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SEQUELS OF SUCCESS
808 SICK-SINUS SYNDROME DISEASE of the conducting tissues of the heart gives rise to difficult therapeutic problems. These have been highlighted by the arrhythmias in acute myocardial infarction, but more chronic conduction faults are in some ways equally serious. In sinoatrialnode disease the associated arrhythmias may be Wan, particularly numerous and troublesome. Lee, and Toh1 have reviewed the clinical aspects on the basis of experience with 15 patients in The arrhythmias ranged from sinus Singapore. bradycardia, multifocal atrial ectopics, and runs of
atrial tachycardia to prolonged sinoatrial arrest with temporary total cardiac standstill. The series indicates
that, though precise electrophysiological explanations are as yet enigmatic in man, for practical purposes failure of sinoatrial-node activity can be divided into two main categories-bradycardia and tachycardia. Bradycardia may be caused by slowing of the sinus beat, sinoatrial block, and sinus arrest; tachycardia may be in the form of multiple atrial ectopics, atrial tachycardia, and other escape rhythms initiated during a period of bradycardia. Atrial fibrillation may be the final
outcome.
Clinical management of the various " sick-sinus syndromes " depends on the underlying disease. In the Singapore review such diverse aetiologies as thyrotoxicosis, ischaemic heart-disease, drugs, subarachnoid haemorrhage, cardiomyopathies, and myocarditis are discussed. Syncope due to prolonged sinoatrial-node arrest was the presenting feature in half the cases. Nearly three-quarters of the patients had radiological evidence of cardiomegaly, though clinical cardiac failure was uncommon. (The investigation excluded patients with acute myocardial infarction-probably the commonest cause of sinoatrial-node Sinus disturbance, especially sinus bradycardia.) bradycardia mainly happens in association with posterior myocardial infarction and the two together can result in profound circulation failure. However, in this context the arrhythmia is usually innocent and selflimiting. Severe syncope can be counteracted by raising the legs or giving atropine intravenously in incremental doses of approximately 0-3 mg."2 Adgey et al. have proposed that serious ectopic rhythms follow bradycardia in the earliest stages of acute myocardial infarction and that counteracting bradycardia will substantially reduce early mortality. A comprehensive investigation in New Zealand suggests, 4 on the other hand, that despite experimental evidence supporting this possibility, acute-coronary patients with bradycardia, seen rather later than those in the coronary ambulance of Adgey et al., show no higher incidence of serious arrhythmias than do patients without bradycardia.5 The management of patients with long-term sicksinus syndrome is more difficult. When an underlying Wan, S. H., Lee, G. S., Toh, C. S. Br. Heart J. 1972, 34, 942. Thomas, M., Woodgate, D. ibid. 1966, 28, 409. Adgey, A. A. J., Allen, J. D., Geddes, J. S., James, R. G. G., Webb, S. W., Zaidi, S. A., Pantridge, J. F. Lancet, 1971, ii, 501. 4. Han, J., De Traglia, J., Millet, D., Moe, G. J. Am. Heart J. 1966, 72, 632. 5. Norris, R. M., Mercer, C. J., Yeates, S. E. Br. Heart J. 1972, 34, 901. 1. 2. 3.
aaiology is identifiable (such as thyrotoxicosis) it should be treated, but this may take time and the cardiac problems will have to be dealt with in the Treatment with vagolytic drugs for the interim. bradycardia rhythm, whether sinus bradycardia, nodal rhythm, or sinoatrial block or arrest, stems from a belief that these arrhythmias may be due to vagotonic effect. Atropine and sympathomimetic agents such as long-acting isoprenaline are not always effective, but they are well worth careful trial. The quality of life may be much improved by elimination of a tendency to syncope or by elimination of escape rhythm by speeding up the basic sinus rate.Especially difficult to treat are those patients with both bradycardia and When disability is severe, primary tachycardia. atrial pacing may have to be started: this controls bradycardia and also allows depressant antiarrhythmic drugs to be used more safely. Alternatively, high-rate pacing may override the tachycardia. In the most unstable patients, and with the uncertainty of the natural history of sinoatrial-node disease, it is perhaps more secure to establish pacing from the right ventricle, either fixed-rate or demand, to ensure maintenance of a heart-beat under any circumstance of supraventricular conduction fault.
SEQUELS OF SUCCESS THE Office of Health Economics’s latest pamphlet7 looks at the ways medical practice has been changed by the successes of the past 40 years. Spectacular triumphs have been achieved by surgery and by drugs, and the expectation of life is much greater; but there have been some unforeseen and unwelcome sequels. People live longer-but they demand more. Death before maturity is comparatively rare, and is consequently less easy to accept; the doctor is now expected to make every effort just to prolong life-often irrespective of its quality. Besides this, invalids get less support from their families, they are not trained in Victorian stoicism, and they have less faith in the Churches. The stresses on all are far greater in the shape of noise, rush, and job mobility; the doctor is still there to help, and sometimes open discussion of all this helps. But to get a doctor’s help, many believe they must have physical complaints (some of which may indeed be the result of stress) and the doctor’s training still is focused more on physical than on emotional illness. For all these reasons many more people today are seeking and getting medical help, in physical terms, for illnesses which are due to social or personal stress and are primarily psychological in nature.
Out of
this, understandably, has come the habit of prescribing many psychotropic drugs; in a decade, tranquillisers have increased threefold in Britain, from 6 million to 18 million
prescriptions a year, and antisevenfold. depressants nearly Surprisingly, hypnotics have shown far less change, except that barbiturates have been replaced by others. The cash cost is enormous; the danger of habituation considerable. As the pamphlet says, it is more reasonable to 6. Linanthal, A. J., Zoll, P. M. Circulation, 1963, 27, 5. 7. Medicine and Society: the Changing Demands for Medical Care. Office of Health Economics. 25p.
809
than to provide labels, duodenal ulcer, as alibis; but the publication such must be criticised, and the press-release even more so, for the misleading impression that there is no third alternative-which is simple psychotherapy. Although psychotherapy may take longer its effects may be longer lasting. It is ironic here that Balint’s emphasis of the importance of social stress 8 is cited approvingly, though Balint himself taught that psychotropic drugs must be used with discretion, and never repeated unthinkingly. It would be sad if this excellent review of the changing practice of medicine led any doctor to add to the load of drugs taken each year, instead of helping the patient understand and cope with his symptoms and their causes.
prescribe psychotropic drugs as
UPDATING THE O.E.D.
IF any new proof were necessary, the response to occasional column on medical words, Medical Idioticon, has demonstrated the interest of the profession in the words it uses-a concern that, though it goes far beyond the utilitarian, is rooted in a constant need to find words both exact and flexible to describe the immensely complex processes with which doctors have to deal. It is a need that has never been easy to meet, and becomes harder with the accelerated process of changes of concepts and techniques, with the increasing separation of the profession into specialties each with its own dialect, and with the use of English as a medical and scientific lingua anglica all over the world. Words are invented mostly by the innovators of ideas and methods, and go through a variety of sieves of which the innovators’ audiences form the first and the editors of journals probably the most important. They then need to be recorded in glossaries and dictionaries. This is ostensibly for the benefit of the uninitiated, but it also has a valuable effect of fixing the sense of the word, at least for a time, within some kind of limits: though the language must change, it needs some kind of stable skeleton to move from. Purely medical dictionaries are useful but insufficient, partly because of the difficulty of setting a boundary to their coverage, but far more so because common and medical languages react constantly Medicine absorbs the linguistic upon each other. tricks of its environment (hospitalisation, A.C.T.H., prognosis-wise could only have been coined this century) and the general language takes its pick of our
our
jargon (morbid, allergic, aseptic, mutation, X-ray, mention all the anatomical structures and diseases for which the more exact medical terms are slowly replacing the vernacular). In consequence, probably at least as many British doctors own a Shorter Oxford English Dictionary as own a specialised medical dictionary of any kind. We all tend to regard " the Oxford " as the ultimate authority, and if we cannot afford either the money or the space for the 13-volume O.E.D. we make do with the Shorter. The only major defect of the two larger Oxford dictionaries is that for everyday use they are getting a little out of date. It is a major undertaking to revise
not to
8.
Balint,
M. The Doctor, His Patient and the Illness.
London, 1957.
pocket dictionary. To remake the O.E.D., which took 44 years (1884-1928) to get into print, is beyond reasonable possibility: in any case the original volumes are best regarded as they stand as a record of the English language up to about 1900. A limited attempt to bring it up to date was made in the 1933 Supplement, dealing chiefly with material collected since the earlier volumes were printed. The first really major addition to it is a new 3-volume Suppleeven a
ment, which includes both the 1933 material and extensive collections up to the present. The old O.E.D. covered 900 years of the English language: the size of the new Supplement would seem to indicate that 70 more years have sufficed to produce a 25 % increase in the number of words in use. This week sees the publication of the first volume of these three-1300 pages long and in the same format as the old O.E.D.1’- In the few more years needed to produce the two remaining, it will be possible, by adding them to the new compact two-volume edition of the old O.E.D.,2readable with a magnifying glass, to have the whole set up-to-date within reasonable shelf-space and (relatively) reasonable cost. The new volume makes fascinating reading. More than half of the new words and senses are technical terms. The others are a very mixed bag. Many are slang (glam and goo for instance) or improbable new formations (to gondole) or notable as being new enough not to be recorded earlier (gluily, Biafran, Dubliner, dubbin as a verb, and so on). The fourletter words are all in, appropriately deadpan. About 12% of the terms, on a rough sampling, have some medical connections. Most of them are obvious enough-a whole mass of words in glyco- and gluco-, for instance, many drugs, new techniques such as freeze-dry, chromatography, and arteriography (the latter once was used for description of arteries, and the present entry is a new sense rather than a new word), adenoma, adenosine, and adenovirus, innumerable anti-’s, cephalosporin and cephalin, cerebrate and cerebroside-and so on, and so on. Except among the more recondite biochemicals, drugs, and eponyms it is hard to find anything important that is missing, unless one seeks terms as new as Australia antigen or
Cogwheeling. There must be defects in so large a work. One might complain that the definition of bacterium, which says nothing of the cell wall, could serve for most other groups of microorganisms; that a chondroma is formed of rather than arises from chondrocytes ; that the grossly misleading definition of acne (in S.O.E.D. admittedly, not O.E.D.) has not been corrected; and that many people (though not this journal) have long ago abandoned the ligatured diphthong in words like gynxcology and galactoseeniia. No doubt a generation of doctors will occupy some of their time in increasing this list-they are recommended, if they wish to complain about it, to support their views by illustrative quotations. But no-one will deny that this first volume is
a
remarkable achievement.
Supplement to the Oxford English Dictionary: vol. I, A-G. Edited by R. W. BURCHFIELD. Oxford: Clarendon Press. 1972. Pp. 1331. £15. 2. Compact Edition of the Oxford English Dictionary. Oxford: Clarendon Press. 1971. Pp. 4134. 2 vols. £32. 1. A
atrial tachycardia to prolonged sinoatrial arrest with temporary total cardiac standstill. The series indicates
that, though precise electrophysiological explanations are as yet enigmatic in man, for practical purposes failure of sinoatrial-node activity can be divided into two main categories-bradycardia and tachycardia. Bradycardia may be caused by slowing of the sinus beat, sinoatrial block, and sinus arrest; tachycardia may be in the form of multiple atrial ectopics, atrial tachycardia, and other escape rhythms initiated during a period of bradycardia. Atrial fibrillation may be the final
outcome.
Clinical management of the various " sick-sinus syndromes " depends on the underlying disease. In the Singapore review such diverse aetiologies as thyrotoxicosis, ischaemic heart-disease, drugs, subarachnoid haemorrhage, cardiomyopathies, and myocarditis are discussed. Syncope due to prolonged sinoatrial-node arrest was the presenting feature in half the cases. Nearly three-quarters of the patients had radiological evidence of cardiomegaly, though clinical cardiac failure was uncommon. (The investigation excluded patients with acute myocardial infarction-probably the commonest cause of sinoatrial-node Sinus disturbance, especially sinus bradycardia.) bradycardia mainly happens in association with posterior myocardial infarction and the two together can result in profound circulation failure. However, in this context the arrhythmia is usually innocent and selflimiting. Severe syncope can be counteracted by raising the legs or giving atropine intravenously in incremental doses of approximately 0-3 mg."2 Adgey et al. have proposed that serious ectopic rhythms follow bradycardia in the earliest stages of acute myocardial infarction and that counteracting bradycardia will substantially reduce early mortality. A comprehensive investigation in New Zealand suggests, 4 on the other hand, that despite experimental evidence supporting this possibility, acute-coronary patients with bradycardia, seen rather later than those in the coronary ambulance of Adgey et al., show no higher incidence of serious arrhythmias than do patients without bradycardia.5 The management of patients with long-term sicksinus syndrome is more difficult. When an underlying Wan, S. H., Lee, G. S., Toh, C. S. Br. Heart J. 1972, 34, 942. Thomas, M., Woodgate, D. ibid. 1966, 28, 409. Adgey, A. A. J., Allen, J. D., Geddes, J. S., James, R. G. G., Webb, S. W., Zaidi, S. A., Pantridge, J. F. Lancet, 1971, ii, 501. 4. Han, J., De Traglia, J., Millet, D., Moe, G. J. Am. Heart J. 1966, 72, 632. 5. Norris, R. M., Mercer, C. J., Yeates, S. E. Br. Heart J. 1972, 34, 901. 1. 2. 3.
aaiology is identifiable (such as thyrotoxicosis) it should be treated, but this may take time and the cardiac problems will have to be dealt with in the Treatment with vagolytic drugs for the interim. bradycardia rhythm, whether sinus bradycardia, nodal rhythm, or sinoatrial block or arrest, stems from a belief that these arrhythmias may be due to vagotonic effect. Atropine and sympathomimetic agents such as long-acting isoprenaline are not always effective, but they are well worth careful trial. The quality of life may be much improved by elimination of a tendency to syncope or by elimination of escape rhythm by speeding up the basic sinus rate.Especially difficult to treat are those patients with both bradycardia and When disability is severe, primary tachycardia. atrial pacing may have to be started: this controls bradycardia and also allows depressant antiarrhythmic drugs to be used more safely. Alternatively, high-rate pacing may override the tachycardia. In the most unstable patients, and with the uncertainty of the natural history of sinoatrial-node disease, it is perhaps more secure to establish pacing from the right ventricle, either fixed-rate or demand, to ensure maintenance of a heart-beat under any circumstance of supraventricular conduction fault.
SEQUELS OF SUCCESS THE Office of Health Economics’s latest pamphlet7 looks at the ways medical practice has been changed by the successes of the past 40 years. Spectacular triumphs have been achieved by surgery and by drugs, and the expectation of life is much greater; but there have been some unforeseen and unwelcome sequels. People live longer-but they demand more. Death before maturity is comparatively rare, and is consequently less easy to accept; the doctor is now expected to make every effort just to prolong life-often irrespective of its quality. Besides this, invalids get less support from their families, they are not trained in Victorian stoicism, and they have less faith in the Churches. The stresses on all are far greater in the shape of noise, rush, and job mobility; the doctor is still there to help, and sometimes open discussion of all this helps. But to get a doctor’s help, many believe they must have physical complaints (some of which may indeed be the result of stress) and the doctor’s training still is focused more on physical than on emotional illness. For all these reasons many more people today are seeking and getting medical help, in physical terms, for illnesses which are due to social or personal stress and are primarily psychological in nature.
Out of
this, understandably, has come the habit of prescribing many psychotropic drugs; in a decade, tranquillisers have increased threefold in Britain, from 6 million to 18 million
prescriptions a year, and antisevenfold. depressants nearly Surprisingly, hypnotics have shown far less change, except that barbiturates have been replaced by others. The cash cost is enormous; the danger of habituation considerable. As the pamphlet says, it is more reasonable to 6. Linanthal, A. J., Zoll, P. M. Circulation, 1963, 27, 5. 7. Medicine and Society: the Changing Demands for Medical Care. Office of Health Economics. 25p.
809
than to provide labels, duodenal ulcer, as alibis; but the publication such must be criticised, and the press-release even more so, for the misleading impression that there is no third alternative-which is simple psychotherapy. Although psychotherapy may take longer its effects may be longer lasting. It is ironic here that Balint’s emphasis of the importance of social stress 8 is cited approvingly, though Balint himself taught that psychotropic drugs must be used with discretion, and never repeated unthinkingly. It would be sad if this excellent review of the changing practice of medicine led any doctor to add to the load of drugs taken each year, instead of helping the patient understand and cope with his symptoms and their causes.
prescribe psychotropic drugs as
UPDATING THE O.E.D.
IF any new proof were necessary, the response to occasional column on medical words, Medical Idioticon, has demonstrated the interest of the profession in the words it uses-a concern that, though it goes far beyond the utilitarian, is rooted in a constant need to find words both exact and flexible to describe the immensely complex processes with which doctors have to deal. It is a need that has never been easy to meet, and becomes harder with the accelerated process of changes of concepts and techniques, with the increasing separation of the profession into specialties each with its own dialect, and with the use of English as a medical and scientific lingua anglica all over the world. Words are invented mostly by the innovators of ideas and methods, and go through a variety of sieves of which the innovators’ audiences form the first and the editors of journals probably the most important. They then need to be recorded in glossaries and dictionaries. This is ostensibly for the benefit of the uninitiated, but it also has a valuable effect of fixing the sense of the word, at least for a time, within some kind of limits: though the language must change, it needs some kind of stable skeleton to move from. Purely medical dictionaries are useful but insufficient, partly because of the difficulty of setting a boundary to their coverage, but far more so because common and medical languages react constantly Medicine absorbs the linguistic upon each other. tricks of its environment (hospitalisation, A.C.T.H., prognosis-wise could only have been coined this century) and the general language takes its pick of our
our
jargon (morbid, allergic, aseptic, mutation, X-ray, mention all the anatomical structures and diseases for which the more exact medical terms are slowly replacing the vernacular). In consequence, probably at least as many British doctors own a Shorter Oxford English Dictionary as own a specialised medical dictionary of any kind. We all tend to regard " the Oxford " as the ultimate authority, and if we cannot afford either the money or the space for the 13-volume O.E.D. we make do with the Shorter. The only major defect of the two larger Oxford dictionaries is that for everyday use they are getting a little out of date. It is a major undertaking to revise
not to
8.
Balint,
M. The Doctor, His Patient and the Illness.
London, 1957.
pocket dictionary. To remake the O.E.D., which took 44 years (1884-1928) to get into print, is beyond reasonable possibility: in any case the original volumes are best regarded as they stand as a record of the English language up to about 1900. A limited attempt to bring it up to date was made in the 1933 Supplement, dealing chiefly with material collected since the earlier volumes were printed. The first really major addition to it is a new 3-volume Suppleeven a
ment, which includes both the 1933 material and extensive collections up to the present. The old O.E.D. covered 900 years of the English language: the size of the new Supplement would seem to indicate that 70 more years have sufficed to produce a 25 % increase in the number of words in use. This week sees the publication of the first volume of these three-1300 pages long and in the same format as the old O.E.D.1’- In the few more years needed to produce the two remaining, it will be possible, by adding them to the new compact two-volume edition of the old O.E.D.,2readable with a magnifying glass, to have the whole set up-to-date within reasonable shelf-space and (relatively) reasonable cost. The new volume makes fascinating reading. More than half of the new words and senses are technical terms. The others are a very mixed bag. Many are slang (glam and goo for instance) or improbable new formations (to gondole) or notable as being new enough not to be recorded earlier (gluily, Biafran, Dubliner, dubbin as a verb, and so on). The fourletter words are all in, appropriately deadpan. About 12% of the terms, on a rough sampling, have some medical connections. Most of them are obvious enough-a whole mass of words in glyco- and gluco-, for instance, many drugs, new techniques such as freeze-dry, chromatography, and arteriography (the latter once was used for description of arteries, and the present entry is a new sense rather than a new word), adenoma, adenosine, and adenovirus, innumerable anti-’s, cephalosporin and cephalin, cerebrate and cerebroside-and so on, and so on. Except among the more recondite biochemicals, drugs, and eponyms it is hard to find anything important that is missing, unless one seeks terms as new as Australia antigen or
Cogwheeling. There must be defects in so large a work. One might complain that the definition of bacterium, which says nothing of the cell wall, could serve for most other groups of microorganisms; that a chondroma is formed of rather than arises from chondrocytes ; that the grossly misleading definition of acne (in S.O.E.D. admittedly, not O.E.D.) has not been corrected; and that many people (though not this journal) have long ago abandoned the ligatured diphthong in words like gynxcology and galactoseeniia. No doubt a generation of doctors will occupy some of their time in increasing this list-they are recommended, if they wish to complain about it, to support their views by illustrative quotations. But no-one will deny that this first volume is
a
remarkable achievement.
Supplement to the Oxford English Dictionary: vol. I, A-G. Edited by R. W. BURCHFIELD. Oxford: Clarendon Press. 1972. Pp. 1331. £15. 2. Compact Edition of the Oxford English Dictionary. Oxford: Clarendon Press. 1971. Pp. 4134. 2 vols. £32. 1. A