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Objective: To determine the precision (interobserver agreement) and accuracy (agreement with criterion standard) of clinical and radiological signs in premature infants at risk of patent ductus arteriosus (PDA) with left-to-right shunting. Design: Masked comparison of clinical and radiological examination with Doppler flow echocardiography (criterion standard). Setting: Neonatal intensive care unit. Patients: One hundred infants with birth weights less than 1750 g were studied once between days 3 and 7 of life. A third of the cohort was intubated at the time of study. Intervention: Five independent observers noted the presence or absence of an increased pulse volume, an active precordium, a heart murmur, a cardiothoracic ratio greater than 60%, increased pulmonary vascular markings on a concurrent chest x-ray film, and a relative increase of the cardiothoracic ratio compared with that from the previous chest x-ray film. Pulsed and color flow Doppler echocardiography was performed within 4 hours. All 100 tapes were reviewed by a second pediatric cardiologist. Results: Twenty-three infants had a PDA with left-to-right shunting. The precision of clinical signs was modest, with average κ values of 0.15 fκr pulse volume, 0.32 for precordium, and 0.41 for murmur. Pulse quality (43%) and murmur (42%) had the highest mean sensitivities. Corresponding specificities were 74% for pulse volume and 87% for murmur. The combination of a cardiac murmur with an abnormal pulse volume had the highest positive predictive value (77%). The radiological examination did not improve the observers' ability to distinguish between patients with and without PDA. Conclusions: The precision and accuracy of clinical and radiological signs of a PDA with left-to-right shunting are unsatisfactory. Therefore, Doppler flow echocardiography is required to diagnose PDA confidently in preterm infants between days 3 and 7 of life. (Arch Pediatr Adolesc Med. 1995;149:1136-1141)

A FULL-TERM infant weighing 3153 g was delivered by spontaneous vaginal delivery following an uncomplicated pregnancy. The Apgar scores were 8 and 8 at 1 and 5 minutes, respectively. On the second day, tachypnea (80 breaths per minute), subcostal retractions, and duskiness were noted. The heart rate was 140 beats per minute, and peripheral pulses were normally palpable. The blood pressure measurements in all extremities were normal for age and gestation, and the precordium was hyperactive. A grade 2/6 systolic murmur was heard over the lower left sternal border. The liver was enlarged, was palpable 3 cm below the right costal margin, and was not tender. A diagnosis of congestive heart failure was made. The laboratory findings were as follows: white blood cell count, 15.1×109/L with a normal differential cell count; hemoglobin, 148 g/L; and platelet count, 151×109/L. Results of a blood culture were normal. A

SELECTED CASES Case 1 A 6-year-old boy was referred to the National Institutes of Health (NIH) in 1974 for evaluation of xanthomas and hypercholesterolemia. Raised, yellowish plaques had first appeared between his fingers at the age of 4 years. When he was 6 years of age, his pediatrician also noted the presence of tuberous xanthomas on his elbows and knees. After it was determined that his blood cholesterol level was 29.2 mmol/L (1120 mg/dL), the patient was referred to the NIH for evaluation and treatment. Physical examination disclosed the presence of planar and tuberous xanthomas on the hands (Fig 1, A), circumferential arcus corneae (Fig 1, B), and tuberous xanthomas on the elbows (Fig 1, C). Planar xanthomas on the knees were also detected (Fig 1, D). Cardiac examination disclosed a normal S1 and S2, but a III/VI systolic ejection murmur at the left base radiated throughout the precordium and

Objective. —To assess the accuracy and reproducibility of indirect definitive precordial percussion in detecting increased left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM), and left ventricular end-diastolic wall thickness (LVEDWT), and to compare it with palpation of the apical impulse. Design. —Descriptive study. Setting. —Hospitals and clinics of a university medical center. Patients. —Convenience sample of 103 patients (62 men and 41 women) referred for ultrafast computed tomography (CT) of the heart. Interventions. —Percussion dullness distance from the midsternal line in the left fourth through sixth intercostal spaces, distance of the apical impulse from the midsternal line, and apical impulse diameter in the left lateral decubitus position were measured on all patients. Measurements of LVEDV, LVM, and LVEDWT were taken using ultrafast CT of the heart. Investigators performing the physical diagnostic maneuvers were blinded to the clinical history and CT results, and investigators performing the CT scans were blinded to physical findings. Results. —Percussion dullness distance in the left fifth intercostal space was the best discriminator of LVEDV (receiver operating characteristic [ROC] area, 0.680; 95% confidence interval [Cl], 0.547 to 0.813), and dullness distance in the left sixth intercostal space was the best discriminator of LVM and LVEDWT (ROC areas, 0.831, 95% Cl, 0.674 to 0.988; and 0.849, 95% Cl, 0.651 to 0.999, respectively). A percussion dullness distance of greater than 10.5 cm in the left fifth intercostal space detected increased LVEDV or LVM with a sensitivity of 91.3% (95% Cl, 70.5% to 98.5%) and a specificity of 30.3% (95% Cl, 19.9% to 43.0%). There was moderate concordance between investigators for percussion dullness distance (κ, 0.57; 95% Cl, 0.18 to 0.96). In patients in whom an impulse was palpated, an apical impulse diameter of greater than 3.0 cm in the left lateral decubitus detected increased LVEDV or LVM with a sensitivity of 100% (95% Cl, 77.1% to 100%) and a specificity of 40% (95% Cl, 23.2% to 59.3%). However, an impulse was palpable in only 53% of cases and showed only slight interobserver reproducibility (κ, 0.18; 95% Cl, 0.0 to 0.58). Conclusion. —Indirect definitive percussion of the precordium is a sensitive and moderately reproducible maneuver for excluding cardiomegaly due to increased LVEDV or LVM. Although measurement of apical impulse diameter was also sensitive in excluding cardiomegaly, lack of a palpable impulse in many patients and low precision between physicians may limit its utility in clinical practice. (JAMA. 1993;270:1943-1948)

To the Editor:— It may be of interest to your readers to add a note as to the peregrination of the medical curiosity reported inThe Journalby Dr. W. B. Porter March 21, 1936, page 992, and by Drs. Whitehead, Burnett and Lagen April 1, 1939, page 1236, as a case of diaphragmatic flutter with symptoms of angina pectoris. The patient was brought to the Massachusetts General Hospital Oct. 27, 1937, by police ambulance with the identical clinical picture as described by the previous writers. He lay doubled up on his right side, moaning in pain and in no respiratory distress, with a pulse of 80 and a blood pressure 130/80. He was not perspiring and his color was good. A rapid flutter could be felt and ausculted over the precordium and abdomen, and could be seen as a ripple over the latter. Fluoroscopy showed a normally beating heart

To the Editor. —Pericarditis as a complication of thyrotoxicosis has been reported only once in the literature. 1 Report of a Case. —A 67-year-old man had tremor, palpitations, excessive heat radiation, and chest pressure. The resting pulse rate was 130 beats per minute, and cardiovascular examination showed a hyperactive precordium, a scratching systolic Lerman's sound, and hyperactive reflexes. The ECG showed no ST-T-segment abnormalities. The thyroxine (T 4 ) radioimmunoassay level was 23.7% (normal, 4.5% to 12.0%). Triiodothyronine (T 3 ) uptake was 60% (normal, 31% to 45%). He was given propranolol hydrochloride, 20 mg three times daily, and propylthiouracil, 100 mg three times daily. On July 25, 1980, he noticed substernal chest pain on exertion. The ECG showed slower heart rate, but a 2-mm inferior ST-segment elevation. Propranolol hydrochloride therapy was increased to 80 mg three times daily, and isosorbide dinitrate, nitroglycerin, potassium iodide, and methylprednisolone acetate were added. By July 31, 1980

The importance of noninvasive techniques for following the evolution of ischemic injury in patients with acute myocardial infarction is indisputable. The current great interest in such methods stems from the realization that damage to more than 40% of left ventricular myocardium is incompatible with survival, 1 and from extrapolation to the clinical situation of experimental data, which suggests that the initial ischemic injury may require some period of time for demarcation and cell death to occur. 2 One technique for following the progression of ischemic injury is the method of serial precordial mapping of the ECG. Clinical application of precordial mapping has followed several years of experimental work, during which epicardial electrograms were correlated with histological and histochemical evidence of necrosis resulting from coronary occlusion. 3 The observation that ST-segment elevations recorded simultaneously from the epicardium and precordium in dogs move in parallel during experimental manipulations that alter the magnitude

ENDOCARDITIS is a rare complication of gonococcal infection.1We describe an unusual case in which treatment was complicated by two severe episodes of drug-induced neutropenia. This report emphasizes the important role of echocardiography in the diagnosis and management of endocarditis. Report of a Case An 18-year-old woman was admitted with a three-week history of fever, chest pain, and painful swellings on the left index finger and thumb. One week previously, her right knee had been swollen and painful. Her temperature was 38 °C, splinter hemorrhages were noted, and Osler's nodes were present on the left index finger and thumb. The carotid pulse was regular with a sharp upstroke. The blood pressure was 150/60 mm Hg. There were no signs of heart failure. An ejection systolic murmur and a loud early diastolic murmur were audible over the precordium. The ECG showed sinus rhythm and widespread nonspecific T-wave flattening. The chest

In a previous publication1attention was directed to a series of cases in which radicular pain radiating to the shoulder girdle, the arm and the precordium originated in the cervical portion of the spinal column and was due to arthritic changes. The symptoms and the diagnosis were discussed, and a suspension type of traction therapy was suggested. It was further suggested that overhead traction was of distinct value as a diagnostic aid. Particular attention was directed to the precordial reference of cervical radicular pain and to the necessity for differentiating this type of pain from true anginal pain. Since this earlier publication, it has been possible to study a much larger group of cases of the condition described, and an opportunity has presented itself to study and observe many other conditions which simulate this one in the syndrome produced. It was accordingly deemed advisable to supplement the previous publication

During the last ten years, the more general use of the electrocardiograph and the intensive study of cardiac conditions in children have revealed disturbances of rhythm and conduction in a considerable number of patients. Heart block is one of the less common forms of abnormal cardiac mechanisms found in childhood. In 1922 I was able to collect thirty-six cases of heart block in infancy and childhood from the literature, and added one observed in a girl, aged 11 years, with a congenital cardiac lesion. 1 The etiologic factors in the cases described were as follows: Diphtheria, sixteen cases; rheumatism, two cases; congenital syphilis, one case; cardiac tumor, one case; nose and throat infection, one case; associated congenital cardiac lesion, twelve cases and unknown cause, three cases. Heart block occurring in patients during the course of diphtheria present the gravest outlook, the mortality in the collected cases having been 93.7 per

A man, aged 42, came to the Medical Rest Rooms in April, 1931, complaining of "neuritis" in the left wrist and arm. One week before, while on the train, he had been conscious of an occasional sharp twinge in the left wrist. During the journey these twinges occurred several times during the day, and it was noticed that with successive attacks they radiated farther up the ulnar side of the arm until, on the day prior to examination, one or two reached the precordium accompanied by a band of constriction about the midchest. The past history was unproductive save for a poorly defined reference to several sensations of "smothering" during exertion two years before. Periodic examinations had revealed nothing. The patient was somewhat obese, but apparently in excellent health. No cardiovascular changes were found except slight sclerosis of the brachial, radial and retinal arteries, and tactile hyperesthesia of the skin

In complete transposition of the great vessels, the aorta arises from the right ventricle and the pulmonary artery from the left ventricle. This congenital anomaly is incompatible with survival unless there is a septal defect which allows mixture of arterial and venous blood. The case reported here is of particular interest because an electrocardiogram taken a few hours before death showed the pattern of an impending anterior myocardial infarction. This, as far as could be determined, has not been previously reported in a 7-week-old infant with complete transposition of the great vessels. Report of a Case In a male infant who was born at St. Mary's Hospital on March 27, 1957, marked cyanosis appeared soon after birth. X-ray of the chest showed no evidence of pathology. An electrocardiogram taken two days after birth (fig. 1) was not definitely abnormal. A systolic mumur was heard over the precordium. The infant made

Simply to read about heart sounds and try to form a mental image of sound from a verbal description is, for the novice, a frustrating experience. Phonocardiograms help, particularly to portray matters of timing. But nothing can match persevering bedside experience with a capable, articulate, and patient teacher. For the person who wishes to study cardiac auscultation on his own, Segal and Likoff have prepared a concise guide. Their text is coordinated with recordings available in high-fidelity 33 1/3 rpm longplaying discs and also on tapes at 3 3/4 and 7 1/2 inches per second. The authors concern themselves with more than merely heart sounds and murmurs, for examination of the precordium, the venous and the arterial pulses are also covered. The authors examine current theories of the genesis and transmission of heart sounds and murmurs in the light of evidence culled from a sound bibliography, and they adduce additional

KEITH 1 reported that patent ductus arteriosus (PDA) was responsible for cardiac failure in 10% of the diagnosed instances in the first week of life. Diagnosis of this lesion may be quite difficult in the neonate since classical auscultatory and other physical findings may be absent. In patients with PDA, an electrocardiographic evaluation might be helpful if it characterized the size of the left-to-right shunt or the pulmonary artery pressure. Elevated pulmonary vascular resistance in infants with respiratory distress syndrome (RDS) is characterized by tall R waves over the right precordium and low pulmonary vascular resistance is characterized by a deep S wave over the right precordium. 2 This evidence suggests that even in the newborn period, a large left-to-right shunt without pulmonary arterial hypertension produces ECG evidence of left ventricular hypertrophy. The purpose of this study was to determine if these ECG findings of high resistance in the pulmonary

SEVERAL AUTHORITIES RECOMMEND a sharp blow over the intact precordium as a method of restarting the arrested heart. Actual proof that this is possible is hard to find. Roberts et al. and Brandenburg reported recovery from apparent cardiac standstill after the application of this method, but I have been unable to find any reference furnishing absolute proof that the heart was indeed arrested before the reviving blow was struck. Indeed, in a report by Turk and Glenn, of 44 patients in supposed asystole undergoing emergency thoracotomy for rhythmic cardiac compression, 2 were found to have beating hearts. As Harken has pointed out, circulatory arrest is what is usually diagnosed, because pulse and blood pressure are unobtainable. A simultaneous electrocardiogram may show regular electrical impulses, proving that cardiac arrest has indeed not occurred. The question was of greater import when open thoracotomy was the only method of reviving the arrested heart.

I wish to report three cases of coarctation of the aorta that presented an interesting variety of detail both clinically and at necropsy. REPORT OF CASES Case1.—A boy died twenty-one and one-half hours after birth. Delivery was normal. The baby was blue, and it did not breathe for ten minutes after birth. It remained blue up to the time of death. Birth was said to be five weeks premature although the weight was 7 pounds and 3 ounces (3,260.04 Gm.) and the body length was 20½ inches (52 cm.). A murmur was heard over the precordium which was thought to be systolic. The mother had five children living and well; her family history was irrelevant. At necropsy the face was very cyanotic. The lips were blue and dry. The conjunctivae were congested. When the thorax was opened the pericardium and its contents were found to occupy practically the entire

Techniques for electric control of cardiac rhythm began with the demonstration of an action current preceding each myocardial contraction. Next came direct stimulation and countershock defibrillation with electrodes placed directly on the exposed heart. Later, external electric stimulation and external countershock with electrodes on the precordium permitted emergency resuscitation from ventricular standstill and fibrillation and provided a means for stopping rapid arrhythmias. Cardiac monitors permit the prompt recognition and identification of arrhythmias; they led to the widespread growth of coronary-care units. Cardiac pacing is now undergoing extensive development and application in many new directions.

In a previous article,1we came to the conclusion that the single exposure of the precordium to roentgen rays of the quality and quantity described in that paper, and corresponding to a so-called human erythema dose, does not produce definite and irreparable injury to the heart muscles of adult rats and rabbits. The next step in these investigations suggested itself, i. e., the study of the effect of a series of exposures as they are carried out in the treatment of human beings. All malignant lesions in the region of the heart, for instance, mediastinal growth, carcinoma of the left breast, bronchus or a tumor of the lung are repeatedly treated at certain intervals with a single dose, varying from a part to a full tolerance dose. The latter term is used in preference to the "erythema dose," which implies a unit, but careful investigations have shown that it is

The recent articles of Brown and Coffee, and of Muller., have given added interest to, as well as a summary of, our present knowledge of the control of the sympathetic over the vascular system. The barrenness of the literature on this subject justifies another case report with some remarks on the technic and regional anatomy of this operation. REPORT OF CASE G. J., a man, aged 78, a cement worker, born in Germany, who had three healthy adult children over 50, whose father died of cancer at 84, and whose mother died of nephritis at 30, had always been robust. He always had chronic bronchitis, which he believed followed an attack of malaria in childhood. He was a moderate drinker and a very hard worker. About three years ago, while climbing a hill, he was suddenly seized with a heavy feeling in the chest, over the precordium, which quickly disappeared

There appear to be three general indications for the use of nitroglycerin in medicine, namely, to relieve distressing or dangerous symptoms due to local arteriosclerosis or arterial spasm; to lower the general blood-pressure when its continuance at the existing height threatens accidents to the cardiovascular apparatus, and to clear the diagnosis. The power of nitroglycerin is perhaps best shown when it is used to free the circulation in vitally important regions of the body where the supplying arteries are unduly contracted. The two most important vital regions are the heart itself and the brain; and arterial disease in these regions is usually attended with high blood-pressure. Sclerosis of the coronary arteries, when the lesion is pronounced, may be attended by some or all of the following symptoms: soreness, oppression or pain in the precordium, especially behind the sternum; pain in the neck, shoulders and arms, particularly the inside of the

Aging of the heart has not impressed the physician, although the striking anatomic change, brown atrophy, has long been known and recently has been emphasized by quantitative studies. 1 The electron microscope has shown that there are comparable changes in the mitochondria, 2 and the biochemists measure the decline in the enzymes needed to maintain contraction. 3 The nervous elements also atrophy, 4 so that the heart can less effectively mobilize the catecholamines which augment the speed and force of contraction when the circulatory needs are increased by stress. The observations of I. Starr and his disciples on the change in headfoot ballistocardiograms and pulse contours in an aging "normal" population, 5,6 and those of Harrison's group on the motion of the precordium, 7 seem to point to a steady decline in the force of contraction and rise in resistance to diastolic filling, from nonage to nonagenarity. The data on

Angina pectoris is a disease characterized primarily by subjective clinical phenomena. There is pain in the left side of the chest, occasionally with radiation of pain down the left arm. Objective clinical methods for the recognition of this disease are generally lacking, so that the patient's complaints must determine the diagnosis. Obviously, if other diseases exist that may give the same type of pain, careful differentiation must be attempted to avoid condemning those suffering with benign ailments to the rigid regimen of the anginal patient. The importance of this differentiation is exemplified by a patient seen in 1929 for a pain in the cervical spine. This man had been confined to bed for several weeks because of a supposedly bad heart. The internist had found no objective evidence of cardiac dysfunction, but. since the patient complained of severe pains in the precordium, at times stabbing in character and often associated

Four patients have undergone surgery for the treatment of elongate coarctation of the aorta during the past 10 years at either the Cook County or the Presbyterian Hospital of Chicago. We are presenting the salient features in these cases. Report of Cases Case 1. —A 22-year-old Mexican woman was admitted to the hospital because of exertional dyspnea and precordial pain, which had been present since childhood. She also complained of headaches, dizziness, and numbness in her legs. Examination revealed blood pressures of 160/110 and 290/130 mm. Hg in the right and left arms, respectively. There were no pulses or blood pressure obtainable in the legs. The heart was enlarged to the left, and there were a systolic murmur and a thrill over the precordium. Aortography performed by retrograde technique through the femoral artery demonstrated an extremely long, irregular coarctation (Fig. 1). Exploration was done in the hope

Da Silva, 1 working under the direction of Bozzolo, made the first special study of the influence of the application of the ice-bag to the precordial region. He concluded that in the normal individual the systolic arterial blood pressure would rise from 30 to 40 mm. of mercury after an hour's application of the ice-bag, and that this rise in pressure was explained by an increase in vascular and cardiac tone. Corresponding to the increase of arterial pressure, the cardiac rate fell an average of 8 beats a minute. Intracardiac thermic determinations on dogs showed a decrease in temperature of 1 to 5 degrees C. Da Silva concluded that these effects resulted from the direct action on the cardiac fibers. Winternitz 2 made practically the same observations as da Silva, but included a somewhat more exhaustive study of the therapeutic indications of such hydrotherapy. Hirschfelder 3 has briefly summarized their

Bubbling, clicking, crunching, knocking and tapping sounds emanating from the chest are rarely encountered in civilian practice and their significance is not generally appreciated. With the current great military mobilization physicians will undoubtedly encounter these sounds in many instances of thoracic wounds in military personnel and in civilians. It appears pertinent, therefore, to emphasize their mechanism of production and their diagnostic significance. Tapping, clicking and snapping metallic sounds were encountered by Rees and Hughes 1 and Smith 2 in soldiers with wounds of the left side of the chest during the last war. These sounds varied in intensity from ones audible only with the stethoscope applied over the precordium to those which could be heard 6 to 8 feet (183 to 244 cm.) from the patient. They were synchronous with the heart beat but varied in relation to the cardiac cycle. Some were audible only during systole, others only during

With an ultrasonic fetal heart detector, several low-frequency Doppler signals can be heard over the precordium. In normals, the characteristic pattern comprises atrial (a) ventricular systolic (β), and ventricular diastolic (8) components. During quiet breathing the β signal is usually loudest (β pattern), but on deep inspiration, lying, or squatting, the α signal predominates (α pattern). In atrial flutter or fibrillation the a signal disappears, and in some cases quivering noises (ψ signals) are audible. The Dopplercardiophone can also be useful at the bedside, in conjunction with the stethoscope, in elucidating gallop rhythm. Simultaneous recordings of the Doppler-cardiogram with electrocardiogram and phonocardiogram help to relate the signals to discrete cardiac events. The Doppler signals are probably mainly due to blood flow, movement of the heart wall, or both. The contribution of valve closure is relatively minor.

In the preceding paper 1 the use of multiple points over the precordium in obtaining lead IV was discussed. In that paper the findings for patients with normal hearts and for those with various pathologic conditions of the heart and lungs other than myocardial infarction were reported. A similar study has been made of patients suffering from, or suspected of having, myocardial infarction. The technic was the same as that used in our previous study; i. e., nine designated points over the precordium were employed (see figure 1 in the first paper). If the apex was outside the ninth position an additional tracing was made with the electrode placed directly over the apex of the heart. The positions will be referred to in the future as leads IV 1 , IV 2 , IV 3 , etc. The customary German silver electrodes (11/2 by 2 inches [3.8 by 5 cm.]) were used. The

This paper is concerned with the study and treatment of a group of cases in which, with the exception of one, the outstanding symptom was pain in the vicinity of the shoulder girdle and arm. In these cases, evidence of local disease of the arm and shoulder was absent and the pain was probably a manifestation of irritation or actual inflammation (radiculitis) of cervical spinal nerve roots due to cervical arthritis. In the one excepted case, precordial pain was the outstanding feature and was similarly due to a radiculitis or irritation of nerve roots due to cervical arthritis. It is believed that cases of this type are more frequent than is generally supposed. Their prompt recognition has led in most instances to complete therapeutic relief. The present paper is essentially a clinical one with emphasis on diagnosis and treatment, some reference being made to the pathologic process and its correlation

The report of a transitory hyperglycemia and glycosuria occurring in a patient with acute coronary occlusion follows: M. E., a white woman, aged 52, entered the Cedars of Lebanon medical ward, service of Dr. H. H. Lissner, at 3 a. m., Jan. 16, 1936. She complained of cutting pain in the precordium radiating down the inner aspect of the left arm, nausea and vomiting. The patient had had a known hypertension for several years, according to her attending physician, and during the past year had noted a mild pain of a similar character which had been induced by exertion, excitement or heavy eating and relieved by rest. These pains had been gradually becoming more severe and frequent. On the day previous to admission she had felt somewhat weak and about 10: 30 p. m., while resting, the onset of the pain had occurred very suddenly. She was apparently in shock

An example of both mitral stenosis and bilateral coronary occlusion has not been found in the literature. The case reported here, presenting a tight mitral stenosis and an occlusion of all the main coronary arteries, furnishes an interesting example of the remarkable potentialities of the various compensatory mechanisms of the heart and its blood supply. REPORT OF CASE S. B., a white man, aged 63, a tailor, was admitted to the Brooklyn Jewish Hospital in the general medical service of Dr. Joseph Rosenthal, complaining of generalized weakness, dyspnea on exertion, and edema of the ankles. Three years before, he had an attack of pain over the precordium and shortness of breath. He was taken to a hospital, where he stayed three weeks. Since then he had remained quite well and was able to go to work daily. Slight dyspnea on exertion was the only symptom that persisted. About three weeks

The venous hum, a continuous murmur usually of maximum intensity in the supraclavicular area, is a common auscultatory finding. Heard particularly in children, it is of no known pathological significance. Its importance lies rather in its often close resemblance, because of its continuous or predominantly diastolic characteristic, to pathological murmurs. Our interest in the venous hum stems from the observation of numerous patients in the cardiology and pediatric clinics of the Medical College of South Carolina, in whom the murmur was transmitted down to various areas of the precordium where its presence was of concern in auscultation. In this presentation the clinical features of venous hum are discussed as they pertain to cardiac auscultation. Emphasis is placed on procedures that permit the differentiation of this murmur from murmurs of pathological significance on the basis of clinical findings alone. Most present-day textbooks of cardiology and pediatrics give brief, if any, mention

A 9 year old girl with congenital heart disease who was intensely cyanosed acquired a right hemiplegia due to a cerebral thrombus. She recovered in about three months. Two years later she became diabetic and was given insulin; during a hypoglycemic reaction a right hemiplegia again developed. Because transitory focal cerebral symptoms may occur as a manifestation of insulin shock (Ford, 1 Root 2 and Woodyatt 3 ) and closely simulate cerebral vascular accidents, this case is reported in detail. REPORT OF A CASE M. Y., a 4 year old girl, was first seen at Mount Sinai Hospital in 1935. She had been cyanosed at intervals since birth. A rough systolic murmur was heard over most of the precordium, and a diagnosis of congenital heart disease was made. By 1937, when she was 6 years old, the cyanosis had become constant. The cardiac condition was diagnosed as the tetralogy of Fallot.

It is our desire to call attention to certain toxic results of the administration of dyes intravenously in cases of bacterial septicemia. In the case of mercurochrome-220 soluble especially, we have noted the occurrence of stomatitis of a severe grade with hemorrhage, diarrhea and dysentery, and the appearance of casts and albumin in the urine. These effects have had the usual clinical features of mercurialism. In some cases we have obtained excellent and immediate improvement with the oral and rectal administration of sodium thiosulphate solutions. REPORT OF CASES Case 1.—History. —O. M., a man, aged 45, entered the medical service of Lane Hospital, July 1, 1924, complaining of weakness, dyspnea, swollen ankles, loss of 20 pounds (9 kg.) and afternoon fever for the preceding six weeks. Examination showed only a substantial secondary anemia and a loud systolic blow over the precordium, together with enlarged spleen and small petechiae over