Sir Thomas Lewis Pioneer Cardiologist and Clinical Scientist

Transcription

1 Sir Thomas Lewis Pioneer Cardiologist and Clinical Scientist

2 Springer London Berlin Heidelberg New York Barcelona Budapest Hong Kong Milan Paris Santa Clara Singapore Tokyo

3 Arthur Hollman Sir Thomas Lewis Pioneer Cardiologist and Clinical Scientist With 145 Figures Springer

4 Dr Arthur Hollman, M.D. F.R.C.P. F.L.S. Emeritus consulting cardiologist, University College Hospital, London, UK Honorary Senior Lecturer, Department of Medicine, University College London Medical School Sea Bank, Chick Hill, Pett, East Sussex TN35 4EQ, UK Cover illustration: The main photograph on the front cover shows Thomas Lewis aged 27 in 1909 (Chapter 2, Figure 10) ISBN-13: DOl: / e-isbn-13: British Library Cataloguing in Publication Data Hollman, Arthur Sir Thomas Lewis: pioneer cardiologist and clinical scientist I. Lewis, Sir Thomas 2. Cardiologists - Great Britain - Biography I. Title 616.1'2'092 Library of Congress Cataloging-in-Publication Data Hollman, A. (Arthur) Sir Thomas Lewis: pioneer cardiologist and clinical scientist 1 Arthur Hollman. p. cm. Includes index. ISBN-13: (paperback: alk. paper) I. Lewis, Thomas, Sir, Cardiologists-Great Britain-Biography. 3. Electrocardiography-History. I. Title. [DNLM: I. Lewis, Thomas, Sir, Cardiology-biography WZ 100 L676H 1996] RC L49H '2'0092-dc20 [B] DNLM/DLC for Library of Congress CIP Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. Springer-Verlag London Limited 1997 Softcover reprint ofthe hardcover 1st edition 1997 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Typeset by EXPO Holdings, Malaysia 28/ Printed on acid-free paper

5 For my wife and our daughters, and in memory of my parents who gave me a medical education

6 Foreword It is timely that Arthur Hollman's biography of Sir Thomas Lewis, with an account of his philosophy of clinical science as well as of his personal contributions to medicine, should appear now, just over 50 years since his death. While one could have anticipated that the life of such an eminent physician would have been written sooner, we have the advantage of the detailed scrutiny of his work and of the records to which Hollman has devoted himself for some years. Indeed, as the book went to press, he was able to locate and speak to the 87 year old Dr Werner Hess, one of the two German postgraduate students who had worked with Lewis in 1931, and confirm that his portrait shows a duelling scar. This meticulous attention to detail and the depiction of Lewis' relationships with his colleagues and students underpins the biography. British cardiologists recognise the key role played by Lewis in the establishment of their specialty. The important influence that he had on American cardiology and on electrocardiography in particular has not been forgotten by those with a sense of history. Yet active work in cardiology, with dedication to electrocardiography, research on arrhythmias and conduction disturbances in particular, occupied no more than 15 years of his life; but he did of course continue to take a profound interest in diseases of the cardiovascular system and to teach and to write on the subject to the end of his days. A keen writer and critical journal editor, he played a key role in the genesis of the Cardiac Club, forerunner of the British Cardiac Society. Only now has the British Heart Journal reverted to his original journal title, Heart, established by Lewis in Lewis is of course well remembered for being one of the first to describe the electrocardiographic appearances of atrial fibrillation in man, making his initial observations a few months after Rothberger and Winterberg of Vienna. He characterised virtually every other rhythm disorder save for the pre-excitation syndromes, but did not focus on cardiac infarction and ischaemia, where the electrocardiograph has played so major a role. He was not always right when it came to the distinction between left and right bundle branch block, the importance of left ventricular failure and the mechanical problems created by valve disease, but as he considered the evidence over the years, he did where necessary accept the views of others. Cardiac catheterisation was introduced towards the end of his life and he was rather negative about it. Yet, over all, he had a profound positive influence in the development of cardiology as a specialty, and in the

7 FOREWORD recognition of war-induced stress, during the First World War, and Paul Wood took matters further during the Second World War. As he completed the classical third edition of his Mechanism and Graphic Registration of the Heart Beat, Lewis turned to other aspects of medicine including cutaneous reactions, peripheral vascular disease, and pain perception. Underlying all these various interests was his quest for the physiological explanation for clinical phenomena, in other words clinical science. Careful observation of physical signs allied to their sound interpretation still forms a proper scaffold for clinical medicine at the end of this century, and the importance of linking basic research with clinical presentation is as valid today as he had demonstrated it to be from the outset of his career. We get an absorbing picture of a man who was clearly perceived in different ways by those who worked with him; above all, a man who concentrated powerfully on what he was doing and who was an explicit and stimulating clinical teacher to his pupil who now gives us this account of his life. Weare fully apprised of his family background and see the interplay of family life and friendships. In Arthur Hollman, his teacher Sir Thomas Lewis has found a fair and thorough biographer who while critical where appropriate is sympathetic to him and his cause in giving us a detailed account of a man of considerable intellect and influence. Dennis M. Krikler viii

8 Preface For your own satisfaction and for mine, please read this preface St. Francis of Sales: preface to Introduction to Devout Life (1609) When I was a medical student at University College Hospital from 1943 to 1945 I had the good fortune to be a pupil of Sir Thomas Lewis. I was a clinical clerk on his firm for three months and attended his course of lectures. As a result I became very interested in clinical science and with Sir Thomas' help I started to investigate the mechanism of 'stitch' in his department. So it was natural for me to remember him with respect as a great medical scientist and a fine teacher. This led me on the tenth anniversary of his death to ask some of his former associates to record their reminiscences of working with him in a special issue of the University College Hospital Magazine. In his lectures, Lewis spoke about former great physicians and of medical discoveries and this gave me my first interest in the history of medicine. I then realised that many medical biographies were based on second and third hand accounts and I therefore resolved to obtain further information from men and women who had worked directly with Lewis. With the generous assistance of the Wellcome Trust I was able to record interviews with 24 of his research associates, house physicians or students, and I believe that these oral history recordings could also be of value to other medical historians. In addition I obtained useful information from informal interviews and from correspondence. This is the first biography of Lewis and although originally I did not intend to write it myself, it gradually became apparent that I would be the author. An especial catalyst to that idea came from Dr Dennis Krikler when he recommended to the British Cardiac Society that I should be appointed their Thomas Lewis Lecturer in 1981 in order to speak on Lewis' work. Dr Krikler has been a tremendous source of encouragement and information ever since and I am deeply grateful to him. It has of course taken far too long and although it is now completed I do not wish to imply that it could not be usefully extended. I continue to see areas that could well be expanded or better explained, but one has to draw a line somewhere. I decided that the book should consist mainly of accounts oflewis' scientific work. Perhaps this sounds obvious but what I have tried to do is to concentrate on his own achievements as an electrophysiologist and clinical scientist without, as a rule, describing what other investigators were doing at the same time. To have done so would have meant diluting the essential message about Lewis' work with a

9 PREFACE rather poor history of cardiology and experimental medicine. In any case, a lot of his work was truly original. I have also attempted to summarise the main points of his research endeavours rather than give long accounts of them. Like all attempts to write briefly, this has involved much more work than writing at length, because I have had to try and understand the nature of his research. In some cases, especially the effort syndrome and pain, this was not always an easy thing to do. However I have not hesitated to quote directly, and sometimes at length, from his own writing when I felt that this would give a better picture of what he was saying, rather than paraphrase it. The other decision I made early on was that this would be a book for doctors. So there are inevitably technical aspects which I regret nonmedical readers will find difficult to follow. On the whole the layout is chronological, but at times it was appropriate to deviate from this approach. For example there are separate chapters on clinical science, on his hospital, departmental and teaching work, and on his family life and hobbies. But although Lewis' work is described quite briefly, I have gone to some trouble to give as many references as I can to all aspects of it, including even brief passages of his correspondence, in order to help other workers. I have read every reference myself. No reference has been included for the sake of completeness. Some of the references, particularly to those in the Wellcome Institute Contemporary Medical Archives Centre, are being published for the first time, for example Lewis' help to German Jewish refugee doctors. It is a mistake to regard Lewis just as a cardiovascular specialist (he disliked the term cardiologist). His mission in life was that of experimental medicine, or clinical science as he came to call it, but his work on the heart was the first, and became the best known, of his research endeavours. In fact his investigations into pain, in my opinion, were intellectually even better than his highly praised electrocardiographic studies. And his identification of a chemical factor, the H substance, as the mechanism of injury to the skin was also a fine achievement. However many do still remember him chiefly for his seminal work on the electrophysiology of the heart and on cardiac arrhythmias, and I have not hesitated to give emphasis to these exciting discoveries. Being a cardiologist, I am not free from bias in this respect! In some quarters there is now a strong tendency to play down the personal contributions of individuals and to emphasise instead the general events of their lifetime. In other words to demonstrate the importance of what is called social history. But I have not felt the urge to join this movement. Quite apart from being an essential duty, it is a great pleasure to thank those who have encouraged, assisted and educated me during the writing of this book. Dr Gerald Graham, formerly my colleague at the Hospital for Sick Children, London, did the most important thing by recommending my work to Springer Verlag. Writing a book is one thing, but getting it published it quite another, and Dr Graham did this without my even asking him for help. I am deeply grateful to him x

10 PREFACE for his assistance which came entirely from kindness of heart and his interest in the subject. Professor John Pattison is the Dean of University College London Medical School and I cannot thank him enough for the continued interest he has taken in this book which has led to the School providing the essential and very generous financial support needed to ensure publication. A draft of the manuscript was perused in detail by Dr Howard Burchell of St Paul Minnesota who gave it his approval. Because he is one of the world's leading cardiac historians his approval was important and I thank him warmly for it, and for all his help. It has been good also to have the appreciated support and advice of other historian friends in the United States, namely Drs W. Bruce Fye, Paul Kligfield and Charles F. Wooley. Dr John Honour was Lewis' personal laboratory assistant for 18 years. He has been a friend ever since my student days and I cannot overestimate the value of the information he has given me on many occasions. I wish to thank him warmly for his unstinted help and advice. I have been fortunate in having tremendous support and help from Sir Thomas' family. Lady Lewis, who survived her husband by 44 years, very kindly talked to me on several occasions and her assistance was invaluable. The eldest daughter Pat and her husband Sinclair Watson have been of immense help. They have answered many queries, have supplied family photographs, and have been generous with their time and hospitality. The younger daughter Pip, Mrs Phillip a Althaus, wrote a nice account of her father. The son, Dr Christopher Lewis, has written a long and valuable account of recollections of his father. I am deeply grateful to them all. I thank the Wellcome Trust for its important help and financial support. The staff of the Wellcome Institute for the History of Medicine have been very helpful and I am grateful to Dr Christopher Lawrence for his advice. Mrs Julie Beckwith, assistant librarian at the Royal College of Physicians London, has my warm thanks for answering an almost unending number of enquiries with precision and good humour. Mr Stephen Paratian has taken many photographs for me and Mrs Berti Rooke-Ley has often given secretarial help. They both work in UCL Medical School and I am grateful for their assistance. It has been a pleasure to work with Springer and I appreciate the friendly and immensely efficient help I have had from Rebecca Moore, Nick Mowat and Nicolas Wilson. My wife, Catharine, has patiently put up with long and solitary hours when I have either been writing in my study, or visiting libraries. Luckily she too was a medical student at University College Hospital so the project was quite a personal one for her also and she has followed it with especial interest and with great benefit to myself for which I offer her my very best thanks. The Greek physician Galen ( ) is said to have given the following reasons why a man should write a book. 'Firstly, to satisfy his xi

11 PREFACE own friends; secondly to exercise his best mental powers; and thirdly to be saved from the oblivion incident to old age'. I sincerely hope that my family and friends will give their approval to this book. Should they do so then I too will be satisfied. Arthur Hollman Numbering of Notes and References Bracketed superior numbers in the text refer to Notes shown at the end of each chapter. Unbracketed superior numbers refer to the References section which starts on page 279. xii

12 Acknowledgements I am grateful to Mrs Patricia Watson (nee Lewis) for generously lending me photographs of her family and her father's associates and allowing me to publish them. Dr Herbert J. Levine kindly gave me a photograph of his father, Dr Samuel A. Levine. I thank Dr Joel D. Howell and Dr D.W. Sonneborn for lending me photographs taken at Ann Arbor of Willem Einthoven, Frank N. Wilson and Sir Thomas and Lady Lewis. Dr A.J. Honour kindly gave me a photograph of himself, and Dr Alan Sykes supplied a picture of A.D. Waller. Permission to reproduce pictorial and written material in their possession has been granted by the following authorities. The Museum Boerhaave Leiden for Figures 3.1 and 7.1. The British Medical Journal Publishing Group for Figures 3.9, 11.4 and The Gambit Press, Boston, for the quotation from reference 255. Peabody and Arnold, Boston, for Figures 13.1, 13.2, 13.3, 13.5, 17.1, 17.2 and The Medical Research Council for quotations from their archives. The National Library of Medicine Washington DC for Figure The Portland Press Ltd for Figures 14.1, 14.2 and The Rockefeller Foundation for Figure The Royal College of Physicians of London for Figures 2.2, 9.5, 10.2, 11.2, and The Royal Society of London for Lewis' personal record. Shaw and Sons Ltd for Figures 2.7, 3.11 and 5.3. The Librarian University College London for Figures 1.8 and 2.1. The Wellcome Institute Library London for Figures 5.1, 5.4, and 9.3. If by unintended oversight I have omitted to request permission to publish, or have failed in any way to acknowledge copyright material, I offer my sincere apologies.

13 Contents Chronology xvii Chapter 1 Early life. Family. Education. Medical School at University College Cardiff and University College London... 1 Chapter 2 Graduates. House appointments at University College Hospital. Research on pulse and blood pressure. Meets Dr James Mackenzie in 1908 Becomes editor of Heart Chapter 3 The electrocardiograph. Elucidates atrial fibrillation and other arrhythmias. Gets his own department. Writes a much acclaimed monograph. Meets Willem Einthoven Chapter 4 Appointed to the staff of UCH Studies on the excitatory wave, bundle branch block, and ventricular hypertrophy. Research in medicine. Visit to Canada and the United States of America Chapter 5 The Medical Research Committee. The World War. The Soldier's Heart and the Effort Syndrome Chapter 6 Department of clinical research established. Atrial fibrillation and the circus movement. Mechanism and Graphic Registration of the Heart Beat. Experimental and clinical studies with quinidine Chapter 7 Visits Einthoven in Leiden Endocarditis research. Congenital heart disease. Visit to the United States of America ChapterS War injuries used as research models. The triple response of the skin to injury, the H substance. Monograph on blood vessels of the human skin. Physiology and medicine. Third edition of The Mechanism. Nobel Prize for Einthoven Death of Mackenzie. Controversy over dog experiments

14 CONTENTS Chapter 9 Has a myocardial infarction _ The Harvey Film _ Royal Medal of the Royal Society _ Disagreement with W.H. Craib_ Presentation volume from his associates Chapter 10 Clinical Science Chapter 11 Cold and the skin _ Cold urticaria and haemoglobinuria _ Acrocyanosis _ Raynaud's disease Chapter 12 Intermittent claudication _ Factor P. Angina pectoris _ Erythralgia _ A visit to the United States of America in R.T. Grant's 1000 patient follow up study Chapter 13 Diseases of the Heart _ The Harveian Oration _ Completion of eight years' work on the peripheral circulation - The last volume of Heart _ Vascular Disorders of the Limbs _ A second myocardial infarction Chapter 14 Studies of pain _ The nocifensor system of nerves _ Double pain response in the skin _ Referred pain and tenderness Chapter 15 The Cardiographic Department and the Department of Clinical Research _ Hospital duties and teaching Chapter 16 Marriage _ Family life _ Holidays _ Hobbies Chapter 17 The war years _ Effort syndrome _ Llandough Hospital - Monograph on Pain _ Views on digitalis _ Copley Medal - Final illness and death Appendices References Index xvi

15 Chronology 1881 Born in Cardiff, Wales Attended Clifton College Bristol for one year. Before and after that he was educated at home Decided at the age of 13 to become a doctor Home tuition continued by a tutor, until aged Went to University College Cardiff B Sc (Wales) with honours. 2nd MB (London) with gold medal. Primary FRCS (England) Publishes his first scientific paper Enters University College Hospital London (UCH) Elected to the Physiological Society. Conjoint diploma Final MB BS (London) with University gold medal. D Sc (Wales) House surgeon and house physician at UCH, until Undertakes original research work on the pulse Appointed to the staff of the City of London Hospital and the Seamans' Hospital. Working in the laboratory of Professor E.H. Starling at University College London (UCL). MD (London), MRCP (London). Elected Fellow ofucl Meets Dr James Mackenzie, a pioneer of cardiac investigation, who greatly influences his career, and who encourages him to study irregular heart action Starts private consulting practice in Wimpole Street Founds the journal Heart and becomes its first editor. Now aged Visits Willem Einthoven, the great pioneer of electrocardiography in Leiden, and initiates a long collaboration and friendship with him Acquires his first electrocardiograph machine and begins an intensive study of cardiac arrhythmias. Elucidates atrial fibrillation in man.

16 CHRONOLOGY 1910 Awarded a Beit Memorial Fellowship. Appointed lecturer in cardiac pathology at UCH Pioneer monograph The Mechanism of the Heart Beat Appointed assistant physician at UCH. Elected FRCP (London). Writes a teaching book on Clinical disorders of the heart beat, followed in 1913 by Clinical Electrocardiography Invited to the United States of America to give the Herter and the Harvey Lectures His first communication to the Royal Society of London Appointed physician at the Military Heart Hospital Hampstead. Appointed physician on the staff of the Medical Research Committee, the first full time post in clinical medicine in Britain. Commences research work on 'Soldier's Heart', which he re-names the Effort Syndrome. Gives up private practice Marries Miss Lorna James of Merthyr Tydfil, Wales Croonian Lecture at the Royal Society summarises his outstanding work in cardiac electrophysiology Monograph The Soldier's Heart and the Effort Syndrome. Elected a Fellow of the Royal Society of London First child, Patricia, is born Appointed Physician at UCH, and establishes the Department of Clinical Research in UCH Medical School under the Medical Research Council Appointed Commander of the British Empire. Writes an article for British Birds on the Little Tern Created a Knight Bachelor. Intensive study of the mechanism of atrial flutter and fibrillation leading to his hypothesis of the circus movement Founder member and first chairman of the Cardiac Club Gives invited lectures in the United States Second child, Christopher, is born Studies the vascular reactions of the skin to injury and proposes the 'H substance' as the mechanism of the triple response to injury. Gives up research on the heart Publishes the third and highly acclaimed edition of The Mechanism and Graphic Registration of the Heart Beat Monograph, The blood vessels of the human skin and their responses. Has a myocardial infarction at the age of 45 and recovers well. Awarded the Royal Medal of the Royal Society. xviii

17 CHRONOLOGY 1929 Commences a study of Raynaud's disease He founds, with others, the Medical Research Society and becomes its first chairman Research on pain in muscular ischaemia, with its cause identified as a chemical substance, 'factor P' Third child, Phillip a (Pip), is born. A third lecture tour in the United States when he enjoys bird watching with Dr Frank Wilson at Ann Arbor He has been a member of the Council of the Royal Society from and Identifies the mechanism of Raynaud's disease Delivers the Harveian Oration on Clinical Science. He founds the journal, Clinical Science incorporating Heart and becomes its editor. He is appointed a member of the Medical Research Council, and serves until Diseases of the Heart is published and becomes very popular with students and doctors The family moves to a new house in the country with a large garden and a trout stream He recounts his own research work in Clinical Science, illustrated by personal experiences Has a second myocardial infarction. Delivers the Huxley Lecture on clinical science Writes an excellent teaching book, Vascular disorders of the limbs He proposes that cutaneous hyperalgesia is due to a hitherto undescribed 'nocifensor system' of nerves in the skin. His hypothesis is attacked but is validated 50 years later Makes a teaching film on heart failure called 'The signs of venous congestion' Concludes three years work on the double pain response in the skin, and on the experimental production of referred pain The outbreak of World War 2 terminates the work in his department, never to be re-established. The hospital and medical school are evacuated from London Takes charge of teaching UCH students at Llandough Hospital near Cardiff Wales Is awarded the Copley Medal of the Royal Society which is its most prestigious award. xix

18 CHRONOLOGY 1942 His monograph Pain is published in the United States Articles on reform in medical education His book Exercises in Human Physiology is designed to introduce physiology students to clinical medicine Dies at his home with a third myocardial infarction on March 17 at the age of 63. xx