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18. Morgagni and Pathologic Anatomy

THE CONCEPT that processes of disease might originate in localized areas of the body unfamiliar to ancient men of medicine. In their opinion, diseases acted generally throughout the body; illness either was ascribed to disturbance of the Renaissance these old ideas slowly changed as medical men began to do autopsies. Systematic examination of the dead led to realization that in beginning stages disease usually affects but one organ or group of tissues, and sometimes for long periods may be localized in one area of the body. To adjust to this new concept of disease, physicians had radically to change their ideas regarding both diagnosis and treatment for aliments suffered by their patients. Yet despite the accumulating evidence, “generalistic’’ and “localistic” philosophies regarding illness existed side, peacefully and incongruously, for many years in schools, in books, and in minds of medical teachers. It was not until the end of the eighteenth century that the localistic, or anatomic, ideas become dominant.

Contributing largely to this changing viewpoint in medicine was publication, in 1761, of a significant treatise entitled On the Seats and Causes of Disease. The author was a 79-year-old practitioner, professor of anatomy at Padua, Giovanni Battista Morgagni. This publication still may be considered one of the great landmarks in medical history, because tremendous progress, in medicine as well as in surgery, during the nineteenth century would have been impossible, had not the localistic image of disease become generally accepted.

Author of the books and protagonist of the idea relating pathologic anatomy to diagnosis, Giovanni Battista Morgagni (or, as Anglicized. John Baptist Morgagni) was a happy, home-loving man who lived in almost patriarchal simplicity, as contrasted with the turbulent lives of many of his fellow greats in medicine’s history. In addition to being both a great teacher and a great writer, he enjoyed an influence among his contemporaries seldom equaled in medical circles.

Giambatista Morgagni(as he habitually signed his writings) was born February25, 1682, in Forli, capital of a small Papal state. At age 15 he began the study of medicine at the university in the neighboring city of Bologna. He was fortunate to come under the influence of two celebrated professors of the period, Albertini, and Valsalva, a pupil of Malpighi. Morgagni soon attracted the attention of Valsalva, who was engaged in research on the anatomy of the ear, and become his assistant.

In 1701, Morgagni was granted doctorates in medicine and in philosophy. During graduate studies, from time to time he took over the professorial chair during Valsalva’s absences. Morgagni’s acticities in Bolognese academic and organizational circles continued until he retired, for health reasons, to his native village to recuperate and to take up active practice of medicine. It was during this period of his life that he published, in 1704, the first volume of Adversaria Anatomica, a collection of essays that was to establish his position as a scientist.

Morgagni’s reputation grew; and in 1711 he was offered a second professorship of medicine at the University of Padua, which he took over, March 17, 1712. Three years later, in 1715, the Senate of Venice elevated him to the chair of Professor of Anatomy at Padua. Thus, before reaching the age of 35, Morgagni occupied one of the great university professorships of the eighteenth century-one which had just been vacated by Vallisnieri, and which had been held by men of such stature as Vesalius, Colombus, Fallopius, Fabrizia d’ Acquapendente, Casserius, Spigelius, and Vesling. Morgagni proved to be an enthusiastic teacher. He enjoyed nothing better than applasuse from his students. Furthermore, opportunities for research were ample. Popularity of his lectures and demonstrations , in the famous anatomic amphitheatre built in 1594 under the direction of Fabrizio d’ Acquapendente, attracted many students to Padua from other countries, especially from those of northern Europe. The venerable amphitheatre, its steep balconies rising like an oval cone. Still as one of the show places at the University of Padua.

In Padua Morgagni founded a new branch of medical science-pathologic anatomy. Dissection of human bodies combined with a genius for observation led him to connect external signs of disease with anatomic changes found to have taken place in organs as a result of injury or of disease. Throughout his lifetime he kept notes of these observations, setting them down in the form of letters to interested contemporaries.

In his writings, Morgagni reveals mastery in serial fields, as literary scholar, as historian, and as experimental physiologist. His case histories began by setting forth signs observed in the patient during life. Then followed consideration of causes thereof. Next was an account of observations made at autopsy, and descriptions of lesions observed during dissection. Finally, Morgagni drew conclusions from facts accumulated and added various suggestions, theoretical and practical, that might serve physicians in treatment of patients exhibiting similar combinations of symptoms and signs. Morgagni’s interests were not limited to rare or curious diseases; primarily, he was concerned with those ailments occurring most frequently in patients confronting physicians in daily practice.

Dissections were considered essential by the great teacher. He insisted on good clinical histories, without which autopsy results were meaningless. Furthermore, he frequently resorted to comparative anatomy, using animal dissections and experiments to obtain information useful in solving human clinical problems.

Morgagni realized that delicate interconnections between various parts of the nervous system might be related to symptoms quite remote from the site of actual disease. He paid considerable attention to the possibility of influence of mind and emotions on blood circulation and on aneurysms. He knew that apoplexy primarily resulted from changes in blood vessels and not from lesions in the brain with affected movements of the opposite side of the body. He conducted many experiments involving pulmonary veins, jugular veins. And the pericardium. He ligated blood vessels, and observed effects thereof. Morgagni also believed that weather had considerable influence on the body, especially on circulation. He paid much attention to the influence of occupation on disease. He was familiar with syphilis and its lesions in skin, in cerebral vessels, and in bone, and he described gummata of the liver and of the brain. He described cirrhosis of the liver, various calculi, and numerous tumors. Where feasible he recommended surgical operation for malignant tumors.

While Morgagni seriously considered the importance of mechanical causes associated with disease processes, he was well aware of the operation of chemical causes. He was aware of dangers of infectious and contagious diseases; this was the basis of his refusal to dissect cadavers of persons who had died of tuberculosis, of smallpox, or of other dangerous fevers.

Epilepsy, Morgagni believed, was caused by too-early closing of external sores and that syphilis was sometimes a cause. Reopening epileptics’ healed ulcers to permit removal of acrid and irritating substances was recommended. Further, he advocated internal medicines and purges to augment this treatment. Prescriptions for epilepsy included combinations of such ingredients as peony root, dittany, and scrapings of deer’s horn, mother of pearl, amber, cinnabar, sarsaparilla, viper’s flesh, chicory, primrose, mercury, and asses’s milk.

While Morgagni’s first publication, Adversaria Anatomica, in his twenty-fifth year, founded his reputation, his greatest work, the one that preserved his fame for all time, was not published until 1761, when he was in his seventy-ninth year. Entitled De sedibus et causis morborum per anatomen indagatis libri quinque(On the Seats and Causes of Disease, Anatomically Studied), this five-book opus (published in two volumes) was one of the great scientific works of the eighteenth century. After nearly 50 years of teaching, Morgagni had assembled 70 of his epistles, describing findings in some 700 autopsies, to which he added his comments, analyses, and conjectures. He quoted freely from the works of other scientists, including Valsalva, Bonetus, Wepfer, Vallisnieri, Lancisi, Haller, Boerhaave, and Mead, always giving them due credit. It is interesting to note that, through published 101 years before discovery of the famous surgical papyrus by Edwin Smith, Morgagni’s essays follow virtually the same order as did that ancient Egyptian document dating from 1550 B.C.-conditions found in the head were discussed first then in order, those of the chest, of the abdomen, and of the extremities. Additional chapters were devoted to general diseases and to surgery.

Although Morgagni’s De Sedibus contained no single great discovery, it added innumerable important new details and observations to the body of medical knowledge of the day. From his accurate descriptions many diseases could be identified, through in his time their differentiation was not understood, even by the author. De Sedibus is impressive and unprecedented in its systematic arrangement its massive quantities of carefully evaluated evidence, its contributions to understanding of gross anatomy, and its rational and extensive methods for determining sites of disease in relation to human anatomy.

Morgagni’s personal life seems to have been happy and tranquil. Few controversies disturbed his professional career. It was a satisfaction to him that most members of his large family entered services of the church. Scholar, historian, sstylist, anatomist, experimental physiologist, and clinician, he also was a man of cultivated tastes in art, in literature, and in languages. Patricians of Venice, who ruled Padua also, and King Emanuel III of Sardinia, were proud to consider him a personal friend. Morgagni had a close acquaintance also with five Popes. These relationships helped to spread Morgagni’s ideas regarding medical education throughout the eighteenth-century world.

In addition to local honors, Morgagni received wide recongnition in other countries. His work as an anatomist brought him memberships: in the Leopoldinian Academy in 1708; in the Royal Society of England in 1724; in the Academy of Sciences of Paris in 1731; in the Imperial Academy of St. Petersburg in 1735; and in the Academy of Berlin in 1754. Much later came still another honor-Il Morgagni, which became one of the best known of Italian medical journals for three quarters of a century, was founded in Milan in 1857, continuing until 1935.

The great anatomist of Padua was to live another ten years after publication of De Sedibus. He continued to teach until the very last and was nearly 90 years of age when he died, quietly, in 1771.