Bristol Journal Medico-Chirurgical Volume 104 (iv) November 1989

Carey Franklin Coombs 1879?1932

Clive F M Weston Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff

Carey Coombs was only 53 when he died in 1932. In the his preceding 20 years he had won world-wide acclaim for research and writings on rheumatic disease and had established himself amongst the best-known physicians in the provinces. In this he carried on a long tradition of famous Bristol medical men. He was universally liked and admired and would be more frequently quoted today had it not been for the virtual disappearance of and cardio- vascular syphilis from all but the third world. Now he is remembered as an eponym for a murmur that few in this country will ever hear, yet a study of his life and work provides an insight into the development of early 20th century scientific inquiry where laboratory-based research was accom- plished and applied for the benefit of society, rather than for the increase of knowledge alone. It also throws light upon a man who was highly respected and who should be recognised as a founding father of modern cardiology. Carey Franklin Coombs was born at Castle Cary in Somerset on 5th September 1879, the son of Carey Pearce Coombs, the local general practitioner, and Mary Leslie Franklin of Coventry. Carey Coombs (senior) was a singular man?tall and ruddy, God-fearing and kind. His was a deeply religious household. The children, Carey Franklin included, attended the Congregational Chapel at Castle Cary where their father was treasurer. Though the family did not disdain people of other persuasions and were non-sectarian in their secular activities, his Free-Church upbringing was to be important when Carey Franklin entered the divided world of the Bristol medical establishment.

Education and time in London Carey Coombs (junior) was the only son. He had three elder at the sisters and one younger. He was sent to school charity school at Keyford on the southern outskirts of Frome. He later attended University College Bristol, gaining London matriculation in January 1896 and passes in chemistry and biology in University of London examination in 1897. With financial help from his father he enrolled as a medical student on Gazette at St Mary's Hospital Medical School, starting his studies (edited by Poynton) carried the following remarks: In the "His 1st October 1987, being one of an intake of fifty-four. remarkable successes in the School during the last was are well to same year a certain Dr Frederick John Poynton year known all St Mary's men, and his future appointed Medical Registrar to the in-patients at the hospital. doings will be watched with interest." (3). Bristol and St In 1903 he was He was also a product of University College elected Medical Registrar to the Hospital, was 10 older than out of the Mary's Hospital Medical School but years moving "House" and residing at No. 2 St Mary's Coombs. His reputation as a teacher was exceptional and Terrace, Paddington. Coombs would have been among the many students who "A more popular appointment could hardly have been flocked to and his demon- to the attend his rounds pathology made", according Gazette, "our interviewer reports the of that he never strations. Poynton was already interested in aetiology had such a bashful patient as our new Medical an article with Dr He had to chase rheumatism and in 1900 published Registrar; his victim round three wards and a of rheumatism as a corridor before he was Alexander Paine expounding the theory able to slake his fact-thirsty pen." (4). was to His duties as result of streptococcal infection (1). He directly Registrar included the day-to-day care of the in- a friend. and the influence the young Coombs and became life-long patients performance of autopsies on medical cases, was student who lived for which he Coombs a gifted and industrious up received ?75 per annum. There was also a to intermediate his father's high standards. He passed the commitment to teaching students and the need to provide and almost articles case M.B. by July 1899, in the minimum possible time, and reports for the Gazette, though this latter cleared the board of prizes in his final year. task was performed "under some slight protest" (5). In all was in Within a few of he awarded prizes Medicine, Surgery, days becoming Registrar, Coombs was Pathology, Hygiene, Forensic Medicine and Psychological waylaid outside De Hirsh ward by Dr Poynton who invited him to Medicine, and obtained a General Proficiency Scholarship develop an interest in rheumatic heart disease. For the worth ?20 He also won the Gold Medal in Clinical old (2). twenty-three year Coombs, this meeting with a man he so an "The clinical occurrence of Medicine for essay entitled obviously admired presented an opportunity not to be excess urine". The St missed. In a of potassium idoxyl sulphate in Mary's lecture prepared just before his death, and

97 Bristol Medico-Chirurgical Journal Volume 104 (iv) November 1989

addressed to Poynton, Coombs states: ties for epidemiological research. Therefore it can be con- "That grain of mustard seed has given me a tree with cluded with some certainty that he never lost sight of an aim many branches in which ideas of all kinds have found a to combine clinical practice and research. lodging." (6). Carey Coombs spent less than 12 months in general prac- Poynton advised Coombs to start by studying the case- tice and was appointed Registrar at the Bristol Children's notes of his father's old teacher Sir William Broadbent, so Hospital within a year of leaving London, and in 1905 held that he could gain insight into the many manifestations of this post simultaneously with that of Curator of the museum rheumatic diseases. The inspection of Broadbent's notes led at the B.G.H. He continued to record cases of rheumatic to the publication of an article in the Lancet entitled. "Some heart disease and from these began to form his own opinions clinical aspects of the rheumatic infection" in 1904 (7). Here regarding the condition. He had notes on over 150 patients he described three types of reaction to rheumatic infection, with valvular heart disease (not all rheumatic in origin), namely transitory, protracted and malignant, and suggested personally examined at St Mary's and 65 children with acute that the organism responsible persisted in the infected tissue rheumatic fever seen as in-patients there and at the Children's after all had disappeared, and was Hospital. He also collected autopsy reports of children dying capable of recrudescence. He looked upon and of heart disease in the Bristol area, and from these two mitral stenosis developing in adulthood as evidence of this sources attempted to describe more fully the natural history recrudescence. These views were not particularly innovative, of rheumatic heart disease, especially in terms of physical but they were a start. signs. He was particularly impressed by the degree of myocar- During his student days at St Mary's, Coombs met a nurse dial involvement seen at one post-mortem of a child under his called Nina May Matthews. She was also from Somerset care at B.G.H. in 1906 (8), and this led him to embark on a where her father had been a farmer at Walton near Clevedon. painstaking study of the histological changes in both acute Her family had broken-up following the death of her parents and chronic stages of the disorder. For this purpose he in the mid-1890's, and at the age of 19, she began nursing, became the Demonstrator of Pathology at University College first at Boston, Lincolnshire, and later Paddington. At the Bristol, where he worked under Professor Walker-Hall. In turn of the century she went to train in massage at the 1907, Coombs moved to the General Hospital as Assistant National Hospital (for Nervous Diseases) and in 1902 was Physician. appointed sister with responsibilities in the theatre. Here she The results of Coombs' early studies reinforced the views of worked with Sir Victor Horsley, a pioneer of neurosurgery Poynton; namely that rheumatic disease of the heart was a who had performed the first successful removal of the spinal pan-carditis due to a blood-borne infection. It was shown that cord tumour with recovery of function. Through his fiancee, the major effects in the early stages were on the myocardium Coombs became a friend of Horsley, sharing as they did the with consequent ventricular enlargement, and that only in same views on suffrage and temperance. As a wedding later years did permanent valvular lesions become important. present Horsley gave the couple a silver cigarette box, which Of 65 children with acute rheumatic fever he found a is still in the possession of the Coombs family. specific collection of signs in 38, among which were a blurring Carey Franklin Coombs and Nina May Matthews were of the first heart sound, a mitral regurgitant murmur, married at the parish church Wooburn, Buckingham on 5th doubling of the second sound, and a diastolic murmur (later October 1904. They were a devoted couple and throughout known as the Carey Coombs murmur) (9). This diastolic his life, Nina was to prove a great support for Coombs. She noise was not a new finding. In fact Waler Cheadle had was a determined character who encouraged her husband in mentioned it specifically as a manifestation of the "rheumtaic his work and almost idolised him for his successes. They had state" in his Harveian Lecture of 1889 (10), believing it to five children. Following his death and the resulting devastat- indicate a narrowed . Carey Coombs demon- ing reduction in financial resources, she cut expenses radically strated the presence of the murmur in cases which, when and took paying guests before moving to a smaller house. examined after death, had no evidence of mitral stenosis. He With the help of Coombs' former colleagues and the sym- explained the physical sign by postulating a relative stenosis pathy of both University of Bristol and Clifton College of the valve, caused by a greater cubic expansion of the left (where her husband had been the consultant to the sana- ventricular cavity compared to the increase in cross-sectional torium) she managed to ensure the completion of all her area of the mitral valve ring (11). Likewise he thought the childrens' educations. obvious mitral regurgitation resulted from stretching of the valve ring rather than involvement of the valve leaflets. His histological work, largely funded by the British Medical Pre-War Bristol Association, confirmed the findings of Aschoff (12). Coombs 1904 was an eventful year for Carey Coombs. At its beginning recorded the presence of subniiliary nodules in all his cases of he was Registrar at a major London teaching hospital, he had acute rheumatic carditis and carefully noted their positions just published his first article in a reputable journal and he within the heart and thier relationship to coronary had been successful in the M.D. examinations of the branches. He concluded that cardiac rheumatism was due to a University of London. By its end he was a married man in specific agent whose invasion of the heart via the coronary general practice on Henleaze Road, Bristol. Quite why he left led to nodule formation. London is unclear. He certainly appeared well-placed to He also felt that invasion of the other organs could lead to make a name for himself among the medical fraternity of the the other manifestations of rheumatism, though his search for capital. Perhaps he never intended to stay there and looked nodules elsewhere was not very successful. The identity of the upon his M.D. as the culmination of his academic work there. infecting organism was a matter of debate, but Coombs was It is also possible that either he, or his wife, or both simply did convinced by the work of Poynton and Paine that suggested not like life in the capital, for they had both been brought up the culprit was a streptococcus usually found in the gastro- in the country. Furthermore, if he wanted to be a General intestinal tract. However he was never able to isolate the Practitioner why did he not go into practice with his father at bacteria microscopically and mused that toxins produced Castle Cary, as was frequently the case in medical families? outside the heart, perhaps in the tonsils, could be responsible The answer seems to be that Coombs entered general for the myocardial damage. practice in order to gain experience, looking on it more as a Coombs' reputation continued to grow amongst Bristol necessary part of his training, as his father advocated, rather medical circles. He was an active contributor to the meetings than an end in itself. Later in his life he explained his choice of the Bristol Medico-Chirurgical Society, in whose journal of Bristol in terms of its diversity and the resultant opportuni- his work was frequently published. In November 1909 he Bristol Journal Medico-Chirurgical Volume 104 (iv) November 1989

formed a clinical for the medical students and admission to due to sickness society junior hospital approached 1,500 per staff in order to bring forward "good cases in the wards". His 1,000 troops each year. Coombs took great pains to record lectures to were was the number cases the students enjoyed and he very popular large of of depression and general exhaus- with saw them. The following couplet appeared in the students' tion he and it is clear that he did not enjoy his time there magazine, "The Stethoscope", nor the degree of suffering he witnessed around him. One of the few advantages was the chance to renew his "C stands for Carey, that wonderful man, acquaintance with Sir Victor Horsley, now a colonel, who had Who cures broken whenever he can." arrived in Basra in March 1916. Unfortunately Coombs was becoming unwell himself, suffering weight-loss, diarrhoea He to an of the to began advocate the benefits of amalgamation (initially thought be cholera), and finally a type of nephri- staffs and and the General tis. He saw a deal facilities of the Royal Infirmary great of Horsley during his last weeks at Hospital. Although he received much support from other Amarah, but eventually left there on 8th June 1916 and members of staff, suspicions and prejudices thwarted all arrived back in Southampton on 23rd July. Any elation he attempts at a union until after his death. At a dinner in 1909, may have experienced on his return was tempered by the first marking the creation of the University of Bristol, he spoke of newspaper he read, which reported the death of Horsley from the great responsibilities placed upon clinical teachers, the sun-stroke at Amarah one week before. need for coordination between the different institutions and Coombs convalesced Carey speedily in England and was less of resources. these views the two transferred to active duplication Despite service in 1917, when with promotion to hospitals continued to develop separately. Coombs believed the rank of Major, he was put in charge of the medical wards the opening of the new wing at the General Hospital in the of a base hospital in the Rouen area of northern France. week before the First War, together with the building of the Coombs was sent to collect information on chemical injuries King Edward VII wing at the Royal Infirmary, signalled the sustained by soldiers who had been gassed during the battle of end of any hope of joining together. Ypres in July, though this data was not made public until after the war (16). He with more than a also, passing self-interest, studied cases The War Years of the nephritis among troops, amassing notes on 160 cases in The outbreak of the war, whilst allowing the honorary staff of his seven month stay in Franch (17). both to work with each other, did not come at a In the same he was a hospitals year elected Fellow of the Royal time Coombs. His research was good for Carey planned College of Physicians of London. He was restored to the was mid-thirties with a wife and three postponed. He in his medical establishment on 26th January 1918 and remained in children to support (two more being born during the war Bristol for the rest of the war. years), and while he spent part of this time at home in Bristol he also served in Europe and the Middle East. At the start of the war in 1914, Coombs was called-up and Post-War Researches began work in the King Edward VII Memorial Building at the At the war's end, Coombs took up his research into rheuma- Royal Infirmary and at the new "Poor Law" hospital at tic heart disease again. With a grant from the Colston Southern Southmead, which together made up the "Second Research Fund and the help of Dr D S Davies, the Medical General Much of his work in the Southmead Officer of Health for Hospital". Bristol, he surveyed the death registers section was assessment of men's fitness to for the the involved with city during years 1876 to 1913. He discovered that return to In he was interested in the contem- the due to fight. particular mortality rheumatic heart disease had fallen over debate valvular disease of the heart, the 37 but not as as porary regarding years, sharply the death rate generally the or "V.D.H.", and disordered action of heart, "D.A.H.", (18). Using the "spot map" method pioneered by William irritable heart Budd, a former Bristol he failed to (13). physician, show any This latter characterised between the incidence of the condition, by dyspnoea, palpi- relationship disease and geo- tations and dizziness was thought by some to be a form of logy, housing or proximity to rivers, all factors and considered previously malingering, by others to be of psychological aetiology, important. He did demonstrate an inverse associa- some to bacterial toxins on the tion between result from the action of vagal incidence and annual rainfall. Coombs also while a noticed that when the innervation of the heart. Coombs, advocating "supra- city boundaries had been extended to cardiac" cause was to such take in a area of sympathetic patients, writing: large countryside, there had been no increase will be more useful to their in Not did this sow "They country making mortality. only the seeds for a bigger study shells than and knocked-down the counties being morally physically by involving surrounding Bristol, but it also con- them" vinced Coombs of (14). the importance of fresh air in the treatment He the British Force, attached to and of acute as joined Expeditionary prevention rheumatism, was already the case Number 32 General Hospital, during 1915, but was back in for tuberculosis patients. Bristol 1916 he was to Coombs was by the end of the year. In posted very much aware of the loss of continuity that via the war had Mesopotamia (present day Iraq), travelling Marseilles, caused, especially with respect to his case-notes. and in the However was Egypt Bombay, and arriving in Basra springtime. he too busy to chase-up the "lost" patients The hot was and to Coombs the himself. In weather just beginning 1921 he successfully applied for a grant from the "a vast colourless almost devoid of Medical Research with country appeared plain, Council, which he employed a young 140 miles man trees, shimmering in the heat" (15). He journeyed called Emery. Emery's job was to visit the last known the river at addresses of up Tigris to the 23rd Stationary Hospital Amarah, Coombs' patients, of which there were about where he found conditions. 700, and them to appalling encourage attend the General Hospital for a The were difficulties in a reexamination hospitals unsuitable. The securing by Coombs or his colleague from the Royal site on were and tents were Dr high ground insuperable, pitched Infirmary, Charles E K Herapath. If the patient no on with trans- lived at the longer marshy land. There were also great problems address, Emery had to track them down. The vast so that until of were portation of both men and supplies, up May majority patients found in this way, enabling Coombs there were no electric fans or and no water to the natural of 1916, lights study history rheumatic heart disease over a purifying equipment. Coombs and a few friends boiled their period of 15 years. but most men had to make do with filters and In the water, gravity 1920, Ministry of Pensions appointed consultants in bleach. there was a incidence of illnesses, to assist in Consequently high Cardiology the treatment and assessment of and it was calculated that the rate of cardiac particularly diarrhoea, patients. Carey Coombs took on this responsibility for Bristol Medico-Chirurgical Journal Volume 104 (iv) November 1989

the south-west region. These consultants met occasionally in cation of his book. He longed to set up a post-graduate London to discuss Ministry business, but also took the oppor- research unit along the lines of James Mackenzie's at the tunity to talk about interesting cardiological topics. These London Hospital and Lewis' at University College Hospital. meetings were enjoyed by all who attended, and formed the He therefore began seeking financial support. In 1927 the impetus to establish the Cardiac Club, the forerunner of the "Centre for Cardiac Research" was officially opened by British Cardiac Society (19). The official accoucheurs were Thomas Horder, a fellow member of the Cardiac Club. The Coombs, Tom Cotton, John Cowan of Glasgow and William Centre was housed in cubicles, formerly nurses' bedrooms, Hume from Newcastle. on the first floor of the Octagon tower of the General Coombs had the honour of chairing the third Annual Hospital, this accommodation being loaned by the manage- meeting which took place in Bristol on 5th June 1924, at ment of the Hospital for an initial period of three years. The which he introduced the subject of "Heart disease in chil- main funding came from the R L St J Harmsworth Memorial dren", and secured the election of his friend Herapath into Fund (24), but there were also contributions from the the Club. Medical Research Council and the Colston Research Society. Another important event that took place in 1924 was the A Cambridge string galvanometer electrocardiograph was completion of Coombs' book, "Rheumatic Heart Disease", provided by the University, on loan from the Physiology published by John Wright & Sons of Bristol at a price of Department, and because of this the Centre was renamed the twelve shillings and sixpence (20). Its 376 pages contained the "University Centre for Cardiac Research". sum of Coombs' experience and thoughts on the subject, The grant from the Colston Society provided ?200 per year gained in more than twenty years research, and covered research fellowship for an assistant for Coombs. The holder aspects of histology, history and clinical manifestations, treat- of this fellowship was the then Medical Registrar, Dr C Bruce ment and prevention. The introduction was written by Perry (later Professor of Medicine at the Royal Infirmary). Poynton who had started the young Coombs on this road in As part of his training for the post, Bruce Perry was sent to be the first place and with whose theory of the aetiology of Poynton's House physician at Great Ormond Street, spending rheumatism the latter readily agreed. two afternoons each week at the London Hospital with Evan The style of writing, as in his previous publications, was Bedford and John Parkinson, learning how to take an ECG. clear and concise, with specific cases used to illustrate the These were the days when obtaining an ECG was a laborious important points. The book was therefore easy to read and business, involving taking a trace, developing the plate and was greeted by the Lancet as a "valuable monograph". In making the print. Over 2,500 such recordings were made particular, the chapters on treatment (rest, salicylates and during the first three years of the Centre alone. The majority hospital schools) and prevention (education and prospective of these were on hospital patients, but a service was also studies) were of great interest. From this time he began to provided to private patients, who would contribute a small diversify his interests and to become increasingly occupied sum towards the upkeep of the unit. Money was also received with committee work. from the Bristol Education Committee because the Centre His authority in the field of rheumatic heart disease was provided a referral service for children who were suspected of recognised when, in the same year, he was appointed to a having cardiac disease. special sub-committee of the British Medical Association's In 1923 Coombs and Herapath began receiving, from the Science Committee, whose brief was to inquire into the schools' medical officer, Dr Askins, such children who had prevention, detection and treatment of cardiac disease in been examined and found to have abnormal symptoms or children. Both Coombs and Poynton were among the six signs. Three years later, following the publication of the members of the group who, with the help of Sir Thomas B.M.A. report into rheumatism, the clinic was extended to Lewis, reported on the subject in July 1926 (21). He strongly take children from the surrounding counties. Coombs circu- supported the proposals regarding the provision of accommo- lated an information package to the schools describing the dation for institutional care of rheumatic children, where they early signs of rheumatic fever: an early example of health could receive controlled rest, with plentiful sunlight and fresh education. He persuaded the Medical Officers of Health in air, concurrently with education over a period of months. In these areas to make the disease notifiable, and organise for all March 1927 he delivered the Chadwick Lectures on the cases to be seen by a selected physician. causes and prevention of rheumatism (22), in which he These children, together with 337 cases sent by private emphasised the part played by such accommodation by quot- practitioners, accounted for the 754 cases analysed at the ing Longfellow's couplet: Centre of Cardiac Research and reported at the annual meeting of the Royal Society of Medicine's section for the "Joy and temperance and repose study of disease in children in Bath 1931 (25). This demon- Slam the door in the doctor's nose". strated conclusively that the incidence of the disease per 1,000 of the population was five times higher in Bristol than in the The post-war years saw Coombs' influence growing in neighbouring counties. The collaboration of these provincial Bristol as well. He had moved into a house in the affluent physicians continued until Coombs' death, and formed the suburb of Clifton, at 3 Pembroke Road. No fewer than 12 framework for the West Country Physicians Club, which doctors lived in that street alone, including two senior Perry organised some years later. physicians from the General Hospital. He was held in high Carey Coombs' beliefs regarding the management of chil- esteem by his peers, and following a postal vote of all the dren with rheumatic fever have been alluded to earlier. There practitioners in the city, was elected Honorary Secretary of was already an orthopaedic hospital of 36 beds on Grove the Bristol Medical Committee, the first local advisory Road in Redland, Bristol, which predominantly took in council in the country (23). He also became joint editor of the children with osteomyelitis and tuberculous spinal disorders. Bristol based "Medical Annual" sharing this responsibility With the help of another colleague. Professor Hey Groves with Mr Rendle Short (later Professor of Surgery at the Royal (the profesor of surgery), Coombs began campaigning for a Infirmary) with whom he formed a firm friendship. residential hospital to be built outside Bristol. At first there Coombs was invited to give the Long Fox Memorial was a lot of opposition to this from those who foresaw the Lecture to the University of Bristol on the causes of heart difficulties of transporting the parents from central Bristol at disease. visiting times, and the response to the appeal was disappoint- In 1927, upon the resignation of Dr J Odery Symes, Carey ing. Coombs felt this apparent lack of care very keenly, and Coombs became a full physician at the General Hospital. expended vast amounts of time and energy in getting the Coombs' plans for research had not ended with the publi- scheme off the ground. Finally, with the amalgamation of the

100 Bristol Medico-Chirurgical Journal Volume 104 (iv) November 1989

Redland He was also Orthopaedic Hospital and the Bristol Crippled struck by the frequency with which syphilis Childrens' Society, the new Winford Orthopaedic Hospital caused chest pains compared to the rare association of the was built on south of Bristol. disease with the foothills of the Mendips, myocardial infarction. Bruce Perry undertook to Even after the opening by Prince George on 31st May 1930, inject the coronary arteries of five "syphilitic" hearts with the hospital remained short of funds, much to Coombs' radio-opaque bismuth, and using X-rays demonstrated the chagrin (26). absence of any stenoses along the length of the arteries, while Though primarily an orthopaedic hospital, there were their origins were critically narrowed. Coombs explained beds allocated for cardiac cases and this number soon the chest in terms of twenty pains poor diastolic coronary blood increased. Perry and Herapath were in direct charge of the flow, and the infrequency of infarction because of the lack with Coombs and of atheroma and patients Poynton being Honorary consequent improbability of coronary Consulting Physicians. The Winford project was close to thrombosis. His of the Coombs' heart, and the family connection continued long theory aetiology of cardiac pain was based on the after his subscribers to the ischaemic model, that a of death with his sisters being annual namely failure supply of oxyge- hospital and his wife serving on the Management Committee nated blood to the myocardial cells resulted in pain, and he from 1935 until 1948. used as evidence for this belief the similar pains experienced in syphilis, coronary disease and pernicious anaemia. This is not to that Coombs no say attached importance whatsoever to Cardiovascular the and Syphilis aorta, believed that the loss of elastic recoil of the Coombs had first become interested in cardiovascular syphilis aorta atheromatous could also be implicated as a mechanism as a student at St He remained of the Mary's. cognisant for poor diastolic coronary flow. advances in this field, particularly regarding the treatment of the condition, though he was too busy with other matters to contribute directly. After the war he was mindful of the great Coronary Artery Disease increase in the incidence of primary syphilis consequent upon The subjects of coronary thrombosis and myocardial infarc- it, an of the war. tion aspect occupied Coombs towards the end of his life. These were disorders, the first "as sordid as it has been constant in newly-recognised diagnosis of myocardial infarction made life all modern during being generally credited to campaigns" (27) Obrastzow and Straschesko (29), who published their cases in and sought to estimate the repercussions to health that this the German literature in 1910. However, in the early 1900's would come. on Coombs attended a who have in years to His work the topic took very clergyman had high blood pressure much the same as on rheumatic heart and had suffered a stroke. In his form that disease, presence the patient had an attack of severe namely a combination of clinical and histological reports. sub-sternal pain, and soon after developed acute Coombs In order to furnish a basis for a review, he analysed the pericarditis. postulated that what had hap- in the man's records of 103 patients with cardiovascular syphilis seen by pened cerebral circulation had now occurred in the his himself in all parts of his practice in the twelve years since coronary circulation, namely a coronary thrombosis. war. He A L then the for the also enlisted the help of Dr Taylor, Fortunately clergyman, though not for Coombs, the at the General to examine the attack was not and was pathologist Hospital, post- fatal, Coombs robbed of the chance to mortem records of at the B.G.H. from confirm his 1,750 patients dying diagnosis by post-mortem, and with it a more 1919 until 1929. His pathological enquires took the form of significant place in history (30). of sections obtained from 21 hearts of affected The 1925 of the microscopy meeting Cardiac Club devoted a large was work. Around 120 of patients. Once again this laborious proportion the proceedings to a discussion of "Anaemic sections were from each heart. whereas necrosis of the examined However, heart", introduced by the then Secretary, Dr in his on rheumatism Coombs had to A G but previous studies prepare Gibson, including contributions from most of the all the he now had the assistance of members. This was specimens himself, very much a "state of the art" symposium, technicians. The iruits of this labour on were and similar were held syphilis pre- meetings under the auspices of both the when sented to the Royal College of Physicians Coombs Royal Society of Medicine and the British Medical delivered three Lumleian Lectures in 1930 In Association over the next (28). holding few years. Carey Coombs and this of Osier lectureship he followed in the footsteps Harvery, Geoffrey Hadfield, the pathologist at the Bristol General and an honour which he with their data Horder, recognised pride. Hospital, presented regarding the consequences of The revealved that accounted obstruction: acute post-mortem study syphilis coronary ventricular failure, chronic car- for 12.7% of all cardiovascular deaths in the ten diac failure and sudden death year period, before diagnosis. They thought which was as as his clinical records that infection could be a almost twice much sug- precipitating factor, because of the This was the inclusion of raised white blood cell count gested. discrepancy explained by and pyrexia that often accom- sudden deaths, mistaken diagnoses and subclinical infections. panied the attacks. The main of the was an aortitis and 1927 Coombs had finding histological study By collected 36 cases of coronary throm- a reduction in the of the even in the absence bosis, no elasticity aorta, though surprisingly post-mortem examinations were of an The was felt to be a of on the aneurysm. aortitis consequence performed 18 patients who had died, and by 1932 he infiltration from the and had details of 144 inflammatory peri-aortic lymphatics, (31). From this latter group he was able to resulted in a of the aortic valve to obtain information tethering cusps leading pertaining to the prognosis in myocardial aortic observation was the infarction. He regurgitation. Another striking found that about one third died shortly after lack of the a any specific myocardial change. attack, further third died within a year of the attack and The clinical review revealed the to be that the remainder early symptoms survived with variable disability. Although and cardiac with an of 2.5 there were obvious dyspnoea pain, average lifespan predisposing factors: age, sex, high blood years from the onset of these In over half his and a complaints. pressure family history of similar disease, the prognosis there was evidence of aortic was on patients syphilitic regurgitation. dependant the severity of the attack rather than the Coombs differentiated the murmur of syphilitic aortic regur- background to it. gitation from that of rheumatic of the position of The attack was severe in the aetiology judged presence of a peri- maximal loudness: the former heard best at the cardial being right rub, persistent , a fall in systolic blood sternal at the left. He also mentioned the and a edge and the latter pressure reduction in pressure. use a to listen for This on practice of to wooden stethoscope work disease was Herapath coronary artery published pos- these murmurs. In late thumously. August 1932 Coombs took a rare break

101 Bristol Medico-Chirurgical Journal Volume 104 (iv) November 1989

from his various medical and administrative duties and went General Hospital in the evenings to see urgent cases. If the on a family holiday to Scotland. While walking up a particu- case was of interest, the junior doctor would return to his larly steep slope in the Cairngorms with his youngest son, room to find a full written case-history, together with text Richard, he suddenly stopped, and after a brief rest carried books open at the appropriate pages, lying on the table. on gently by a less arduous route. He had . The Similarly, if in the course of a ward round Coombs found any significance of this was not lost on Coombs. clinical observation of importance he would make sure that Within a few weeks he was admitted to his own ward in the everyone had seen it and understood its relevance before he Bristol General Hospital, having collapsed at the bottom of passed on to the next patient. Park Street while walking with Dr R H Perry, the Medical He took such duties extemely seriously and prided himself Officer of the city. Although he did not suffer pain on this on the amount of work he got through. He spent a lot of time occasion, it was felt that he had undergone a "coronary examining, both at Bristol and elsewhere, and was thought, if accident", and was extremely ill. He rallied, and after a anything, to be too kind, especially to the female students. number of days was well enough to continue work, in a His complete charm and courtesy tended to suggest that he fashion, from his hospital bed. He was allowed visitors, and accepted everything that the candidate said, whereas he to known many of his colleagues came to see him. As weeks went by his actually expected the basic facts be exactly. Many strength returned and his confidence obviously grew. He examinees were shocked to discover they had failed and enthused with Poynton about a lecture he was due to deliver probably blamed the other examiner for it was inconceivable at University College Hospital concerning his latest experi- that it was the "nice one's" fault. ences in rheumatic heart disease, and joked that his enforced He was most particular on politeness and punctuality, bed-rest made him feel like the "small boy whose nether values that he himself exhibited and expected in others. He garments had been hidden". His secretary, Miss Michel would quote the motto "Manners maketh man", and looked Clarke, attended him, and with her help he corrected various upon rudeness as a greater sin than ignorance. manuscripts. It irritated him if he was late for any appointment or kept a Ironically, one such amendment was a letter by Coombs to patient or another doctor waiting. Similarly, if any of his the Editor of the Bristol Medico-Chirurgical Journal (who children were late coming down for a meal they would receive received it the day before Coombs' death) relating to his very dark looks, though no actual punishment. Coombs paper on the prognosis in coronary thrombosis. In an extra maintained discipline through respect. paragraph Coombs stressed that survival for more than one Relaxation during the working week was difficult to was medical year following a myocardial infarction was often associated achieve and mostly in the form of reading: with complete recovery, including a return of full-time work. books, religious works and also articles on history, archeo- He explained the addition by saying, logy and architecture. When his father was alive Coombs would drive the family down to Castle Cary for a weekend in "I think it is only fair to others in the same boat to the country, and later, family holidays were spent on farms all dwell a little more than I have done on the bright side.". over Great Britain. Though they lived in the city, all the Coombs' children developed a strong love of nature, encour- in of these brave and optimistic sen- Unfortunately, spite aged more actively by their mother. Coombs adored hill- timents Coombs died on 19th December Carey suddenly walking and would sometimes cover twenty miles in a day. He 1932 (32). was not over-keen on driving which was a very necessary part As mentioned earlier, Coombs left a young family not too of his job as a visiting consultant, and enjoyed the freedom well off. His eldest son, Noel, was a doctor, already qualified that these breaks provided, often travelling to the base and the next, Franklin, was at Bristol Medical School. His destination by train. was a trainee nurse. The two only daughter Mary, remaining There was an ambience of the medical world within the sons were still in full-time education, Martin (later killed house in Bristol, not only because of his intense preoccu- while in the was an course serving R.A.F.) doing engineering pation with medicine and his wife's admiration of him and his at and had to return to his studies in Cambridge complete work, but also because of the developing interest in medicine Bristol, and Richard who was a at Clifton College day-boy exhibited by his two eldest sons. There were also a stream of and later a in at Bristol got degree geography University. visitors from other hospitals and institutions, both in this Coombs' a collection, the interest from colleagues arranged country and abroad, who experienced Coombs' friendly hos- which was to his widow until the children were educated. paid pitality. However there was always encouragement for the When this was the money was utilised to accomplished children to pursue other interests, whether it took the form a and the Coombs Memorial Lecture, provide prize, Carey of, for example, Franklin's love of ornithology, Martin's the first such delivered Lawrence on being by O'Shaughnessy interest in motorbikes or Richard's in geography and history. the of in 1937. subject "Cardio-omentopexy", It was a happy household, if not, by present-day standards, Coombs' lives on in Bristol in other memory ways, largely a little austere. Coombs would take a cold bath in the due to the influence of Bruce his former research Perry, mornings and expected his children to do likewise. Although who became Professor of Medicine in 1935. When registrar, not rigidly tee-total, he did not drink alcohol in the house, the General and the amalga- Hospital Royal Infirmary finally and what few meals he ate away from home were either mated in June 1940, named one of the medical wards Perry medical dinners or taken on journeys. There were always Coombs Ward" after his old chief, though as there "Carey traditional family prayers before breakfast, as there had been were by that time no medical beds at the General Hospital at his father's house in Castle Cary, and he would occasio- this ward was located in the old building of the Infirmary. nally read passages from the Bible aloud at mealtimes. The There was also a "Carey Coombs Research Fellowship", whole family would attend the Congregational Highbury started in 1952 and continuing until today, the original holder Chapel in the suburb of Cotham, each Sunday, usually being Dr D W Barritt. walking the mile or so from home to church, though Coombs frequently drove down to the General Hospital beforehand. Coombs: The Man It should not be thought that he was dull or morose. In fact It is clear that, particularly towards the end of his life, he was he was notorious for his cheerfulness and supply of amusing overwhelmingly busy with research and committee work. He stories. He was a genial companion who radiated sincerity was renowned as a good and enthusiastic teacher of students, and openness. Handsome and well attired, he had a style and junior staff and his colleagues. His penultimate houseman clarity of speech that was both informative and unpreten- recalls occasions when Coombs was called back to the tious, and although there was a private side to him, when he

102 Bristol Journal Medico-Chirurgical Volume 104 (iv) November 1989

died there were a large number of people who felt a personal 11. In "Rheumatic myocarditis" QJ Med, (1908), 2, 26-47. Coombs loss. explains that "... a relative stenosis is established, and blood sucked this small John Poynton wrote, "With the untimely death of Dr Carey through relatively mitral ring by the rapid expansion of an enlarged ventircle is thrown into vibrations Coombs passes a friend bound to me by the ties of affection, which are appreciated by the clincial observer as a mid-diastolic . . . a man makes me to regard and comradeship. Such proud murmur.". be a doctor.". 12. Although Aschoff described the submiliary nodules a few months Rendle Short commented, "Many consulting physicians are before Coombs found them, Coombs claimed priority in realising their brethren for their their highly respected by professional aetiological importance when he delivered the Long Fox works sake; some are loved for their own sake. It is no funeral Memorial Lecture in Bristol on 9th December 1925. flattery, but the barest truth, to say that Carey Coombs 13. For a discussion of this topic and its relevance to the later

.... formation of the Cardicac Club see enjoyed in full measure the double tribute But there was Joel D. Howell, "Soldiers heart: The redefinition of heart disease and something more, and we loved him. . . . Usually a death in speciality formation in early twentieth century Great Britain" Medical medical circles is like a stone dropped on water; there is a History, (1985), suppl no 5, p. 34-52. splash, some circles or wavelets, then all is still spreading 14. COOMBS, CAREY F. (1915) "Cardiac diseases and disorders in Not so in this case. again. (33) warfare", Bris Med-Chir J. 33, 149-56. It is now over years since the death of Carey Coombs. 15. CAREY F. fifty COOMBS, (1916) "Medicine and surgery in Though Coombs would have wished to have lived to see the Mesopotamia", Bris Med-Chir J., 34, 136-44. and to witness final amalgamation of the Bristol hospitals 16. COOMBS, CAREY F, STACK, H. E. and ROLFE, R. (1920) Winford Hospital put on firmer financial foundations, he "Poisoning by mustard gas", Bris Med-Chir J., 37, 151-62. 17. could be proud of many things. The major achievements COOMBS, CAREY F. (1918) "Army nephritis", Lancet, i, 495. his in the founding of the Cardie Club, the opening 18. COOMBS, CAREY F. (1920) "The incidence of fatal rheumatic being help heart disease in Bristol: of the Centre for Cardiac Research, the building of the 1876-1913.", Lancet., ii, 226. 19. COWAN, JOHN et. al., "Some notes on the at Winford, and the coordination of a large (1939) Cardiac hospital-school Club", Brit Heart J., 1, 97-103, and number of medical in his studies of rheumatic CAMPBELL, MAURICE. practitioners (1962) "The British Cardiac Society and the Cardiac Club: 1926? heart disease. 1961.", Brit Heart J., 24, 673-95. It cannot be said that Coombs' work 20. displayed great COOMBS, CAREY, F. (1924) "Rheumatic Heart Disease.", genius, although his book and his Lumleian lectures are both Bristol, John Wright & Sons Ltd. landmarks in their respective fields. His researches were 21. Brit Med J., (1926) suppl, 9-25. 22. built, not on sudden inspiration, but upon meticulous thought COOMBS, CAREY, F. (1927) "Rheumatic infections of child- hood.". and and hard work. He was a superb organiser whose enthusiasm Lancet, i, 579-80, 634-5, "The chronic rheumatic diseases", Lancet, i, 739?41, 802?3. motivated those around him. He was primarily a physician 23. The medical advisory committee was made of whose through Victorian values allowed him to up representatives upbringing from members of the following groups: Bristol medical art and science of medicine. panel, span the gulf between the not on the general practitioners panel, women practitioners, whole-time administrative officers, and hospital staff. Their role Acknowledgements was to advise public bodies as to the views of the local medical I should like to thank the following people for their help: Dr. profession and to forge greater links among their number. 24. The fund was set the Noel Coombs, Dr. Franklin Coombs, Mr. Richard Coombs, up by Harmsworth family to promote research into endocarditis. Prof. C. B. Perry, Dr. Douglas Johnson, Miss B. A. Michell Three members of the family had died of this disease. When a cure for Clarke, Dr. Juliet Dr. C. Rendle Short, Dr. Arthur the disease was found the capital Rogers, was to be to the successful Hollman. given researcher. In fact, when it became clear that Penicillin was an effective treatment, the money was divided between Flemming, Florey and Chain. When REFERENCES Coombs died the funding of the Centre for Cardiac Research "The of 1. POYNTON, F. J. and PAINE, A. E. (1900) etiology finished, although Bruce Perry was commissioned to write a book For more details of on bacterial endocarditis. rheumatic fever", Lancet, ii, 861-9. Poynton's The M.R.C. grant was mainly for clerical in the career see Munk's Roll, vol IV p 454-4. expenses running of epidemiological studies. The record work of the Centre is 2. These awards are listed in Coombs' student card, together described by Coombs in "The work of the with details of clinical attachments from January 1900 until May University Centre of Cardiac Research: 1927-31." 1901. Bris Med-Chir J., (1931), 48, 179-88. 3. St VII: 154. 25. COOMBS, F. Mary's Hospital Gazette, 1901, CAREY, (1931) "The incidence of juvenile car- diac rheumatism in the west 4. St Mary's Hospital Gazette, 1903, IX:54. of England.", Proc Roy Soc Med., 5. St Mary's Hospital Gazette, 1903, IX:87. 24,1611-2. between Coombs 26. The initial cost for the 6. This quotation and the account of the meeting Winford project was ?40,000 but by the in the of this had risen to and Poynton is found in "Thirty years progress study opening ?64,000 and there was an outstanding rheumatic heart disease", Bris Med-Chir J., 1933, 50, 93-112, debt of ?18,000. of London 27. which Dr Bruce Perry delivered to the University COOMBS, CAREY, F. (1932) "The diagnosis and treatment of soon after Coombs' death. syphilis of the aorta and heart.", Q J Med, 1, 179-211. of 7. COOMBS, CAREY F. (1904) "Some clinical aspects the 28. The Lumleian Lectures were published as "Syphilis of the heart rheumatic infection", Lancet, i, 565-8. and great vessels.", Lancet, (1931), ii, 227-31, 281-6, 333-9. infection of the 29. 8. COOMBS, CAREY F. (1922) "Streptococcal OBRASTZOW, W. P., STRASCHESKO, N. D., (1910) "Zur heart", Quart J Med, 25, 114. kenntnis der thrombose der koronararterian des herzens.", Zeits 9. In "Rheumatic carditis in childhood" Bris Med-Chir J, (1907), Klin Med, 71, 116-32. sound 25, 193-200. Coombs states: "Next the apical second 30. COOMBS, CAREY, F. (1927) "Coronary obstruction.", Bris becomes doubled and then, but often not till some time after, a Med-Chir J., 44, 249-56. this second sound. 31. murmur is added to the second half of This, COOMBS, CAREY, F. (1932) "Prognosis in coronary thrombo- hard to distinguish at first, lengthens and strengthens till at last it sis.", Bris Med-Chir J., 49, 277-84. runs into the of the next in fact, a pre- 32. the state beginning cycle, becoming, Although obituary reports that he died of coronary and loud as that of mitral systolic murmur. This is not as rough thrombosis, it is odd that both the initial attack and the fatal disease.". were obstruction and it is not due to valvular episode painless. In fact at later examination there was no 10. manifestations of the rheu- obvious cardiac CHEADLE, W. B. (1889) "Various infarction and the coronary arteries were good. 33. These and matic state as exemplified in childhood and early life", Lancet, i, other memorials are found in Brit Med J., ii, 1267, 821-7. 1171, and Lancet, (1932), ii, 1361-2, and Medical Annual.