Roger (1879) gave the first description of isolated ventricular septal defect. Cases are often detected during routine medical examinations of school children by the characteristic loud, harsh systolic murmur over the third or fourth left interspace close to the sternum, but others simulating this may have only innocent parasternal murmurs (Wood, 1950).The usual site of the defect is near the base of the septum. In Abbott's series there were 50 patients with lesions at this site and only 5 with defects that were multiple or were situated elsewhere (Bauer and Astbury, 1944). Weiss (1927) had a case with a defect in the interventricular septum near the apex of the heart. Brown (1950) noted right axis deviation in his case where the defect was near the apex.The present patient had peculiar clinical features due to the unusual site of the defect and had also congenital anomalies in other parts of the body.An unmarried man, aged 35 years, was admitted under one of us (N.R.K.) with history of dyspncea and cough for five months, and oedema of the legs for 15 days. The dyspnoea was at first on exertion only but later it became constant. He had no fever. Till the onset of dyspncea he had good health and was of active habits. There was no significant past, family or personal history. The patient was of poor build and nutrition, and hair was very scanty over his face, axillk, and pubes. There was moderate cyanosis but no clubbing of fingers. Pitting cedema was present over both feet, legs, and thighs.He had bilateral branchial and pre-auricular fistulk. There were no testes in the scrotal sacs. The chest was box shaped and the sternum was depressed.The pulse was 90 a minute and regular. The blood pressure was 85/65 mm. Hg. A feeble apical impulse was felt over the fifth left interspace in the midclavicular line. There was a systolic thrill in this area. A localized systolic murmur of moderate intensity was heard in the mitral area. The pulmonary second sound was accentuated and split, and a systolic murmur was also heard in this area. Crepitations were heard over both lung bases. The veins of the neck were full. The liver was enlarged three fingers' breadth below the costal margin and was firm and tender. The spleen was just palpable. There was a little fluid in the peritoneal cavity.The hmemoglobin was 12-6 g. per 100 ml. and the total white count and the differential count, and the blood sedimentation rate were normal. The Wasserman reaction was negative.Radiological examination showed slight enlargement of the right ventricle and moderate enlargement of the left ventricle and pulmonary conus (Fig. 1). There was moderate pulmonary congestion but no hilar dance. The electrocardiograms showed sinus rhythm, right axis deviation, depressed S-T in II and III, biphasic T waves in II and III, and normal QRS complexes. The slow rate and S-T depressions were due to digitalis. On cardiac catheterization the right atrial pressure was 5 mm. Hg and the oxygen saturation of its blood was 62 per cent. The catheter could not be passed to...

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A murmur may be audible over the heart and blood vessels in cases of anaemi. A systolic murmur was heard over the liver in three cases of severe anaemia. To our knowledge no reference to such a murmur has been made previously. CASE REPORTSThe patients were female aged 38, 40, and 12 years suffering from nutritional macrocytic anaemia with ankylostomiasis, nutritional macrocytic anaemia, and thalassaemia. The chief complaints were weakness, pallor, palpitation, exertional dyspnoea, and dependent oedema. Their haemoglobin levels varied from 1.45 to .2.9 g./100 ml. The pulse was of water-hammer type and the rate varied In two patients a soft systolic murmur was heard over the pulmonary area. Their electrocardiograms did not reveal any significant abnormality. The liver was non-pulsatile, tender, and enlarged to 3.4 fingerbreadths below the right costal arch. It was soft in two cases and firm in one. There was a systolic high-pitched murmur over the liver, best heard about 2.5 cm. below the costal arch in the continuation of the right midclavicular line. Application of pressure over the area by the chest-piece of the stethoscope made the murmur a little louder. A phonocardiogram taken in one of the cases recorded the systolic murmur (see Fig.).In the first case transfusion of 300 ml. of whole blood precipitated pulmonary oedema. Partial exchange transfusion of 400 ml. of concentrated red cells with simultaneous withdrawal of 500 ml. of blood saved her. The other two patients had a very slow transfusion of 200 ml. of concentrated red cells. With transfusion of blood the patients became less dyspnoeic, their pulse rates came down, blood pressures improved, the size of the Livers diminished, and the murmurs disappeared within a few hours. COMMENTThe murmur was probably produced in the hepatic artery owing to accelerated circulation of blood through it as a manifestation of hyperkinetic circulatory state. After appropriate blood transfusion along with improvement of the circulatory state, the size of the liver was reduced and the murmur disappeared.The murmur was best heard over the liver about 2.5 cm. below the costal arch in the continuation of the right midclavicular line. This site suggests that the origin of the murmur was in the hepatic artery. The murmur was not a transmitted one from the heart or the abdominal aorta, as in none of these cases was there a murmur in the abdominal aorta and that heard over the pulmonary area was never very pronounced.