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Ontology of Programmed Instruction
EDITORIALS It is the need for bridging the gap, to lessen the isolation between all specialties directed to a system within the chest that Diseases of the Chest fulfills. Here is a specialty journal which allows communication between various specialties and can present specialized knowledge, specialized practice and established methods and integrate this material related to the chest. Thus, it provides a medium for the continuing education of the chest specialist and communication behveen the more limited specialists and a forum for discussion. In our present era of numerous journals, exponential growth of publication and accumulation of knowledge, there needs to be at least some unifying medium and attempts at relating specific important facts into a broad presentation of rational ideas, concepts, innovations and controversial views within the area of the specialties concerned with the chest. Disea~esof the Chest is an admirably suited journal for this function and fulfills a real need for inter-communication between all the specialties which directly or indirectly deal with chest problems. Knowledge advances by questioning established concepts and by developing new ones, and the specialist, whatever he may be, should be an educated man. Harold A. Lyons, Bf.D., F.C.C.P.
Professor of hledlcine, State University of Kew York, Downstate hledical Center, Broobn
REFERESW 1 WARE.\I.: The general medical journal in cl~nicalmedicine, New Eng. I. Aled., 2783, 1968. 2 LUSH, B.: Preface to Concepfs of Medicine, Pergamon
Press Ltd., S e w York, 1961.
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'
W h a t Constitutes a Critical Review?
-
A torrent of data confronts the clinician; much of this information is confusing or may appear to be irrelevant. Therefore, an incisive review article which clarifies the clinical implications of a host of obscure or conflicting reports in current medical literature can serve as an important forum for continuing education. The editors believe that the communications to he published in o w new department, Critical Review, will provide such authoritative guidance to the physician in his choices of specific diagnostic and therapeutic measures. All too often authors succumb to the temptation to follow a path of minimal interpretation or personal commitment. Using this format one need only provide a 'laundry list" of references to or synopses of recently published studies. Indeed, like most harried editors, I have come to believe that some
brewer of mischief has encouraged large numbers of authors to prokide "comprehensive bibliographies, regardless of the scientific merit or clinical reletionce of the papers cited. Naturally, such mmmunications proudly proclaim the inclusion of a "review of the literature" (what an over-used phrase that is! ). A conscientiously structured progress report or review article should emphasize the limitations, as well as the positive potential of diagnostic or therapeutic procedures. Without such objectivity, a review may represent an enthusiastic endorsement rather than a reasoned evaluation. However, editors should not only permit, but they must encourage authors to accept the privilege of editorializing in the discussions section so that the reader is not left in doubt as to the guidelines which the investigator follows in his own practice. Both proponent and opponent aspects of conflicting viewpoints should be cited, but it is neither arbitrary nor immodest for the reviewer to cite the course of clinical management which he regards as reasonable in the light of current knowledge. Obviously, the preparation of this type of review requires skill in writing, as well as scientific authority. Ln a recent communication1 I noted, "A survey is actually a judgment. for that which is considered irrelevant or unproven is deleted at the discretion of the author. Experienced investigators are best qualified to distract a meaningful distillent so that the practicing physician and instructor obtain a balanced and practical approach." The Editorial Board of Diseases of the Chest is grateful to the distinguished scientists who responded to our invitation to participate in this editorial endeavor. The first contribution to the department, Critical Review, was prepared by Lopez and Wagner (see page 356). Alfred Soffer, Jl.D., F.C.C.P. Chicago 1"The Rev~ew-.i Creative Synthesis," JAhfA, 195.384.1986
Ontology of Programmed Instruction Programmed instruction has become very popular in recent years.l Presently, if anything, it complements conventional teaching. It is doubtful that it will ever substitute for the latter or even become an universally accepted method. There are several factors accounting for this. Since we all learn in different ways, it is clear that not e v e ~ b o d ywill profit from this technique. Not all topics can be programmed, and even those which can, might not be analyzed with the proper depth. The very intelli-
DIS. CHEST. VOL. 54. NO. 4, OCTOBER 1968
EDITORIALS
FICL~E 1. Portrait is of a painting by Chavanner in the Boston Public Library.
gent student might find it superfluous. The response to short courses which we have presented in various scientific exhibits shown recently in national meetings, as well as extensive cooperation with students, house staff and practitioners, has suggested that vectorcardiography is perhaps a good subject suited for this p u r p ~ s eSuch . ~ an assumption was not conceived by chance, but by the knowledge that one of the earliest programmers (Socrates) was fond of using geometric figures which had a great resemblance to the vector loops of today. The importance of programmed instruction lies not so much in what it teaches, but in how it accomplishes its purpose. We should not forget that its underlying philosophy has had a tremendous iduence in shaping the education trends of the Western n~orldthroughout the years. An evaluation of certain fundamental concepts was considered essential since the term programmation can also be identified with the use of one of the most sophisticated machines of modem times, the computer. This constitutes a departure from the original con-
DIS. CHEST, VOL. 54. NO. 4. OCTOBER 1968
text in which the method was conceived, as we will now see. What is known today as programmed instruction originated 22 centuries ago in Athens, when Soc rates introduced its oral counterpart-the tutorial form of teaching.3 Of the many images left by Plato of his distinguished teacher, none is more convincing than the one presented in his dialogue, Meno.' Here Socrates appears teaching mathematics to a young boy. But how is he accomplishing the task? It is not by giving him information, and then demanding an automatic answer. On the contrary, by simply drawing a diagram and asking the proper questions, the pupil comes out with the correct response. The truth was reached by the boy's own effort in a process in which the role of the teacher was not simply filling an empty mind. Socrates conceived learning as a process of recollection and exposure of knowledge already possessed by the pupil. In fact, knowledge itself was included amongst the components of that mythical element idealized by metaphysicians-the "soul." It is important to emphasize that Socrates' concept of the soul was a very far reaching one, including mystical, as well as human properties. He never gave another definition of the soul except =thatwithin us, cohateoer it is, in virtue of which we are denominated wise and foolish, good and evil.' His basic thought was that the function of this constituent of man "just to know-to try to apprehend things as they really are." According to the theory of learning as recollection, the soul of each person existed before birth in another world inhabited by the gods and forms, in full possession of eternal truths and moral values. However, this knowledge was lost at birth to be reacquired at later stages by the process called learning. In honor to the huth, it has to be accepted that not even Plato himself took this theory seriously. But there is no doubt that all his dialogues are in keeping with the fact that human mind had a structure of its own by which it does simply take what is offered. but always has the ability to integrate the information in an individual way. This can he done subconsciously with the help of the teacher who a d s as a catalyst in this process. Even Aristotle approached this theory with caution; yet it is interesting that it reappears, although without any religious association, in his Posterior Adytics, as his own account of the way by which first principles were suggested by what we know today as induction? This short recollection of the history of programmation was made to show that its background
314
EDITORIALS
is both idealistic and existential, hence departing somewhat from its present day context in association with teaching machines, as happened when the method was rediscovered in the mid twenties.' I t is true that mechanized teaching has become a n effective way of imparting knowledge. T h e value of this method, however, cannot be overstressed since there is no machine which can be a complete substitute for the human element. This refers to the impact made by the personality of the teacher itself, and certainly not by the quality of the material presented. In fact, it has been said that a teacher w h o can b e substituted by a machine deserved t o b e replaced. Admittedly, there is almost n o limit to what the machine can d o a t the computing level. But not even the Lnrononents of the fascinatine field of D cybernetics have proved ( a t least for the time being) that even higher-order programming ma. chines can experience sensations such as love, hate, envy, sorrow, anxiety and fear.' Some degree of feeling is necessary in any meaningful teacherstudent or doctor-patient relationship. Althoueh manv can decide that old theories should be Or reshaped, it is true that no scientific refutation of the L
original philosophy of teaching has been able to dispose of it. After several centuries these principles still provide the best symbolism available for the well-intentioned professor. For w e might not agree with Socrates' assumptions, b u t there is no reason why w e cannot keep the ideals which have exalted the uniqueness of the human mind. This is particularly necessary in our troubled times. Agwtin Casfellanos, Jr., M.D.. 'From the Section of Cardiology, Department of Sledicine. University of Sliami School of Sledicine, and the Veterans Administration Hospital. Sliami, Florida ~ ~ WII_LIA\I. A : Guide to programmed imtrucfirm, John Wiley and Sons, New York.
1 LYSAUGHT. J. P ,
1963. 2 C.C~-SOS, A., JR., LL\IBERC,L., A>D SAUUXCI, L.: Proflammed \,ectorcardiomaphy p he ST-T loop in
the horizontal plane, Amer. Heart I., 75:260, 1988. A , E,:Socratej: The and his D ~ ~ M ~ xew ~ york. ~ ~1 8 3. . A ~ ~ ~ ~ ~ 4 HI>-. H. W : Whitehead's conmpt of organism and the mind-bdy problem, in Hmk, S. (ed.) D i m e n r i m of Books,Sew York. ~ ~ ~requests: r i ~Dr.t Castelknos, ladrson Memorial Hospxtal, Sfiami, Florida 33136
"The Angina Pectoris" As Described by Heberden The angina pectoris, as far as I have been able to investigate, belongs to the class of spasmodic, not of inflammatory complaints. For, in the first place, the access and the recess of the fit is sudden; secondlv, there are long intervals of perfect health; thirdly, wine and spiritous liquors and opium afford considerable relief; fourthly, it is increased by disturbance of the mind; fifthly, it continues many years without any other injury to the health; sixthly, in the beginning, it is not brought on by riding on horseback or in a carriage, as is usual in diseases arising from scirrhus, or inflammation; seventhly, during the fit the pulse is not quickened. Lastly, its attacks are often after the first sleep, which is a circumstance common to many spasmodic disorders. Yet it is not to be denied that I have met with one or hvo patients who have told me they now and then spit up matter and blood and that it seemed to them to come from the seat of the disease. In another, who fell down dead without any notice, there immediatelv arose such an offensive smell as made all who were present judge that some f w l abscess had just been broken. On opening the body of one who died suddenly of this disease, a v e n skillful anatomist could discover no fault in the heart, in the valves, in the arteries, or
neighboring \.eins, excepting smaU rudiments of ossification in the aorta. The brain mas likewise everywhere sound. In this person. as it has happened to others who have died by the same disease, the blood continued Ro~dtwo or three days after death. not dividing itself into crassamentum and serum, but thick, like cream. Hence when a vein has been opened a l~ttlebefore death, or perhaps soon after, the blood has continued to m z e out as long as the body remained unburied. With respect to the treatment of this complaint. I have little or nothing to advance: nor indeed is it to be expected we should have made much progress in the cure of a disease which has hitherto hardly had a place, or a name in medical books. Quiet and warmth and spiritous liquors help to restore patients who are nearly exhausted and to dispel the effects of a fit when it does not soon go off. Opium taken at bed time will prevent the attacks at night. I know one who set himself a task of sawing \ v w d for half an hour every day and was nearly cured. In one also, the disorder ceased of itself. Bleeding, vomiting and purging appear to me to be improper.
4
DIS. CHEST, VOL. 54. NO. 4. OCTOBER 1968
HEBERDEX,W, as quoted in William. F. .4. and Keys, T. E.: C k , r of Cardiology, \'ol I, Dover Publications. Sea- York, 1941.
.
Professor of hledlcine, State University of Kew York, Downstate hledical Center, Broobn
REFERESW 1 WARE.\I.: The general medical journal in cl~nicalmedicine, New Eng. I. Aled., 2783, 1968. 2 LUSH, B.: Preface to Concepfs of Medicine, Pergamon
Press Ltd., S e w York, 1961.
-
'
W h a t Constitutes a Critical Review?
-
A torrent of data confronts the clinician; much of this information is confusing or may appear to be irrelevant. Therefore, an incisive review article which clarifies the clinical implications of a host of obscure or conflicting reports in current medical literature can serve as an important forum for continuing education. The editors believe that the communications to he published in o w new department, Critical Review, will provide such authoritative guidance to the physician in his choices of specific diagnostic and therapeutic measures. All too often authors succumb to the temptation to follow a path of minimal interpretation or personal commitment. Using this format one need only provide a 'laundry list" of references to or synopses of recently published studies. Indeed, like most harried editors, I have come to believe that some
brewer of mischief has encouraged large numbers of authors to prokide "comprehensive bibliographies, regardless of the scientific merit or clinical reletionce of the papers cited. Naturally, such mmmunications proudly proclaim the inclusion of a "review of the literature" (what an over-used phrase that is! ). A conscientiously structured progress report or review article should emphasize the limitations, as well as the positive potential of diagnostic or therapeutic procedures. Without such objectivity, a review may represent an enthusiastic endorsement rather than a reasoned evaluation. However, editors should not only permit, but they must encourage authors to accept the privilege of editorializing in the discussions section so that the reader is not left in doubt as to the guidelines which the investigator follows in his own practice. Both proponent and opponent aspects of conflicting viewpoints should be cited, but it is neither arbitrary nor immodest for the reviewer to cite the course of clinical management which he regards as reasonable in the light of current knowledge. Obviously, the preparation of this type of review requires skill in writing, as well as scientific authority. Ln a recent communication1 I noted, "A survey is actually a judgment. for that which is considered irrelevant or unproven is deleted at the discretion of the author. Experienced investigators are best qualified to distract a meaningful distillent so that the practicing physician and instructor obtain a balanced and practical approach." The Editorial Board of Diseases of the Chest is grateful to the distinguished scientists who responded to our invitation to participate in this editorial endeavor. The first contribution to the department, Critical Review, was prepared by Lopez and Wagner (see page 356). Alfred Soffer, Jl.D., F.C.C.P. Chicago 1"The Rev~ew-.i Creative Synthesis," JAhfA, 195.384.1986
Ontology of Programmed Instruction Programmed instruction has become very popular in recent years.l Presently, if anything, it complements conventional teaching. It is doubtful that it will ever substitute for the latter or even become an universally accepted method. There are several factors accounting for this. Since we all learn in different ways, it is clear that not e v e ~ b o d ywill profit from this technique. Not all topics can be programmed, and even those which can, might not be analyzed with the proper depth. The very intelli-
DIS. CHEST. VOL. 54. NO. 4, OCTOBER 1968
EDITORIALS
FICL~E 1. Portrait is of a painting by Chavanner in the Boston Public Library.
gent student might find it superfluous. The response to short courses which we have presented in various scientific exhibits shown recently in national meetings, as well as extensive cooperation with students, house staff and practitioners, has suggested that vectorcardiography is perhaps a good subject suited for this p u r p ~ s eSuch . ~ an assumption was not conceived by chance, but by the knowledge that one of the earliest programmers (Socrates) was fond of using geometric figures which had a great resemblance to the vector loops of today. The importance of programmed instruction lies not so much in what it teaches, but in how it accomplishes its purpose. We should not forget that its underlying philosophy has had a tremendous iduence in shaping the education trends of the Western n~orldthroughout the years. An evaluation of certain fundamental concepts was considered essential since the term programmation can also be identified with the use of one of the most sophisticated machines of modem times, the computer. This constitutes a departure from the original con-
DIS. CHEST, VOL. 54. NO. 4. OCTOBER 1968
text in which the method was conceived, as we will now see. What is known today as programmed instruction originated 22 centuries ago in Athens, when Soc rates introduced its oral counterpart-the tutorial form of teaching.3 Of the many images left by Plato of his distinguished teacher, none is more convincing than the one presented in his dialogue, Meno.' Here Socrates appears teaching mathematics to a young boy. But how is he accomplishing the task? It is not by giving him information, and then demanding an automatic answer. On the contrary, by simply drawing a diagram and asking the proper questions, the pupil comes out with the correct response. The truth was reached by the boy's own effort in a process in which the role of the teacher was not simply filling an empty mind. Socrates conceived learning as a process of recollection and exposure of knowledge already possessed by the pupil. In fact, knowledge itself was included amongst the components of that mythical element idealized by metaphysicians-the "soul." It is important to emphasize that Socrates' concept of the soul was a very far reaching one, including mystical, as well as human properties. He never gave another definition of the soul except =thatwithin us, cohateoer it is, in virtue of which we are denominated wise and foolish, good and evil.' His basic thought was that the function of this constituent of man "just to know-to try to apprehend things as they really are." According to the theory of learning as recollection, the soul of each person existed before birth in another world inhabited by the gods and forms, in full possession of eternal truths and moral values. However, this knowledge was lost at birth to be reacquired at later stages by the process called learning. In honor to the huth, it has to be accepted that not even Plato himself took this theory seriously. But there is no doubt that all his dialogues are in keeping with the fact that human mind had a structure of its own by which it does simply take what is offered. but always has the ability to integrate the information in an individual way. This can he done subconsciously with the help of the teacher who a d s as a catalyst in this process. Even Aristotle approached this theory with caution; yet it is interesting that it reappears, although without any religious association, in his Posterior Adytics, as his own account of the way by which first principles were suggested by what we know today as induction? This short recollection of the history of programmation was made to show that its background
314
EDITORIALS
is both idealistic and existential, hence departing somewhat from its present day context in association with teaching machines, as happened when the method was rediscovered in the mid twenties.' I t is true that mechanized teaching has become a n effective way of imparting knowledge. T h e value of this method, however, cannot be overstressed since there is no machine which can be a complete substitute for the human element. This refers to the impact made by the personality of the teacher itself, and certainly not by the quality of the material presented. In fact, it has been said that a teacher w h o can b e substituted by a machine deserved t o b e replaced. Admittedly, there is almost n o limit to what the machine can d o a t the computing level. But not even the Lnrononents of the fascinatine field of D cybernetics have proved ( a t least for the time being) that even higher-order programming ma. chines can experience sensations such as love, hate, envy, sorrow, anxiety and fear.' Some degree of feeling is necessary in any meaningful teacherstudent or doctor-patient relationship. Althoueh manv can decide that old theories should be Or reshaped, it is true that no scientific refutation of the L
original philosophy of teaching has been able to dispose of it. After several centuries these principles still provide the best symbolism available for the well-intentioned professor. For w e might not agree with Socrates' assumptions, b u t there is no reason why w e cannot keep the ideals which have exalted the uniqueness of the human mind. This is particularly necessary in our troubled times. Agwtin Casfellanos, Jr., M.D.. 'From the Section of Cardiology, Department of Sledicine. University of Sliami School of Sledicine, and the Veterans Administration Hospital. Sliami, Florida ~ ~ WII_LIA\
1 LYSAUGHT. J. P ,
1963. 2 C.C~-SOS, A., JR., LL\IBERC,L., A>D SAUUXCI, L.: Proflammed \,ectorcardiomaphy p he ST-T loop in
the horizontal plane, Amer. Heart I., 75:260, 1988. A , E,:Socratej: The and his D ~ ~ M ~ xew ~ york. ~ ~1 8 3. . A ~ ~ ~ ~ ~ 4 HI>-. H. W : Whitehead's conmpt of organism and the mind-bdy problem, in Hmk, S. (ed.) D i m e n r i m of Books,Sew York. ~ ~ ~requests: r i ~Dr.t Castelknos, ladrson Memorial Hospxtal, Sfiami, Florida 33136
"The Angina Pectoris" As Described by Heberden The angina pectoris, as far as I have been able to investigate, belongs to the class of spasmodic, not of inflammatory complaints. For, in the first place, the access and the recess of the fit is sudden; secondlv, there are long intervals of perfect health; thirdly, wine and spiritous liquors and opium afford considerable relief; fourthly, it is increased by disturbance of the mind; fifthly, it continues many years without any other injury to the health; sixthly, in the beginning, it is not brought on by riding on horseback or in a carriage, as is usual in diseases arising from scirrhus, or inflammation; seventhly, during the fit the pulse is not quickened. Lastly, its attacks are often after the first sleep, which is a circumstance common to many spasmodic disorders. Yet it is not to be denied that I have met with one or hvo patients who have told me they now and then spit up matter and blood and that it seemed to them to come from the seat of the disease. In another, who fell down dead without any notice, there immediatelv arose such an offensive smell as made all who were present judge that some f w l abscess had just been broken. On opening the body of one who died suddenly of this disease, a v e n skillful anatomist could discover no fault in the heart, in the valves, in the arteries, or
neighboring \.eins, excepting smaU rudiments of ossification in the aorta. The brain mas likewise everywhere sound. In this person. as it has happened to others who have died by the same disease, the blood continued Ro~dtwo or three days after death. not dividing itself into crassamentum and serum, but thick, like cream. Hence when a vein has been opened a l~ttlebefore death, or perhaps soon after, the blood has continued to m z e out as long as the body remained unburied. With respect to the treatment of this complaint. I have little or nothing to advance: nor indeed is it to be expected we should have made much progress in the cure of a disease which has hitherto hardly had a place, or a name in medical books. Quiet and warmth and spiritous liquors help to restore patients who are nearly exhausted and to dispel the effects of a fit when it does not soon go off. Opium taken at bed time will prevent the attacks at night. I know one who set himself a task of sawing \ v w d for half an hour every day and was nearly cured. In one also, the disorder ceased of itself. Bleeding, vomiting and purging appear to me to be improper.
4
DIS. CHEST, VOL. 54. NO. 4. OCTOBER 1968
HEBERDEX,W, as quoted in William. F. .4. and Keys, T. E.: C k , r of Cardiology, \'ol I, Dover Publications. Sea- York, 1941.
.