When British cardiologist Graham Steell (1851-1942) examined patients with heart disease at the Manchester Royal Infirmary, Manchester, England, he had only a few instruments at his disposal. He made his diagnoses without an ECG and, in most cases, without a chest x‑ray; instead, he relied on patient history, palpation, percussion, auscultation, and occasionally, pulse tracings made with a sphygmograph. In 1906, Steell summarized his experience in the textbook Diseases of the Heart.

Medical historian Peter Dean Mohr from the Department of Museum Medicine & Health at the University of Manchester, Manchester, recalled this phase of medicine in the Journal of Medical Biography. He described Steell’s approach as an example of an era when the stethoscope, percussion hammer, and a well‑trained ear were the most important tools of cardiology.

A Scottish Doctor in Manchester

Steell was born in 1851 in Edinburgh. His family belonged to the city’s artistic elite: his father, Sir John Robert Steell, was a well‑known sculptor and an official court artist to Queen Victoria. Other family members worked as artists or architects. Steell himself chose to study medicine at the University of Edinburgh, Edinburgh, Scotland, graduating in 1872. During his training, he worked under the internist George Balfour, who focused intensely on heart disease and helped shape Steell’s later interest.

After several posts in fever hospitals — including those in Edinburgh, Leeds, and London — Steell went to Manchester in 1878. There, he initially served as a resident medical officer at the Manchester Royal Infirmary and later rose to become chief physician. His clinical work increasingly focused on heart disease, although he continued to treat patients with infectious diseases. Contemporaries described him as reserved, almost shy. On ward rounds, however, he was an impressive teacher who conveyed to students the importance of meticulous clinical observation.

Cardiology Before Diagnostic Machines

Steell’s career falls in a transitional period of medicine. For most of his working life, he had neither electrocardiography nor chest x‑rays available. Diagnoses therefore had to be inferred from clinical signs. For Steell, this meant a very systematic physical examination: inspection of the chest, palpation of the cardiac apex, careful percussion to determine heart size, and finally, auscultation with a long, monaural stethoscope.

He was especially interested in the interaction between the heart and lungs. In his publications, he described heart murmurs with unusual detail and tried to explain them by anatomic changes. Two papers from 1888 are typical examples. In them, he analyzed the acoustic signs of mitral stenosis and an early diastolic murmur at the pulmonary valve. He interpreted the latter as a sign of elevated pressure in the pulmonary artery that could cause functional insufficiency of an otherwise normal valve.

The Puzzle of the Diastolic Pulmonary Sound

This diastolic murmur later became known as the “Graham‑Steell murmur.” In his original description, Steell gave a detailed definition: it was a soft,blowing diastolic murmur resulting from pulmonary regurgitation due to persistently elevated pressure in the pulmonary artery. Crucial, he argued, was that there need not be structural valvular damage. Pressure overload alone could cause dilatation of the vessel and thus a functional insufficiency.

Steell himself apparently wasn’t very comfortable with the later name. In his writings, he usually referred to it as the murmur of high pressure in the pulmonary artery. His clinical analysis remains a classic account of this finding.

Instruments of the Victorian Clinic

Steell’s most important instrument was a long wooden monaural stethoscope. In the 1880s, he even designed his own model with a distinctive, funnel‑shaped earpiece and an ergonomic handle. The instruments were manufactured by a firm in Manchester and came in two lengths. Steell would occasionally explain to students, with dry humor, that the longer model was useful because it was longer than the jump of a flea — a reference to the very long stethoscopes once used on infectious disease wards.

Besides the stethoscope, Steell used a percussion hammer and a sphygmograph, which recorded the pulse wave on soot-blackened paper. Such devices for the first time produced a graphic representation of the pulse and provided clues to rhythm disturbances or valvular disease. Still, interpretation depended heavily on clinical experience. While he knew that elevated arterial pressure could damage the heart and kidneys, systematic blood pressure measurements played no role in his work.

The Clinician’s Perspective

Contemporaries described Steell as a taciturn man who was not a big fan of lecturing. On the wards, however, he was said to teach vividly and illustratively. Students reported that he could describe cardiac findings as if he saw the anatomic changes before him. This ability for internal visualization was perhaps influenced by his artistic family background, which honed an eye for form and structure.

When Steell retired in 1911, the technical revolution in cardiology was just beginning. ECG and chest x‑rays were rapidly gaining importance. Steell expressed some skepticism and warned that clinical medicine might lose some of its old charm to new machines. Nevertheless, his name remains associated with a period in which the diagnosis and pathophysiology of heart disease were developed primarily at the bedside.

Pulse Wave Recording

An important part of Steell’s clinical work was the sphygmograph. This device, developed in the second half of the 19th century, transmitted the pulse motion of the radial artery via a system of levers to a moving paper strip. The tracing was made on a surface blackened with soot and showed characteristic waveforms. For physicians of the time, the method offered a semi‑objective representation of the pulse curve and allowed comparisons between patients or disease states.

Steell used the technique regularly in patients with heart disease. In his textbook and several articles, he published pulse diagrams documenting arrhythmias or changes in pulse amplitude. He placed particular importance on linking clinical findings to physiologic explanations. Although the method now seems crude, it represented an early step toward functional cardiology. It complemented auscultation and showed that clinicians had attempted to make the dynamics of the heartbeat technically visible well before the age of electrophysiology.

Clinical Observation as Method

Steell’s work shows how strongly late‑19th‑century medicine depended on careful observation. Without imaging, physicians had to interpret sounds, pulse forms, and the cardiac borders found by percussion and correlate them with pathologic findings at autopsy.

Many of his descriptions seem unusually detailed by today’s standards. But they reflect the attempt to apprehend a complex physiologic system using only the examiner’s senses. For Mohr, Steell’s work represents a late high point of classical clinical diagnosis in a time of growing technical possibilities.

This story was translated from Univadis Germany, part of the Medscape Professional Network.