View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Journal of the American College of Cardiology Vol. 33, No. 5, 1999 © 1999 by the American College of Cardiology ISSN 0735-1097/99/$20.00 Published by Elsevier Science Inc. PII S0735-1097(99)00027-3 REVIEW ARTICLES A View From the Millennium: The Practice of Cardiology Circa 1950 and Thereafter Mark E. Silverman, MD, FACC Atlanta, Georgia The knowledge and treatment of cardiology as practiced circa 1950 is discussed as abstracted from authoritative textbooks of that time and other sources. Advances in treatment and diagnostic techniques since 1950 are presented. Dramatic changes in cardiology have come at the expense of bedside cardiology which needs to be balanced with the technology. (J Am Coll Cardiol 1999;33:1141–51) © 1999 by the American College of Cardiology The year 2000 provides a vantage point to look back and see ment, though a primary nonobstructive arteriosclerotic aor- how cardiology has progressed. I have chosen 1950 as a tic condition (Monckeberg’s sclerosis) was described (3). pivotal moment because, as it turned out, that year roughly Mitral valve prolapse was not yet reported. Aortic dissection divides two vastly different eras in cardiology—one in which was a rare etiology of aortic regurgitation; however, primary cardiology was practiced predominately by generalists and dilation of the aortic root was not mentioned. Endocarditis internist-cardiologists who depended upon their bedside was a common problem. skills, a few basic tests, and limited medical and surgical options, and the other a post–World War II exuberant Rheumatic fever. Acute rheumatic fever was common growth, fueled by government and pharmaceutical funding, between ages 5 and 12. Though noted to be on a slight that would eventually become dominated by highly trained, decline, it was still the leading cause of death from ages 5 to full-time specialists, the cardiac catheter and a proliferation 20 in the United States. During World War II, 4%–5% of of therapeutic options. young soldiers infected by hemolytic streptococcus devel- To comprehend the enormous changes that have oc- oped acute rheumatic fever. Paul Dudley White commented curred since 1950, I have provided an in-depth discussion of (1), “One of the most important reasons why rheumatic the understanding of heart disease from that period based heart disease is so serious is the fact that it is particularly a on authoritative American and British texts published pri- disease of youth, crippling and killing many children and marily between 1946 and 1951 (1–10) and other sources young adults.” (11–14). The terminology of that time has been used The cause of rheumatic fever was uncertain, but its throughout. Advances in treatment and technology since connection with certain streptococcal strains was well 1950 are then presented in Tables 1 and 2. known (1). The absence of a clinical history in 40% to 50% of patients was puzzling but suspected to be due to atypical VALVULAR HEART DISEASE and unrecognized attacks. Carditis was suspected when one In 1950, valvular heart disease was understood to be mostly or more of the following was found: a pericardial rub, due to the inflammatory consequences of rheumatic fever. cardiac enlargement, heart failure, aortic or mitral regurgi- Syphilis was still frequent and an important cause of aortic tation, a diastolic mitral murmur (Carey-Coombs murmur) regurgitation. Stretching of the aortic ring, due to hyper- or a presystolic gallop (4). The sedimentation rate, white tension, was thought to produce “functional aortic regurgi- blood cell count and temperature were followed for evidence tation;” “functional mitral regurgitation” was a secondary of continuing rheumatic activity. effect of left ventricular failure and dilatation (3). In most Prophylactic prevention stressed avoidance of respiratory cases, aortic valve calcification and stenosis, even in the infections, prompt penicillin treatment of streptococcal elderly, was attributed to long-standing rheumatic involve- pharyngitis, small doses of sulfonamides or penicillin throughout the winter or spring in susceptible children and tonsillectomy. Treatment for acute rheumatic fever was From the Division of Cardiology, Department of Medicine, Emory University School of Medicine and Chief of Cardiology, Piedmont Hospital, Atlanta, Georgia. limited to salicylates and absolute bed rest for several The research for this article was undertaken on a Burroughs-Wellcome travel grant at months or longer. Fever therapy, up to 106°F, was some- the Wellcome Institute for the History of Medicine, London, England. Manuscript received August 28, 1998; revised manuscript received November 24, times tried for chorea. Corticosteroids, just introduced in 1998, accepted January 5, 1999. 1949, were reported to be successful in early small series (2). 1142 Silverman JACC Vol. 33, No. 5, 1999 The Practice of Cardiology in 1950 April 1999:1141–51 Clinical findings. These were the times of unoperated, forbidden or terminated early if symptoms and signs of advanced rheumatic valvular disease. By 1950, the symp- heart failure appear early or if there have ever been symp- toms and bedside cardiac findings had been extensively toms or signs (1).” It was estimated that 90% of cardiac correlated with the chest X-ray, fluoroscopy and the elec- disease in pregnant women was due to rheumatic valvular trocardiogram. Typical facial appearances were sought—a disease, and that mitral stenosis alone or in combination malar, cyanotic flush on a pale background was suggestive of with aortic valve disease was present in 75% of these cases. mitral stenosis, while a delicate pink “Dresden china” At the turn of the 20th century, the mortality in symp- appearance was noted with aortic stenosis (2). The cardiac tomatic pregnant patients was around 50%, and the fetal examination had become a fine art as practiced by Paul mortality was correspondingly alarming (3). If pregnancy Wood, Samuel Levine, Paul Dudley White and others was restricted to women who were classed as New York (1–4). Heart Association Class I (no limitation of activity) or II The classic auscultatory findings of each valve abnormal- (slight or moderate limitation of activity) who had never ity were well known. Valvular regurgitation was most been in heart failure, then the mortality was nil (3). The commonly called “insufficiency” in the United States (3) and management of symptomatic patients relied upon strict bed “incompetence” in Great Britain (2). Late systolic murmurs rest, salt restriction, digitalis, mercurial diuretics, quinidine were often attributed to an extracardiac or innocent source. and, for acute pulmonary edema, morphine was the choice. Paul Wood said, “It is now known, however, that apical With strict care, the overall mortality, had fallen to 2%–3% systolic murmurs may be cardiac or extracardiac, and if in 1950 (3). cardiac may be due to mitral incompetence...mitral in- competence itself may be organic or functional (2).” HYPERTENSION Laboratory. The chest x-ray included oblique and barium- Hypertension was defined according to the diastolic pres- filled esophageal views to check for cardiomegaly or specific sure alone and was graded as mild (90–110 mm), moderate chamber enlargement. Office fluoroscopy was routinely (110–130 mm) and severe (130–150 mm) (7). Malignant or done. The electrocardiogram was important for rhythm accelerated hypertension indicated a diastolic pressure in the analysis and could point to chamber dilatation or hypertro- severe range associated with funduscopic abnormalities and phy. Right heart catheterization and angiography was pos- rapidly worsening renal function. Systolic blood pressure sible in a few academic centers only beginning in 1945 at the elevation was attributed to rigidity of the great vessels and Johns Hopkins and the Peter Bent Brigham Hospitals (11). dismissed as not serious; a diastolic elevation was vasocon- Treatment. When significant valvular disease was present, strictive in origin and the cause of true hypertension. patients were advised to avoid effort and to seek a sedentary Incidence and etiology. Hypertension was common, said occupation. Charles Bailey in Philadelphia and Dwight to affect 30%–40% of the U.S. and British population over Harken in Boston initiated surgery for acquired valvular age 40, and account for 15%–20% mortality in those times disease with their reports of successful mitral commissurot- when treatment was so limited. As Paul Dudley White omy for mitral stenosis in 1948 (12). commented, “The most common and important of all types Prognosis. Persistent or recurrent rheumatic carditis with of heart disease by and large the world over is that due to cardiomegaly predicted a worse outcome. Auricular fibrilla- systemic hypertension with elevation of diastolic blood tion was ominous. Marked mitral insufficiency brought pressure. It is often serious and frequently followed by about death in “just a few years” at best. Patients with congestive failure and death (1).” significant mitral stenosis could live 10–20 years, and Known etiologies of hypertension were listed as acute and occasionally much longer. Their average age at death was chronic renal disease, endocrine disorders, coarctation of the 35, however, 25% survived to age 50 or longer (2,3). aorta, central nervous system lesions and toxemia of preg- Aortic valve disease due to syphilis carried a worse nancy (3). The classic experimental