Dr Carey Coombs and his non-existent cardiac infarct
Editor,—Carey Franklin Coombs, 1879–1932, was a physician at the Bristol General Hospital. He made important studies of rheumatic fever describing the diastolic murmur of acute rheumatic mitral valvulitis, which bears his name, and taking a great interest in the prevention and management of heart disease in children. His 1924 monograph Rheumatic heart diseasebecame a standard work on the subject. He also did pioneering work in coronary heart disease, and around 1910 he made a clinical diagnosis of coronary thrombosis at a time when the condition was almost unheard of. His patient survived, so without necropsy proof he did not achieve priority of recognition, which went to James Herrick of Chicago in 1912.1 His interest in the disease continued, and by 1932 he had studied and published 144 cases of coronary thrombosis.2
His own illness
In 1932, aged 53, he stopped with chest pain while walking up a steep hill. A short time later, he had an unheralded syncopal attack and was admitted to hospital. On recovery he had no pain. The ECG showed bundle branch block and a diagnosis of coronary thrombosis was made. As was then the rule, he was kept in bed for six weeks. He was then allowed up, but suddenly fell down dead.
Carey Coombs's medical registrar at that time was C Bruce Perry (1903–96), who later became the professor of medicine in Bristol. It was he who told me about Coombs's illness and its aftermath. On the day before the funeral, Mrs Coombs asked Perry to remove her husband's heart saying that it had been his wish to have it placed in the pathology museum. By then the body was in a coffin in Coombs's consulting room, but Perry unscrewed the lid and took out the heart with the help of a postmortem technician. Perry, a young registrar aged 29, was then presented with a dilemma that he later wrote about: “Externally the heart looked normal. I did not know what to do, or to say to the people who had looked after him. Geoffrey Hadfield [then pathologist at Barts having been previously in Bristol] was coming to the funeral so I phoned him and he agreed to ‘demonstrate’ the heart to the senior physicians afterwards. This he did showing them an infarct that was not there but they were satisfied. When they had gone he gave me the heart and said ‘now find out what was wrong’. We took sections of all parts histologically and finally found a small lesion in the region of the AV bundle. I am afraid there was nothing to put in the museum. Looking back on it I think he had a Stokes-Adams attack when he fell unconscious and a massive pulmonary embolism when he died. But of course we did not examine the lungs so we shall never know. One should not agree to a partial incomplete examination if one wants to get as near as possible to the truth” (personal communication).
Another domiciliary necropsy done by Bruce Perry
One of the cases in the 1932 paper1 was a man whom Carey Coombs had seen in the patient's home in 1928, in consultation with the general practitioner. There was then no portable ECG to support the clinical diagnosis. The patient died and Perry recounted that he was sent to get the heart: “I took knives etc from the postmortem room and lots of old newspapers. The body was lying on a bed and as I lifted it onto the floor covered in newspapers a wig fell off. The general practitioner was present and said, ‘Oh dear, I have known him all these years and did not know he had a wig.’” The heart when opened showed a classic infarct which Coombs had photographed, but apparently never published.
An excellent and full account of Carey Coombs's life and work has been written by Clive Weston,1 and his influence lives on in Bristol with a research scholarship named after him.