Portal de Periódicos da CAPES

The Herrick Lecture

2008; Elsevier BV; Volume: 101; Issue: 10 Linguagem: Inglês

10.1016/j.amjcard.2008.01.034

1879-1913

David R. Holmes,

Cardiac Imaging and Diagnostics

Hero worship or mentor worship is universal; in some societies, of course, it is more deeply ingrained than in others. Those individuals who are the focus of hero or mentor worship may be characterized by many things that I will define as "ity" things. You are perhaps wondering what those "ity" things are in hero or mentor worship. They include, among others, sagacity, tenacity, humility, creativity, curiosity, authority, and honesity. These are the "ity" things. These qualities belong to the people we would like to grow up to be, although, as I look around this room, many of us are actually already grown up. James Bryan Herrick typifies that kind of individual we want to grow up to be like.1Herrick J.B. Thrombosis of the coronary arteries.JAMA. 1919; 72: 387-390Crossref Scopus (44) Google Scholar, 2Harvey A.M. Classic in clinical science: from horse and buggy doctor to clinical investigation: the story of James Bryan Herrick.Am J Med. 1980; 68: 639Abstract Full Text PDF PubMed Scopus (2) Google Scholar, 3Herrick J.B. Peculiar elongated and sickle shaped red blood corpuscles in a case of severe anemia 1910.Yale J Biol Med. 2001; 74: 179-184PubMed Google Scholar, 4Herrick J.B. Memories of Eighty Years. University of Chicago Press, Chicago, Illinois1949Google Scholar, 5Herrick J.B. Certain clinical features of sudden obstruction of the coronary arteries.JAMA. 1912; 59: 2015-2020Crossref Scopus (448) Google Scholar, 6Herrick J.B. An intimate account of my early experience with coronary thrombosis.Am Heart J. 1944; 27: 1-18Abstract Full Text PDF Scopus (12) Google Scholar As I read his autobiography, many things come to mind. He and I were born in the same small town, Oak Park, Illinois. Although some of you might believe that we were contemporaries, actually, he was a little bit ahead of me in school. In fact, we went to the same high school, Oak Park High School, and in 1877, he and 2 other boys were the first graduating class ever sent out from that high school. Although I did not know it at the time, every day as I walked to high school, I walked right by the corner where the house stood in which Dr. Herrick had been born and in which he grew up. I have no idea whether it was the exact same house, but I do know that it was the exact same corner: the northwest corner of Oak Park Avenue and Ontario Street. After graduating, Dr. Herrick taught at the same high school that he and I went to. Now, when I was in high school, I had always thought that Oak Park High School was 100 years old; perhaps it was, perhaps Dr. Herrick might have actually walked the same halls that I walked. In an interesting footnote, another hero of mine, Ernest Hemingway, was also born and raised in Oak Park, Illinois. It turns out that after Mother O'Leary's cow did her thing in 1871 and caused the great Chicago fire, Dr. Herrick's father, who was a grocer, and Ernest Hemingway's grandfather, A.T. Hemingway, who was then secretary of the Chicago YMCA, drove through the "still hot sand of the lakeshore to deliver food" to the needy. Curiosity is one of those "ity" words I mentioned earlier. In Herrick's own words, he "was thankful for the companionship of other boys, who like myself, were neither hopelessly nor offensively good, whose moral lapses were neither regarded as sins nor had they left an indelible stain." Herrick also wrote about storing cocoons in his dresser drawers and then having to get rid of the mess of eggs before the grubs hatched out among his shirts and socks. Now, fast forward, if you will, >1/2 century later, when Dr. Herrick was asked to fill in as a speaker at the annual dinner of the Association of American Physicians. The title of his talk was "Why I Read Chaucer at the Age of 70." How many people read Chaucer at 70? Herrick said that the talk went over well, although before the talk, he heard a young "Turk" say, "I know who Dr. Herrick is, but who in the hell is Chaucer?" So, curiosity is one of those "ity" components that Dr. James Bryan Herrick possessed. We regard Dr. Herrick as that giant who so elegantly and eloquently described the issues of coronary thrombosis before the Association of American Physicians on May 14, 1912, when he talked about a classic case of cardiogenic shock and death from acute myocardial infarction. Herrick described "being keyed up to a high pitch, as I feared someone else might jump into print ahead of me." His anxiety, however, was groundless, because no one even asked a question. It turns out that coronary thrombosis had been described before.7Krehl L. Diseases of the myocardium and nervous diseases of the heart.in: Dock G. Diseases of the Heart. W.B. Saunders, Philadelphia, Pennsylvania1908: 421-763Google Scholar, 8Obrastzow W.P. Straschesko N.D. Zur Kenntnis der Thrombose der Koronararterien des Herzens.Z Klin Med. 1910; 71: 116-132Google Scholar, 9Fye W.B. The delayed diagnosis of myocardial infarction: it took half a century!.Circulation. 1985; 72: 262-271Crossref PubMed Scopus (15) Google Scholar, 10Fye W.B. Acute Myocardial Infarction: A Historical Summary. Elsevier Science, New York, New York1990Google Scholar There was an earlier report in Russia, which described in Russian a case of a patient dying from acute myocardial infarction.8Obrastzow W.P. Straschesko N.D. Zur Kenntnis der Thrombose der Koronararterien des Herzens.Z Klin Med. 1910; 71: 116-132Google Scholar However, Herrick introduced the concept and elevated it, and as you know, it has become the hallmark of acute myocardial infarction, forming the basis of treatment of patients with myocardial infarction and reperfusion therapy over the past century. Dr. Herrick's description of the seminal initial case was classic, but the attendant memories that he wrote about add form and substance. He described the patient as a slender, active man, head of a private banking house. He had taken a midnight meal of a sandwich and a bottle of beer after he and his wife had returned from the theater in Chicago to the suburbs, where they lived, and had then become ill. Dr. Herrick and another physician, Dr. Murphy, were asked to help by Dr. Frank Billings because the rapid feeble pulse Billings found was a puzzling and difficult feature. Dr. Billings admitted that he did not know the exact cause, but he spoke of the possibility of a cardiac accident. As Dr. Herrick recalls, at the request of the family, Dr. Murphy and he came back in the evening and stayed all night in the patient's house. Now that was a house call. Dr. Herrick continued, writing that they were in a big room with twin beds. Murphy, hearing Herrick turn in bed but not wishing to awaken him if he was asleep, would whisper, "Herrick, are you awake? Say, are you sure about there being no pneumothorax?" A little later, from Herrick's bed, also in a stage whisper: "Dr. Murphy, do you think this might be acute pancreatitis or possibly a strangulated diaphragmatic hernia?" Dr. Herrick wrote that neither man slept much that night. As we all know, the autopsy revealed a clot in the coronary artery, which Dr. Herrick had mentioned as a likely cause. The pathologist called and said that the clot was in the coronary artery, all right, but "how in God's name did you guess it?" Dr. Herrick wrote, "Among my treasured letters is one from Dr. Murphy, who warmly congratulated me on my diagnosis." What with that exposure, Dr. Herrick started to do what he called "missionary work—preaching the gospel of the pathology and clinical symptoms of acute coronary obstruction." Although we remember Dr. Herrick for coronary thrombosis, we also need to remember that in 1904, he described a "peculiar, elongated, and sickle-shaped red blood corpuscle in a case of severe anemia," the first case of sickle-cell disease and anemia. And so form and substance and intellectual curiosity grew up with Dr. Herrick and his work.3Herrick J.B. Peculiar elongated and sickle shaped red blood corpuscles in a case of severe anemia 1910.Yale J Biol Med. 2001; 74: 179-184PubMed Google Scholar Other "itys" related to James Herrick are sagacity and authority. By all accounts, Dr. Herrick was a superb teacher. He quoted William J. Mayo, saying, "Teaching in those days was chiefly by the didactic lecture in a large clinic, a method that was windy and wordy during which time the students heard much, saw little, and did nothing." Listen to that again: "Teaching in those days was chiefly by the didactic lecture in a large clinic, a method that was windy and wordy during which time the students heard much, saw little, and did nothing." Dr. Herrick did much to change that, with the introduction of small ward rounds, which focused on specific patient care and teaching. Dr. Herrick also had interesting comments about two important things during a visit to Rochester and the Mayo Clinic. He said, "The first lesson was that all medicine needs periodic overhauling." Listen to that again: "The first lesson was that all medicine needs periodic overhauling." He went on to say that we should avoid "the paralyzing influence of the dead hand of tradition." The second lesson that Dr. Herrick talked about during that visit to the Mayo Clinic was that "there was still room for sane, careful bedside observation." How true these words stand today. The road we travel on our journey is rarely straight, and so we see Dr. James Bryan Herrick going from having cocoons in his dresser drawers to being an independent family practitioner in the basement of his own home, where he was a family doctor, and where, as he described, he had "a rather limited armamentarium, a gynecological table, a storage battery to cauterize hypertrophied turbinates," and where he saw an occasional patient with venereal disease who wandered in, although the latter group of patients received such a cool reception, Herrick wrote, that "they seldom came back." From that modest beginning, he went on to write the first description of sickle-cell disease and then to document and widely disseminate the pathophysiology of myocardial infarction. Along the way Dr. Herrick took time to evaluate new technology—and I want you to think about this the next time each of you has your own general examination—he described the "rubber glove as a device of precision—it encourages digital examinations." One wonders what things were like before rubber gloves. Goodness sakes. Also along the way, of course, he received too many awards to enumerate for such a late-night gathering as this, but appropriately enough, he served as president of the American Heart Association and received its Gold Heart Award before his death. Another "ity" word is "audacity"; that is the word that comes to mind when over breakfast, you mention to your spouse your latest great idea, whatever it is, and your spouse looks at you as if you are crazed, dumb, or just naive, or some nice combination of all 3, and then says, "You want to do what?" That is audacity. The road we have been taking with Dr. Herrick then turns from description of the "sickle shaped red blood corpuscles" of sickle-cell anemia, to coronary thrombosis, to now Gerda Ditzen.11Forssmann-Flack R. Werner Forssmann: a pioneer of cardiology.Am J Cardiol. 1997; 79: 651-660Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 12Forssmann W. Die Sondierung des rechten Herzens.Klin Wschr. 1929; 8: 2085-2087Crossref Scopus (273) Google Scholar, 13Forssman W. Experiments on Myself: Memoirs of a Surgeon in Germany. St. Martin's, New York, New York1974Google Scholar And she is a central character in the well-known but marvelous story of "well-oiled." You are wondering where this next "well-oiled" step takes us. It takes us further along the path we are traveling tonight. A surgical intern in Eberswalde was interested in the central delivery of drugs, although his chief had forbidden him to continue along the lines he was following. In the spirit of audacity, of "You want to do what?" this intern convinced Gerda Ditzen to help. In a moment of inattentiveness, he tied Gerda to the operating table, pretending to do a venosection on her, when he was actually doing it on himself. He inserted now a "well lubricated, well-oiled" ureteral catheter into the vein in his arm and pushed it in about 65 cm. He writes that he experienced a sensation of warmth on the wall of the vein when he moved the catheter and a slight cough. As you know, in the rest of the story, Dr. Werner Forssman then walked downstairs to another floor and the x-ray room and documented the catheter position moving into his heart. As you also know, after this "dangerous stunt," as it was called by his chief, Dr. Forssman abandoned thoughts of cardiology and trained as a urologist. And so part of the road we travel is related to the "ity" of audacity. Where does the road lead next? What more do we know of men and women who are the objects of hero or mentor worship? Because of what I do, the road leads to someone whose parents gave him the middle name Roland. It is unclear to me why parents would ever saddle a child with a middle name of a person who may have been a nephew of Charlemagne—the name of a man who became a pop icon in medieval minstrel culture, but be that as it may, that man, with that middle name, Andreas Roland Gruentzig, transformed cardiovascular medicine as much as Herrick had done 50 to 60 years before; he was another of those rare "ity" people characterized by sagacity, creativity, and curiosity, among others. So the road leads to him as we then talk about interventional cardiology.14Grüntzig A. Letter to the editor.Lancet. 1978; 1: 263Abstract PubMed Scopus (1062) Google Scholar, 15Grüntzig A.R. Senning A. Siegenthaler W.E. Nonoperative dilation of coronary artery stenosis: percutaneous transluminal coronary angioplasty.N Engl J Med. 1979; 301: 61-68Crossref PubMed Scopus (1848) Google Scholar, 16Holmes Jr, D.R. Creativity, ingenuity, serendipity.Can J Cardiol. 2005; 21: 1061-1065PubMed Google Scholar, 17King III, S.B. The development of interventional cardiology.J Am Coll Cardiol. 1998; 31: 64B-88BAbstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 18Hurst J.W. The first coronary angioplasty as described by Andreas Gruentzig.Am J Cardiol. 1986; 51: 185-186Abstract Full Text PDF Scopus (29) Google Scholar, 19Monahan D. Williams D.O. Journey into the Heart. Gotham Books, New York, New York2007Google Scholar The legacy of Andreas Roland Gruentzig is that he would, at the end of his life, say, "Whatever becomes of the method, I have left one mark on medicine; I have shown that man and woman can work therapeutically within the coronary arteries themselves in the face of an alert and comfortable patient." This "one mark on medicine" has changed the world and is his greatest achievement. Andreas Roland Gruentzig started out at the feet of masters, stood on their shoulders, and then went from the kitchen table—think about that, a kitchen table—where the first balloon catheters were made, and then Gruentzig became the shoulders upon which modern cardiovascular care stands. There is not a field in cardiovascular medicine that does not owe some of its existence to Andreas Roland Gruentzig, to his openness to observe, his desire to improve, his willingness to share and to teach, and his drive to help people fight and prevent that scourge of modern medicine, cardiovascular disease. His legacy is like ripples on a pond, the ripples of evidence-based medicine, randomized clinical trials, percutaneous transluminal coronary angioplasty, percutaneous coronary intervention with stents, intravascular ultrasound, angioscopy, invasive electrophysiology, percutaneous valve replacement, the treatment of peripheral arterial disease and carotid arterial disease, stroke centers, myocardial infarction centers, as well as other diseases, such as sinusitis, epilepsy, gastrointestinal disease, and urologic disorders. No matter what gender you and I are or what state you and I are at in life, we all will individually benefit from the sound barrier, the thought barrier, the audacity barrier that Andreas Roland Gruentzig broke. Where will this road now take us? That's an interesting question, and it is also an interesting challenge. It has been said that the only thing that will limit us is our ability to imagine, our ability to create, and our ability to dream. The road to the future will not be straight. It has not been straight in the past, and it will not be straight in the future. We will see some dead ends in the road and some forks in the road, and we will see some bumps and some curves, but the road to the future will continue on its way. We will see specialized and miniaturized devices capable of detecting, preventing, and/or treating early cardiovascular disease. We will see these technologies controlled remotely, perhaps with magnetic guidance, in a variety of vascular and nonvascular beds. We will see enhanced screening techniques for early detection. We will see the development of drugs based on genetic and proteomic testing. Finally, we will see a new specialty of interventionalists working together. They will come from different backgrounds: they will come from surgery, radiology, cardiology, vascular biology, but they will all be working toward the common goal of healing all manner of sickness and restoring health—all manner of sickness and restoring health. The future of the road ahead will be based on several "ity" things. These "ity" things will include the "ity" things of sagacity, tenacity, humility, creativity, curiosity, authority, and honesity. It will be based, however, ultimately on the most important thing of all, which is the truest gift of all, and that is the gift of the patients who entrust their lives, their dreams, and their hopes to us, to each of us who are privileged to take care of them. At the end of Dr. James Bryan Herrick's biography, to return full circle, he has a quotation that he calls "The Doctor's Farewell." It came toward the end of his life, and this is what it says: "I know the night is near at hand. The mists lie low on hill and bay. The autumn sheaves are dewless, dry, but I have had the day." Let me repeat that and burn it into your heart and mind: "I know the night is near at hand. The mists lie low on hill and bay. The autumn sheaves are dewless, dry, but I have had the day." Such a quotation as this is perhaps the best thing that we can always carry with us as physicians. "We will have the chance to have the day, to make a difference."