CONSULTANT TliORAClC SURGEON, N.W. REGIONAL HOSPITAL BOARD INJURIES of the chest wall and lungs are now common as a result of the driver being flung violently against the steering-wheel following a head-on collision.This may result in fractures of the ribs and sternum, pneumothorax, haemopneumothorax, and, very rarely, damage to the trachea and oesophagus resulting in a fistulous communication.When one considers the vast number of traffic accidents and the high speeds of the modern car, it is strange that amongst the many and varied injuries that can result from such accidents tracheo-oesophageal fistula has been reported on only 9 occasions. In addition, 3 similar cases have been recorded following accidents of a different type. T h e case reported appears to be the tenth instance following a steering-wheel injury. CASE REPORTIn the early hours of 9 Dec., 1959, a young man. aged 28 years, driving a saloon car left the road and ran into a tree. He was admitted into a local hospital and found to be suffering from slight concussion, minor facial injuries, a broken nose, and fractures of the first and second ribs on the right, and the first, second, third, fourth, and fifth ribs on the left. The chest was strapped but the strapping was removed on the next day owing to difficulty in breathing. On the day after the accident he coughed up a little blood and on swalloying fluids felt the throat to be 'restricted and blocked . On the fifth day a radiograph showed a left-sided pneumothorax, which was treated by the insertion of a needle and continuous suction. He was also given some iced water to drink and this made him cough violently and he vomited up a quantity of dark brown blood. From now onwards any food or drink made him cough and, as a test, he was given a drink of Ribena which he coughed back a second or two after swallowing. It appears that he was considered to have some nerve damage causing fluid to enter the trachea and a Ryle's tube was passed and feeding instituted through this for a week.Meanwhile, he was treated for a lung infection which cleared slowly. On removal of the Ryle's tube, he found that the taking of food, particularly drink, again produced paroxysms of coughing, although after a time he learned that by adopting a certain position he could swallow perhaps a quarter of the food without too much reaction.
I t is an unusual tumour in its behaviour and has been given a variety of names of which 'endometrial stromal sarcoma' seems the most appropriate. This case is presented to record the unique behaviour of a pulmonary metastasis. CASE REPORTAn English housewife, aged 40 years, was first seen in March, 1956, with a history of intermenstrual bleeding for the preceding 18 months. This had started as a 'show' in mid-cycle and gradually increased in duration and quantity until it continued throughout the cycle. The menarche had been at 13 years and the menstrual cycle was regular. There was no history of previous illness and the obstetric history comprised three normal pregnancies, the last in 1949, and one abortion. On examination the uterus was enlarged and palpable abdominally just above the pubis. A diagnosis of fibroids was made.Total hysterectomy was performed a month later. Enlargement of the uterus was the only abnormality found at operation and the ovaries, which appeared normal, were conserved. The uterus was opened after removal and was found to contain numerous gelatinous polyps and a sub-mucous tumour, thought to be a fibroid. The pathologist reported that the utFrus contained a polygonal and spindle-celled sarcoma probably arising in the endometrial stroma' (Fig. I). The myometrium was lined by hyperplastic endometrium in the secretory phase of the cycle. Recovery after the operation was uneventful. A radiograph of the chest did not reveal any abnormality. Radiotherapy was suggested but the husband refused to consent to this.
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