Dr Graham Steell and monaural stethoscopes: Cardiology before the ECG

Abstract

Dr Graham Steell, MB CM MD FRCP (1851–1942), an Edinburgh graduate, was a physician at the Manchester Royal Infirmary (1878–1911) and professor of medicine at the Victoria Manchester University (1907–1911). He is mainly remembered for describing the ‘Graham Steel murmur’, however his name is also associated with the ‘Graham Steell monaural stethoscope’, which he designed. His clinical examination of the cardiovascular system at the bedside was meticulous, using only his stethoscope, percussion hammer, and a sphygmograph to record the radial pulse. His work is described in his monograph, Diseases of the Heart (1906) and other numerous papers. The University of Manchester Museum of Medicine and Health has a collection of monaural stethoscopes, percussors and sphygmographs. This article explores Dr Steell's clinical techniques and contribution to cardiology in an era before chest X-rays and electrocardiography, and also discusses the use of monaural stethoscopes and percussion hammers by the wider medical profession during the Victorian and Edwardian period.

Introduction

Graham Steell, physician at the Manchester Royal Infirmary (MRI), has been described as ‘the leading cardiologist of his time in the North of England’. ¹ He is remembered for his description of the pulmonary diastolic murmur due to pulmonary hypertension, known as the ‘Graham Steell murmur’, originally described in cases of mitral stenosis and reported by him at a meeting of the Manchester Medical Society in 1888. ² Steell was shy with a ‘modest retiring disposition’, and was embarrassed by the association of his name with the murmur, nevertheless he wanted it to be recognised as an ‘auscultatory sign’ indicating pulmonary regurgitation. ³ He stressed that the diastolic murmur was variable and sometimes difficult to localise and could also be heard in diseases that cause high pulmonary artery pressure other than mitral stenosis. ⁴

He used a long, 10-inch monaural stethoscope, and a percussor hammer, but makes no mention of ever using a sphygmomanometer, X-rays or the electrocardiogram (ECG). ⁵ His teaching and research relied on his clinical skills – a detailed history and clinical examination, supplemented by sphygmograph pulse tracings and post-mortem findings. ⁶ A biographical sketch by MRI cardiologist Crighton Bramwell (1889–1976) provides a good account of Steell's life and work. ⁷ Numerous papers have discussed the Graham Steell murmur, and his obituaries chronicle his career at the MRI and highlight his personality and appearance. ⁸ The University of Manchester holds a large archive relating to his career and publications, and the Museum of Medicine and Health (MMH) has a collection of Graham Steell stethoscopes, percussor hammers and sphygmographs.

This article sketches out his life and work and asks how far did Graham Steell, armed only with his stethoscope and percussor, advance cardiology in an era before ECG and chest X-rays? The monaural stethoscope was important for a physician interested in heart disease but what was the impact of it on the general medical profession? The following sections examine his career as a cardiologist, the eponymous murmur, his medical armamentarium, and the influence of his artistic family background on his medical practice.

Early life and education

Graham Steell was born in Edinburgh on 27 July 1851, the son of Sir John Robert Steell (1804–1891) and his wife, Elizabeth (d.1885). The family was artistic; Graham's grandfather, John Steell senior (d.1829) had been a woodcarver and guilder. His father was a sculptor of international renown and royal sculptor to Queen Victoria, and his uncle, Gourlay Steell (1819–1894), a Scottish artist, was Queen Victoria's official painter of animals. Graham's older brother, William Steell (1836–1917), was an architect. ⁹

Graham was educated at Edinburgh Academy. In his youth he was keen on boxing and wanted to join the army, however his brother persuaded him to study medicine at Edinburgh University, where he graduated in 1872. After a short sojourn in Berlin he was appointed as house physician at the Edinburgh Royal Infirmary (ERI) under the physician, George Balfour (1823–1903), who was an early influence on Steell's interest in heart disease. ¹⁰ However, he was also interested in infectious diseases, and after the ERI he worked at fever hospitals in Edinburgh, Leeds and London, which were the inspiration for his gold medal MD thesis on scarlet fever (1877). ¹¹ For a time, he was then medical assistant for materia medica at Edinburgh before moving to Manchester. ¹²

Manchester Royal Infirmary

In 1878 Dr Steell was appointed Resident Medical Officer (RMO) at the MRI in the centre of Manchester. In 1883 he became an honorary assistant physician and was promoted to full honorary physician in 1889. He was appointed as professor of medicine in 1907, shortly before the MRI relocated to a new site near the University, allowing more clinical work and ward teaching. He was chiefly concerned with diseases of the heart, but he also maintained an interest in infectious diseases and was honorary physician to Monsall Fever Hospital, the Christie Cancer Hospital and the Manchester Skin Hospital. ¹³

The various accounts of his life all comment on his personality and physical appearance. He is described as ‘a character’, ‘shy and reticent’, ‘a delicate skeletal of a man’, wearing pince-nez, with marked baldness, attributed to typhus (Figure 1). Despite his delicate appearance and episodes of ill health, he was an advocate of walking and horse riding and lived to the age of 91. He was a poor conversationalist and lecturer, but was more relaxed on the ward where he was a ‘first-rate bedside teacher’; students who avoided his lectures flocked to his ward rounds and demonstrations. He was a prolific writer with over 60 publications; his 2 guide books, Physical signs of cardiac disease (1881) and Physical signs of pulmonary disease (1882) provided a detailed description of the techniques of clinical examination, and were popular with the students. ¹⁴

Figure 1.

Photographs of Dr Steell as young man and in later life. The University of Manchester Archives.

Despite his reticence, he built a reputation as a cardiologist and was quick to defend any criticism of his published work. He was an efficient professor of medicine, president of the Manchester Medical Society (1897), he delivered the Bradshaw Lecture on ‘Intrathoracic Tumours and Aneurysms’ at the Royal College of Physicians (1911), and on his retirement he agreed to having his portrait engraved by artist Percy Martingale (1869–1943). He married Agnes Dunlop McKie, Superintendent of Nurses, in 1886; she pre-deceased him in 1910, and after he retired in 1911 he lived with his son, Dr John Graham Steell (1887–1972). ¹⁵ He was troubled with an irregular pulse and trigeminal neuralgia, but otherwise retained his mental and physical wellbeing until he died 10 January 1942.

Dr Graham Steell, the cardiologist

Steell became interested in heart disease in 1872 when he was house physician at ERI under Dr Balfour, who was an authority on mitral stenosis. ¹⁶ After Dr Steell had started as RMO at the MRI, nearly all his publications were related to cardiology; he viewed the heart and lungs as a single physiological unit and correlated the patient's clinical signs, especially the auscultatory sounds and murmurs, with the underlying anatomy and pathophysiology. His two seminal papers in 1888 are good examples of his detailed descriptive style; in his article on mitral stenosis, he lists every murmur and sound from each heart valve, explaining their origin and pathology. In his second paper on the pulmonary early diastolic murmur (the ‘Graham Steell murmur’), he explains how it is caused by a diastolic resurgence of blood-flow through the pulmonary valve, which itself is structurally normal, but dilated by the high pulmonary artery pressure. ¹⁷ A series of papers in the Lancet, Manchester Medical Chronicle and other journals focus on cardiac diseases including cardiomegaly, pericarditis, alcoholic heart disease, bradycardia and aortic stenosis. ¹⁸ Two reviews, A Retrospect (1879) and Present day view (1901) provide interesting overviews of the development of nineteenth century cardiology. ¹⁹ His Text-Book on diseases of the heart (1906) was a landmark in his career. This monograph presents a full account of cardiology at that time, including, anatomy, physiology, pathology and symptoms. The clinical examination is explained in detail, with several pages devoted to palpation and percussion. His section on auscultation is especially complex, describing the pathogenesis of each heart sound and murmur, including the Graham Steell murmur, which he calls ‘the murmur of high pressure in the pulmonary artery’. ²⁰

Steell's research was essentially clinical, using his long monaural wooden stethoscope and percussor hammer, along with careful clinical records of his patients. He was aware that ‘increased arterial tension’ damaged the heart and the kidney's, but he never used the term ‘hypertension’ or used any type of sphygmomanometer. ²¹ Although Alfred Barclay (1876–1949), the first radiologist at the MRI, had opened a small X-ray Department in 1908, chest X-rays were not available until after1914. ²² Steell used a Mohamed sphygmograph to record the pulse, and he also allowed Dr James Mackenzie (1853–1925) to make polygraph recordings of his in-patients, which are illustrated in Steell's Text-Book. ²³ Mackenzie, then still a general physician in Burnley, had demonstrated his polygraph to the Manchester Medical Society in 1892, and regularly visited the MRI to make the polygraph recordings with his original two-channel machine, which traced the radial or jugular venous pulse, and a time-marker, onto strips of smoked paper (he later designed an improved ‘ink polygraph’ with three channels). ²⁴

Dr Steell had many patients with arrhythmias, and was interested in the research at that time on the cardiac conduction system: ‘such advance is the result of laborious investigation of scientists and clinicists – Keith, Gaskell and especially Mackenzie and Wenckebach’. ²⁵ His appointment as professor of medicine in 1907 established him as the leading cardiologist in the North of England; he had slowly built-up his private practice in Manchester and was frequently asked to see patients across Lancashire.

Eponyms and the Graham Steell murmur

Dr Steell's ‘definition’ of the murmur in his original paper (1888), is typical of his detailed descriptive style and is over a page in length. The first paragraph starts:

‘I wish to plead for the admission among the recognized auscultatory signs of disease of a murmur due to pulmonary regurgitation, occurring independently of disease or deformity of the valves, and is the result of long-continued excess of blood pressure in the pulmonary artery’. ²⁶

He described it as ‘a soft blowing diastolic murmur’ and added that there were no signs of aortic regurgitation. He emphasised that it could be difficult to hear and could also occur with pulmonary hypertension not related to mitral stenosis; it was a rare sign – he only found it in 1 patient out of 60 cases of mitral stenosis. ²⁷ Of course, Dr Steell never called it the ‘Graham Steell murmur’, and usually referred to it as ‘the murmur of high-pressure in the pulmonary artery’. A full copy of the ‘definition’ can be found in Bramwell's homage to Steell. ²⁸

The ‘Graham Steell murmur’ has been the subject of papers discussing the priority of earlier reports, the origin of the eponymous label, and confusion with the Austin Flint murmur of aortic incompetence, which Steell called, ‘Flint's auscultatory sign’. ²⁹ William Osler, in his Principles and practices of medicine (1897), refers to a soft diastolic murmur, ‘which Steell called, the murmur of high pressure’. ³⁰ Steell's BMJ obituary states that the phrase ‘Graham Steell murmur’ was first used by American physicians, and Fraser and Weston, in their paper, ‘eponymous serendipity’ (1991), state that by 1914 the use of the eponym was established in America, however, it was only after a paper in 1929, entitled ‘The Graham Steell Murmur, report of a case’ by American cardiologist, Paul White (1886–1973), that the use of the eponymous phrase came into general use – PubMed lists seven papers with ‘Graham Steell Murmur’ in the title, between 1961 and 1991. ³¹

Other physicians have reported murmurs associated with pulmonary hypertension. James Hope (1801–1841) at the Marylebone Infirmary, described a case of a pulmonary resurgence murmur as early as 1832. ³² Steell's old chief, Dr Balfour, was aware of a murmur associated with pulmonary hypertension, but thought it was caused by a narrowed mitral valve. Dyce Duckworth (1840–1928), physician at St Bartholomew's Hospital, reported a case of mitral stenosis with the signs of pulmonary hypertension in February 1888, prior to Steell's publications in May and December. ³³ George Gibson (1875–1950), physician at the Radcliff Infirmary, reported three cases with post-mortems in 1894, and stated that he had demonstrated experimental pulmonary incompetence in cadavers in 1880. ³⁴ However, Steell deserves credit for his meticulous, page-long definition and explanation of the pathophysiology of the murmur in his 1888 paper, all subsequently confirmed by modern medical technology.

Stethoscopes, percussors and sphygmographs

Dr Steell perfected the use of a wooden monaural stethoscope while working for Dr Balfour at Edinburgh. Sometime during the 1880s he designed his own model with a larger bell-shaped ear-piece with an inner cone-shaped cavity, which presumably had better acoustics, and a nicely rounded hand-grip. They were manufactured by the Manchester company, James Woolley and Sons, in two sizes (10 inch and 8 inch), and were listed in Woolley's surgical instrument catalogues until 1931. ³⁵ Steell used the 10-inch model, probably for comfort, though he told the students that it was because it was longer ‘than that of a flea jump’ (about 8 inches); an old joke from when he worked in the infectious disease hospitals where they used 12-inch, communal ‘ward stethoscopes’ to reduce close-contact. ³⁶ Steell's stethoscopes were sold solely by Woolley's, and were more expensive (6/6^d) than other models, probably because of the intricately turned ear-piece. There are nine Steell stethoscopes in the MMH collection, most donated by former doctors or their relatives (Figure 2). One model was donated by Dr Eugenia Cooper (1888–1991), lecturer in histology, perhaps collected as an antique or possibly saved from her student days (1916–21). ³⁷ Two more (10 and 8 inches) were donated by the MRI archivist, Miss Pauline Leech, the daughter of Dr Ernest Bosdin Leech (1875–1950), an MRI physician and close friend of Steell. ³⁸

Figure 2.

Graham Steell stethoscopes. 10” and two 8” models. The Museum of Medicine and Health collection.

Medical historian Caroline Avery has provided a comprehensive history of the monaural stethoscope and the uptake of mediated auscultation in her excellent PhD thesis, ‘Importing the Stethoscope’ (2020). ³⁹ Rene Laennec's (1781–1826) book, De Auscultation mediate (1819), was not well-known in Britain until after Dr John Forbes’ (1787–1861) translation in 1821 and his monograph, Treatise on diseases of the chest (1824). ⁴⁰ A few early enthusiasts such as the Manchester ophthalmic surgeon, John Windsor (1787–1868) and London physician, James Hope (1801–1841), travelled to Paris to learn the technique, and William Stokes (1804–1878), a student in Edinburgh, published a book on the instrument in 1825. ⁴¹ However, many doctors were opposed to the stethoscope; some thought it was just a gimmick that would pass, while others, who had not been taught how to use the instrument, were disappointed when it failed to give the instant diagnosis they had hoped for. Many patients were frightened of the stethoscope; some thought the doctor could read their thoughts and some found the prolonged examination unpleasant and painful. ⁴²

The early use of the stethoscope was mainly limited to physicians interested in chest and heart diseases, and it was only after its use was taught in the medical schools that it was taken up by new generations of medical graduates. In 1829, the French professor of medicine, Pierre Piorry (1794–1879), designed a stethoscope with a narrow, shorter stem, which replaced Laennec's wide-bore tube. ⁴³ Nevertheless some physicians complained that even this new style was cumbersome to carry around, and some, like the flamboyant Manchester gynaecologist Lloyd Roberts (1834–1920), took to clipping them inside their top-hats! ⁴⁴ By the 1870s the monaural stethoscope was in universal use and there was a large choice of models – during the 1890s Arnold & Sons were advertising 22 different types. The transition was slow, however by the 1930s most physicians were using binaural stethoscopes, though Down Bros. were still advertising the 12-inch ‘monaural ward model’ in 1955! ⁴⁵

Dr Steell was the master of percussion, especially for accessing the size of the heart. He preferred to use a metal percussion hammer with soft rubber tip; he stated, ‘personally, I use the hammer, my finger being interposed between it and the patient’. ⁴⁶ Digital percussion, as an aid to diagnosis, was described by Leopold Auenbrugger (1722–1809) in 1761, and in 1826 Priorry introduced the ‘pleximeter’, a small disc, to transmit the tap from the finger. Two years later Scottish physician, David Barry (1781–1836) suggested using a small hammer to tap the pleximeter, and in 1841 the German doctor, Max Wintrich (1812–1882) designed a small L-shaped ‘percussion hammer’ with a metal head and a wooden or metal handle. ⁴⁷ The model advertised in British instrument catalogues was the ‘Bennett percussor’, similar to Wintrich's and recommended by John Bennett (1812–1875), professor of medicine at Edinburgh, in his Introduction to clinical medicine (1853). ⁴⁸ The MMH holds three Bennett percussors with rubber tips, similar to the type that Steell would have used (Figure 3).

Figure 3.

Bennett's percussor. The Museum of Medicine and Health collection.

The MMH also holds a Mohamed sphygmograph made by Krohne and Sesemann Co., still in its original case and dated ‘13 September 1875’, its origin is stated as ‘physiology’, so it may even have been used by Steell (Figure 4). Dr Steell was fascinated with the Mohamed sphygmograph; he routinely took pulse tracings of his cardiac patients and published several examples in his papers and books. ⁴⁹ Steell was a friend of Frederick Mahomed (1849–1884); they had probably met when they were both junior doctors at the London Fever Hospital (c.1875). Dr Mahomed, while a student at Guy's Hospital, had won the Pupil's Physician Society Prize for his design of an improved sphygmograph, which recorded the pulse tracing on a strip of smoked paper. ⁵⁰ Mohamed's extensive research into blood pressure, Bright's disease and typhoid has been highlighted by social historian, Professor Arup Chatterjee in his on-line essay (2018). ⁵¹ Fever hospitals were dangerous places; Dr Mohamed contracted typhoid and died, aged 35, while Steell is said to have had his health and appearance affected by the after-effects of typhus, typhoid and tuberculosis, contracted in his early career.

Figure 4.

Mohamed sphygmograph. The Museum of Medicine and Health collection.

Discussion

Graham Steell's biographers all comment on his distinguished, artistic family; his father, Sir John Steell, a famous sculptor, and his uncle, Gourlay Steell, a well-known artist, were both patronised by Queen Victoria. William, his older brother, was an architect, however, he was regarded as ‘of little merit’ and ‘his career saved by designing pedestals for his father's statues’. ⁵² Dr Steell was repeatedly described as having a difficult personality – shy, modest, retiring, awkward, laconic, etc. However, only Fraser and Weston make the link between the family dynamics and his diffident personality, stating: ‘it is possible that his shyness was a reaction to the fame and attention that surrounded his family when he was young’. ⁵³ Graham Steell provides a classic example of the problems sometimes faced by the ‘sons of famous fathers’, constantly exposed and compared to their father's achievements. ⁵⁴ Graham was perhaps also subjected to a controlling upbringing; his only escape was to join the army, fortunately, his brother William (himself shackled by his father's patronage), recognising Graham's intelligence, and persuaded him to take-up medical studies.

Of course, Graham may have still inherited the ‘artistic gaze’; his design of the ear-piece of his wooden stethoscope perhaps harkens to the work of his grandfather who was woodwork turner, or the statue bases designed by his brother. More important, was his ability to visualise the inner anatomy of his patients during clinical examination could be compared with the artist's gaze on their subject. Although a poor lecturer, it was this ‘visualisation’ that made him an excellent bedside teacher; his students would often enter his lecture late in anticipation that he would abandon it, and say ‘let's go and see some patients’. He was in his element demonstrating percussion and auscultation and explaining how the clinical signs related to the mechanics of the beating heart. He may have found socialising and conversation difficult, but he was fluent during his bedside teaching and in his publications.

His career can be described as ‘solid’; 33 years dedicated to the MRI, the Medical School and cardiology. His research was ‘clinical’, based on his patients, case reports and sphygmograph tracings. He is of course remembered for his eponymous murmur; the term ‘Graham Steell murmur’ has been in common usage for many years, partly because it has been the subject of so many papers. It seems unlikely that the eponym will go out of fashion, and the confirmation of his description by modern imaging and other techniques perhaps justifies its continued use. ⁵⁵

He was content with his life and career in Manchester and the Infirmary; he married Agnes McKie, the Superintendent of Nursing, in 1886, and as his private practice grew, he came to be considered as the leading consultant for heart disease in the north of England. In contrast, his ambitious friend James Mackenzie, moved to London in 1907 and set-up as a cardiologist at the London Hospital and Harley Street. ⁵⁶ He founded the Cardiac Club (1922); Steell was not an active member but was listed as a ‘collaborator’ on the cover of the journal, Heart (1909) and was one of the ‘honorary members’ in 1937 when the Club was renamed as the Cardiac Society of Great Britain and Ireland (later, the British Cardiovascular Society, 1946). ⁵⁷

Professor Steell's legacy was more than just an eponymous murmur; his published works were exemplary, his patients were at the centre of his research, and he taught hundreds of medical students the bedside examination. He knew of the work done by the anatomist, Arthur Keith (1866–1955) and others on the cardiac conduction system, however, he was a generation too early to contribute to electrophysiology. Indeed, Steell was concerned that advances such as ECG and X-rays might blunt the skills of the bedside examination – at his retirement he warned, ‘clinical medicine seems to me at the present moment to be in danger of losing something of its old charm, and in future of losing much more’. ⁵⁸ Perhaps this is also a warning for present-day practice; certainly, modern medical imaging and technology are essential, but their use still needs to be guided by careful clinical assessment. Indeed, the post-Covid trend for ‘telephone consultations’ is a temptation to order scans and investigations prior to any face-to-face meeting, a scenario that could bias the examiner's judgement, as well as setting a bad example for students. Dr Steell's lasting legacy was that he ‘kept the flag flying’ for the clinical examination – inspection, palpation, percussion and auscultation.