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 PNEUMOTHORAX, ITS ETIOLOGY, SYMPTOMS AND 
 SIGNS WITH A STUDY OF TWELVE CASES. 
 
 BV 
 
 W. F. HAMILTON. M.D., 
 
 Demonsfr.'itor In CllniiMl .MeiUolne, Mi'Uill University 
 
 f{i>viil N'icioriii llnsi ■..,•' 
 
 Assistant PhyKlclan 
 
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 Jl{i'l)riiili'(l I'roni thr Monlnn/ Mi'ilicdl Joiinidl, Devemhei\ ISUS.) 
 
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 1 
 
 '1 
 
 PNEUMOTHORAX, ITS ETIOLOCJY, SYMPTOiMS ANIJ SIGNS 
 WITH A STUDY OF TWELVE CASES. 
 
 BY 
 
 W. F. Hamilton, M.l)., 
 
 Demonstrator in Clinical Medicine, McGill Univurnily ; Assistant IMiy-sician, 
 
 Royal Victoria Hospital. 
 
 The following cases, with but one exception, have lieen observed in 
 the wards of tlie Royal Victoria Hospital, and form the sum total of 
 such cases treated in that institution since its openini,'. I am greatly 
 indebted to Drs. James Stewart and liell for permission to study and 
 report their cases. 
 
 Case I.— H. M., male, aged -SO, admitted May, IMOT, re-admitted in 
 August, again'* re-admitted Jan. 1S9(S. He presented when first 
 admitted marked pleural cttusion of the left side. Fro)n the 
 hi.story given it was chronic and of undoubted tuliercular origin 
 The onset was marked by .severe pain in the side, with dyspno'a and, 
 after several weeks, with an audible splash, first heard by the patient 
 himself. Two years previous to this onset, his health had failed him 
 somewhat, and he was the subject of cough with expectoration. The 
 family history gave no evidence of tuberculosis. The patient never 
 spat blood. The heart was much displaced to the right, the coin 
 sound was absent and succussion was not made out. The amount of 
 fluid present was so great that aspiration was urgently indicated and 
 several ounces were withdrawn with considerable relief to the patient. 
 After some weeks the splashing sound of which the patient pi-eviously 
 complained returned. 
 
 The general condition of the patient was much improved for several 
 months, and though the displaced heart returned partially to its nor- 
 mal position after aspiration it remained permanently to the right, 
 
2 
 
 where it wns rlonlitless held by plcnro-pericanliftl fldhcsions. The 
 com pressed hiiijf never re-expandcd, l>ut occupied a siiinll ])(trti()ii oi' 
 the thorax })Osteri()rly towards the apex and tlu- middle hue. Numer- 
 ous aspirations wore made and finally in Feh. ISOS, a portion of the 
 8th rib was excised on the left side postericjrly, and large (piantities 
 of pus continued to discharge until the patient <lied, Aug. 2!)tli, 26 
 months after the occurrence of this complication. All the pliysical 
 signs together witli a fairly characteristic onset of pneumothorax 
 were present in this case, and the patient afforded a striking example 
 of how pneumo-thorax may arrest the progress of puhnonary tuber- 
 culosis. This arrested state was inferred from the following facts. 
 The quantity of expectoration was greatly diminished. There was a 
 total absence of febrile movement for several months, except after the 
 application of the tuV)erculin test. The patient during this period 
 showa'd little tendency to emaciate The case terminated with signs 
 of sepsis and chronic diarrluea, doubtless of tubercular origin. Clini- 
 cally the opposite lung showed but few traces of disea ie. 
 
 Case II. — J. L., aged 17, male, was admitted March 20th, lcS95, 
 with left-.sided pneumothorax of tubercular origin. The, onset was 
 sudden, with .severe post-axillary pain in left side four months pre- 
 vious to admis.sion, when he felt something giving way in his lung, 
 followed by marked dyspncna. This was more marked on exertion. 
 His previous health had not been good. For nine months he had had 
 a cough with loss of flesh and weakness. His condition on admission 
 was afebrile, respirations and pulse slightly accelerated. Signs of 
 left pneumothorax were nianifest in prominence of left side, char- 
 acter of the percussion note, metallic tinkling, coin sound and succus- 
 sion splash. The course of the case was favourable, the temperature 
 variable, sometimes febrile, sometimes subnormal. He was dischartred, 
 improved, four and a half weeks after admission. Physical signs were 
 not materially changed. 
 
 Case III. — K. F., female, aged SH, with left-sided pyopneumo- 
 thorax. The onset was iiulefinite. It was not possible to fix the date. 
 Her health had l)een failing for a year previous. 8he had spent con- 
 sidei-able time in bed ; she coughed and expectorated, but never spat 
 blood. Shortness of l)natli, variable in degree, had exi.sted .several 
 months, but had never been .severe until two weeks before adini.s.sion. 
 Six months after on.set of illne.ss, hence about six months before 
 admission, .she complained of s])lashing sounds on the left side of her 
 chest, which were oltserved cner a period of about six weeks, then dis- 
 appeared. She noticed the heart palpitate on the right side of 
 chest. Sh(! {presented on admission, well-marked signs of effusion into 
 
the left pleura, with compression of the left luns;, anrl displacement of 
 the heart. After two aspirations of -io oz. of pus in all hipp(jcra- 
 tic succussion was ohtained, wiiile the coin sound and niotailic tink- 
 ling were ahsent. The third aspiration was performed nine days 
 after, after which metallic tiiiklin^f, the coin sound and succussion splash 
 were elicited. The course of the case in the hospital was afehrile 
 with hut one exception and patient showed marked improvement, 
 doubtless due to the aspiration. Further operations were not per- 
 formed, as the patient left the hospital and was lost sight of. In this 
 patient downward displacement of the spleen was observed, while her 
 case afFt)rds a typical example of latent pyopneumotliorax. 
 
 Case IV.— M. 1). McM., aged 24, male, was admitted August, 1H95, 
 with pyopneumothorax of tubercular origin, left-sided. The onset 
 had been sudden with almost total collapse. His previous health had 
 been failing, marked by loss of flesh, cough, chills and fever, malaise 
 and sweating at night. There had been slight t!xpectoration of blood, 
 Physical examination of the chest on adnussion showed cardiac dis- 
 placement to the right ; the left side of thorax was bulging, with a 
 tympanitic note ; the coin sound was present, but no succussion. 
 Metallic tinkling on respiration was present and succussion was elicited 
 after several weeks. It may be said, however, that the patient's con- 
 dition did not justify the movements necessary to demonstrate the 
 presence of succussion until several weeks after he was admitted. The 
 pulse was constantly rapid, the temperature febrile during most of 
 patient's stay in hospital and dyspn(ea was a variable feature. The 
 right lung showed signs of di.sease, manifest by localised pleuritic 
 rub, and a few fine crepitant rales. The patient after nine weeks 
 in the hospital accomplished a train journey of several hundred miles 
 and lived for some months, fully seven months and a half after the 
 onset of this complication. 
 
 Case V.— K. H., aged 14, female, was admitted on 11th of January, 
 1896, with right-sided pneumothorax, of tubercular origin. Tlie pre- 
 vious health had been poor as shown by weakness, co\igh, hoarseness, 
 feverislmess. The onset was rathei- sudden, characterised by severe 
 pain in right side, but no marked shortness of lireath. Condition on 
 admission was as follows : l'\"bi-ile temperatiu'e, rapid pulse, dyspnrea, 
 signs of apical infiltration of the right lung with pneumothorax over 
 the lower portion of the thorax, shown in cardiac disj>lacement to the 
 left, dulness beginning one inch to the left of the left edge of the 
 •sternum, distant amphoric breathing. Tympanitic resonance, faint 
 respiration.s, metallic tinklings, the coin test, were obsei-ved but no .suc- 
 cussion splash. Thirteen days after admission succussion splash was 
 
clicitfd over tho rifrht side. Tlie patient died tivo weeks after the 
 onset of this coniplieation manifestly witli •■•eneral tulterculous infec" 
 tion as both lungs sliowed tuliercular disease. She was ilelirious and 
 diarrhtea was a constant feature. 
 
 Cask VI.— K. N., female, aged ID, was admitted on Oct. 5th, 189N, 
 with right-sided pneumothorax. The (inset was sudden. The health 
 had been failing, marked by lo-ss of Hesh, slight cough, tendency to 
 take "cold," recent aniiinia and weakness. One sister gave a history of 
 tuberculoses. (More particularly ; after a severe chill on awakening one 
 morning and getting up, she returned to bed and slept for about two 
 hours, to awaken again in profuse perspiration, with .substernal pam, 
 lasting for two days and then referred to her right side, with catchy 
 breathing, amounting to dyspn(ea). 
 
 Condition on admission ; normal temperature, respirations 40, pulse, 
 100 ; with one exception the temperature remained normal through- 
 out the following 18 days of stay in hospital. The pulse and respirations 
 were not accelerated after the 4th day. Dyspnwa was not a marked 
 feature. Attitude in bed was dorsal and lateral, without preference. 
 The thoracic examination showed asymmetry, right side more prom- 
 inent, hyper-resonance of the right side, weak re.spiratory sounds with 
 moist rales of a peculiar metallic ring. Vocal resonance had a metallic 
 ring also, the whispering was .son-.ewhat cavernous. Coin sound and suc- 
 cussion .soiuid were ab.sent. Cardiac displacement was marked, the 
 mid-axillary line in the 7 th interspace showing the apex pulsation. Dul- 
 ness from aViove downwards Ijegan at the level of the nipple and trans- 
 verse cardiac dulness liegan t(j the right of the mammillary line. 
 Abdomen, right upper tiuadrant, showed evidence of displaced liver. 
 The progress itf the case was favourabk- throughout, dyspnoea dimin- 
 ished and a state of general wellbeing was experienced. The coin 
 sound wiis elicited on the Sth of October, seven days after the probable 
 onset, in a very limited area about one inch square just at the level 
 of the seventh rib at the posterior axillary border. 
 
 Oct. 12th. — Four days later two other small areas were discovered 
 giving this sign. One was found just below the angle of the scapula 
 and was about the size of the bell of an ordinary stethoscope while the 
 other about the same size was in the axillary space at the level of 
 the 8th interspace. 
 
 Oct. 16th. — Yet four days later, the anterior and posterior areas 
 above mentioned, /. e., the first and third failed to give this nott^ and 
 the coin test was positive in one area only. 
 On Oct. 20th it was absent. 
 On Nov. 3rd it was still absent. 
 
All motalUc quality oF voice and rt-spiratory souiuls have <li.sap- 
 pearud. Tho patitiiit siitlcr.s nn iiiediivfiru'iict! oxcupt that due to over 
 oxoi'tion and is now attending' to lit^ht liousc! work. 
 
 Signs of Hnid were ni-ver found. 
 
 Case VII. — J. P., ajjed 59, niale, seen in consultation with Dr. II. S. 
 Shaw, was (;ne of pn(Munothorax of douhtful ori<.(in. I'n-viously he 
 (uijoyed jrood health. On Nov. 27th, 1H97, lie fell and hroke his lejf. 
 lie roiuained umler treatuu'Ut in l»ed till Dec. 22ud, when some pain 
 developed in rij^ht side of the chest. This pain passed away liy 2Gth. 
 On Jan. 1st, while still in lied severe rij^dit-sideil pain developed and a 
 few rales were heard over the area. On the 2nd a dyspu(eie attack 
 occuri'ed and the si<^iis of i)neuinothorax were manifest. The coin 
 sound was olitainaltle widely over his rii;ht chest, weak distant am- 
 jilun-ic l)reathin<f was present. 'l'h(> i)atient improved, sij^ns of cardiac 
 displacement disappeared, the coin sound ivlso disappeared and was 
 (iompletely ah.sent on llth Feb., and Mai-ch 1st j.atient was at work, 
 and has l»een in yooil health ever situf. The cause of this ca.se is 
 doubtful, and nnist remain so since there is no evidence eitlicir from 
 the history or the; physical siifus jiointin*,' to tuberculosis, while the 
 occurrence of such an event in one contined to one's bed by no 
 exhaustin<i- illness inducing; throud)osis or embolism, with subse(|uent 
 localized pulmonary <ranwrene, renders a decision very difficult. 
 
 Case VIII.— H., male, aged li). The date of on.set is doubtful. 
 His previous health had been good. While walking upon the street 
 four or five months previous to admission he experienced dyspncwi. 
 It was not severe, he continucid his journey to his ])lace of work per- 
 forming his duties that day. Some thoracic pain developed after a 
 few days, but no distressed breathing to interfere with his work. 
 About three weeks ago, about Oct. 1st, while pulling on a hoist, he 
 experienced dyspnct'a and subsequently pain in the left side. On 
 admission he presented .signs of ]ineumothorax on the left side shown 
 in cardiac displacement to the right side, fulness of the left chest 
 with cbliteration of intercostal sjjaces, hyper-resonant note through- 
 out, metallic echo of vocal resonance, and faintly heard coin sound. 
 There was no succussion. He was afebrile, not dyspnceic. The course of 
 the case has been uneventful except that it is thought the left chest 
 shows less fulness, while tlie area of cardiac pulsation is less promin- 
 ent toward the right, succussion splash has not developed, the coin- 
 sound is very variable. It is best heard when tested in the left supra- 
 clavicular area and the lower portion of axillary space. It transgresses 
 the median line, passing to the right above the junction of the 1. stand 
 2nd pieces of the sternum. It nuiy lie heard also from axilla posteriorly 
 
6 
 
 over the lower part of the thorax l.iit this is tl()ul)tt'ul. 'I'ht- patient i)r»- 
 sents the type of latent piienniothonix according' to the French 
 authors since there is at least attenuation of tlie pain an<l .lyspnu-a 
 which so freciuently usher in this ct>n<lition. 
 
 Tlie case is in all prohal.ility one of partial pneumothorax, for 
 reasons which we may discuss later. 
 
 Case IX.— CI., aj^'eil lU. This is the ca.se to which reference will 
 l)e ina(h- in discusNin.; the etiolo;ry ..f ])neumothorax, and will he 
 triven in sufficient iletail there. 
 
 Cask X.— M. L., male, a;;vd !). Pyopneumothorax, orifjin douht- 
 ful. Left pleura. He had been ill with si-iis of pulmonary disease, 
 either of pleuri.sy or pneumonia or l»)th, which set in with consider- 
 able pain and cou<,di On sitting,' up after two weeks in bed consider- 
 able thoracic pain and <lyspn(ea weiv experienced. The cause of his 
 illness appears to hav(; been empyema. There was no succussion nor 
 coin-.sound present. This patieiit was operated on, a resection of a 
 portion of the Hth rib was done and drain introduced. The recovery 
 was uneventful. 
 
 Case XL— Female, E. H., a<red 29. This patient was under treat- 
 ment for pulmonary tuberculosis of several months duration. The 
 disease was one of .severe type and i-apidly progressive. No signs of 
 a coniplicatinn with this condition were present, although signs of 
 cavitation were described. The night before she died she complained 
 of pain in the left lower axillary region. There were no other signs 
 or symptoms recorded, denoting the presence of pneumothorax which 
 was' demonstrated by an autopsy and found to belong to the partial 
 type, being situated about the upper lobe. 
 
 Case XIL— Male, aged 56. Left pyopneumothorax. The patient 
 had been ill with pleurisy and empyema several months an.l had been 
 fre(,uently aspirated. One cannot tix the date of the pneumothorax. 
 Hippocratic succussion ami the coin-.sound were both present. He 
 died three weeks after operation, resection of a portion of a rib, and 
 fioiri the autopsy report it is evident that the original cause of the 
 complication described was tuberculosis. 
 
 The Etioi.()(;v oi' Pnei'mothohax. 
 
 Much interest has always gathovd about the question of the etiology 
 of the somewhat rare condition of pneumothorax which occurs accord- 
 in.- to <.-oo.1 authorities in from :? per cent, to 12 per cent, of all eases 
 of pulmonary tulxirculosis. 
 
 The anatomists of many years ago who taught that the arteries 
 were air tubes, regarded the presence of air in the pleural sac as an 
 
" exhalation" from i]w vhmsoIs of the plftura invnlv»'(l. Tlien also its 
 occurrniiCf was cxplniiicd hy tin- process of j^'atij^rene of the pleura 
 or hy a process of decompositioii in the i)leuritic exudate found so 
 often in such cases. A third explanation had reference to tho most 
 conunon condition — that of ftcrfnintiov — which i^ now the only 
 reco^fui/ed iiinnediate cause. 
 
 iitennec, who first tauj^dit directly ooncerniny; tlu; presence of air in 
 tlu' pleura, descrihefl the cases under three clas.ses : (a) Sinipli' or 
 essential pneumothorax ; (/>) the presence of air or i^as together with 
 fluid eH'usion ; (f) aii or oas with fluid effusion and a tistultnis open- 
 ino' conjunuiicatin;^ with the hronchi. 
 
 Thus two forms may lie included under the division of non-perfora- 
 tive pneumothorax, while tlu' other, form {c) is classified as the per- 
 forativ(' variety. 
 
 Ct)nccrnin<^ the first form, essential pneumothorax, authors did hut 
 little more than hint at the po.ssihility of the secretion of air or jjas 
 hy the pleural sac. Walshe, in speaking,' of the development of 
 tympanitic sound over a pneumonic area asks, whether the pheno- 
 menon can depend on temporary secretion of air hy the j)leural 
 sac. In referrinj^ again to this point in another .section of hi.s work 
 on Diseases of the Lungs, he says : " It seems admissihle as a hare 
 possibility .... tympanitic resonance may he caused hy air 
 secreted hy the pleura." This teaching, neviM- positive however, has 
 lonsr Hince been regarded as fallacious, an<l thus one form of Liuiniec's 
 classification has passed away. Such an origin for the gas is physio- 
 logically impossible. 
 
 It was contended by Jaccoud in 1 804 that there was no evidence 
 I for either form of non-perforative [jueumothorax, but such cases were 
 most likely due to minute pleural perforations which .soon closed and 
 the air was ab.sorbed. In this opinion many high authorities con- 
 curred, among whom may be mentioned the names of Fagge and 
 Powell. 
 
 Quoting from the former author we Hud as follows: " Most writers 
 have admitted that in exceptional cases gases may l)e found in the 
 pleural cavity as the result of chemical decomposition of Uqui<l effusion, 
 and perhaps by direct secretion (or rather exhalation) from the lining 
 membrane. Such notions, however, accord ill with the general doc- 
 trines that are now held by almost everyone — and as neither of these 
 suppo.sed causes of pneumothorax has in its favour the .slightest 
 clinical evidence, we may now% guided by the experience of moi'e than 
 half a century, rt^iect them altogether, and assume that air is never 
 fiiMud in the interior of the ])leui'al space except as the result of a 
 
breach in the continuity of its surface, placing it more or less in 
 direct communication with the external atmosphere." 
 
 This seems scarcely the teaching of the present day, however, and 
 guided by the observation of the last decade, we may assume that 
 simple pneumothorax does exist, oi- at least, such a condition without 
 perforation, and gases may he formed witlnn the pleural cavity and give 
 rise to all tlie signs characteristic of that condition. Bacteriological 
 examination into such cases ha. established the pi .nee of gas produc- 
 ing organisms of anaerobic type. 
 
 Three case reports may '«e cited supporting this view. The Hrst is 
 that reported two years ago by E. Levy, of Strasbourg, in which no 
 perforation was found, but the exudate contained on two occas.ons an 
 anaerobic micro-organism capable of producing gas in cultures as well 
 as in guinea-pig tests. From the clinical history of his case, it would 
 seem Ihat this infection was one of secondary character, and in pre- 
 sentino- his report Dr. Uvv makes ' ^r essential pneumothorax. 
 
 The"second is that reported in t. sches Archiv flir Khnische 
 
 Medicin 61 Baml. Dr. Richard May ...... i)r. Adolf Gebhart describe 
 
 a case of pneumothorax of this cUiss in which the gas formation was 
 evidently due to the presence of the bacterium coll. 
 
 The third case is No. IX., in our series. A patient un.ler 
 treatment for a severe form of appe.v.Ucitis, was operated on ami four 
 or five days later he developed signs of disease in the right lung and 
 subsequently in the pericardium-signs leading to a diagnosis of 
 pneumonia and pleurisy of the right side with hydropneumo pericar- 
 dium The autopsy confirmed the diagnosis and further revealed a 
 pyo-hiemo-pneumothorax of the right side, as well as a pleurisy ot 
 the left side. The pericardial effusion was similar to that in the 
 pleura, but the pus elements were more .scanty. 
 
 An examination of the abdomen showed a suppurative track—a 
 retroperitoneal dissecting abscess, extending upwards, traceable along 
 the inferior vena cava to the diaphragm. Viewed from the pleural 
 side ro perforation was discoveral)le, but near that point where the 
 inferior vena cava emerged through the diaphragm a reddish grumous 
 broken-down area existed. The pericardium presented no such area sug- 
 gesting even the possibility of perforation, although, as we have said.it 
 contained ante-mortem and post-mortem signs of pneumo pericardium. 
 Subsequent examination of the organs of this patient, as reported 
 by Dr. A. G. Nicholls, in the BrliUhMedicalJoivnial, of 1897, showed 
 the pre.sence of the Imcillus aerogenes capsulatus in lai-ge numbers— 
 and the gas found in the serous sacs was doubtless due to an infection 
 with this gas producing bacillus. 
 
 \ 
 
 I 
 
I 
 
 I 
 
 9 
 
 Granting, however, that such cases of pneumothorax do exist, they 
 are very rare, and each case suspected of being such must be carefully 
 followed out in order to determine whether or not perforation is 
 present, and if al)sent, what forms of organisms account for the 
 formation of gases. Clinically such cases ai-e scarcely within the 
 range of precise diagnosis. 
 
 Pneumothorax occurs not infrequently in tho.se appai-ently health}', 
 and many observers regard it possible that such may be really 
 healthy. This observation gathers strength in the light of many such 
 cases going on to recovery within a few weeks, leaving no sign of the 
 cause of such a condition. 
 
 Flowever, in such cases there is amph; ground for doubt, ami among 
 those who oppose this teaching no one has done so more strongly nor 
 more logically than Sanmel West, who maintains upon the following 
 grounds that in all probability a pulmonary h'siun has given rise to 
 a perforation under conditions of over-strain. 
 
 Perhaps all will admit the grounds upon which he reasons concern- 
 ing this point. Tliey are in substance as follows : 
 
 1. Lesions exist undetected clinically. 
 
 2. Recovery may be complete from pneumothorax, even though 
 there be a tubercular process at the bottom. 
 
 3. The bursting power of a healthy lung is greater than could be 
 exerted by any expiratory ettbrt. 
 
 Doubtless many cases occurring in the apparently healthy are 
 caused by tuberculosis. 
 
 Not only in the advanced cases with cavity formation may this 
 complication occur, but an early case where small superticial caseating 
 areas exist, — so small that they can not be discovered clinically — 
 pneumothorax may develop while the subject of it is regarded as 
 previously healthy. 
 
 Of interest under this division of the subject are the statistics of a 
 larire number of cases. Some years ago Biach collected from the 
 records of 8S years the reports of 918 cases in three of the large hos- 
 pitals in Vienna. 
 His table showed : 
 
 Tuberculosis in 715 cases, 76 per cent. 
 
 Gangrene of Lung 65 
 
 Emjyema 45 
 
 Injiry -^2 '; 
 
 Bronchiectasis 10 
 
 Lung Abscess 10 
 
 Empliysema 7 
 
 Necrotic Hiemorrhagie Infarct. ■+ " Total, S.SiS 
 
10 
 
 Of the remaining '^0 cases, 14 were undecided, while the other 10 
 were divided between thoracentesis, parasitic— peritoneal and intestinal 
 origin — and carious changes in ribs and sternuu). 
 
 Other observers show about 90 per cent, of cases due to tuberculosis. 
 
 In this ffrouT- of 12 eases the causes are as follows : Tuberculosis, 5 
 cases ; empyema, 2 cases ; unknown, 4 cases ; B. aerogenes capsulatus, 
 1 case. 
 
 Latent forms were found in (Nos. 3, 11, 8, 12) 4 cases. 
 
 Purulent Huid was demonstrated in 9 cases. No signs of fluid were 
 found in 8 cases. Of the twelve cases, six are dead while two are at 
 work, one under observation ; one, a child running about ; two others 
 showed some improvement under treatment and were finally lost 
 sight of. The left side was involved 8 times, the right side was 
 involved 4 times. 
 
 There were 7 men, 3 women, and 2 children, 9 and 14 years of age, 
 and the length of time varied from 2 days to 26 months. 
 
 The Diagnosis. 
 
 The diagnosis of pneumothorax is not always made clinically. 
 Much stress has been laid upon the two syynptoms which frequently 
 mark the onset, viz., pain and dyspncea, while in addition sometimes a 
 sense of tearing or a crackling is realised in the chest. The dyspnoea 
 may amomit to orthopnoea,— the pulmonary insufficiency of Wintrich. 
 These, however, may be absent or so slight as to pass unnoticed, 
 as Pierre Angereau has recently pointed out, and the presence of air 
 in the pleural sac may be discovered incidentally when making an ex- 
 amination in the usual way. 
 
 This author whose monograph has been published recently deals 
 with the subject of such forms of pneumo-thorax which he terms latent 
 pneumuthomx. Among other conclusions he states : 
 
 1st, that total pneumothorax is attended by much pain and dyspntea ; 
 
 2nd, that in partial pneumothorax pain and dyspno'a may be slight 
 
 or wanting ; 
 
 3rd, that there exist forms of general pneumothorax absolutely 
 ,silent in their symptoms without pain or dyspncfa. 
 
 Levy is cited by Angereau as saying that partial pneumothorax in 
 its insidious onset is generally in the advanced cases of tuberculosis. 
 
 As factors which may mitigati; the severity of the symptoms pain 
 and dy.spn(i'a usually noticed on the onset, tnie may c<msider the size of 
 the perforation ; the directness or indirectness of it ; the presence of 
 adhesions, preventing sudden and complete collapse of the lung ; the 
 condition of the patient, whether weakened or not ; the presence of 
 Huid, already calling for considerable accouunoilation to this new con- 
 dition, vi/., the use of one lung. 
 
 I I 
 
11 
 
 The s'ixfns of pneumothorax are as follows : .J h k J 
 
 (1.) Displacement of the heai't and mediastinum!- "^ ^^'f'Y'^^^'^1^' 
 (2) Tympanitic resonance over the greater part of lung area, with 
 
 feeble breathing and dulness at the l)ase. 
 
 (8) Metallic sounds, including metallic tinkling and metallic echo — 
 
 the bruit d'airain. 
 
 (4) Hippocratic succussion. 
 
 1. Displacement of the heart or mediastinum does not always occur 
 it is true, yet so constant a sign is it that it is remarkable how recently 
 oidy it has been described. Notwithstanding the writings of Laennec 
 and others on this subject, it remained to M. Gaide in 1828 to describe 
 and lay special stress upon this as a point in diagnosis. One may 
 readily suppose that in such cases where strong pericardial and pleural 
 adhesions have been formed as well as in those where the opposite lung 
 is consolidated, such a mediastinal displacement would not be found. 
 
 So quickly does this displacement take place that even before the 
 first severe pain following the perforation is over, the heart cannot be 
 found in its normal place. 
 
 1 recall the remark made by the first patient whom I had 
 under ti'eatment with this condition. He was a very intelligent 
 young man recently at Saranac Lake for phthisis. One day after 
 dinner, while lying upon his bed, he was seized with a severe pain in 
 his left side and experienced a faint feeling. " Believing," as he said, 
 " it was heart failure, I put my hand in my bosom to feel my heart 
 beat, but it could not be found in the right place." Shortly after, his 
 physician found the apex of the heart in the region of the right nipple 
 and every characteristic sign of pneumothorax well marked. 
 
 It would appear that such a change of position must arise from one 
 of two possil)le causes, either increased intrathoracic pressure by 
 which the heart and mediastinum are pushed over, or diminished 
 traction of the elastic lung on the affected side, leaving the other in a 
 normal state of elasticity unopposed. From the rapidity with which 
 cardiac displacen\ent takes place, as shown by clinical observation and 
 experiment, it is pretty well establisheil that increased intrathoracic 
 pressure does not at first exist. Again the lung of the affected sitle 
 loses its eiasticit}'. Hence we may believe that the heart is pulltMl, 
 rather than pushed toward the healthy lung. 
 
 2. The characteristic variety of percussion note is readily under- 
 stood, but in this, considt-rabh? variation may Ir- observed owing to the 
 tension of clit'st wall. When pneumothorax occurs, in a very large 
 percentage of those cases when^ life is prolcmged, some form of tiuid 
 exudate developes in the pleura. Generally a purulent pleurisy is in- 
 
 sJs^ 
 
12 
 
 duced, and then the characteristic basic dulness is found, but only 
 after considerable eti'usion has been poured out. 
 
 H. Metallic sounds are not' characteristic of pyopneumothorax, 
 since they are sometimes heard in other thoracic conditions. Yet 
 they are very frequently associated vvitli the condition, and even the 
 coin sound or bndt <rairain may be heard over lar<re smooth-vvalhMl 
 cavities. Indeed, according to Osier's note recently published, this 
 sign was present and a localized pneumothorax was strongly sus- 
 pected. The autopsy revealed a large cavity, the walls of which were 
 covered with " granulation tissue and presented here and there 
 papillary projections which, on section, contained reuuiants of branches 
 of the vessels and bronchi." 
 
 This sign is not always pre.sent, and it has been .seen to vary from 
 time to time in the same subject. 
 
 4. Hippocratic succussion is a conclusive sign, concerning the pres- 
 ence of air (gas) and li(iuid simultaneously within a cavity. 
 
 A (luestion in the iliagnosis of perforative pneumothorax t)ften 
 arises, whether one has a valvular or free opening, or if the case is 
 seen after this condition has been present for some time, whether 
 there be any communication remaining between the bronchus and the 
 pleural sac. Some have urged that one can decide upon this question 
 by observing the character of the breath sounds. If one hears the 
 inspiratory nnirmur and the expiratory umrmur one must conclude 
 that the air enters and leaves the pleural cavity. It would appear, 
 however, from the history of several cases that this is not reliable, 
 Such auscultatory findings show at most, perhaps, that air enters the 
 lung involved and doubtless the changed character of the respiratory 
 murmur is a product of collapsed lung and resonating chamber,— 
 
 the pleura sac. 
 
 Powell, of London, in his work on Diseases of the Lungs and Pleura, 
 holds, on the contrary, that an amphoric respiratory murmur is diag- 
 nostic of a free opening and of special value on this point is the expi- 
 ratory portion of the amphoric sound. 
 
 Conclusions. 
 
 1. There is such a form of pneumothorax as the non-jierforative 
 
 form. 
 
 2. Latent pneumothorax is not infrequent. 
 
 3. Occurring in the course of pulmonary tuberculosis pneumotho- 
 may have a retarding effect upon the disease. 
 
 4. Recovery of a total pneumothorax may take place without any 
 
 sign of fluid. 
 
 5. In the advanced cases of pulmonary tuberculosis, or at any rate 
 rate where the patients were regarded as the subjects of pulmonary 
 tuberculous, fluid is present and the prognosis is grave. 
 
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