ROCKEFELLER PLANS
1
774 cheese makers whose carefully controlled fermentations are brought to naught by a trace of penicillin. They can, no doubt, defend themselves. ROCKEFELLER PLANS ON its 50th birthday, earlier this year, the Rockefeller Foundation was able to present a record of resourceful and apposite munificence.1 For donations of money, as well as of blood, matching is important, and the Rocke- feller trustees have always been at great pains to give discerning support to fundamental needs. The success of their early campaigns for public health allowed the scope of their work to spread from the control of com- munity diseases to the control of other community haz- ards, and their concern for these is to continue. For the next half century, which seems likely to offer both chal- lenge and change, the trustees wisely feel that they can offer no detailed blueprint, but they have recognised priorities among current human needs. The first of the international projects they have selected-the conquest of hunger and the related problem of population-are both closely associated with the Foundation’s medical work. Toward the conquest of hunger the trustees propose " to strengthen the Foundation’s programme on human nutrition, and to support the search for new knowledge leading to a better use of land and water resources, develop- ment of non-conventional agricultural techniques, and investigation of the changing environment in which we live ". The trustees believe " the grim, steady swelling in the size of the world’s population," to be of tremendous significance for all mankind, and they expect to expand support of critical research and action programmes in population dynamics and population stabilisation. CONVERSION OF ATRIAL FIBRILLATION BY DIRECT-CURRENT SHOCK CARDIAC output is reduced by atrial fibrillation, even when the heart-rate is controlled by digitalis; and there is a constant risk of embolism, even in the absence of valve stenosis. Conversion to regular rhythm with quinidine has been practised since 1918,2 but atrial fibrillation often recurs. Standard practice has therefore been to attempt quinidine conversion only when some factor responsible for fibrillation has been removed: after thyroidectomy, after pregnancy, or when rheumatic fever or pneumonia has precipitated the arrhythmia. A new method of con- version to regular rhythm, by a direct-current shock, is now available. This has proved safe, quick, and more pleasant for the patient than quinidine; and a more aggressive approach to atrial fibrillation may now be justified. Lown et at. 3 4 developed this method of terminating atrial fibrillation by a brief high-energy electric shock across the intact chest under light anxsthesia. The dis- charge was synchronised from the electrocardiograph to be delivered at the end of the R wave; the risk of ventricular fibrillation from a shock in the short vulnerable period at the apex of the T wave was thus avoided. 65 episodes of atrial fibrillation in 50 patients were treated. All but 3 of the patients had mitral-valve disease; half had been in fibrillation for more than a year, and one for seventeen 1. See Lancet, 1963, i, 873. 2. Frey, W. Berl. klin. Wschr. 1918, 55, 417. 3. Lown, B., Amarasingham, R., Neuman, J. J. Amer. med. Ass. 1962, 182, 548. 4. Lown, B., Perlroth, M. G., Kaidbey, S., Abe, T., Harken, D. E. New Engl. J. Med. 1963, 269, 325. years. 38 were in heart-failure. Quinidine had been tried previously in 23 patients, with successful conversion in only 4. To patients with mitral-valve disease, anticoagu- lants were given for three weeks before attempted conversion. In 45 of the 50 patients fibrillation was terminated, and maintenance treatment with quinidine 1-2 g. (gr. 20) daily was started. In 5 patients, all with predominant mitral incompetence, fibrillation persisted. Cardiac arrest and ventricular fibrillation were never seen; transient atrio- ventricular block or conduction delay was common. In 1 patient, not treated with anticoagulants, a splenic infarct developed. The period of follow-up is too short to assess the stability of sinus rhythm, but atrial fibrillation usually recurred in mitral incompetence despite quinidine. Oram et awl. have used this technique at King’s College Hospital, London, in 22 cases with successful conversion to sinus rhythm in 20. Atrial fibrillation has since recurred in 3 (the period of follow-up is not stated). Their patients showed an impressive increase of cardiac output, from a mean level of 2-49 litres per minute in 10 patients in atrial fibrillation to 3-75 litres per minute at five to sixteen days after reversion to sinus rhythm. The value of this technique will be assessed largely on the duration of sinus rhythm after conversion. It seems to be relatively safe and effective; but anticoagulant treat- ment should probably be given prophylactically, for the incidence of embolism at this time is about 5%. s 5. Oram, S., Davies, J. P. H., Weinbren, I., Taggart, P., Kitchen, L. D. Lancet, July 27, 1963, p. 159. 6. Wood, P. Diseases of the Heart and Circulation. London, 1956. THE LANCET: RISE OF PRICE FROM the beginning of next year subscribers to THE LANCET will be charged E4 4s. a year (post free), and single copies will cost 2s. This increase of price, which we had hoped to postpone, has become necessary because of further rises in the expense of production and in postage. Since the first world war, the price of our journal has been raised only twice-in 1920 and in 1955. The new rate will apply to all subscriptions renewable after our issue of Dec. 28, except that there will be no change in the charge to medical students (El lls. 6d.) and that half-rates (E2 2s.) will still be payable by doctors within two years of registration. We hope that overseas subscribers will again consider the advantages of an airmail subscription. Almost everywhere in the world, each week’s issue can now be read before the next is published; and, technically, there is no further need for the dis- tressing delays of a month or more before distant subscribers take part in urgent correspondence. Looking forward to the day when all readers and writers abroad will be on equal terms with those at home, we are maintaining the airmail subscriptions at their present uneconomic rates. For Canada, the United States, Australia, New Zealand, India, Pakistan, Malaya, China, Japan, South Africa, and some other parts of Africa, the inclusive annual charge is E10 10s., and for certain African countries (including Egypt, Ethiopia, Sudan, Libya, and Morocco) and the Middle East it is E8 8s.
Transcript of ROCKEFELLER PLANS
774
cheese makers whose carefully controlled fermentationsare brought to naught by a trace of penicillin. They can,no doubt, defend themselves.
ROCKEFELLER PLANS
ON its 50th birthday, earlier this year, the RockefellerFoundation was able to present a record of resourcefuland apposite munificence.1 For donations of money, aswell as of blood, matching is important, and the Rocke-feller trustees have always been at great pains to givediscerning support to fundamental needs. The successof their early campaigns for public health allowed thescope of their work to spread from the control of com-munity diseases to the control of other community haz-ards, and their concern for these is to continue. For thenext half century, which seems likely to offer both chal-lenge and change, the trustees wisely feel that they canoffer no detailed blueprint, but they have recognisedpriorities among current human needs. The first of theinternational projects they have selected-the conquest ofhunger and the related problem of population-are bothclosely associated with the Foundation’s medical work.Toward the conquest of hunger the trustees propose" to strengthen the Foundation’s programme on human
nutrition, and to support the search for new knowledgeleading to a better use of land and water resources, develop-ment of non-conventional agricultural techniques, andinvestigation of the changing environment in which welive ". The trustees believe " the grim, steady swellingin the size of the world’s population," to be of tremendoussignificance for all mankind, and they expect to expandsupport of critical research and action programmes in
population dynamics and population stabilisation.
CONVERSION OF ATRIAL FIBRILLATIONBY DIRECT-CURRENT SHOCK
CARDIAC output is reduced by atrial fibrillation, evenwhen the heart-rate is controlled by digitalis; and there isa constant risk of embolism, even in the absence of valvestenosis. Conversion to regular rhythm with quinidinehas been practised since 1918,2 but atrial fibrillation oftenrecurs. Standard practice has therefore been to attemptquinidine conversion only when some factor responsiblefor fibrillation has been removed: after thyroidectomy,after pregnancy, or when rheumatic fever or pneumoniahas precipitated the arrhythmia. A new method of con-version to regular rhythm, by a direct-current shock, isnow available. This has proved safe, quick, and morepleasant for the patient than quinidine; and a more
aggressive approach to atrial fibrillation may now be
justified.Lown et at. 3 4 developed this method of terminating
atrial fibrillation by a brief high-energy electric shockacross the intact chest under light anxsthesia. The dis-
charge was synchronised from the electrocardiograph to bedelivered at the end of the R wave; the risk of ventricularfibrillation from a shock in the short vulnerable period atthe apex of the T wave was thus avoided. 65 episodes ofatrial fibrillation in 50 patients were treated. All but 3 ofthe patients had mitral-valve disease; half had been infibrillation for more than a year, and one for seventeen
1. See Lancet, 1963, i, 873.2. Frey, W. Berl. klin. Wschr. 1918, 55, 417.3. Lown, B., Amarasingham, R., Neuman, J. J. Amer. med. Ass. 1962,
182, 548.4. Lown, B., Perlroth, M. G., Kaidbey, S., Abe, T., Harken, D. E. New
Engl. J. Med. 1963, 269, 325.
years. 38 were in heart-failure. Quinidine had been triedpreviously in 23 patients, with successful conversion inonly 4. To patients with mitral-valve disease, anticoagu-lants were given for three weeks before attemptedconversion.
In 45 of the 50 patients fibrillation was terminated, andmaintenance treatment with quinidine 1-2 g. (gr. 20) dailywas started. In 5 patients, all with predominant mitralincompetence, fibrillation persisted. Cardiac arrest andventricular fibrillation were never seen; transient atrio-ventricular block or conduction delay was common. In1 patient, not treated with anticoagulants, a splenic infarctdeveloped. The period of follow-up is too short to assessthe stability of sinus rhythm, but atrial fibrillation usuallyrecurred in mitral incompetence despite quinidine.Oram et awl. have used this technique at King’s College
Hospital, London, in 22 cases with successful conversionto sinus rhythm in 20. Atrial fibrillation has since recurredin 3 (the period of follow-up is not stated). Their patientsshowed an impressive increase of cardiac output, from amean level of 2-49 litres per minute in 10 patients in atrialfibrillation to 3-75 litres per minute at five to sixteen daysafter reversion to sinus rhythm.The value of this technique will be assessed largely on
the duration of sinus rhythm after conversion. It seems tobe relatively safe and effective; but anticoagulant treat-ment should probably be given prophylactically, for theincidence of embolism at this time is about 5%. s
5. Oram, S., Davies, J. P. H., Weinbren, I., Taggart, P., Kitchen, L. D.Lancet, July 27, 1963, p. 159.
6. Wood, P. Diseases of the Heart and Circulation. London, 1956.
THE LANCET: RISE OF PRICE
FROM the beginning of next year subscribers toTHE LANCET will be charged E4 4s. a year (post free),and single copies will cost 2s. This increase of price,which we had hoped to postpone, has become
necessary because of further rises in the expense of
production and in postage. Since the first world
war, the price of our journal has been raised onlytwice-in 1920 and in 1955.The new rate will apply to all subscriptions
renewable after our issue of Dec. 28, except thatthere will be no change in the charge to medicalstudents (El lls. 6d.) and that half-rates (E2 2s.)will still be payable by doctors within two years ofregistration.We hope that overseas subscribers will again
consider the advantages of an airmail subscription.Almost everywhere in the world, each week’s issuecan now be read before the next is published; and,technically, there is no further need for the dis-
tressing delays of a month or more before distantsubscribers take part in urgent correspondence.Looking forward to the day when all readers andwriters abroad will be on equal terms with those athome, we are maintaining the airmail subscriptionsat their present uneconomic rates. For Canada, theUnited States, Australia, New Zealand, India,Pakistan, Malaya, China, Japan, South Africa, andsome other parts of Africa, the inclusive annualcharge is E10 10s., and for certain African countries(including Egypt, Ethiopia, Sudan, Libya, and
Morocco) and the Middle East it is E8 8s.
