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RARE OR OBSCURE CASES A CASE OF CONGENITAL DEFECT OF THE SPRENGEL’S DEFORMITY. THORAX, 325 WITH BY CAPTAIN HAROLD BURROWS, R.A.M.C. (T.P.) THEpatient, age 20, is a private in the machine-gun corps. I n peace time he is a grocer’s assistant. All his life he has noticed a bulging of the left chest whenever he coughed, 1 : ~ .?9C,.--L’atierit nlicii a t ease. Outliiies 011 rlicst dernarrate boiiiiilaries of defect i n chesc wall as eii<.ited by lmlpatioii aiid verified by rsdiogam. PIG. ?!?i.--Shows patient while mn1:itic. expiratory etfort. :I forreii but he has not experienced any particular inconvenience from this. He was able to undergo his course of training as a soldier, and made no complaint on account of his deformity, though he says he has always found it difficult t o carry his pack. On examination of his chest, i t was found that the left anterior chest wall is defective, considerable sections of the second, third, and fourth costal cartilages and ribs being ahsent (BYgs. 296, 297). The remaining ribs are normal in number, position, and shape. The pectoralis major on the affected side is ill-developed ; otherwise no defect of muscle or nerve is t o be observed. The left nipple is smaller than the right, and is situated at a higher level. A hernia of the lung is visible when the patient coughs. On viewing the patient from behind, the left shoulder is seen t o be hunched up, while the left scapula is slightly smaller than the right, nearer t o the vertebrre, and at a higher level (Pig.298). The scapular muscles, however, appear t o be well developed, though the posterior superior angle of FIG. 2!18.-Back view of patient. the scapula is more clearly noticeable on the left side than on the right. There is a. lateral curvature of the spine. with the masimrirn ciirve in the dorsal region, the convexity being directed to the right. 326 THE BRITISH JOURNAL O F SURGERY The left chest is retracted t o a remarkable degree, as shown by the accompanying cyrtometer tracings (Pigs. 299, 300, 301). My colleague, Lieutenant S. Owen, informs me that there is no dextrocardia or other visceral abnormality to be found, nor are there any congenital defects other than those already mentioned FIG.P~g.-Cyrtometer tracing a t level of iirst interspace. FIG.300.-Traciiig R at level of fourth rib cartilagc. = 18 in. L = 14; ill. Circumferential measurement : R = 20 in. FIG. 301.-Tracing R = L = 1st in. at level of tip of eighth cartilage. 151 in. L = 111 in. The case is remarkable on account of its rarity, and also because the patient suffered so little inconvenience from his abnormalities. I am indebted to Dr. F. Brigham, of Harvard University, for the photographs.