CONCEPTS OF CARDIAC PATHOLOGY BEFORE MORGAGNI*

By ESMOND R. LONG, M.D.

PHILADELPHIA

HIS title has been chosen with erroneous concepts of cardiac pathol­ the purpose of presenting not ogy, the hairy heart and the clot within only the bizarre notions of car­ the heart. The first was of minor im­ diac pathology that clouded portance, but the puzzle of the polyp Tmedicine in the early years of theits heart made a jumble of treatises growth, but also the substantial devel­ on cardiac disease for three centuries, opment in its true understanding be­ from which we have hardly recovered fore the great morbid anatomist Mor­ yet, and the great Morgagni was no gagni came upon the scene. The view more free from its influence than his is still widely current that modern predecessors. knowledge of pathological anatomy be­ The advent of the “hairy heart” in gan with the distinguished professor of pathological literature is an illuminat­ anatomy at Padua. It is true that the ing example of the explosion of rev­ huge collection “De sedibus et causis erence for the classics incident with the morborum” formed a compilation of Renaissance and the naive acceptance accurate observations in morbid anat­ of anything from ancient Greece or omy such as had never been seen be­ Rome. Homer wrote of the Xao-tov Kfjp fore, and set a new standard in the ana­ of certain heroes of old; Hesiod used a tomical description of disease. Yet it is similar term, as did other Greek and only fair to add that almost every lesion Latin authors. Pliny the Naturalist described by Morgagni had been seen took pains to note the hairy heart of and described, in part at least, if not Aristomenes, the semilegendary hero of well, by some predecessor, and this the Messenian revolt against Sparta, holds not only for general pathology, and in one place or another hairy but for cardiac and vascular pathology, hearts were accorded to various other in which Morgagni was preeminent. ancient heroes, including the Spartan The discussion will be limited to the Leonidas, who held the pass at Ther­ two and one-half centuries before Mor­ mopylae, and the Spartan warrior Ly- gagni, i.e., the early period of patho­ sander, who three times defeated the logical anatomy. Athenian fleet and finally captured The first printed book in which an Athens. Indeed it was recorded that all appreciable number of necropsy pro­ the Sabine men, the Italian tribe so tocols are recorded is the work “De intimately bound up with the begin­ abditis causis morborum’’ of Antonio nings of Rome, were characterized by Benivieni of Florence, and in it are two the same badge of courage, a hairy reports that illustrate two interesting heart. * Read before the American Association of the History of Medicine, Atlantic City, May 4, 1936- And so Benivieni, a lover of the clas­ as in our own. as presumptive evidence sics. was misled. Watching the autopsy of exceptional fortitude, and a mark of a highwayman who had been hanged enjoyed by Aristomenes. Lysander. for his crimes, he was impressed by the fact that once before this man had been hanged, but proved so hardy that he had survived the first hanging, and on resuscitation by his friends returned to terrorize the countryside. In the peri­ cardial sac of this lusty robber was a stringy substance, which to us would be a fibrinous exudate. But to Benivieni. fresh from the pages of Pliny, it was a confirmation of the Naturalist, for here was a hairy heart like that of Aris- tomenes. Other similar reports followed, and were readily taken at their face value in a time when the bizarre and the mirac­ ulous were favored over the ordinary and commonplace. But even then the doubters would have overthrown this curious concept of cardiac pathology had not the anatomists Fabricius Hil- danus, Ruysch and others called atten­ tion to the unquestionable occasional From the “Observaiioncs medicae” of Nicholaas Tulp, Amsterdam, 1641. The polyp occurrence of hair in cysts of the ovary, (bb, with branches aa and feet ccc') was and if hair could occur in the ovary, recorded as present in the left ventricle of why not in the heart? the heart in a man dying suddenly. It was more than two centuries be­ fore this error was finally buried. In the Leonidas and the rest in company with meantime serofibrinous and fibrino- a multitude of other men. purulent pericarditis, not to mention I he other cardiac abnormality re­ adherent pericardium, had been seen corded by Benivieni was a frustulum and reported as such over and again, nigrioris carnis, a piece of black flesh but the old records stood, and were still shaped like a medlar, in the left ven­ quoted, if a little doubtfully. At last tricle of the heart, found in a woman the French cardiologist Senac, in the long troubled with pain in the chest, second edition of his treatise on the and considered by Benivieni to be the heart, which followed Morgagni’s great cause of her death. This was presum­ book, with all the new knowledge be­ ably a postmortem clot, and the obser­ fore him, and a longer acquaintance vation is of importance only as an early with the classics behind, gave the sim­ forerunner of countless descriptions of ple explanation that the ancients were “polyps’’ within the heart. Every pa­ prone to poetic license, that the “hairy thologist today knows how variable is heart’’ was probably nothing but a the appearance of the postmortem hairy chest, accepted in Senac’s time, intracardiac clot. I he length of time between death and necropsy, the posi­ the difference between the true and the tion of the body after death, the viscos­ false polyps of the heart. ity and coagulability of the blood, all If space were available it would be these and other factors affect the size interesting to go into the ramifications and appearance of such clots. But from of the subject of polyps, such as the the fifteenth to the nineteenth century curious belief in the occurrence of these clots were taken very seriously. worms and snakes in the chambers of They were by far the most frequently the heart. These were also ordinary described lesion of the heart, and time postmortem clots, pulled out of the and time again were reported as the great vessels attached to the heart, but cause of death. To the early patholo­ in the seventeenth century as “serpents gists and anatomists, not omitting corroding the walls of the heart’’ these Vesalius, the polyps of the heart were coagula received extended recognition. so conspicuous that the necropsy in ob­ Riolan, Zacutus Lusitanus, Severino, scure cases, including judicial necrop­ Bartholin, and many more put more or sies, commonly ended with their dis­ less faith in the reports of worms in the covery. Even the finding of polyps of heart, and Pierre de Castro of Verona, the heart in men dead of wounds in Vidius the younger and others reported battle did not explode the myth; the their constant occurrence in the hearts polyps were unexpected evidence of of those dying in certain widespread, disease already present, or by the less fatal epidemics. credulous were looked upon as forma­ The subject of polyps may be con­ tions subsequent to the wound and the cluded by pointing out that the signifi­ actual and final causes of death. cance accorded to the postmortem clots A huge literature devoted to the prevented recognition of the signifi­ polyp of the heart grew up, most of it cance of vegetations on the valves. Un­ purely objective, but some of it theo­ mistakable descriptions of such vegeta­ retical and philosophical like the dis­ tions are found in the pre-Morgagnian sertation “De polypo cordis’’ by the literature as well as in the “De sedibus” celebrated Malpighi. of Morgagni, but in general no more Men of great experience must have importance was attached to them than known that polyps were adventitious to the polyps in general. One of the products, but so much importance was best descriptions is in Lancisi’s book attached to them in the general medical on Sudden Death, in which he de­ literature that even Morgagni in the scribed a necropsy performed by two of middle of the eighteenth century, me­ his physician friends at which “he was ticulously, and often at great length, present, noting all things diligently.’’ described their appearance in his cases, His report states that the heart ex­ without committing himself, however, hibited a rare thing to them, viz., cer­ on their significance. At approximately tain irregular fleshy tumors, “like con­ this time tracts casting doubt on the dylomas,’’ adherent to the semilunar importance of polyps of the heart be­ valves of the aorta. He added that many came increasingly common, but the had seen fungoid bodies on the outside term endured into the nineteenth cen­ of the heart, but it was new to find tury and physicians still living were them in the heart (except, of course, medical graduates when Rokitanksy polyps) . There was an ordinary polyp was teaching students, none too clearly, in this case, but it is interesting to note that Lancisi ascribed little significance early seventeenth centuries, were oc­ to it, but related the fungoid masses on casional vague correlations of general the aortic-valve cusps to the man's his­ edema and abnormality of the heart. In tory of repeated syncope. In passing it may be noted that just a century later this same condyloma­ tous appearance was to lead Corvisart astray. The resemblance to venereal condylomata seemed to him too close to be without meaning, and he there­ fore described the vegetations of endo­ carditis as lesions of venereal disease. I he relation of vegetations to articular rheumatism was not understood until a quarter of a century later through the investigations of Jean-Baptiste Bouil- laud (1836). But if the subacute vegetative phase of rheumatic mitral and aortic disease was little known in pre-Morgagnian times, the sequelae, mitral and aortic stenosis and regurgitation, were well known. Many descriptions might be cited, but we can go all the way back to From the “De abscessuum recondita natura libri viii” of Marco Aurelio Severino, edition 1715, in the “Traite du coeur” of of 1724. Ihe “serpent” was found in 1639 Raymond Vieussens, to find one of the by Edward May, vir in medicinae arte un- best. Here we read of dilatation of the diquaque conspicuous, in the heart of one heart due to disease of the mitral ori­ John Pennant of London, twenty-one years fice. In this case the mitral cusps were old, who died with suppurative nephritis. described as ossified (the general term The description was repeated not only by Severino, but also by Zacutus Lusitanus and for calcified in those days) , pulled others. Severino expressed some doubt of the downward, fused at their margins, and animal nature of the intracardiac anomaly. too short to meet, so that an oval gap was left when they should have been the massive assemblage by Bonet (“Se- closed. The atrium was dilated from pulcretum,” 1679), while ascites was arrest of blood, and so, also, was the rest commonly and often correctly attrib­ of the vascular system. As Senac wrote uted to disease of the liver, one section a few decades later, many other cases was devoted to ascites in cases charac­ could be cited, but this one will suffice. terized anatomically by various sup­ Valvular incompetence brings us to posed cardiac abnormalities, chiefly another subject, decompensation of the polyp, and clinically by palpitation. heart. As a functional matter this was Somewhat later more definite cor­ understood long before Morgagni. In relation of dropsy and anasarca was the early reports on dropsy, such as made. Richard Lower in his “Trac- those of Pieter Pauw and Thomas tatus de corde” (1669) clearly de­ Bartholin in the late sixteenth and scribed hypostatic congestion and edema from failing heart. In connec­ naturally, the “polyps,’’ and more sur­ tion with his observations on experi­ prisingly the worms, in which Lancisi mental deliberate obstruction of the put faith) and particularly hyper­ circulation in animals he called atten­ tion to the fact that people in bad health, short of breath on climbing stairs, were subject to dilatation of the capillary vessels and dropsy of the feet, and that this disappeared when they lay down and the feet were elevated. Lower’s experiments and deductions, it may be noted, were given a promi­ nent place in the interpretation of the cardiac symptoms of Johann Wepfer, the discoverer of the nature of apo­ plexy, in an elaborate description when that man’s biography was written in 1727. In the general consideration of the pathology of the heart three well- known conditions received attention from all writers on the subject, viz. dilatation, hypertrophy and rupture. At first the two former were not clearly distinguished, but by 1700 the distinc­ tion was definite. Of the several out­ standing works devoted exclusively or largely to diseases of the heart, the two trophy of the heart and aneurysms of monographs “De subitaneis mortibus” the aorta, came in for extended con­ and “De motu cordis et aneurysmati- sideration. The following may be taken bus” by Giovanni Maria Lancisi for an example: A young man suffered proved among the most important. In for more than two years with palpita­ 1706 Lancisi was commissioned by tion of the heart, a sense of suffocation Pope Clement xi to investigate the sub­ and nasal hemorrhage. Exacerbations ject of sudden death, which seemed to and remissions occurred, but the gen­ be all too frequent in Rome. Lancisi’s eral course was bad. A type of asthma studies took him inevitably to an inti­ with orthopnea developed. The action mate investigation of the heart. He of the heart was noticeable to the pa­ came to the conclusion that three tient in sudden starts and jumps (pre­ things were necessary to life as far as sumably extrasystoles) . The pulse was the heart was concerned, normal struc­ powerful but irregular. The eyes ture of heart and arteries, freedom of showed the pulsation of the carotids. the passages, and finally the moving Finally the abdomen and feet swelled, power or pulsive faculty. Failure of the sense of suffocation increased and these requisites could promptly kill. the patient died. At necropsy the heart Wounds, external or internal obstruc­ was found enlarged to twice, and the tions of the vascular system (including, right auricle to three times the normal size. I he right ventricle was dilated made to present a comprehensive ac­ and the wall correspondingly thin. In count of the development of knowledge contrast the left heart was greatly of heart disease. It is altogether prob­ hypertrophied. Except for some loss of able that before Morgagni, as now, only elasticity the aorta was normal. Is not the more enlightened members of the this an almost modern description of profession kept up with the times. The hypertension, with hypertrophy and less enlightened, presumably in larger ultimate decompensation of the heart? proportion in those days before the ad­ It was written half a century before the vent of circulating journals, in all prob­ appearance of Morgagni's great text. ability practiced medicine with the Surprisingly numerous are the early heritage of the past, i.e., the old-fash­ descriptions of rupture of the heart. ioned humoral pathology. The latter One of the best known comes from the was by no means dead. The teaching of pen of the discoverer of the circulation the sixteenth century was still to a con­ himself (1628) . In his second letter to siderable extent the teaching of the the doubter Riolan, William Harvey eighteenth. The celebrated Fernel had described the case of Sir Robert Darcy, taught a more or less mythical division who suffered from suffocating attacks of lesions of the heart into inflamma­ of pain in the chest, and finally died in tion, erysipelas, tumors contra naturam, one of his paroxysms. At necropsy the ulcers and wounds. Actually, however, wall of the left ventricle, while appar­ symptoms in his time and long after­ ently thick and strong, was found to ward were attributed to toxic humors be the seat of a rent large enough to inhibiting the vital force. The pulse admit any of Harvey’s fingers. Presum­ was the index to the internal state. I he ably the rent occurred in an infarct, hot, intemperate constitution was re­ and the condition of the coronary ar­ flected in the hard and rapid pulse, and teries was overlooked. These arteries the cold, intemperate constitution, in a were not always omitted from observa­ tion, for scores of descriptions of calci­ pulse that was slow and soft. A small, fied coronary arteries can be found in soft, languid pulse indicated a humid the pre-Morgagnian descriptions. But constitution, while one that was small, while Morgagni too described several thin and hard went with a constitution cases of rupture of the heart, neither he excessively dry. The never-forgotten nor his successors for many years to bile entered largely into the concept of come understood the underlying cause. cardiac disease, and the blackness of Full understanding came only with the the blood, dark like the evil black bile, thorough investigations of Carl Wei- was as good evidence of abnormality to gert on thrombosis and infarction, many who went so far as to study the practically in our own time. heart itself, as the more definite lesions With these few examples we may of texture. But good descriptions of the conclude this discussion of views on the latter were on record in astounding pathology of the heart before Mor­ number long before Morgagni, and gagni. Needless to say they are but only awaited his masterly exposition to examples, and no attempt has been make them general knowledge.