3 The Causes of Heart Disease Become Clearer: 1760-1819 'a great number of organic lesions, whose existence has not by a majority of [physicians) been even recognised' Nicolas Corvisart, 18061 In the years covered in this chapter more and more physicians, each his own pathologist, began to compare clinical features with patho­ logical findings after death in his patients with heart disease. As they did so, each of them arranged the pieces of new information he acquired to form a pattern of cardiological knowledge unique to himsel( M~.t_ch was learnt and recorded and, by the beginning of the nineteenth c~ntury, several physicians were sufficiently confident in the arrangement of their pattern to write lengthy accounts of their views on diseases of the heart. These accounts bore little resemblance to the textbooks of today for they consisted largely of descriptions of the authors' own cases with commentaries on how they had attempted to make sense of their findings. Something recognisable today as cardiology was being practised; what was lacking was a consensus on the theory and practice of this specialty such as any modern textbook would be expected to describe. Such a consensus did not emerge until late in the nineteenth century. This period was perhaps most notable for the beginning of the process which separated important varieties of heart disease from an aetiologically undifferentiated mass. Congenital heart disease, of course, had already been recognised and, from the late eighteenth century onwards, the association of rheumatic fever with heart disease became clear. The rheumatic aetiology of many of the, by then, well-known valve lesions became recognised and by 1830 or so the concept of chronic rheumatic heart disease was well established. 23 The Causes ofHeart Disease Become Clearer: 1760-1819 The term 'angina pectoris' was first used by William Heberden in 1768. His was essentially a clinical description, which stimulated considerable interest and, over the next 40 years, the pathological basis of angina and the concept of myocardial ischaemia very nearly became as firmly established as rheumatic heart disease - but doubts remained. The early efforts of physicians to understand the mech­ anism of angina and the recognition of rheumatic heart disease are described in Chapters 5 and 6. A New Diagnostic Technique In the middle of the eighteenth century, Vienna was a famous centre of clinical teaching. The Old Vienna School, so-called to distinguish it from the New Vienna School of Skoda and Rokitansky in the next century, had been founded by the Dutchman, Gerhard van Swieten, in 1749, at the express desire of the Empress Maria Theresa. One of van Swieten's pupils was Leopold Auenbrugger, son of an inn-keeper at Graz, who introduced percussion as a valuable technique in the examination of the chest. The story goes that the idea came to him as a result of watching his father tapping casks to detect how much wine was left in them; he certainly referred to this practice in his Inventum novum ex percussione thoracis humani of 17 61. 2 This book begins with a detailed account of the technique and deals mainly with the use of percussion in the diagnosis of disease of the lungs. There are also two short chapters on percussion of the heart, one in pericardia! effusion and the other in aneurysm (enlargement) of the heart. In both conditions Auenbrugger noted the 'deadened' percus­ sion note over the heart 'as if the percussion were applied to a fleshy limb' and contrasts it with the normal note over the heart, which is 'more obscure than in other parts of the chest'. Auenbrugger thus recognised differences in the degree of impairment of the percussion note, aided, perhaps, by his ear for music. This he had inherited from his mother and it enabled him, later in his life, to write the libretto of an opera by Antonio Salieri, Mozart's bete noire.' The opera was not a success, nor was the initial reception of the lnventum novum at all encouraging. Both van Swieten and his successor, Anton de Haen, ignored it completely and almost the only faint praise it received was from Oliver Goldsmith who said 'If it cannot cure, it can do you no harm.'4 Haller also thought that percussion was 'worthy of close attention' and Maximilian Stoll, who succeeded de Haen at Vienna, made some use of it. It was, perhaps, not to be expected that a technique by means of which an anatomical diagnosis could be made would be regarded with much favour until the teaching of Morgagni, 24 .