John Marshall Cowan: An appreciation

Abstract

John Marshall Cowan (1870–1947) descended from a long line of Glasgow medical practitioners. He was at the forefront in the great advances made in cardiology during the first quarter of the 20th century. He was a founder member of the Cardiac Club and the principal author of a major text book Diseases of the Heart, first published in 1914. He had a distinguished military career and was physician in charge of wards in the Royal Infirmary, Glasgow and Professor of Medicine at Anderson's College, Glasgow. This article outlines Cowan's life, career and publications and also provides an examination of his magnum opus, Diseases of the Heart.

Keywords

Cardiac Club cardiology Glasgow Royal Infirmary John Marshall Cowan

Introduction

John Marshall Cowan (1870–1947) was a member of a remarkable Glasgow medical family who gave more than 200 years of service to the city of Glasgow and to the Royal Infirmary. He had a distinguished military career, was a physician in charge of wards, a prolific contributor to medical literature and, in 1914, was the principal author of Diseases of The Heart, an important textbook. Updated and expanded editions of the work were published in 1922 and 1935 which reflected the increasing advances in cardiology. A founder member of the Cardiac Club, Cowan was a considerable figure in the development of cardiology in the United Kingdom. This review sets out to show the range and importance of his contributions.

The Cowan antecedents

Cowan's ancestors played an important part in the history of medicine in Glasgow dating back to Henry Marshall (d.1727), the son of Patrick Marshall (1631–1697), surgeon in Kilsyth (Figure 1). Henry Marshall followed his father in becoming a surgeon and was to become a leading practitioner in Glasgow, but this was not achieved without considerable controversy. An important point of principle was involved in the disagreement that arose as a consequence of his request to be admitted to the Faculty of Physicians and Surgeons of Glasgow. Marshall was refused admittance under an Act of the Faculty of 1679 restricting the admission of strangers. He subsequently obtained a licence to practise from the Town Council. This led to a long court case between the Faculty and the Council as to who had the right to appoint; the Court of Session finally decided in favour of the Faculty in 1691. Magnanimous in victory, the Faculty admitted Marshall the same year.¹ Marshall's great grand-daughter married Robert Cowan (1769–1808) who was admitted to the Faculty in 1790. His son (John Marshall Cowan's grandfather) also Robert, was admitted in 1819 and subsequently became Professor of Medical Jurisprudence in the University of Glasgow.² John Marshall Cowan's father, John Black Cowan (1829–1896), was Regius Professor of Materia Medica in the University of Glasgow and Physician to the Glasgow Royal Infirmary.³ Service to the Glasgow Royal Infirmary was a strong part of the Cowan heritage beginning with Robert Cowan in 1794.⁴

Figure 1.

Cowan family tree (Duncan, Memorials, 1896).

Education and early career

John Marshall Cowan was born in Helensburgh in 1870, the youngest of four children. Following schooling at Fettes College, Edinburgh, he initially matriculated for the 1887/1888 session in Medicine in the University of Glasgow before moving to King's College Cambridge where he graduated B.A. in 1891, M.B. and B.Ch. in 1895, and M.D. in 1902. He subsequently returned to Glasgow, his early interest in cardiology clearly apparent in his conferred D.Sc, ‘Papers on the Myocardium’,⁵ awarded in 1904 by the University. In keeping with his family connections, he became a Fellow of the Faculty (later Royal College) of Physicians and Surgeons of Glasgow in 1898 (Figure 2).

Figure 2.

Portrait of John Marshall Cowan (Cardiac Society Archives).

Following graduation, Cowan held resident positions in Glasgow at the Western Infirmary and the Royal Hospital for Sick Children and acted as Assistant Physician at Belvidere Hospital. He returned to the Western Infirmary as Dispensary Physician in 1899 and at the same time worked with Robert Muir in the pathological department, one of the most advanced pathological departments of the time.⁶

Research and teaching

Cowan's research interests remained strong throughout his career. He was elected Foulis Memorial Scholar in 1903 and in 1904 Research Fellow of the University of Glasgow. By the early 1920s, he was researching the heart in disease, mainly electrocardiographic research, the reaction of the heart in pneumonia and the significance of an increased R wave.⁷ He was a Lecturer in Medicine in the Western Medical School from 1900 to 1907 and Professor of Medicine in Anderson's College from 1907 to 1921. He was best teaching at the bedside and initially was not a popular lecturer as his delivery was ‘difficult to follow at times’.⁸ He gradually overcame this difficulty, however, and in 1926, gave the George Gibson Lecture at the Royal College of Physicians of Edinburgh and the St. Cyres Lecture at the National Hospital for Diseases of the Heart in 1930.⁹

Military service

Military service was also part of the Cowan heritage. John Black Cowan had served as a civilian physician during the Crimean War.¹⁰ In April 1900, John Marshall Cowan set sail for Cape Town to serve as physician to the Scottish National Red Cross Hospital which was established at Kroonstad. He subsequently published a graphic account of the conditions in The Scottish Medical and Surgical Journal.¹¹ Over 600 sick troops mostly suffering from enteric fever had been left behind in Kroonstad by the advancing British Army. A church had been utilised as a hospital in addition to two hotels (Figure 3). Pews had been removed from the church and mattresses arranged in rows:

A few beds, perhaps a dozen in all, had been obtained, and these were used for the most serious cases. Pillows were few in number, a bundle of clothing making a fair substitute, and there was a sufficiency of blankets. There were, of course, no pre-existing latrines, so night stools had been placed in the porches for such patients as were able to get up.

Figure 3

The Church at Kroonstad, 1900 (RCPSG 39/3/28).

The mortality rate was high and often ‘complicated by pulmonary symptoms’, which occurred in the majority of those lying on mattresses on the floor. A tented hospital with hospital beds was established once the equipment arrived and conditions improved. In addition to noting the medical cases, Cowan also mentioned the success of the experiment made by the hospital of using medical students, mostly members of the Student Volunteer Medical Corps, as nursing orderlies:

I cannot speak too highly of these gentlemen, who underwent many real discomforts and put themselves in many cases to serious inconvenience by the postponement of their examinations in order to undertake the work of attending to the sick and wounded.

He returned home on the hospital ship, Trojan, in September 1900 with members of the Red Cross Hospital being placed in charge of the 77 sick and wounded on board – the first time, according to their Principal Medical Officer, Professor Clark, that a voluntary hospital had ‘brought home an hospital ship’.¹²

Cowan subsequently continued his association with military medicine in the Royal Army Medical Corps (RAMC), being attached to the RAMC Territorial Force in July 1908 at 3rd Scottish General Hospital, Stobhill with the rank of Major. He was promoted to Lieutenant Colonel in 1917 and Colonel in 1918. He served in Egypt and Palestine during the First World War, being present at Sollum at the engagement at Agagia on 26 February 1916. He published on his experiences of treating dysentery and malaria at the General Hospital in Alexandria¹³ and, after the war, presented a lecture to the Post-Graduate Course at Glasgow Royal Infirmary of the problems arising from those returning having suffered with these diseases.¹⁴

Cowan's connection with the Army continued during the inter-war years when, in 1921, he became Medical Officer to the 5th Scottish Rifles. In the early years of the Second World War, he took part in medical assessments at 20th General Hospital based at Buchanan Castle, Stirlingshire.

Glasgow Royal Infirmary

The majority of Cowan's professional career as a physician was spent at the Glasgow Royal Infirmary and it was here that he invested much of his time and energy. In 1906, he was appointed Visiting Physician and found that there was a great deal to be done to raise the standard of work, and spent a large part of his day in the wards. He was tireless in his efforts and ‘got things done in the end, as he always did, and put the wards on sound and modern lines’. He was meticulous in his examination of cases, welcoming the opinion of juniors ‘even when it directly countered his own, and was always prepared to discuss the differences’.¹⁵

In addition to his clinical work, he was also influential in contributing to the management of the Infirmary. The Local Government (Scotland) Act of 1929, which became effective in 1930, enabled the Corporation of Glasgow's Health Department to take over former Poor Law hospitals and develop a comprehensive municipal medical service, providing treatment for all the inhabitants, not just the very poor, including those who previously would only have been accepted at a voluntary hospital such as Glasgow Royal Infirmary. The Royal Infirmary remained as a voluntary hospital until the introduction of the NHS following the Second World War, but it was clear that it would have to change its ethos and services in order to maintain its voluntary status and offer areas of expertise which the Corporation was unable to provide. The views of many of the medical staff and managers were summarised by Cowan in a memorandum written in 1932. The memorandum provided the basis for a wide-ranging debate which led to new policies and strategies and strengthened the hospital's position within Glasgow's expanding hospital network. In the memorandum, Cowan insisted that the hospital had a vital role to play in the education of doctors and nurses and as a centre for research. However, the hospital needed to be stricter on the admittance of patients to prevent the overcrowding of wards, clinics and dispensaries. Cowan felt it was essential to provide clinical services for those most in need:

At present, many patients who are not desirable are admitted to wards; patients with incurable chronic diseases; and those with trivial disorders who should be treated in their homes. Others, a nuisance to their doctors, are sent to hospital to get them out of the way.¹⁶

The situation of overcrowding in the Royal Infirmary mirrored that existing in Glasgow hospitals as a whole.¹⁷ Subsequent more rigorous vetting of patients at the Royal Infirmary through the introduction of an almoner service in 1932 and the provision of convalescent and nursing homes at Canniesburn for paying patients (opened in 1938) helped ease the problem.

Cowan's memorandum also called for the introduction of salaries for junior doctors. By this date, the residents at the other large hospitals in the city, the Royal Hospital for Sick Children, the Victoria and Western Infirmaries received honoraria. Cowan argued that in order for the Royal to continue to attract the very best residents it, too, would have to provide them with payment. The managers, realising that filling vacancies with suitable junior staff was a growing problem, took immediate action and introduced honoraria similar to the other Glasgow hospitals.¹⁸

The Royal Medico-Chirurgical Society of Glasgow

Cowan was an active member of the Royal Medico-Chirurgical Society of Glasgow (founded 1814) and consistently presented demonstrations and papers relating to cardiac medicine at many of the meetings including in April 1910 ‘Coupled Rhythms of The Heart (Pulsus Bigeminus)’ and in October 1913 ‘Lantern Demonstration of Auricular Flutter’.¹⁹ This latter included a demonstration of abnormal rhythms as depicted by the electrocardiogram and was possibly the first such demonstration in Glasgow.

He was president of the Society in 1927–1928 as had been his grandfather, Robert Cowan in 1839–1840. Women had first been admitted as members in 1911 and the number of women members gradually increased, partly due to the expansion of Redlands Hospital for Women in Glasgow, and also as a consequence of support from the Pathology Department of Glasgow Royal Infirmary.²⁰ During Cowan's presidency, on 4 March 1927, two women doctors from the Infirmary's Pathology Department were responsible for the business of a meeting:

Dr Cowan (the President) referred to the fact that for the first time in the history of the Society the Public Business before the meeting consisted of communications from lady members.²¹

Two years later, one of the speakers, Dr Alice Marshall, was elected to Council, indicating an increasingly positive attitude towards women practitioners within the Society.

Non-cardiology contributions

Cowan regarded himself as a general physician first and a cardiologist second. In a letter signed ‘A General Physician’ published in the British Medical Journal in 1925 he wrote:

We must not confine ourselves, in our practice, to heart disease alone, for it is from our knowledge of the reactions of the heart to general infections, and to local infections in organs other than the heart that we will become best fitted to afford help²²

Between 1897 and 1939, he published just over a 100 papers or contributions. Many, but by no means all were, of course, on cardiac medicine but his range of interests was wide. His contributions arising from war service have already been mentioned but other papers included articles on the topics of poisoning, anaemia and, possibly the most notable, on the serum treatment of pneumonia. This latter paper arose from an investigation carried out over a number of years which ‘threw much fresh light on the whole subject of pneumonia’.²³

Cardiology contributions – Cowan and the Cardiac Club

The coming of the 20th century brought about a ferment of activity in British cardiology with John Cowan playing a significant part. In 1939 he wrote:

It is difficult to convey to the Georgian a proper impression of the attitude of the late Victorians to heart disease. Laennec's discovery of auscultation dominated the succeeding fifty years, and towards the end of the century the characteristic sounds of the various valvular lesions had been fully elucidated. For a time medicine stagnated. Those of us who were Residents in medical wards viewed the outlook with dismay, for the progress of surgery at that time, under the influence of Lister's work, was phenomenal. But better times were at hand.²⁴

Experimental cardiac physiologists had been at work for some years but had been largely ignored by clinicians who considered that skill in palpation, percussion and auscultation plus experience were all that was needed. The ‘new cardiologists’ sought to incorporate the findings of the experimental physiologists into clinical medicine. A major change was the concept of the ‘living heart’ with its properties of rhythmicity, contractility and conductivity.²⁵ The focus of the exponents of this concept, such as James Mackenzie and Thomas Lewis, was on dynamic studies of the heart using and adapting new techniques such as the polygraph, electrocardiograph, the sphygmomanometer, and later X-rays.²⁶ Cowan very much exemplified the changes that were taking place and these were clearly manifest in his textbook Diseases of the Heart first published in 1914 (vide infra).

The First World War and its aftermath gave a major impact to cardiology. Large numbers of servicemen were deemed to have heart disease but accurate diagnosis was lacking, with patients being categorised as suffering from either V.D.H. (Valvular Disease of the Heart) or D.A.H. (Disordered Action of the Heart). In April 1920, the Ministry of Pensions appointed consultants to advise on the treatment and assessment of cardiac patients. John Cowan was one of the ‘new cardiologists’ appointed. Conferences were held where clinical as well as administrative matters were discussed and were so successful that in 1922 W.E. Hume wrote to Cowan as a senior member to suggest that those interested in cardiology should come together regularly.²⁷ The subsequent Cardiac Club was formed on 22 April 1922. There were 15 members, all notable figures in British cardiology with James Mackenzie elected as an honorary member.²⁸ Membership was confined to 25 members and Cowan was nominated as the Club's first secretary. Annual meetings were held in different parts of the country. Developments in cardiology and increasing numbers interested in the subject led to the expansion of the Cardiac Club into a larger and more representative society. The inaugural meeting of the Cardiac Society was held in Edinburgh in 1937. Election to membership usually required a paper be delivered to a meeting. Membership was eagerly sought but not always obtained. The Cardiac Society flourished, developing and expanding to become the Society for Cardiovascular Medicine with a membership of more than 3000.

Hume, also a founder member of the Cardiac Club, wrote a notable tribute in 1948 after Cowan's death: ‘The original Cardiac Club owed much to Cowan's enthusiasm. As a physician he was already ripe in wisdom and experience, and had the youthful enthusiasm to practise and master the newer methods of cardiovascular investigation’.²⁹

Diseases of the Heart first edition

Although Cowan published a wide range of papers in the field of cardiology, his magnum opus was Diseases of the Heart, first published in 1914. In his preface to the first edition, Cowan writes:

During the past ten years great advances have been made in our knowledge of diseases of the heart and arteries. … The sphygmomanometer, the polygraph, the electrocardiograph and the Röntgen rays, have become accessible to the clinician and the data thus acquired have elucidated some of the many problems which awaited solution.

He continues that the book is based in the main upon his own personal experience and the records in his wards while acknowledging that he has utilised, ‘where it seemed desirable, the numerous monographs, and articles, which have recently appeared and the experience of my medical friends’.³⁰

The book has 39 chapters. The first five discuss disease of the myocardium. The first chapter, ‘The Diseases of the Myocardium’, focusing on the pathology of the heart, is notable for its superb illustrations by A.K. Maxwell and Richard Muir. The work and findings of the ‘new cardiology’ with its concept of the ‘living heart’ and the use of instrumentation is reflected throughout the book. On pages 105–106, for example, Cowan writes:

The investigation of the special functions of the cardiac muscle, its power of producing rhythmic stimuli, its excitability and contractility, the variations in the rate of conduction of the stimuli from part to part, and the tonicity of the organ as a whole, has been pursued in the laboratory for many years past; but it has only been possible within the last few years to apply laboratory methods to clinical work … By graphic methods the relationship of the contractions of the various chambers can be readily demonstrated. (Figure 4)

Figure 4.

Fig 65 – Simultaneous records of the cervical curve and of the ECG (Cowan, Diseases of the Heart, 1914).

Cowan was an expert on the polygraph which required meticulous work to obtain recordings and skill and experience to interpret the results. Tracings could be made, for example, from the brachial artery at the level of the elbow, from the right side of the neck immediately above the clavicle and from the apex impulse.

The polygraph is no longer routinely employed, but the amount of information gained by skilled operators was prodigious and, through the subsequent increased knowledge of cardiac function, greatly enhanced the development of cardiology. Twelve chapters of Cowan's work are devoted to disorders of rhythm and conduction. Copious illustrations demonstrate the type of information that can be gained from the polygraph. Figure 5, for example, illustrates the radial pulse in atrial fibrillation and Cowan's observations on atrial fibrillation are, in particular, most astute.

Figure 5.

The radial pulse in atrial fibrillation (Cowan, Diseases of the Heart, 1914).

Two chapters of the work are written by colleagues of Cowan whom he recognised as authorities on their particular subjects.³¹ Chapter VI, ‘The Ocular Manifestations in Arterio-Sclerosis’ is written by Arthur J. Ballantyne, surgeon at the Eye Infirmary, Glasgow. Ballantyne was later to become the first Tennent Professor of Ophthalmology in the Western Infirmary, Glasgow. The early use of the electrocardiogram is explored in Chapter VII written by W.T. Ritchie (then Assistant Physician at Glasgow Royal Infirmary and later to become Professor of Medicine and Clinical Medicine, University of Edinburgh). Subsequent chapters, including those on acute and chronic valve disease, are engrossing and thorough in terms of symptoms, clinical findings and prognosis. These chapters are enhanced by descriptions of individual clinical cases.

However, the historian Christopher Lawrence has suggested that the ‘new cardiology’ did have its drawbacks. Abnormalities of structure were relegated, and function was promoted to become all-important. The clinical symptoms we now recognise as due to coronary artery disease were regarded as an extreme form of myocardial exhaustion: ‘Symptoms were thus the signs of cardiac distress from whatever cause’.³² The focus was on the performance of the whole myocardium. The clinical/pathological syndrome went unrecognised till the 1920s. The first edition of Diseases of the Heart has only one reference to angina:

Chest discomfort or pain is frequently experienced. The most common complaint is of palpitation, the patient becoming conscious of the cardiac contractions as a fluttering or throbbing sensation within the chest … In cardiac disease it may be due to several causes. It occurs on slight exertion in cases where the cardiac work is being carried on with difficulty.³³

Clinical findings were still not being related to the underlying coronary artery pathology. Cowan was of course well acquainted with coronary pathology, the subject of several of his early papers. On page 5, he writes:

The majority of cases with gross disease of the coronary arteries show more or less change in the cardiac muscle, for the nutrient arteries are end-arteries … and their complete obstruction entails the death of the area which they supply.

A further example of this can be seen on page 27:

Fibrosis of the heart may thus be due to several causes. In the great majority of cases, and in all examples of gross disease, it is the result of ischaemic destruction of the muscle cells, following obstruction of the coronary arteries and secondary connective-tissue hyperplasia.

In his discussion of myocardial infarction and myomalacia cordis, he remarks ‘The nutrient arteries may be occluded by emboli or thrombi, the latter being more common’.³⁴ Cowan therefore believed that thrombi were a major factor – a theory not accepted by many famous cardiologists until many years later.

Thus, disease of the circulation and its consequence for the myocardium was well known. What was lacking was the pathological clinical link which came after the publication of Cowan's first edition in the 1920s. In 1926, Cowan delivered the George Alexander Gibson Memorial Lectures in Edinburgh entitled ‘The Failing Heart’, subsequently published in the Edinburgh Medical Journal.³⁵ The lectures were an extensive review of clinical cardiology in the 1920s reviewing the clinical features and pathology of valvular disease and, inter alia, a long discussion on rhythm and other conduction abnormalities. The clinical features of myocardial infarction had been first reported by J.B. Herrick in 1912³⁶ at a meeting of the American Association of Physicians but caused little comment until 1919 when Herrick readdressed the same association.³⁷ Cowan was aware of these developments:

There is a large group of cases in which failure occurs as a result of disease of the coronary arteries. It has been known for long that these vessels are frequently affected by pathological lesions, and in fact, as a rule, show some pathological change after middle life. The orifices may be implicated in diseases of the aorta and plaques of atheroma and diffuse thickening of the coats are not uncommon in the larger branches. Similar lesions are also found in the smaller vessels.³⁸

Infarct, rupture, fibrosis and aneurysm are the direct results of coronary artery disease.³⁹

He also discusses the signs of ischaemic necrosis of the myocardium in 17 patients. Seven showed a sudden and 10 a gradual onset:

The pain in these patients resembles that of angina in many respects. It may be just as intense and overwhelming, and may be felt in the same sites. But it may differ. It sometimes occurs when the patient is at rest, even asleep … The pain is often very persistent … One finds them sitting up in bed, with an anxious expression, their countenance pale and blue and bedewed by sweat, their extremities cold, clammy and cyanosed. … The cardinal sign of infarct is a pericardial rub.⁴⁰

Cowan is describing what would now be recognised as an acute myocardial infarction.

Subsequent editions of Diseases of the Heart

Developments in cardiology continued apace between the second edition of Diseases of the Heart in 1922 and the third in 1935. Coronary artery disease and its clinical consequences were coming to the forefront. In the preface to the 1935 edition, Cowan states:

The many additions which have been made to the general store of knowledge concerning the circulation in health and disease during the last twelve years have necessitated a complete revision of the last edition … New chapters deal with the blood supply of the heart, angina pectoris, myocardial infarction.⁴¹

One of the great strengths of Cowan's book is the clinical cases he describes. This as much as anything makes the book immensely readable. Clinical descriptions remain prominent through all editions of the work with later editions reflecting the developments and improved understanding in clinical cardiology. Many of the patients with cardiac ischaemic symptoms died suddenly, underscoring one of the great challenges in cardiology then and now – how to prevent sudden death.

The 1935 edition mentions the ECG appearance during chest pain and how in angina it often resembles the appearance of a myocardial infarction. However importantly, Cowan also states that a normal ECG does not necessarily indicate a ‘normal muscle’ and that the ECG may return to normal post infarction.

There remains much on disorders of rhythm and on vascular disease including the use of the term ventricular anarchy which describes multi-focal ventricular extrasystoles which are often a precursor of ventricular fibrillation. Cowan continues to emphasise the value of the polygraph but also shows the links developing with electrocardiography and the information obtained especially in terms of clinical coronary heart disease. Contributions from WT Ritchie (on electrocardiography) and AJ Ballantyne (on ophthalmology of arteriosclerosis) remain. Both men are now recognised as co-authors in the third edition.

In chapter XXVII, ‘Angina Pectoris. Infarct of the Heart’, Cowan remarks ‘angina pectoris is not a specific disease of the heart, but merely a symptom, of varied origin’.⁴² He observes that angina is more common in men than women and also, in his opinion, ‘It is more common in brain workers, and those whose occupation entails nervous strain’.⁴³ The chapter provides an excellent review of symptoms and clinical findings associated with angina and myocardial infarction.

In the treatment of angina and infarction in addition to general tonics and vasodilators, he also comments ‘glucose, aided if necessary by insulin has been advocated’.⁴⁴ This had a resurgence of interest in the 1970s treatment of acute infarction when it became known as the Sodi-Pallares regime.⁴⁵

Cowan also considers the possibility of surgical treatment of angina which involved severing the sensory paths between the heart and the brain or by reducing postulated spasm of the coronary arteries by severing parasympathetic fibres in the neck. However, he is not an advocate of this technique since he regards angina as a danger signal and an indication that physical activities are harmful and must cease: ‘we have not, as yet, thought fit to recommend operative interference in any of our patients’.⁴⁶ Note the term ‘interference’. It was 50 years or so later that coronary artery bypass surgery revolutionised the management of angina.⁴⁷

By the 1930s, the electrocardiogram had become an ubiquitous tool for investigation and the authors were keen to emphasise the science behind it. They discuss the principle of the electrocardiograph and how it represents cardiac contraction. Cowan does, however, advise caution against over reliance on technology:

Definite evidence of myocardial disease may be shown by the electrocardiogram, but too much must not be expected from this form of investigation . . Deformities will only occur if the mass of muscle thrown out of gear is considerable and localised.⁴⁸ (Figure 6)

Figure 6.

Leads 1, 2 and 3 of an electrocardiogram taken one day after coronary thrombosis (Cowan, Diseases of the Heart, 1935).

The prognosis in myocardial infarction

By the 1930s, the diagnosis of myocardial infarction was, albeit slowly, making its way into clinical cardiology. Harrington and Wright, also based in Glasgow Royal Infirmary, reported in 1933 on 148 cases of myocardial infarction.⁴⁹ They felt the condition was both under-diagnosed and increasing. In addition to the clinical features, they noted pyrexia and leukocytosis and commented on the frequent abnormalities of the electrocardiogram.

Prognosis after infarction was regarded as poor and Cowan sought to redress the balance. In his article on the subject in 1936, he wrote:

The dramatic symptoms which sometimes occur when a coronary artery becomes blocked and the not infrequent termination of life, have led to a pessimistic outlook in these cases … Abrupt closure of a main coronary artery causes sudden death but if the closure is gradual anastomotic developments may take place and prevent serious results'.⁵⁰

He examined the clinical records of 66 patients (58 men, 8 women) who had an infarct of the heart and survived for more than six months. Thirty-three were still alive at the time of writing. Forty-four had lived for more than two years and 28 had resumed their work, which, however, was never manual.

Electrocardiograms were taken in 50 patients in this series and showed various abnormalities. The records are too scanty to afford useful information as to the relative importance of the different defects but a normal record is evidently a favourable sign. Inversion of T in all leads and flatness of T waves are unfavourable.⁵¹

An example of sequential T wave changes is shown in Figure 7. Throughout his published work, Cowan clearly demonstrates his journey in clinical practice towards a present day understanding of the symptoms and pathology of coronary heart disease.

Figure 7.

Series of electrocardiograms after the occurrence of an infarct, taken at different time intervals (Cowan, Diseases of the Heart, 1935).

Conclusion

John Marshall Cowan was a man of many parts: soldier, skilled physician, early clinical scientist and a man whose vision was to have a major influence on the development of British cardiology. He was appointed Physician in Scotland to King George V, King Edward VIII and King George VI. In 1937, he was awarded an honorary LL.D. by the University of Glasgow as a ‘consequence of his researches and published writings which have won him an international reputation in cardiology’.⁵² For the occasion Cowan wore the gown of his father, John Black Cowan, who had received his LL.D. from the University 57 years previously.⁵³

One perhaps surprising aspect of his career was a lack of involvement in the work of the Royal Faculty (now College) of Physicians and Surgeons of Glasgow. His father, Dr. John B Cowan was visitor from 1876 to 1877 but did not become president. Although he did not take an active role in the life of the Faculty, he was clearly proud of his family's long association with the incorporation and bequeathed to the Faculty a gold-headed cane, writing in his will: ‘I wish a good Malacca cane be sent to the Faculty for the use of the President as he thinks fit. A gold crest of the Faculty on top and around the initials of my forebears’. Neither of Cowan's sons, who both pre-deceased him, went into medicine and he was the last in a long line of practitioners who had served Glasgow and its surrounding area for almost 300 years. The bequest mirrors that of the original physician's gold-headed cane which can be found at the Royal College of Physicians of London and was owned by six of the most eminent physicians from 1689 to 1825 including William Hunter and the renowned anatomist Matthew Baillie, the last of its owners.⁵⁴

Cowan seems to have had a somewhat reserved personality, but this may have been a front. As his obituary in the British Medical Journal states: ‘His rather aloof manner made him difficult to know, but all who had the privilege of working with him recognised the generous and loyal nature that underlay the rather stiff and formal surface’.⁵⁵

He was a man of wide interests, including philately. He fished and in his younger years played a little cricket and golf. He spent much of his retirement researching his family and the history of Glasgow, and the results of his work Some Yesterdays was published after his death in 1949. His wife, Maude, died in 1936 and his daughter, Katherine, cared for her father in his years of widowhood and regarded herself as custodian of her father's papers and guardian of his memory.

Footnotes

Acknowledgements

The authors thank Lauren McMahon and Clare Harrison for the considerable help given in organising this paper.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

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Duncan. Memorials, p.277.

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10.

John Black Cowan was a friend of Glasgow surgeon George Buchanan (amongst others) during the Crimea War see: Buchanan G. Camp Life As Seen by a Civilian. Glasgow, 1871.

11.

Cowan JM. Kroonstad, May-September 1900. Scottish Med Surg J 1901; 8: 21–29.

12.

Royal College of Physicians and Surgeons of Glasgow (hereafter RCPSG) RCPSG 21/2 newspaper cutting, ‘Interview with Professor Clark’, 1900.

13.

Cowan JM, and Miller H. Dysentery – a clinical study. J R Army Med Corps 1918; 31: 217–228 and 1918; 31: 277–295; Cowan JM and Mackie TJ. A note on the modes of infection in bacillary dysentery. J R Army Med Corps 1919; 32: 209–214; Cowan JM and Strong RH. The treatment of malaria. QJM 1919; 13: 1–24.

14.

Cowan JM. The aftermath of dysentery and Malaria. Glasgow Med J 1919; 92: 65–74.

15.

As quoted by Archbald Harrington in Hume, WE. John Cowan. Br Heart J 1948; 10: 1, 2.

16.

As quoted in Jenkinson J, Moss M and Russell I. The Royal: the history of the Glasgow Royal Infirmary 1794–1994. Glasgow: Glasgow Royal Infirmary NHS Trust, 1994, p.179.

17.

See: Kinnaird J. The hospitals. In: McLachlan G (ed.) Improving the common weal, aspects of the scottish health services 1900–1984. Edinburgh University Press, 1987, pp.225–228.

18.

Jenkinson et al. The Royal, pp.184–185.

19.

Cowan JH. Lantern demonstration illustrative of ‘Auricular Flutter’. Glasgow Med J 1914; 81: 128–129.

20.

Dow DA. The oldest and leading medical society in Glasgow, 1919–44. In: Dow DA and Calman KC (eds) Glasgow: Glasgow Royal Infirmary NHS Trust, 1994, p.179, pp.63–75 especially p.67.

21.

RCPSG 1/3 Royal Medico-Chirurgical Society of Glasgow Minute Book, 1922–1936.

22.

Cowan JM. Neo-cardiology. BMJ 1925; ii: 1245.

23.

Obituary, John Marshall Cowan. Glasgow Med J 1947; 28: 306.

24.

Cowan J. Some notes on the Cardiac Club. Br Heart J 1939 1: 97–104, 97. ‘Georgian’ refers to the then King, King George VI.

25.

Lawrence C. Moderns and ancients: the ‘New Cardiology’ in Britain 1880–1930. Med Hist 1985; Suppl 5: 1–33.

26.

Frank R Jr. The Telltale heart: physiological instruments, graphic methods, and clinical hopes, 1854–1914. In: Coleman W and Holmes FL (eds) The investigative enterprise: experimental physiology in 19th century medicine. Berkeley: University of California Press, 1988, pp.211–290.

27.

Cowan J. Some notes on the Cardiac Club. Br Heart J 1939; 1: 97–104, 98.

28.

The original members were: CF Coombs, TF Cotton, J Cowan, JG Emanuel, AG Gibson, T Wardrop Griffith, J Hay, TJ Horder, WE Hume, T Lewis, JE MacIlwaine, J Parkinson, WT Ritchie, HJ Starling, KD Wilkinson.

29.

Hume WE. John Cowan. Br Heart J 1948; 10: 1–3, 2.

30.

Cowan JM. Diseases of the heart. 1914, p. vii.

31.

Cowan JM. Diseases of the heart. 1914, p. viii.

32.

Lawrence, 27.

33.

Cowan. Diseases of the heart, 1914, p.289.

34.

Cowan. Diseases of the heart, 1914, p.16.

35.

Cowan JM. The failing heart. Edinb Med J 1926; 33: 465–479, and 533–565.

36.

Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 1912; 59: 2015–2104.

37.

Olszewski T. James Herrick (1861–1954): Consultant Physician and Cardiologist. J Med Biogr.

38.

Cowan, The failing heart, p.466.

39.

Cowan, The failing heart, p.469.

40.

Cowan, The failing heart, pp.561–562.

41.

Cowan J, Ritchie WT and Ballantyne AJ. Diseases of the heart. 3rd ed. London: Edward Arnold, 1935, p.vii.

42.

Cowan. Diseases of the heart. 1935, p.418.

43.

Cowan. Diseases of the heart. 1935, p.421.

44.

Cowan. Diseases of the heart. 1935, p.447.

45.

Sodi-Pallares D, Testelli MR, Fishleder BL, et al. Effects of an intravenous infusion of a potassium-glucose-insulin solution on the electrocardiographic signs of myocardial infarction: a preliminary clinical report. Am J Cardiol 1962; 9: 166–181.

46.

Cowan. Diseases of the heart. 1935, p.449.

47.

European Coronary Surgery Study Group, Coronary-artery bypass surgery in stable angina pectoris: survival at two years. Lancet 1979; 313: 889–893.

48.

Cowan. Diseases of the heart. 1935, p.414.

49.

Harrington AW and Wright JH. Cardiac infarction: a study of 148 cases. Glasgow Med J 1933; 119: 1–12.

50.

Cowan JM. The prognosis after infarct of the heart. A clinical study. Lancet 1936; 227: 356–359, 356.

51.

Ibid, 358.

52.

GUAS Acc. 44/010, Commemoration Day, 16 June 1937.

53.

GUAS IP6/1/25, Newspaper cutting book, p.58.

54.

Beaton JJ, Miller R and Boyle IT. Treasures of the College. Glasgow: Carnyx Group on behalf of the RCPSG, 1988, pp.43–45.

55.

Obituary, John Marshall Cowan. BMJ 1947; 2: 435.