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DETECTION OF GALLOP RHYTHM
545 .7th
day
there
was
severe
generalised cedema, heavy
blood-urea level of 200 mg. per 100 ml. Cortisone was at once discontinued ; but from this time until his death 6 weeks later he remained very ill, with persistent oedema and a blood-urea level varying between 250 and 300 mg. per 100 ml. The daily urinary output did not fall below 1200 ml., and the blood-pressure did not rise. It is interesting to note that the arthritis, which had not responded well to cortisone, improved markedly during this stage of cedema and uraemia.
albuminuria, and
a
Dr. Skelton has described the post-mortem findings of extensive amyloid disease, from which it is clear that the renal involvement must have been of long standing. While it cannot, of course, be stated with absolute certainty that cortisone was the cause of the exacerbation, the association of events is too close and direct to ignore. Although Thorn and his colleagues1 reported no similar experience when cortisone and of A.C.T.H. were deliberately administered to cases nephritis and nephrosis, we regard it as questionable whether cortisone can ever safely be given when chronic renal disease is known, or to he present. GEOFFREY E. LOXTON London, W.I. DAVID LE VAY.
suspected,
DETECTION OF GALLOP RHYTHM
SIR,—We would like to present a finding which we have often found helpful in clinical examination. We have noticed that gallop rhythm, whether presystolic or protodiastolic, is markedly suppressed if the patient undergoes Valsalva’s test-i.e., forcibly expiring against a closed glottis. On the other hand, if the patient undergoes Mueller’s test-i.e., forcibly inspiring against a closed glottis-the gallop rhythm is usually greatly augmented. Mueller’s manoeuvre greatly augments the venous return, whereas Valsalva’s diminishes it. Since gallop rhythm is intimately related to the venous return the augmenting effect of Mueller’s test, and the suppressive effect of Valsalva’s, on the gallop rhythm are easy to understand. We have found that Mueller’s test augments the gallop rhythm in most cases. In some patients whose gallop rhythm has disappeared under treatment, we have demonstrated its presence by Mueller’s test though it could no longer be heard during quiet breathing. In some cases of hypertension with an enlarged heart a gallop rhythm could only be heard by Mueller’s test.
accompanying figure shows a phonocardiographic tracing in a patient, aged 50 years, who had a moderate degree of heart-failure. Gallop rhythm could be heard faintly and was registered over the apex during quiet breathing. This completely disappeared during Valsalva’s manoeuvre and was much augmented by The
Mueller’s test. Mueller’s test
provides a means by which faint gallop be augmented, or can be revealed in cases where it cannot be heard by auscultation during quiet hreathins’.
rhythm
can
Postgraduate Medical Section, Fuad I University Hospital, Cairo.
ANWAR EL MOFTY AHMED A. ISMAIL.
THE EXPERT IN COURT
SIR,—Your leader of Sept. 15, setting out the merits of " French legal procedure " at which the expert medical evidence is given by a witness. " who owes his appointment to the judge " makes no distinction between the various French (or English) courts-and contains one reflection on the integrity of the expert witness that will not lie easily. Civil litigation, it is true, occasionally admits the sorry spectacle of contentious medical argument, but this is no longer true of the doctors’ appearances in other
English courts-coroners’, magistrates’, sessions, or assize. These are courts in which the expert medical evidence is directed, without bias or partisanship, to the prosecution of only one thing-the truth of the matter, or as near it as the facts and honest opinion can attain. It is a pleasure to attest to the fair-mindedness of both bench and bar in this endeavour. There is no sense of being concerned with prosecution or defence ;= indeed, the doctors’ services and opinion have usually been given-and irrevocably committed-before proceedings of any kind commenced. To say that " the party which has brought in an expert, has taken a preliminary statement from him, and has undertaken to pay his fee, will expect him to support, or at least favourably represent, its contentions " is a regrettable misrepresentation of expert medical opinion at Courts of Inquisition or of Criminal Law. Admiralty and Probate, Bankruptcy and Ecclesiastical Courts are not, happily, fields for medicine
or
science. KEITH SIMPSON.
Guy’s Hospital, London.
A TRAGIC PARADOX 1. Thorn, W., Merrill, J. P., Smith, S., Roche, M., Frawley, T. F. Arch. intern. Med. 1950, 86, 319.
SIR,—It is unfortunately
true
that the
classics,
Dr. O’Brien cites last week, are no any rate in their traditional forms, for the education of the medical man. It is still more obviously true (and one says it with the weary and hopeless insistence of a defendant in a political trial) that study of the natural sciences is not educative at all. The collation of information and familiarity with a methodology of severely limited usefulness cannot ever teach a man to think, to discriminate, to know what is good, even as well as the triad that Dr. O’Brien desires to emulate. Neither he nor I nor another can look with any hope for a better system of education until we have seen our own contemporary standards for what they are, and then persuaded ourselves and the rest that utility however well-intentioned, and reflexes however thoroughly conditioned, are not an adequate basis for human relations. Still less can they instil a purpose into human efforts. Or has Dr. O’Brien’s biology really persuaded him that ? men and mice have no essential difference Boxmoor, Herts. R. H. HARDY.
history,
or
modern
languages," which longer adequate, at
,
SIR,—Dr. O’Brien, in his letter last week, misconstrues what I said (Sept. 1). It seems to me, however, that we both arrive at the same conclusion-that the 1st M.B.
day
there
was
severe
generalised cedema, heavy
blood-urea level of 200 mg. per 100 ml. Cortisone was at once discontinued ; but from this time until his death 6 weeks later he remained very ill, with persistent oedema and a blood-urea level varying between 250 and 300 mg. per 100 ml. The daily urinary output did not fall below 1200 ml., and the blood-pressure did not rise. It is interesting to note that the arthritis, which had not responded well to cortisone, improved markedly during this stage of cedema and uraemia.
albuminuria, and
a
Dr. Skelton has described the post-mortem findings of extensive amyloid disease, from which it is clear that the renal involvement must have been of long standing. While it cannot, of course, be stated with absolute certainty that cortisone was the cause of the exacerbation, the association of events is too close and direct to ignore. Although Thorn and his colleagues1 reported no similar experience when cortisone and of A.C.T.H. were deliberately administered to cases nephritis and nephrosis, we regard it as questionable whether cortisone can ever safely be given when chronic renal disease is known, or to he present. GEOFFREY E. LOXTON London, W.I. DAVID LE VAY.
suspected,
DETECTION OF GALLOP RHYTHM
SIR,—We would like to present a finding which we have often found helpful in clinical examination. We have noticed that gallop rhythm, whether presystolic or protodiastolic, is markedly suppressed if the patient undergoes Valsalva’s test-i.e., forcibly expiring against a closed glottis. On the other hand, if the patient undergoes Mueller’s test-i.e., forcibly inspiring against a closed glottis-the gallop rhythm is usually greatly augmented. Mueller’s manoeuvre greatly augments the venous return, whereas Valsalva’s diminishes it. Since gallop rhythm is intimately related to the venous return the augmenting effect of Mueller’s test, and the suppressive effect of Valsalva’s, on the gallop rhythm are easy to understand. We have found that Mueller’s test augments the gallop rhythm in most cases. In some patients whose gallop rhythm has disappeared under treatment, we have demonstrated its presence by Mueller’s test though it could no longer be heard during quiet breathing. In some cases of hypertension with an enlarged heart a gallop rhythm could only be heard by Mueller’s test.
accompanying figure shows a phonocardiographic tracing in a patient, aged 50 years, who had a moderate degree of heart-failure. Gallop rhythm could be heard faintly and was registered over the apex during quiet breathing. This completely disappeared during Valsalva’s manoeuvre and was much augmented by The
Mueller’s test. Mueller’s test
provides a means by which faint gallop be augmented, or can be revealed in cases where it cannot be heard by auscultation during quiet hreathins’.
rhythm
can
Postgraduate Medical Section, Fuad I University Hospital, Cairo.
ANWAR EL MOFTY AHMED A. ISMAIL.
THE EXPERT IN COURT
SIR,—Your leader of Sept. 15, setting out the merits of " French legal procedure " at which the expert medical evidence is given by a witness. " who owes his appointment to the judge " makes no distinction between the various French (or English) courts-and contains one reflection on the integrity of the expert witness that will not lie easily. Civil litigation, it is true, occasionally admits the sorry spectacle of contentious medical argument, but this is no longer true of the doctors’ appearances in other
English courts-coroners’, magistrates’, sessions, or assize. These are courts in which the expert medical evidence is directed, without bias or partisanship, to the prosecution of only one thing-the truth of the matter, or as near it as the facts and honest opinion can attain. It is a pleasure to attest to the fair-mindedness of both bench and bar in this endeavour. There is no sense of being concerned with prosecution or defence ;= indeed, the doctors’ services and opinion have usually been given-and irrevocably committed-before proceedings of any kind commenced. To say that " the party which has brought in an expert, has taken a preliminary statement from him, and has undertaken to pay his fee, will expect him to support, or at least favourably represent, its contentions " is a regrettable misrepresentation of expert medical opinion at Courts of Inquisition or of Criminal Law. Admiralty and Probate, Bankruptcy and Ecclesiastical Courts are not, happily, fields for medicine
or
science. KEITH SIMPSON.
Guy’s Hospital, London.
A TRAGIC PARADOX 1. Thorn, W., Merrill, J. P., Smith, S., Roche, M., Frawley, T. F. Arch. intern. Med. 1950, 86, 319.
SIR,—It is unfortunately
true
that the
classics,
Dr. O’Brien cites last week, are no any rate in their traditional forms, for the education of the medical man. It is still more obviously true (and one says it with the weary and hopeless insistence of a defendant in a political trial) that study of the natural sciences is not educative at all. The collation of information and familiarity with a methodology of severely limited usefulness cannot ever teach a man to think, to discriminate, to know what is good, even as well as the triad that Dr. O’Brien desires to emulate. Neither he nor I nor another can look with any hope for a better system of education until we have seen our own contemporary standards for what they are, and then persuaded ourselves and the rest that utility however well-intentioned, and reflexes however thoroughly conditioned, are not an adequate basis for human relations. Still less can they instil a purpose into human efforts. Or has Dr. O’Brien’s biology really persuaded him that ? men and mice have no essential difference Boxmoor, Herts. R. H. HARDY.
history,
or
modern
languages," which longer adequate, at
,
SIR,—Dr. O’Brien, in his letter last week, misconstrues what I said (Sept. 1). It seems to me, however, that we both arrive at the same conclusion-that the 1st M.B.