Coronary disease and modern stress*

IMcDG Stewart

Senior Medical Registrar, Bristol Royal Infirmary, Tutor in Medicine in the University of Bristol.

There has been a vast increase in coronary disease during the present century. The malady strikes predominantly men in middle life. It is common to all modern States, yet in some thickly populated parts of the world it is unknown. The immunity enjoyed by members of primitive races disappears if they subject themselves, in exile, to the rigours of civilised life. Two main influences are brought to them by civilisation—unfamiliar mental stress, and increased richness of diet. The first of these is considered here.

The mind and disease

We are continually assured that the 20th century belongs to the Common Man. In medicine it is the Whole Man who has become the fashion. This is the age of the psychosomatic approach. An early question to be decided on first encountering a patient is: What sort of person is this? In the language of the initiate, assiduous efforts are now made to relate organic illness with basic personality type. It proves a considerable task, since personality not only creates its own endogenous stresses but also determines such factors as occupation, which further introduce the extraneous influences of environment.

In some diseases, however, the relation appears clear enough. Thus, few doctors could have much difficulty in agreeing with Avery Jones (1948) that sufferers from peptic ulceration tend to be ‘tense, possess unusual drive, and are over-conscientious in their work. They ... worry unduly, but do not give way to their emotions.’ In fact, they belong to what Ogilvie (1949)describes as the ‘surgical registrar type’, a category not so narrow, one ventures to think, as totally to exclude medical registrars.

A similar connection between disease and type of personality is sometimes claimed on grounds which appear less substantial. Wittkower (1938)studied 40 unselected cases of ulcerative colitis. According to him the illness was preceded by psychological abnormalities in 37 of them. He ascribed to these patients a fair selection of the traits of human temperament.

In particular he decided, like Hardy (1945), that colitis tends to occur in a ‘mother‘s boy’ sort of person, contrasting thus with the psychologically mature ulcer type. Paulley (1949)now suggests that the temperament of regional ileitis victims may be somewhere between the two. At this rate it appears that a precise mentality is shortly to be affixed to disorder in every foot of gut.

Inevitably there is also a ’coronary type’ personality. Most physicians have their own ideas of it. The psychiatrists are explicit. Describing the temperaments he found in a group of people who had suffered coronary infarction Arlow (1945), at a meeting in America, remarked that ‘what disturbed these patients most was to fail in the role of their deeper identification, and to fail under circumstances which convinced both the outer world and themselves that they were not as good as they thought ...’ Fear of failure, he observed, was always liable to turn to aggression, ‘the kind of identification one sees in women ...’ It was then associated with ‘sexual fear and identification with the male ...’ accompanied by ‘a desire to oppose them in open competition’.

The trouble with this kind of speculation is that it is too comprehensive. There is something for everybody. ‘I thought I recognised myself rather clearly’ was Dock‘s comment after he had listened to these observations by Arlow. There remains always the fundamental question: How far does all this affect structure? ‘Do you gentlemen mean’, inquired Boas quizzically at the same distinguished gathering, ‘that these mental mechanisms are the cause of arterioscleroris?’

In truth the problem is not simple. Ogilvie (1949)accepts essential hypertension as ‘a new disease, and a stress disease ... the price the millionaire pays for his directorship and the clerk for his failure.’ But when asked how stress can cause this effect he replies: ‘I do not know, and if anyone does he has not told me.’ Any attempts to find a psychosomatic explanation for coronary atheroma and its syndromes must encounter much the same difficulty. Witts (1949)has pointed out that the role of the mind in the pathogenesis of organic illness is more difficult to assess than is popularly supposed, and that in those few maladies, such as thyrotoxicosis, in which its influence has been established, the demonstration has been achieved only as a result of elaborate laboratory research, never (according to Witts) from the recesses of an armchair. And seldom, I suggest, from within the curtained closets of the psychiatrists. Nevertheless, there are recognisable today many associations between conditions of life and specific illness. Always there is the hope that study of such links may produce a clue to aetiology. That the stress of modern times may contribute to the causation of coronary disease is a possibility that merits such examination.

The genesis of mental stress must depend on the nature of the predicament that causes it in relation to the character of the person involved. Heredity is the main factor in the determination of character. Admittedly it is responsible for much else besides. At this stage let us consider in all its aspects heredity as it bears on the aetiology of coronary disease. Later there will be examined the forms of mental stress which may be evoked by modern conditions of life in persons whose native temperament renders them susceptible. Finally there will remain to be answered the fundamental question whether sufferers from coronary disease can be identified as the particular victims of these new mental stresses.

Heredity

Boyd (1934) includes coronary disease among those conditions which may result from inherited constitutional ‘weakness’. Coombs (1916) and Hadfield (1927) took much the same view. Indeed the contention is scarcely in dispute. It receives general assent from clinicians. Cassidy (1946) considered that half his cases showed a family history of the illness, and Levine (1929) holds that heredity is of ‘considerable importance’, adding ‘it is amazing how frequently one finds various members of the same family suffering from early vascular hypertension or coronary disease’. Ryle (1948), too, accepted the fact that ‘genetic factors’ probably play a part, ‘whether through physical or temperamental predispositions or both’. Dock (1946) points out that there is a hereditary variation in the thickness of the coronary intima which follows the sex difference in the incidence of coronary disease.

Controlled statistics have been provided by Yater et al. (1948) for myocardial infarctions in young American soldiers. They discovered a history of coronary or hypertensive disease in 41% of close relatives, a term which they define as including only father, mother, brother and sister. This percentage they compared with a group of hospital amputation patients. Of these only 13% admitted a similar family history. Hypertension and coronary disorder are, of course, by no means invariably associated. Nevertheless there exists a close relation between the two, particularly among women at all ages and in the older patients of both sexes. It is reasonable to conclude that heredity is an important factor in the pathogenesis of coronary affection. Further inquiry is thus suggested into the physical and mental components of diathesis.

The famous physicians of the recent past judged constitution to be of great significance. In assessing it they tended, perhaps, to rely more upon physical qualities than upon the temperament of their patients. Hurst, in the tradition of Addison, Bright, and Hodkin, was wont to assume a whole chapter of information from the width of a costal angle. According to this school of thought coronary disease develops in the sthenic or Falstaffian type of man. Olser (1910), however, already took account of temperament in maintaining that he could recognise his angina patients as they entered the room. He described in detail ‘a well-set man from 45 to 55 years of age, with military bearing, iron-grey, and florid complexion ...’ He would be ‘robust and vigorous in mind and body, the keen and ambitious man, the indicator of whose engines is always set at "Full Speed Ahead"’. Levine’s (1929) phraseology is much the same: ‘The typical patient is a well-set person, somewhat overweight ... physically strong ... with appearance of good health and capable of vigorous physical effort.’ Many physicians today would agree with these impressions.

In Boston they deal with somatotypes. According to White and Ferrero (1949) they have been finding there that it is ‘the mesomorphic young male who is particularly prone to early coronary thrombosis ...’ whereas the ectomorphic type is happily spared. Even in America, however, statistics scarcely keep pace with clinical impressions. Yater et al. (1948) concluded that stature was irrelevant.

Investigation by many authorities has, in fact, revealed that the physical element in constitution, so far as it is perceptible to clinical examination, is not very helpful. Little more can be shown than the fact that obesity, particularly in men, predisposes somewhat to coronary atheroma. The hereditary variation in the thickness of the coronary intima may be of much greater importance.

Neither can there be any clear-cut standard of ‘temperamental predisposition’ to mental stress. The test of war proves that the resources of human nature are unpredictable. In time of peace a man’s inherent temper guides him in his choice of employment. Any tension which his work may engender then plays back on his mind and personality. It is reasonable, therefore, before attempting to survey the problem of stress as a whole, to pass from the mental and physical sanctions exacted by heredity to those deriving from environment as presented by education, occupation, and class.

Education, occupation, and class

It is well established that not all members of the community are equally menaced by coronary disease. Doctors are wont to complain with reason that they are worse hit than any. Much has recently been written on the subject in America. It has been shown that the death-rate among medical practitioners rises sharply, in comparison with the average, above the age of 45, this increase being largely due to cardiac maladies. Dublin et al. (1947) give as 1.18 the mortality ratio expressing the death-rate due to heart-disease among doctors compared with that affecting the general male population of parallel age. Others go further. Dickinson and Walker (1948) echo Olser and many of their own contemporaries in declaring roundly that ‘heart disease is in reality an occupational hazard of the medical profession’. The Journal of the American Medical Association (1944) blamed it for 1 death in 5 among American physicians. During a clinical meeting in the same year Dock observed to his interested colleagues that coronary affliction might well be worthy of their interest, since ‘a quarter of us in this room are going to die of it’.

How does this proportion compare with that in other professions? Cassidy (1946) maintained that there was ‘an unquestionably heavier incidence of coronary disease in the non-hospital as opposed to the hospital population’. Although they refer to a period which includes some of the years before the war of 1939–45, the figures provided by the Registrar General’s last Decennial Supplement afford information of great interest. The adult population is divided into five successive classes on grounds of occupation and income, two factors which a few years ago bore a closer relation to each other than in these days, when the charwoman is so much better off than the ward sister, and the income of a prolific docker exceeds that of a celibate university tutor. Class 1 contains the professional workers, and the grades then proceed to class 5, which is made up of unskilled labourers. It is seen that the proportion of deaths from coronary disease is well above the average in the first two classes, and well below it in the last three. Even more remarkable is a comparison of occupational groups in which the figure 100 is taken to represent the average death-rate from coronary disease for all males aged 20–65. The following significant figures are revealed:

Agricultural workers 32

Coalminers below ground 40

Banking and insurance officials1 83

Anglican clergy 218

Physicians and surgeons 368

In the face of such evidence it is difficult to see how Master (1947) can justify his contention that ‘no occupation has any priority in this disease’, even if it be true that ‘rich and poor, the labourer, the executive, the ordinary man at his desk are all possible victims’. His view sharply exemplifies the dissent at the highest professional level that so often enlivens discussion of aetiology of coronary heart-disease.

Less attention has been paid to physical stress. Levine (1929) is ‘inclined to think that hard physical work is conducive to early disease of the coronary arteries’. He declares himself to have been ‘impressed by the fact that athletes seem to succumb to vascular disease in surprisingly early years of adult life’. It is generally believed, however, that great exertion never initiates damage to the heart. The effect of physical labour was further investigated in America by Phipps (1936), who showed that the prognosis after a thrombotic attack was better in his labouring-class patients than in the white-collar workers.

It seems to be beyond dispute that the better educated, and those who work with their brains, are more liable than their fellows to coronary disease. Why this should be is not clear. Reasonably it may be postulated that these people are exposed to a particular form of stress. If it could be proved that such stress may lead to metabolic change, perhaps to increased blood-pressure, an important step might have been taken towards finding a cause for generalised atheroma. There would still require to be explained the strange predilection by which atheroma develops disproportionately in the coronary vessels, arising there not infrequently in the total absence of lesions elsewhere. According to Dock (1946) ‘the chief cause of death of American men during their period of highest earning capacity is to be sought in the peculiar susceptibilities of a few tenths of a gramme, or at most in a few grammes, of coronary intima’. This selectivity of the pathological change is the kernel of the problem. The solution must await the results of further research conducted in the laboratory and requiring the assistance of expert biochemists and morbid histologists. From such recondite spheres mere speculation withdraws in modest confusion. In the meantime it is important that improved understanding by clinicians can already indicate the most likely victims. The appreciation is empirical but none the less valuable.

What is it, then, that in the lives of professional men predestines so many of them to death from coronary disease? Are they more harassed than their less educated contemporaries? Do their ranks contain a monopoly of ‘worriers’?

Mental stress is elusive. It does not flaunt its dominion. Rather does it lurk within the shadows of life. The shapes which it assumes are infinite, and constantly changing, appearing to no two men alike. Trials which to some might be intolerable are by others not even perceived. Is there some form of stress which weighs upon the ‘workers by brain’ more heavily than upon the ‘workers by hand’? It is necessary to go more closely into these questions.

Origins of stress

Nowadays it is scarcely possible to open a newspaper without seeing a reference to the ‘stress’ of modern existence. It seems to be held almost universally today that things are pretty tough—bad enough, in fact, to account for almost anything.

Most leading cardiologists regard this proposition with caution. There was a time when many of them seemed ready to welcome it as an explanation of the new forms of vascular disease. Paul White has admitted that in the first edition of his book Diseases of the Heart the element of stress as a factor in the pathogenesis of coronary disease was emphasised in italics; in the second edition the reference appeared in ordinary print; in the third it was deleted.

The trials of life have usually appeared exceptional to the generation called on to bear them. In 1910 Olser was already asking whether the ‘high-pressure life’ of the new century was making angina more common. To readers of Sackville-West the Edwardian period now suggests the tranquillity of a Golden Age. In the slums, at the turn of the century, things were less happy, but Olser was not referring to the troubles of the poor. Time, like distance, lends enchantment. The magnolia-scented South of America was perhaps never quite so gracious as reputed of the days that are gone with the wind, nor England ever so ‘merrie’ as she appears in retrospect. Mere survival during the Wars of Roses and the Rebellion must have provided ordeals no less trying than the modern fish-queue. It is tempting to agree with Master (1947) when he maintains that ‘stress and strain today is not greater than that which existed in ancient times during periods of war, great fires, plagues, and famine’. Yet in those times coronary disease seems to have been rare.

Neither is it easy to trace evidence of particular stress in those who have developed heart-disease. Cassidy (1946) believed that most of his cardiac patients had lived ‘remarkably placid and sheltered lives’. Levine (1929) has written: ‘Concerning mental tension it is our impression that it is only of minor importance in coronary disease.’ Despite such scepticism the Spens Committee accepted the suggestion that it is the ‘strain of medical practice’ that shortens the expectation of life in doctors—largely because of heart-disease.

What conclusion can be drawn from such varied opinions?

Mankind has always been subject to the constraints of human bondage. The question thus becomes: Has there developed during the last few decades, as a result of the increased ‘pace’ of life, any special stress bearing preponderantly upon the educated male section of the community? I believe that there has—and that its influence is becoming more widespread.

The essence of this stress is that it confronts its victim with an opposition which he feels himself driven to combat, and capable of surmounting, but only at the cost of extreme and long-continued effort. In the end he is as likely as not to fail, to have it forced upon him, in fact, as Arlow (1945) suggests, that he is not as good as he thought. ‘Ambition minus reality equals neurosis’, writes Beverley Nichols, quoting the words of a woman psychologist who thus identifies the source of many ills in modern America. Or it may be that a man’s work is mentally distasteful to him. Experimentally such a situation has been investigated by Wolff (1946), who found that a healthy individual when ‘asked to do a task he did not relish ... at which he was convinced he would fail, exhibited ... a striking increase in blood-pressure’, which might persist for forty-eight hours.

The corroding effect of such endeavour is not usually revealed. The physician may miss it. Indeed he is seldom consulted and has little opportunity to discern it. Disasters such as flood and famine, war, and pestilence are outside the control of the individual. They do not produce the same tension. They are accepted—since there is no alternative. The victim becomes débrouillard. He does what he can. If that should not suffice, he cannot blame himself. There is no element of competition. He need not feel that he has wasted half a lifetime, that if things had been a little different then he, and not Jones, would have won the promotion on which he had set his heart.

Not all temperaments are susceptible to this modern stress. Women are almost immune. It belongs to the office and the technician’s bench, not to the kitchen or the Labour Exchange. For all sorts of women there is perhaps no greater anxiety than that of too often repeated pregnancies. The haunting possibility of what seems an almost intolerable further burden is seldom far from the thoughts of the average housewife. Yet should her fears be realised she is usually ready to accept what appears to be inevitable. No mental conflict develops. She is saved by her philosophy of acceptance. So also is the unskilled labourer—and for the same reason.

Today, more than ever before, the intuition of the manual labourer is to put his trust in collective action and wait for something to turn up. ‘The worker has not got the individualistic ethic’, wrote Giles Romilly recently in the New Statesman; ‘his standards and values are cooperative, not competitive’. Individual providence he regards with contempt. Whatever the size of his pay-packet he makes a point of spending all that he earns. So long as things are going well for him, he takes inflated prices in his stride, scorning to limit his consumption of beer and tobacco, while continuing to invest an average of ten shillings a week on horses, dogs, and football pools. He is content, if not with his lot, at least with himself. No sentiment of self-reproach assails his peace of mind. Neither is he troubled by ambition. He does not plague himself to master new techniques. Indeed he is profoundly suspicious of all change unless it promises shorter hours or higher pay. One of his deepest instincts is his distrust of rivalry in any form. To him the faintest breath of competition carries with it the odour of past exploitation. He wants neither more nor less than his fellows. Loyalty to his ‘own people’ is his supreme concern. All his problems are laid upon the altar of this restricted solidarity. He knows it for his source of strength and he will have no truck with anything that might impair it. From time to time he is likely to decide, in conjunction with his mates, that it would best serve his interest to take a few days off. On these occasions it may well happen that a private soldier, being required briefly to take his place, will learn between breakfast and lunch to perform with equal efficiency the labour at which he has spent a life-time. He will observe the fact without a pang.

The same tendency is plain among adolescents. It remains the dearest wish of most of them to leave school at the earliest possible moment, thus qualifying without delay for the quick rewards available in industry. Neither do they later evince the slightest desire to learn more than will barely suffice for their employment. A recent inquiry conducted by the West Hill Training College revealed much about the habits of teen-agers in Birmingham. The general impression was judged to be ‘depressing’. The lives of these boys and girls, it was thought, must be ‘empty and barren’. The organisers of the inquiry professed themselves ‘astonished’ that the standard of writing and spelling should be so poor, and that the reading of a great many should be limited to ‘comics’. Such findings are unlikely to surprise anyone who has lived with troops or worked in the wards of a hospital. As might have been expected, the cinema was shown to be universally popular among these young people, the whole group averaging three visits a fortnight. Expense proved no handicap. They had plenty of pocket-money. Indeed about 13% of the boys were betting regularly each week. Of their newspapers the Daily Mirror easily topped the list. Not that they concerned themselves greatly with happenings of the day. With few exceptions the most that might be said of their study of affairs was that if their interest could be momentarily captured by a comic strip, or a picture of a half-naked girl, it might prove possible so far further to entice their recalcitrant attention as to bring them to figure out a line or two of black type.

It is surely undeniable, from a cursory study of contemporary life in England, that most people, both young and old, feel no inclination whatever towards individual self-betterment. No doubt it has always been so. Illiteracy 50 years ago was far more widespread even than it is now. Despite the temporary setback of war it will no doubt continue to decrease. Neither does absence of personal ambition imply any lack of manifold stalwart virtues, though perhaps it is to be feared that the changed economic and political trends of the modern world will threaten increasingly those whose philosophy is that of acceptance. Orwell (1949) saw the workers of 1949 as the ‘proles’ of 1984. They had undergone a subtle degeneration: ‘heavy physical work, the care of home and children, petty quarrels with neighbours, films, football, beer, and, above all, gambling, filled up the horizon of their minds. To keep them in control was not difficult ...’ But the proles, nevertheless, whatever their masters may have thought of them, were the only happy people in Oceana. One can be sure that, like their prototypes, they were little troubled by coronary disease.

How different is the attitude of the minority. During the last 50 years the progress of what Witts calls the Second Reformation has induced the stirrings of ambition in many young men who, in an earlier age, would have spent their lives in manual toil. No other possibility would have occurred to them. Today their newborn hopes have been fostered by increased facilities for secondary education. As a result these budding engineers, clerks, and craftsmen have found themselves entering into bitter competition with each other in an effort to secure scope for their new talents and consequent entry to the pathways of personal advancement. In this way new sections of the population have become exposed to the modern form of stress. The struggle which awaits them proves severe. Blacker (1949) points out that the aspirations so kindled are likely to become increasingly thwarted. There are not enough places to go round. To quote a university student: ‘There is a sense of fighting all the time ...’, with the consciousness that ‘it is vital not to let anyone get ahead’. While the contest lasts poverty depresses the standard of living among these young men below that of the lowest paid manual worker. Of those that fail few can accept with equanimity the return to well-fed serfdom in factory, dock, or mine. They have lost their habit of acceptance. The memories of vanished hopes pursue them relentlessly in defeat. Nevermore can they escape their own attempt to strike out for themselves.

There remain too, in England, the tattered survivors of the former ‘middle classes’, from whom it is now thought proper that resentful and idle mediocrity should exact every conceivable tribute. From the first these were the chosen victims of coronary disease, whether or not as the result of their way of life. Recently the many modern troubles which assail their domestic security have become disproportionately aggravated. In the words of Mabane (1949) ‘to all who pursue an independent life, and who by their ability and effort achieve a high earning capacity, the problem of provision for retirement and even more, provision for dependants on death, is a constant and gnawing anxiety’.

At this half-way stage of the twentieth century there are, in fact, two Englands; but they are not the Englands referred to by Disraeli when he wrote of the Chartists in his novel Sybil, not the England of power and privilege on the one hand and poverty and constraint on the other. Rather does the division lie today between the few who still regard independence as the ultimate goal, striving towards it in circumstances of unprecedented difficulty, and the many who are prepared to surrender it in return for the nebulous rewards offered by the Welfare State. Only upon the few does modern life exert its particular stress, and from among them exact its fatal tribute.

Conclusion

Here then is a significant parallel. New conditions of stress, and a heavy preponderance of coronary disease, have in recent years arisen concurrently within the same small sections of civilised communities. These two developments have been present long enough for it to be possible that the first should be cause and the second effect. It is, in fact, reasonable to identify sufferers from coronary disease as the selected victims of modern stress. Little more can be said at present. Nothing is proved. Nevertheless, the coincidence is remarkable.

Ian McDougall Guthrie Stewart (1914–1988) joined the Royal Army Medical Corps immediately after qualifying in medicine in 1939. He was a prisoner of war from 1941–1945, after getting captured during the battle for Crete. Surviving punishment for repeated incidents of insubordination, he returned to hospital medical posts in London, Bristol and Lytham. In parallel with his clinical work and research in hypertension, he had a career as a sports commentator on radio, notching up over 500 broadcasts. His 1966 military history The Struggle for Crete] remains in print 36 years after publication.

Notes

* Extracted from the Carey Coombs prize essay, University of Bristol, for 1949. Back

First published in The Lancet 1950;867–70. Reprinted with permission.

References

Arlow JA. (1945) Psychosom Med 7, 195.[ISI]

Blacker CP. (1949) see Brit med J i, 406.

Boyd W. (1934) A Text-book of Pathology. 2nd ed., London; p. 380.

Cassidy M. (1946) Brit med J ii, 782.

Coombs CF. (1926)Bristol med-chir J 43, 1.

Dickinson FG, Walker EC. (1949)J Amer med Ass 139, 1129.

Dock W (1946) Ibid 131, 875.

Dublin LI, Spiegelman M, Leland RG. (1947)Post-grad Med J 2, 188.

Hadfield G. (1927)Bristol med-chir J 44, 257.

Hardy TL. (1945)Lancet, i, 519.[CrossRef]

Jones FA. (1948) in Daley and Miller’s Progress in Clinical Medicine. London; p. 69.

Journal of the American Medical Association (1944).

Levine SA. (1929)Medicine, Baltimore,8, 245.

Mabane W. (1949)Sunday Times, March 13.

Master AM. (1947)Amer Heart J 33, 135.[CrossRef][ISI]

Ogilvie H. (1949)Brit med J i, 645.

Orwell G. (1949)Nineteen-eighty-four. London.

Osler W. (1910)Lancet i, 697.[CrossRef]

Paulley JW. (1949)Proc R. Soc Med 42, 241.

Phipps C. (1936)Amer med Ass 106, 761.

Romilly G. (1949)New Statesman and Nation 37, 222.

Ryle JA. (1949)Changing Disciplines. London.

White PD, Ferrero C. (1949)Ann intern Med 31, 33.[ISI]

Wittkower E. (1938)Br med J ii, 1356.

Witts LJ. (1949)BBC broadcast, April 12.

Wolf GA jun., Wolff HG. (1946)Psychosom Med 8, 293.[ISI]

Yater WM, Traum AH, Brown WG, Fitzgerald RP, Geisler MA, Wilcox BB. (1948)Amer Heart J 36, 481.[CrossRef][ISI]





This Article
Extract
FREE Full Text (PDF)
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Request Permissions
Google Scholar
Articles by Stewart, I.
PubMed
PubMed Citation
Articles by Stewart, I.