British Cardiology in the 20th Century Springer London Berlin Heidelberg New York Barcelona Hong Kong Milan Paris Singapore Tokyo Edited by Mark E Silverman, Peter R Fleming, Arthur Hollman, Desmond G Julian and Dennis M Krikler British Cardiology in the 20th Century

With a Foreword by Walter Somerville

Springer British Library Cataloguing in Publication Data British cardiology in the 20th century I. Cardiology - Great Britain - History - 20th century I. Silverman, Mark E. 616.1'2'00941 '0904 ISBN-13: 978-1-4471-1199-3

Library of Congress Cataloging-in-Publication Data British cardiology in the 20th century/Mark E. Silverman . .. let a/.J (eds); with a foreword by Walter Somerville. p. ; em. Includes bibliographical references and index. ISBN-I3: 978-1-4471-1199-3 e-ISBN-I3: 978-1-4471-0773-6 001: 10.1007/978-1-4471-0773-6 I. Cardiology-Great Britain-History- 20th century. I. Title: British cardiology in the twentieth century. II. Silverman, Mark E. IDNLM: I. Cardiology-history- Great Britain. 2. History of Medicine, 20th Cent.- Great Britain. WG II FAI B862 2000J RC666.S.B7S 2000 0O-Q36S74

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28/3830-543210 Printed on acid-free paper SPIN 10765440 Foreword

I have been accorded the honour of writing a foreword, meaning words said before something more significant that follows. I shall take the prerogative, at my mature age, to look backwards first. As I reflect upon the last century, I realise that our knowledge of cardiology, obscure in 1900, has been like a distant mountain whose magnificent features became more sharply outlined and appreciated as we have travelled through the century. In 1900, the origin of ischaemic chest pain, for example, was a total blur and we did not even know how to diagnose coronary thrombosis. I take great pleasure that certain major disorders which affected so many, so cruelly in the past have been tamed, and in some cases almost eradicated. Among other benefits this century has seen are the dramatic fall in incidence of rheumatic fever; the precise control of coagulation of blood; the discovery of effective treatments for hypertension, syphilis, and endocarditis, and the remarkable develop• ments in safe surgery for acquired and congenital heart disease. British cardiology can be justly proud of its many contributions to the clinical understanding and the science of cardiology in the 20th century. The teachings of Mackenzie, Lewis, Parkinson, Wood, Pickering, and many respectfully remembered others from this country spring immediately to my mind. British cardiology has been a discipline that is recognised as one of our strong scientific exports. That this progress has occurred here despite the prolonged havoc and disruption of two world wars is all the more note• worthy. As I look forward, however, I wonder if our wisdom will increase as much as our knowledge has in the past. Coronary disease, thought to be uncommon in the early years of this century, has become an increasing menace to our lives despite many advances in diagnosis and treatment. Can molecular biology be a stepping stone to its solution? Will the determina• tion of the genetic code help us to eradicate congenital heart disease and cardiomyopathy as we have successfully overcome other problems? What will we do about the care of our ageing and expanding population, tobacco related disease, and the pervasive toxins that threaten our environment and our health? Finally, I wonder whether the stethoscope, the precious tool of the cardiologist, will be replaced by the computer as the symbol of the doctor in the eyes of the patient. This book was not, of course, designed to answer these questions. But it does provide a fine perspective from which to view British contributions

v vi British Cardiology in the 20th Century

to cardiology and to tell us how far we have come in our 20th century journey to learn about the mountain ... which no longer seems so distant or so mysterious. The editors and authors are to be congratulated and thanked for this important historical document.

Walter Somerville Honorary Physician Middlesex Hospital, London President British Cardiac Society, 1976-81 October 1999 Preface

British Cardiology in the 20th Century came about through a happy combi• nation of circumstances. In May 1998, I came to London from Atlanta, Georgia as a visiting academic at the Wellcome Institute for the History of Medicine to undertake research on Paul Wood. After a lengthy search of archival resources, it became apparent that, with a few notable exceptions, relatively little had been written about British cardiology in this century. Considering the historical importance of British cardiology, beginning with William Harvey and extending through James Mackenzie and Thomas Lewis into modern times, this void was rather surprising. The concept of coediting a multiauthored book devoted to 20th century cardiology was discussed with Peter Fleming, Arthur Hollman, Desmond Julian, and Dennis Krikler - all like minded cardiologist-historians - at an initial meeting at the British Cardiac Society on 21 October 1998. After due consideration of the many obstacles such a book would encounter, the group agreed that the idea was worthy. The purposes of the book were defined, chapter subjects developed, and potential authors selected. Potential publishers were contacted and financial support was obtained. The authors responded with enthusiasm and scholarship and within a year a vivid history of British cardiology in the 20th century has emerged. I am grateful to the Burroughs Well come Fund in Durham, North Carolina and to the Academic Unit and library staff at the Wellcome Institute for the History of Medicine who made it possible for me to partic• ipate in this fulfilling project.

Mark E Silverman

vii Contents

Chapter 1 British Cardiology 1900-50 Peter Fleming ...... 1 Heart failure ...... 1 Cardiac arrhythmias ...... 7 Conduction defects ...... 8 Electrocardiography ...... 9 Ischaemic heart disease ...... 10 Angina ...... 10 Myocardial infarction ...... 12 Chronic rheumatic heart disease ...... 15 Infections of the heart ...... 18 Hypertensive heart disease ...... 18 Pulmonary heart disease ...... 19 Congenital heart disease ...... 20 Da Costa's syndrome and related conditions ...... 20

The Development of the Speciality

Chapter 2 The Second World War and the NHS - the Framework for the Development of Cardiology Geoffrey Rivett ...... 27 Hospitals and specialists before the war ...... 27 Planning for district hospitals ...... 28 Speciality development ...... 29 Development of cardiology and cardiac surgery ...... 30 NHS organisation and specialist services ...... 32 London issues ...... 33 Equity, cost, and quality ...... 34 x British Cardiology in the 20th Century

Chapter 3 The Training, Number, and Distribution of Cardiologists Douglas Chamberlain ...... 38 Training within the NHS ...... 38 Introduction of formal training ...... 42 Regulating numbers ...... 45 Growth and geographical distribution ...... 49

The Organisations Involved in the Growth of Cardiology

Chapter 4 Societies, Journals, and Books Arthur Hollman ...... 52 The Cardiac Club ...... 52 The British Cardiac Society ...... 54 Other British cardiology organisations ...... 62 Journals and books ...... 63...... Chapter 5 The British Heart Foundation Desmond G Julian and Brian Pentecost 74 Founding committee ...... 74 Statement of purpose ...... 75 Fundraising ...... 75 Governance ...... 77 The medical department ...... 77 Research ...... 77 Professorial chairs ...... 78 Education ...... 78 Cardiac care ...... 80 Chapter 6 Part I. The National Heart Hospital: The First of its Kind Mark E Silverman ...... 83 London hospitals prior to special hospitals ...... 83 The rise of special hospitals ...... 84 Special hospitals gain recognition ...... 84 The origins of the National Heart Hospital ...... 85 The Dr Eldridge Spratt melodrama ...... 85 The hospital gains sound footing and respect ...... 87 The Second World War period ...... 88 The National Heart Hospital and Institute of Cardiology ...... 89 Cardiac catheterization and cardiovascular surgery ...... 89 Closure and rebirth of the Heart Hospital ...... 90 Acknowledgements ...... 90 Contents xi

Part II. The Institute of Cardiology and the National Heart and Lung Institute Mark E Silverman and Aubrey Leatham ...... 92 Formation of special institutes for postgraduate education ...... 92 National Heart Hospital ...... 93 Institute of Cardiology ...... 94 Formation of the National Heart and Lung Institute ...... 98

Chapter 7 The Hammersmith Hospital and the Royal Postgraduate Medical School Mark E Silverman, Arthur Hollman and Dennis M Krikler 103 Foundation ...... 103 Voluntary hospitals and research ...... 104 The Hammersmith model ...... 105 Cardiac catheterisation ...... 105 The Second World War ...... 106 Cardiac surgery ...... 107 Further research ...... 108

Diagnosis and Treatment in Cardiology

Chapter 8 Bedside Diagnosis Aubrey Leatham ...... III Principles of examination ...... III Development of the phonocardiogram ...... 112 Studies on identifying components of the second heart sound .... 115 Studies on components and intensity of the first heart sound . . . .. 118 Studies on early systolic sounds ...... 120

Chapter 9 The Chest X Ray in Cardiac Diagnosis, 1930-60 Derek Gibson ...... 123 Early use of the chest x ray...... 123 Improvement in radiological methods ...... 124 First techniques ...... 125 Cardiac enlargement and the pulmonary blood vessels ...... 127 Heart failure ...... 128 Cardiac catheterisation helps interpretation ...... 128 Investigating pulmonary blood flow and oedema ...... 129 Pulmonary hypertension ...... 130 Xll British Cardiology in the 20th Century

Chapter 10 Electrocardiography, Electrophysiology, and Arrhythmias Dennis M Krikler ...... 133 Electrocardiography ...... 133 Intracardiac electrocardiography ...... 138 Developments in surface electrocardiography ...... 138 Antiarrhythmic therapy ...... 139

Chapter 11 Cardiac Catheterisation Malcolm Towers and Simon Davies 143 Early work ...... 143 The Paul Wood era ...... 144 Work in the 1960s and 1970s ...... 146 Angioplasty ...... 150

Chapter 12 Nuclear Medicine and Cardiology Peter J Ell ...... 155 The MRC medical cyclotron unit ...... 156 Cardiac imaging ...... 156 New tracers ...... 158 Emission tomography ...... 159 British Nuclear Cardiology Society...... 159 Cost-benefit analysis of scintigraphy ...... 159

Chapter 13 Cardiovascular Magnetic Resonance Donald B Longmore and S Richard Underwood ...... 163 Early days of imaging ...... 163 CORDA ...... 164 Brompton Magnetic Resonance Unit ...... 164 Magnetic resonance spectroscopy ...... 166 Coronary and myocardial perfusion imaging ...... 166 Specialist societies...... 167

Chapter 14 The Development of Cardiac Ultrasound Stewart Hunter ...... 170 Beginnings ...... 170 Developments in the 1970s and 1980s ...... 172 Importance in paediatric cardiology ...... 173 Transoesophageal echo ...... 173 Ultrasound's role in cardiology ...... 174 The next millennium ...... 174 Contents xiii

Chapter 15 Prevention of Heart Disease Ross Lorimer ...... 176 Rheumatic heart disease ...... 176 Coronary heart disease ...... 177 Epidemiological studies ...... 179 Prevention ...... 184 Decreasing mortality from coronary heart disease ...... 186 Hypertension ...... 187

Chapter 16 Cardiac Surgery Tom Treasure ...... 192 Back to the beginning ...... 193 Closing in on the heart ...... 197 Specialisation develops ...... 197 Next wave of valvular surgery ...... 199 Disseminating information ...... 201 Impact of hypothermia and stopping the circulation ...... 202 Further developments in valve surgery ...... 205 Transplantation ...... 207 Coronary artery surgery ...... 208 Issues of conflict and quality ...... 209

Chapter 17 Cardiac Pacing Aubrey Leatham and Ronald Gold 214 Early Days of Pacing at St George's Hospital ...... 214 From St George's to the National Heart Hospital ...... 219 Recollections of Pacing from a Regional Centre ...... 225

Chapter 18 Cardiac Rehabilitation Helen Stokes ...... 232 Moving on from bed rest ...... 232 Cardiac rehabilitation as a developing speciality ...... 233 Cardiology and rehabilitation ...... 234 Psychosocial factors in cardiac rehabilitation ...... 235 Safety and effectiveness of rehabilitation services ...... 235 Expansion of services ...... 236 Reviewing service provision ...... 238 Consumer involvement ...... 239 Where are we now? ...... 239 xiv British Cardiology in the 20th Century

Chapter 19 Clinical Trials Desmond G Julian and Stuart Pocock 242 Prevention and treatment of thrombosis ...... 242 13 adrenergic blocking drugs, calcium antagonists, nitrates, and magnesium in and after myocardial infarction ...... 245 Hypertension ...... 246 Heart failure ...... 247 The coronary care unit ...... 248 Coronary artery bypass surgery and angioplasty ...... 248 Lifestyle, diet, and lipid modifying drugs ...... 249 Methodology of randomised clinical trials ...... 250

Selected Cardiac Disorders

Chapter 20 Cardiovascular Pathology Michael J Davies ...... 255 Morphology ...... 255 Academic pathology ...... 256 Atherosclerosis research ...... 256 Cardiomyopathy and myocarditis ...... 264 Reginald Hudson ...... 264 Cardiovascular pathology in the 1990s ...... 266

Chapter 21 Paediatric Cardiology Gerald Graham and James Taylor 269 Pioneers and pioneering procedures ...... 269 Establishing paediatric cardiac units ...... 272 Establishment of consultant posts ...... 274 Professional associations ...... 274 Development of a paediatric cardiac service ...... 275 Academic units ...... 279 Conclusions and prospects ...... 279

Chapter 22 Grown Up Congenital Heart (GUCH) Services for Adolescents and Adults Jane Somerville ...... 281 Development of paediatric cardiology and cardiac surgery ...... 282 Establishing a service ...... 282 Other aspects of GUCH ...... 286 GUCH information and services across the world ...... 288 Contents xv

Chapter 23 Rheumatic Fever Edwin Besterman ...... 290 History ...... 290 Murmurs ...... 291 Cardiac dilatation ...... 291 Chorea ...... 292 Aetiology ...... 292 Changing prevalence ...... 292 Canadian Red Cross Memorial Hospital, Taplow ...... 294 Treating rheumatic fever ...... 297 Remaining problems ...... 297

Chapter 24 Valvular Disease, Endocarditis, and Cardiomyopathy Celia M Oakley ...... 300 Valvular heart disease in Britain ...... 300 . . . Infective endocarditis ...... 303 Cardiomyopathy ...... 304

Chapter 25 Hypertension William A Littler ...... 310 Work of Pickering ...... 310 Battle of the knights ...... 312 Epidemiological studies ...... 314 Benign and malignant hypertension ...... 315 Early drug treatments ...... 316 Trial ethics ...... 317 Research at the Hammersmith in the 1950s and 1960s ...... 318 13 blockers ...... 319 MRC trial of drug treatment in mild hypertension ...... 320 Role of meta-analysis ...... 321

Chapter 26 Atherosclerosis Research after the Second World War Michael F Oliver ...... 323 Early post war history...... 323. Increasing incidence of coronary heart disease ...... 324 Risk factors ...... 325 The arterial wall ...... 328 Thrombosis research...... 329...... Lipid and lipoprotein research ...... 331 Organisational developments ...... 332 Cardiovascular survey methods ...... 333 xvi British Cardiology in the 20th Century

Major research developments after 1970 ...... 333 Clinical trials on the reduction or prevention of atheromatous coronary heart disease ...... 336

Chapter 27 Clinical Coronary Heart Disease Desmond G Julian ...... 343 Myocardial infarction - 1945-60 ...... 343 Myocardial infarction - 1960 onward ...... 345 Unstable angina ...... 349 Variant angina ...... 351 Stable angina ...... 351

Chapter 28 Leaders of British Cardiology Arthur Hollman, Gaston E Bauer and Mark E Silverman ...... 357 Russell Claude Brock, Lord Brock of Wimbledon ...... 357 Sir Thomas Lewis ...... 360 Sir James Mackenzie ...... 363 Sir John McMichael ...... 367 Sir John Parkinson ...... 370 Paul Hamilton Wood ...... 374

Index •••••.•..•...... 379 Contributors

Gaston E Bauer Peter Fleming Consultant Cardiologist, Royal North Formerly Senior Lecturer in Medicine, Shore Hospital, Sydney, Australia Charing Cross and Westminster Medical School, London Edwin Besterman Consultant Cardiologist, University Derek Gibson Hospital, University of West Indies, Consultant Cardiologist, Royal Jamaica; Honorary Consultant Brompton and Harefield NHS Trust, Cardiologist, St Mary's Hospital, London London; Honorary Consultant Cardiologist, Royal Postgraduate Ronald Gold Medical School, Hammersmith Formerly Consultant Cardiologist, Hospital, London Freeman Hospital, Newcastle upon Tyne and Clinical Lecturer in Douglas Chamberlain Cardiology, University of Newcastle Honorary Consultant Cardiologist, upon Tyne Brighton Health Care NHS Trust, Sussex, England; Honorary Professor Gerald Graham of Resuscitation Medicine, University Emeritus Consultant Clinical of Wales College of Medicine, Cardiff Physiologist, Great Ormond Street Hospital for Children NHS Trust Michael J Davies British Heart Foundation - Professor Arthur Hollman of Cardiovascular Pathology, Formerly Consultant Cardiologist, St George's Hospital, London University College Hospital, London; Archivist, The British Cardiac Society Simon Davies Consultant Cardiologist, Royal Stewart Hunter Brompton and Harefield NHS Trust, Consultant in Paediatric Cardiology, London Freeman Hospital, Newcastle upon Tyne and Honorary Senior Lecturer in Peter J Ell Paediatrics, University of Newcastle Professor of Nuclear Medicine, upon Tyne University of London; Director, Institute of Nuclear Medicine, University College London

xvii xviii British Cardiology in the 20th Century

Desmond G Julian Stuart Pocock Emeritus Professor of Cardiology, Professor of Medical Statistics, London University of Newcastle upon Tyne School of Hygiene and Tropical and Former Medical Director, British Medicine, London Heart Foundation Anthony Rickards Dennis M Krikler Consultant Cardiologist, Royal Consultant Cardiologist; former Senior Brompton Hospital; Vice Dean of the Lecturer in Cardiology, Royal Institute of Cardiology Postgraduate Medical School, Hammersmith Hospital, London Geoffrey Rivett Medical historian; formerly Senior Aubrey Leatham Principal Medical Officer, Department Formerly Consultant Physician, of Heath, England St George's and National Heart Hospitals; formerly Dean of the Mark E Silverman Institute of Cardiology Professor of Cardiology, Emory University and Chief of Cardiology, the William A Littler Fuqua Heart Center, Piedmont Professor of Cardiovascular Medicine, Hospital, Atlanta, Georgia, USA University of Birmingham; Consultant Cardiologist, Queen Elizabeth Hospital, Jane Somerville Birmingham Emeritus Consultant Cardiologist, Royal Brompton Hospital, London; Donald B Longmore Consultant Cardiologist, Grown Up Professor of Cardiovascular Magnetic Congenital Heart (GUCH) Unit, Resonance, Brompton MR Enterprises, Middlesex Hospital, London; Professor Royal Brompton Hospital, London of Cardiology, Imperial College London School of Medicine Ross Lorimer Honorary Professor in Medicine and Helen Stokes Medical Cardiology, University of Project Officer, Education and Training Glasgow; Consultant Physician and for Cardiac Rehabilitation, Department Cardiologist, Royal Infirmary, Glasgow of Health Studies University of York; Past President, British Association for Celia M Oakley Cardiac Rehabilitation Consultant Cardiologist and Emeritus Professor of Clinical Cardiology, James Taylor Imperial College School of Medicine, Consultant Paediatric Cardiologist, Hammersmith Hospital Great Ormond Street Hospital for Children NHS Trust Michael F Oliver Professor Emeritus of Cardiology, Malcolm Towers University of Edinburgh; President, Formerly Consultant Cardiologist, British Cardiac Society 1980-84 Harefield Hospital, Middlesex

Brian Pentecost S Richard Underwood Emeritus Professor of Cardiology, Professor of Cardiac Imaging, Imperial University of Birmingham and Former College School of Medicine, London Medical Director, British Heart Foundation Introduction

I have tried to tell you something of the men who built the barn and gath• ered the first ears of the amazing harvest that their successors reap in the vast field of cardiology. They were not saints, but simple, kindly men with a great sense of duty ... they cared for suffering hearts and by their labours won the affection and gratitude of many. Robert Marshall. Early days in Westmoreland Street (The National Heart Hospital). Br Heart J 1964:26: 140.

British Cardiology in the 20th Century is a compilation of essays written with the following goals in mind: • To highlight British contributions to cardiology in the 20th century; • To provide a history of some of the figures, institutions, and organisa• tions which played an important part in British cardiology; • To describe British practice and treatment for heart disease during the 20th century; • To explain how the specialty evolved in Britain - including the effects of the National Health Service, the second world war, and changing ideas about professional development and training; • To stimulate interest in and awareness of British cardiology in an inter• national audience; • To provide a reliable historical resource for current and future writers. British Cardiology in the 20th Century is not intended to be a compre• hensive, chronological story of the entire field of British cardiology. The format of the book was dictated by the mid-century acceleration in cardio• logy and its subsequent division into many subspecialty interests. Therefore, the first chapter covers 1900 to 1950, during which period cardiology, although undergoing great changes, was mostly unified. The next two chap• ters are devoted to the emergence of cardiology as a specialty, the organising influences of the second world war and the NHS, and the development of manpower planning and the training pathway for aspiring cardiologists. From then on, contributing authors have been asked to write a narration of their special interest. Thus, each chapter and its accompanying refer• ences and notes can be used as a separate resource. The editors considered that some overlap between chapters was desirable to widen the historical perspective. It is recognised that these chapters are personal and selective. The editors wish to point out that in some chapters particular statements are made that they would not endorse. Inevitably, a number of institutions and individuals who have made valuable contributions to British cardiology do not receive

xix xx British Cardiology in the 20th Century appropriate recognition. For these omissions, we apologise. We have, however, tried to cover the subject as broadly as possible and are proud to publish this first tribute to British cardiology in the past century. The editors express their gratitude to the authors who have undertaken such a formidable task; to our publisher, Springer-Verlag, for their commit• ment; and to Norma Pearce, our indispensable technical editor. Their splendid work and dedication in bringing this book to completion at the end of the 20th century is greatly appreciated. We are grateful to the British Heart Foundation, the British Cardiac Society, and the Fuqua Heart Center of Piedmont Hospital, Atlanta, Georgia for their generous financial support without which this book would not have been possible. British Cardiology in the 20th Century is dedicated to "the men who built the barn ... and the amazing harvest that their successors reap in the vast field of cardiology:'

Mark E Silverman Peter R Fleming Arthur Hollman Desmond G Julian Dennis M Krikler