Book Review

American Cardiology: The history of a specialty and its college

N Engl J Med 1996; 335:1401-1402October 31, 1996

Article

American Cardiology: The history of a specialty and its college
By W. Bruce Fye. 489 pp. Baltimore, Johns Hopkins University Press, 1996. $24.95. ISBN: 0-8018-5292-7

The American College of Cardiology “was at the beginning, of course, a miserable organization but I can well see that perhaps . . . it is headed for better days.” That is how Paul Dudley White, the leading academic and clinical cardiologist of his day, described the new organization in 1959. Bruce Fye's American Cardiology is very much a saga of the American College of Cardiology from its origin in 1949 to its current position as the leading educational and political voice of more than 22,000 cardiovascular specialists.

The American College of Cardiology commissioned this work, so it is hardly surprising that Fye champions the organization, particularly in relation to the powerful American Heart Association. His book is a story not so much of physicians and their ideas, but of the organizations and political and economic forces that shaped the history of cardiovascular medicine in the United States. The stories of the American College of Cardiology and American cardiology are given equal weight here.

The creation of the American Heart Association in the 1920s was a seminal moment for American cardiology, for it united the interests of epidemiologists, who needed new diseases to attack because of the decline of infectious diseases; cardiovascular physiologists, who were making new discoveries about the circulation; and academic physicians, who had a new technique, electrocardiography, with which to study heart disease. Their joint goal was to attack chronic heart diseases through research. The American Heart Association offered no role for practitioners of cardiology, who had increased in numbers with the availability of electrocardiographs in the 1940s and 1950s. Furthermore, to increase funding, the American Heart Association extended its membership to laypersons in the 1940s.

A group consisting largely of immigrant New York–based cardiologists formed the American College of Cardiology in 1949 as a professional organization primarily for clinical cardiologists. Their leader was Franz Groedel, a German immigrant who was the leading authority on bath therapy for cardiovascular diseases. It is small wonder that the leaders of the American Heart Association establishment looked askance at the upstart organization. Howard Sprague, a prominent Boston cardiologist and leader of the American Heart Association, thought that the American College of Cardiology was “merely the attempt of a few individuals who have apparently been unable to make the adjustment between the American scene and their refugee status.”

Fye's book chronicles nicely the growing pains of the American College of Cardiology as it sought legitimacy and, ultimately, parity and partnership with the American Heart Association. He deals with all the contentious issues that others have raised, including professional snobbery, elitism, and anti-Semitism on the part of the establishment. Ironically, after achieving success, the American College of Cardiology had to ease some of its earlier stalwarts into the background and turn to academicians to establish its position of leadership.

Bruce Fye, a clinician (he is the chief of cardiology at Marshfield Clinic), bibliophile, and dealer in rare medical books, is no amateur historian. He was trained at the Johns Hopkins Institute of the History of Medicine and has written extensively on historical matters relating to cardiology, internal medicine, and physiology. He is a meticulous chronicler and a careful analyst who can relate events to bigger historical pictures. His exhaustive use of the medical literature, political documents, biographical material, and American College of Cardiology archives provides a wealth of information about the growth of cardiology and medicine in general in the 20th century. Interviews with nearly 50 physicians who participated in that history furnish informative opinions about the events described. Nearly a third of this book is devoted to tables, figures, notes, bibliography, and index. The use of tables to present factual and even biographical matters allows the narrative to flow easily, in an almost novelistic style.

The final chapter, “The Price of Success: Tensions in and around Cardiology,” is particularly sobering. Earlier, Fye describes the successful efforts of the American College of Cardiology and American Heart Association and many people to increase government funding for cardiovascular research and training in the 1950s and 1960s. This effort fueled the phenomenal growth of cardiovascular research and cardiology training programs from the 1960s through the 1990s. Training, for example, rose from 19 programs and 37 trainees in 1950 to 210 programs and 2633 trainees in 1995. Coincidentally, the Medicare program was established in 1965. Cardiology was poised to take advantage of its reimbursement system, which promoted the use of procedures, with new forms of technology and procedures using surgery and catheterization to manage coronary artery disease. As a result, cardiology divisions became disproportionately powerful and often unruly members of departments of medicine. Cardiologists' incomes soared to the point at which they reached third place among medical and surgical specialists.

Readers of Fye's book will appreciate the contrast between the scientific idealism of the founders of cardiovascular medicine in the first half of the century and the later ascendancy of technology and economics in cardiology. Also evident is the striking success of those scientific efforts to manage and prevent heart disease. This book is so full of historical material, so rich in insight and observation, and so well written that anyone interested in the history of medicine will enjoy it. As is so often true of excellent histories, there is much here to learn about our current situation as well.

Nicholas J. Fortuin, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205