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service, both for those being delivered at home and forthose having their babies in hospital. Many of SHEEHAN’Sdata are derived from a time when maternal mortalitywas higher than it is now, and before the organisation ofdomiciliary transfusion for maternity cases based on ourregional blood-transfusion centres was established.

Nevertheless, since early and sufficient blood-transfusionis now readily at hand not only to save lives from traumabut also to prevent the onset of acute renal failure, canwe not hope to reduce further the number of pituitarycripples by a transfusion service whose first aim is tosave maternal life ?

Tricuspid StenosisABNORMALITIES of the tricuspid valve, though much

less common than those of other heart valves, are by nomeans rare, and yet they often pass unnoticed. Most

physicians are now familiar with the functional regurgi-tation of heart-failure (and EBSTEIN’s anomaly has latelyreceived rather more than its fair share of attention), buttricuspid stenosis remains a relatively neglected valvularlesion. Although stenosis may be congenital, andoccasionally it is found in association with carcinoid,2 2

fibroelastosis,3 systemic lupus erythematosus,4 and

endomyocardial fibrosis,5 the great majority of cases arerheumatic, and one of the main reasons why tricuspidstenosis so often escapes detection is that it seldomarises alone. As part of a wider rheumatic process, its

signs are either masked or overshadowed by those ofother lesions, and its hxmodynamic significance oftenbecomes apparent only after the surgical treatment ofmitral 6 or aortic stenosis,7 when patients fail to improveafter a technically successful valvotomy. The tricuspidvalve should therefore be carefully assessed as part ofroutine preoperative examination in all cases of rheu-matic heart-disease, so that unsuspected obstruction onthe right side of the heart will not continue to limitcardiac output after the relief of obstruction on the left.

By asking a series of well-chosen questions designedto test the validity of the accepted clinical, electro-

cardiographic, radiological, and hxmodynamic featuresof severe tricuspid stenosis, KITCHIN and TURNER inEdinburgh emphasised many points that need clarifica-tion. Setting out to establish reliable criteria for thediagnosis, they studied 17 patients who required tri-cuspid valvotomy in a series of 550 consecutive patientswho had valvotomies for mitral stenosis; and they com-pared them with a further 5 who were found to havedominant incompetence when the tricuspid valve wasexplored. Their figure of 3-1% of surgically significanttricuspid stenosis in this group is similar to the 3-3%found clinically in mitral stenosis by WooD.9 In aconsecutive series of 100 necropsies in KITCHIN andTURNER’S hospital on patients who died with rheumaticheart-disease during the same period as the clinical1. Paul, M. H., Lev, M. Circulation, 1960, 22, 198.2. Millman, S. Am. Heart J. 1943, 25, 391.3. Dennis, J. L., Hansen, A. E., Corpening, T. N. Pediatrics, 1953, 12, 130.4. Gibson, R., Wood, P. Br. Heart J. 1955, 17, 552.5. Davies, J. N. P., Ball, J. D. ibid. p. 337.6. Pantridge, J. F., Marshall, R. J. Lancet, 1957, i, 1319.7. Watson, H., Lowe, K. G. Br. Heart J. 1962, 24, 241.8. Kitchin, A., Turner, R. ibid. 1964, 26, 354.9. Wood, P. Br. med.J. 1954, i, 1113.

study, 14% were recorded as having tricuspid stenosis.These figures reflect the difference between the patho-logist’s yardstick of " three fingers " (or, to be more

‘

precise, a valve orifice of less than 7 sq. cm.) and the1-1-5 sq. cm. orifice found by the surgeon. Morbidanatomists have always reported a much higher incidenceof tricuspid stenosis than clinicians, and, even whenrheumatic heart-disease was much more virulent than itis today, they found it in between 20% and 40% ofcases at a time when COOMBS 10 estimated its clinicalincidence at 14%. The importance of these surgicallyproved findings is that only relatively severe tricuspidstenosis seems to be haemodynamically significant-which agrees with WHITE’S view

11 that the lesion couldbe recognised only if the diameter of the valve was lessthan 2-5 cm.The signs that should raise suspicion of tricuspid

stenosis were clearly set out in 1955 by GIBSON andWOOD who were able to make the correct diagnosis in12 of their 15 patients at the bedside. A large flickinga wave in the jugular venous pulse is often the first clue,and the patient may remark on the abnormal pulse. Thissign is, of course, absent in atrial fibrillation, when thesystolic wave will be dominant; but a slow y descent andthe absence of a y trough in these circumstances may stillbe suggestive, and there is no doubt that fewer caseswould be missed if more attention was paid to the routineexamination of pulsations in the neck veins. A mid-diastolic or presystolic murmur with an opening snapalong the left sternal edge in the tricuspid area canusually be readily distinguished from the murmur ofmitral stenosis, and its clear waxing and waning withrespiration is a valuable auscultatory sign. It is dis-

quieting to read, however, that KITCHIN and TURNERfound indistinguishable murmurs in some of their

patients who had dominant tricuspid incompetence.They also emphasise that the electrocardiographic andradiological findings in stenosis are not specific, and theypoint out that tall p waves and right atrial enlargementare common in patients with incompetent valves, orright ventricular hypertrophy with normal valves. TheP-R interval too, though long in the series as a whole,was not helpful in diagnosis of the individual case.

GIBSON and WOOD 4 laid stress on the radiologicalfeatures of a conspicuous right atrial shadow withoutenlargement of the main pulmonary artery and littleevidence of pulmonary venous congestion. But the

Edinburgh workers note that 2 of their patients withtight tricuspid stenosis had no right atrial enlargement,and there was only a rough correlation between themean pressure in the right atrium and its X-ray size.They suggest that factors other than the cross-section ofthe valve must be involved; and the extent to which theright atrial musculature has been affected by therheumatic process may be one influence. The size ofthe pulmonary trunk and the presence or absence ofseptal lines were also of little diagnostic value in thisseries, and they seemed to depend on whether themitral or tricuspid valve was the more severely stenosed.

10. Coombs, C. F. Rheumatic Heart Disease. Bristol, 1924.11. White, P. D. Heart Disease; p. 629. New York, 1944.

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In view of the uncertainty of these physical signs, thesimplest way to make a diagnosis might seem to be tomeasure the pressure gradient across the tricuspid valvewith a cardiac catheter; but here too there have beendifficulties in interpretation, especially when atrialfibrillation is present. FERRER et al.12 spoke of theimportance of the gradient at the end-diastolic point;McCoRD et al.13 thought that an increase in the earlydiastolic gradient was the most dependable haemo-dynamic sign that tricuspid stenosis required operation;and GIBSON and WOOD 4 took the largest gradient acrossthe valve at any moment in diastole as the index ofstenosis. KILLIP and LUCAS 14 pointed out, however, thatearly diastolic gradients were particularly unreliable, sincethere may be a difference of 3 or 4 mm. Hg betweenthe right ventricle and the right atrium at this phase ofthe cardiac cycle in patients without tricuspid stenosis.Reiterating principles defined by GORLIN and GoRLiN,15they maintained that the mean gradient across the valvewas the most important index, and that a raised meangradient widening with exercise was the most reliablecriterion on which to base a diagnosis of tricuspidstenosis.

KITCHIN and TURNER 8 support this view and, havingmeasured the gradients at all phases, they find that themean gradient throughout the diastolic filling period,obtained by integration or planimetry, is clearly to bepreferred to other measurements because it is lessinfluenced by artefacts or by individual variations inpulse-wave contours. The most consistent confirmatoryevidence of severe stenosis in their series, however, wasthe dissociation of right atrial and right ventriculardiastolic pressures during respiration. In presentingtheir hxmodynamic data, they have restated the oftenforgotten relationship between pressure and flow.

Large gradients were found both in stenotic valves andin those where there was increased flow through narrowbut predominantly incompetent valves, and for thisreason the size of the gradient bore no close relationshipto the severity of the stenosis. Though GOODWIN et al.16thought that a gradient exceeding 5 mm. Hg was goodevidence of severe stenosis, KITCHIN and TURNER had 3patients at this level with predominant incompetenceand no operable stenosis, and 1 with relatively mildstenosis in whom a large flow had produced a gradientof 11 mm. Hg across the tricuspid valve.By thus tilting at some of the more hallowed of our

ideas about this most elusive of valvular lesions, KITCHINand TURNER should stimulate further careful observa-tions at the bedside, on the catheter table, and in theoperating-theatre, since the surgical treatment of

tricuspid stenosis has already entered the new era ofvalve replacement. Some surgeons now have patientswith, not one or two, but three artificial valves; andclearly the diagnosis must be very soundly based beforepatients are submitted to such extensive operations.12. Ferrer, M. I., Harvey, R. M., Kuschner, M., Richards, D. W.,

Cournand, A. Circulation Res. 1953, 1, 49.13. McCord, M. C., Swan, H., Blount, S. G. Am. Heart J. 1954, 48, 405.14. Killip, T., Lucas, D. S. Circulation, 1957, 16, 3.15. Gorlin, R., Gorlin, S. G. Am. Heart J. 1951, 41, 1.16. Goodwin, J. F., Rab, S. M., Sinha, A. K., Zoob, M. Br. med. J. 1957,

ii, 1383.

The Specialty of Medical AdministrationOUTSIDE the local-authority services, whole-time

medical administrators in the National Health Serviceare few. The Ministry of Health and the Scottish Homeand Health Department employ about 100; 150 are onthe staff of the 21 regional hospital boards; and some 40are superintendents or deputies in the Scottish hospitalservice. But though their number is small, their

importance to medicine is great, and their colleaguesin all parts of the Health Service should have an eyeto their standing, both now and in the future. At presentthe medical administrator is not held to be’a specialistby his colleagues, by the lay administrators, or byprofessional technical staff. He has no formal trainingand no recognised qualification, and the task of teachinghim to do the job falls to his already overburdenedsenior colleagues.

In industry the method of learning on the job is

regarded, at best, as dangerous, for it is slow and oftenincomplete as a teaching device. Some regional hos-pital boards have short but inadequate in-servicecourses with or without attachments to the Ministry ofHealth. Many of the present administrators hold thediploma in public health, but its relevance to hospitalplanning and administration is slight. Some, too, havehigher degrees gained by thesis, but these are not ofrecent origin and are of little value to anyone save theirowners. Not more than half a dozen doctors haveattended the course for the diploma in medical servicesadministration at the University of Edinburgh, and notrainee medical administrator is enrolled in the presentcourse. Courses of 3-4 weeks are now offered at the

King Edward’s Hospital Fund Staff College in Londonand the Nuffield Centre at the University of Leeds,but these are concerned mainly with skills and

techniques in planning.All this makes a gloomy picture, and the question is

often raised-does it really matter ? In our opinion itdoes. For one thing, the Ministry of Health is noworganising advanced courses in management for

newly recruited non-medical graduates and in-serviceadministrators of promise. In due course these well-trained and competent young men and women willoccupy senior posts, and beside them the medicaladministrator will be ill prepared for his job. And hisjob is growing more difficult as the work of regionalhospital boards becomes more complex. Certainly eachboard has a welter of committees and advisory machinery.It is, however, difficult for a committee to be creative,or for an adviser to offer advice on subjects about whichhe has not been consulted. Who seeks and channels theadvice of the advisers ? Who puts ideas to the com-mittees ? Who is responsible for correlating the medicalviewpoint with financial, statistical, and administrativeconsiderations ? Who, when the advisers and thecommittees have had their say, carries out theirdecisions ? The answer to all these questions is thesenior administrative medical officer and his staff, andsimilar questions would bring similar answers in the