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The King Is Dead: Clark Gable’s Heart Attack
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The King is Dead: Clark Gable’s Heart Attack Short Title : Clark Gable’s Heart Attack
Robert S. Pinals M.D. Clinical Professor of Medicine Rutgers University Robert Wood Johnson Medical School 1 Robert Wood Johnson Pl. New Brunswick, NJ 08903 [email protected]
Harold Smulyan M.D. Emeritus Professor of Medicine State University of New York Upstate Medical University 90 Presidential Plaza Syracuse NY 13208 [email protected]
Corresponding Author Harold Smulyan M.D. Upstate Medical University Department of Medicine Cardiology Division 90 Presidential Plaza Syracuse, NY 13208 Tel 315-464-4535 [email protected]
The authors have no conflict of Interest and no funding source
Key Words – movies, air corps, myocardial infarction coronary care
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Abstract Clark Gable was born in a small Ohio mining town and never finished high school. Stage struck as a young man, he did menial jobs while working his way up to movie stardom – his most famous role was in “Gone with the Wind”. He married 5 times. During WWII, he enlisted in the Army Air Corps, flew a few combat missions as a gunner and won the Distinguished Service Cross. Personally, he was intermittently obese, a drinker, smoker, hypertensive and predictably in 1960, he suffered an acute myocardial infarction. His clinical course was benign until the 10th hospital day, when he died suddenly. No resuscitation was attempted. At the time of his death, preventive cardiology, mouth-to-mouth ventilation, closed chest cardiac massage and defibrillation and coronary care units were in their infancy. The history of these and subsequent therapeutic practices are reviewed but Gable died a bit too early for their application.
Introduction In November, 1960 the world was shocked to learn of the sudden death of 59 year old Hollywood star Clark Gable 1-3. He was in a hospital recovering from a “mild” heart attack which had occurred 10 days earlier, just after completion of his last movie. He had appeared in over 60 films, playing opposite most of Hollywood's most popular actresses as a virile, adventurous and romantic leading man. Movie fan magazines titled him the “King of Hollywood” and documented his marriages, affairs and other activities in breathless detail 2. In this report we review Gable's life, career and untimely death after a myocardial infarction. We also discuss the major changes in the prevention and management of coronary disease and its complications 2
that occurred in the 1960’s, including identification of risk factors, cardiac monitoring and resuscitation.
LIFE AND CAREER
Clark Gable's life began inauspiciously in a rented room in Cadiz, a small coal-mining town in southeastern Ohio. His mother had been disabled by an unspecified illness, which featured seizures and psychosis. The baby weighed 10 ½ lbs with large hands and feet and prominent protruding ears and was said to resemble his father, a worker in the oil fields 20 miles away. Clark's mother died when he was 10 months old, but fortunately his father soon married a woman who would devote herself to his upbringing. Perhaps this established a pattern which would persist into adulthood; his first two wives were older women who would nurture him and support his career. Clark left high school before graduation and held a number of blue collar jobs before discovering his true calling on seeing his first stage play in Akron. This was a melodrama set in Hawaii, with grass-skirted hula dancers. While looking for a theatrical opportunity he migrated westward, supporting himself with temporary menial jobs. In Oregon he met Josephine Dillon, a former actress, now a drama teacher, 17 years older than Gable; she took him under her wing and later became the first of his 5 wives. Dillon supported his early acting career and in 1924 they moved to Los Angeles, where Gable found work in a gas station and as a movie extra. On the stage he advanced to leading man roles, with help from another older woman, Pauline Frederick, a star on Broadway and in silent movies. She had an affair with Gable, recommended him for more important roles and paid to have his teeth fixed. In 1927-28 Gable became a matinee idol while working for a stock company in Houston. There 3
he met Maria Langham, a wealthy divorcee who was 14 years older; after a discrete affair she became his second wife and arranged for plastic surgery to move his ears closer to his head.
Gable's movie career started in 1931 in supporting roles, but his star potential was recognized by Irving Thalberg, MGMs production chief, and Gable was a leading man before the year ended. With his 21st movie in 1934, It Happened One Night, Gable won his first and only Academy Award as Best Actor. Over the next quarter century Gable was often described as the “King of Hollywood” and type-cast as a strong dominant male, respected as a leader of men and irresistible to women. He played opposite most of Hollywood's leading ladies and had affairs with many, to the delight of fan magazines and gossip columnists. In 1939, before filming Gone with the Wind, Gable purchased a ranch in Encino, in the San Fernando Valley, for himself and star actress Carole Lombard, whom he would marry later. She was the love of his life and the next 3 years would be his happiest. In January 1942, just after America's entry into World War II, Carole was invited to launch a war bond campaign. She traveled across the country by train making stops in several cities and ending in her home state, Indiana. She had a train ticket to return home from Indianapolis after the final event, but changed plans abruptly upon hearing that Clark had started work on a new movie with Lana Turner. Before departing on her trip Carole had a heated argument with Clark about a rumored affair with Lana while making an earlier movie, Honky Tonk. Carole's flight left Indianapolis at 4 AM and was scheduled to arrive in Los Angeles that evening, with 3 stops along the way, but the plane crashed in the Sierra Nevada mountains with no survivors. After the accident Gable was deeply depressed; he lost 20 pounds and drank heavily but was able to return to work 5 weeks later. After completing 4
Somewhere I'll Find You costarring Lana Turner, Gable announced his enlistment in the Army Air Corps and was assigned to a heavy bomber group, which would soon leave for England. His job was to film aerial combat missions in a B-17 and on a few occasions he replaced wounded gunners. Eventually he was promoted to Captain and awarded the Distinguished Flying Cross. After returning to Hollywood he used the film footage from his combat flights to make Army training and recruiting films.
His career at MGM resumed in 1945 but many of his dozen films received negative reviews and lost money; Gable blamed the studio and made no effort to renew his contract in 1954. His last 9 movies were made in 4 different studios. The last two of his 5 wives were attractive blondes who were said to resemble Carole Lombard. In 1949 he wed Lady Sylvia Ashley, the widow of Douglas Fairbanks; this marriage ended in divorce 1 ½ years later. In 1955 he married Kay Sprekels, a 39 year old divorcee with 2 children. She was a former model and actress who shared Gable's love of outdoors activities like fishing, hunting and golf. Although she was 17 years younger than Gable, she was hospitalized for chest pain before their first anniversary. After several brief attacks, a more severe episode lasted 25 minutes. Her diagnosis was angina pectoris and Kay spent 3 weeks in the hospital. ILLNESS AND DEATH On November 4, 1960, Gable completed the final scene 0f his last movie, The Misfits; sitting in the cab of a truck next to co-star Marilyn Monroe he delivered his last line: ”Just head for that big star; it will take us home.” The production had been very stressful for him because Monroe invariably appeared hours late for the day's filming, unable to remember her lines. The final
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scenes were also physically demanding for a 59 year old. In one, for which several takes were required, he lay prone on the desert floor, clinging to a rope tied to a fleeing mustang. The next afternoon at his Encino ranch he decided to change a tire on his jeep, but while jacking the car up he felt a severe stabbing chest pain and broke out into a cold sweat. After several minutes the pain subsided and he returned to the house. His wife Kay, who was 3 months pregnant, was alarmed by his appearance but he would not allow her to call a doctor. He slept well through the night, arising once to take aspirin for a headache. While dressing in the morning there was a recurrence of severe chest pain and Kay called Dr. Fred Cerini, his personal physician. The Fire Department Rescue Squad was administering oxygen when Dr. Cerini arrived. After a brief assessment an ambulance was summoned to take Gable, accompanied by his wife, to the Hollywood Presbyterian Hospital.
Gable was reported to have had 2 previous brief episodes of chest pain but he did not seek medical care. One occurred while he was golfing and another while driving on a freeway 2. His father had died of a “heart attack” at age 78. In February 1960 he had a physical exam for insurance and was found to have hypertension. He was referred to his personal physician, who placed him on a medication and ordered him to rest in bed for 2 weeks and stop smoking. Whether or not he complied is unknown but on his next exam his blood pressure was lower. Gable had been hospitalized previously for removal of his tonsils, appendix, gall bladder and teeth. Severe pyorrhea had been a problem for many years, causing difficulty chewing food and bad breath. The latter led to embarrassing moments when kissing leading ladies. Finally in 1933 all of his teeth were extracted and replaced with dentures. Gable had been a 3 pack/day smoker 6
since age 16, and a heavy whiskey drinker; in 1945 he crashed his car into a tree after a party, sustaining head and shoulder injuries. Gable's diet was high in meat, eggs and pasta. Later in life he usually gained weight between movies and had to resort to “crash” diets, supplemented with Dexedrine, which caused disturbing tremors of his hands and head. Before his final movie, The Misfits, his weight dropped from 235 to 190 lbs on this regimen.
On admission to the hospital an electrocardiogram and other tests confirmed Dr. Cerini's diagnosis of a coronary thrombosis. “The back of the heart muscle had been damaged”2. He was placed on bed rest with a cardiac monitor and treatment included oxygen, anticoagulants and sedatives. Reporters were told that Gable had suffered a “mild heart attack” and would have to spend 3 weeks in the hospital. Dr. George C. Griffith was called in as a consultant. He was a Professor at USC Medical School/ LA County Hospital and a nationally recognized academic cardiologist 4.
Gable's hospital course appeared to be benign and uncomplicated. There was no recurrence of chest pain. Soon he was sitting up in bed to read and watch television. He was very keen on voting for Nixon and arrangements were made for an absentee ballot. On the tenth hospital day he was taken off the danger list. Cardiac monitoring had been discontinued 2 or 3 days earlier. In the evening his wife retired to her room across the hall, leaving Gable with a special duty nurse. Dr. Cerini stopped in to see him on his usual evening rounds and found his patient looking well and reading a magazine. A few minutes later the nurse observed Gable's head fall back on his pillow and breathing ceased. Dr. Cerini was called and returned a few minutes later.
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Attempts were made to revive Gable using “routine measures” including oxygen but to no avail. He was pronounced dead at 10:50 pm. On the following day's press conference Drs. Griffith and Cerini said that death was probably due to a second coronary thrombosis. Dr. Griffith also said that heart massage, which was sometimes used to save patients would probably have caused a cardiac rupture. He mentioned that a machine to stimulate the heart electrically might have helped but was not available in Gable's room 5.
AFTERMATH
Gable was entombed at Forest Lawn Cemetery next to his third wife, Carole Lombard. A week later his widow, Kay, in an interview with columnist Louella Parsons, blamed his death on the stressful filming of The Misfits and the interminable waiting for Marilyn Monroe. Upset by this accusation, Marilyn required daily visits to her psychoanalyst. The Misfits would also be her last movie. Kay gave birth to a son 4 months after Clark's death. John Clark Gable became an expert auto mechanic, a builder and driver of racing cars. He restored his father's birthplace in Cadiz, Ohio as a historical museum. Kay Gable continued to have cardiac problems for many years. In 1983 she underwent triple bypass surgery and never regained consciousness afterward. She died 2 weeks later at age 65. Since the advent of television channels showing old movies, Clark Gable's reign as the “King of Hollywood” has been extended in perpetuity. DISCUSSION After Gable's hospital admission for chest pain an electrocardiogram confirmed the diagnosis of a myocardial infarction, apparently involving the posterior wall of the heart. The traditional treatment plan in 1960 called for bed rest and 3 weeks in the hospital in the absence of
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complications. He was placed in a private room with a special duty nurse. There was cardiac monitoring but the details of this are unknown and it was discontinued after a week because he had no further chest pain or other symptoms. Gable's sudden death on the tenth hospital day was completely unexpected and was not preceded by any symptoms. There was no aggressive attempt at resuscitation. A second coronary thrombosis was suggested as the cause of death but ventricular fibrillation or heart block with asystole might be more likely.
Predictability of Heart Disease Today, the prediction that Clark Gable would develop cardiovascular disease in 10 years is 60% 6
. But in 1960, the year of his death, such predictions were in their infancy. The early
development of risk prediction was carried out by the Framingham Heart Study that enrolled its first patient in 1948, almost 70 years ago 7. Early reports of the results, published in 1957, identified hypertension, obesity and hypercholesterolemia as predictors of coronary heart disease with a predilection for men over women 8. In 1961, just one year after Gables’ death, Kannel et al reported a 6 year follow-up experience and added the ECG identification of left ventricular hypertrophy to (LVH), hypercholesterolemia and hypertension as predictors 9. They stressed the importance of identification of the coronary prone patient years before the clinical occurrence of disease. But it was not until 1976 that the Framingham Study reported what then became widely known as “risk factors” – elevated serum cholesterol, hypertension, smoking, LVH and diabetes - as efficient means for identifying those patients in need of preventive treatment 10. It all came together in 1998, when the Framingham group proposed a mathematical algorithm to predict the likelihood of subsequent coronary heart disease in
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patients who were symptom free 11. Since then, the algorithm has been revised and updated along with readily available computerized easy-to-use calculators. A recent version simplifies risk prediction by substituting the body mass index for the cholesterol values 6. This algorithm was used in the above calculation of Gable’s CV risk by today’s standards. Gable’s high value of a 60% 10 year risk might even be higher if a positive family history (his father died of a “heart attack”) and Gable’s severe periodontal disease and edentulism 12 could have been included. The timing of Gable’s death in 1960 came just before the tipping point in the understanding of risk prediction. His death also occurred at the beginning of a momentous change in the care of patients with myocardial infarction – the coronary care unit (CCU). The CCU, in turn, developed as the combined value of mouth-to-mouth ventilation, closed chest cardiac massage and closed chest cardiac defibrillation became obvious.
Mouth-to-mouth Ventilation Two anesthesiologists, James O. Elam and Peter J. Safar met by chance at the American Society of Anesthesiologists in Kansas City in October of 1956 13. This meeting and their subsequent collaboration led to a sea change in the development and acceptance of this new resuscitative technique 14. Elam was born in 1918 in Austin Texas and received his medical degree at Johns Hopkins University. From there, he was an itinerant trainee in Physiology, Surgery and Anesthesiology at the University of Minnesota, Barnes Hospital in St. Louis, Massachusetts General Hospital and the University of Iowa. He served as a research assistant at Barnes for 2 years and in 1953 relocated to the Roswell Park Memorial Institute in Buffalo NY where he was
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Chief of Anesthesiology. In this research friendly environment, he and co-workers developed a new improved anesthetic ventilator and the soda lime canister that scrubs CO2 from expired air 15
. In his major contribution, he was the first to show that expired air was an adequate
resuscitative gas for mouth-to-mask ventilation 16. By contrast, Safar was born in Vienna in 1924. Although conscripted, he avoided military combat, survived WW II and started medical school there at the age of 19. After graduation, he came to the United States where he spent some time as a surgical resident at Yale University but then completed a residency in anesthesiology at the University of Pennsylvania 14. He returned to Vienna to satisfy immigration requirements and to marry. In 1950, he returned to Philadelphia with his new wife, 4 suitcases and 5 dollars 13. In 1952, visa requirements led him to Peru where, under rudimentary conditions, he established their first academic department of anesthesiology. Two years later he returned to the United States and did the same thing at the Baltimore City Hospital. It was during that tenure that he met Elam in Kansas City. Collaboration of these 2 anesthesiologists led to major publications from both17, 18 and the succeeding widespread use of mouth-to-mouth resuscitation both in the hospital and in the field. Their results were “a bombshell” when in 1957, Safar reported their findings to the American Society of Anesthesiologists 13. Elam went on to become the chairman of the department of anesthesiology at the University of Missouri, later moving to the University of Chicago 19. Safar gained fame for introducing the first physician staffed intensive care unit in the United States at the Baltimore City Hospital in 1958 13 and by his long and distinguished service as chairman of the anesthesia department at the University of Pittsburgh 14.
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In an interesting sidelight, Safar spoke at the Scandinavian Society of Anesthetists in Norway in 1958 and was put in contact with a Norwegian toymaker, Asmund Laerdal. Laerdal came to the United States to meet Safar and then developed the manikin Resusci Anne, which played a vital role in the training of a generation of resuscitators13,14.
Closed Chest Cardiac Defibrillation In 1926, the Consolidated Edison Co. of New York became concerned about the number of electrical accidents and deaths among their linemen. Five committees from 4 institutions were convened to address the problem. At age 40, William B. Kouwenhoven from the engineering department at Johns Hopkins University was chosen as a member of the team to study the effects of electricity on the human body 20, 21. Kouwenhoven was born in Brooklyn NY and attended the Polytechnic Institute of Brooklyn where he received his degree in electrical engineering in 1906. He taught briefly there and then traveled to Germany where he received his doctorate in engineering from the Karlsruhe Technische Hochschule in 1913. He returned to the USA and the following year accepted an appointment as an instructor in electrical engineering at the Johns Hopkins University 21. He advanced to professor in 1930, became dean of the Engineering School in 1938, Chair of Electrical Engineering in 1942 and retired with Emeritus status in 1954. His early investigations on electricity and the heart were interrupted by WWII but resumed in 1951 when The Edison Electric Institute, an organization of private electrical utilities, re-addressed the problem of increasing numbers of linemen being killed by electrical shocks - associated with increasing electrical usage after the war. Since open chest defibrillation had already been described by Beck in 1947 22, Edison asked that a closed chest 12
defibrillator be developed that could be placed on every line truck 20. Kowenhoven and his team investigated AC countershocks, external electrode sizes, their surface composition, and chest placement and by 1957 developed and built the Hopkins AC defibrillator 20, 23. This was already 3 years after his retirement. After multiple successes in animals, the first closed chest human defibrillation took place at Johns Hopkins on March 28, 1957. But this defibrillator weighed 280 pounds and was hardly portable. To save weight, a portable DC defibrillator was developed that weighed only 40 pounds. At about the same time, (1956) Paul M. Zoll at the Beth Israel Hospital Harvard Medical School in Boston reported on the use of closed chest defibrillation using AC current in animals and in 5 patients with a single survivor 24, 25. Thereafter, a debate persisted regarding which of the 2 current modalities was better until 1962, when Lown et al tested AC defibrillation vs. DC defibrillation in dogs and demonstrated the superiority of the DC method 26. All of the studies in animals and in man had shown that closed chest defibrillation was effective in terminating the arrhythmia, but survival was unlikely unless an effective rhythm was restored promptly. Time was needed from the onset of ventricular fibrillation until a defibrillator could be deployed. This problem was solved by a near chance observation in Kouwenhoven’s laboratory. Closed Chest Cardiac Massage This major clinical observation was described by 3 investigators, only one of whom was a physician 27, 28. James R. Jude was a surgical resident but G. Guy Knickerbocker, a graduate student, and William B. Kouwenhoven were from the Johns Hopkins school of Electrical 13
Engineering. They noticed, only incidentally, that forcible placement of the defibrillator paddles on the dog chest produced an arterial pulse 13. The details of their subsequent investigations, described by Kouwenhoven himself 20, showed that by using chest compressions, a dog with a fibrillating heart could be kept alive for 30 minutes until subsequent defibrillation reversed the arrhythmia. The technique was demonstrated to a doubtful clinical staff at Johns Hopkins in 1959, until the first patient there was saved by the application of these resuscitative techniques – one year before Gable’s death 20. In 1960, the method was formally described in the Journal of the American Medical Association 27. Records of the ECG, carotid arterial flow and femoral arterial pressure in the dog were displayed before, during and after ventricular fibrillation. Flows and pressures were maintained during cardiac arrest by closed chest cardiac compressions. They also reported the use of the method along with artificial respiration in 20 patients, 3 of whom were in ventricular fibrillation. All 20 were resuscitated with 14 long term survivors. This paper was followed the next year in the same journal by the same authors reporting application of external cardiac massage in 138 episodes of cardiac arrest in 118 patients 28. Cardiac action was restored in 78% of the arrests, 60% regained prearrest CNS status and 24% of the 118 patients left the hospital. The potential for closed chest cardiac massage to extend the time needed for successful defibrillation was not lost on the authors or their readers and the combination of mouth-to mouth ventilation, closed chest cardiac massage and closed chest defibrillation led to the development of coronary care units where all 3 modalities were made available at the same location.
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History of the CCU With all the pieces in place, the birth of coronary care units was inevitable and occurred in a number of locations near simultaneously. First results were not encouraging in patients who were monitored in general medical beds at the Bethany Medical Center – University of Kansas Medical School in Kansas City. But their effort attracted the attention of the Hartford Foundation in New York City who awarded them a sizeable grant to build and develop a separate unit. They named it a coronary care unit and opened it to patients on May 20, 1962 29. Their first presentation was to the American College of Chest Physicians later that year. In October 1962, a 2 bed unit was opened at the Presbyterian Hospital in Philadelphia and a third, newly designed CCU opened in November of 1963 at the Miami Heart Institute 29. Outside the United States, a 4 bed unit opened at the Toronto General Hospital 30 in 1962 and in the same year monitoring of patients with myocardial infarction became routine at the Sydney Hospital in Australia 31. The reported success of these early units in the early 1960’s led to widespread interest, development and experience in their use. By 1964, the US Public Health Service released a booklet of guidelines for the establishment and operation of CCU’s. The first printing was exhausted in 60 days and by 1967 it had been re-printed 6 times 32. All descriptions of early CCU’s and the subsequent guidelines for CCU operation detailed the required space and equipment but, most importantly, all insisted on the necessity for specially trained nurses and ancillary staff to promptly detect and treat myocardial infarction complications.
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It was not long before CCU’s became home to other aspects of myocardial infarction care. In 1967, Pantridge et al put the CCU on wheels describing a mobile unit that offered intensive care from home to hospital with successful resuscitations enroute 33. Lown et al, in the same year, indicated a shift in emphasis from the treatment of cardiac arrest to its prevention by the identification and treatment of pre-fibrillation and/or pre-heart block arrhythmias 34. The CCU since has become a base for treatment of heart failure, shock, and the limitation of infarct size with fibrinolytic therapy and coronary angioplasty. All agree that there has been a marked reduction in the mortality of MI from pre-CCU to the present time but because of other simultaneous advances in management, an accurate assessment of the singular contribution of the CCU can probably never be made 31, 35.
Reperfusion Therapy When Gable died in 1960, the proximate cause of acute infarction was still under debate. In Diseases of the Heart published in 1966, coronary thrombosis was presented as only one of several possibilities 36. In 1980, DeWood broke an unwritten rule and performed coronary angiography on 322 patients with acute MI37. In 126 patients studied within 4 hours of pain onset, 110 (87%) had evidence of intracoronary thrombus but only 37 of 57 (65%) studied 12 hours later had thrombi. DeWood correctly suspected spontaneous recanalization. Identification of thrombus as a major player in acute MI prompted the idea that these clots could be dissolved. Streptokinase (STK) had been discovered long before and as early as 1950 was used to treat hemothorax, empyema and abscess cavities38. The first dissolution of thrombus by intracoronary STK was published by Chazov in a Russian journal in 1976 39 and repeated in 1979, when Rentrop in West Germany succeeded in 4 of 5 patients 40. But the lack 16
of available skilled catheterization laboratories and the large number of potential patients made this technique a logistical nightmare. When IV thrombolytic agents were found to be as effective and could be administered in hospitals, clinics, ambulances or even in the home, the logistical problem appeared to have been solved. Many small clinical trials supported IV use but the procedure was firmly established in 1986 when the GISSI trial 41 in more than 11,000 patients demonstrated reduced mortality and stressed the importance of early therapy to salvage threatened myocardium. But IV thrombolysis was not free of problems. It initiated a systemic lytic state that invited serious hemorrhage especially in the elderly, was antigenic preventing its repeated use, achieved complete patency in only 55-60% of cases and suffered from occasional re-occlusion42. Some of these problems were ameliorated by the development of fibrin selective fibrinolytic drugs but residual coronary narrowing after clot lysis became a promising target for angiographers. Percutaneous transluminal coronary angioplasty (PTCA) gained traction after publication of several small successful series but was brought abruptly to the front in 1993 by the publication of 3 papers all in the same issue of the New England Journal of Medicine 43-45 that cemented PTCA as the superior reperfusion method. In experienced centers, PTCA when compared to fibrinolysis, offered higher patency rates, shorter hospital stays, decreased costs lower stroke and re-infarction rates and a 35% decrease in mortality 46. The later addition of stents to balloon inflation alone further improved the results. But logistical problems remained. At that time, only 18% of the hospitals in the US had angioplasty capability 47. Over the succeeding years the number of facilities with skilled 24/7 coverage increased along with improved timely
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transportation to those centers. However, IV thrombolysis remains as a backup for those patients with an acute MI who cannot reach a catheterization facility in time for benefit. Emergency coronary bypass surgery, another means of reperfusion, is used mostly in the settings of failed lytic or PTCA therapy, cardiogenic shock or reparable complications of acute MI such as mitral insufficiency, ventricular septal defect or myocardial rupture 48. Severe logistical problems persist and unavoidable surgical complications make it an alternative only in special circumstances. Medical advances during this era have largely consisted of pharmaceuticals that maintain vessel patency after reperfusion has been established – these include aspirin, anticoagulants and anti platelet agents 42,46. All things considered in summary and in hindsight, reperfusion therapy has become one of the most successful achievements in modern medicine 42.
Summary Clark Gable’s beginnings were humble. He never finished high school and after working at some menial jobs, he became attracted to the theater. Starting at the bottom, he worked his way up to movie stardom. His natural good looks were improved by dentures and by plastic surgery on his protruding ears. Although a movie star and over age for military service at the time of WW II, he managed to enlist in the Army Air Corps and flew a number of combat missions as a waist gunner on a B –17 bomber. His personal life was checkered with 5 marriages and several interspersed dalliances. From a medical perspective, his father died of a heart attack and, in addition to this positive family history, Gable had what are now recognized as coronary risk factors – obesity, smoking, hypertension and poor dietary habits. He had some 18
early undiagnosed episodes of chest pain but then at age 59 sustained a definite myocardial infarction. Initially, he did well, but then died unexpectedly on the 10 th day. There were no efforts at resuscitation.
The time of his death in 1960 marked the beginnings of the recognition of treatable coronary risk factors. And shortly thereafter, major changes in the care of myocardial infarction were introduced with the descriptions of mouth-to-mouth resuscitation, closed-cardiac massage and closed-chest defibrillation. These new modalities combined and became the basis for the coronary care unit. Intracoronary thrombolysis and PTCA for the treatment of acute MI followed. These historical developments are reviewed but Gable died a bit too early for their application that possibly could have extended his life.
Conclusions Clark Gable died suddenly a few years too soon. His death in 1960 was on the cusp of major changes in the understanding and treatment of coronary heart disease. Had he developed his disease later, he could have had the advantage of atherosclerosis prevention, and newer lifesaving, resuscitative and therapeutic techniques available for myocardial infarction. The “King of Hollywood” might have lived to reign a bit longer.
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12. Spahr A, Klein E, Khuseyinova N, Boeckh C, Muche R, Kunze M, Rothenbacher D, Pezeshki G, Hoffmeister A, Koenig W. Periodontal infections and coronary heart disease. Role of periodontal bacteria and importance of total pathogen burden in the Coronary Event and Periodontal Disease (CORODONT) Study. Arch Int Med 2006; 166: 554-559. 13. Baskett PJF. The Resuscitation Greats. Peter J. Safar, the early years 1924-1961, the birth of CPR. Resuscitation 2001; 50: 17-22. 14. Acierno LJ, Worrell LT. Profiles in Cardiology. Peter Safar: Father of modern cardiopulmonary resuscitation. Clin Cardiol 2007; 30: 52-54. 15. Sands RP Jr, Bacon DR. An Inventive Mind. The career of James O. Elam, M.D. (1918-1995). Anesthesiology 1998; 88: 1107-1112. 16. Elam JO, Greene DG, Brown ES, Clements JA. Oxygen and carbon dioxide exchange and energy cost of expired air resuscitation. JAMA 1958; 167: 328-334. 17. Elam JO, Brown ES, Elder JD Jr. Artificial respiration by mouth-to-mask method. A study of the respiratory gas exchange of paralyzed patients ventilated by operator’s expired air. N Eng J Med 1954: 250: 749-754. 18. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. Airway obstruction during manual and mouth-to-mouth artificial respiration. JAMA 1958; 167: 335-341. 19. Safar P. The Resuscitation Greats. James O. Elam MD, 1918-1995. Resuscitation 2001; 50: 249-256. 20. Kouwenhoven WB. The development of the defibrillator. Ann Int Med 1969; 71: 449-458. 21. Beaudouin D. W.B. Kowenhoven: Reviving the body electric. The Johns Hopkins Whiting School of Engineering Magazine. Fall 2002. 21
22. Beck CS, Pritchard WH, Feil HS. Ventricular fibrillation of long duration abolished by electric shock. JAMA 1947; 135: 985-986. 23. Kouwenhoven WB, Milnor WR, Knickerbocker GG, Chestnut WR. Closed chest defibrillation of the heart. Surgery 1957; 42: 550-561. 24. Zoll PM, Linenthal AJ, Gibson W, Paul MH, Norman LR. Termination of ventricular fibrillation in man by externally applied electrical countershock. N Eng J Med 1956; 254: 727-732. 25. Zoll PM, Paul MH, Linenthal AJ, Norman LR, Gibson W. The effects of external electric currents on the heart. Control of cardiac rhythm and induction and termination of cardiac arrhythmias. Circulation 1956; 14: 745-756. 26. Lown B, Neuman J, Amarasingham R, Berkovits BV. Comparison of alternating current with direct current electroschock across the closed chest. Am J Cardiol 1962; 10: 223-233. 27. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173: 1064-1067. 28. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac arrest. Report of application of external cardiac massage on 118 patients. JAMA 1961; 178: 1063-1070. 29. Day HW. History of coronary care units. Am J Cardiol 1972; 30: 405-407. 30. Brown KWG, MacMillan RL, Forbath N, Mel’grano F, Scott JW. Coronary unit. An intensivecare centre for acute myocardial infarction. Lancet 1963; 282: 349-352. 31. Julian DG. The history of coronary care units. Br Heart J 1987; 57: 497-502. 32. Caswell JE. A brief history of coronary care units. Public Health Reports 1967; 12: 11051111.
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33. Pantridge JF, Geddes JS. A mobile intensive-care unit in the management of myocardial infarction. Lancet 1967; 290: 271-273. 34. Lown B, Fakhro AM, Hood W, Thorn GW. The coronary care unit. New perspectives and directions. JAMA 1967; 199: 188-198. 35. Oliver MF, Julian DG, Donald KW. Problems in evaluating coronary care units. Am J Cardiol 1967; 20: 465-474 36. Friedberg CK. Diseases of the heart. 3rd ed. Philadelphia and London. W.B. Saunders Co; 1966 37. DeWood MA, Spores J, Notske R, Mouser LT, Burroughs R, Golden MS, Lang HT. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Eng J Med 1980; 303: 897-902 38. Maroo A, Topol EJ. The early history and development of thrombolysis in acute myocardial infarction. J Thromb Haemost 2004; 2: 1867-1870 39. Chazov EI, Matveeva LS, Mazaev AV, Sargin KE, Sadovskaia GV, Ruda MI. Intracoronary administration of fibrinolysin in acute myocardial infarction (in Russian). Ter Arkh 1976; 48: 8-19. (from reference # 42) 40. Rentrop KP, Blanke H, Karsch KR, Weigand V, Kostering H, Oster H, Leitz K. Acute myocardial infarction: Intracoronary application of nitroglygerine and streptokinase. Clin Cardiol 1979; 2: 354-363. 41. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;1(8478): 397-402. 23
42. Van de Werf F. The history of coronary reperfusion. Eur Heart J 2014; 35: 2510-2515 43. Grines CL, Browne KF, Marko J, et al for the Primary Angioplasty in Myocardial Infarction Study Group. N Eng J Med 1993; 328: 673-679. 44. Zijlstra F. de Boer MJ, Hoorntje JCA, Reiffers S, Reiber JHC, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Eng J Med 1993; 328: 680-684. 45. Gibbons RJ, Holmes DR, Reeder GS, Bailey KR, Hopfenspirger MR, Gersh BJ. N Eng J Med 1993; 328: 685-691. 46. Katritsis D, Karvouni E, Webb-Peploe MM. Reperfusion in acute myocardial infarction: Current concepts. Prog CV Dis 2003; 45: 481-492. 47. Lange RA, Hillis LD. Immediate angioplasty for acute myocardial infarction. N Eng J Med 1993; 328: 726-728. 48. von Segesser LK, Popp J, Amann FW, Turina MI. Surgical revascularization in acute myocardial infarction. Eur J Cardio-thorac Surg 1994; 8: 363-369.
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Legends
Figure 1. Clark Gable – photo from Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Clark_Gable_-_publicity.JPG#file
Figure 2.
Clark Gable and Carole Lombard - Carole and Clark, shortly after their marriage, on their ranch in the San Fernando Valley. From Flickr – Home Design Ideas
Figure 3. Clark Gable posed with the left waist gun of a B-17 Flying Fortress on June 6, 1943. Photo Courtesy National Archives, photo no. 26-G-3422 https://www.fold3.com/search/#query=clark+gable&offset=10&preview=1&t=495
25
26
27
28
Table 1.
Year
Gable Timeline
Event
Author
1947
Open Chest Cardiac Defibrillation
1948
Framingham Study admits First Patient
1950
Clinical Use of Streptokinase
1954
Use of Expired Air as a Resuscitative Gas
Elam
1956
Closed Chest Cardiac Defibrillation – AC Current
Zoll
1057
Closed Chest Cardiac Defibrillation – DC Current
Kowenhoven
1957
Mouth-to-Mouth Resuscitation – report to the American Society of Anesthesiologists
1957
Beck
Safar
Framingham Study Report Identifies Hypertension, Obesity, Hypercholesterolemia as Risk Factors
1960
Death of Clark Gable
1961
External Cardiac Massage
Jude
1962
Superiority of DC over AC Current for Defibrillation
Lown
1962
Opening of First Coronary Care Unit - Kansas
1975
Intracoronary Streptokinase
Chazov
1983
Percutaneous Coronary Angioplasty
Harzler
1986
Intravenous Streptokinase
GISSI trial
1998
Framingham Algorithm for Calculation of Cardiac Risk
2008
Framingham CV Risk Profile for use in Primary Care
29
PII: DOI: Reference:
S0002-9629(18)30127-7 https://doi.org/10.1016/j.amjms.2018.03.019 AMJMS643
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To appear in: The American Journal of the Medical Sciences Cite this article as: , , The American Journal of the Medical Sciences,doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
The King is Dead: Clark Gable’s Heart Attack Short Title : Clark Gable’s Heart Attack
Robert S. Pinals M.D. Clinical Professor of Medicine Rutgers University Robert Wood Johnson Medical School 1 Robert Wood Johnson Pl. New Brunswick, NJ 08903 [email protected]
Harold Smulyan M.D. Emeritus Professor of Medicine State University of New York Upstate Medical University 90 Presidential Plaza Syracuse NY 13208 [email protected]
Corresponding Author Harold Smulyan M.D. Upstate Medical University Department of Medicine Cardiology Division 90 Presidential Plaza Syracuse, NY 13208 Tel 315-464-4535 [email protected]
The authors have no conflict of Interest and no funding source
Key Words – movies, air corps, myocardial infarction coronary care
1
Abstract Clark Gable was born in a small Ohio mining town and never finished high school. Stage struck as a young man, he did menial jobs while working his way up to movie stardom – his most famous role was in “Gone with the Wind”. He married 5 times. During WWII, he enlisted in the Army Air Corps, flew a few combat missions as a gunner and won the Distinguished Service Cross. Personally, he was intermittently obese, a drinker, smoker, hypertensive and predictably in 1960, he suffered an acute myocardial infarction. His clinical course was benign until the 10th hospital day, when he died suddenly. No resuscitation was attempted. At the time of his death, preventive cardiology, mouth-to-mouth ventilation, closed chest cardiac massage and defibrillation and coronary care units were in their infancy. The history of these and subsequent therapeutic practices are reviewed but Gable died a bit too early for their application.
Introduction In November, 1960 the world was shocked to learn of the sudden death of 59 year old Hollywood star Clark Gable 1-3. He was in a hospital recovering from a “mild” heart attack which had occurred 10 days earlier, just after completion of his last movie. He had appeared in over 60 films, playing opposite most of Hollywood's most popular actresses as a virile, adventurous and romantic leading man. Movie fan magazines titled him the “King of Hollywood” and documented his marriages, affairs and other activities in breathless detail 2. In this report we review Gable's life, career and untimely death after a myocardial infarction. We also discuss the major changes in the prevention and management of coronary disease and its complications 2
that occurred in the 1960’s, including identification of risk factors, cardiac monitoring and resuscitation.
LIFE AND CAREER
Clark Gable's life began inauspiciously in a rented room in Cadiz, a small coal-mining town in southeastern Ohio. His mother had been disabled by an unspecified illness, which featured seizures and psychosis. The baby weighed 10 ½ lbs with large hands and feet and prominent protruding ears and was said to resemble his father, a worker in the oil fields 20 miles away. Clark's mother died when he was 10 months old, but fortunately his father soon married a woman who would devote herself to his upbringing. Perhaps this established a pattern which would persist into adulthood; his first two wives were older women who would nurture him and support his career. Clark left high school before graduation and held a number of blue collar jobs before discovering his true calling on seeing his first stage play in Akron. This was a melodrama set in Hawaii, with grass-skirted hula dancers. While looking for a theatrical opportunity he migrated westward, supporting himself with temporary menial jobs. In Oregon he met Josephine Dillon, a former actress, now a drama teacher, 17 years older than Gable; she took him under her wing and later became the first of his 5 wives. Dillon supported his early acting career and in 1924 they moved to Los Angeles, where Gable found work in a gas station and as a movie extra. On the stage he advanced to leading man roles, with help from another older woman, Pauline Frederick, a star on Broadway and in silent movies. She had an affair with Gable, recommended him for more important roles and paid to have his teeth fixed. In 1927-28 Gable became a matinee idol while working for a stock company in Houston. There 3
he met Maria Langham, a wealthy divorcee who was 14 years older; after a discrete affair she became his second wife and arranged for plastic surgery to move his ears closer to his head.
Gable's movie career started in 1931 in supporting roles, but his star potential was recognized by Irving Thalberg, MGMs production chief, and Gable was a leading man before the year ended. With his 21st movie in 1934, It Happened One Night, Gable won his first and only Academy Award as Best Actor. Over the next quarter century Gable was often described as the “King of Hollywood” and type-cast as a strong dominant male, respected as a leader of men and irresistible to women. He played opposite most of Hollywood's leading ladies and had affairs with many, to the delight of fan magazines and gossip columnists. In 1939, before filming Gone with the Wind, Gable purchased a ranch in Encino, in the San Fernando Valley, for himself and star actress Carole Lombard, whom he would marry later. She was the love of his life and the next 3 years would be his happiest. In January 1942, just after America's entry into World War II, Carole was invited to launch a war bond campaign. She traveled across the country by train making stops in several cities and ending in her home state, Indiana. She had a train ticket to return home from Indianapolis after the final event, but changed plans abruptly upon hearing that Clark had started work on a new movie with Lana Turner. Before departing on her trip Carole had a heated argument with Clark about a rumored affair with Lana while making an earlier movie, Honky Tonk. Carole's flight left Indianapolis at 4 AM and was scheduled to arrive in Los Angeles that evening, with 3 stops along the way, but the plane crashed in the Sierra Nevada mountains with no survivors. After the accident Gable was deeply depressed; he lost 20 pounds and drank heavily but was able to return to work 5 weeks later. After completing 4
Somewhere I'll Find You costarring Lana Turner, Gable announced his enlistment in the Army Air Corps and was assigned to a heavy bomber group, which would soon leave for England. His job was to film aerial combat missions in a B-17 and on a few occasions he replaced wounded gunners. Eventually he was promoted to Captain and awarded the Distinguished Flying Cross. After returning to Hollywood he used the film footage from his combat flights to make Army training and recruiting films.
His career at MGM resumed in 1945 but many of his dozen films received negative reviews and lost money; Gable blamed the studio and made no effort to renew his contract in 1954. His last 9 movies were made in 4 different studios. The last two of his 5 wives were attractive blondes who were said to resemble Carole Lombard. In 1949 he wed Lady Sylvia Ashley, the widow of Douglas Fairbanks; this marriage ended in divorce 1 ½ years later. In 1955 he married Kay Sprekels, a 39 year old divorcee with 2 children. She was a former model and actress who shared Gable's love of outdoors activities like fishing, hunting and golf. Although she was 17 years younger than Gable, she was hospitalized for chest pain before their first anniversary. After several brief attacks, a more severe episode lasted 25 minutes. Her diagnosis was angina pectoris and Kay spent 3 weeks in the hospital. ILLNESS AND DEATH On November 4, 1960, Gable completed the final scene 0f his last movie, The Misfits; sitting in the cab of a truck next to co-star Marilyn Monroe he delivered his last line: ”Just head for that big star; it will take us home.” The production had been very stressful for him because Monroe invariably appeared hours late for the day's filming, unable to remember her lines. The final
5
scenes were also physically demanding for a 59 year old. In one, for which several takes were required, he lay prone on the desert floor, clinging to a rope tied to a fleeing mustang. The next afternoon at his Encino ranch he decided to change a tire on his jeep, but while jacking the car up he felt a severe stabbing chest pain and broke out into a cold sweat. After several minutes the pain subsided and he returned to the house. His wife Kay, who was 3 months pregnant, was alarmed by his appearance but he would not allow her to call a doctor. He slept well through the night, arising once to take aspirin for a headache. While dressing in the morning there was a recurrence of severe chest pain and Kay called Dr. Fred Cerini, his personal physician. The Fire Department Rescue Squad was administering oxygen when Dr. Cerini arrived. After a brief assessment an ambulance was summoned to take Gable, accompanied by his wife, to the Hollywood Presbyterian Hospital.
Gable was reported to have had 2 previous brief episodes of chest pain but he did not seek medical care. One occurred while he was golfing and another while driving on a freeway 2. His father had died of a “heart attack” at age 78. In February 1960 he had a physical exam for insurance and was found to have hypertension. He was referred to his personal physician, who placed him on a medication and ordered him to rest in bed for 2 weeks and stop smoking. Whether or not he complied is unknown but on his next exam his blood pressure was lower. Gable had been hospitalized previously for removal of his tonsils, appendix, gall bladder and teeth. Severe pyorrhea had been a problem for many years, causing difficulty chewing food and bad breath. The latter led to embarrassing moments when kissing leading ladies. Finally in 1933 all of his teeth were extracted and replaced with dentures. Gable had been a 3 pack/day smoker 6
since age 16, and a heavy whiskey drinker; in 1945 he crashed his car into a tree after a party, sustaining head and shoulder injuries. Gable's diet was high in meat, eggs and pasta. Later in life he usually gained weight between movies and had to resort to “crash” diets, supplemented with Dexedrine, which caused disturbing tremors of his hands and head. Before his final movie, The Misfits, his weight dropped from 235 to 190 lbs on this regimen.
On admission to the hospital an electrocardiogram and other tests confirmed Dr. Cerini's diagnosis of a coronary thrombosis. “The back of the heart muscle had been damaged”2. He was placed on bed rest with a cardiac monitor and treatment included oxygen, anticoagulants and sedatives. Reporters were told that Gable had suffered a “mild heart attack” and would have to spend 3 weeks in the hospital. Dr. George C. Griffith was called in as a consultant. He was a Professor at USC Medical School/ LA County Hospital and a nationally recognized academic cardiologist 4.
Gable's hospital course appeared to be benign and uncomplicated. There was no recurrence of chest pain. Soon he was sitting up in bed to read and watch television. He was very keen on voting for Nixon and arrangements were made for an absentee ballot. On the tenth hospital day he was taken off the danger list. Cardiac monitoring had been discontinued 2 or 3 days earlier. In the evening his wife retired to her room across the hall, leaving Gable with a special duty nurse. Dr. Cerini stopped in to see him on his usual evening rounds and found his patient looking well and reading a magazine. A few minutes later the nurse observed Gable's head fall back on his pillow and breathing ceased. Dr. Cerini was called and returned a few minutes later.
7
Attempts were made to revive Gable using “routine measures” including oxygen but to no avail. He was pronounced dead at 10:50 pm. On the following day's press conference Drs. Griffith and Cerini said that death was probably due to a second coronary thrombosis. Dr. Griffith also said that heart massage, which was sometimes used to save patients would probably have caused a cardiac rupture. He mentioned that a machine to stimulate the heart electrically might have helped but was not available in Gable's room 5.
AFTERMATH
Gable was entombed at Forest Lawn Cemetery next to his third wife, Carole Lombard. A week later his widow, Kay, in an interview with columnist Louella Parsons, blamed his death on the stressful filming of The Misfits and the interminable waiting for Marilyn Monroe. Upset by this accusation, Marilyn required daily visits to her psychoanalyst. The Misfits would also be her last movie. Kay gave birth to a son 4 months after Clark's death. John Clark Gable became an expert auto mechanic, a builder and driver of racing cars. He restored his father's birthplace in Cadiz, Ohio as a historical museum. Kay Gable continued to have cardiac problems for many years. In 1983 she underwent triple bypass surgery and never regained consciousness afterward. She died 2 weeks later at age 65. Since the advent of television channels showing old movies, Clark Gable's reign as the “King of Hollywood” has been extended in perpetuity. DISCUSSION After Gable's hospital admission for chest pain an electrocardiogram confirmed the diagnosis of a myocardial infarction, apparently involving the posterior wall of the heart. The traditional treatment plan in 1960 called for bed rest and 3 weeks in the hospital in the absence of
8
complications. He was placed in a private room with a special duty nurse. There was cardiac monitoring but the details of this are unknown and it was discontinued after a week because he had no further chest pain or other symptoms. Gable's sudden death on the tenth hospital day was completely unexpected and was not preceded by any symptoms. There was no aggressive attempt at resuscitation. A second coronary thrombosis was suggested as the cause of death but ventricular fibrillation or heart block with asystole might be more likely.
Predictability of Heart Disease Today, the prediction that Clark Gable would develop cardiovascular disease in 10 years is 60% 6
. But in 1960, the year of his death, such predictions were in their infancy. The early
development of risk prediction was carried out by the Framingham Heart Study that enrolled its first patient in 1948, almost 70 years ago 7. Early reports of the results, published in 1957, identified hypertension, obesity and hypercholesterolemia as predictors of coronary heart disease with a predilection for men over women 8. In 1961, just one year after Gables’ death, Kannel et al reported a 6 year follow-up experience and added the ECG identification of left ventricular hypertrophy to (LVH), hypercholesterolemia and hypertension as predictors 9. They stressed the importance of identification of the coronary prone patient years before the clinical occurrence of disease. But it was not until 1976 that the Framingham Study reported what then became widely known as “risk factors” – elevated serum cholesterol, hypertension, smoking, LVH and diabetes - as efficient means for identifying those patients in need of preventive treatment 10. It all came together in 1998, when the Framingham group proposed a mathematical algorithm to predict the likelihood of subsequent coronary heart disease in
9
patients who were symptom free 11. Since then, the algorithm has been revised and updated along with readily available computerized easy-to-use calculators. A recent version simplifies risk prediction by substituting the body mass index for the cholesterol values 6. This algorithm was used in the above calculation of Gable’s CV risk by today’s standards. Gable’s high value of a 60% 10 year risk might even be higher if a positive family history (his father died of a “heart attack”) and Gable’s severe periodontal disease and edentulism 12 could have been included. The timing of Gable’s death in 1960 came just before the tipping point in the understanding of risk prediction. His death also occurred at the beginning of a momentous change in the care of patients with myocardial infarction – the coronary care unit (CCU). The CCU, in turn, developed as the combined value of mouth-to-mouth ventilation, closed chest cardiac massage and closed chest cardiac defibrillation became obvious.
Mouth-to-mouth Ventilation Two anesthesiologists, James O. Elam and Peter J. Safar met by chance at the American Society of Anesthesiologists in Kansas City in October of 1956 13. This meeting and their subsequent collaboration led to a sea change in the development and acceptance of this new resuscitative technique 14. Elam was born in 1918 in Austin Texas and received his medical degree at Johns Hopkins University. From there, he was an itinerant trainee in Physiology, Surgery and Anesthesiology at the University of Minnesota, Barnes Hospital in St. Louis, Massachusetts General Hospital and the University of Iowa. He served as a research assistant at Barnes for 2 years and in 1953 relocated to the Roswell Park Memorial Institute in Buffalo NY where he was
10
Chief of Anesthesiology. In this research friendly environment, he and co-workers developed a new improved anesthetic ventilator and the soda lime canister that scrubs CO2 from expired air 15
. In his major contribution, he was the first to show that expired air was an adequate
resuscitative gas for mouth-to-mask ventilation 16. By contrast, Safar was born in Vienna in 1924. Although conscripted, he avoided military combat, survived WW II and started medical school there at the age of 19. After graduation, he came to the United States where he spent some time as a surgical resident at Yale University but then completed a residency in anesthesiology at the University of Pennsylvania 14. He returned to Vienna to satisfy immigration requirements and to marry. In 1950, he returned to Philadelphia with his new wife, 4 suitcases and 5 dollars 13. In 1952, visa requirements led him to Peru where, under rudimentary conditions, he established their first academic department of anesthesiology. Two years later he returned to the United States and did the same thing at the Baltimore City Hospital. It was during that tenure that he met Elam in Kansas City. Collaboration of these 2 anesthesiologists led to major publications from both17, 18 and the succeeding widespread use of mouth-to-mouth resuscitation both in the hospital and in the field. Their results were “a bombshell” when in 1957, Safar reported their findings to the American Society of Anesthesiologists 13. Elam went on to become the chairman of the department of anesthesiology at the University of Missouri, later moving to the University of Chicago 19. Safar gained fame for introducing the first physician staffed intensive care unit in the United States at the Baltimore City Hospital in 1958 13 and by his long and distinguished service as chairman of the anesthesia department at the University of Pittsburgh 14.
11
In an interesting sidelight, Safar spoke at the Scandinavian Society of Anesthetists in Norway in 1958 and was put in contact with a Norwegian toymaker, Asmund Laerdal. Laerdal came to the United States to meet Safar and then developed the manikin Resusci Anne, which played a vital role in the training of a generation of resuscitators13,14.
Closed Chest Cardiac Defibrillation In 1926, the Consolidated Edison Co. of New York became concerned about the number of electrical accidents and deaths among their linemen. Five committees from 4 institutions were convened to address the problem. At age 40, William B. Kouwenhoven from the engineering department at Johns Hopkins University was chosen as a member of the team to study the effects of electricity on the human body 20, 21. Kouwenhoven was born in Brooklyn NY and attended the Polytechnic Institute of Brooklyn where he received his degree in electrical engineering in 1906. He taught briefly there and then traveled to Germany where he received his doctorate in engineering from the Karlsruhe Technische Hochschule in 1913. He returned to the USA and the following year accepted an appointment as an instructor in electrical engineering at the Johns Hopkins University 21. He advanced to professor in 1930, became dean of the Engineering School in 1938, Chair of Electrical Engineering in 1942 and retired with Emeritus status in 1954. His early investigations on electricity and the heart were interrupted by WWII but resumed in 1951 when The Edison Electric Institute, an organization of private electrical utilities, re-addressed the problem of increasing numbers of linemen being killed by electrical shocks - associated with increasing electrical usage after the war. Since open chest defibrillation had already been described by Beck in 1947 22, Edison asked that a closed chest 12
defibrillator be developed that could be placed on every line truck 20. Kowenhoven and his team investigated AC countershocks, external electrode sizes, their surface composition, and chest placement and by 1957 developed and built the Hopkins AC defibrillator 20, 23. This was already 3 years after his retirement. After multiple successes in animals, the first closed chest human defibrillation took place at Johns Hopkins on March 28, 1957. But this defibrillator weighed 280 pounds and was hardly portable. To save weight, a portable DC defibrillator was developed that weighed only 40 pounds. At about the same time, (1956) Paul M. Zoll at the Beth Israel Hospital Harvard Medical School in Boston reported on the use of closed chest defibrillation using AC current in animals and in 5 patients with a single survivor 24, 25. Thereafter, a debate persisted regarding which of the 2 current modalities was better until 1962, when Lown et al tested AC defibrillation vs. DC defibrillation in dogs and demonstrated the superiority of the DC method 26. All of the studies in animals and in man had shown that closed chest defibrillation was effective in terminating the arrhythmia, but survival was unlikely unless an effective rhythm was restored promptly. Time was needed from the onset of ventricular fibrillation until a defibrillator could be deployed. This problem was solved by a near chance observation in Kouwenhoven’s laboratory. Closed Chest Cardiac Massage This major clinical observation was described by 3 investigators, only one of whom was a physician 27, 28. James R. Jude was a surgical resident but G. Guy Knickerbocker, a graduate student, and William B. Kouwenhoven were from the Johns Hopkins school of Electrical 13
Engineering. They noticed, only incidentally, that forcible placement of the defibrillator paddles on the dog chest produced an arterial pulse 13. The details of their subsequent investigations, described by Kouwenhoven himself 20, showed that by using chest compressions, a dog with a fibrillating heart could be kept alive for 30 minutes until subsequent defibrillation reversed the arrhythmia. The technique was demonstrated to a doubtful clinical staff at Johns Hopkins in 1959, until the first patient there was saved by the application of these resuscitative techniques – one year before Gable’s death 20. In 1960, the method was formally described in the Journal of the American Medical Association 27. Records of the ECG, carotid arterial flow and femoral arterial pressure in the dog were displayed before, during and after ventricular fibrillation. Flows and pressures were maintained during cardiac arrest by closed chest cardiac compressions. They also reported the use of the method along with artificial respiration in 20 patients, 3 of whom were in ventricular fibrillation. All 20 were resuscitated with 14 long term survivors. This paper was followed the next year in the same journal by the same authors reporting application of external cardiac massage in 138 episodes of cardiac arrest in 118 patients 28. Cardiac action was restored in 78% of the arrests, 60% regained prearrest CNS status and 24% of the 118 patients left the hospital. The potential for closed chest cardiac massage to extend the time needed for successful defibrillation was not lost on the authors or their readers and the combination of mouth-to mouth ventilation, closed chest cardiac massage and closed chest defibrillation led to the development of coronary care units where all 3 modalities were made available at the same location.
14
History of the CCU With all the pieces in place, the birth of coronary care units was inevitable and occurred in a number of locations near simultaneously. First results were not encouraging in patients who were monitored in general medical beds at the Bethany Medical Center – University of Kansas Medical School in Kansas City. But their effort attracted the attention of the Hartford Foundation in New York City who awarded them a sizeable grant to build and develop a separate unit. They named it a coronary care unit and opened it to patients on May 20, 1962 29. Their first presentation was to the American College of Chest Physicians later that year. In October 1962, a 2 bed unit was opened at the Presbyterian Hospital in Philadelphia and a third, newly designed CCU opened in November of 1963 at the Miami Heart Institute 29. Outside the United States, a 4 bed unit opened at the Toronto General Hospital 30 in 1962 and in the same year monitoring of patients with myocardial infarction became routine at the Sydney Hospital in Australia 31. The reported success of these early units in the early 1960’s led to widespread interest, development and experience in their use. By 1964, the US Public Health Service released a booklet of guidelines for the establishment and operation of CCU’s. The first printing was exhausted in 60 days and by 1967 it had been re-printed 6 times 32. All descriptions of early CCU’s and the subsequent guidelines for CCU operation detailed the required space and equipment but, most importantly, all insisted on the necessity for specially trained nurses and ancillary staff to promptly detect and treat myocardial infarction complications.
15
It was not long before CCU’s became home to other aspects of myocardial infarction care. In 1967, Pantridge et al put the CCU on wheels describing a mobile unit that offered intensive care from home to hospital with successful resuscitations enroute 33. Lown et al, in the same year, indicated a shift in emphasis from the treatment of cardiac arrest to its prevention by the identification and treatment of pre-fibrillation and/or pre-heart block arrhythmias 34. The CCU since has become a base for treatment of heart failure, shock, and the limitation of infarct size with fibrinolytic therapy and coronary angioplasty. All agree that there has been a marked reduction in the mortality of MI from pre-CCU to the present time but because of other simultaneous advances in management, an accurate assessment of the singular contribution of the CCU can probably never be made 31, 35.
Reperfusion Therapy When Gable died in 1960, the proximate cause of acute infarction was still under debate. In Diseases of the Heart published in 1966, coronary thrombosis was presented as only one of several possibilities 36. In 1980, DeWood broke an unwritten rule and performed coronary angiography on 322 patients with acute MI37. In 126 patients studied within 4 hours of pain onset, 110 (87%) had evidence of intracoronary thrombus but only 37 of 57 (65%) studied 12 hours later had thrombi. DeWood correctly suspected spontaneous recanalization. Identification of thrombus as a major player in acute MI prompted the idea that these clots could be dissolved. Streptokinase (STK) had been discovered long before and as early as 1950 was used to treat hemothorax, empyema and abscess cavities38. The first dissolution of thrombus by intracoronary STK was published by Chazov in a Russian journal in 1976 39 and repeated in 1979, when Rentrop in West Germany succeeded in 4 of 5 patients 40. But the lack 16
of available skilled catheterization laboratories and the large number of potential patients made this technique a logistical nightmare. When IV thrombolytic agents were found to be as effective and could be administered in hospitals, clinics, ambulances or even in the home, the logistical problem appeared to have been solved. Many small clinical trials supported IV use but the procedure was firmly established in 1986 when the GISSI trial 41 in more than 11,000 patients demonstrated reduced mortality and stressed the importance of early therapy to salvage threatened myocardium. But IV thrombolysis was not free of problems. It initiated a systemic lytic state that invited serious hemorrhage especially in the elderly, was antigenic preventing its repeated use, achieved complete patency in only 55-60% of cases and suffered from occasional re-occlusion42. Some of these problems were ameliorated by the development of fibrin selective fibrinolytic drugs but residual coronary narrowing after clot lysis became a promising target for angiographers. Percutaneous transluminal coronary angioplasty (PTCA) gained traction after publication of several small successful series but was brought abruptly to the front in 1993 by the publication of 3 papers all in the same issue of the New England Journal of Medicine 43-45 that cemented PTCA as the superior reperfusion method. In experienced centers, PTCA when compared to fibrinolysis, offered higher patency rates, shorter hospital stays, decreased costs lower stroke and re-infarction rates and a 35% decrease in mortality 46. The later addition of stents to balloon inflation alone further improved the results. But logistical problems remained. At that time, only 18% of the hospitals in the US had angioplasty capability 47. Over the succeeding years the number of facilities with skilled 24/7 coverage increased along with improved timely
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transportation to those centers. However, IV thrombolysis remains as a backup for those patients with an acute MI who cannot reach a catheterization facility in time for benefit. Emergency coronary bypass surgery, another means of reperfusion, is used mostly in the settings of failed lytic or PTCA therapy, cardiogenic shock or reparable complications of acute MI such as mitral insufficiency, ventricular septal defect or myocardial rupture 48. Severe logistical problems persist and unavoidable surgical complications make it an alternative only in special circumstances. Medical advances during this era have largely consisted of pharmaceuticals that maintain vessel patency after reperfusion has been established – these include aspirin, anticoagulants and anti platelet agents 42,46. All things considered in summary and in hindsight, reperfusion therapy has become one of the most successful achievements in modern medicine 42.
Summary Clark Gable’s beginnings were humble. He never finished high school and after working at some menial jobs, he became attracted to the theater. Starting at the bottom, he worked his way up to movie stardom. His natural good looks were improved by dentures and by plastic surgery on his protruding ears. Although a movie star and over age for military service at the time of WW II, he managed to enlist in the Army Air Corps and flew a number of combat missions as a waist gunner on a B –17 bomber. His personal life was checkered with 5 marriages and several interspersed dalliances. From a medical perspective, his father died of a heart attack and, in addition to this positive family history, Gable had what are now recognized as coronary risk factors – obesity, smoking, hypertension and poor dietary habits. He had some 18
early undiagnosed episodes of chest pain but then at age 59 sustained a definite myocardial infarction. Initially, he did well, but then died unexpectedly on the 10 th day. There were no efforts at resuscitation.
The time of his death in 1960 marked the beginnings of the recognition of treatable coronary risk factors. And shortly thereafter, major changes in the care of myocardial infarction were introduced with the descriptions of mouth-to-mouth resuscitation, closed-cardiac massage and closed-chest defibrillation. These new modalities combined and became the basis for the coronary care unit. Intracoronary thrombolysis and PTCA for the treatment of acute MI followed. These historical developments are reviewed but Gable died a bit too early for their application that possibly could have extended his life.
Conclusions Clark Gable died suddenly a few years too soon. His death in 1960 was on the cusp of major changes in the understanding and treatment of coronary heart disease. Had he developed his disease later, he could have had the advantage of atherosclerosis prevention, and newer lifesaving, resuscitative and therapeutic techniques available for myocardial infarction. The “King of Hollywood” might have lived to reign a bit longer.
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REFERENCES 1. Harris W. Clark Gable: A Biography. New York, NY: Harmony Books; 2002. 2. Tornabene L. Long Live the King; a Biography of Clark Gable. New York, NY: G.P. Putnam& Sons; 1976. 3. Clark Gable dies at 59. Los Angeles Times, November 17,1960. 4. Manning PR. Profiles in Cardiology: George C. Griffith. Clin Cardiol.1988;11:59-60. 5. Clark Gable's death caused by a blood clot. Ocala Star Banner, November 18, 1960 6. D’Agostino RB, Vasan RS, Pencina MJ, Wolf PA, Cobain M, Massaro JM, Kannel WB. General cardiovascular risk profile for use in primary care. The Framingham Study. Circulation 2008; 117: 743-753. 7. Mahmood SS, Levy D, Vasan RS, Wang TJ. The Framingham heart study and the epidemiology of cardiovascular diseases: A historical perspective. Lancet 2014; 383: 9991008. 8. Dawber TR, Moore FE, Mann GV. II. Coronary heart disease in the Framingham Study. Am J Public Health 1957; 47 (4 part 2):4-24. 9. Kannel WB, Dawber TR, Kagan A, Revotskie N, Stokes J III. Factors of risk in the development of coronary heart disease - six-year follow-up experience. Ann Int Med 1961; 55: 33-50. 10. Kannel WB, McGee D, Gordon T. A general cardiovascular risk profile: The Framingham Study. Am J Cardiol 1976; 38: 46-51. 11. Wilson PWF, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation 1998; 97: 1837-1847.
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12. Spahr A, Klein E, Khuseyinova N, Boeckh C, Muche R, Kunze M, Rothenbacher D, Pezeshki G, Hoffmeister A, Koenig W. Periodontal infections and coronary heart disease. Role of periodontal bacteria and importance of total pathogen burden in the Coronary Event and Periodontal Disease (CORODONT) Study. Arch Int Med 2006; 166: 554-559. 13. Baskett PJF. The Resuscitation Greats. Peter J. Safar, the early years 1924-1961, the birth of CPR. Resuscitation 2001; 50: 17-22. 14. Acierno LJ, Worrell LT. Profiles in Cardiology. Peter Safar: Father of modern cardiopulmonary resuscitation. Clin Cardiol 2007; 30: 52-54. 15. Sands RP Jr, Bacon DR. An Inventive Mind. The career of James O. Elam, M.D. (1918-1995). Anesthesiology 1998; 88: 1107-1112. 16. Elam JO, Greene DG, Brown ES, Clements JA. Oxygen and carbon dioxide exchange and energy cost of expired air resuscitation. JAMA 1958; 167: 328-334. 17. Elam JO, Brown ES, Elder JD Jr. Artificial respiration by mouth-to-mask method. A study of the respiratory gas exchange of paralyzed patients ventilated by operator’s expired air. N Eng J Med 1954: 250: 749-754. 18. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. Airway obstruction during manual and mouth-to-mouth artificial respiration. JAMA 1958; 167: 335-341. 19. Safar P. The Resuscitation Greats. James O. Elam MD, 1918-1995. Resuscitation 2001; 50: 249-256. 20. Kouwenhoven WB. The development of the defibrillator. Ann Int Med 1969; 71: 449-458. 21. Beaudouin D. W.B. Kowenhoven: Reviving the body electric. The Johns Hopkins Whiting School of Engineering Magazine. Fall 2002. 21
22. Beck CS, Pritchard WH, Feil HS. Ventricular fibrillation of long duration abolished by electric shock. JAMA 1947; 135: 985-986. 23. Kouwenhoven WB, Milnor WR, Knickerbocker GG, Chestnut WR. Closed chest defibrillation of the heart. Surgery 1957; 42: 550-561. 24. Zoll PM, Linenthal AJ, Gibson W, Paul MH, Norman LR. Termination of ventricular fibrillation in man by externally applied electrical countershock. N Eng J Med 1956; 254: 727-732. 25. Zoll PM, Paul MH, Linenthal AJ, Norman LR, Gibson W. The effects of external electric currents on the heart. Control of cardiac rhythm and induction and termination of cardiac arrhythmias. Circulation 1956; 14: 745-756. 26. Lown B, Neuman J, Amarasingham R, Berkovits BV. Comparison of alternating current with direct current electroschock across the closed chest. Am J Cardiol 1962; 10: 223-233. 27. Kouwenhoven WB, Jude JR, Knickerbocker GG. Closed-chest cardiac massage. JAMA 1960; 173: 1064-1067. 28. Jude JR, Kouwenhoven WB, Knickerbocker GG. Cardiac arrest. Report of application of external cardiac massage on 118 patients. JAMA 1961; 178: 1063-1070. 29. Day HW. History of coronary care units. Am J Cardiol 1972; 30: 405-407. 30. Brown KWG, MacMillan RL, Forbath N, Mel’grano F, Scott JW. Coronary unit. An intensivecare centre for acute myocardial infarction. Lancet 1963; 282: 349-352. 31. Julian DG. The history of coronary care units. Br Heart J 1987; 57: 497-502. 32. Caswell JE. A brief history of coronary care units. Public Health Reports 1967; 12: 11051111.
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33. Pantridge JF, Geddes JS. A mobile intensive-care unit in the management of myocardial infarction. Lancet 1967; 290: 271-273. 34. Lown B, Fakhro AM, Hood W, Thorn GW. The coronary care unit. New perspectives and directions. JAMA 1967; 199: 188-198. 35. Oliver MF, Julian DG, Donald KW. Problems in evaluating coronary care units. Am J Cardiol 1967; 20: 465-474 36. Friedberg CK. Diseases of the heart. 3rd ed. Philadelphia and London. W.B. Saunders Co; 1966 37. DeWood MA, Spores J, Notske R, Mouser LT, Burroughs R, Golden MS, Lang HT. Prevalence of total coronary occlusion during the early hours of transmural myocardial infarction. N Eng J Med 1980; 303: 897-902 38. Maroo A, Topol EJ. The early history and development of thrombolysis in acute myocardial infarction. J Thromb Haemost 2004; 2: 1867-1870 39. Chazov EI, Matveeva LS, Mazaev AV, Sargin KE, Sadovskaia GV, Ruda MI. Intracoronary administration of fibrinolysin in acute myocardial infarction (in Russian). Ter Arkh 1976; 48: 8-19. (from reference # 42) 40. Rentrop KP, Blanke H, Karsch KR, Weigand V, Kostering H, Oster H, Leitz K. Acute myocardial infarction: Intracoronary application of nitroglygerine and streptokinase. Clin Cardiol 1979; 2: 354-363. 41. Gruppo Italiano per lo Studio della Streptochinasi nell’Infarto Miocardico (GISSI). Effectiveness of intravenous thrombolytic treatment in acute myocardial infarction. Lancet 1986;1(8478): 397-402. 23
42. Van de Werf F. The history of coronary reperfusion. Eur Heart J 2014; 35: 2510-2515 43. Grines CL, Browne KF, Marko J, et al for the Primary Angioplasty in Myocardial Infarction Study Group. N Eng J Med 1993; 328: 673-679. 44. Zijlstra F. de Boer MJ, Hoorntje JCA, Reiffers S, Reiber JHC, Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Eng J Med 1993; 328: 680-684. 45. Gibbons RJ, Holmes DR, Reeder GS, Bailey KR, Hopfenspirger MR, Gersh BJ. N Eng J Med 1993; 328: 685-691. 46. Katritsis D, Karvouni E, Webb-Peploe MM. Reperfusion in acute myocardial infarction: Current concepts. Prog CV Dis 2003; 45: 481-492. 47. Lange RA, Hillis LD. Immediate angioplasty for acute myocardial infarction. N Eng J Med 1993; 328: 726-728. 48. von Segesser LK, Popp J, Amann FW, Turina MI. Surgical revascularization in acute myocardial infarction. Eur J Cardio-thorac Surg 1994; 8: 363-369.
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Legends
Figure 1. Clark Gable – photo from Wikimedia Commons. https://commons.wikimedia.org/wiki/File:Clark_Gable_-_publicity.JPG#file
Figure 2.
Clark Gable and Carole Lombard - Carole and Clark, shortly after their marriage, on their ranch in the San Fernando Valley. From Flickr – Home Design Ideas
Figure 3. Clark Gable posed with the left waist gun of a B-17 Flying Fortress on June 6, 1943. Photo Courtesy National Archives, photo no. 26-G-3422 https://www.fold3.com/search/#query=clark+gable&offset=10&preview=1&t=495
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Table 1.
Year
Gable Timeline
Event
Author
1947
Open Chest Cardiac Defibrillation
1948
Framingham Study admits First Patient
1950
Clinical Use of Streptokinase
1954
Use of Expired Air as a Resuscitative Gas
Elam
1956
Closed Chest Cardiac Defibrillation – AC Current
Zoll
1057
Closed Chest Cardiac Defibrillation – DC Current
Kowenhoven
1957
Mouth-to-Mouth Resuscitation – report to the American Society of Anesthesiologists
1957
Beck
Safar
Framingham Study Report Identifies Hypertension, Obesity, Hypercholesterolemia as Risk Factors
1960
Death of Clark Gable
1961
External Cardiac Massage
Jude
1962
Superiority of DC over AC Current for Defibrillation
Lown
1962
Opening of First Coronary Care Unit - Kansas
1975
Intracoronary Streptokinase
Chazov
1983
Percutaneous Coronary Angioplasty
Harzler
1986
Intravenous Streptokinase
GISSI trial
1998
Framingham Algorithm for Calculation of Cardiac Risk
2008
Framingham CV Risk Profile for use in Primary Care
29