A History of the Development of Cardiology as a Medical Specialty
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Disease does not respect national boundaries, and with our present ease and speed of travel this has never been so true. We cannot help but feel that it is most appropriate that medical effort and medical knowledge follow this trend; the doctor must feel that his work, his research, his findings must always be internationally oriented. Actually, this has been the case to a large extent.
A whole list of great names have made contributions that are known and of use all over the world. Certainly Pasteur, Wasserman, Ehrlich, are names that are connected with such basic medical facts that their nationality is hardly thought about. There is a long list of other contributions less well known, but they should be at least mentioned to support the thesis of "no boundaries." Therefore I shall present a brief history of the development of clinical cardiology as a medical specialty as seen from the view-point of an American cardiologist.
The whole concept of graphic registration of physiological processes began with Thomas Young, an English physician probably best remembered for his translation of Egyptian hieroglyphics and for his research into the physics of light. He built a kymograph in the early 1800's consisting of a smoked drum on which a stylus inscribed impulse waves. The concept was to remain dormant for a half century until Karl Ludwig, a German Physicist and an ingenious instrument maker, adapted Young's kymograph to the recording of the oscillations of the pulse and of the respirations.
Ludwig was not only the great physiological investigator but a wonderful and dedicated teacher; almost every important physiologist of the succeeding decades was trained in Ludwig's laboratory. Although Ludwig must be credited with the start of a flood of graphic investigations into the shape of the pulse curve, he was far from the first to have an intense interest in the pulse; a whole system of diagnostic medicine in China dating back a thousand years was based upon a tactile study of the pulse.
An English physician, Sir John Floyer, became fascinated with this Chinese method of diagnosis; he was distressed that there was no way of determining the speed of the pulse. He commissioned Daniel Quare, a well known English watchmaker, to make a "pulse watch" that would have a minute hand. Quare made such a watch; it had a minute hand and no other hands at all. In 1700 Floyer published a book based on his studies with this instrument. He called the book "The Physician's Pulse Watch." It described as part of the clinical picture of disease the characteristic pulsations of the artery at the wrist, its rate, rhythm, amplitude, forcefulness and compressibility. There was at that time no thought of a graphic record. That had to wait a hundred and fifty years, to Karl Ludwig. A pulse controller made by Castagna in 1885 is illustrated in Fig. 1.
Figure 1: Pulse Controller. made by Castagna of Vienna. 1885. A clock measures the pressure of a screw type clamp required to obliterate the arterial pulse at the wrist.
It is difficult for a student today, with all the electronic help at hand, to realize how much the physician of a century ago could learn with careful observation and diagnostic acumen. Let me illustrate this point. In the 1830's, an Irish physician, Dominic John Corrigan, described aortic insufficiency diagnosed by a sharply declining "water hammer" pulse. Even today we call this a "Corrigan Pulse." We must note that this basic diagnostic description that has not been bettered in over a hundred years was done by a doctor that had only a monaural wooden stethoscope (Fig. 2), no other help to his fingers and his observing mind, no ECG, no X-ray, no kymograph, no way of measuring the blood pressure. When all of these modalities came into being, all they could do was to corroborate what Corrigan had so well described from his unaided observation.
Corrigan's stethoscope was about twenty years old; it had been devised by a Frenchman, René Théophile Laënnec. Here was another careful observer. About 1820 he published a book on his observations of the chest sounds, the sounds of the heart and lungs. If anything, with his crude instrument which was actually a short piece of wooden broomstick, he was patient, tireless and thorough. His book was rapidly translated from French into English and other languages. Laënnec described various sounds with careful accuracy and worked up a complete vocabulary of names for the various sounds. Today, more than a century later, the names are still used; they were so accurately descriptive that with all our present wonderful equipment we have not been able to better the nomenclature.
Figure 2: Monaural stethoscopes, circa 1850. These are all essentially Laennec's model, turned into fancy shapes with dilated cusps for the ear and the chest. One specimen is screwed apart for ease in carrying.
In searching out the roots of Cardiology there are a few more names that may be mentioned for what may be considered widely divergent contributions. Andreas Vesalius in his "Fabricius," a wonderfully complete atlas of anatomy published in the middle 1500's, called the heart the "center of life," and we shall see how that was the basis of the seal of the American College of Cardiology. William Withering in 1783, a well informed botanist, showed that an infusion of Foxglove was of great use in the cure of dropsy, though it is doubtful if he connected dropsy to cardiac malfunction. Stephen Hales in the 1730's demonstrated that the blood in the arteries was under the influence of pressure, but it was over 100 years before there was a successful instrument designed to measure human blood pressure without actually cutting into the body. That contribution came from an Italian, Riva Rocci, in 1895; his mercurial manometer and arm band is the ancestor of all the blood pressure instruments in use today.
There are but a few of the roots, and we have not gone far enough back to search out many more. There can be no doubt that the importance of the heart as the center of life must have been understood by prehistoric man. I can picture the savage crouching in his jungle, realizing that the pounding in his chest was the real sign of life. If the sleeping form had that chest throb, no matter how much it resembled death, it meant an awakening. If that throb had stopped, life was gone. Even today, the pronouncement that the heart has stopped is the legal time of death; that has not changed from prehistoric man. With all the electronic modalities recently available there is an attempt to make "brain waves" the symbol of life, but this is a legal wrangle, far from decided. The heart beat is still the symbol of Life.
With all these roots, we must find a starting point for the history of cardiology that will be beyond dispute. We nominate William Harvey who in the 1620's demonstrated the circulation of the blood. This took unusual courage, since the capillaries had not yet been known, microscopy had still to be developed, and how the blood got from arteries to veins was a matter of imagination. Harvey was English; he studied at Padua in Italy; he published his research by printing it in Frankfort, Germany, in 1628. So this starting point illustrates our primary thesis:
medical knowledge knows no national boundaries.
Harvey's thesis gave a profound answer to a great many questions that up to that time had no answers. It was simple arithmetic to show that the quantity and velocity of the blood made it physically impossible for the blood to do otherwise than to return to the heart by way of the veins. Harvey demonstrated the "one way" valve in the veins and in the heart; a famous painting shows him demonstrating the valves in the veins to the King (Fig. 3).
Figure 3: William Harvey demonstraling the "one way" valves in the veins and in the heart to King Charles I.
One might naturally expect that this sudden and complete clarification of the action of the blood in the body might be gratefully accepted by the entire medical profession, but that isn't what happened. The English profession was slow to change from their older concepts and there was even some religious opposition to these radical ideas.
The first edition of this important book was refused publication by English printers and Harvey found that the Germans seemed more open minded to the new, and the book was printed in Frankfort.
Harvey continued his work and his lectures and lived to the age of 79; by that time he was able to see that his idea had generally been accepted throughout the world.
There is at least one other landmark that equals in importance for our specialty the work of Harvey, and that is the contribution of William Einthoven2, several centuries later, actually the early 1900's. The electrocardiograph has provided what is uniformly considered one of the most widely employed and valuable tools in diagnostic clinical medicine.
It was understood by physiologists that the heart beat must have some relationship to an electrical impulse. A British physiologist, named Augustus Waller5, devised a capillary electrometer in which a tiny column of mercury in contact with dilute acid rose and fell with change in the electrical potential at the interface between the mercury and the acid. The movement was microscopic, but it could be recorded by a photographic beam of light. The response of the electrometer was relatively sluggish, and many investigators tried to work out some more accurate instrument. All of this was just before the turn of the twentieth century.
There was at this time a d'Arsonval galvanometer that moved a mirror in response to electrical current, but it was far beyond the tiny current that might be considered in the heart beat. Something radically delicate was needed, something that would detect the most infinitesimal currents. Here were needed patience, technical ability and imagination. Einthoven had all three.
William Einthoven was Dutch, born in Java, son of a physician. The father died when William was six, and his mother moved to Utrecht. The young man was a diligent student; at the university where he prepared for a medical career he received his doctorate cum laude. He started to practice but was soon appointed professor of physiology and histology at the University of Leyden. Here he did research and teaching; he was a hard worker who enjoyed what he was doing and kept well informed about what he was going on. He knew, of course, about Waller's work and he set himself to devise a galvanometer that would be delicate enough to detect heart currents.
Figure 4: William Einthoven in his laboratory in Leyden University with the original Einthoven Galvanometer Outfit.
He finally succeeded; his galvanometer (Fig. 4) had a monstrous electromagnet formed like a horseshoe. In the interval between the poles he suspended a very fine quartz fiber plated with gold to carry current. The movement of this string were projected through a microscope to a camera that rotated photographic paper behind a slit. The tension on the string could be finely adjusted so that a millivolt of current caused a deflection on the graph of one centimeter. In the first quarter of this century the use of this instrument laid the basis for what was to become our important specialty of cardiology.
Getting the graph was only part of the problem. The great necessity now was to find out what the jiggles meant. Ever since Sir John Player, physicians had been interested in pulse tracings but it was not until the middle of the 1800's that an instrument was available to make clinical tracings of the pulse at the wrist. It was devised by a French physician, Etienne Jules Marey (Fig. 5). As the years went by, more and more physicians took tracings with these machines; some of the machines were made in England and some by French instrument makers. They were improved and made to have transmission tambours, so that the apex beat of the heart and the beat of the jugular could be taken at the same time side by side on the same record.
The recording was a matter of great technical skill. The graph was made on paper, glazed and covered with a thin layer of soot; after the scratch marks had been made by the stylus attached to the drum, the record was passed through a bath of shellac to fix it. This recording method went right back to Karl Ludwig. However, if the whole idea of making pulse records was to be more generally employed, it obviously had to be made simpler and less delicate.
This was the challenge taken up by Sir James Mackenzie3, an enterprising small town British doctor who came at last to London. His polygraph (Fig. 6) took the three tracings on a roll of paper with styli that wrote with ink; gone were the smudges and the mess; gone was the shellac. Most important was the fact that the tracings could be run to any length, so that rate and rhythm could be studied in detail. Mackenzie was diligent in making hundreds of these tracings. Now, in addition to the polygraph, there was the electrocardiograph of Einthoven, another important diagnostic tool, and Mackenzie was eager to use it.
Figure 5: Marey's Wrist Sphygmograph, 1857. This was the first clinical instrument by which the graphic method of registering the arterial pulse could be made in a living patient. Original instrument in the Reichert Collection, Cornell University Medical School.
No one had any real knowledge of what the electrical records meant; Mackenzie took polygraph and ECG tracings side by side. This seemed the best way to figure out what the records meant; the physical examination, the history, the heart sounds... all these correlated with both the polygraph and the ECG were bound in the end to clarify the tracings.
Cardiology as a Specialty
Mackenzie was a specialist in cardiology, a Harley Street specialist. There were other specialists in cardiology in Europe, going back into the end of the 1880's. The greatest group was at the spas in Austria and Germany. No American physician considered himself a real doctor until he had done postgraduate work in Vienna or in one of the great universities in Germany. Each year there was a regular emigration of American patients to their favorite watering places in Europe; they went for the "cure." They were purged and bathed, exercised in graded series, relieved of ascites and dependent edema, lessened chest pain. They came back to their American practitioners with tales of the great doctors of Germany. And there was the parallel exodus each year of the ambitious American medical practitioners for postgraduate training in Germany.
There is no mystery about the start of cardiological clinical practice in the United States. One young medical practitioner could not understand why there should not be a well set up cardiological office in the U.S. and he was willing to try it. He was Louis Faugeres Bishop, M.D., and he had made the annual pilgrimage to Bad Nauheim year after year, studying with the Groedels who were steeped in the treatment of cardiac cases. Bishop had one of the Einthoven string cardiograph machines in his office on the east side of Manhattan; he puzzled over the records and studied and compared; in Bad Nauheim he asked questions.
Figure 6: Mackenzie's Polygraph. The simple horizontal levers of Marey's Sphygmograph are activated by lambours that are connected by rubber tubing to cups placed on the chest and the jugular region of the neck. The use of ink-writing pens makes possible a lenghty tracing on a roll of paper. Original instrument in the Reichert Collection. Cornell University Medical School.
At one time Bishop made an unannounced visit to James Mackenzie in Harley Street, London. The doctor had an office full of waiting patients and had no time for an intruder. Bishop asked a few sharp questions; the good doctor was astonished and immediately interested. He discharged the waiting patients and sat down to a long and fruitful discussion with young Bishop. Mackenzie could not understand why there was no specialist in cardiology in America. He encouraged Bishop to start it.
The Groedels of Bad Nauheim were a strongly entrenched family of doctors, father and sons medical specialists and all deeply interested in the treatment of the cardiac cases that came to their clinic and spa. They were well fixed financially after so many years of running such a successful venture; one of the sons, young Franz, was a completely relaxed and strongly motivated investigator. All of his ideas of equipment and assistance were his for the asking and he published countless papers on new methods for diagnosis and treatment; his imagination had no limit.
Franz Groedel was interested in the Roentgen measurement of the cardiac outlines; he was interested in Einthoven's electronic diagnostic machine; he was interested in the pulse writers, and especially in the polygraph that made possible long tracings of rate and rhythm. It did not matter to Franz how much time and effort he expended on anyone patient. The whole intent was to learn as much as it was possible to learn about each case. Young Bishop was fascinated with Franz Groedel.
What happened next was far from cardiology but it had a tremendous influence on its international phase. It was the First World War. The year 1914 was critical for the patients that had made a habit of the trek to Europe. But the slow and patient work of the Bishop office suddenly blossomed. Here in America was a well trained and completely equipped cardiological specialist; there was no longer the pressing need to get to the European spa for diagnosis and treatment. Bishop was overwhelmed.
The American College of Cardiology
There was so much to do and so many patients to care for that Bishop had another dream. He had a son who was to follow in his footsteps, but that would not be enough. He must get more American doctors to learn about the cardiac methods, to get the instruments and the knowledge; Bishop wanted to share what he knew. There was no reason in the world that there should not be a great cardiological specialty group here in the United States. Bishop was dedicated to this idea. He started little groups of medical friends, sharing, teaching, lecturing.
In Atlantic City on May 3rd, 1927, there was a meeting of the American Section of the International Association of Medical History. Bishop thought that this might be a great opportunity to talk about the possibility of a national society for the study of this new science in medicine. His remarks give us a vivid picture of the situation in America at that time. We are fortunate to have a copy of what Bishop said:
“I date my definite association with cardiology from the year 1907. In the fall of that year I decided to concentrate my work upon this particular field of medical knowledge, and it is this period of twenty years that I wish to cover. I am particularly fitted to do this because my first organized effort in entering this special field was to make a survey of cardiology in America and Europe. I went from place to place where cardiology was taught, and where men's minds were turned specially to this problem.
The first thing that impressed me in America was what little progress had been made in the development of cardiological knowledge. What little progress that had been made was through immediate contact with the problems of people afflicted with heart disease. Rest was the one universal prescription, and invalidism was encouraged on every side. A heart lesion was a legitimate excuse for laziness and indulgence. Our great consulting-physicians of that day were Janeway in New York; Pepper and Musser in Philadelphia; Fitz in Boston; and Forchheimer in Cincinnati. These and other great consultants in the large cities of the country had a very valuable empirical knowledge of the heart, but no information whatsoever upon the subject of the technical matters of the present day. In London and Edinburgh I found much the same condition, though in Edinburgh and Dublin practice was much influenced by the very great students of cardiology of the generation just previous — Stokes, Corrigan and Hope. They were just this far ahead of America in that they recognized, definitely, the value of graduated exercises in the restoration of the person whose heart had become a problem.
That year I had the pleasure of meeting Sir James Mackenzie in London and if I had the time I would like to tell you something of the operation of the mind of this great man. Two or three questions from me, a total stranger, threw him into an enthusiasm that led him to dismiss his patients and give me his day. He was a canny Scot but he had an uncanny insight into medical truth and falsehood. He had no use for the doctor whose beliefs were founded on medical authority alone.
On the continent I came in contact with the French school of medicine when I met Vaquez. The French school of medicine has always fascinated me by its profound philosophy that combines so well the intensely ideal with the intensely practical. Huchard anticipated by many years the teaching that arteriosclerosis is a general constitutional disease and not a disease of the blood vessels primarily. The French still rely mainly upon drugs and are remarkable for the elegance of their prescribing and intricate details of their advice.
In Austria, Italy and Switzerland, I did not find much difference from London and Paris. It was in Germany that I discovered a cardiology that seemed to me worthy of study and imitation. I returned to Germany nearly every summer until the war broke out (World War I). I followed and assimilated as far as possible the work of the German physicians. They had a unique opportunity for academic study, half-the-year in universities, with the rest of the time devoted to the practical application of their theoretical knowledge to a large group of people who sought the "cure" in Germany for the restoration of their health.
In America I had never known of such a thing as a deferred diagnosis, that is, a definite time set when a conclusion can be reached; up to which time the case was allowed to remain fallow, so that the final diagnosis could be independent and complete. The American concept of the diagnostician was that of a fashionable physician, driving to a conference in state, and pronouncing in elegant language, a diagnosis founded upon the quick operation of his shrewdness and intuition. In other words, the great diagnostician was a great guesser.
In Germany I found that the great diagnostician was the final step in a process. In other words, the investigation was carried on, to lead up to a diagnosis, rather than to prove the diagnosis that was already made. It had taken this twenty years for the technical cardiology which was well under way in German clinics to spread over the world and become accepted as a real human asset.
I was an early convert to technical cardiology and with the other pioneers had to stand the adverse criticism of those who did not understand when I insisted that everyone who presented a cardiological problem, should have the benefit of a complete technical examination. I was accused of commercialism because I paid too much attention to people brought to me by their physicians with the old-fashioned demand for a listen-and-guess diagnosis. But cardiology was a wonder-field of blossoming flowers and new ideas and here and there a sturdy plant that represented definite results in the rescue of human wrecks, from invalidism and even worse.
This cardiological field was pleasant and interesting and I knew that in time others would come into it and that eventually cardiology would become a recognized specialty. Whether that time has arrived or not, I have been unable to decide. But there are some signs that make me believe that very soon there will be a group of men, devoted to cardiology, large enough to form their own national society, where they can confer with each other on their intimate problems. At the present time, the intimate problems of cardiology must be carried to general meetings where they receive an unsympathetic hearing from those who do not understand.
We are forced to fight our losing battles in private, and publish practically only our successes. It is only when cardiologists decided to get together in private, that the profound difficulties of cardiology can be properly attacked and solved."
Bishop's remarks were a little off the topic of the meeting; he was politely applauded, and that was that. Some of the members present expressed some interest in what Bishop had said, but nothing came of it, and no practical steps were taken at that time. However, Bishop did not relax his effort; he was critical of the lack of willingness of the American profession to adopt his method of deferring diagnosis until all aspects of the diagnostic investigation were complete. It must be admitted that the patient and the patient's family were for the most part reluctant as well, and much preferred the masterful and impressive "guesswork" immediate diagnosis. With the amount of treatment possibilities that existed it is still possible that it did not much matter in 1927.
Eight years later, in 1934, with the help and counsel of Russel Burton Opitz, a practicing cardiologist and professor of physiology at a medical school, Bishop was able to convene a group and organize the New York Cardiological Society. Sixteen doctors were present; a slate of officers was chosen, committees appointed, and the project got off to a real start.
Before this, there had been a Heart Committee of the New York Tuberculosis Society, but it was not a medical group; it was concerned with the social aspects of getting medical help to the poor and underprivileged. The physicians that were a part of this organization were naturally dissatisfied with the obvious fact that there was no attempt to spread the technical knowledge of cardiac diagnosis that was beginning to be known and discussed.
The New York Cardiological Society had no specific entrance requirement except that every member had to be a registered physician. The programs were meant to teach and physicians were invited to lecture from medical schools all over the country and there were occasional speakers from medical schools and hospitals in Europe. For the group that started this new society there was a definite need that it filled; the membership committee was active and the ranks slowly grew. Bishop's idea was to form a national organization, but that seemed far off for the present. The five boroughs of New York contributed most of the new members, with a few from nearby New Jersey and a few from Philadelphia.
There seemed to be no lack of suitable topics for programs. The Saratoga Springs Commission had set up what they labeled "Nauheim Hydrotherapy," and the director of the Commission, Dr. Walter S. McClellan, gave a talk on the "Carbon Dioxide Therapy in the Treatment of Heart Disease."
Temple University Medical School in Philadelphia had a department of experimental pharmacology; the professor heading the department was chief of the research staff of a pharmaceutical manufacturing company. Dr. James C. Munch lectured on "Recent Studies on Digitalis and its Allies."
One of the features was the presentation of clinical cases from the various hospitals in New York City. With an active discussion these presentations were always instructive.
The programs were published in the medical journals, and all physicians and medical students were invited; there was no admission fee. Discussion was open to all.
At about this time I came personally into the picture, but I must go back a few years to make the whole accidental contact seem more plausible. After graduating in medicine from Cornell University, I had an exciting internship at the New York City pest house, the Willard Parker Hospital for Contagious Diseases. Diphtheria was a plague that killed hundreds of children, by choking on diphtheria membrane or by cardiac complications of the toxin. The O'Dwyer intralaryngeal tube was a great life saver, but it had to be placed early, and it was a tricky manoeuver, needing skill and trained fingers. Mechanical manipulation had been a hobby of mine for years; I was soon the recognized expert with the O'Dwyer tube. I became Resident Pathologist of the hospital and was finally recommended to Rockefeller Institute.
Here again the mechanical dexterity came to the fore, and when Warburg brought one of his microbic respiration devices to New York, Simon Flexner, the Head of the Institute, assigned it to me. I must skip what is not relevant to this history; I spent some years with Bela Schick at Mount Sinai Hospital, then went back to my work on diphtheria. By this time, I became interested in the one specialty in medicine that had the most complicated and mysterious mechanism, the Einthoven electrocardiograph. Here was a specialty that required manual dexterity and seemed by this graphic method to give a kind of information and measurement that was not available in any other field. When my work with Schick came to a stopping place, I transferred to the Cardiac Clinic and decided to make myself an expert in electrocardiography. Here in all of medicine was something that one could tie up to, something definite.
I had spent my undergraduate days as a blood chemist at the Roosevelt Hospital in New York and I was familiar with much of the laboratory work needed in diagnosis. By this time, I had an electrocardiac machine that was "portable" (by comparison), and I made for myself a portable laboratory in a wooden box with a small microscope. I was all set for doing a real job of diagnosis; we must remember that at that time a physician made house calls. It was not long before my reputation for accuracy spread, and I soon had an active practice, much of it referred, rather unusual for a young physician. I knew about the New York Cardiological Society that I was told about, but I decided to wait and see.
One day in 1935, a man was ushered into my office; he said his name was Groedel. He had been recommended to me because he wanted to have made a double string electrocardiograph. Nobody knew how to make this but in several places my name had been mentioned. I looked at this gentleman with interest and a little suspicion. The Groedel that I remembered from pictures had a great beard, spoke German and for all I knew was probably dead. This Groedel was clean shaven, smooth talking in faultless English, and wanted something that would have to cost a lot of time, effort and money. That was the least of it, said my visitor, pulling out a check book and astonishing me with a substantial check. The bearded one, I learned, was his father. He was Franz Maximilian; a brother Theodore had been killed in the First World War. The whole thing began to assume a new aspect and my reputation for dexterity made this wonderful person come into my life.
Groedel and I came into the New York Cardiological Society at its 37th meeting, February 26th, 1941. We were both of us immediately useful to the new society. I had been a registered parliamentarian; he was the world's greatest expert on chest leads in electrocardiography. He was a tireless worker and developed a method in which he took chest leads all over the chest, inches apart, a complete map of the chest ECGs. With this he was able to demonstrate that there was a definite difference between the right and left heart ECGs.
His first lecture, given the evening we were voted into membership, was on "Isolated Electrocardiogram of Either Right or Left Ventricle." The meeting was at the New York Academy of Medicine; it was well attended. Groedel was meticulous in showing the tracings that confirmed his theory, ingeniously taken on patients with thin chest walls. The evening was of tremendous value to every practicing physician in the audience.
At the end of 1941, the elder Bishop died. He had lived long enough to see his son a respected cardiological doctor and to see the Society grow into a useful and recognized teaching element. But the whole idea of a national society had been quietly laid to rest. The Society president was Dr. Walter Bensel, a serious and careful physician, somewhat arrogant in his attitude, given to written instructions that must be exactly followed, but above all, a generous host; the trustees meetings were at his place, combined office and home, with a carefully arranged late supper. Dr. Bensel carved the meat, and graciously served everything.
It was not hard to see why the idea of spreading out into the rest of the country was disliked. All of the profession was invited to the meetings and could benefit from the teaching, but the running of the Society must remain in the tight little local group, where everybody was a close friend of everybody else. I was the secretary and treasurer, elected because of my parliamentary certificate, and Bensel loved to see me carry out his orders so efficiently. The set-up was a theatrical play.
Looking through the programs it is obvious that they were important reports of the steps that made the specialty an ever broadening field. Hitler had made our country a gift of some extremely valuable physicians, and the progress that was being made was directly, I think, attributable to the names of Emil R. Zak, Bruno Kisch, and Franz Maximilian Groedel as well as a few others from the well established cardiac clinics of Germany and Austria.
One area of interest one can easily understand was the life insurance companies, since they were most concerned with the statistics of death from cardiac and arterial causes. The Metropolitan Life Insurance Company had underwritten an order for 100 blood pressure instruments that put the Baum Company in business. The Insurance Company had a statistician as a vice-president, a Ph.D. named Louis I. Dublin, whom I had the pleasure of knowing; he spoke often at the society meeting and his reports were always mathematically proven and therefore most impressive.
By 1944, Dr. Bensel was again the President but Franz Groedel had moved up to the Vice Presidency; I remained the perennial Secretary-Treasurer. In 1949, Groedel became President with Louis Bishop, Jr., as Vice President and, of course, Reichert in the same old job. Groedel lost no time to get going on the matter of a national society, and the counsel was directed to incorporate the name AMERICAN COLLEGE OF CARDIOLOGY. It wasn't clear sailing; it meant the loss of the comfortable little club with its little dinner meetings. To some of the members that was a disaster, but Groedel had his eye set on the target. What was needed was his kind of determination, and, may I say it, his kind of money. Groedel wanted to register the corporation in every state of the union, so that nobody could "muscle in" on the project. There were rumblings of discontent in other societies that published their view that this College was not needed, and there was the fear that the annual fund raising of the Heart Society would be impaired. Groedel insisted that the College would in no way solicit public fund support; when this was recognized much of the opposition faded.
The actual incorporation procedure was again complicated by Bensel's reluctance and his instructions to our lawyer that caused one delay after another. The inner group of the New York Society was friendly; nobody wanted to hurt anyone's feelings, and the idea of converting to a great impersonal national organization had to be carefully considered. There were a number of discussion meetings, but Groedel kept pushing; he had a clear notion of the national College and what it could do to make the American specialty of cardiology come up to the European standard. He actually slowed up his practice and put his office staff to work on starting a membership drive, writing up the whole organizational plan. He even went ahead on a plan to incorporate in the District of Columbia, bypassing the society's lawyer. Groedel succeeded.
The American College of Cardiology achieved its legal start with the granting of its charter on December 2, 1949. The constitution, the bylaws and all the paraphernalia of the organization were in order. One member of the founding group was certified parliamentarian and that was a great help. But the seal remained a special problem.
The central motif must obviously be a heart, but an exact copy from Gray's Anatomy seemed too trite. We had set the goal of the College as an educational institution strictly within the medical profession; we needed something in the best tradition of the early beginnings of scientific medicine.
For many centuries the Church had forbidden as a sacrilege the dissection of the human body. Medical men had their learning out of books; Aristotle and Galen were the authorities. The early 16th century saw the beginnings of rebellion. Leonardo da Vinci did human dissections at a time when one needed the protection of a powerful prince. The authority must be not what one read but what one saw. Leonardo's drawings were accurate and beautiful, but were not published in his lifetime. Their influence was limited, but a vogue of thought was started. Twenty years after Leonardo died, his ideas caught fire.
By 1530, Padua had become the greatest university in Europe, and a hotbed of new thinking among students and faculty. Andreas Vesalius gave the impetus to the new activity in anatomic dissection. The bodies were of criminals and, since stealing a loaf of bread was a capital offense, there was no dearth of bodies. Vesalius dissected, taught, lectured, drew and supervised drawings. A whole dynasty of important researchers and teachers came from the halls of Padua, among them William Harvey. Finally, in 1543 Vesalius published the first complete book of anatomic drawings. Its influence was immediate and immense. Great surgeons like Ambroise Paré were trained in the new knowledge. Padua was a center of learning and knowing, the final emancipation from ancient tradition, a rebirth.
We wanted our seal to memorialize the great beginnings of scientific medicine in Padua. We searched Vesalius' book and found that heart that he drew with the Latin labeling it "the center of life." We had it copied exactly as Vesalius drew it with the aorta, pulmonary artery, great veins and what seem to be the vessels radiating to the ribs. We believed that the Vesalian heart was a fitting symbol of what our College wanted to achieve, a teaching rebirth (Fig. 7).
Figure 7: The seal of the American College of Cardiology. copied from Plate 90 of the Vesalian Alias of Human Anatomy.
Our first meeting was comprised of three men, Groedel, Reichert and Groedel's assistant, Max Miller. We elected officers, Groedel, President, Max Miller, Assistant Secretary, and Reichert, Secretary as usual. Groedel's concept of the College was what he thought would be completely simple. The programs were to be built with the thought that each doctor in the audience must leave with a solid chunk of new thinking that he could use in his practice. It was no secret that the programs of many society and hospital meetings were arranged to brighten the image of the lecturer; too few were meant to be useful to every member of the audience. In the new College we would have a specialty group in the highest sense of the word, run entirely by and for the benefit of physicians, no lay members, no lay money, no salaries for officers or lecturers, no lay control. He envisioned an organization absolutely free of politics, free from commercial taint, free from insurance schemes, free from travel clubs and all the other sideshows that other societies seemed to need to stay alive.
We felt that we would not compete with or duplicate any existing organization since we had an area of usefulness that no other organization was completely devoted to cover. Sticking by that set of rules has been the real reason behind the phenomenal growth of the College. By the time the first general meeting was held in June 1952, the program attracted a medical audience of almost 500 physicians, from almost every state in the union, from Canada and from as far away as Hawaii. The scientific papers delivered by a distinguished list of cardiologists, surgeons and clinical investigators adequately covered the medical and surgical management of heart failure, cardiac arrhythmias, coronary insufficiency, myocardial infarction, arterial hypertension and rheumatic heart disease. Particular stress was placed on the evaluation of digitalis, quinidine, dicumarol, coronary vasodilators, other drugs for angina pectoris. The surgery of hypertension, mitral stenosis, pericarditis and coronary insufficiency were all covered with the knowledge and experience then available. The management of the diabetic cardiac was also on the program. It would be inconceivable that any attentive member of the medical audience would not have profited greatly from his attendance.
Naturally, the serious nature of the College was widely recognized and the membership grew quickly. The group that had complained that this organization was not needed had to be impressed with the numerical growth that underlined the real need, the nature of its purpose and the honesty of its adherence to its objects. Slowly the vocal antagonists were stilled; slowly they applied for membership. There was no other place where this kind of postgraduate education was available, and free.
By the time of the first convention we had lost our Founding President, Franz Groedel; Bruno Kisch was now the leader; he was adamant in adhering to the program methods that had been set by Groedel. Kisch made an extensive European tour, presenting the College before many of the medical universities in six countries. When he returned, he reported on the enthusiasm and the interest of the European cardiologists in the future plans and in the ideals of the American College of Cardiology.
Bruno Kisch had other advanced ideas about the College. One of the most important was that too much of the local work was done by the local group; if we were to branch out into the nation, we must concentrate on nationally known figures. One of the first was Robert P. Glover of Philadelphia, a pioneer in intracardiac surgery. Glover was world renowned for his introduction of surgical relief of mitral stenosis. Glover became the third President in 1953.
Glover was far from an easy leader; he had a surgeon's ideas of direct handling of problems. The one problem was a financial one; none of the officers received a salary and actually paid their own expenses of travel and office help. This had been fine for Groedel but it did narrow the field of available officers and committee chairmen. Glover sent a group of auditors (at his expense) to inaugurate a set of books. The treasurer and secretaries' offices were combined to insure accuracy and completeness of records. An office secretary had to be employed at a salary, and that required care and judgment.
The College was fortunate to find that the national treasurer of the Volunteers of America, Miss Maude Crafts, was leaving the Volunteers and would be available to the College. The best part of getting so experienced a person was that her experience in a charitable organization made her salary requirements below the market price for that kind of service. So now the College had a central office set-up with a round the clock office manager.
One of the meetings that was fascinating for me was on the subject of graphic registrations which was of great interest to me. The very fact that a blood pressure machine was so easily available made it popular in use; that happened to everything that came into diagnostic use. Anything that was too expensive or too difficult to acquire would naturally be less frequently seen in a doctor's armamentarium. Some instruments that were cheaply made were of course deficient in accuracy and reliability, and all this was for me a most interesting field to explore. I began to collect all of the old apparatus I could lay hands on; many of the instrument dealers had the effects of deceased doctors, some things too old and old fashioned to be of any use for possible resale. These dealers were happy to find someone who would want to acquire such things.
Franz Groedel had some of the European apparatus that he contributed. It was not long before I had amassed quite a collection. Lou Bishop found in his cellar a group of things his father had brought from his work in Europe; one of these was a Mackenzie polygraph that the elder Bishop had used in his practice for years. It was still in perfect shape. Other pieces of apparatus needed repair, and, I, set up a workshop to make usable pulse writers, string ECGs, blood pressure manometers and clock dial manometers. I learned a great deal about the reliability of all of these old instruments, how successive "improvements" often were incorrect. The whole field of graphic registration of the cardiac cycle became clear to me, an I conceived the idea of setting up a museum of these instruments, showing the successive steps in the development of each. The Burroughs Wellcome Company had always been museum conscious and they helped by publishing a handbook outline of the collection.1 It found its way into the Smithsonian Institution in Washington on a loan basis; when it came back to my place I set it up in the New York Hospital-Cornell University Medical School as a permanent exhibit. They have a well staffed Archives Department, and it seems an appropriate place for such a historical resource, indeed.
Hubert Mann had, three years before, constructed a cardiograph that was really portable.4 This was rendered possible by the newer electronic components, much more compact and easier to assemble than those so far manufactured. The small model was soon known as the Cardiette and widely distributed. A bedside ECG was now much more simple; many more were taken and of course much more was learned about their meaning.
Hubert Mann now showed another of his ideas, a graphic representation of the electrical field set up around the heart during depolarization and repolarization of the myocardium. He called this the vectorcardiogram and at this meeting he correlated the spatial vectorcardiogram with the conventional tracings. The vectorcardiogram is still in use today, still studied and discussed; Hubert Mann lived until 1977. He was always a recluse, came to meetings, spoke very little and acted quietly. But when he did speak he was authoritative and clear.
The West Coast of the United States was curiously controlled by a relatively small group of very active physicians who had many clever ideas and made interesting meetings. Their hospitals employed the newest techniques; they seemed to be exactly the type of member that could do the College the most good. I had met one of them some years ago at a meeting of the American Medical Association where he had a clever and informative exhibit, and I had stopped to discuss it with him. He was George Griffith; he did not remember me, of course, but I recalled the incident to him and what had so completely impressed me. He was not interested in coming into any organization just to be another member; he wanted to "do things" that the organization made possible. The College did not seem to offer anything that he did not already have on the West Coast. I wrote Griffith a number of long letters. I hammered on the idea that he did not need the College, but that we needed him; we needed him for all the clever things he could do and wanted to do. We could make many things possible working with him.
Griffith finally surrendered; he was put on a program Committee and showed his mettle at once. His influence was far reaching; he knew how to get important investigators willing to appear on the program. He was suffused with the thought that the program must give to every person present an honest piece of useful knowledge, and indeed this was what the College had tried to do for years. Only Griffith knew how to do it better. After a few years he was elected president as a normal course of events.
Griffith was followed by another West Coast man, and he, too, was full of new and unusual ideas. The most important one was an international circuit course, an attempt to visit one or two foreign countries, invited by the local cardiac group or university department; the visiting team always consisted of an internist, a cardiac surgeon, a physiologist and possibly a clinical pharmacologist. The team varied in make-up from time to time, and it was changed so that different men had the chance to travel in this way. There was no fee for the work, although all expenses were paid; the number of men who made themselves available was large and the praise for the work was a matter of international renown. Elliot Corday was the sponsor of the whole concept; the first several courses had to be paid for; Corday insisted on not taxing the College for this but paid out of his own pocket, a matter that was more or less secret. But the U. S. Department of State saw an immense value of these peace envoys, and soon came to realize that they could best use some of their own funds by underwriting the expenses of these circuit courses.
Each succeeding President had some new idea and the College prospered in many directions. Another West Coast president started a cassette learning program that grew into a project that increased enormously out of sheer excellence. Dr. E. Grey Dimond continues to head the program; the monthly cassettes are on all subjects in cardiology with supplemental programs of history of cardiological development, things like the lives of cardiological investigators and what each contributed, a whole set of vectorcardiograms and what they show in each type of abnormality. Dimond also started the Young Investigators Award, an annual competition of young research men, encouraged to work and to publish.
The solidity of cardiology as a recognized specialty is by 1978 well established all over the world, and to a large extent due to the dream of Louis Bishop, Sr., and of Franz Groedel. The small group that was at the beginning was industrious and sincere; the men who followed them were imaginative in many ways. The basic aim was never departed from, and many of the methods that were devised to accomplish the basic aim were copied by many organizations in many places.
It was a happy accident that the founding of the College was coincident with a sudden explosion of knowledge in all of medicine. The electronic engineers came into the picture, the surgeons and many other specialists. New modalities in diagnosis and in treatment came into use, new drugs and new laboratory procedures. A new postgraduate teaching format was at once urgently needed; the College inaugurated a whole new series of workshops, seminars, exhibits, circuit courses and audiovisual cassettes, and the end is not in sight. The Founders had no way of seeing so far ahead but they did construct a well built basis on which all these things could prosper.
The size of this superstructure is hardly known to many. The Journal of the American Medical Association lists 7330 postgraduate courses for physicians offered by 1500 institutions. The College of Cardiology did more than establish the specialty; it prodded a whole new aspect of medical education. It is indeed an appropriate parallel to the rebirth of medical knowledge that took place at Padua, fittingly commemorated by the seal of Vesalius.
- Burroughs Wellcome & Co.: Diagnostic instruments and techniques in medicine. The Reichert Collection. Burroughs Wellcome & Co., Inc., New York 1942
- Einthoven, W M: Ein neues Galvanometer. Arch. de Physiol. 4, 1059 (1903)
- Reichert, P: Sir James Mackenzie and his polygraph. Am. J. Cardiol. 24,401 (1969)
- Mann, H: The monocardiograph. Am. Heart J. 15, 681 (1938)
- Waller, A D: On the electromotive changes connected with the beat of the mamalian heart. Philos. Trans. Roy. Soc. London, 169-194 (1889)
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