Philip R. Liebson
Chicago, Illinois, United States

In an era where the use of imaging and other technological testing frequently takes the place of bedside diagnosis, it is intriguing to recall the state of cardiovascular diagnosis when the clinician relied on his or her eyes, ears, and hands—with a little help from the stethoscope and electrocardiogram. During the last century, Samuel Albert Levine (1891–1966), a Harvard clinician, was among the giants in the field. Born in Poland, Sam Levine was brought to the United States by his family at the age of three, where he grew up in Boston. The usual immigrant struggle for survival led to his efforts at such occupations as a streetcar conductor, elevator operator, tutor, and newsboy. The latter brought him a Newsboy Union Scholarship to Harvard, where, having heard a lecture by Dr. Richard C. Cabot on medicine, he decided to pursue a career as a physician. On completing his studies at Harvard Medical School, he took his residency at the then Peter Bent Brigham Hospital, where he had previously rotated as its first medical student. His mentor was Dr. Henry Christian, the dean of the medical school, Hersey professor of physic, and physician-in-chief.

In 1913, Sam spent a year at the Rockefeller Institute under Dr. Alfred E. Cohen, who taught him electrocardiography, a new device with which he had worked briefly as a medical student. In 1916, while a resident at the Brigham, he made probably the second antemortem diagnosis of acute coronary thrombosis, which Chicago’s James B. Herrick had initially described in 1912. Sam later contributed a comprehensive monograph on the subject in 1929.

When the US entered WWI, Sam volunteered for the British Medical Corps, where he was assigned to the British Heart Hospital. He worked with such outstanding clinicians as James Mackenzie, William Osler, and Thomas Lewis. Although Sam learned a good deal from them, he could be acerbic in his observations. In his recollections, for example, he indicated that “Sir James (Mackenzie) is growing old and therefore refractory and stubborn in his ideas” although “he stands out as one of the very great men in clinical medicine in the last century.” On the basis of their observations at the Heart Hospital, Sam and Thomas Lewis contributed to the literature on “neurocirculatory asthenia,” a syndrome that appeared to be related to psychological state of soldiers.

Five years after the end of the war, with the surgeon Elliott Cutler, Sam reported the first mitral valulotomy for mitral stenosis in a 12-year-old girl, who survived four-and-a-half years after the operation. However, the next three operations we unsuccessful, and valvulotomy was not revived until 1948. In 1936 Levine published the first edition of Clinical Heart Disease, an intriguing narrative about cardiovascular disease that was based entirely on his experience—without the handicap of attributed references. Reading like an astute conversationalist discussing clinical cardiology around a comfortable table, the book’s final and fifth edition was published in 1958.

While continuing to establish a large national practice, Sam continued teaching medical students at the Brigham through the 1960s. After WWII, W. Proctor Harvey, later to become an outstanding clinician and teacher at Georgetown, became Sam’s first cardiology fellow. Together they published “the little green book,” a book on clinical auscultation of the heart complete with phonocardiographic recordings illustrating clinical findings. Interestingly enough, Harvey and Levine’s long-time mentor, Henry Christian shared the hometown of Lynchburg, Virginia, likely contributing to the close professional relationship that developed between the three men.

Arguing to get myocardial infarction patients out of bed within days of the attack, Sam broke ground against early 1950s conventional wisdom regarding cardiac patient care, which prescribed four-to-six weeks of bed rest—as far from the nursing station as possible—to assure adequate recovery. Startling at the time, in the modern era of coronary care units, Sam’s recommendation is considered rather conservative.

Although Sam was adept at the use of state-of-the-art cardiovascular medicine, he was critical of excessive use of medications. (However, except for digitalis, quinidine, and Coumadin, few phameceutical options existed during most of his career.) Once after examining an anorexic heart patient on 13 different medications, he asked the intern to stop all but two medicines. “Dr. Levine, which two?” asked the intern. “Any two,” was the response. On the other hand, he was not critical of all medication, stating, “I encourage patients with angina to take nitroglycerine. . . . If you use nitroglycerine freely, you will outlive your physician.” He was also very practical about the realities of medical diagnosis and available treatment: “I would rather miss 10 cases of amyotrophic lateral sclerosis [ALS] than a single case of pheochromocytoma [a rare tumor of the adrenal gland].”

In 1954 an endowed professorship at Harvard was created under his name, at that time the largest endowed chair in the history of Harvard Medical School. Less than a decade later, after over 50 years at the Brigham and Harvard Medical School, Sam was diagnosed with a gastric carcinoma; he died in March, 1966. On his gravestone is written, “Above all else, the crown of a good name.”

References

1. Harvey, W. P., and S. A. 1959. Levine. Clinical Auscultation of the Heart. Philadelphia and London: W. B. Saunders.
2. JAMA.1966. “Samuel Albert Levine, M. D. Dies.” JAMA 196 (5):38.
   Levine, H. J. 1992. “Profiles in Cardiology: Samuel A. Levine (1891–1966).” Clin Cardiol 15: 473–476.
3. Levine, S. A. 1958. Clinical Heart Disease. 5th ed. Philadelphia and London: W. B. Saunders.
4. Lown, B. 2008. “Tribute to a Teacher: Clinical Pearls.” Brookline, Mass: Lown Cardiovascular Research Foundation. Accessed December 21. http://www.procor.org/usr_doc/Bernard_Lown_Clinical_Pearls_ProCor_spreads.pdf.
5. Wooley, C. F. 2005. “Proc, Dr. Sam, Uncle Henry and ‘The Little Green Book.’” American Heart Hospital Journal 3: 8–13.
6. Wooley, C. F., and J. M. Stang. 1990. “Samuel A Levine’s First World War Encounters with Mackenzie and Lewis.” Br Heart J 64: 166–170.