rupture of a right ventricular papillary muscle from any cause is rare. In our review of the literature we found only five reported cases.1-4 Antemortem diagnosis was established in only two. This report concerns hemodynamic data and operative treatment of a patient with traumatic rupture of the anterior papillary muscle of the tricuspid valve. Case Report A 33-year-old Negro soldier in previous good health was severely injured in an auto accident on June 10, 1962. During a head-on collision he

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... was thrown against an unpadded dashboard sustaining a crushing injury to the chest and multiple injuries elsewhere in the body. He was semicomatose on arrival at a nearby military hospital. Pertinent findings on admission were shock, paradoxic motion of the left anterior chest wall, prominent pulsations in the neck, evidence of intra-abdominal injurv, and multiple fractures of the right leg. Chest x-rays revealed fractures of the second through seventh ribs anteriorly on the left, and of the eighth, ninth, and tenth ribs posteriorly on the right. There was a pleural effusion on the left, which yielded grossly bloody fluid when aspirated. An exploratory laparotomy was performed, and a tear in the right lobe of the liver was found and packed with Gelfoam. The left chest was then stabilized with traction, a tracheostomy was performed, and the fractured right leg placed in a cast. Rapid improvement subsequently occurred. During the second month of hospitalization progressive ambulation was attempted, but was tolerated poorly because of dyspnea, fatigue, and symptoms referable to the right leg. Because prominent cervical pulsations persisted, intracardiac injury was suspected and an intravenous angiocardiogram was obtained. A precise anatomic diagnosis could not be established, however, and the patient was therefore transferred to Walter Reed General Hospital for further evaluation and treatment. Physical examination at Walter Reed General Hospital revealed a thin, anxious Negro man who was experiencing mild orthopnea. Pulse 100 per minute; blood pressure 118/88 mm. Hg. Marked pulsation in the neck was evident. The pulsation was synchronous with ventricular systole and so marked that casual inspection suggested severe aortic insufficiency. On more careful inspection the pulsations were more lateral in the neck than seen in aortic lesions and could be differentiated from the normal pulsation in the carotid arteries by palpation. The left border of cardiac dullness was percussed 1 cm. lateral to the midelavicular line. The apex impulse was normal. There was a slight right ventricular lift along the left sternal border. There were no thrills, and pulmonary valve closure could not be felt. A quadruple rhythm was present that was proved by phonocardiography to consist of the first and second heart sounds and an atrial and ventricular gallop. The first heart sound was diminished, and there was a grade I-II/VI systolic murmur heard maximally at the lower left sternal border. The murmur increased with inspiration. On maximum inspiration the liver edge was palpated 2 cm. below the right costal margin in the midclavicular line. Mild, but distinct expansile pulsation was present. There was a positive hepatojugular reflex. Breath sounds were normal, and there were no rales. There was no peripheral edema. The venous pressure was recorded as 130 mm. of saline. The electrocardiogram was within normal limits, but when compared to a tracing taken prior to the accident there was some increase in P-wave voltage suggesting right atrial enlargement. A routine chest x-ray taken 3 months prior to the accident was normal in all respects. X-rays on admission demonstrated considerable increase in the transverse diameter of the heart ( fig. 1 ). In the lateral view there was encroachment on the retrosternal space by an enlarged right ventricle. The venous angiocardiogram ( fig. 2) showed tricuspid regurgitation, dilatation of the superior vena cava, reflux into the hepatic veins, and simultaneous opacification of the aorta and pulmonary artery. The latter finding suggested the presence of a right-to-left shunt.