DYSFUNCTION

. Dr. Palmer's second patient, a married woman, aged thirty-eig'ht years, had as her only complaints pain in the left side of the chest extending from the infrascapular area to the precordium, mild exertional dyspncea and winter bronchitis for several years. The chest pain had diminished since she had left heavy cleaning work. She had had pneumonia at the age of twenty-three years, for which X-ray examination was made. Cardiac enlargement was diagnosed at that time. Investigation of the family history revealed that the patient's mother had a congenital sternal deformity and bronchial asthma; she had died at the age of forty-seven years. One brother had a "pigeon chest" deformity and one brother had asthma. There were two normal siblings. Examination of the lower half of the sternum showed a saucer-shaped depression with a deep groove running horizontally. On palpation the whole precordium was quiet and the apex beat was not palpable. The first mitral and second pulmonary sounds were split. A grade II systolic murmur was audible down the left border of the sternum. Venous pressure was normal. No clubbing of the fingers or cyanosis was present. Breath sounds were normal. The blood pressure was within normal range. X-ray examination of the chest showed a great increase in the width of the cardiac shadow both to the right and to the left. !he heart was abnormally translucent owing to the flattemng. In the oblique views the distension caused both ventricles to appear enlarged. In the barium-filled cesophagus two unusually distinct indentations due to the aorta and pulmonary artery were seen. The lung fields were normal. In the electrocardiogram, the P waves were 2'5 millimetres in height in lead II, appearing tall and broad in comparison with the low voltage QRS complexes. There was notching of the QRS complexes, with delayed intraventricular conduction. No evidence of right ventricular hypertrophy was present.