New book details development of modern cardiac care

"Caring for the Heart: Mayo Clinic and the Rise of Specialization," by W. Bruce Fye, M.D., and published by Oxford University Press in 2015, describes major developments in the diagnosis and treatment of heart disease and explains how Mayo Clinic became a prominent medical center. The book shows how scientific advances and technological innovations — along with national and international societies — helped create contemporary heart care and stimulate subspecialization.

"Caring for the Heart" was written for health care professionals, historians and policy analysts, as well as the general public. Dr. Fye spent more than a dozen years researching and writing it. In the process, he reviewed more than 15,000 printed and unpublished documents and interviewed 63 individuals, including physicians, surgeons, scientists, nurses and technicians.

Dr. Fye, now an emeritus cardiologist at Mayo Clinic in Rochester, Minnesota, is a past president of the American College of Cardiology and the American Association for the History of Medicine. We are pleased to present highlights from this fascinating book as we conclude the yearlong celebration marking the 100th anniversary of the inauguration of formal cardiac services at Mayo Clinic.

The electrocardiograph and the birth of cardiology (chapter 5)

Franklin Lane had served under Presidents Theodore Roosevelt, William Howard Taft and Woodrow Wilson. During 1920, the beloved 56-year-old Lane became progressively disabled by chest pain that occurred with activity and at rest. He also had recurring upper abdominal pain. After an East Coast doctor diagnosed gallbladder disease, Lane decided to go to Mayo Clinic.

Writing from Rochester in December, he said, "I am being ground and wound and twisted and fed into and out of the Mayo mill, and a great mill it is." An ECG led to a sudden change in the treatment strategy; it revealed abnormalities during an episode of chest pain that suggested that elective abdominal surgery was too risky. Dr. Will Mayo would not operate on Lane's abdomen.

Another Mayo surgeon took out his tonsils. Took out his tonsils? The decision to perform a tonsillectomy was based on the focal infection theory, which was proposed in an era when doctors thought bacteria might cause some noncontagious diseases.

Challenges and changes during the Depression (chapter 6)

Mayo clinical investigators pioneered the use of two blood thinners: intravenous heparin in 1938 and an oral agent that would be termed dicumarol three years later. The Mayo researchers had a unique opportunity to compare heparin and dicumarol because both anticoagulants were available in Rochester before almost any other clinical investigators had access to either one.

Commercialized versions of heparin and dicumarol (and a similar drug that would be named warfarin) would become mainstays of therapy to prevent acute and chronic thrombosis and embolism. The ability of these drugs to prevent blood from clotting made them indispensable for the development of technologies that revolutionized lifesaving treatments after World War II, such as kidney dialysis and open-heart surgery.

President Roosevelt's secret hypertensive heart disease (chapter 7)

When Howard Bruenn, the chief of cardiology at the Naval Medical Center in Bethesda, first examined President Franklin Roosevelt on March 24, 1944, he discovered that his blood pressure was high (186/108 mm Hg), and he had worrisome findings, including mitral regurgitation and congestive heart failure. An ECG demonstrated dramatic T wave inversions; New York cardiologist Harold Pardee had written three years earlier, "Follow-up reports of the Mayo Clinic show that when associated with other abnormalities of the cardiovascular system, T wave abnormality added considerably to the gravity of the prognosis, such patients having a shorter average duration of life than those with normal T waves."

During the first week of April 1944, President Roosevelt's nine blood pressure readings averaged 210/114 mm Hg. At the time, documenting hypertension was relatively easy, but treating it was almost impossible.

Gossip regarding the president's health circulated at Bethesda Naval Hospital in Maryland and at Mayo Clinic, prompting the White House to request FBI director J. Edgar Hoover to investigate. The timing and pace of this investigation reflected the fact that the election was just days away. One of the FBI agents recalled that he had been sent to Rochester "in what proved to be an attempt to prevent the information on FDR's circulatory disease from becoming public knowledge."

The media had made no mention of the casual conversations in Rochester and Bethesda, and press secretary Steve Early wanted to keep it that way. White House physician Ross McIntire misled reporters about the president's medical evaluations and never informed the press or the public that Roosevelt had significant hypertension or that a cardiologist had diagnosed heart failure. In fact, he continued to deceive the public in 1946, a year after Roosevelt died of a stroke.

McIntire claimed, "There are some conditions, of course, in which we think we can predict it, such as extremely high blood pressure and advanced general arteriolosclerosis, although there is no certainty. President Roosevelt did not have either of these. His blood pressure was not alarming at any time."

Pioneering open-heart durgery at the University of Minnesota and Mayo Clinic (chapter 10)

On March 22, 1955, surgeon John Kirklin led a team that helped him perform Mayo's first open-heart operation on a 5-year-old girl who had been born with a large ventricular septal defect. Two months later, Kirklin reported the results of the first eight open-heart operations.

The patients, who ranged in age from 4 months to 11 years, were severely symptomatic from congenital heart disease and had a very poor prognosis. Half of the children died. Despite the high mortality rate, Kirklin concluded that the new Mayo-Gibbon heart-lung machine functioned well and "established excellent conditions for precise, unhurried intracardiac surgery."

In that year, open-heart surgery was done on a regularly scheduled basis in just two institutions in the world: the University of Minnesota and Mayo Clinic. Heart surgery pioneer Harris Shumacker later claimed that "the 1955 report of John Kirklin and his colleagues of their first clinical experiences was most important in the history in the development of contemporary cardiac surgery."

Creating coronary care units and empowering nurses (chapter 13)

Clark Gable finished filming "The Misfits" with Marilyn Monroe on Nov. 4, 1960, four days before John Kennedy was elected president. But the 59-year-old actor did not have a chance to celebrate the movie's completion or cast his vote. Gable was admitted to the hospital with a heart attack on Nov. 6.

Former President Dwight Eisenhower, who had spent a month in bed after an acute myocardial infarction six years earlier, wrote to the actor, "I learned from the paper this morning that you have suffered a mild coronary thrombosis. I trust that your recovery will be rapid and complete." Gable's recovery went well until the 10th day, when he died suddenly in his hospital room. The actor was not connected to a heart monitor, and no one was aware that he had a cardiac arrest.

Physicians recognized the lifesaving potential of the technologies clustered in specialized coronary care units during the 1960s, and their widespread establishment contributed to a very significant shift in the traditional relationship between doctors and nurses. Support for granting specially trained nurses authority to defibrillate patients grew during the second half of the decade. The practice of nurses using defibrillators also gained popularity because it represented an alternative to having a doctor less than five minutes away from vulnerable patients at all times. There simply were not enough physicians to provide instantaneous round-the-clock coverage, especially at community hospitals without interns or residents.

Challenges and opportunities around the new millennium (chapter 20)

In 2009, Boston surgeon and best-selling author Atul Gawande published "The Cost Conundrum" in The New Yorker magazine. The academic surgeon observed, "Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse. For example, Rochester, Minnesota, where the Mayo Clinic dominates the scene, has fantastically high levels of technological capability and quality, but its Medicare spending is in the lowest 15 percent of the country."

Gawande had drawn some of his conclusions from a trip to Rochester as a visiting surgeon. Characterizing Mayo as one of the highest quality, lowest cost health care systems in America, he described some of the human interactions he observed. Gawande was impressed with "how much time the doctors spend with the patients. There was no churn — no shuttling patients in and out of rooms while the doctor bounces from one to the other."

For more information

Fye WB. Caring for the Heart: Mayo Clinic and the Rise of Specialization. New York, N.Y.: Oxford University Press; 2015.