Minority Report of the Committee on the Effect of Strain and Trauma on the Heart and Great Vessels

Preamble The report of the Committee on the Effect of Strain and Trauma on the Heart and Great Vessels was published in Circulation in October 1962, with a footnote stating that Dr. J. C. Paterson, the only dissenting member of the Committee., wished to present his viewpoint on one particular but important aspect of the subject. His Minority Report is here published to permit this in advance of the appearance of any later monograph planned to include both reports, details of some of the studies on which the reports were based, and the bibliography. Dr. Paterson agrees with those who have stated that intimal hemorrhage "may be the critical secondary lesion" in acute and chronic coronary artery atherosclerotic disease, that such hemorrhages may be "caused by stress," and that "in certain circumstances some of them may have acute casualty-producing effects." And furthermore, the time relationships between stress and the effects thereof might thereby be prolonged beyond the limits considered likely by the majority of the Committee. Such divergent views are incapable of proof at present,. even though clearly possible from either standpoint. The immediate duty of the Committee, however, was to define criteria for, and to outline, the probabilities of, causal relationships for the guidance of the medical and legal professions. The statistical evidence, admittedly lacking in perfect certitude, is strongly against stress as the primary or essential factor in coronary occlusion and in sudden death from obstructive coronary atherosclerotic disease, in which 60 per cent or more of victims show no recent occlusion from necropsy. Since the legal process requires definite affirmative or negative decisions, the scientist's "perhaps" can only be assessed by the weight of probability and the careful scrutiny of the evidence in every contested case. The Minority Report should be useful in supple-menting the Majority Report in this respect. But inasmuch as coronary thrombosis, like a good many other diseases, is not primarily due to work but to other causes, it should be removed from litigationi in the courts under the category of Workmen's Compensation and taken care of by some form of health insurance. PAUL D. WHITE, M.D. HOWARD B. SPRAGUE, M.D.