Dr. Klaus Rentrop Shares Acute Myocardial Infarction: Part 2
Dr. Stephen B. Guss observes in his book, “The Quest to Know the Human Heart: The Disruptors Who Created Modern Cardiology and Cardiac Surgery,” that progress was sometimes impeded by other scientists due to pride, arrogance, professional jealousy, and more. Karl Weigert’s discovery of the cause of acute myocardial infarction, published in 1880, has encountered such problems twice. First came the obliteration of Weigert’s name, which began during his lifetime (1845 – 1904).
The second problem arose in the 1960s, when cardiologists rejected his insights, which delayed the introduction of current lifesaving infarct therapies by 30 years. Dr. Klaus Rentrop takes a closer look at the cancellation of Weigert’s name, whose contributions laid the foundations for modern infarct therapy.
Photo courtesy of Klaus Rentrop
Karl Weigert
Karl Weigert, a pupil of Rudolph Virchow and Julius Friederich Cohnheim’s assistant in Leipzig, Germany, developed new methods to study tissues and cells. In his classic 1880 monograph on the microscopic characteristics of infarcts in different organs, he introduced the term myocardial infarction for the first time. He provided its first microscopic description, labeling it a “coagulative necrosis”, a term still used today, which also covers infarcts of the kidney and spleen. He also identified for the first time the cause of myocardial infarction: abrupt obstruction of a coronary artery by a blood clot, which occurs at the site of atherosclerotic narrowing. The clinical histories of the patients in Weigert’s infarct study were published in 1882 by Carl Huber, who concluded that myocardial infarction as well as angina pectoris are expressions of coronary atherosclerosis.
Two years later, Ernst von Leyden, a physician and pathologist in Berlin, studied the relationship between specific changes in the coronary arteries, such as presence or absence of blood clots and the patients’ symptoms during life. Cohnheim deduced from his animal studies that obstruction of a major coronary artery was usually rapidly fatal, whereas the occlusion of smaller branches would often be survived, sometimes even without any consequences. Physicians at the time, captivated by discoveries in the field of infectious diseases, did not pay much attention to these groundbreaking publications; heart attacks were not seen as clinically important.
René Marie in France attempted to change this perception with his 1896 book “L’Infarctus du Myocarde Et Ses Conséquences: Ruptures, Plaques Fibreuses, Anéurismes du Cœur”. On 214 pages, he presented case reviews, autopsy results including skillful drawings of microscopic images, the early and late outcomes of coronary occlusions, and a comprehensive literature analysis. However, as Andrzej Wincewicz documented in a 2023 paper, René Marie presented some of Weigert’s key insights without proper quotation. This led to the impression that he, the book’s author, coined the term myocardial infarction and elucidated its nature. The book eventually became a widely cited classic but failed to convince physicians at the time that acute myocardial infarction was important in their clinical practice. “It took the right salesman to convince the medical world. Dr James Herrick was this person,” observes Dr. Guss.
This brings us to the United States, into the city of Chicago, to be precise, where Herrick practiced and taught. Herrick realized that his colleagues were caught in the erroneous belief that myocardial infarction was usually rapidly fatal. Having worked in Germany for some time, he was familiar with the latest European literature, which dispelled this error. In 1912, he concisely summarized the literature. He added his own clinical observations, arguing in an oral presentation and a paper that acute myocardial infarction was a clinically important entity caused by coronary thrombosis, which was not always fatal. But his efforts were met with profound disinterest.
Herrick understood that he had to tackle another, bigger problem: acute myocardial infarction presented a diagnostic challenge because its symptoms were often not typical, and even typical symptoms could be mimicked by other conditions. A tool was needed to establish the diagnosis objectively. Herrick turned from a salesman into an investigator. He studied changes in the electrocardiogram caused by infarcts in experimental animals and his patients. His papers in 1918 and 1919 demonstrated that the electrocardiogram could be used to diagnose acute myocardial infarction objectively, the first time clinicians had such a tool. These publications, which also reviewed the literature comprehensively, created a huge interest. Weigert’s concepts finally became mainstream, but not his name. Herrick did not mention it in his publications, and people began to attribute the insights of the Leipzig group to Herrick.
Failure to give credit might be due to motives like pride and professional jealousy, as Dr Guss indicated. Andrzej Wincewicz suggested additional reasons when he stressed that Weigert was a German Jewish professor. Antisemitism, which dodged Weigert’s academic career in Germany, was a pan-European and North American phenomenon. Nationalism ran high in Europe at the time of Weigert’s publication in 1880, ten years after the Franco Prussian War, which created lasting resentment in France due to the loss of Alsace Lorraine, and 35 years before the cataclysm of World War One with its suppression of German culture in the United States. The atrocities of the Nazi period potentiated these factors.
In 1962, the American cardiologist Dr. William Dock published a historical editorial on myocardial infarction in the influential journal Circulation. He referenced Marie’s book “L’Infarctus du Myocarde…” in his opening paragraph and again later in the paper. (France was close to Dock’s heart; he retired to Paris.) He also reviewed Herrick’s contribution extensively. The earlier discoveries of the Leipzig group and von Leyden’s insights were ignored.
More than 20 years after Dock’s editorial, Drs Feit and Peter Rentrop wrote in the 1985 Update to Harrison’s Principles of Internal Medicine. “The ‘term coronary thrombosis’ was first used by Herrick in 1912 to describe the often dramatic clinical picture that correlates with a necropsy finding of thrombosis of a coronary artery and necrosis of portions of the left ventricle.” The name Weigert did not appear in their update. Like most cardiologists of their generation, they never had heard of him.
Coda: The New England Journal of Medicine, the world’s most prestigious medical publication, celebrated its 200th birth year in 2012 with an authoritative review of the history of acute myocardial infarction by Drs. Elizabeth G. Nabel and Eugene Braunwald. They introduced the pathologist Ludwig Hektoen as the person who first had the insight that myocardial infarction is caused by coronary thrombosis “secondary to sclerotic changes in the coronaries”. This quote referred to the autopsy report of a 32-year-old man who had died suddenly from an embolism of his left main coronary artery, published by Hektoen in 1892. Hektoen concluded his case report with thoughts about the causes of sudden death, not acute myocardial infarction, a term that never appeared in his paper. The discovery of nature and causes of acute myocardial infarction by Weigert and his colleagues a decade earlier was not mentioned in the celebratory New England Journal of Medicine article.
Historical truth does not always prevail, however, in the case of Karl Weigert and his co-investigators, publications such as those of Drs. Stephen B. Guss, Andrzej Wincewicz, and the medical historian and cardiologist Bruce Fye finally acknowledge their contributions and are beginning to turn the tide.
