Irish Contributions to our Understanding of Heart Disease

Laurence Simpson, FRACS

Epworth Hospital, Melbourne, Australia

Ireland has made an amazing contribution to our understanding of heart disease. From RobertGraves in 1796 to Jeremy Swan and Denis Burkitt in the 1990s, the names of many Irishmen havebecome familiar to all of us. (Heart, Lung and Circulation 2003; 12: S73–S77)

In Dublin, there are no spectacular monuments, nograndiose museums, no hilltop castles, and no temples.

Frommers

Yet Dublin has a subtle charm that grows on you as youwalk its streets and meet its people. However here we willmeet some of its people, some famous doctors who contrib-uted to the world, who helped us in our understanding ofthe heart and heart disease.

Dr Robert Graves

Robert Graves (1796–1853)Graves (Fig. 1) obtained first place in the Trinity EntranceExam at the age of 15. Following his graduation in 1818,he travelled widely in Europe visiting Gottingen, Copen-hagen, Berlin, and on to Paris and Italy. He was greatlyimpressed with the bedside teaching prevalent in Euro-pean hospitals at that time. He returned to Dublin, and in1824, was involved in the founding of the Park St. School

of Medicine. He was also appointed to the staff of theMeath Hospital. He quickly instituted two major changeswithin the hospital; clerkship of patients by the studentsand bedside teaching.

In 1827, he was appointed King’s Professor of Medi-cine at Trinity College. Five years later, he published theJournal of Medical Science. In 1838, his clinical lectureswere published in Philadelphia.

Robert Graves made many contributions to ourunderstanding of heart disease, such as describing pulseand its change with posture and disease. With WilliamStokes, he introduced the stethoscope into Irish medicalpractice. He also described the cardiac changes of thyro-toxicosis, including long periods of tachycardia and pal-pitation associated with increased swelling of the thyroidgland.

William Stokes (1804–1878) Stokes (Fig. 2) had no formal education but was tutoredat home by his father, Whitley Stokes (1763–1845), arespected physician and Regius Professor of Medicine inDublin. The younger Stokes enrolled in the College ofSurgeons School where his father had succeeded JohnCheyne as professor of medicine. He went to Edinburghwhere he made friends with Dominic John Corrigan, andfrom where he graduated M.D. in 1825. When his fatherresigned from Meath Hospital in 1826, William waselected in his place and for the next 20 years was closelyassociated with Robert Graves.

Stokes was a pioneer in the new methods of clinicaldiagnosis and teaching. Although he was by this time awell established and well-liked physician, the College ofPhysicians could not make him a fellow, as he had notgraduated in Arts and his medical degree had beenobtained in Edinburgh rather than Dublin.Figure 1. Robert Graves

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This obstacle was finally circumvented with TrinityCollege awarding him an honorary M.D. and Stokes wasadmitted to fellowship. Upon the death of his father in1845, he was confirmed as Regius Professor of Medicine.

Stokes published over a hundred scientific works, butamong the most significant were, A treatise on the diagnosisand treatment of diseases of the chest, published in 1837, andThe diseases of the heart and aorta, published in 1854.

He is remembered for Stokes Adams attacks, CheyneStokes respiration and Stoke’s Law, which states that amuscle lying above an inflamed serous or mucous mem-brane may be paralysed.

Sir Dominic Corrigan (1802–1880) Corrigan (Fig. 3) was born in Dublin and educated inEdinburgh, graduating M.D. in 1825. He was awardedF.R.C.S. (Hon) in 1843 and then M.D. (Dublin) in 1849.On his return to Dublin after graduation, he wasappointed to the largest dispensary in the city. Withintwo years he had published papers in the Lancet on aorticaneurysm and systolic heart murmurs. In 1832, he pub-lished his classic article ‘Permanent patency of the aorticvalves’. He also wrote about the possible development ofangina in cases of aortitis.

He was a great teacher and in view of this wasappointed Commissioner for Education and later electedto Parliament. He was the President of the College ofPhysicians on five occasions and later purchased the landand supervised the building of the College of Physiciansof Ireland, which opened in 1864.

Although interested in many related branches of med-icine, Corrigan was a continuing advocate for the higheststandards in clinical medicine. He represented Ireland atWestminster as a baronet.

Robert Adams (1791–1875) The son of a Dublin solicitor, Adams (Fig. 4) studied atTrinity College, Dublin, and then at the College of Sur-geons, graduating in 1815. He did not receive his medicaldegree until 1842, the same year he received a M.D. fromTrinity College. He founded the Richmond School ofMedicine and Surgery with Richard Carmichael.

He was a prolific writer, normally the domain ofthe physicians. Adams contributed some 100 articles tomedical literature.

In 1827, he published a paper, ‘Cases of diseases of theheart with pathological observations’, making the connec-tion between slow pulse and loss of consciousness. Hewas the first to appreciate that cerebral symptoms may becaused by disorders of the cardiac rhythm. It was some20 years later that Stokes also wrote up this condition.

In his memoirs, he also wrote that mitral obstructioncauses enlargement not only of the left atrium, but also ofthe right ventricle. He demonstrated that the pulsation in

Figure 2. William Stokes

Figure 3. Sir Dominic Corrigan

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the jugular veins synchronous with the ventricularimpulse occurs in insufficiency of the tricuspid valve.

Sir Arthur Leared (1822–1879)Leared was born in Wexford County. After graduating in1847 from Trinity College, he joined the staff of theMeath Hospital. Soon after, however, he set off to travel.Following the Crimean War, Leared returned to Englandand was appointed to the staff of the Brompton Hospital.There he developed the bi-aural stethoscope, which wasdemonstrated to Queen Victoria at the Great Exhibitionheld to celebrate the opening of the Crystal Palace inLondon. He obtained his PhD on the thesis of ‘Thesounds of the circulation’.

Henry Martin (1848–1893)Born in County Down, the eldest of 12 children, Martin(Fig. 5) received most of his early education from hisschoolmaster father. At 15, he travelled to London wherehe sat and passed the matriculation at The UniversityCollege and began to study medicine. He attended thelectures in physiology given by Michael Foster, who wasimpressed with his abilities and subsequently invitedhim to become his demonstrator.

In 1870, Martin went to Cambridge on a scholarship,graduating B.Sc., and then D.Sc. in physiology. He

returned to London where he took the M.B. exam andbegan working once again with Foster. Martin andFoster, along with Thomas Huxley, collaborated at theRoyal College of Science to publish a book on PracticalBiology. In 1876, on the recommendation of Foster andHuxley, Martin was invited to become the first professorof physiology and biology in the newly established JohnsHopkins University in Baltimore. In the clinical school atthe same time were the founding professors, Osler,Halsted, Kelly and Welch.

Martin stayed there for 17 years. He and his wifeconducted a weekly teaching meeting for students andothers at their home. As there was little known about thephysiology of the heart, he constructed a heart-lungpreparation of the mammalian heart in order to study theparameters of function (Fig. 6). They spent the next threeyears developing the preparation, and commencedstudying the effects of drugs on the heart. This was laterdescribed as the greatest single contribution to come

Figure 4. Robert Adams

Figure 5. Henry Martin

Figure 6. The heart-lung preparation of themammalian heart constructed by Henry Martin.

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from an American physiology laboratory. The prepar-ation was the basis from which Starling worked in hisstudies on the heart-lung preparation.

Sir Ivan Whiteside Magill (1888–1986)Born in Larne County Antrim, Magill (Fig. 7) wasawarded the gold medal for English before going on tostudy at Queen’s University in Belfast. His M.D. thesis on‘The blind nasal intubation of the trachea’ was initiallyrejected. Twenty-five years later, this decision wasreversed and the work was recognised.

During World War I, he was asked to work at Sidcupin Kent. There, he and Rowbotham performed anaes-thesia for Harold Gillies, who was attempting recon-structive surgery on the face and jaws of the wounded.He invented a forceps to facilitate the passage of theendotracheal tube being passed blindly into the trachea.He later developed a laryngoscope with a light poweredby batteries in the handle, and then the cuffed endo-tracheal tube. In response to a complaint from Gilliesabout the effect of the anaesthetic gases on the surgicalteam, he developed a bag to collect the returning gasesfrom the patient, which previously had been releasedinto the atmosphere.

In 1923, Magill was appointed to Brompton Hospital,and later to the Westminster Hospital. At the time, physi-cians were appointed to the Brompton for life, surgeonsfor three years and anaesthetists for 12 months. He wasthe pioneer in campaigning to have anaesthesia removedfrom the dominance of the surgeons, both practically andadministratively, seeking to establish anaesthesia as aspecialty in its own right. This was only achieved afterhis death

The following tribute was given in the Lancet obituary,‘…Every anaesthetist in the world has been influencedby the work of Sir Ivan Magill, and has benefited fromhis foresight…’.

Sir Peter Kerley (1900–1979)Born in Dundalk, Northern Ireland, Kerley (Fig. 8) wasthe youngest of 13 children. He graduated in Dublin in1923 and received his M.D. 1932. He travelled to Viennato study E.N.T. but switched to Radiology. Returning toCambridge, and then to Westminster Hospital, he wasinvolved in the development of thoracic surgery withClement Price Thomas, Stanford Cade and Ivan Magill.

He was a founding member of the College of Radi-ology, and later its president. He became the Editor ofthe Journal of Radiology, and later wrote the six volume,Textbook of X-ray diagnosis, which includes the descriptionof the Kerley B lines of left ventricular failure, and the A& C lines on the chest X-ray.

His outside interest was trout fishing in Scotland,where his companion was George VI. When the localdoctor suggested an X-ray for the monarch, it was Kerleywho arranged the procedure back in London and brokethe news to the King.

Dr Jeremy Swan (Born 1922)Born in Sligo of medical parents, Swan (Fig. 9) waseducated primarily in Limerick but studied medicine atSt. Thomas’ Hospital, London. Following his graduationin 1945, he was sent to Iraq. After completing his militarytraining, he returned to St. Thomas’ to become assistantto Henry Barcroft, Professor of Physiology. He publishedthe first paper on noradrenaline and he and Barcroftwrote the initial monograph for the Physiological SocietyMonographs on the same subject.

Figure 7. Sir Ivan Whiteside Magill

Figure 8. Sir Peter Kerley

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In 1951, after obtaining his PhD, he succeeded in hisapplication to the Mayo Clinic to work with Earl Wood.In 1955 Swan was appointed Consultant Physician andAssociate Professor of Physiology there.

In 1959, he became director of the cardiac laboratoryat the Clinic, an era of great development there. He andJohn Kirklin developed techniques for the physiologicalmeasurement of clinical cardiac conditions, whichbecame the basis of the computerised management ofpatients following cardiac surgery and characterised themanagement of patients undergoing cardiac surgery atthe Mayo Clinic.

He was then appointed Professor of Cardiology atU.C.L.A and associated with Dr Willie Ganz. The twosaw the value in monitoring of physiological parametersin the Coronary Care Unit. With the addition of the flowguided balloon, this monitoring moved from the coro-nary care unit to the clinical setting in many differentsituations. The Swan-Ganz catheter is still the gold stand-ard catheter for the study of the physiological measure-ment of the heart in both medical and surgical unitsthroughout the world.

Dr Denis Burkitt (1911–1993)Denis Burkitt’s father was a country surveyor and natu-ralist, whom a publication in 1970 named among thetop 10 Irish scientists. Attending the local school inCounty Fermanagh, Denis (Fig. 10) was involved in a

fight and lost an eye. He was then sent to Wales forschool, but returned to Dublin to attend medical studiesat Trinity College. He obtained his F.R.C.S. in 1938,following which he was called up for military service inWorld War II.

After this he went to Uganda with the Foreign Servicewhere he described the lymphoma that bears his name.He not only worked out the details of the tumour, butalso postulated its viral aetiology, and sent specimens toLondon for viral studies. There Barr and Epstein isolatedthe virus. This was the first tumour to be routinely curedwith methotrexate.

Resigning from surgery in favour of an African sur-geon, he worked in epidemiology, first in Kampala, andthen in London with the British Research Council. Out ofhis studies on the differences in African and Westernmedicine, he became known as the ‘Bran Man’, andchanged the eating habits of the Western world.

Like all of the above, he was a remarkable man,exemplifying many of the qualities of stature to whichmany aspire. He had several sayings, but I remember onone occasion he finished a talk with the following verse,which I have kept as it so typified the man, his personal-ity and his dedication.

Attitudes are more important than abilitiesMotives are more important than methodsCharacter is more important than clevernessAnd the heart takes precedence over the head

Figure 9. Jeremy SwanFigure 10. Denis Burkitt