1. Two cases of bilateral fracture of the first rib are reported. The fractures were situated near the neck of the first rib. 2. A possible mechanism responsible for the bilateral fracture of the first rib at this particular site has been suggested.

No abstract

No abstract

Extramedullary plasmacytomata form an interesting group of tumours, the nature and behaviour of which are still not well understood. The majority of such tumours are situated in the pharynx, upper respiratory tract, and conjunctiva (Hellwig, 1943). Less frequent sites have been the thyroid, intestine, ovary, and kidney. A study of the literature available to us has revealed that so far 18 cases (Ackerman, 1953 ;Brunn, 1939;Carson, Ackerman, and Maltby, 1955;Childress and Adie, 1950;Cotton and Penido, 1952;Gordon and Walker, 1944;Hill and White, 1953;Kilburn and Schmidt, 1960;Kuley and Kuntman, 1951;Lane, Krohn, Kolozsi, and Whitehead, 1955;Lisovskii and Grindzhiliya, 1962;Rambaldi, Odoardi, and Vergine, 1959;Robson and Knudsen, 1959;Romanoff and Milwidsky, 1962;Rozsa and Frieman, 1953;Tchertkoff, Lee, and Wagner, 1963;Uvarova and Dubrovaskii, 1962;Viszloy and Dar6czy, 1960) Examination of the cardiovascular system revealed that the praecordium was bulging slightly. The apex beat was palpable in the left fifth space in the midclavicular line. On percussion the left border of the heart could not be made out because of dullness all over the left side of the chest. The heart sounds were normal. No murmurs were audible.On examination of the respiratory system the trachea was central. The movements of the left side of the chest were diminished. Tactile vocal fremitus was also diminished on the left side. On percussion the entire left side of the chest was dull, and on auscultation the breath sounds were diminished in intensity and occasional rales were present.Examination of the abdomen showed that both the spleen and the liver were palpable two fingerbreadths below the costal margin. Other systems were normal.

Summ aryThe simultaneous correction of a po t en t ially haza rd o us combi nat io n of adult post-ductet coarctation and aortic insufficie ncy is described . Th e fami liar left thoracotomy and median sternotomy approach was used . One and a half y ea r followup and pos toperative aortogra m show good functio nal resu lts .Th is is considered to be the first re po rt o f a success f ul o nestage correction of t hese 2 lesio ns using a left -sid ed th o racoto my and a med ia n sternotomy .Key -Words: Post-ductal coarctation -Ao rt ic i nsuf f ic iencyAortoptestv -Left t horacoto my -Med ian stern otomy appr oach Int roductionCongenital isthmic coarctation of the aor ta presenting at an adult age is not uncommon in India. In fact, 90 % of the patients who have undergone surgery for coarctation at the K.E.M. Hospital, Bombay, have been in the adult age group. An association of aortic valvular disease with congenital coarctation has been well documented (I , 4 to 7). However, when eithe r aor tic lesion is severe surgical management becomes difficult . The majority of the cases have been approached by two-stage operations perfonned with a time interval of 2 or more weeks. In this repor t we present a case in which aortic valve replacement with repair of aortic coarctation was performed at the same time but through 2 separate incisions (F ig. I). From our knowledge and review of the literatur e this appears to be th e first successful operation performed using this appro ach.CllSe report M.F., an l S-year-old boy was admitt ed to the K.E.M. Hospital, Bombay for evaluation of chest pain, exe rtional dyspnea and giddiness. The symptoms had been progressively increasing over the previous year.He was well built and nourished, weighing 48 kg. The radial pul se was regular at 80 beats/min, collapsing in char acter. The pulsations in the neck and upper ex tre mit y were boun cing with a definite delay of the femora l pulse. Pedal pul ses were not palpab le. Blood pressure in the right arm was 160 /50 mmHg and in the left arm it was 154/50 mmHg. No blood pressure could be recorded in the lower extremit y. Fig . 1 A diagram sho wi ng both lesion s and t h eir su rgic al correct ionThe apex beat was sit uated in the left sixth interspace and was heaving in characte r. There was a grade III/VI diastolic murmur of aort ic regurgitat ion at the left sternal border with radiation to the apex. A harsh systolic murmur could also be clearly heard over the inte rscapular area.The electrocardiogram showed left axis deviation wit h evidence of left ventri cular hype rt rophy. Radiogram of the chest showed cardio megaly, left ventri cular hypertrophy and a prominen t aorti c kn uckle. Rib notching was obvious on bo th sides from the third to sixth interco stal space. Cardiac catheterizatio n and aortographyLeft heart cathe terization was performed by Seldinger 's tech nique through the right femo ral arte ry. Angiography revealed a dilated lef t vent ricle with an end-diastolic pressure of 16 mmHg at rest. However, the contrac tility of...