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Hagiographic works refer to the biographies of saints and ecclesiastic leaders, particularly those of the Roman Catholic Church (1). These can often incorporate a valuable record of institutional and local history, and evidence of popular cults, customs, and traditions. Given their descriptive nature, they often refer to relevant illnesses that these individuals experienced, and thus, can provide insight into potential pertinent differential diagnoses.
For instance, consider the graphic representations of Saint
Gerard Majella, a prominent Italian saint of the eighteenth century. Most of
his painted portraits are anonymous, but they share common physical features
(Figure 1). His body habitus was slender, and it could be argued that this was
solely related to fasting for spiritual purposes, a consistent practice common
for most Catholic saints. However, a closer inspection of his anatomy as
portrayed by contemporary painters reveals a long slender face, with
enophthalmos (deep sunken eyes), downward slanting palpebral fissures, relative
maxillary hypoplasia and some degree of micrognathia. The most
striking feature, which catches the eye rapidly, is the presence of long slender hands with arachnodactyly;
the distal phalanx of both his left fourth and fifth fingers show an abnormal
curvature while resting delicately over his chest, which could be related to
increased joint elasticity. When we pay
attention to the relative proportions, if Saint Gerard extended his hand in
front of the inert cranium that lies on the table, it could easily reach its
vertex. All of these physical signs could be consistent with Marfan syndrome (2). However, these observations are subject to the many limitations of retrospective diagnosis,
including the fact that the images that we have from Saint Gerard are not photographs, and therefore, were subject to the artist’s own
perception of reality. Consistency amongst different artists is however
remarkable. No specific comments about his stature are present in his
biographies, which is pertinent given the higher than average height of
patients with Marfan syndrome. Though such limitations to the definitive
diagnosis exist, the details of his short but exemplary life and death add
further credibility to the hypothesis that he suffered from this disease.
Figure 1. Depiction of Saint Gerard Majella
The life of Saint Gerard Majella was full of unexpected surprises and was crowded with miraculous events per hagiographic descriptions. He was born in the small town of Muro Lucano in the southern province of Potenza, in Naples, Italy on April 6th of 1726. His father, Domingo Majella, was a humble tailor responsible for most of the household income during his childhood; his mother, Benita Galella, was a hard-working housekeeper who also helped with farming chores. He had three older sisters. Gerard attended school from ages 7 to 12, and his performance was remarkable, particularly in terms of knowledge of the Christian doctrines. He found a passion for prayer and good deeds during his childhood, guided by his mother, who was a devout woman, and introduced him early on to the Catholic Church. He was expected to follow his father’s business as a tailor, but he would continuously seek his calling “doing God’s will.” The earliest miracle reported by his first hagiographer, father Tannoia, happened at age 6; Gerard would frequently visit the humble church of Capodigiano with his mother, and when praying, he received a small, white loaf of bread. When asked about the source, he replied that it was a gift from baby Jesus (3). His father died unexpectedly when he was 12 years old, and this would represent a major break point in his life, as he had to abandon school and work under the supervision of an extremely strict tailor named Martin Pannutto. He was a constant victim of physical and emotional aggression by the Workshop Master, but he rejoiced on each occasion as a true martyr, judging that these experiences could bring him to a better understanding of the sufferings of Christ (3). Paradoxically, a working experience that was intended to make him focus on a secular career would serve to fuel his passion for a religious life.
Twice he had applied for admission to the Capuchin monastery at Muro. But a glance “at his sunken chest and thin white hands”, and the Capuchins turned him down (3). The description of a “sunken chest” becomes particularly relevant to the hypothesis of Marfan syndrome, since there are only a few conditions that can give rise to such deformity, the most common one being pectus excavatum (Latin for excavated chest). Pectus excavatum is one of the most common congenital defects of the thoracic cage, occurring in 1 in 400 to 1 in 1000 births; it may exist as an isolated lesion or in association with a genetic syndrome such as Marfan syndrome, when it becomes an additional physical examination clue for the diagnosis (4).
Gerard Majella was repeatedly told that he did not have the health or the stamina required for the strenuous life of an 18th century clergyman. When he was 23 years old, he applied to the Mission of the Redemptorists during their trip to Muro. The young man pleaded to be admitted, but his “chronically ill” aspect was against him, and his mother and sisters did not want him to leave home. He was locked in his room, as his family suspected that he might follow the missioners. He made a rope with his linens and climbed out of his window, and chased the missioners down the road. After roughly 12 miles, they saw a cloud of dust that was approaching them from behind. It was Saint Gerard, gasping for air, almost fainting and trying to yell: “fathers, please accept me.” Such insistence made the missionaries reconsider him, but their expectations continued to be low. His recommendation letter to his superior in Deliceto read this way: “Here we send a useless brother, in terms of fatigue, given his weak complexion, however, we seemed forced to offer him a chance giving his insistence and respectable reputation in his home town.” Soon enough, they realized that his frail appearance was in profound contrast to his spiritual attributes and unbreakable will (5).
The list of miracles attributed to Saint Gerard is quite extensive, taking into consideration his premature death (5). His hagiographers describe more than fifty miracles. Once he lost a key that fell in a well, and to recover it, he tied a sculpture of Christ to the end of a rope; when he retrieved it from the bottom of the well, the image had the key tied to the neck. He split the waters of a river in half to allow a father and two daughters to arrive to a monastery. Through prayer, he was able to clean the house of a poor farmer from a severe rat infestation and to stop a rampant fire another time. In many occasions he multiplied bread and wheat in his hands to provide for the poor and hungry. One time he visited the Pirofalo family; before leaving, he accidentally dropped his handkerchief, which was retrieved by one of the younger Pirofalo girls. He advised her to keep it as it may become useful one day. Years later, during a complicated delivery, the young girl remembered Saint Gerard’s prediction, and she asked for the handkerchief. Immediately after holding it, her distress from labor ceased and she gave birth to a healthy child. This miracle was extremely famous, to the extent that many of his portraits have the legend: “Insignis parturientium protector” (notable protector of childbirth) (5). He had become quite popular in Naples, and was constantly sought by orphans, widows and the poor. His superiors believed that these contacts were interfering with his religious duties and thus sent him to a retirement house in Caposele (5). He spent his last summer trying to collect funds for a new construction for the Redemptorists.
However, health rapidly deteriorated. The Rector of Materdomini was heartbroken when Brother Gerard came back to visit him in August of 1755, as he appeared extremely worn and emaciated. “Cheer up, Father. It is God’s Will,” said Gerard with a smile. “We must do His Will with gladness.” We do not find a detailed description of his symptoms at that time; cough, hemoptysis and profound dyspnea even at rest are mentioned by some historians (5,6,7). It seems that his last weeks were “a combination of physical sufferings alternating with moments of extasis.” His episodes of hemoptysis became more frequent and voluminous during his final days (5). It would be interesting to speculate if his profound shortness of breath was a manifestation of heart failure, perhaps related to severe aortic regurgitation, not uncommon in patients with Marfan syndrome or just due to malnutrition, deconditioning and tuberculosis, the latter which has been attributed as his immediate cause of death. He died in October of 1755, at the age of 29. Even in the modern medical era, life expectancy can be greatly reduced in patients with Marfan syndrome; a large series of patients with this condition in the 1970’s documented an average life expectancy in the 40’s (8). He was beatified in 1893 and later canonized by the Catholic Church in 1904.
Despite his short life, Saint Gerard Majella had a profound impact on Catholic believers, and his legacy continues today, as he is venerated as the Patron of children (born and unborn) and motherhood, and several churches throughout America and Europe are named after him. Phenotypic examinations of contemporary portraits and scattered hagiographic clues such as the description of his pectus excavatum have raised our suspicion that he may have suffered Marfan syndrome; this however, remains as an intriguing speculation. In the Modern Medicine era, physicians and health organizations encourage recognition of Marfan syndrome in the community based on physical and historical features, since early diagnosis can allow prevention and treatment of catastrophic complications (9).
1. Heffernan, Thomas J. Sacred Biography: Saints and Their Biographers in the Middle Ages. New York: Oxford University Press; 1992.
2. Pyeritz RE. Evaluation of the adolescent or adult with some features of Marfan syndrome. Genet Med. 2012; 14 (1): 171-1773. San Gerardo Mayela, Page 1. Mercaba.org. Retrieved July 1, 2014. Available from http://www.mercaba.org/SANTORAL/Vida/10/10-16_S_Gerardo_mayela.htm
4. Rhee D, Solowiejczyk D, Altmann K, Prakash A, Gersony WM, Stolar C et al. Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With Marfan Syndrome. JAMA Ped. 2008; 162 (9): 882-88
5. Santos Redentoristas: San Gerardo Mayela, Page 3. Milagrosobogota.com. Retrieved July 1, 2014. Available from http://milagrosobogota.com/home/cms/front_content.php?idcat=50
6. The Story of Saint Gerard, Page 1. (n.d.). SaintGerard.com. Retrieved February 11, 2013. Available from http://saintgerard.com/his_story_p2.htm
7. Omer, E. St. Gerard Majella: the wonder-worker and patron of expectant mothers. Rockford, Ilinois: Tan Books; 1999.
8. Murdoch JL, Walker BA, Halpern BL, Kuzma JA, McKusick VA. Life expectancy and causes of death in Marfan syndrome. N Eng J Med 1972; 286: 804-808.
9. Stheneur C, Tubach F, Jouneaux M, Roy C, Benoist G, Chevallier B et al. Study of phenotype evolution during childhood in Marfan syndrome to improve clinical recognition. Genet Med. 2014; 16 (3): 246-250
About the Author: Jorge Brenes-Salazar, MD is a cardiologist in Rochester, Minnesota and is affiliated with Mayo Clinic. He is one of 120 doctors at Mayo Clinic who specializes in Cardiovascular Disease. Brenes-Salazar has a particular interest in Geriatric Cardiology as well as undiagnosed illness in historical figures, especially in regards to the Catholic Church. (Email: firstname.lastname@example.org).
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