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Among the various rhythms reported in the course of a Stokes-Adams attack, one of the rarest is standstill of the ventricle as an episode during normal rhythm. Such a condition may be called paroxysmal ventricular standstill, and is to be distinguished from the condition of alternating complete block and normal rhythm to which the term paroxysmal heart block may be applied. Three cases of paroxysmal ventricular standstill have been observed, in two of which there was paroxysmal heart block also, and ventricular standstill was also provoked by carotid sinus pressure.Weiss and Baker (1933) described several cases of total cardiac standstill, auricular standstlil, or extreme sinus bradycardia, and one of complete block in auricular fibrillation as a result of carotid sinus pressure: all of these had cardiovascular disease. Starling (1921) reported ventricular standstill on* swallowing but no cardiographic records were made of the attacks. Yater and Williams (1928-29) described a case of complete cardiac and ventricular standstill with slow irregular P waves. The case of Lewis (1920) showed ventricular standstill with auricular rhythm preserved; this patient later developed a complete block. A case recorded by Alexander and Bauerlein (1936) had variations in the degree of heart block with changes of posture but not with carotid sinus pressure. Holmes and Weill (1945) recorded mild grades of heart block in healthy men when they lay down; carotid sinus pressure caused a decrease in the P-R interval. Turner (1948) recorded the case of a man of 61 with cardiac asystole with pressure on either carotid sinus, whose attacks ceased after bilateral carotid sinus denervation. Parkinson et. al. (1941) recorded 5 examples of ventricular standstill, and collected 28 others that had been reported. Among all these there was only one in which the standstill was immediately followed by normal rhythm with unimpaired A-V conduction; this patient showed complete heart block on another day. Isolated cases of ventricular standstill are mentioned in two or three textbooks. CASE REPORTSThree patients have been observed with attacks of ventricular standstill, two of whom had normal rhythm and conduction before and after the standstill. In two of them the attacks could be provoked in various ways, in addition to those that had no apparent provocation. Case 1. A woman of 82 had retinal hemorrhage and diabetes for which she was having an injection of 50 units of insulin daily. For seven months she had been having syncopal and convulsive attacks. Physical examination was normal except for the retinal hsemorrhage. A cardiogram showed normal rhythm, right bundle branch block, but no delay in A-V conduction. As the record was being completed with lead IV R, the ventricle suddenly stopped with immediate loss of consciousness and a generalized convulsion after 5 seconds (Fig. 1); the movement of the record off the paper indicates the beginning of limb movements. The recording, when resumed at the end of the convulsion shows normal rhythm and conduc...

The widespread clinical trial of thiouracil and its derivatives in toxic goitre since 1943 has shown that they are very effective in reducing the excessive thyroid secretion of this condition. A partial answer can now be given to those questions which naturally arose as to the value of these antithyroid drugs compared with other methods of treatment. The first question was whether or not thyroid function would remain normal after the drug was discontinued, and how long it would be necessary to give the drug before it could be discontinued. Equally important were the nature and the frequency of toxic effects and how, if at all, they were to be avoided. Thirdly, were there any particular age groups or clinical types for which thiouracil was especially suitable or contraindicated ? The answers to these problems would of course decide the place of thiouracil in relation to other methods of treatment, thyroidectomy in particular.With regard to remissions, Beierwaltes and Sturgis (1946a) noted eight in 45 cases; the course of thiouracil had averaged 101 months in the eight cases, and the duration of the remission (to date) was from 3 to 12 months. Their cases of nodular goitre were not treated by thiouracil but by thyroidectomy. Himsworth et. al. (1947)

JDBRrr pain which kills only sometimes, but which maims all the time unless under careful and wise supervision. Miss E. M. Goldberg, of the medical research unit, and Miss M. E. Druett, almoner to the cardiac department, of the London Hospital, have given me great help in the interrogation of those patients who had passed through an attack of cardiac infarction.

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Thoracic pain, the cardinal symptom, may be absent in acute cardiac infarction, the best known equivalents being dyspnea or other signs of congestive failure, and more rarely abdominal and cerebral syndromes. With pain of great intensity, syncopal symptoms may occur also as a result of cerebral vascular complications, and sudden death, which is not infrequent in this condition, can be regarded as the extreme form of syncopal attack. But occasionally disturbances of consciousness are a most prominent feature of the attack apart from all these conditions, with pain absent or displaced into the background. This is especially so at the onset of the attack. Many papers on cardiac infarction without much or any pain have referred mainly to patients with congestive failure, and disturbances of consciousness have not often been mentioned.

If in this case the hernia had been strangulated it is highly probable that the bladder would have been pulled down, and in such an event the division of Gimbernat's ligament as usually advised would involve a very real dan-ger of injury to the bladder. It should be remembered that protrusions of the bladder are by no means uncommon comiiplications of femoral hernia. Conclusions.I venture to think that the points to which I have referred are of practical importance in the diagnosis and treatment of a femoral hernia. They may be briefly sdnumarized as follows:1. In miost eases the presence of a femoral hernia is characterized by the appearance of a soft, spherical swelling in the angle between Poupart's ligament and thle tendon of the adductor longus.2. The pubic spine is not so satisfactory as Poupart's ligament itself as a boundary between inguinal and femoral Ilernias.3. Gimbernat's ligament is not directly concerned in the strangulation of a femoral hernia, and its division serves no useful purpose, and may be dangerous. THlE following case is an example of occupational cancer.It is an instance of epithelioma of the skin of the right hand in a worker exposed for many years to creosote. It will be iioted that he had also a few warty growths on the left arm, onie of which presented evidence pointing to possible early .alignant changes.The patient, who was 66 years of age at the time of his death, had worked for thirty-three years in a creosote factory; his work was to carry wood after creosoting, and he stated that he was " up to the eyes in creosote." A good many years ago (certainly fifteen) a small swelling (?) appeared at the back of his right lhand, " like a corn." Every now and then it cracked open and lhealed up again. Eight years ago the growth had increased to the size of a two-shilling piece; subsequently it gradually spread uintil just before operation it was a large fungating ulcer covering the dorsum of the hanid (see special plate).A portion of the edge of the ulcer, removed and examined hiistologically previous to amputation, proved to be a squamous epithelioma.A circular amputation above the elbow was performed by Mr. S. Raw Post-mortein jxnnamination. There were a few small warts on the left forearm. Bevond changes commion to his age, the organs were healthy, save that there were small secondary epitheliomatous deposits in both lungs, in the liver, and in both kidneys. There were also two secondary deposits in the heart walls-one the size of a walnut in the left ventricular wall, involving its whole thickness and beginning to break down in the interior, and the other, the size of a pea, at tlle right border of the right ventricle.The case is put on record because it appears fairly certain that creosote was the cause of the malignant growth aiid subsequent death of the worker. It will be noted that the internal organs showed numerous secondary deposits of cancer. The large deposit involving the wall of the heart projected into its interior. The gland;s in the right armpit were enlarged and invad...

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