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means that contacting a doctor in the afternoon and evening can bedifficult. Telyukov attributed the low salaries and poor workingconditions of doctors to government attitudes about female

employment, two-thirds of doctors being women.The effectiveness of the crumbling Soviet health system is

reflected in simple statistics. Life expectancy is 69-5 years (USA749), all-cause death rate 1010 per 100 000 (USA 872), maternalmortality rate 47-7 per 100 000 (USA 6- 1), and infant mortality rate24-7 (USA 9-9).Reform is clearly essential, and the Soviet Goverment has

suggested cosmetic changes, such as abolishing health boards. Amore radical experiment has been undertaken in Leningrad.American-style diagnostic-related groups were defmed and, on thebasis of past sentce needs, polyclinics were reimbursed in advancefor their projected clinical requirements. A financial audit took placeat the end of one year, and if the health status of the local populationhad improved-eg, maternal and infant mortality rates had fallen,and the budget had not been exceeded-these polyclinics receivedbonuses. Improvements were reported, but the programme has hadonly limited success because of lack of investment in community-care facilities. These financial difficulties seem unlikely to be solvedwhile the general economy remains in collapse. Competition foravailable resources has caused health to be marginalised as an issue.The debate over health may be further submerged as theGovernment seeks western aid for the country’s ailing industrialand agricultural base.

Nevertheless, the Soviet Union as a whole, and the RussianFederation in particular, are planning to decentralise health-serviceadministration, increase funding, and improve the status of thehealth professions. The precise balance between comprehensivehealth-care coverage and a market-led health service remains to beworked out. Since 45% of the population are outside the labourforce, a simple workplace-based scheme of health insurance wouldbe difficult to implement. Resolution of the Soviet health-care crisisdoes not seem to be an immediate prospect.

The Austin Flint shudder

nrst reported by the US physician Austin runt in 1862, thenature of his eponymous murmur has been a source of vigorousdebate for over a century. The first challenge for any physician is tohear this mid-diastolic rumble that often has a further presystoliccomponent. Best heard at the cardiac apex, the murmur isassociated with aortic incompetence, although not every patientwith an incompetent valve will have an audible Austin Flint sound.The mechanism by which this murmur is generated is obscure.Flint described his "blubbering murmur" as arising from thevibration of the mitral leaflets during atrial contraction. He

suggested that these vibrations were generated by blood beingforced through the mitral valve while the leaflets were stronglyapposed because of left ventricular distension. Others had variouslyascribed the murmur to functional mitral stenosis as a result of aorticbackflow on to the anterior leaflet of the mitral valve, anterior leafletvibration, direct impact of the transmitral jet with the aorticregurgitant jet, or mitral incompetence.Rahko has applied doppler echocardiography to investigate the

origins of the Austin Flint murmur.1 He divided patients with aorticincompetence into those with an audible Austin Flint sound andthose without. In patients with the mid-diastolic murmur, the aorticjet tended to be directed at the mitral valve and was associated with agreater frequency of anterior mitral leaflet distortion together withdoppler striations over the aortic jet. The left ventricular end-diastolic dimension was significantly greater in those with theAustin Flint murmur. Rahko concluded that the main cause of themid-diastolic rumble is a jet of blood directed through the aorticvalve at the anterior mitral leaflet. This jet causes the leaflet toshudder, and the vibrations and shock waves that result probablyaccount for the sound of the murmur.

1. Rahko PS. Doppler and echocardiographic characteristics of patients having an AustinFlint murmur. Circulation 1991; 83: 1940-50.

The gift of life

"In spite of the triple coat of mail, with which the surgeon must oftenencase his heart, in order to accomplish his task successfully, he is,nevertheless, a man, a human being, and as such he is unavoidably andmost painfully affected by suffering and death ..."

Rudolph Matas

These words, written by an American surgeon, encapsulate theopposing facets of the surgeon-the cold and remote versus thecompassionate and understanding. Organ transplantation carries anespecially heavy burden. The stresses of such responsibility must bedifficult to ease, but Sir Roy Calne has found a way: he paints. Healso enjoys painting. Calne has recently said, "Most transplants areperformed with organs taken from recently dead patients; there istherefore in every case an associated tragedy to permit life for therecipient. The faces of the bereaved relatives who have generouslygiven permission for organ removal from their loved ones arepowerful images ... I think the necessary tragedy to rescue a dyingpatient is a distressing concept for all transplant surgeons." Thesentiment expressed in these words is vividly shown in hispaintings, which depict various aspects of his work on livertransplantation, patients, and colleagues-from surgery in progressto patient care.

His portraits are his most powerful and poignant pieces. Forexample, the oil Boy After a Liver Transplant 1989 (figure) wasCalne’s personal tribute to a young man who showed enormousfortitude in the face of extreme adversity and illustrates the intimacyof the unique patient-surgeon relationship. He does not spare theonlooker the stark reality of despair, vulnerability, or sadness, butthere is also courage, determination, and hope. Nor does he leavemuch to the imagination: tubes, drips, drainage bags, the bloodinessof surgical procedures, and other accoutrements of hospital life arenot for the squeamish. The greater freedom of expression seen in hislater work is down to the influence of a former patient, the artistJohn Bellany, who encouraged Calne to use brighter colours and alarger format and to paint in oil as well as watercolour. Calne’s workof the past four years can now be seen at an exhibition, The Gift ofLife-one of the many events in the UK to mark National

Transplant Week (July 21-28). The exhibition also includes someof Calne’s more conventional representations of his flowerpiece andlandscape watercolours.The inescapable aura from this emotive display is the realisation

that life is the most precious gift that a person can bestow on a fellowhuman being. Calne sums it up well when he says, "... most of thepatients requiring such drastic surgery are exceedingly ill and havealready suffered greatly and have realized the hopelessness of theirprognosis unless they have a major painful operation which involvesconsiderable risk. I have always been amazed at their courage andthe faces of many patients are deeply etched on my memory".

Perhaps more doctors should paint.The exhibition is being held at the Barbican Centre, London (July 24-Aug

11) and is accompanied by a fully illustrated catalogue ([8.50). Proceeds fromthe sale of catalogues and paintings will be donated to the University ofCambridge Children’s Liver Fund.