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The Herrick Lecture

David R. Holmes, Jr., MD*

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Hero worship or mentor worship is universal; in someocieties, of course, it is more deeply ingrained than inthers. Those individuals who are the focus of hero orentor worship may be characterized by many things that Iill define as “ity” things. You are perhaps wondering what

hose “ity” things are in hero or mentor worship. Theynclude, among others, sagacity, tenacity, humility, creativ-ty, curiosity, authority, and honesity. These are the “ity”hings. These qualities belong to the people we would likeo grow up to be, although, as I look around this room, manyf us are actually already grown up.

James Bryan Herrick typifies that kind of individual weant to grow up to be like.1–6 As I read his autobiography,any things come to mind. He and I were born in the same

mall town, Oak Park, Illinois. Although some of you mightelieve that we were contemporaries, actually, he was aittle bit ahead of me in school. In fact, we went to the sameigh school, Oak Park High School, and in 1877, he and 2ther boys were the first graduating class ever sent out fromhat high school. Although I did not know it at the time,very day as I walked to high school, I walked right by theorner where the house stood in which Dr. Herrick had beenorn and in which he grew up. I have no idea whether it washe exact same house, but I do know that it was the exactame corner: the northwest corner of Oak Park Avenue andntario Street. After graduating, Dr. Herrick taught at the

ame high school that he and I went to. Now, when I was inigh school, I had always thought that Oak Park Highchool was 100 years old; perhaps it was, perhaps Dr.errick might have actually walked the same halls thatwalked.

In an interesting footnote, another hero of mine, Ernestemingway, was also born and raised in Oak Park, Illinois.

t turns out that after Mother O’Leary’s cow did her thing in871 and caused the great Chicago fire, Dr. Herrick’s father,ho was a grocer, and Ernest Hemingway’s grandfather,.T. Hemingway, who was then secretary of the ChicagoMCA, drove through the “still hot sand of the lakeshore toeliver food” to the needy.

Curiosity is one of those “ity” words I mentioned earlier.n Herrick’s own words, he “was thankful for the compan-onship of other boys, who like myself, were neither hope-essly nor offensively good, whose moral lapses were nei-her regarded as sins nor had they left an indelible stain.”errick also wrote about storing cocoons in his dresserrawers and then having to get rid of the mess of eggsefore the grubs hatched out among his shirts and socks.

Now, fast forward, if you will, �1/2 century later, whenr. Herrick was asked to fill in as a speaker at the annual

Mayo Clinic, Rochester, Minnesota. Manuscript received January 8,008; revised manuscript received and accepted January 11, 2008.

*Corresponding author: Tel: 507-255-2504; fax: 507-255-2550.

sE-mail address: holmes.david@mayo.edu (D.R. Holmes).

002-9149/08/$ – see front matteroi:10.1016/j.amjcard.2008.01.034

inner of the Association of American Physicians. The titlef his talk was “Why I Read Chaucer at the Age of 70.”ow many people read Chaucer at 70? Herrick said that the

alk went over well, although before the talk, he heard aoung “Turk” say, “I know who Dr. Herrick is, but who inhe hell is Chaucer?” So, curiosity is one of those “ity”omponents that Dr. James Bryan Herrick possessed.

We regard Dr. Herrick as that giant who so elegantly andloquently described the issues of coronary thrombosis be-ore the Association of American Physicians on May 14,912, when he talked about a classic case of cardiogenichock and death from acute myocardial infarction. Herrickescribed “being keyed up to a high pitch, as I fearedomeone else might jump into print ahead of me.” Hisnxiety, however, was groundless, because no one evensked a question. It turns out that coronary thrombosis hadeen described before.7–10 There was an earlier report inussia, which described in Russian a case of a patient dying

rom acute myocardial infarction.8 However, Herrick intro-uced the concept and elevated it, and as you know, it hasecome the hallmark of acute myocardial infarction, form-ng the basis of treatment of patients with myocardial in-arction and reperfusion therapy over the past century.

Dr. Herrick’s description of the seminal initial case waslassic, but the attendant memories that he wrote about addorm and substance. He described the patient as a slender,ctive man, head of a private banking house. He had takenmidnight meal of a sandwich and a bottle of beer after he

nd his wife had returned from the theater in Chicago to theuburbs, where they lived, and had then become ill. Dr.errick and another physician, Dr. Murphy, were asked toelp by Dr. Frank Billings because the rapid feeble pulseillings found was a puzzling and difficult feature. Dr.illings admitted that he did not know the exact cause, bute spoke of the possibility of a cardiac accident. As Dr.errick recalls, at the request of the family, Dr. Murphy ande came back in the evening and stayed all night in theatient’s house. Now that was a house call. Dr. Herrickontinued, writing that they were in a big room with twineds. Murphy, hearing Herrick turn in bed but not wishingo awaken him if he was asleep, would whisper, “Herrick,re you awake? Say, are you sure about there being noneumothorax?” A little later, from Herrick’s bed, also in atage whisper: “Dr. Murphy, do you think this might becute pancreatitis or possibly a strangulated diaphragmaticernia?” Dr. Herrick wrote that neither man slept much thatight. As we all know, the autopsy revealed a clot in theoronary artery, which Dr. Herrick had mentioned as aikely cause. The pathologist called and said that the clotas in the coronary artery, all right, but “how in God’same did you guess it?” Dr. Herrick wrote, “Among myreasured letters is one from Dr. Murphy, who warmlyongratulated me on my diagnosis.” What with that expo-

ure, Dr. Herrick started to do what he called “missionary

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1511Historical Study/The Herrick Lecture

ork—preaching the gospel of the pathology and clinicalymptoms of acute coronary obstruction.”

Although we remember Dr. Herrick for coronary throm-osis, we also need to remember that in 1904, he described“peculiar, elongated, and sickle-shaped red blood corpus-

le in a case of severe anemia,” the first case of sickle-cellisease and anemia. And so form and substance and intel-ectual curiosity grew up with Dr. Herrick and his work.3

Other “itys” related to James Herrick are sagacity anduthority. By all accounts, Dr. Herrick was a superb teacher.e quoted William J. Mayo, saying, “Teaching in thoseays was chiefly by the didactic lecture in a large clinic, aethod that was windy and wordy during which time the

tudents heard much, saw little, and did nothing.” Listen tohat again: “Teaching in those days was chiefly by theidactic lecture in a large clinic, a method that was windynd wordy during which time the students heard much, sawittle, and did nothing.” Dr. Herrick did much to change that,ith the introduction of small ward rounds, which focusedn specific patient care and teaching. Dr. Herrick also hadnteresting comments about two important things during aisit to Rochester and the Mayo Clinic. He said, “The firstesson was that all medicine needs periodic overhauling.”isten to that again: “The first lesson was that all medicineeeds periodic overhauling.” He went on to say that wehould avoid “the paralyzing influence of the dead hand ofradition.” The second lesson that Dr. Herrick talked abouturing that visit to the Mayo Clinic was that “there was stilloom for sane, careful bedside observation.” How true theseords stand today.The road we travel on our journey is rarely straight, and

o we see Dr. James Bryan Herrick going from havingocoons in his dresser drawers to being an independentamily practitioner in the basement of his own home, wheree was a family doctor, and where, as he described, he hada rather limited armamentarium, a gynecological table, atorage battery to cauterize hypertrophied turbinates,” andhere he saw an occasional patient with venereal diseaseho wandered in, although the latter group of patients

eceived such a cool reception, Herrick wrote, that “theyeldom came back.” From that modest beginning, he wentn to write the first description of sickle-cell disease andhen to document and widely disseminate the pathophysi-logy of myocardial infarction.

Along the way Dr. Herrick took time to evaluate newechnology—and I want you to think about this the nextime each of you has your own general examination—heescribed the “rubber glove as a device of precision—itncourages digital examinations.” One wonders what thingsere like before rubber gloves. Goodness sakes.Also along the way, of course, he received too many

wards to enumerate for such a late-night gathering as this,ut appropriately enough, he served as president of themerican Heart Association and received its Gold Heartward before his death.Another “ity” word is “audacity”; that is the word that

omes to mind when over breakfast, you mention to yourpouse your latest great idea, whatever it is, and your spouseooks at you as if you are crazed, dumb, or just naive, orome nice combination of all 3, and then says, “You want to

o what?” That is audacity. c

The road we have been taking with Dr. Herrick thenurns from description of the “sickle shaped red blood cor-uscles” of sickle-cell anemia, to coronary thrombosis, toow Gerda Ditzen.11–13 And she is a central character in theell-known but marvelous story of “well-oiled.” You areondering where this next “well-oiled” step takes us. It

akes us further along the path we are traveling tonight. Aurgical intern in Eberswalde was interested in the centralelivery of drugs, although his chief had forbidden him toontinue along the lines he was following. In the spirit ofudacity, of “You want to do what?” this intern convincederda Ditzen to help. In a moment of inattentiveness, he

ied Gerda to the operating table, pretending to do aenosection on her, when he was actually doing it on him-elf. He inserted now a “well lubricated, well-oiled” ureteralatheter into the vein in his arm and pushed it in about 65m. He writes that he experienced a sensation of warmth onhe wall of the vein when he moved the catheter and a slightough. As you know, in the rest of the story, Dr. Wernerorssman then walked downstairs to another floor and the-ray room and documented the catheter position movingnto his heart. As you also know, after this “dangeroustunt,” as it was called by his chief, Dr. Forssman aban-oned thoughts of cardiology and trained as a urologist. Ando part of the road we travel is related to the “ity” ofudacity.

Where does the road lead next? What more do we knowf men and women who are the objects of hero or mentororship? Because of what I do, the road leads to someonehose parents gave him the middle name Roland. It isnclear to me why parents would ever saddle a child with aiddle name of a person who may have been a nephew ofharlemagne—the name of a man who became a pop icon

n medieval minstrel culture, but be that as it may, that man,ith that middle name, Andreas Roland Gruentzig, trans-

ormed cardiovascular medicine as much as Herrick hadone 50 to 60 years before; he was another of those rareity” people characterized by sagacity, creativity, and curi-sity, among others.

So the road leads to him as we then talk about interven-ional cardiology.14–19 The legacy of Andreas Roland Gru-ntzig is that he would, at the end of his life, say, “Whateverecomes of the method, I have left one mark on medicine;have shown that man and woman can work therapeuticallyithin the coronary arteries themselves in the face of an

lert and comfortable patient.” This “one mark on medi-ine” has changed the world and is his greatest achievement.ndreas Roland Gruentzig started out at the feet of masters,

tood on their shoulders, and then went from the kitchenable—think about that, a kitchen table—where the firstalloon catheters were made, and then Gruentzig becamehe shoulders upon which modern cardiovascular care stands.

There is not a field in cardiovascular medicine that doesot owe some of its existence to Andreas Roland Gruentzig,o his openness to observe, his desire to improve, his will-ngness to share and to teach, and his drive to help peopleght and prevent that scourge of modern medicine, cardio-ascular disease. His legacy is like ripples on a pond, theipples of evidence-based medicine, randomized clinicalrials, percutaneous transluminal coronary angioplasty, per-

utaneous coronary intervention with stents, intravascular

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1512 The American Journal of Cardiology (www.AJConline.org)

ltrasound, angioscopy, invasive electrophysiology, percu-aneous valve replacement, the treatment of peripheral ar-erial disease and carotid arterial disease, stroke centers,yocardial infarction centers, as well as other diseases,

uch as sinusitis, epilepsy, gastrointestinal disease, and uro-ogic disorders. No matter what gender you and I are orhat state you and I are at in life, we all will individuallyenefit from the sound barrier, the thought barrier, theudacity barrier that Andreas Roland Gruentzig broke.

Where will this road now take us? That’s an interestinguestion, and it is also an interesting challenge. It has beenaid that the only thing that will limit us is our ability tomagine, our ability to create, and our ability to dream. Theoad to the future will not be straight. It has not been straightn the past, and it will not be straight in the future. We willee some dead ends in the road and some forks in the road,nd we will see some bumps and some curves, but the roado the future will continue on its way. We will see special-zed and miniaturized devices capable of detecting, prevent-ng, and/or treating early cardiovascular disease. We willee these technologies controlled remotely, perhaps withagnetic guidance, in a variety of vascular and nonvascular

eds. We will see enhanced screening techniques for earlyetection. We will see the development of drugs based onenetic and proteomic testing.

Finally, we will see a new specialty of interventionalistsorking together. They will come from different back-rounds: they will come from surgery, radiology, cardiol-gy, vascular biology, but they will all be working towardhe common goal of healing all manner of sickness andestoring health—all manner of sickness and restoring health.

The future of the road ahead will be based on severality” things. These “ity” things will include the “ity” thingsf sagacity, tenacity, humility, creativity, curiosity, author-ty, and honesity. It will be based, however, ultimately onhe most important thing of all, which is the truest gift of all,nd that is the gift of the patients who entrust their lives,heir dreams, and their hopes to us, to each of us who arerivileged to take care of them.

At the end of Dr. James Bryan Herrick’s biography, toeturn full circle, he has a quotation that he calls “Theoctor’s Farewell.” It came toward the end of his life, and

his is what it says: “I know the night is near at hand. The

ists lie low on hill and bay. The autumn sheaves areewless, dry, but I have had the day.” Let me repeat that andurn it into your heart and mind: “I know the night is neart hand. The mists lie low on hill and bay. The autumnheaves are dewless, dry, but I have had the day.”

Such a quotation as this is perhaps the best thing that wean always carry with us as physicians. “We will have thehance to have the day, to make a difference.”

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2. Harvey AM. Classic in clinical science: from horse and buggy doctorto clinical investigation: the story of James Bryan Herrick. Am J Med1980;68:639.

3. Herrick JB. Peculiar elongated and sickle shaped red blood corpusclesin a case of severe anemia 1910. Yale J Biol Med 2001;74:179–184.

4. Herrick JB. Memories of Eighty Years. Chicago, Illinois: University ofChicago Press, 1949:37.

5. Herrick JB. Certain clinical features of sudden obstruction of thecoronary arteries. JAMA 1912;59:2015–2020.

6. Herrick JB. An intimate account of my early experience with coronarythrombosis. Am Heart J 1944;27:1–18.

7. Krehl L. Diseases of the myocardium and nervous diseases of theheart. In Dock G, ed. Diseases of the Heart. Philadelphia, Pennsylva-nia: W.B. Saunders, 1908:421–763.

8. Obrastzow WP, Straschesko ND. Zur Kenntnis der Thrombose derKoronararterien des Herzens. Z Klin Med 1910;71:116–132.

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1. Forssmann-Flack R. Werner Forssmann: a pioneer of cardiology. Am JCardiol 1997;79:651–660.

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3. Forssman W. Experiments on Myself: Memoirs of a Surgeon in Ger-many. New York, New York: St. Martin’s, 1974:81–83.

4. Grüntzig A. Letter to the editor. Lancet 1978;1:263.5. Grüntzig AR, Senning A, Siegenthaler WE. Nonoperative dilation of

coronary artery stenosis: percutaneous transluminal coronary angio-plasty. N Engl J Med 1979;301:61–68.

6. Holmes DR Jr. Creativity, ingenuity, serendipity. Can J Cardiol 2005;21:1061–1065.

7. King SB III. The development of interventional cardiology. J Am CollCardiol 1998;31:64B–88B.

8. Hurst JW. The first coronary angioplasty as described by AndreasGruentzig. Am J Cardiol 1986;51:185–186.

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