A S S E S S M E N T F O R V A L V O T O M Y 31

t h a t on ly the advanced cases, wi th a low cardiac ou tpu t , were admi t ted in years gone by. We still teach the mi t ra l facies to s tudents , bu t they should also 1se told about t he opening snap and o ther significant s i g n s

As regards the resu l t s of operatiort we cannot give an exact account of each pa t i en t ' s p rogress as we have no t yet conducted a complete follow-up. Six dea ths have occurred a m o n g s t these 38 pat ients , of w h o m 4 were a m o n g s t the first 6 operated on. Three died f rom pos topera t ive embol i sm. Two died suddenly after opera t ion and cne f rem p u l m o n a r y insufficiency two years af ter operat ion.

Opera t ion dur ing p regnancy should be given greater considerat ion in the fu tu r e : by th is means we m a y get a lowering of ma te rna l and foetal m o r t a l i t y on the one hand and a reduct ion of the a m o u n t of disabi l i ty and illvalidism on the other .

No pa t i en t was opera ted on under 19 years of age, b u t we would no t hesi ta te to opera te on th is young age-group if indicat ions were s t rong enough. We have no t been presen ted wi th such a p rob lem so far. q~he pa t i en t s wi th bronehiectasis were rejected on account of the p u l m o n a r y changes. We have no t done such eases because we had more su i table pa t i en t s on the wai t ing list . We have no t been t roubled b y the recrud- escence of active cardit is af ter operat ion. We have, however two patien%s, b o t h of w h o m after successful opera t ion are st i l l in hear t failure and require very large dosage of digitalis. This unsa t i s fac to ry s ta te is due to t r icuspid incompetence in one pa t i en t ; there is no evidence of a t r icuspid lesion in the o ther : our present tenta t ive conclusion is t h a t he has smoulder ing carditis.

The in tens i ty of the mid-diastol ic and presystol ic m u r m u r s was referred to. A very loud presystol ic m u r m u r indicates s t rong left a tr ial ac t iv i ty and it can p robab ly also be t aken as s t rong evidence of a t ight mi t r a l valve. However , there are so m a n y factors which affect the in tens i ty of these m u r m u r s t h a t no direct conclusion about the valve can be reached f rom auscul ta t ion . I t is p robab ly t rue t h a t a pa t ien t wi th a loud presystol ic m u r m u r , b y vir tue of the s t rong left a t r ium and of the na r row valve present , is more prone to p u l m o n a r y oedema t h a n m o s t pat ients . A loud clear first hear t sound is very reassur ing and is p robab ly a phenomenon associated wi th a type of valve which causes the opening snap. I t suggests a very mobi le valve. I t also suggests high left a t r ia l pressure push ing the valve deep down in the ventricle. Levine has shown tha t the deeper the valve at the begi lming of vent r icu la r systole, the louder the first sound. Ano the r factor ill- causing the loud sound m a y be the tent- l ike shape of the valve. These three fea tures are found in pure mi t r a l stenosis and hence the impor tance of a clear loud first sound in assessing pa t i en t s for operat ion. The p u h n o n a r y second sound is f r equen t ly accentuated in mi t r a l disease, b u t the in tens i ty of th is sound is affected b y so m a n y different factors t ha t the in te rp re ta t ion of i ts qua l i ty is of little value in helping us to select pa t ients .

BOOKS R E C E I V E D .

DUKE ELD~'R, SIR S. (Parsons') Diseases of the Eye. Churchill 12th Ed. 42/-. BO~,'ERS, V~ r. F. Surgery of Trauma. Lippincot t . £6 0s. 0d. JARAMILLO-ARANGA, J. The British Contribution to Medicine. Livingstone. 25/-. MYLES, M . F . Textboot: for Midwives. Livingstone. 42/-. GARDNER, A . D . Bacteriology for Students and Practitioners. Cumber lege , Oxford.

4 th Ed. 12/6. [~HLENHUTH, S. Anatomy of the Pelvis. Lippineot t . 84/-. LYLE and WALKER. Practical Ortlmptics in the Treatment of ST~int. Lewis. 63/-. SOl~HI)~I~, J . ToxcEmias of Pregnancy. But te rwor th . 25/-. PRATT and DUFENOY. Antibiotics. Lippincot t . 2rid Ed. 60/-. McBRIDE, E. D. Disability Evaluation. Lippincot t . 5th Ed. £6 0s. 0d. LEE, J . A. Synopsis of Anwsthesia. Wright . 3rd Ed. 21/-. VY'OLSTENHOLME, G. Eo ~ r Mammalian Germ Ceils. (Ciba Founda t ion Sympos ium) .

Churchill. 30/-.

Corrigendu~.

T R E A T M E N T OF P U L M O N A R Y T U B E R C U L O S I S (C. S. BREATHh~ACH).

By oversight , due to has ty proof-reading, in the November 1953 issue, p. 437, line 17, an erroneous s t a t e m e n t of dosage of isoniazid (600 mgm. per kg. in five doses daily) was allowed to pass uncorrected. The dosage used was 300 mgm. per ki logram body- weight .