The man with a snake in his heart

I was fascinated to stumble across this seventeenth-century autopsy report in an old edition of the British Medical Journal.  It was unearthed by Benjamin (later Sir Benjamin) Ward Richardson, one of the great figures of Victorian medicine. His name is less familiar today than that of his friend John Snow, the leading British exponent of early anaesthesia, but he was also a major figure.  It was Richardson who discovered the efficacy of amyl nitrite (a vasodilator) in easing angina pain, the first effective symptomatic relief for coronary artery disease. In 1860 he gave a lecture on ‘fibrous depositions in the heart’ – and appended to it is this intriguing story, narrated by a London physician, a Dr May:

The seventh of October this year current, 1637, the Lady Herris wife unto Sir Francis Herris Knight, came unto me and desired that I would bring a surgeon with me, to dissect the body of her Nephew John Pennant, the night before deceased, to satisfy his friends concerning the causes of his long sickness and of his death: And that his mother, to whom myself had given help some years before concerning the stone, might be ascertained whether her son died of the stone or no?

‘The stone’ being bladder or possibly kidney stones.

Upon which entreaty I sent for Master Jacob Heydan, Surgeon, dwelling against the Castle Tavern behind St. Clements church in the Strand, who with his manservant came unto me: And in a word we went to the house and chamber where the dead man lay: We dissected the natural region and found the bladder of the young man full of purulent and ulcerous matter: The upper parts of it broken, and all of it rotten. The right kidney quite consumed, the left tumified as big as any two kidneys, and full of sanious matter. All the inward and carnose [fleshy] parts eaten away and nothing remaining but exterior skins.

‘Sanious matter’ means bloody pus. So far it sounds as if a catastrophic infection had wrecked his urinary system.

Nowhere did we find in his body either stone or gravel. The spleen and liver not affected in any discernible degree, only part of the liver was grown unto the costal membranes, by reason of his writing profession.

His liver appears to have been enlarged and impinged upon the pleura, the membrane surrounding the lungs. Interesting to see that a writer of this date associates liver complaints with being a writer. There may well be an association – one mediated by alcohol.

We, ascending to the vital region [i.e. the thorax] found the lungs reasonable good, the heart more globose [round] and dilated, than long; the right ventricle of an ashen colour shrivelled, and wrinkled like a leather purse without money, and not anything at all in it: the pericardium, and nervous membrane, which containeth that illustrious liquor of the lungs, in which the heart doth bathe itself, was quite dried also.

I like Dr May’s turn of phrase. The ‘illustrious liquor of the lungs’ is pericardial fluid, which sits inside the pericardial sac that surrounds the heart. Its main function is to lubricate the outer surface of the heart as it beats.

The left ventricle of the heart, being felt by the surgeon’s hand, appeared to him to be as hard as a stone, and much greater than the right; wherefore I wished M. Heydon to make incision, upon which issued out a very great quantity of blood; and to speak the whole verity, all the blood that was in his body left, was gathered to the left ventricle, and contained in it.

A common observation in early autopsy reports was that the major vessels were empty of blood, leading some authorities to suggest that it somehow ‘retreated’ to the heart after death. In fact in the absence of a heartbeat the blood obeys gravity, sinking to the lowest point of the body. In forensic pathology this can offer a useful indication of whether a body has been moved after death.

No sooner was that ventricle emptied, but M. Heydon still complaining of the greatness and hardness of the same, myself seeming to neglect his words, because the left ventricle is thrice as thick of flesh as the right is in sound men for conservation of vital spirits; I directed him to another disquisition: but he keeping his hand still upon the heart, would not leave it, but said again that it was of a strange greatness and hardness.

Two interesting points here. First, Dr May correctly points out that the muscle of a healthy left ventricle is approximately three times thicker than that of the right. This is because it operates at higher pressure, pumping oxygenated blood to the whole body, whereas the right ventricle merely propels deoxygenated blood to the lungs.

The ‘strange greatness and hardness’ sounds like left ventricular hypertrophy, a thickening of the heart muscle. It has several possible causes, mostly cardiac in origin. Its presence indicates that the man had been ill for some time, since it takes a while to develop.

Dr May asked Mr Heydon to make a larger incision in the ventricle:

…by which means we presently perceived a carnouse substance, as it seemed to us wreathed together in folds like a worm or serpent; at which we both much wondered, and I entreated him to separate it from the heart, which he did, and we carried it from the body to the window, and there laid it out, in those just dimensions which are here expressed in the figure.

heart serpent
The heart ‘serpent’

The body was white of the very colour of the whitest skin of man’s body: but the skin was bright and shining, as if it had been varnished over; the head all bloody, and so like the head of a serpent, that the Lady Herris then shivered to see it, and since hath often spoken it, that she was inwardly troubled at it, because the head of it was so truly like the head of a snake. The thighs and branches were of flesh colour, as were also all these fibres, strings, nerves, or whatsoever else they were.

I wasn’t aware that snakes had thighs. Dr May was at first sceptical that a human heart could contain a snake, but decided to inspect more closely.

After much contemplation and conjectures what strange thing that part of the heart had brought forth unto us, I resolved to try the certainty, and to make full exploration, both for mine own experience and satisfaction, as also to give true testimony to others that should hear of it: And thereupon I searched all parts of it, to find whether it were a pituitose and bloody collection, or the like: Or a true organical body, and conception.

‘Pituitose’ is a rare medical word, and one new to me, meaning ‘rheumy’; Dr May wondered whether the ‘snake’ might just be a mass of bloody phlegm. This conjecture we will return to later.

I first searched the head and found it of a thick substance, bloody and glandulous about the neck, somewhat broken (as I conceived) by a sudden or violent separation of it from the heart, which yet seemed to me to come from it easily enough. The body I searched likewise with a bodkin between the legs or thighs, and I found it perforate, or hollow, and a solid body, to the very length of a silver bodkin, as is here described: At which the spectators wondered. And as not crediting [believing] me, some of them took the bodkin after me, made trial themselves, and remained satisfied, that there was a gut, vein or artery, or some such analogical thing that was to serve that monster for uses natural.

Intriguing. In summary, Dr May believed the object before him was undoubtedly a worm, snake or other creature, with identifiable anatomical features. Others agreed:

Amongst whom the Lady Herris and the surgeon made trial after me with their own hands, and have given their hands that this relation is true.

They evidently believed that their story would not be believed, because appended to the report and its drawing is this declaration:Declaration

Had they really found a snake inside the young man’s heart? No. Dr May’s first thought about a ‘bloody collection’ was probably more accurate. When Benjamin Ward Richardson quoted this case in 1860 it was in the context of a lecture entitled ‘On Fibrinous Depositions in the Heart’ – he was discussing the formation of thrombi (clots) inside the cardiac chambers.  Richardson notes that clots come in all shapes and sizes: sometimes they formed long strings, and even hollow tubes, with blood continuing to flow through a central channel. He suggests that this is what Dr May found inside the young man’s heart. As for what killed him: clots inside the cardiac chambers are often an indication of stagnant flow. The left ventricular hypertrophy was a sign of advanced heart disease; it’s possible that the organ’s ability to pump had been significantly impaired, resulting in low flow and creating the conditions for thrombus formation.  The infection in his kidneys might have been a consequence, or a coincidence that dealt the final blow to his weakened system. But this is only a guess – those better qualified than me are welcome to offer an alternative hypothesis in the comments.

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