Cardiology.

Although cardiology was advancing rapidly in the 1950s it remained, like neurology, primarily a clinical discipline. Diagnosis relied on physical examination with some additional help from the electrocardiogram, chest X-ray and right heart catheterisation. Cardiac imaging was in its infancy. The specialty was led by some remarkable clinicians, notably Dr Paul Wood to whom I was house physician in 1959. The assessment of patients with mitral valve disease at that time illustrates the importance of clinical skills. Acute rheumatic fever was uncommon but the care of those with rheumatic valve disease remained a major feature of cardiological practice. Mitral valvotomy was already established in the UK but valve replacement awaited the development of cardiopulmonary bypass in the 1960s. Successful outcome from closed valvotomy required the careful selection of patients with mitral stenosis without significant regurgitation and with a sufficiently mobile valve to split along its commissures. Severity of stenosis and mobility of the valve were determined mainly by auscultation. Chest X-rays were examined for signs of left ventricular enlargement, signifying mitral regurgitation, or valvular calcification which made a successful split less likely. The severity of stenosis and any regurgitation was confirmed by analysis of the indirect left atrial pressure wave. If pulmonary hypertension was present the benefits of surgery had to be balanced against an increased operative mortality.