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AURICULAR FIBRILLATION IN NORMAL HEARTS
570 a fine membrane, before being sprayed into the volunteer’s nostrils and oropharynx. In one experiment a laboratory worker standing at least ten feet away from this spraying operation, contracted rubella ; so the minimal effective dose was probably much smaller than that actually given. In these experiments the incubation period ranged-from thirteen to twenty days, and sometimes lymphadenopathy preceded the appearance of the rash by as much as six days. In general, the longer the incubation period the milder was the attack. Attempts to transmit the disease to 9 subjects who had had a natural attack 6—9 years before, failed ; and it was concluded that the induced disease conferred a like immunity, which would cover the average childbearing life of modern women. Probably, however, this method will not come into general use until the risk of inadvertently transmitting other virus diseases—notably poliomyelitis—is excluded. Meanwhile it is a relief to learn that vaccination has been exonerated from suspicion of causing harm to the growing fœtus.6
AURICULAR
FIBRILLATION
IN
NORMAL HEARTS
OVER thirty years ago English workerspointed out that auricular fibrillation may arise in patients whose cardiovascular system seems otherwise normal; and of 651 cases of auricular fibrillation lately studied at the Lahey Clinic by Hanson and Rutledge,8 30 (4-6%) were in patients with normal hearts. Of these, 10 were established cases and 20 paroxysmal. All the established cases and more than half of the paroxysmal were in males. The age at onset varied considerably, but two-thirds of the established cases were in patients aged 30-40, whilst the paroxysmal form tended to appear a decade or so later. Threequarters of the paroxysmal cases were associated with " a psychogenic or functional element," but in the established cases no precipitating factor was found, and indeed four-fifths of the patients in this group were unaware of the arrhythmia and had no symptoms ; ’all had a relatively slow ventricular rate (60-90 per minute) with no appreciable pulse-deficit. Of the paroxysmal cases, the great majority experienced palpitations during an attack ; and then, in nine out of ten, the ventricular rate ranged from 70 to 110 per minute. In this The prognosis in such cases is excellent.9 series no patient suffered any incapacity because of the arrhythmia ; and in 2 cases established auricular fibrillation had been present for over 40 years when the patients were first seen. Once established, the arrhythmia tends to persist. Of the paroxysmal cases in this series, one became established spontaneously and 2 following digitalis therapy. More than a third of these patients received no treatment. Should treatment be required, quinidine is the drug of choice, although digitalis may sometimes be of value. Assessing the effect of treatment in paroxysmal auricular fibrillation is often difficult, since paroxysms tend to be irregular. As Hanson and Rutledge point out, quinidine is a potent drug which is not altogether non-toxic-a fact that should be borne in mind when considering its use in an otherwise healthy person whose only complaint is of palpitations during a
paroxysm.
of this interesting condition is obscure, there is some evidence that it originates from a nervous reflex. Perhaps, however, Hanson and Rutledge are rather rash to say that " auricular fibrillation is a disturbance of auricular impulse formation and conThe
setiology
though
6. Greenberg, M., Yankauer, A. jun., Krugman, S., Osborn, J. J., Ward, R. S., Dancis, J. Pediatrics, 1949, 3, 456. 7. Mackenzie, J. Heart, 1911, 2, 273. Gossage, A. M., Hicks, J. A. B. Quart. J. Med. 1913, 6, 435. 8. Hanson, H. H., Rutledge, D. I. New Engl. J. Med. 1949, 240, 947. 9. Cooke, W. T., White, P. D. Brit. Heart J. 1942, 4, 153.
duction that is
a physiologic phenomenon and not pathogenic one." This is surely stretching the meaning of physiologic too far, even for these eclectic days. In diagnosis the important thing is to exclude the presence of acknowledged causes of fibrillation and especially thyrotoxicosis. Most physicians will more than once have seen a diagnosis of auricular fibrillation in a normal heart " changed ultimately to " auricular fibrillation due to thyrotoxicosis."
a
"
"
"
TOWARDS GROUP
PRACTICE
STEPS towards group practice that seem " desirable and feasible" are outlined in a memorandum to Scottish executive councils from the Department- of Health, which asks for the councils’ comment in two months’ time. " There are," the Department rightly says, " many gradations between the fully developed health centre with its special building, complete staff and organisation on the one hand and the purely individualistic singlehanded practice on the other " ; and as the possibility of large expenditure recedes into the distance it is increasingly important to see what can be done with small material changes. Thus " it might be possible to find accommodation for the administrative headquarters of a group from which the health visitors, district nurses, and midwives could work, which would form the centre for receiving and distributing messages, and which would house any necessary clerical staff.... Even in the absence of any special buildings at all, arrangements might be made among the group of practitioners for relief duty, sharing of clerical assistance, and more intimate coöperation with health visitor and district nurse." More specifically, the recommended developments include (1) extension of the mutual assistance between practitioners to mutual relief in off-duty periods; (2) arrangements among a group for the receipt of telephone messages for any of their number who are not immediately available, and provision for the calling of a deputising doctor in urgent cases ; (3) cooperation of neighbouring doctors in the employment of clerical assis-
tance ; (4) the provision of simple laboratory and other aids to diagnosis for the benefit of a group where this provision would not be possible for an individual practitioner ; (5) cooperation between a group of practitioners the one hand and district nurses and health visitors the other, by arrangement between the group and the local authority ; and (6) arrangements between groups of practitioners and hospital units for consultation references, clinical discussions, and ward visits. The memorandum, which is framed on recommendations from the Scottish Standing Advisory Committee on General Practitioner Services, acknowledges that practitioners themselves must decide the extent to which they adopt group practice ; but it insists that some authority with local knowledge must be responsible for developing practice along these lines, and this duty, it says, should rest with the executive council, working closely with the local authority and the local medical committee. It may be doubtful how far local-authority and general-practitioner services can be integrated in the absence of a single building from which both can operate ; but the attempt is worth making. Certainly, as isolated experiments have proved, a great deal can be done to improve conditions of general practice if practitioners will join together to do it ; and we hope that much will come of this new Scottish initiative. on
on
THE INDEX and title-page to Vol. I, 1949, which was completed with THE LANCET of June 25, is now in preparation. A copy will be sent gratis to subscribers on receipt of a postcard addressed to the Manager of SubTHE LANCET, 7, Adam Street, Adelphi, W.C.2. scribers who have not already indicated their desire to receive indexes regularly as published should do so now.
AURICULAR
FIBRILLATION
IN
NORMAL HEARTS
OVER thirty years ago English workerspointed out that auricular fibrillation may arise in patients whose cardiovascular system seems otherwise normal; and of 651 cases of auricular fibrillation lately studied at the Lahey Clinic by Hanson and Rutledge,8 30 (4-6%) were in patients with normal hearts. Of these, 10 were established cases and 20 paroxysmal. All the established cases and more than half of the paroxysmal were in males. The age at onset varied considerably, but two-thirds of the established cases were in patients aged 30-40, whilst the paroxysmal form tended to appear a decade or so later. Threequarters of the paroxysmal cases were associated with " a psychogenic or functional element," but in the established cases no precipitating factor was found, and indeed four-fifths of the patients in this group were unaware of the arrhythmia and had no symptoms ; ’all had a relatively slow ventricular rate (60-90 per minute) with no appreciable pulse-deficit. Of the paroxysmal cases, the great majority experienced palpitations during an attack ; and then, in nine out of ten, the ventricular rate ranged from 70 to 110 per minute. In this The prognosis in such cases is excellent.9 series no patient suffered any incapacity because of the arrhythmia ; and in 2 cases established auricular fibrillation had been present for over 40 years when the patients were first seen. Once established, the arrhythmia tends to persist. Of the paroxysmal cases in this series, one became established spontaneously and 2 following digitalis therapy. More than a third of these patients received no treatment. Should treatment be required, quinidine is the drug of choice, although digitalis may sometimes be of value. Assessing the effect of treatment in paroxysmal auricular fibrillation is often difficult, since paroxysms tend to be irregular. As Hanson and Rutledge point out, quinidine is a potent drug which is not altogether non-toxic-a fact that should be borne in mind when considering its use in an otherwise healthy person whose only complaint is of palpitations during a
paroxysm.
of this interesting condition is obscure, there is some evidence that it originates from a nervous reflex. Perhaps, however, Hanson and Rutledge are rather rash to say that " auricular fibrillation is a disturbance of auricular impulse formation and conThe
setiology
though
6. Greenberg, M., Yankauer, A. jun., Krugman, S., Osborn, J. J., Ward, R. S., Dancis, J. Pediatrics, 1949, 3, 456. 7. Mackenzie, J. Heart, 1911, 2, 273. Gossage, A. M., Hicks, J. A. B. Quart. J. Med. 1913, 6, 435. 8. Hanson, H. H., Rutledge, D. I. New Engl. J. Med. 1949, 240, 947. 9. Cooke, W. T., White, P. D. Brit. Heart J. 1942, 4, 153.
duction that is
a physiologic phenomenon and not pathogenic one." This is surely stretching the meaning of physiologic too far, even for these eclectic days. In diagnosis the important thing is to exclude the presence of acknowledged causes of fibrillation and especially thyrotoxicosis. Most physicians will more than once have seen a diagnosis of auricular fibrillation in a normal heart " changed ultimately to " auricular fibrillation due to thyrotoxicosis."
a
"
"
"
TOWARDS GROUP
PRACTICE
STEPS towards group practice that seem " desirable and feasible" are outlined in a memorandum to Scottish executive councils from the Department- of Health, which asks for the councils’ comment in two months’ time. " There are," the Department rightly says, " many gradations between the fully developed health centre with its special building, complete staff and organisation on the one hand and the purely individualistic singlehanded practice on the other " ; and as the possibility of large expenditure recedes into the distance it is increasingly important to see what can be done with small material changes. Thus " it might be possible to find accommodation for the administrative headquarters of a group from which the health visitors, district nurses, and midwives could work, which would form the centre for receiving and distributing messages, and which would house any necessary clerical staff.... Even in the absence of any special buildings at all, arrangements might be made among the group of practitioners for relief duty, sharing of clerical assistance, and more intimate coöperation with health visitor and district nurse." More specifically, the recommended developments include (1) extension of the mutual assistance between practitioners to mutual relief in off-duty periods; (2) arrangements among a group for the receipt of telephone messages for any of their number who are not immediately available, and provision for the calling of a deputising doctor in urgent cases ; (3) cooperation of neighbouring doctors in the employment of clerical assis-
tance ; (4) the provision of simple laboratory and other aids to diagnosis for the benefit of a group where this provision would not be possible for an individual practitioner ; (5) cooperation between a group of practitioners the one hand and district nurses and health visitors the other, by arrangement between the group and the local authority ; and (6) arrangements between groups of practitioners and hospital units for consultation references, clinical discussions, and ward visits. The memorandum, which is framed on recommendations from the Scottish Standing Advisory Committee on General Practitioner Services, acknowledges that practitioners themselves must decide the extent to which they adopt group practice ; but it insists that some authority with local knowledge must be responsible for developing practice along these lines, and this duty, it says, should rest with the executive council, working closely with the local authority and the local medical committee. It may be doubtful how far local-authority and general-practitioner services can be integrated in the absence of a single building from which both can operate ; but the attempt is worth making. Certainly, as isolated experiments have proved, a great deal can be done to improve conditions of general practice if practitioners will join together to do it ; and we hope that much will come of this new Scottish initiative. on
on
THE INDEX and title-page to Vol. I, 1949, which was completed with THE LANCET of June 25, is now in preparation. A copy will be sent gratis to subscribers on receipt of a postcard addressed to the Manager of SubTHE LANCET, 7, Adam Street, Adelphi, W.C.2. scribers who have not already indicated their desire to receive indexes regularly as published should do so now.