Department of Medicine, The University of Manchester.
SirRecovering from an acute respiratory infection has given me more leisure than usual to peruse your issue of Dec. 23, and with it Dr. Stewarts article. This I much enjoyed, though more as an English essay than as a scientific paper. I suppose one can enjoy an essay and still question some of the premises and disagree with some of the conclusions of the essayist.
Dr. Stewart starts with a few dogmatic statements which are surely very controversial, and goes on to a cautious and fairly critical examination of the evidence as to whether modern stress has caused an increase in coronary disease, and finds that much of this evidence is inconclusive or conflicting. He does, however, seem convinced that the better educated and those who work with their brains are more liable than their fellows to coronary disease. The only statistical evidence for this which Dr. Stewart cites (and it is surely a question of statistics) is: (1) Dublin et al.,1 that the mortality ratio of heart-disease amongst doctors is 1.18 of the general male population of parallel agenot a very striking figure compared with influenza, for instance (vide infra)and (2) the Registrar-Generals Decennial Supplement for 1931 (the last to be published) which shows that if the death-rate from coronary disease in the general male population is 100, it is for:
Agricultural workers 32
Coalminers below ground 40
Banking and insurance officials 183
Anglican clergy 218
Physicians and surgeons 368
Now I am very fond of the R-Gs Decennial Supplement and happen to have it in bed with me; but its accuracy depends, as I have pointed out before2 upon the accuracy of the material from which it is compilednamely, death certificates. The majority of persons do not die in modern well-equipped hospitals, do not have post-mortem examinations, and are not seen by consulting physicians or cardiologists. The death certificates from which these figures were compiled were from the years 193032. Levines classical article on coronary thrombosis was published in 1929, and although the condition had been recognised before, and the association between coronary-artery disease and angina pectoris had long been known, it is fair to say that coronary thrombosis as a cause of death was not commonly diagnosed even by experienced physicians until about 1930, amazing though it may seem. The majority of such deaths would be certified as myocarditis and myocardial degeneration. Diagram 3 (p. 30) of the Decennial Supplement shows clearly that while angina pectoris increases as we go up the social scale, myocardial disease does exactly the opposite; and the table on p. 162 shows that the figures for myocardial disease are for banking officials, etc., 59, and for anglican clergy 57; whereas for cotton strippers and grinders (social class IVsurely not educated brain-workers) the figure is 213. Doctors show an excess in both categories.
As the R-G (or one of his henchman) points out on p. 60:
degenerative disease in the heart affects all classes of males to much the same extent, but whereas amongst men whose social conditions are most favourable it tends to express itself as angina pectoris or coronary disease, at the other end of the scale it tends to take forms described on death certificates as myocarditis or myocardial or cardiovascular degeneration.
This is surely a most important statement without which most of the figures quoted by Dr. Stewart are very nearly meaningless. (He probably had not the benefit of a respiratory infection when compiling his paper.)
I venture to suggest that the likelihood of persons dying in 193032 having seen a consulting physician or cardiologist might well be in the following order:
Physicians and surgeons
Anglican clergy
Banking and insurance officials
Coalminers below ground
Agricultural workers
and that the chief difference is not one of disease but of nomenclature. Perhaps the 195052 figures will show an equally nice social distinction between coronary thrombosis and myocardial infarction.
Despite this there is still a slight preponderance of deaths due to heart-disease in males of social class I, and probably a considerable preponderance in doctors. I am not trying to make out that it does not existmerely that a great deal of it is illusory.
Incidentally, if my present illness should require entry on a death certificate I feel sure that it will be described (probably erroneously) as influenza and I am sorry to note (Decennial Supplement, p. 256) that the standardised mortality ratio for doctors of my age-group is 133 (or 1.33 in the terminology of Dublin et al.); but the fact that the highest rate for influenza is amongst makers of non-metalliferous mine and quarry products restores some of my hopes for the New Year. As a bedside author I can recommend the R-G very highly.
Robert Platt (19001978), latterly Lord Platt of Grindleford, was a major figure in 20th century British medicine. His research work was on diseases of the kidney, but he is perhaps now best remembered to epidemiologists as a participant in the "Platt versus Pickering" debate regarding the nature of essential hypertension.1 Platt took the position that hypertension consisted of a distinct (largely genetic) condition, rather than reflecting the upper portion of a normal distribution. The competing articles of Platt and Sir George Pickering have been edited elegantly by the late John Swales,1 and still make constructive reading. However, as Swales points out, at times it appeared that the debate was maintained for its own sake. When Platt misquoted Lewis Carrolls "The Hunting of the Snark" by attributing the phase "what I tell you three times is true" to the snark rather than the bellman, the following poem appeared in the correspondence column of the Lancet.
Sir
Schoolmen contending, ego on high.
Words without ending, truths never nigh.
Facts may be lackingarguments free,
Keep on attaching, P versus P
"Your curves biphasic". "Single bell mine".
"Your brains dysplastic, weak in design".
Readers are tiring, editors bored,
Spare us more firing, spare us, O Lord!
Peace be to Pickering, silence on Platt
Truce to their bickering, leave it at that.
Candles are flickering, Platts in the dark,
"Goodnight, dear Pickering; wrong about Snark".
Birmingham DOUGLAS HUBBLE
Notes
First published in The Lancet 1951;51. Reprinted with permission.
References
1 Dublin LI, Spiegelman M, Leland RG. Post-Grad Med J 1947;2:188.
1 Swales JD (editor) Platt versus Pickering: An episode in recent medical history. Cambridge: The Keynes Press, 1985.