From syncope to orthostatic hypertension, stress cardiomyopathy to autonomic dysreflexia, cardiovascular disorders of the autonomic nervous system are manifold and complex. Yet the autonomic nervous system was for a long time a relatively neglected area of research—so much so, that Sir George Pickering in the last century described a review of autonomic function as ‘no more than an overture. The main body of the work is to come’ (Mathias and Bannister, 1999).
Sir Roger Bannister, a one-time student of Sir George, added much to that body of work through his lifetime studies of the autonomic nervous system (though he acknowledges that the human body remains ‘millennia ahead of the physiologist’) (Bannister, 2014). In 2005, he was presented with the American Academy of Neurology's first ‘lifetime achievement award’ for his work on autonomic disorders, having written over 80 original articles on the subject. Working in partnership with Professor Christopher Mathias, Bannister's training as a physiologist and neurologist neatly complemented Mathias' expertise in cardiovascular medicine. In 2013, the fifth edition of their joint textbook, Autonomic Failure was published and it is read in medical libraries around the world (Mathias and Bannister, 2013). The Clinical Autonomic Research Society, established by Bannister, now has counterparts in America, Canada, Australia, France, Italy and Japan.
Sir Roger Bannister
To the world, Sir Roger Bannister was known as the first man to run a sub-4-minute mile. However, he worked in medicine for 60 years while, in his words, he ‘ran for about eight’ (Graham, 2018). With this in mind, his life story will be told through the lens of sport, but with the emphasis on his work in neurocardiology. Much inspiration has been taken from Bannister's own autobiography, appropriately entitled, Twin Tracks (Bannister, 2014).
Starting blocks
In the autobiography, Bannister writes that he ‘struggled into the world on 23 March 1929’ and famously describes how he ‘ran anywhere and everywhere’—never as an end in itself, but because, for him, it was easier to run than to walk. He recalls that his parents taught him to respect authority, work hard and do well; his was a ‘heads-down and homework-encompassed life’, undergirded by a feeling that life promised something more (Bannister, 2014).
Bannister had a cousin, Edith, who was the first member of his family to attend Oxford University, and, in his autobiography, Bannister remembers absorbing his parents' ambitions that he should follow in her footsteps.
Pacesetters
A pacesetter, or pacemaker, is a runner who leads a running event for the first section to ensure a fast time. Chris Brasher and Chris Chataway were the pacemakers for Bannister when he became the first man to break the 4-minute mile barrier in 1954.
Setting the pace for Bannister in his medical career were Sir Charles Sherrington, who retired from Oxford just before Bannister arrived, and who had won the Nobel Prize for his work on spinal reflexes, and David Whitteridge, another prominent neurophysiologist, who tutored Bannister on control of the heart and circulation (Creed et al, 1932; Martin, 1994).
The last half of the 20th century, when Bannister completed much of his research work, was an era of extraordinary innovation and discovery in neurophysiology. In his autobiography, Bannister also acknowledges the work of Sir George Pickering, Professor Peter Sever and Sir Ludwig Guttman. Pickering sought to establish whether essential hypertension was a result of renal disease or whether it represented normal distribution of blood pressure in the population (Oldham et al, 1960). Sever mastered the technique of measuring plasma noradrenaline and later collaborated with Bannister to assess its levels in patients with autonomic failure (Bannister et al, 1977; Vecht et al, 1978). Guttman is remembered as the father of the Paralympic Games and as a doctor who revolutionised the care of patients with spinal cord injuries by introducing relatively simple techniques, such as turning regimes and intermittent catheterisation, and by creating an entirely new spinal unit in Aylesbury, which is still in use today (Akkermans, 2016).
Most poignantly of all, Bannister credits much influence to the men only a few years older than him who had lost their lives during the Second World War, who never had ‘the chance to show what they could achieve in sport and the rest of their lives’. He believes that this spurred him to ‘grasp every opportunity’, and to seek some way of showing that, had he been older, he might have ‘displayed at least some of their spirit’ (Bannister, 2014).
Team spirit
Bannister describes the sub-4-minute mile as a team achievement in which all members played crucial parts. He writes that ‘without any one of us, it would not have been run on 6 May 1954’ (Bannister, 2014). As well as his pacesetters, he credits his coach, Franz Stampfl, for—among other things—convincing him to run the historic race despite the weather, lest he miss his only chance at the record, and Norris McWhirter, who kept the time that day and famously announced the result (Fordyce, 2004).
Off the track, Bannister was a team player too. Speaking of his hospital work, he said ‘the nurses needed the junior doctors as much as we needed them’ (Bannister, 2014). He recalls carving the Christmas turkey for the wards at St Mary's Hospital, where he was a consultant. His children would accompany him, and he recalls the time when a nurse offered his 6-year-old daughter a ‘rather marvelous doll’, only for her brother to insist she gave it back to the ward for a sick child.
Bannister and his wife complemented each other as a team. He was married to Moyra for over 60 years and, in his autobiography, he credits her steadier disposition as an invaluable counterbalance to his nature; he valued her good judgement and their shared intellectual interests. In the celebration of his life, held at the Sheldonian Theatre in Oxford in November 2018, it was said that Sir Roger and Lady Moyra felt their greatest achievements were their four children and their fourteen grandchildren (service sheet at memorial ceremony, 14 November 2018).
Breaking new ground
On 6 May 1954, after working his shift at St Mary's hospital, Bannister took the midmorning train to Oxford and ran the ‘Miracle Mile’ that afternoon, watched by around 3000 spectators. His victory was called the most stunning athletic achievement of the 20th century in a tribute published in the Hippocratic Post, but Bannister maintained that, given the choice between making a great breakthrough in the study of the autonomic nervous system or running the 4-minute mile, he would choose the former (Wallersteiner, 2018; Pandya, 2018).
Bannister began his research in the control of breathing during exercise, when studying for a Master's degree (Bannister et al, 1954). He was also interested in heat illness, having observed several deaths among the troops in Yemen (where he served his National Service as a doctor with the Royal Army Medical Corps). His theory was that infection triggered anhidrosis (where perspiration is diminished or absent), and his results were published in the Lancet (Bannister, 1960). In his autobiography, Bannister describes the three deaths during army exercises on Brecon Beacons in a 2013 heatwave as ‘quite unnecessary’ in light of the recommendations made in his research (Bannister, 2014).
The subject of postural hypotension and autonomic control of blood pressure came to Bannister's attention when he read a report from America in 1960 on two patients with the condition in whom it was found that there was degeneration of sympathetic neurons in the spinal cord (Bannister, 2014). In the textbook edited by Bannister and Mathias, Autonomic Failure, a significant chapter is devoted to postural hypotension, with discussion of precipitating factors such as diurnal changes in blood pressure, straining during micturition and defaecation, exposure to a warm environment, and the effect of food, alcohol, exercise and certain drugs (Mathias and Bannister, 1999).
In 1968, Bannister set up the Autonomic Function Laboratory at the National Hospital, which helps treat conditions such as syncope, postural hypotension, amyloidosis, dysautonomia, postural tachycardia syndrome and multiple-system atrophy (University College London Hospitals, 2019). In 1983, Bannister wrote a summary of his findings on autonomic function and dysfunction in the Journal of the Autonomic Nervous System (Bannister, 1983).
Ahead of his time, and pre-empting some very modern medical ideas, Bannister wrote a remarkable letter to the Lancet in March 1973. This time, his subject was not autonomic failure, but lifestyle medicine—a subject today lauded as an ‘emerging new discipline’ (Association of American Medical Colleges, 2019). Reflecting on the prescription of drugs for lowering blood lipid levels, he asks whether doctors should more readily give ‘blunt advice which is free’ (Bannister, 1973). He wrote: ‘perhaps, instead of reaching for the prescription pad we should help to swing our patients over to a more positive view of health so that they change their lifestyle to include sufficient exercise’.
Different disciplines
The International Association of Athletics Federations, the sport's governing body, defines athletics in six disciplines: track and field, road running, race walking, cross-country running, mountain running, and trail running (United Kingdom Athletics, 2018). In acknowledgement of his achievements on the running track, the Sir Roger Bannister athletics track where he ran his 4-minute mile is now a competition standard 400-metre UK Athletics-accredited track (University of Oxford, 2019). Bannister also excelled in cross-country running, winning races (and silencing bullies) when he was evacuated to the city of Bath as a schoolboy (Bannister, 2014).
Despite his specialisation in the autonomic nervous system, Bannister also worked in other disciplines, particularly dementia, eye diseases and Parkinson's. He was himself later diagnosed with Parkinson's (Parkinson's UK, 2018).
As a consultant, Bannister worked at both the National Hospital and at St Mary's Hospital, the former being a specialist neurology hospital and the latter being a general teaching hospital. Alongside his clinical work, he lectured, researched and published articles and books. Like most researchers, he was soon introduced to the competitive nature of the work when, after submitting an important article on plasma noradrenaline levels in autonomic failure for publication in 1977, he saw an American group publish their results first (Bannister, 2014).
Winning medals
At the celebration of his life in Oxford's Sheldonian Theatre on 14th November 2018, the service sheet carried a list of Bannister's achievements alongside pictures of his beloved wife and children. He was, on the day of his wedding, awarded a CBE for his athletic career, but the awards and honours for his academic career were far more numerous.
He was Chairman of the Clinical Autonomic Research Society, Editorial Board Chairman of the international journal Clinical Autonomic Research, Patron of the British Association of Sport and Exercise Medicine, founding trustee of the Autonomic Charitable Trust and, as mentioned earlier, presented with the American Academy of Neurology's first ‘Lifetime achievement award’ for his work on autonomic disorders. He held six honorary fellowships and honorary doctorates including those from Universities of Wales, Bath, Loughborough and Manchester.
It is thanks to the relentless research of Bannister, supported by others such as Professor Christopher Mathias, that the autonomic nervous system ‘is no longer a neglected area of medicine, lying forgotten between neurology, cardiology and general medicine’ (Bannister, 2014).