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Twelve Eponymous Signs ofAortic Regurgitation, One ofWhich Was Named After aPatient Instead of a Physician

Eponyms and acronyms are fa-

vorites of cardiologists.1 For morethan a century, numerous epony-mous signs of aortic regurgitation(AR) have been described in text-books and journals.2 Two articlesthat were published recently2,3 re-viewed the historical backgroundsof these eponyms, but neither waspublished in a cardiological jour-nalone in the Annals of Internal

Medicine 2 and the other in theJournal of Emergency Medicine.3

The purpose of this communica-

tion is twofold: first, to bring thesearticles to the attention of readersof this well known cardiological

journal and, second, to remindthem that one of the eponymoussigns of AR was named not after aphysician but after a patient.

The 12 eponymous signs of ARare listed alphabetically inTable 1.The eponym of a disease or a phys-ical sign is usually attributed to thephysician who first described it. Ofthe 12 eponymous signs of AR

listed inTable 1,there is one sign,the head-bobbing sign of de Mus-set, the eponym of which is attrib-uted not to a physician but to apatient. The patients name is Al-fred de Musset (1810 to 1857), aFrench poet with syphilitic aorticaneurysm and AR .3 The head-bob-bing sign was originally describedby the poets brother, Paul, in hisbiography of the more famous Al-fred, published in 1877.4 Here isthe original description by Paul de

Musset:One morning in the month of

March (of 1842), during lunch, Iobserved that the head of mybrother (Alfred) was showing aslight bobbing which was involun-

tary, seemingly occurring with

each heart beat. He asked mymother and me why we were look-ing at him with such an air of as-tonishment. We told him what wesaw. I did not think you could seeit, he replied, but I will reassure

you.He pressed on his neck, I dont

know exactly how, with his thumband his index finger and in a mo-ment his head stopped bobbingwith each heart beat. You see,he said to us, this dreadful mal-

ady is cured by a method which isnot only simple but inexpensive aswell.

Mother and I were reassured inour ignorance, not realizing thatthis was the first sign of a seriousaffliction which would take his life

just fifteen years later. . .4

The serious affliction waswell known to the doctors whohave kept it a secret, I dont knowwhy. It was a state of alteration ofthe aortic valves, according to

Delpeuch, who proposed the ep-onym in 1900.5

I would like to mention 2 moreeponyms named after the patientsrather than the physicians who de-scribed them. One is Christmasdisease named after StephenChristmas, a 20th century Englishchild;6,7 the other is Mozart earnamed after the famous 19th cen-tury Austrian composer WolfangAmadeus Mozart.8 The Mozart earhas a rounded and sometimes al-

most square appearance, a promi-

nent antihelix that tends to jut out

and obliterate the curve of the he-lix, and an ill-defined or absent earlobe, in contrast to the oval, shell-shaped normal ear that is boundedsuperiorly by a clearly differenti-ated helix and inferiorly by a well-developed ear lobe.8 Incidentally, alithograph from 1828 that pur-ported to depict the Mozart ear,often reproduced in later years inarticles on the subject, is actuallyMozarts sons ear.9

Finally, regarding the debate

over the years about the apostrophes in use with eponyms,10 the is-sue was largely resolved 15 yearsago when the editor of the Annalsof Internal Medicine set down therule that all eponymns should be inthe nonpossessive form.11 The oldconvention was that eponyms witha patients name should be in non-possessive form, e.g., Christmasdisease or Mozart ear, whereas de-scribers of diseases should be inpossessive form, e.g., Cushings

syndrome or Hodgkins disease. Irecalled that, while Chairman ofDepartment of Medicine at TheJohns Hopkins Medical Institu-tions, Victor McKusick made apoint at one of his grand roundsthat Osler of the Oslers node didnot have the Oslers node, butChristmas of the Christmas diseasedid have Christmas disease. Buteven McKusick changed his mindseveral years later; in the introduc-tion of his magnificent catalogs of

human phenotypes, he declared

Letters (from the United States) concerning aparticular article in The American Journal ofCardiology must be received within 2months of the articles publication, and shouldbe limited (with rare exceptions) to 2 double-spaced typewritten pages. Two copies must

be submitted.

TABLE 1 Eponymous Signs of Aortic Regurgitation (listed in alphabetical order)*

Eponym Description

Austin Flint murmur Mid-diastolic murmur not due to organic mitral stenosisBecker sign Accentuated retinal artery pulsation

Corrigan pulse Collapsing pulse or water-hammer pulsede Musset sign Head bobbing with each heart beatDuroziez sign To-and-fro femoral arterial sounds under compressionGerhard sign Pulsatile spleenHill sign Higher systolic blood pressure in legs than armsMayne sign Drop in diastolic pressure 15 mm Hg on arm elevationMueller sign Pulsatile uvulaQuincke sign Exaggerated capillary pulsation of nai l bedRosenbach sign Pulsatile liverTraube sign Booming systolic and diastolic sounds (pistol shot) heard

over femoral artery under light compression

*Adapted from Babu et al.2

1332 2004 by Excerpta Medica, Inc. All rights reserved. 0002-9149/04/$see front matterThe American Journal of Cardiology Vol. 93 May 15, 2004

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that: As a rule, the possessiveform of eponym has not been used(in these catalogs); for example,the Marfan syndrome, notMarfans syndrome, will be foundin the catalogs.12 I am in completeagreement with him; nobody callsLyme disease the Lymes disease.

In conclusion, McKusick stated

in the same introduction to his cat-alogs of human phenotypes,. . .the eponym is merely a han-dle; often the man whose name isused was not the first to describethe condition . . . or did not de-scribe the syndrome as it has sub-sequently become known. As Dar-win put it,Credit is rarely given tothe first one to make a discoverybut rather to him who convincesthe public.12 How true it is!

Tsung O. Cheng, MD

Washington, DC18 December 2003

1. Cheng TO. Eponyms and acronyms. CardiovascRes 1993;27:890 891.

2. Babu AN, Kymes SM, Carpenter Fryer SM. Ep-onyms and the diagnosis of aortic regurgitation:

what says the evidence? Ann Intern Med2003;138:

736 742.3. Mehta NJ, Khan IA. Original descriptions of theclassic signs of aortic valve insufficiency. J Emerg

Med2003;24:69 72.4. Sapira JD. Quincke, de Musset, Duroziez, andHill: some aortic regurgitation. South Med J 1981;74:459 467.

5. Delpeuch A. Le signe de Musset: secousses

rhythmees de la tete chez les aortiques. (de Mussetssign: a rhythmic bobbing of the head in aortic cases.)

Press Med1900;8:237238.

6. Stedmans Medical Dictionary. 27th ed. Balti-more, MD: Lippincott Williams & Wilkins, 2000:

344.7.Dorlands Illustrated Medical Dictionary, 30th ed.Philadelphia, PA: Saunders, 2003:359.

8. Paton A, Pahor AL, Graham GR. Looking forMozart ears. Br Med J1986;293:16221624.

9. von Nissen GN. Biographie W.A. Mozarts nachOriginalbriefen, Samm lungen alles uber ihn Ge-schriebenen, mit vielen neuen Beylagen, Stein-

drucken, Musikbalattern und einem Facsimile, ed.

By Constanze, Nissens widow, earlier Mozartswidow. Leipzig: 1828.

10.Burman KD, Baker JR, Tseng Y-C, Saunders N,Solomon B, Wartofsky L. Eponyms.Ann Intern Med

1988;108:635.11. Editor. Eponyms. Ann Intern Med 1988;108:630 631.12. McKusick VA. Mendelian Inheritance in Man:Catalogs of Autosomal Dominant, Autosomal Re-cessive, and X-linked Phenotypes, 7th ed. Baltimore:

Johns Hopkins University Press; 1986:xxiv.

doi:10.1016/j.amjcard.2003.12.045

Is Depression Following AcuteMyocardial Infarction AnIndependent Risk for Mortality?

We read with interest the con-

clusion of Carney and colleagues1

that depression was an indepen-dent risk factor for death afteracute myocardial infarction(AMI). The main experimentalfinding from the Enhancing Recov-ery In Coronary Heart Disease(ENRICHD) trial was that success-ful treatment of depression yieldedno relative benefit in terms of sub-

sequent mortality2; this was alsoconfirmed in Carney et als reporton data from 4 of the 8 sites. Thus,it is difficult to see how their con-clusion can be sustained. Althoughthey report that, when the treat-ment arm was dropped from anal-yses there was an overall correla-tion between depression andsubsequent mortality, this resultwould appear to generate morequestions than answers.

We have argued elsewhere3 that

associations between depressionand mortality in this context couldreflect the confounding of depres-sion and disease severity. For ex-ample, although the association re-ported by Carney et al withstandsadjustment for a number of possi-ble confounders, including leftventricular ejection fraction(LVEF), residual confounding re-mains a possibility. The ability ofmultivariate statistical models todetermine the independence of an

association depends not only on theappropriateness of the variables re-searchers are adjusting for, but alsothe accuracy of their measurement;any measurement error will inevi-tably lead to underestimation of thetrue impact of confounding vari-ables.4 In other words, it can ap-pear that a putative risk factor,such as depression, is related to anoutcome, such as mortality, afteradjusting for potential confoundingvariables, such as LVEF, as an in-

dex of disease severity. This resid-ual association, however, only ex-ists because of underadjustment forthe real confounder, i.e., diseaseseverity. LVEF is an imprecise in-dex of overall disease severity be-cause a great many other factorsare relevant to defining how ill apatient is.

In our research,5,6 we usedlength of initial hospital stay, Kil-lip class, and the Peel index as in-dexces of disease severity. How-

ever, our 3-year follow-up data6

and more recent analyses of ourdata (unpublished data) reveal thatdischarge medication, particularlyprescription of warfarin, were alsostrong predictors of subsequentcardiac and all-cause mortality inpatients with AMI. It would bewrong to interpret this result as sig-nal that warfarin treatment repre-

sents a major health risk in thiscontext; rather, warfarin prescrip-tion and, accordingly, our findingsreflect the very fine judgments be-ing made by attending cardiolo-gists about how ill their patientsare. It would be interesting to knowwhether the association betweendepression and subsequent mortal-ity reported by Carney et al1 wouldsurvive adjustment for dischargemedications.

It is also important to correct

some errors of fact in this report.The authors state that Two recentstudies that failed to find a relationbetween depression and mortalityfollowed the patients for only 12months. One of these 2 studiesfollowed patients for 18 months,7

and the other for 3 years.6 Theyalso state that Kaufmann and col-leagues8 found that depressionpredicted 12-month but not6-month mortality after AMI.Kaufmann et al,8 however, clearly

state that the association at 12-month follow-up did not surviveadjustment for indexes of diseaseseverity, including LVEF and pre-vious AMI. Finally, our over-riding concern is that prematureclaims that depression is an inde-pendent risk factor for death afterAMI, if subsequently shown to beunfounded, could deflect attentionfrom a very real clinical impera-tive: to recognize and treat symp-toms of depression in the substan-

tial numbers of AMI patients whopresent with them.9

Deirdre Lane, PhD

Gregory Y.H. Lip, MD

Douglas Carroll, PhD

Birmingham, United Kingdom16 December 2003

1. Carney RM, Blumenthal JA, Catellier D, Freed-land KE, Berkman LF, Watkins LL, Czajkowski

SM, Hayano J, Jaffe AS. Depression as a risk factor

for mortality after acute myocardial infarction. Am JCardiol2003;92:12771281.

2.The ENRICHD Investigators. The effects of treat-ing depression and low social support on clinical

events after myocardial infarction: the Enhancing

Recovery In Coronary Heart Disease Patients

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