James B. Herrick Lecture. Matrices of decision making in cardiology.

W ith the increasing focus by university deans, hospital directors, and chairs of departments of medicine on cardiology as a high-income clinical service, many of us who work in medical schools are beginning to wonder how our academic position can be preserved. Maintaining a high profile in basic research becomes increasingly difficult under such conditions. On the other hand, clinical research activity is possible in all work settings, and important contributions have and still are being made by clinical observation and even by library research. It was such nonfederally funded clinical observations in the era before World War I that led to James Herrick's description in 1912 of the clinical syndrome of nonfatal acute myocardial infarction.1 Herrick was a practicing internist and, in 1915, the first president of the Chicago Society of Internal Medicine. Although survival after coronary occlusion had been occasionally suggested by postmortem studies, Herrick's account of the clinical picture with survival for as long as 20 days was convincing and highly influential on subsequent practice. His 1912 article was remarkably insightful and described in detail the clinical findings in several patients (one with autopsy); of course, no electrocardiographic confirmation was available. Based on postmortem studies, in those days there apparently was no question that coronary thrombosis was the problem, and Herrick discussed different syndromes to be expected from occlusion of different vessels, the role of the collateral circulation, and the effects of disease in other nonoccluded vessels.' The term "matrix" refers to a place or an element within which something forms or develops, and as such a matrix gives shape to that which it encloses. In considering matrices for decisions in cardiology, a very broad matrix can be identified; this includes virtually all societal, cultural, and other factors that