never entered Dijon at all, and the troops reviewed there
by Lannes moved away towards Pavia, Melas thought for a moment
that fate had delivered his enemy into his hands, and began to
collect such troops as were at hand at Turin with a view to cutting
off the retreat of the French on Ivrea while Vukassovich held them in
front. It was only when news came of Moncey's arrival in Italy and
of Vukassovich's fighting retreat on Brescia that the magnitude and
purpose of the French column that had penetrated by Ivrea became
evident. Melas promptly decided to give up his western enterprises,
and to concentrate at Alessandria, preparatory to breaking his way
through the network of small columns — as the disseminated Army
of Reserve still appeared to be — which threatened to bar his
retreat. But orders circulated so slowly that he had to wait in Turin
till the 8th of June for Elsnitz, whose retreat was, moreover, sharply
followed up and made exceedingly costly by the enterprising Suchet.
Ott, too, in spite of orders to give up the siege of Genoa at once and
to march with 'all speed to hold the Alessandria-Piacenza road,
waited two days to secure the prize, and agreed (June 4) to allow
Massena's army to go free and to join Suchet. And lastly, the cavalry
of O'Reilly, sent on ahead from Alessandria to the Stradella defile,
reached that point only to encounter the French. The barrage was
complete, and it remained for Melas to break it with the mass that
he was assembling, with all these misfortunes and delays, about
Alessandria. His chances of doing so were anything but desperate.
On the 5th of June Murat, with his own corps and part of
Duhesme's, had moved on Piacenza, and stormed the bridge-head
there. Duhesme with one of his divisions pushed out on Crema and
Orzinovi and also towards Pizzighetone. Moncey's leading regiments
approached Milan, and Berthier thereupon sent on Victor's corps to
support Murat and Lannes. Meantime the half abandoned line of
operations, Ivrea- Vercelli, was briskly attacked by the Austrians,
who had still detachments on the side of Turin, waiting for Elsnitz to
rejoin, and the French artillery train was once more checked. On the
6th Lannes from Pavia, crossing the Po at San Cipriano, encountered
and defeated a large force, (O'Reilly's column), and barred the
Alessandria- Parma main road. Opposite Piacenza Murat had to
spend the day in gathering material for his passage, as the pontoon
bridge had been cut by the retreating garrison of the bridge-head.
On the eastern border of the " zone of manoeuvre " Duhesme's
various columns moved out towards Brescia and Cremona, pushing
back Vukassovich. Meantime .the last divisions of the Army of
Reserve (two of Moncey's excepted) were hurried towards Lannes's
point of passage, as Murat had not yet secured Piacenza. On the
7th, while Duhesme continued to push back Vukassovich and seized
Cremona, Murat at last captured Piacenza, finding there immense
magazines. Meantime the army, division by division, passed over,
slowly owing to a sudden flood, near Belgiojoso, and Lannes's
advanced guard was ordered to open communication with Murat
along the main road Stradella-Piacenza. " Moments are precious "
said the First Consul. He was aware that Elsnitz was retreating
before Suchet, that Melas had left Turin for Alessandria, and that
heavy forces of the enemy were at or east of Tortona. He knew, too,
that Murat had been engaged with certain regiments recently before
Genoa and (wrongly) assumed O'Reilly's column, beaten by Lannes
at San Cipriano, to have come from the same quarter. Whether this
meant the deliverance or the surrender of Genoa he did not yet
know, but it was certain that Massena's holding action was over, and
that Melas was gathering up his forces to recover his
communications. Hence Napoleon's great object was concentration.
" Twenty thousand men at Stradella," in his own words, was the goal
of his efforts, and with the accomplishment of this purpose the
campaign enters on a new phase. On the 8th of June, Lannes's
corps was across, Victor following as quickly as the flood would
allow. Murat was at Piacenza, but the road between Lannes and
Murat was not known to be clear, and the First Consul made the
establishment of the Bonaparte were only conscripts and details. By
the time that the veteran divisions from the west and Paris arrived,
either the spies had been ejected or their news was sent off too late
to be of use.
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MONTEBELLO) FRENCH REVOLUTIONARY WARS 201

connexion, and the construction of a third point of passage midway
between the other two, the principal objects of the day's work. The
army now being disseminated between the *'* Alps, the Apennines,
the Ticino and the Chicse, it was of vital importance to connect up
the various parts into a well-balanced system. But the Napoleon of
1800 solved the problem that lay at the root of his strategy, "
concentrate, but be vulnerable nowhere," in a way that compares
unfavourably indeed with the methods of the Napoleon of 1806.
Duhesme was still absent at Cremona. Lechi was far away in the
Brescia country, Bethencourt detained at Arena. Moncey with about
15,000 men had to cover an area of 40 m. square around Milan,
which constituted the original zone of manoeuvre, and if Melas
chose to break through the flimsy cordon of outposts on this side
(the risk of which was the motive for detaching Moncey at all)
instead of at the Stradella, it would take Moncey two days to
concentrate his force on any battlefield within the area named, and
even then he would be outnumbered by two to one. As for the main
body at the Stradella, its position was wisely chosen, for the ground
was too cramped for the deployment of the superior force that Melas
might bring up, but the strategy that set before itself as an object
20,000 men at the decisive point out of 50,000 available, is, to say
the least, imperfect. The most serious feature in all this was the
injudicious order to Lannes to send forward his advanced guard, and
to attack whatever enemy he met with on the road to Voghera. The
First Consul, in fact, calculated that Melas could not assemble 20,000
men at Alessandria before the i2th of June, and he told Lannes that
if he met the Austrians towards Voghera, they could not be more
than 10,000 strong. A later order betrays some anxiety as to the
exactitude of these assumptions, warns Lannes not to let himself be
surprised, indicates his line of retreat, and, instead of ordering him
to advanceon Voghera, authorizes him to attack any corps that
presented itself at Stradella. But all this came too late. Acting on the
earlier order Lannes fought the battle of Montebello on the gth. This
was a very severe running fight, beginning east of Casteggio and
ending at Montebello, in which the French drove the Austrians from
several successive positions, and which culminated in a savage fight
at close quarters about Montebello itself. The singular feature of the
battle is the disproportion between the losses on either side —
French, 500 out of 12,000 engaged; Austrians, 2100 killed and
wounded and 2100 prisoners out of 14,000. These figures are most
conclusive evidence of the intensity of the French military spirit in
those days. One of the two divisions (Watrin's) was indeed a veteran
organization, but the other, Chambarlhac's, was formed of young
troops and was the same that, in the march to Dijon, had
congratulated itself that only 5 % of its men had deserted. On the
other side the soldiers fought for " the honour of their arms " — not
even with the courage of despair, for they were ignorant of the "
strategic barrage " set in front of them by Napoleon, and the loss of
their communications had not as yet lessened their daily rations by
an ounce. Meanwhile, Napoleon had issued orders for the main body
to stand fast, and for the detachments to take up their definitive
covering positions. Duhesme's corps was directed, from its eastern
foray, to Piacenza, to join the main body. Moncey was to provide for
the defence of the Ticino line, Lechi to form a " flying camp " in the
region of Orzinovi-Brescia and Cremona, and another mixed brigade
was to control the Austrians in Pizzighetone and in the citadel of
Piacenza. On the other side of the Po, between Piacenza and
Montebello, was the main body (Lannes, Murat and part of Victor's
and Duhesme's corps), and a flank guard was stationed near Pavia,
with orders to keep on the right of the army as it advanced (this is
the first and only hint of any intention to go westward) and to fall
back fighting should Melas come on by the left bank. One division
was to be always a day's march behind the army on the right bank,
and a flotilla was to ascend the Po, to facilitate the speedy
reinforcement of the flank guard. Farther to the north was a small
column on the road Milan- Vercelli. All the protective troops, except
the division of the main body detailed as an eventual support for the
flank guard, was to be found by Moncey's corps (which had besides
to watch the Austrians in the citadel of Milan) and Chabran's and
Lechi's weak commands. On this same day Bonaparte tells the
Minister of War, Carnot, that Moncey has only brought half the
expected reinforcements and that half of these are unreliable. As to
the result of the impending contest Napoleon counts greatly upon
the union of 18,000 men under Massdna and Suchet to crush Melas
against the " strategic barrage " of the Army of Reserve, by one or
other bank of the Po, and he seems equally confident of the result in
either case. If Genoa had held out three days more, he says, it
would have been easy to count the number of Melas's men who
escaped. The exact significance of this last notion is difficult to
establish, and all that could be written about it would be merely
conjectural. But it is interesting to note that, without admitting it,
Napoleon felt that his " barrage " might not stand before the flood.
The details of the orders of the gth to the main body (written before
the news of Montebello arrived at headquarters) tend to the closest
possible concentration of the main body towards Casteggio, in view
of a decisive battle on the i2th or i.^th. But another idea had begun
to form itself in his mind. Still believing that Melas would attack him
on the Stradella side, and hastening his preparations to meet this,
he began to allow for the contingency of Melas giving up or failing in
his attempt to re-establish his communication with the Mantovese,
and retiring on Genoa, which was now in his hands and could be
provisioned and reinforced by sea. On the loth Napoleon ordered
reserve ammunition to be sent Scale, i 650 ooo . . > , 6 IMUtt from
Pavia, giving Serravalle, which is south of Novi, as- its probable
destination. But this was surmise, and of the facts he knew nothing.
Would the enemy move east on the Stradella, north-east on the
Ticino or south on Genoa? Such reports as were available indicated
no important movements whatever, which happened to be true, but
could hardly appear so to the French headquarters. On the nth,
though he thereby forfeited the reinforcements coming up from
Duhesme's corps at Cremona, Napoleon ordered the main body to
advance to the Scrivia. Lapoype's division (the .right flank guard),
which was observing the Austrian posts towards Casale, was called
to the south bank of the Po, the zone around Milan was stripped so
bare of troops that there was no escort for the prisoners taken at
Montebello, while information sent by Chabran (now moving up from
Ivrea) as to the construction of bridges at Casale (this was a feint
made by Melas on the loth) passed unheeded. The crisis was at
hand, and, clutching at the reports collected by Lapoype as to the
quietude of the Austrians toward Valenza and Casale, Bonaparte and
Berthier strained every nerve to bring up more men to the
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202 FRENCH REVOLUTIONARY WARS [HOHENLINDEN

Marengo. Voghera side in the hope of preventing the prey from
slipping away to Genoa. On the 1 2th, consequently, the army (the
ordre de batailk of which had been considerably modified on the
nth) moved to the Scrivia, Lannes halting at Castelnuovo, Desaix
(who had just joined the army from Egypt) at Pontecurone, Victor at
Tortona with Murat's cavalry in front towards Alessandria. Lapoype's
division, from the left bank of the Po, was marching in all haste to
join Desaix. Moncey, Duhesme, Lechi and Chabran were absent. The
latter represented almost exactly half of Berthier's command (30,000
out of 58,000), and even the concentration of 28,000 men on the
Scrivia had only been obtained by practically giving up the " barrage
" on the left bank of the Po. Even now the enemy showed nothing
but a rearguard, and the old questions reappeared in a new and
acute form. Was Melas still in Alessandria ? Was he marching on
Valenza and Casale to cross the Po ? or to Acqui against Suchet, or
to Genoa to base himself on the British fleet? As to the first, why
had he given up his chances of fighting on one of the few cavalry
battlegrounds in north Italy — the plain of Marengo — since he
could not stay in Alessandria for any indefinite time ? The second
question had been answered in the negative by Lapoype, but his
latest information was thirty-six hours old. As for the other
questions, no answer whatever was forthcoming, and the only
course open was to postpone decisive measures and to send forward
the cavalry, supported by infantry, to gain information. On the i3th,
therefore, Murat, Lannes and Victor advanced into the plain of
Marengo, traversed it without difficulty and carrying the villages held
by the Austrian rearguard, established themselves for the night
within a mile of the fortress. But meanwhile Napoleon, informed we
may suppose of their progress, had taken a step that was fraught
with the gravest consequences. He had, as we know, no intention of
forcing on a decision until his reconnaissance produced the
information on which to base it, and he had therefore kept back
three divisions under Desaix at Pontecurone. But as the day wore on
without incident, he began to fear that the reconnaissance would be
profitless, and unwilling to give Melas any further start, he sent out
these divisions right and left to find and to hold the enemy,
whichever way the latter had gone. At noon Desaix with one division
was despatched southward to Rivalta to head off Melas from Genoa
and at 9 A.M. on the 14th,1 Lapoype was sent back over the Po to
hold the Austrians should they be advancing from Valenza towards
the Ticino. Thus there remained in hand only 21,000 men when at
last, in the forenoon of the i4th the whole of Melas's army, more
than 40,000 strong, moved out of Alessandria, not southward nor
northward, but due west into the plain of Marengo (q.v.). The
extraordinary battle that followed is described elsewhere. The outline
of it is simple enough. The Austrians advanced slowly and in the face
of the most resolute opposition, until their attack had gathered
weight, and at last they were carrying all before them, when Desaix
returned from beyond Rivalta and initiated a series of
counterstrokes. These were brilliantly successful, and gave the
French not only local victory but the supreme self-confidence that,
next day, enabled them to extort from Melas an agreement to
evacuate all Lombardy as far as the Mincio. And though in this way
the chief prize, Melas's army, escaped after all, Marengo was the
birthday of the First Empire. One more blow, however, was required
before the Second Coalition collapsed, and it was delivered by
Moreau. We have seen that he had crossed the upper Rhine and
defeated Kray at Stokach. This was followed by other partial
victories, and Kray then retired to Ulm, where he reassembled his
forces, hitherto scattered in a long weak line from the Neckar to
Schaffhausen. Moreau continued his advance, extending his forces
up to and over the Danube below Ulm, and winning several
combats, of which the most important was that of Hochstadt, 1 On
the strength of a report, false as it turned out, that the Austrian
rearguard had broken the bridges of the Bormida. fought on the
famous battlegrounds of 1703 and 1704, and memorable for the
death of La Tour d'Auvergne, the " First Grenadier of France " (June
19). Finding himself in danger of envelopment, Kray now retired,
swiftly and skilfully, across the front of the advancing French, and
reached Ingolstadt in safety. Thence he retreated over the Inn,
Moreau following him to the edge of that river, and an armistice put
an end for the moment to further operations. This not resulting in a
treaty of peace, the war was resumed both in Italy and in Germany.
The Army of Reserve and the Army of Italy, after being fused into
one, under Massena's command, were divided again into a fighting
army under Brune, who opposed the Austrians (Bellegarde) on the
Mincio, and a political army under Murat,which re-established French
influence in the Peninsula. The former, extending on a wide front as
usual, won a few strategical successes without tactical victory, the
only incidents of which worth recording are the gallant fight of
Dupont's division, which had become isolated during a manoeuvre,
at Pozzolo on the Mincio (December 25) and the descent of a corps
under Macdonald from the Grisons by way of the Spliigen, an
achievement far surpassing Napoleon's and even Suvirov's exploits,
in that it was made after the winter snows had set in. In Germany
the war for a moment reached the sublime. Kray had been displaced
in command by the young archduke John, who ordered the
denunciation of the armistice and a general advance. His plan, or
that of his advisers, was to cross the lower Inn, out of reach of
Moreau's principal mass, and then to swing round the French flank
until a complete chain was drawn across their rear. But during the
development of the manoeuvre, Moreau also moved, and by rapid
marching made good the time he had lost in concentrating his over-
dispersed forces. The weather was appalling, snow and rain
succeeding one another until the roads were almost impassable. On
the 2nd of December the Austrians were brought to a standstill, but
the inherent mobility of the Revolutionary armies enabled them to
surmount all difficulties, and thanks to the respite afforded him by
the archduke's halt, Moreau was able to see clearly into the enemy's
plans and dispositions. On the 3rd of December, while the Austrians
in many disconnected columns were struggling through the dark and
muddy forest paths about Hohenlinden, Moreau struck the decisive
blow. While Ney and Grouchy held fast the head of the Austrian
main column at Hohenlinden, Richepanse's corps was directed on its
left flank. In the forest Richepanse unexpectedly met a subsidiary
Austrian column which actually cut his column in two. But profiting
by the momentary confusion he drew off that part of his forces
which had passed beyond the point of contact and continued his
march, striking the flank of the archduke's main column, most of
which had not succeeded in deployingoppositeNey,at the village of
Mattempost. First the baggage train and then the artillery park fell
into his hands, and lastly he reached the rear of the troops engaged
opposite Hohenlinden, whereupon the Austrian main body practically
dissolved. The rear of Richepanse's corps, after disengaging itself
from the Austrian column it had met in the earlier part of the day,
arrived at Mattempost in time to head off thousands of fugitives who
had escaped from the carnage at Hohenlinden. The other columns of
the unfortunate army were first checked and then driven back by the
French divisions they met, which, moving more swiftly and fighting
better in the broken ground and the woods, were able to combine
two brigades against one wherever a fight developed. On this
disastrous day the Austrians lost 20,000 men, 1 2,000 of them being
prisoners, and 90 guns. Marengo and Hohenlinden decided the war
of the Second Coalition as Rivoli had decided that of the First, and
the Revolutionary Wars came to an end with the armistice of Steyer
(December 25, 1800) and the treaty of Luneville (February 9, 1801).
But only the first act of the great drama was accomplished. After a
short respite Europe entered upon the Napoleonic Wars.
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NAVAL OPERATIONS, FRENCH REVOLUTIONARY WARS 203

r. — By far the most important modern work* are nuquct's Ut rrrrs
de la Revolution (II monographs forming together a complete hUiory
of the campaigns of 1792-93), and the publication* of the French
General Staff. The latter appear first, a* a rule, in the official " Revue
d'hiatoire " and are then rcpublishcd in wpar.itr M-luine-. of which
every year adds to the number. V. Dupui*' L'Armet du nord 1793'.
Coutanceau'i L'Armte du nord 1794; J. Colin'* Education milttaire de
Napoleon and Campagne de 1793 *• Alsace; and C. de Cugnac'i
Campagne de I'armee de reserve iSoo may be specially named.
Among other works of importance the principal are C. von B(inder)-
K(neglstein), Geist und Staff im Kriege (Vienna, 1896); E. Gachot's
work* on Massena's career (containing invaluable evidence though
written in a somewhat rhetorical style); Ritter von Angeli, Enhertog
Karl (Vienna, 1896); F. N. Maude, Evolution of Modem Strategy; G.
A. Furse, Marengo and Hohenlindm; C. von C'lauscwitz, Feldzug
1796 in Italien and Feldzug 1799 (French translations); H. Bonnal,
De Rosbach a Ulm; Krebs and Moris, Campagnes dans les Alpes
(Paris, 1891-1895); Yorck von Wartenburg, Napoleon als Feldherr
(English and French translation*); F. Bouvier, Bonaparte en Italie
1706; Kuhl, Bonaparte's enter Feldtut; J. W. Fortescue, Hist, of the
British Army, vol. iv. ; G. D. v. Scharnhorst, Ursache des Clucks der
Frantosen 1793-1794 (reprinted in A. Weiss's Short German Military
Readings, London, 1892); E. D'Hauterive, L'Armfe sous la Revolution;
C. Rousset, Les Volonlaires; Max Jahns, Das frantosische I leer; Shad
well. Mountain Warfare; works of Colonel Camon (Guerre
.\apoleonienne, &c.) ; Austrian War Office, Krieg gegen die front.
Revolution 1793-1797 (Vienna, 1905); Archduke Charles, Grundsatte
der Stratetie (1796 campaign in Germany), and Gesch. des
Feldtuges 1799 in Devise kl. und der Schweit; v. Zeissberg,
Erzherzog Karl; the old history called Vieloires ei conquttes des
Franc/tis (27 volumes, Paris, 1817-1825); M. Hartmann, Anteil der
Russen am Feldzug 1799 in der Sckmis (Zurich, 1892); Danelewski-
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