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PRESYSTOLIC MURMUR AFTER CORONARY OCCLUSION
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interchanged at the will of the experimenter and without the knowledge of the subject. The results of the experiments are stated to have been invariablenamely, that there was no change in the inspiratory pressure when one fire was substituted for the other. This was confirmed by statistical analysis of the A comparison of inspiratory pressures recorded. pressures before and during exposure to various sources of radiant heat led to the conclusion that dull and bright sources acted equally as "noseclosers " ;even sunlight had this effect. Moreover, it is stated that a sudden warming of the air of the room (by other than radiant heat) produced noseclosing in a partially stripped subject, as did the application of a fomentation to the arm. Immediate relief was obtained in all cases by the screening or removal of the source of heat. Temporary relief was afforded by sponging any part of the body, whether exposed to the heat or not, with, cold water. No relief was given by any source of incandescent heat or light, nor by placing a trough of water in front of a dull source. Dufton and Bedford thus differ from Sir Leonard Hill, not only on the effects of various forms of infra-red radiation, but also on the measures necessary to neutralise them. It is quite possible, as Hill points out, that infra-red rays of different wave-lengths may have different physiological actions, but the purely objective experiments of Dufton and Bedford seem to show that the nasal mucosa is not a satisfactory index of these, if they exist at all. There can be no doubt about the importance of excluding the possibility of suggestion in investigating any reflexes involving the nose ; to a person suffering from hay-fever the mere mention of his complaint is often enough to start the eyes and nose streaming,
during an otherwise quiescent interval. The reflex curtailment of the nasal blood-supply on chilling any part of the skin is already well known, and has been invoked to explain many common infections. The observations just recorded seem to show that the the authors are careful to converse is also true ; that such nasal out point congestion as is produced is unlikely to be attended with discomfort on the part of a normal person, especially if the. rise of temperature is slow. THE WARNING SIGNS OF ECLAMPSIA
ONE of the advantages of the antenatal clinic is that it provides excellent opportunities for studying the clinical manifestations of the pre-eclamptic toxaemia of pregnancy in its earliest stages. The three cardinal signs of this particular "toxaemia," when fully developed, are cedema, albuminuria, and hypertension. Apart from the generally recognised fact that oedema not infrequently precedes albuminuria, little is known about the order of appearance of the three signs or about their relationship to one another. A paper by Prof. F. J. Browne1 provides useful information on these matters. In order to detect the earliest signs of abnormality Prof. Browne has been compelled to adopt strict criteria. He has accepted, for instance, a rise in blood pressure of a few millimetres above the normal limit of 130/70 as evidence of hypertension. This explains the high incidence of pre-eclamptic toxsemia in his clinic at University College Hospital-320 His results cases in a series of 1674 pregnancies. tend to show that in different cases the three signs may appear and disappear independently of one another, and only occasionally bear close comparison. 1 Jour. Obst. and Gyn. Brit. Emp.,
December, 1933, p. 1160.
None of the signs can therefore be regarded as a consequence of either of the others and, whatever the cause of the condition may be, it is evidently capable of eliciting each sign separately. In some patients oedema appears first, in others albuminuria, and in a considerable number hypertension. What then is the best single criterion of early toxaemia ? Clearly not oedema, for much water must be retained before pitting can be demonstrated. Albuminuria is equally deceptive, for it may be the last sign to appear. Browne concludes that the routine estima. tion of blood pressure is, on the whole, the most sensitive test. It is refreshing to read that he resists the temptation to conclude that the fall in hypertension which occurred in many cases was due to advice received at the clinic. Many and diverse remedies are employed in treating pre-eclamptic toxaemia-for instance, alkalis, calcium preparations, low proteins diets, salt-poor diets, fluids in excess, and fluid restriction. Some of them are used empirically ; the use of others is based on hypotheses. The advocates of all are apt to forget that rest in bed will often work wonders. PRESYSTOLIC MURMUR AFTER CORONARY OCCLUSION THE occurrence of a transient diastolic murmur in two patients recovering from coronary occlusion is reported by Wolferth, Wood, and Margolies.1 These murmurs became audible at the tricuspid area-that is, to the right of the lower part of the sternum-about a fortnight after the onset of the attack, and were situated in the presystolic portion of the cardiac cycle. In one case the time relations of the murmur were so altered with the occurrence of partial heart-block and paroxysms of auricular fibrillation, as to make it certain that the murmur In quality it was was related to auricular systole. unusual, being high pitched and blowing, and thus contrasting with the murmurs of mitral and tricuspid stenosis. Electrocardiograms in both cases suggested that the infarct involved the anterior wall of the left ventricle. The mechanism of production of the murmur is not clear, and the authors of the paper can only suggest possibilities, such as cedema of the tissues near the tricuspid valve, thinning and bulging of the septum into the right ventricle, and a thrombus placed so as to interfere with the opening of the tricuspid valve. As both the patients recovered, no pathological evidence was obtained. However, Wolferth and his colleagues report having seen bulging and thinning of the anterior part of the intraventricular septum in many specimens with infarction of the anterior wall of the left ventricle, but never thrombi under the tricuspid leaflets with infarction in this area. THE PREVENTIVE ASPECTS OF MEDICINE
WE have been compelled to hold over until next week the next lecture in this series. The series will be continued until the holiday break occurs, after which publication will be resumed. WE regret to announce the death on Monday last of Sir William Whitla, doyen of the medical profession in Ulster and a world-wide authority on materia medica. Sir William, who was in his 83rd year, was hon. physician to the King in Ireland and pro-vicechancellor of Queen’s University, Belfast, which he represented in the British Parliament from 1918 to 1923. 1 Wolferth, C. C., Wood, F. C., and Margolies, A.: Amer. Jour. Med. Sci., October, 1933, p. 496.
interchanged at the will of the experimenter and without the knowledge of the subject. The results of the experiments are stated to have been invariablenamely, that there was no change in the inspiratory pressure when one fire was substituted for the other. This was confirmed by statistical analysis of the A comparison of inspiratory pressures recorded. pressures before and during exposure to various sources of radiant heat led to the conclusion that dull and bright sources acted equally as "noseclosers " ;even sunlight had this effect. Moreover, it is stated that a sudden warming of the air of the room (by other than radiant heat) produced noseclosing in a partially stripped subject, as did the application of a fomentation to the arm. Immediate relief was obtained in all cases by the screening or removal of the source of heat. Temporary relief was afforded by sponging any part of the body, whether exposed to the heat or not, with, cold water. No relief was given by any source of incandescent heat or light, nor by placing a trough of water in front of a dull source. Dufton and Bedford thus differ from Sir Leonard Hill, not only on the effects of various forms of infra-red radiation, but also on the measures necessary to neutralise them. It is quite possible, as Hill points out, that infra-red rays of different wave-lengths may have different physiological actions, but the purely objective experiments of Dufton and Bedford seem to show that the nasal mucosa is not a satisfactory index of these, if they exist at all. There can be no doubt about the importance of excluding the possibility of suggestion in investigating any reflexes involving the nose ; to a person suffering from hay-fever the mere mention of his complaint is often enough to start the eyes and nose streaming,
during an otherwise quiescent interval. The reflex curtailment of the nasal blood-supply on chilling any part of the skin is already well known, and has been invoked to explain many common infections. The observations just recorded seem to show that the the authors are careful to converse is also true ; that such nasal out point congestion as is produced is unlikely to be attended with discomfort on the part of a normal person, especially if the. rise of temperature is slow. THE WARNING SIGNS OF ECLAMPSIA
ONE of the advantages of the antenatal clinic is that it provides excellent opportunities for studying the clinical manifestations of the pre-eclamptic toxaemia of pregnancy in its earliest stages. The three cardinal signs of this particular "toxaemia," when fully developed, are cedema, albuminuria, and hypertension. Apart from the generally recognised fact that oedema not infrequently precedes albuminuria, little is known about the order of appearance of the three signs or about their relationship to one another. A paper by Prof. F. J. Browne1 provides useful information on these matters. In order to detect the earliest signs of abnormality Prof. Browne has been compelled to adopt strict criteria. He has accepted, for instance, a rise in blood pressure of a few millimetres above the normal limit of 130/70 as evidence of hypertension. This explains the high incidence of pre-eclamptic toxsemia in his clinic at University College Hospital-320 His results cases in a series of 1674 pregnancies. tend to show that in different cases the three signs may appear and disappear independently of one another, and only occasionally bear close comparison. 1 Jour. Obst. and Gyn. Brit. Emp.,
December, 1933, p. 1160.
None of the signs can therefore be regarded as a consequence of either of the others and, whatever the cause of the condition may be, it is evidently capable of eliciting each sign separately. In some patients oedema appears first, in others albuminuria, and in a considerable number hypertension. What then is the best single criterion of early toxaemia ? Clearly not oedema, for much water must be retained before pitting can be demonstrated. Albuminuria is equally deceptive, for it may be the last sign to appear. Browne concludes that the routine estima. tion of blood pressure is, on the whole, the most sensitive test. It is refreshing to read that he resists the temptation to conclude that the fall in hypertension which occurred in many cases was due to advice received at the clinic. Many and diverse remedies are employed in treating pre-eclamptic toxaemia-for instance, alkalis, calcium preparations, low proteins diets, salt-poor diets, fluids in excess, and fluid restriction. Some of them are used empirically ; the use of others is based on hypotheses. The advocates of all are apt to forget that rest in bed will often work wonders. PRESYSTOLIC MURMUR AFTER CORONARY OCCLUSION THE occurrence of a transient diastolic murmur in two patients recovering from coronary occlusion is reported by Wolferth, Wood, and Margolies.1 These murmurs became audible at the tricuspid area-that is, to the right of the lower part of the sternum-about a fortnight after the onset of the attack, and were situated in the presystolic portion of the cardiac cycle. In one case the time relations of the murmur were so altered with the occurrence of partial heart-block and paroxysms of auricular fibrillation, as to make it certain that the murmur In quality it was was related to auricular systole. unusual, being high pitched and blowing, and thus contrasting with the murmurs of mitral and tricuspid stenosis. Electrocardiograms in both cases suggested that the infarct involved the anterior wall of the left ventricle. The mechanism of production of the murmur is not clear, and the authors of the paper can only suggest possibilities, such as cedema of the tissues near the tricuspid valve, thinning and bulging of the septum into the right ventricle, and a thrombus placed so as to interfere with the opening of the tricuspid valve. As both the patients recovered, no pathological evidence was obtained. However, Wolferth and his colleagues report having seen bulging and thinning of the anterior part of the intraventricular septum in many specimens with infarction of the anterior wall of the left ventricle, but never thrombi under the tricuspid leaflets with infarction in this area. THE PREVENTIVE ASPECTS OF MEDICINE
WE have been compelled to hold over until next week the next lecture in this series. The series will be continued until the holiday break occurs, after which publication will be resumed. WE regret to announce the death on Monday last of Sir William Whitla, doyen of the medical profession in Ulster and a world-wide authority on materia medica. Sir William, who was in his 83rd year, was hon. physician to the King in Ireland and pro-vicechancellor of Queen’s University, Belfast, which he represented in the British Parliament from 1918 to 1923. 1 Wolferth, C. C., Wood, F. C., and Margolies, A.: Amer. Jour. Med. Sci., October, 1933, p. 496.