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Science Marches on—To What End?
critical issues in clinical _~~IIIIIjI------care ------=====- -====-
Science Marches on-To What End? Mark D. Altschule, M.D. *
Clinicians have known for over a century that the symptoms of angina pectoris may occur in response to mental stresses of various types, but that this relation is far from consistent. In recent years, studies by means of electrocardiographic monitoring have shown that probably a majority of instances of socalled ischemia revealed by electrocardiographic studies are in fact not accompanied by anginal symptoms. The question naturally arises concerning whether mental stresses of various types or degree are necessarily accompanied by both physiologic abnormalities and anginal pain. Recent studies bear on this question.' The most recent studies were carried out with the most modern techniques, despite or perhaps because of which they provide no firm answers to the question of angina. One of the jejune concepts derived from the superstitious belief that medicine is scientific is that each physiologic abnormality causes a specific symptom or syndrome. In the studies referred to here, 1 abnormalities in left ventricular wall motion and in ejection fraction were said to have occurred, but there was no consistent relation to angina. Observations of the effects of emotion and of mental effort on the circulation have been recorded in the literature of the past 100 years. They have been performed 2 using no instruments other than a watch and a sphygmomanometer, perhaps attached to a kymograph for making permanent records. The accumulated findings of the past show clearly that the *Francis A. Countway Library of Medicine, Harvard Medical School, Boston. . Reprint requests: Dr: Altschule, Countway Library, 10 Shattuck Street, Boston 02115
tachycardia of emotion is typical but not consistent, that arterial and arteriolar spasm is also common, that not the quality of the emotion but its intensity is important, that simple mental tasks produce the same effects as emotion, and that all the physiologic cardiovascular changes may occur to a marked degree with no facial or any other external indication or any subjective awareness of their occurrence. The physiologic changes can be conditioned (this last fact seems to have escaped the attention of the modern gadgeteers). These older findings have generally been deemed trivial and only their recent unwitting substantiation by means of gadgets gives them, in retrospect, any significance. There are lessons to be learned from all this. One is that one cannot always count on gadgets to reveal what competent observation has not. Another is that the belief held by some tyros, that the use of scientific method guarantees an inexorable march toward TRUTH. This must remain nonsense until this concept answers two questions: a) how does one know that one is on the right path? and b) how does one recognize TRUTH when by chance it is reached? In the meantime, science marches on, pretending to be medical education. REFERENCES 1 Rozanski A, Bairey CN, Krantz DS, Friedman J, Ressor K, Morell M, et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med 1988; 318:1005-12 2 Altschule MD. Bodily physiology in mental and emotional disorders. New York: Grune and Stratton, 1953
CHEST I 94 I 3 I SEPTEMBER, 1988
639
Science Marches on-To What End? Mark D. Altschule, M.D. *
Clinicians have known for over a century that the symptoms of angina pectoris may occur in response to mental stresses of various types, but that this relation is far from consistent. In recent years, studies by means of electrocardiographic monitoring have shown that probably a majority of instances of socalled ischemia revealed by electrocardiographic studies are in fact not accompanied by anginal symptoms. The question naturally arises concerning whether mental stresses of various types or degree are necessarily accompanied by both physiologic abnormalities and anginal pain. Recent studies bear on this question.' The most recent studies were carried out with the most modern techniques, despite or perhaps because of which they provide no firm answers to the question of angina. One of the jejune concepts derived from the superstitious belief that medicine is scientific is that each physiologic abnormality causes a specific symptom or syndrome. In the studies referred to here, 1 abnormalities in left ventricular wall motion and in ejection fraction were said to have occurred, but there was no consistent relation to angina. Observations of the effects of emotion and of mental effort on the circulation have been recorded in the literature of the past 100 years. They have been performed 2 using no instruments other than a watch and a sphygmomanometer, perhaps attached to a kymograph for making permanent records. The accumulated findings of the past show clearly that the *Francis A. Countway Library of Medicine, Harvard Medical School, Boston. . Reprint requests: Dr: Altschule, Countway Library, 10 Shattuck Street, Boston 02115
tachycardia of emotion is typical but not consistent, that arterial and arteriolar spasm is also common, that not the quality of the emotion but its intensity is important, that simple mental tasks produce the same effects as emotion, and that all the physiologic cardiovascular changes may occur to a marked degree with no facial or any other external indication or any subjective awareness of their occurrence. The physiologic changes can be conditioned (this last fact seems to have escaped the attention of the modern gadgeteers). These older findings have generally been deemed trivial and only their recent unwitting substantiation by means of gadgets gives them, in retrospect, any significance. There are lessons to be learned from all this. One is that one cannot always count on gadgets to reveal what competent observation has not. Another is that the belief held by some tyros, that the use of scientific method guarantees an inexorable march toward TRUTH. This must remain nonsense until this concept answers two questions: a) how does one know that one is on the right path? and b) how does one recognize TRUTH when by chance it is reached? In the meantime, science marches on, pretending to be medical education. REFERENCES 1 Rozanski A, Bairey CN, Krantz DS, Friedman J, Ressor K, Morell M, et al. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med 1988; 318:1005-12 2 Altschule MD. Bodily physiology in mental and emotional disorders. New York: Grune and Stratton, 1953
CHEST I 94 I 3 I SEPTEMBER, 1988
639