inches, which was more than twice
its natural width. By approximating his arms he made the ends of his
clavicles overlap. When he coughed, the right lung suddenly protruded
from the chest through the groove and ascended a considerable distance
above the clavicle into the neck. Between the clavicles another
pulsatile swelling was easily felt but hardly seen, which was doubtless
the arch of the aorta, as by putting the fingers on it one could feel a
double shock, synchronous with distention and recoil of a vessel or
opening and closing of the semilunar valves.

Madden pictures (Figs. 134 and 135) a Swede of forty with congenital
absence of osseous structure in the middle line of the sternum, leaving
a fissure 5 3/8 X 1 3/16 X 2 inches, the longest diameter being
vertical. Madden also mentions several analogous instances on record.
Groux's case was in a person of forty-five, and the fissure had the
vertical length of four inches. Hodgen of St. Louis reports a case in
which there was exstrophy of the heart through the fissure. Slocum
reports the occurrence of a sternal fissure 3 X 1 1/2 inches in an
Irishman of twenty-five. Madden also cites the case of Abbott in an
adult negress and a mother. Obermeier mentions several cases. Gibson
and Malet describe a presternal fissure uncovering the base of the
heart. Ziemssen, Wrany, and Williams also record congenital fissures
of the sternum.

Thomson has collected 86 cases of thoracic defects and summarizes his
paper by saying that the structures deficient are generally the hair in
the mammary and axillary regions, the subcutaneous fat over the
muscles, nipples, and breasts, the pectorals and adjacent muscles, the
costal cartilages and anterior ends of ribs, the hand and forearm; he
also adds that there may be a hernia of the lung, not hereditary, but
probably due to the pressure of the arm against the chest. De Marque
gives a curious instance in which the chin and chest were congenitally
fastened together. Muirhead cites an instance in which a firm, broad
strip of cartilage resembling sternomastoid extended from below the
left ear to the left upper corner of the sternum, being entirely
separate from the jaw.

Some preliminary knowledge of embryology is essential to understand the
formation of branchial fissures, and we refer the reader to any of the
standard works on embryology for this information. Dzondi was one of
the first to recognize and classify congenital fistulas of