Clinical Cardiology - April 1978 - Reichert - A History of The Development of Cardiology As A Medical Specialty PDF

Clin. Cardiol.
1,5-15 (1978)
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Review
A History of the Development of Cardiology as a Medical Specialty

P. REICHERT, A.B., M.D.
Introduction Ludwig was not only the great physiological investigator

but a wonderful and dedicated teacher; almost every im-
Disease does not respect national boundaries, and with portant physiologist of the succeeding decades was trained
our present ease and speed of travel this has never been so in Ludwig's laboratory. Although Ludwig must be cre-
true. We cannot help but feel that it is most appropriate dited with the start of a flood of graphic investigations into
that medical effort and medical knowledge follow this the shape of the pulse curve, he was far from the first to
trend; the doctor must feel that his work, his research, his have an intense interest in the pulse; a whole system of
findings must always be internationally oriented. Actually, diagnostic medicine in China dating back a thousand years
this has been the case to a large extent. was based upon a tactile study of the pulse.
A whole list of great names have made contributions An English physician, Sir John Floyer, became fasci-
that are known and of use aU over the world. Certainly nated with this Chinese method of diagnosis ; he was dis-
Pasteur, Wasserman, Ehrlich, are names that are con- tressed that there was no way of determining the speed of
nected with such basic medical facts that their nationality the pulse. He commissioned Daniel Quare, a welJ known
is hardly thought about. There is a long list of other con- EngHsh watchmaker, to make a " pulse watch" that would
tributions less well known, but they should be at least have a minute hand . Quare made such a watch ; it had a
mentioned to support the thesis of "no boundaries." minute hand and no other hands at all. In 1700 Floyer
Therefore I shall present a brief history of the develop- published a book based on his studies with this instrument.
ment of clinical cardiology as a medical specialty as seen He called the book " The Physician' s Pulse Watch". It de-
from the view-point of an American cardiologist. scribed as part of the clinical picture of disease the charac-
teristic pulsations of the artery at the wrist, its rate,
rhythm, amplitude, forcefulness and compressibility. There
The Roots was at that time no thought of a graphic record. That had
to wait a hundred and fifty years, to Karl Ludwig. A pulse
The whole concept of graphic registration of physiologi- controller made by Castagna in 1885 is illustrated in
cal processes began with Thomas Young, an English physi- Fig. 1.
cian probably best remembered for his translation of It is difficult for a student today, with all the electronic
Egyptian hieroglyphics and for his research into the help at hand, to realize how much the physician of a cen-
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.
Address for reprints :

P. Reichert, A. B. , M. D.
Executive Director Emeritus, Historian and Consultant,
American College of Cardiology, 480 Park Avenu e,
New York, N. Y. 10022 USA
Fig. 1 Pulse Controller, made by Castagna of Vienna, 1885. A
Received: October 3, 1977 clock measures the pressure of a screw type clamp required to ob-
Accepted: November 22, 1977 literate the arterial pulse at th e wrist.
6 P. Reichert: Cardiology as Medical Specialty
Fig. 2 Monaural stethoscopes, circa
1850. These are all essentially Laell-
nec's model, turned into fancy shapes
with dilated cusps for the ear and the
chest. One specimen is screwed apart
for ease in carrying.
tury ago could learn with careful observation and diagnos- dropsy to cardiac malfunction. Stephen Hales in the 1730's
tic acumen. Let me illustrate this point. In the 1830's, an demonstrated that tbe blood in the arteries was under the
Irish physician, Dominic John Corrigan, described aortic influence of pressure, but it was over 100 years before
insufficiency diagnosed by a sharply declining "water there was a succesful instrument designed to measure hu-
hammer" pulse. Even today we call this a "Corrigan man blood pressure without actually cutting into the body.
Pulse". We must note that this ba ic diagnostic description That contribution came from an Italian, Riva Roed, in
that has not been bettered in over a hundred years was 1895; his mercurial manometer and arm band i the ances-
done by a doctor that had only a monaural wooden tor of all the blood pressure instruments in use today.
stethoscope (Fig. 2), no other help to his fingers and his There are but a few of the roots, and we have not gone
observing mind, no ECG, no X-ray, no kymograph, no far enough back to search out many more. There can be
way of measuring the blood pressure. When all of these no doubt that the importance of the heart as the center of
modalities came into being, all they could do was to cor- life must have been understood by prehistoric man. I can
roborate what Corrigan had so well described from his un- picture the savage crouching in his jungle, realizing that
aided observation. the pounding in his chest was the real sign of life. If the
Corrigan's stethoscope was about twenty years old; it sleeping form had that chest throb, no matter how much it
had been devised by a Frenchman, Rene Theophile Laen- resembled death , it meant an awakening. If that throb had
nee. Here was another careful observer. About 1820 he stopped, life was gone. Even today, the pronouncement
published a book on his observations of the chest sounds, that the heart has stopped is the legal time of death ; that
the ounds of the heart and lungs. If anything, with his has not changed from prehistoric man . With all the elec-
crude instrument which was actually a short piece of tronic modalities recently avai lab le there is an attempt to
wooden broomstick, be was patient, tireless and thorough. make "brain waves" the symbol of life, but this is a legal
His book was rapidly translated from French into Engli h wrangle, far from decided. The heart beat is still the sym-
and other languages. Laennec described various sounds bol of Life.
with careful accuracy and worked up a complete vocabul- With all these roots, we mu t find a starting point for
ary of names for the various sounds. Today, more than a the history of cardiology that will be beyond dispute. We
century later, the names are still used; they were so accu- nominate William Harvey who in the 1620's demonstrated
rately descriptive that with all our present wonderful the circulation of the blood. Thi took unusual courage,
equipment we have not been able to better the nomencla- since the capillaries had not yet been known , microscopy
ture. had still to be developed, and how the blood got from ar-
In searching out the roots of Cardiology there are a few teries to veins was a matter of imagination . Harvey was
more names that may be mentioned for what may be con- English; he studied at Padua in Italy; he published his re-
sidered widely divergent contributions. Andreas Vesalius search by printing it in Frankfort, Germany, in 1628. So
in his "Fabricius", a wonderfully complete atlas of this starting point illustrates our primary thesis:
anatomy published in the middle 1500's, called the heart
medical knowledge knows no national boundaries.
the "center of life", and we shall see how that was the
basis of the seal of the American ollege of Cardiology. Harvey's thesis gave a profound answer to a great many
William Wirhering in 1783, a well informed botanist, questions that up to that time had no answers. It was sim-
showed that an infusion of Foxglove was of great use in ple arithmetic to show that the quantity and velocity of the
the cure of dropsy, though it is doubtful if he connected blood made it phy ically impossible for the blood to do
Clin. ardiol. Vol. I, April 1978

P. Reichert: Cardiology a Medical Specialty 7
instrument. All of trus was ju t before the turn of the
twentieth century.
There was at trus time a d'Arsonval galvanometer that
moved a mirror in response to electrical current, but it
wa far beyond the tiny current that might be considered
in the heart beat. Sometrung radically delicate was needed,
something that would detect the most infinitesimal cur-
rents. Here were needed patience, technical abili ty and
imagination. Einthoven had all three.
William Einthoven was Dutch , born in Java, son of a
physician. The father died when William was si , 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
Fig. 3 William Harvey demonstrating the "one way" valves in practice but was soon appointed professor of physiology
the veins and in the heart to King Charles I and histology at the University of Leyden. Here he did re-
search and teaching; he was a hard worker who enjoyed
what he was doing and kept well informed about what he
otherwise than to return to the heart by way of the veins. was going on. He knew, of course, about Waller's work
Har vey demonstrated the " one way" valve in the veins and he set himself to devi e a galvanometer that would be
and in the heart; a famous painting shows rum demonstrat- delicate enough to detect heart currents.
ing the valves in the veins to the King (Fig. 3). He finally succeeded; his galvanometer (Fig. 4) had a
One might naturally expect that this sudden and com- monstrous electromagnet formed like a horseshoe. In the
plete clarification of the action of the blood in the body interval between the poles he suspended a very fine quartz
might be gratefully accepted by the entire medical profes- fiber plated with gold to carry current. The movement of
sion, but that isn't what happened. The Engl i h profession this string were projected through a microscope to a cam-
was slow to change from their older concepts and there era that rotated photographic paper behind a slit. The ten-
was even some religious opposition to these radical ideas. sion on the string could be finely adjusted so that a mil-
The first editi on of this important book was refused livolt of current caused a deflection on the graph of one
publication by English printers and Harvey found that the centimeter. In the first quarter of this century the use of
Germans seemed more open minded to the new, and the this instrument laid the basis for what wa to become our
book was printed in Frankfort. important specialty of cardiology.
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.
Cardiographs
There is at least one other landmark that equals in im-

portance for our specialty the work of Harvey, and that is
the contribution of William Ein/hoven (2), several cen-
turies later, actuall y the early 1900's. The electrocardiog-
raph has provided what is uniformly considered one of the
most widely employed and valu able tool 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 Augus/us Waller (5) , devised a
capi llary electrometer in wruch a tiny co lumn of mercury
in contact with di lute 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 re-
sponse of the electrometer was relatively sluggish, and Fig. 4 William Einlhoven in his laboratory al Leyden University
many investigators tried to work out some more accurate with the original Einthoven SIring Galvanometer Outfit
lin . ardiol. Vol. 1, April 1978

Fig. 5 Marey's Wrist Sphygmograph,
1857. This was the first clinical instru-
ment by which the graphic method of
registering the arterial pulse could be ..
made in a living patient. Original instru-
ment in the Reichert Collection, Cornell
University Medical School.
Getting the graph was only part of the problem. The This was the chaUenge taken up by Sir James Mackenzie
great necessity now was to find out what the jiggles meant. (3), an enterprising small town British doctor who came at
Ever since Sir John Player, physicians had been interested last to London. His polygraph (Fig. 6) took the three trac-
in pulse tracings but it was not until the middle of the ings on a roll of paper with styli that wrote with ink; gone
1800's that an instrument was available to make clinical were the smudges and the mess; gone was the shellac.
tracings of the pulse at the wrist. It was devised by a Most important was the fact that the tracings could be run
French physician, Etienne Jules Marey (Fig. 5). As the to any length, so that rate and rhythm could be sturued in
years went by, more and more physicians took tracings detail. Mackenzie was ru ligent in making hundreds of these
with these machines; some of the machines were made in tracings. Now, in adrution to the polygraph, there was the
England and some by French instrument makers. They electrocardjograph of Einthoven, another important diag-
were improved and made to have transmjssion tambours, nostic tool, and Mackenzie was eager to use it.
so that the apex beat of the heart and the beat of the jugu- No one had any real knowledge of what the electrical
lar could be taken at the same time side by side on the records meant; Mackenzie took polygraph and ECG trac-
same record. ings side by side. This seemed the best way to figure out
The recording was a matter of great teclullcal skill. The what the records meant; the physical examination, the his-
graph was made on paper, glazed and covered with a thin tory, the heart sounds ... all these correlated with both the
layer of soot; after the scratch marks had been made by polygraph and the ECG were bound in the end to clarify
the stylus attached to the drum, the record was passed the tracings.
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 Cardiology as a Specialty
employed, it obviously had to be made simpler and less
delicate. Mackenzie was a specialist in carruology, a Harley Street
specialjst. There were other specialists in carruology 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, re-
Ijeved of ascites and dependent edema, lessened chest
pain. They came back to their American practitioners with
Fig. 6 Macken zie's Polygraph. The simple horizontal levers of tales of the great doctors of Germany. And there was the
Marey's Sphygmograph are activated by tambours that are con- parallel exodus each year of the ambitious American me-
nected by rubber tubing to cups placed on the chest and the jugu-
lar region of the neck. The use of ink-writing pens makes possible djcal practitioners for postgraduate training in Germany.
a lenghty tracing on a roll of paper. Original instrument in the There is no mystery about the start of cardiological clini-
Reichert Collection , Cornell University Medical School. cal practice in the United States. One young medical
Clin. Cardiol. Vol. 1, April 1978

P. Reichert: Cardiology as Medical Specialty 9
practitioner could not understand why there should not be cardiac methods, to get the instruments and the know-
a well set up cardiological office in the U. S. and he was ledge; Bishop wanted to share what he knew. There was
willing to try it. He was Louis Faugeres Bishop, M. D., and no reason in the world that there should not be a great
he had made the annual pilgrimage to Bad Nauheim year cardiological specialty group here in the United States.
after year, studying with the Groedels who were steeped in Bishop was dedicated to this idea. He started little groups
the treatment of cardiac cases. Bishop had one of the Eint- of medical friends, sharing, teaching, lecturing.
hoven string cardiograph machines in his office on the In Atlantic City on May 3rd, 1927, there was a meeting
east side of Manhattan; he puzzled over the records and of the American Section of the International Association
studied and compared; in Bad Nauheim he asked ques- of Medical History. Bishop thought that this might be a
tions.. great opportunity to talk about the possibility of a national
At one time Bishop made an unannounced visit to society for the study of this new science in medicine. His
James Mackenzie in Harley Street, London. The doctor remarks give us a viviri picture of the situation in America
had an office full of waiting patients and had no time for at that time. We are fortunate to have a copy of what
an intruder. Bishop asked a few sharp questions; the good Bishop said:
doctor was astonished and immediately interested. He dis- HI date my definite association with cardiology from the
charged the waiting patients and sat down to a long and year 1907. In the fall of that year I decided to concentrate
fruitful discussion with young Bishop. Mackenzie could not my work upon this particular field of medical knowledge,
understand why there was no specialist in cardiology in and it is this period of twenty years that I wish to cover. I
America. He encouraged Bishop to start it. am particularly fitted to do this because my first organized
The Groedels of Bad Nauheim were a strongly en- effort in entering this special field was to make a survey of
trenched family of doctors, father and sons medical cardiology in America and Europe. I went from place to
specialists and all deeply interested in the treatment of the place where cardiology was taught, and where men's minds
cardiac cases that came to their clinic and spa. They were were turned specially to this problem.
well fixed financially after so many years of running such a The first thing that impressed me in America was what
successful venture; one of the sons, young Franz, was a little progress had been made in the development of car-
completely relaxed and strongly motivated investigator. diological knowledge. What little progress that had been
All of his ideas of equipment and assistance were his for made was through immediate contact with the problems of
the asking and he published countless papers on new people afflicted with heart disease. Rest was the one univer-
methods for diagnosis and treatment; his imagination had sal prescription, and invalidism was encouraged on every
no limit. side. A heart lesion was a legitimate excuse for laziness and
Franz Groedel was interested in the Roentgen measure- indulgence. Our great consulting-physicians of that day
ment of the cardiac outlines; he was interested in Eint- were Janeway in New York; Pepper and Musser in
hoven's electronic diagnostic machine; he was interested in Philadelphia; Fitz in Boston; and Forchheimer in Cincin-
the pulse writers, and especially in the polygraph that nati. These and other great consultants in the large cities of
made possible long tracings of rate and rhythm. It did not the country had a very valuable empirical knowledge of the
matter to Franz how much time and effort he expended on heart, but no information whatsoever upon the subject of
anyone patient. The whole intent was to learn as much as the technical matters of the present day. In London and
it was possible to learn about each case. Young Bishop was Edinburgh I found much the same condition, though in
fascinated with Franz Groedel. Edinburgh and Dublin practice was much influenced by the
What happened next was far from cardiology but it had very great students of cardiology of the generation just pre-
a tremendous influence on its international phase. It was vious - Stokes, Corrigan and Hope. They were just this far
the First World War. The year 1914 was critical for the ahead of America in that they recognized, definitely, the
patients that had made a habit of the trek to Europe. But value of graduated exercises in the restoration of the person
the slow and patient work of the Bishop office suddenly whose heart had become a problem.
blossomed. Here in America was a well trained and com- That year I had the pleasure of meeting Sir James Mack-
pletely equipped cardiological specialist; there was no enzie in London and if I had the time I would like to tell
longer the pressing need to get to the European spa for you something of the operation of the mind of this great
diagnosis and treatment. Bishop was overwhelmed. man. Two or three questions from me, a total stranger,
threw him into an enthusiasm that led him to dismiss his pa-
tients and give me his day. He was a canny Scot but he had
The American College of Cardiology an uncanny insight into medical truth and falsehood. He
had no use for the doctor whose beliefs were founded on
There was so much to do and so many patients to care medical authority alone.
for that Bishop had another dream. He had a son who was On the continent I came in contact with the French school
to follow in his footsteps, but that would not be enough. of medicine when I met Vaquez. The French school of
He must get more American doctors to learn about the medicine has always fascinated me by its profound
Clin. Cardiol. Vol. 1. April 1978

philosophy that combines so well the intensely ideal with the must be carried to general meetings where they receive an
intensely practical. Huchard anticipated by many years the unsympathetic hearing from those who do not understand.
teaching that arteriosclerosis is a general constitutional dis- We are forced to fight our losing battles in private, and
ease and not a disease of the blood vessels primarily. The publish practically only our successes. It is only when car-
French still rely mainly upon drugs and are remarkable for diologists decided to get together in private, that the pro-
the elegance of their prescribing and intricate details of their found difficulties of cardiology can be properly attacked and
advice. solved."
In Austria, Italy and Switzerland, I did not find much Bishop's remarks were a little off the topic of the meet-
difference from London and Paris. It was in Germany that ing; he was politely applauded, and that was that. Some of
I discovered a cardiology that seemed to me worthy of study the members present expressed some interest in what
and imitation. I returned to Germany nearly every summer Bishop had said, but nothing came of it, and no practical
until the war broke out (World War I). I followed and as- steps were taken at that time. However, Bishop did not re-
similated as far as possible the work of the German physi- lax his effort; he was critical of the lack of willingness of
cians. They had a unique opportunity for academic study, the American profession to adopt his method of deferring
half-the-year in universities, with the rest of the time de- diagnosis until all aspects of the diagnostic investigation
voted to the practical application of their theoretical know- were complete. It must be admitted that the patient and
ledge to a large group of people who sought the "cure" in the patient's family were for the most part reluctant as
Germany for the restoration of their health. well, and much preferred the masterful and impressive
In America I had never known of such a thing as a defer- "guesswork" immediate diagnosis. With the amount of
red diagnosis, that is, a definite time set when a conclusion treatment possibilities that existed it is still possible that it
can be reached; up to which time the case was allowed to did not much matter in 1927.
remain fallow, so that the final diagnosis could be indepen- Eight years later, in 1934, with the help and counsel of
dent and complete. The American concept of the diagnosti- Russel Burton Opitz, a practicing cardiologist and profes-
cian was that of a fashionable physician, driving to a con- sor of physiology at a medical school, Bishop was able to
ference in state, and pronouncing in elegant language, a convene a group and organize the New York Cardiological
diagnosis founded upon the quick operation of his shrewd- Society. Sixteen doctors were present; a slate of officers
ness and intuition. In other words, the great diagnostician was chosen, committees appointed, and the project got off
was a great guesser. to a real start.
In Germany I found that the great diagnostician was the Before this, there had been a Heart Committee of the
final step in a process. In other words, the investigation was New York Tuberculosis Society, but it was not a medical
carried on, to lead up to a diagnosis, rather than to prove group; it was concerned with the social aspects of getting
the diagnosis that was already made. It had taken this medical help to the poor and underprivileged. The physi-
twenty years for the technical cardiology which was well cians that were a part of this organization were naturally
under way in German clinics to spread over the world and dissatisfied with the obvious fact that there was no attempt
become accepted as a real human asset. to spread the technical knowledge of cardiac diagnosis that
I was an early convert to technical cardiology and with was beginning to be known and discussed.
the other pioneers had to stand the adverse criticism of The New York Cardiological Society had no specific en-
those who did not understand when I insisted that everyone trance requirement except that every member had to be a
who presented a cardiological problem, should have the be- registered physician. The programs were meant to teach
nefit of a complete technical examination. I was accused of and physicians were invited to lecture from medical
commercialism because I paid too much attention to people schools all over the country and there were occasional
brought to me by their physicians with the old-fashioned speakers from medical schools and hospitals in Europe.
demand for a listen-and-guess diagnosis. But cardiology For the group that started this new society there was a de-
was a wonder-field of blossoming flowers and new ideas finite need that it filled; the membership committee was
and here and there a sturdy plant that represented definite active and the ranks slowly grew. Bishop's idea was to
results in the rescue of human wrecks, from invalidism and form a national organization, but that seemed far off for
even worse. the present. The five boroughs of New York contributed
This cardiological field was pleasant and interesting and I most of the new members, with a few from nearby New
knew that in time others would come into it and that even- Jersey and a few from Philadelphia.
tually cardiology would become a recognized specialty. There seemed to be no lack of suitable topics for pro-
Whether that time has arrived or not, I have been unable to grams. The Saratoga Springs Commission had set up what
decide. But there are some signs that make me believe that they labelled" Nauheim Hydrotherapy", and the director
very soon there will be a group of men, devoted to cardiol- of the Commission, Dr. Walter S. McClellan, gave a talk
ogy, large enough to form their own national society, where on the "Carbon Dioxide Therapy in the Treatment of
they can confer with each other on their intimate problems. Heart Disease".
At the present time, the intimate prohlems of cardiology Temple University Medical School in Philadelphia had a
Clin. Cardin\. Vo\. I, April 1975

department of experimental pharmacology; the professor One day in 1935, a man was ushered into my office; he
heading the department was chief of the research staff of a said his name was Groedel. He had been recommended to
pharmaceutical manufactwing company. Dr. James C. me because he wanted to have made a double string elec-
Munch lectured on "Recent Studies on Digitalis and its trocardiograph. Nobody knew how to make this but in se-
Allies" . veral places my name had been mentioned. I looked at this
One of the features was the presentation of clinical cases gentleman with interest and a little suspicion. The Groedel
from the various hospitals in New York City. With an ac- that I remembered from pictures had a great beard, spoke
tive discussion these presentations were always instructive. German and for all I knew was probably dead. This
The programs were published in the medical journals, Groedel was clean shaven, smooth talking in faultless Eng-
and all physicians and medical students were invited; there lish, and wanted something that would have to cost a lot
was no admission fee. Discussion was open to all. of time, effort and money. That was the least of it, said my
At about this time I came personally into the picture, visitor, pulling out a ~heck book and astonishing me with a
but I must go back a few years to make the whole acciden- substantial check. The bearded one, I learned, was his
tal contact seem more plausible. After graduating in father. He was Franz Maximilian; a brother Theodore had
medicine from Cornell University, I had an exciting in- been ki1led in the First World War. The whole thing began
ternship at the New York City pest house, the Willard to assume a new aspect and my reputation for dexterity
Parker Hospital for Contagious Diseases. Diphtheria was a made this wonderful person come into my life.
plague that killed hundreds of children, by choking on Groedel and I came into the New York Cardiological So-
diphtheria membrane or by cardiac complications of the ciety at its 37th meeting, February 26th, 1941. We were
toxin. The O'Dwyer intralaryngeal tube was a great life both of us immediately useful to the new society. I had
saver, but it had ito be placed early, and it was a tricky been a registered parliamentarian; he was the world's
manoeuver, needing skill and trained fingers. Mechanical greatest expert on chest leads in electrocardiography. He
manipulation had been a hobby of mine for years; I was was a tireless worker and developed a method in which he
soon the recognized expert with the O'Dwyer tube. I be- took chest leads all over the chest, inches apart, a com-
came Resident Pathologist of the hospital and was finally plete map of the chest ECGs. With this he was able to
recommended to Rockefeller Institute. demonstrate that there was a definite difference between
Here again the mechanical dexterity came to the fore, the right and left heart ECGs.
and when Warburg brought one of his microbic resIllation His first lecture, given the evening we were voted into
devices to New York, Simon Flexner, the Head of the In- membership, was on "Isolated Electrocardiogram of
stitute, assigned it to me. I must skip what is not relevant Either Right or Left Ventricle." The meeting was at the
to this history; I spent some years with Bela Schick at New York Academy of Medicine; it was well attended.
Mount Sinai Hospital, then went back to my work on Groedel was meticulous in showing the tracings that con-
diphtheria. By this time. I became interested in the one firmed his theory, ingeniously taken on patients with thin
specialty in medicine that had the most complicated and chest walls. The evening was of tremendous value to every
mysterious mechanism, the Eintiwven electrocardiograph. practicing physician in the audience.
Here was a specialty that required manual dexterity and At the end of 1941, the elder Bishop died. He had lived
seemed by this graphic method to give a kind of informa- long enough to see his son a respected cardiological doctor
tion and measurement that was not available in any other and to see the Society grow into a useful and recognized
field. When my work with Schick came to a stopping teaching element. But the whole idea of a national society
place, I transferred to the Cardiac Clinic and decided to had been quietly laid to rest. The Society president was
make myself an expert in electrocardiography. Here in all Dr. Walter Bensel, a serious and careful physician, some-
of medicine was something that one could tie up to, some- what arrogant in his attitude, given to written instructions
thing definite. that must be exactly followed, but above all, a generous
I had spent my undergraduate days as a blood chemist host; the trustees meetings were at his place, combined of-
at the Roosevelt Hospital in New York and I was familiar fice and home, with a carefully arranged late supper. Dr.
with much of the labocalDry work needed in diagnosis. By Bensel carved the meat, and graciously served everything.
this time, I had an ol0ctr0cardiac machine that was "port- It was not hard to see why the idea of spreading out into
able" (by comparison), and I made for myself a portable the rest of the country was disliked. All of the profession
laboratory in a wooden box with a small microscope. I was was invited to the meetings and could benefit from the
all set for doing a real job of diagnosis; we must remember teaching, but the running of the Society must remain in the
that at that time a physician made house calls. It was not tight little local group. where everybody was a close friend
long before my reputation for accuracy spread, and I soon of everybody else. I was the secretary and treasurer.
had an active practice, much of it referred, rather unusual elected because of my parliamentary certificate, and Ben-
for a young physician. I knew about the New York Car- selloved to see me carry out his orders so efficiently. The
diological Society that I was told about, but I decided to set-up was a theatrical play.
wait and see. Looking through the programs it is obvious that they
ain. Cardio!. Vol. 1, April 1978

were important reports of the steps that made the specialty The constitution, the bylaws and all the paraphernalia of
an ever broadening field. Hitler had made our country a the organization were in order. One member of the found-
gift of some extremely valuable physicians, and the pro- ing group was certified parliamentarian and that was a
gress that was being made was directly, I think, attributable great help. But the seal remained a special problem.
to the names of Emil R. Zak, Bruno Kisch, and Franz The central motif must obviously be a heart, but an ex-
Maximilian Groedel as well as a few others from the well act copy from Gray's Anatomy seemed too trite. We had
established cardiac clinics of Germany and Austria. set the goal of the College as an educational institution
One area of interest one can easily understand was the strictly within the medical profession; we needed some-
life insurance companies, since they were most concerned thing in the best tradition of the early beginnings of scien-
with the statistics of death from cardiac and arterial tific medicine.
causes. The Metropolitan Life Insurance Company had For many centuries the Church had forbidden as a sac-
underwritten an order for 100 blood pressure instruments rilege the dissection of the human body. Medical men had
that put the Baum Company in business. The Insurance their learning out of books; Aristotle and Galen were the
Company had a statistician as a vice-president, a Ph. D. authorities. The early 16th century saw the beginnings of
named Louis I. Dublin, whom I had the pleasure of know- rebellion. Leonardo da Vinci did human dissections at a
ing; he spoke often at the society meeting and his reports time when one needed the protection of a powerfuJ prince.
were always mathematically proven and therefore most The authority must be not what one read but what one
impressive. saw. Leonardo's drawings were accurate and beautiful, but
By 1944, Dr. Bensel was again the President but Franz were not published in his lifetime. Their influence was li-
Groedel had moved up to the Vice Presidency; I remained mited, but a vogue of thought was started. Twenty years
the perennial Secretary-Treasurer. In 1949, Groedel be- after Leonardo died, his ideas caught fire.
came President with Louis Bishop, Jr., as Vice President By 1530, Padua had become the greatest university in
and, of course, Reichert in the same old job. Groedel lost Europe, and a hotbed of new thinking among students and
no time to get going on the matter of a national society, faculty. Andreas Vesalius gave the impetus to the new
and the counsel was directed to incorporate the name activity in anatomic dissection. The bodies were of crimi-
AMERICAN COLLEGE OF CARDIOLOGY. It wasn't nals and, since stealing a loaf of bread was a capital of-
clear sailing; it meant the loss of the comfortable little club fense, there was no dearth of bodies. Vesalius dissected,
with its bttle dinner meetings. To some of the members taught, lectured, drew and supervised drawings. A whole
that was a disaster, but Groedel had his eye set on the dynasty of important researchers and teachers came from
target. What was needed was his kind of determination , the halls of Padua, among them William Harvey. Finally,
and, may I say it, his kind of money. Groedel wanted to in 1543 Vesalius published the first complete book of
register the corporation in every state of the union, so that anatomic drawings. Its influence was immediate and im-
nobody could "muscle in" on the project. There were mense. Great surgeons like Ambroise Pare were trained in
rumblings of discontent in other societies that published
their view that this College was not needed, and there was
the fear that the anual 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 compli-
cated 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 convert-
ing 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 Euro-
pean 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 Fig. 7 The seal of the American College of Cardiology. copied
start with the granting of its charter on December 2, 1949. from Plate 90 of the Vesalian Atlas of Human Anatomy
Oin. Cardiol. Vol. 1, April 1978

the new knowledge. Padua was a center of learning and that had complained that this organization was not needed
knowing, the final emancipation from ancient tradition, a had to be impressed with the numerical growth that under-
rebirth. lined the real need, the nature of its purpose and the hon-
We wanted our seal to memorialize the great beginnings esty of its adherence to its objects. Slowly the vocal an-
of scientific medicine in Padua. We searched Vesalius' tagonists were stilled; slowly they applied for membership.
book and found that heart that he drew with the Latin There was no other place where this kind of postgraduate
labelling it "the center of life". We had it copied exactly as education was available, and free.
Vesalius drew it with the aorta, pulmonary artery, great By the time of the first convention we had lost our
veins and what seem to be the vessels radiating to the ribs. Founding President, Franz Groedel; Bruno Kisch was now
We believed that the Vesalian heart was a fitting symbol of the leader; he was adamant in adhering to the program
what our College wanted to achieve, a teaching rebirth methods that had been set by Groedel. Kisch made an ex-
(Fig. 7). tensive European tour, presenting the College before
Our first meeting was comprised of three men, Groedel, many of the medical universities in six countries. When he
Reichert and Groedel's assistant, Max Miller. We elected returned, he reported on the enthusiasm and the interest
officers, Groedel, President, Max Miller, Assistant Secret- of the European cardiologists in the future plans and in
ary, and Reichert, Secretary as usual. Groedel's concept of the ideals of the American College of Cardiology.
the College was what he thought would be completely Bruno Kisch had other advanced ideas about the Col-
simple. The programs were to be built with the thought lege. One of the most important was that too much of the
that each doctor in the audience must leave with a solid local work was done by the local group; if we were to
chunk of new thinking that he could use in his practice. It branch out into the nation, we must concentrate on na-
was no secret that the programs of many society and hos- tionally known figures. One of the first was Robert P.
pital meetings were arranged to brighten the image of the Glover of Philadelphia, a pioneer in intracardiac surgery.
lecturer; too few were meant to be useful to every member Glover was world renowned for his introduction of surgical
of the audience. In the new College we would have a spe- relief of mitral stenosis. Glover became the third President
cialty group in the highest sense of the word, run entirely in 1953.
by and for the benefit of physicians, no lay members, no Glover was far from an easy leader; he had a surgeon's
lay money, no salaries for officers or lecturers, no lay con- ideas of direct handling of problems. The one problem was
tro\. He envisioned an organization absolutely free of poli- a financial one; none of the officers received a salary and
tics, free from commercial taint, free from insurance actually paid their own expenses of travel and office help.
schemes, free from travel clubs and all the other sideshows This had been fine for Groedel but it did narrow the field
that other societies seemed to need to stay alive. of available officers and committee chairmen. Glover sent
We felt that we would not compete with or duplicate a group of auditors (at his expense) to inaugurate a set of
any existing organization since we had an area of useful- books. The treasurer and secretaries' offices were com-
ness that no other organization was completely devoted to bined to insure accuracy and completeness of records. An
cover. Sticking by that set of rules has been the real reason office secretary had to be employed at a salary, and that
behind the phenomenal growth of the College. By the time required care and judgement.
the first general meeting was held in June 1952, the pro- The College was fortunate to find that the national trea-
gram attracted a medical audience of almost 500 physicians, surer of the Volunteers of America, Miss Maude Crafts,
from almost every state in the union, from Canada and was leaving the Volunteers and would be available to the
from as far away as Hawaii. The scientific papers delivered College. The best part of getting so experienced a person
by a distinguished list of cardiologists, surgeons and clini- was that her experience in a charitable organization made
cal investigators adequately covered the medical and sur- her salary requirements below the market price for that
gical management of heart failure, cardiac arrhythmias, kind of service. So now the College had a central office
coronary insufficiency, myocardial infarction, arterial set-up with a round the clock office manager.
hypertension and rheumatic heart disease. Particular stress One of the meetings that was fascinating for me was on
was placed on the evaluation of digitalis, quinidine, di- the subject of graphic registrations which was of great in-
cumarol, coronary vasodilators, other drugs for angina terest to me. The very fact that a blood pressure machine
pectoris. The surgery of hypertension, mitral stenosis, was so easily available made it popular in use; that hap-
pericarditis and coronary insufficiency were all covered pened to everything that came into diagnostic use. Any-
with the knowledge and experience then available. The thing that was too expensive or too difficult to acquire
management of the diabetic cardiac was also on the pro- would naturally be less frequently seen in a doctor's ar-
gram. It would be inconceivable that any attentive member mamentarium. Some instruments that were cheaply made
of the medical audience would not have profited greatly were of course deficient in accuracy and reliability, and all
from his attendance. this was for me a most interesting field to explore. I began
Naturally, the serious nature of the College was widely to collect all of the old apparatus I could lay hands on;
recognized and the membership grew quickly. The group many of the instrument dealers had the effects of deceased
C1in. Cardiol. Vol. 1. April 1978

doctors, some ·things too old and old fashioned to be of was not interested in coming into any organization just to
any use for possible resale. These dealers were happy to be another member; he wanted to "do things" that the or-
find someone who would want to acquire such things. ganization made possible. The College did not seem to of-
Franz Groedel had some of the European apparatus that fer anything that he did not already have on the West
he contributed. It was not long before I had amassed quite Coast. I wrote Griffith a number of long letters. I ham-
a collection. Lou Bishop found in his cellar a group of mered on the idea that he did not need the College, but
things his father had brought from his work in Europe; that we needed him; we needed him for all the clever
one of these was a Mackenzie polygraph that the elder things he could do and wanted to do. We could make
Bishop had used in his practice for years. It was still in many things possible working with him.
perfect shape. Other pieces of apparatus needed repair, Griffith finally surrendered; he was put on a program
and, I, set up a workshop to make usable pulse writers, Committee and showed his mettle at once. His influence
string ECGs, blood pressure manometers and clock dial was far reaching; he knew how to get important inves-
manometers. I learned a great deal about the reliability of tigators willing to appear on the program. He was suffused
all of these old instruments, how successive "improve- with the thought that the program must give to every per-
ments" often were incorrect. The whole field of graphic son present an honest piece of useful knowledge, and in-
registration of the cardiac cycle became clear to me, an I deed this was what the College had tried to do for years.
conceived the idea of setting up a museum of these in- Only Griffith knew how to do it better. After a few years
struments, showing the successive steps in the develop- he was elected president as a normal course of events.
ment of each. The Burroughs Wellcome Company had al-
ways been museum conscious and they helped by publish-
ing a handbook outline of the collection (1). It found its Postgraduate Education
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 Griffith was followed by another West Coast man, and he,
a permanent exhibit. They have a well staffed Archives too, was full of new and unusual ideas. The most impor-
Department, and it seems an appropriate place for such a tant one was an international circuit course, an attempt to
historical resource, indeed. visit one or two foreign countries, invited by the local car-
Hubert Mann had, three years before, constructed a diac group or university department; the visiting team al-
cardiograph that was really portable (4). This was ren- ways consisted of an internist, a cardiac surgeon, a
dered possible by the newer electronic components, physiologist and possibly a clinical pharmacologist. The
much more compact and easier to assemble than those so team varied in make-up from time to time, and it was
far manufactured. The small model was soon known as the changed so that different men had the chance to travel in
Cardiette and widely distributed. A bedside ECG was now this way. There was no fee for the work, although all ex-
much more simple; many more were taken and of course penses were paid; the number of men who made them-
much more ~as learned about their meaning. selves available was large and the praise for the work was
Hubert Mann now showed another of his ideas, a a matter of international renown. Elliot Corday was the
graphic representation of the electrical field set up around sponsor of the whole concept; the first several courses had
the heart during depolarization and repolarization of the to be paid for; Corday insisted on not taxing the College
myocardium. He called this the vectorcardiogram and at for this but paid out of his own pocket, a matter that was
this meeting he correlated the spatial vectorcardiogram more or less secret. But the U. S, Department of State saw
with the conventional tracings. The vectorcardiogram is an immense value of these peace envoys, and soon came
still in use today, still studied and discussed; Hubert Mann to realize that they could best use some of.their own funds
lived until 1977. He was always a recluse, came to meet- by underwriting the expenses of these circuit courses,
ings, spoke very little and acted quietly. But when he did Each succeeding President had some new idea and the
speak he was authoritative and clear. College prospered in many directions. Another West
The West Coast of the United States was curiously con- Coast president started a cassette learning program that
trolled by a relatively small group of very active physicians grew into a project that increased enormously out of sheer
who had many clever ideas and made interesting meetings. excellence. Dr. E. Grey Dimond continues to head the
Their hospitals employed the newest techniques; they program; the monthly cassettes are on all subjects in car-
seemed to be exactly the type of member that could do the diology with supplemental programs of history of car-
College the most good. I had met one of them some years diological development, things like the lives of cardiologi-
ago at a meeting of the American Medical Association cal investigators and what each contributed, a whole set of
where he had a clever and informative exhibit, and I had vectorcardiograms and what they show in each type of ab-
stopped to discuss it with him. He was George Griffith; he normality. Dimond also started the Young Investigators
did not remember me, of course, but I recalled the inci- Award, an annual competition of young research men, en-
dent to him and what had so completely impressed me. He couraged to work and to publish.
Clin, Cardiol. Vol. 1, April 1978

P. Reichert: Cardiology as Medical Specialty
15
Conclusion The size of this superstructure is hardly known to many.

The Journal of the American Medical Association lists
The solidity of cardiology as a recognized specialty is 7330 postgraduate courses for physicians offered by 1500
by 1978 well established all over the world, and to a large institutions. The College of Cardiology did more than es-
extent due to the dream of Louis Bishop, Sr., and of Franz tablish the specialty; it prodded a whole new aspect of
Groedel. The small group that was at the beginning was medical education. It is indeed an appropriate parallel to
industrious and sincere; the men who followed them were the rebirth of medical knowledge that took place at Padua,
imaginative in many ways. The basic aim was never de- fittingly commemorated by the seal of Vesalius.
parted from, and many of the methods that were devised
to accomplish the basic aim were copied by many organiz-
ations in many places.
It was a happy accident that the founding of the College References
was coincident with a sudden explosion of kowledge in all
of medicine. The electronic engineers came into the pic- 1. Burroughs Wellcome & Co.: Diagnostic instruments and tech-
ture, the surgeons and many other specialists. New mod- niques in medicine. The Reichert Collection. Burroughs Well-
alities in diagnosis and in treatment came into use, new come & Co., Inc., New York 1942
2. Einthoven, W M: Ein neues Galvanometer. Arch. de Physiol.
drugs and new laboratory procedures. A new postgraduate 4, 1059 (1903)
teaching format was at once urgently needed; the College 3. Reichert, P: Sir James Mackenzie and his polygraph. Am. J.
inaugurated a whole new series of workshops, seminars, Cardiol. 24,401 (1969)
exhibits, circuit courses and audiovisual cassettes, and the 4. Mann, H: The monocardiograph. Am. Heart J. IS, 681
(1938)
end is not in sight. The Founders had no way of seeing so
5. Waller, A D: On the electromotive changes connected with
far ahead but they did construct a well built basis on which the beat of the mamalian heart. Philos. Trans. Roy. Soc. Lon-
all these things could prosper. don, 169-194 (1889)

Clinical Cardiology - April 1978 - Reichert - A History of The Development of Cardiology As A Medical Specialty PDF

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Clin. Cardiol.

A History of the Development of Cardiology as a Medical Specialty

Introduction Ludwig was not only the great physiological investigator

Address for reprints :

Clin. ardiol. Vol. I, April 1978

There is at least one other landmark that equals in im-

lin . ardiol. Vol. 1, April 1978

Clin. Cardiol. Vol. 1, April 1978

Clin. Cardiol. Vol. 1. April 1978

Clin. Cardin\. Vo\. I, April 1975

ain. Cardio!. Vol. 1, April 1978

Oin. Cardiol. Vol. 1, April 1978

C1in. Cardiol. Vol. 1. April 1978

Clin, Cardiol. Vol. 1, April 1978

Conclusion The size of this superstructure is hardly known to many.

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