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 Papers by the Staff 
 
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 OF THE 
 
 MEDICAL FACULTY, 
 
 MeGlLL UNIVERSITY. 
 
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 Class _J»J.-^A 
 Book -- .I'LL: 
 
 SMITHSONIAN DEPOSIT 
 
 
 -V3.-«i««cr« -■ 
 
imf. 
 
 #' 
 
 PNEUMOTHORAX FROM GAS-PRODUCING BACTKIUA. 
 
 FrarFINLEY, M.D., 
 
 Aslsstant Professor of Medicine and Associate Professor of Clinical Medicine, McCill 
 University ; Pliysieian to the Montreal OenL-ral Hospital. ^ 
 
 Repriuted from the Montreal Medical Journal, Oclootr, 1899. 
 
 <EV5i<®> 
 
•■ ■ ^ ^ J 
 
 1 
 
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is-. 
 
 PNKUMOTUOU.VX I'UOM (i ASPUODUCINrr MACrrURl A * 
 
 I > 'i' 
 
 F. (;. Ki.M.KV, M.l)., 
 
 A«8lMtttiil l'rufes,sor of Medicine im.l AHsnci.Ue PiofusHorof Cllnlciil Me.Uciiie, MdJili 
 
 University ; I'liyslcian to ilie Moiitreiil Uii.erai HoHpltiil. 
 
 The pri'soiicc! (.f yi»s in H'l' pli'iini williout perforation is .'.ii ol<l (iins- 
 tion with incdioal autiiorities. J/viinoc bolievinl tiiat a soc-reti-.m ol' gas 
 could take place in a healthy pleup, ami allhoU{-h this view was con- 
 .sidered untenable for a loyg period, yet subsefiuent writers have regarded 
 it as probable that an evolution oi' gas may occur in certain pathological 
 conditions. Senator-)- states his views on this subject very clearly. He 
 considers that the gases held in solution by fluids in the pleural cavity 
 may escape in accordance with physical laws, provided that tlic pressure 
 is diminished by retraction of the lung, but that such an amount can 
 only be inconsiderable. Further, however, he considers that purulent 
 fluids undergoing decomposition in the pleura can evolve gases. This 
 argument is supported by the facts that subcutaneous emphysema rtiay 
 occur in a limb in the ab,sence of any external wound, and also by the 
 presence of gas occasionally noted in phlegmons. 
 
 It is, however, only within the last four years that any facts have been 
 brought forward placing such -■^-^s on a scientific basis Welch's;}: dis- 
 covery, of the bacillus capsulatus aerogenes, followed by numerous patho- 
 logical observations, remove all doultt as to the production of gas in 
 living tissues by bacteria. In one of Welch's cases pneumo-peritonitis 
 was present without perforation. A large number of his cases involved 
 the abdominal organs (13 out of 23.) 
 
 The following case, although primarily one of subdiaphragmatic 
 abscess rupturing into the phnira, is a good example of a pneumothorax 
 due to gas production by the bacillus coli. 
 
 J. W., cTt 46, a deaf-mute, was admitted December 26th, 1898, to the 
 surgical side of the Montreal General Hospital for sudden severe pain 
 in the abdomen, which -his physician regarded as appen*c;itis. Dr. 
 Hutchison, under whose care he was placed, found no evidence of abdo- 
 minal disease but some days later discovered signs of fluid at the right 
 base, and on aspirating some clear serum was removed. He was trans- 
 ferred to the medical ward on January 21th, and his condition was 
 noted as follows : — 
 
 The patient is emaciated, anxious and prostrate; the skin dry and 
 
 *^einl l)y title at tlie Canadian Medifiil Association, Toroito, September 1, ]899. 
 
 t Senator, Deut. Zeit. fur Med. II. 
 
 J Welch and Flesner, Journal of Exj>. Med. 1. 
 
 II 
 
 H 
 
loiM 
 
 F. p.m.; lospimtion labored 40; 
 
 hot; temperature, l)0*lr." K.a.m. .- - 
 
 the brcuth foul, pul.e IIU and reachly oon.presH bio. 
 
 1' and il" lugK to tl,o back, n.ul tl.cro i, .li.tinct """"''f 7; /"= 
 
 St :tu„a. arc 'ligl^tly ...Ccebled ,.vor other l'"''"-; ,*; ."f^ee 
 
 (In tlic 28th an nwiirntinf "cc<ll» »a» intioduc^d in the 8th spaco 
 
 p„r:'rV.nd t»..n, onn«. o. -^^^^ ^ ;^:^^:t^ 
 
 coagulated immediately in the bottle. ^.^^^^.P''^'' _,f ^" . f„,ther 
 Jh as before but the metallic respiration ^-PPf^!^,^/^; ™ 
 progress of the case was progressively downward . he Pjtration 
 progress .^,,„„^.raturo continued nu.derately elevated 100 , 101 , 
 
 ZZmo , ^tpS became rapid and weaK, and death took place from 
 exhaustion on February 4th. 
 
 Repeated examinations of the rather scanty sputum always faded to 
 
 show tubercle bacinlli. t t i 
 
 Abstract of autopsy performed by Dr. Wyatt Johnston :- 
 
 t^:Z^Z^V^r surface of the right lobe of the liver 
 JZ diaphragm. On pouLg water over the P-toral — ^ -- 
 the axillary line a few bubbles of gas escape on piercmg the chest wall. 
 The right pleura shows some adhesions anteriorly and in the axdla, 
 whilst below it is densely adherent and nearly a quarter of an inch thick 
 There is a thick-walled sac in the pleura posteriorly containing fetid 
 pus After removing the organs en masse, this cavity is found to com- 
 Lnicate by an opening admitting a ^tnger with a space between the 
 H,rht lobe of the liver and the diaphragm, and which contains pus 
 similar to that in the pleura. There is no communication between 
 either cavity and a bronchus, as tested by air and water pressure. There 
 was an acute splenic tumor, but otherwise the abdomen was normal, the 
 appendix and its neighborhood being free from disease. Bacteriological 
 examination showed a mixed culture consisting principally of the bacil- 
 lus coli with proteus. , ,. , ,, * +v. 
 
 The diagnosis during life was that of a localised pneumothorax at the 
 base of the lung. The cause of this was, however, very obscure. There 
 
)ored 40; 
 
 ■iglit aitVj 
 the lU'th 
 •eaoimnt ; 
 
 as far as 
 higluM' in 
 
 is liearel 
 jr axillary 
 osturiorly. 
 Lly feeble, 
 lie: brcath- 
 ;ion. The 
 e lung. 
 8tli space 
 off, which 
 
 remained 
 he further 
 prostration 
 00°, 101°, 
 place from 
 
 ^B failed to 
 
 of the liver 
 luscles near 
 3 chest wall. 
 1 the axilla, 
 1 inch thick, 
 aining fetid 
 und to corn- 
 between the 
 3ontain8 pus 
 ion between 
 sure. There 
 1 normal, the 
 acteriological 
 of the bacil- 
 
 thorax at the 
 icure. There 
 
 was no evidence of tuberculosis of the lung. Imc.lh l^^'''« ^""'-'''"^^y 
 absent In.u the .putu.n. The pus.Mb.niy of a lO'-i-unu, homx jb- 
 nhrcnieus was considered, but against this was the absence of any down 
 a^d displacen.ent ..f the liver and, in add.ti..n, the heart wa.. d.plaoe. 
 to the right, a sign which .s sa.d to be counnouly ab.,eut lu coUecl.ons 
 
 below the diaphragm. , , . , 
 
 The conditions actually found were rather peculiar. An old th ..< 
 llrm abscess wall was seen, bounded below by the liver and above by bo 
 .liaphragm. This cavity had no cummunicalion with any oi the hollow 
 abdominal v.cera, nor was any source of such an abscess discovered m 
 the abdomen. The lung, winch had been pushed up had l<>' '"^j "^ «. ;■ 
 cular ring of adhesions on its pleur.(l surface to the ehestwa 1 dividing 
 the pleural cavity into an upper and lower chamber, iho latter con - 
 municated by a perforation in the diapiiragm with the sub-d,aphragmatic 
 abscess which had hitherto been latent. 
 
 That the presence of gas was not due to any communication with any 
 of the hollow abdominal viscera is clearly shown by the anatomical con- 
 ditions, and the presence of a gas-producing bacillus, the bacil us coli, , 
 seems the only explanation of the presence of gas in the pleural sac 
 
 So few cases have hitherto been reported of pneumothorax resulting 
 from gas-producing organisms, that a synopsis of three previous cases 
 
 uiay be given. . . 
 
 Levy * writing in 1895, describes a case in a man aged 48, beginning 
 with cough, pain in the left side and fever. Examination showed a lett 
 Pided pleurisy. After four aspirations, three months after the onset ol 
 the illness, there was evidence of pneumo-thorax. Owing to dyspnoea 
 the operation for empyema was performed, but the patient sank and died. 
 At the autopsy tliere was bilateral pleurisy and pericarditis with l.o 
 litres of reddish yellow fluid in the right pleura, and in the upper third 
 of the right lung a firm focus, the size of an egg, containing whitish 
 caseous masses. A small yellow nodule was present on the sniall intes- 
 tine and a number on the under surface of the diaphragm. The pleu- 
 ritic' exudate removed during life showed the presence of an anaerobic 
 bacillus, identical with that previously found by Pr^nkel in gas phleg- 
 mons and subcutaneous emphysema and subsequently identified as 
 Welch's bacillus capsulatus aerogenes. The bacillus produced gas both 
 in cultures and in living tissues. , /ox i • 
 
 This case seems, then, to have originated as a tubercular (?) pleurisy 
 with effusion, subsequently infected with the bacillus aerogenes. 
 
 A. G. Nichols,* of Montreal, has recorded^ a case which is less open to 
 
 " • Levy, Ueber a.M. Piie^it.othonvx ohne Perforation, Arch, fiir Kxp. Pharnm 
 
 koloftle, Bd. :«, SIS- 
 
 • Nicholla, Notes on some ca.sea orinfooHon'by the bacillus aeroKene8 capsulatus, 
 British Medical Journal, 1H97, II., p. 1B4J. 
 
ll 
 
 J . 
 
 crifi.'iMM tl.ai, ui.y that l.uv. ha-ii pul.liHliod yot, imiH.imch an g.. dcvol- 
 oiMxl ill the plfuml ami ptirinudiiil cuvitica. 
 'Vho pali.nt. a n.alo. ..t. n, «u* ad.nittod to the IJoyal Vi.^tona Uns,ntal 
 lor Hrveiu alMl.mnnal pan., l.o;;inniMg mx .lays pr.vioUHly. ilu're wuh 
 t.vi.l.iur ..r nonlo.nl.s a.ul a .iiagnn^.s .,f lu-rlurativo api.ou.lic,ti» WUH 
 um.lo. wlu.l, was c.mlinn.d l.y ..pcTuli.-n. A lol't-.ide.l pleurisy wan 
 prenent on adinisHion, n,ul lour dayn later evideii.e ..f pneun.nnia, ami a 
 Imv days later right pi.euinotliorax and pneuin..p.Ti(anliuin were .lis- 
 tinctly recoguised. Sepl.e Hy.npKm.s w. re pr..K...it hut there was lu. 
 HU.I.leu imin ..r e.llap.e «« Ih eo.ninonly louml in perforative pn.ni.iin- 
 th.mix N.. communicallun w.is present helween the ul.lon.mal an.l 
 thoraeie eavitics, ami the case wa. thus elearly .me ..t K^s pn.dm.tinn in 
 llu. pleura and laTieanliun.. 'I lie autopsy lully e...ilinii.'d the al.ove 
 comlitions. ami the Imeilliis capsulutns aerogenes was suhse<iuently dis- 
 covered ni seetions staine.l by Urain-WeiKerfs nieil>..d. Anaen.h..^ eul- 
 tures were not made, as the ease oeeurre.l j.revious to Weleh's puhl.eali.m. 
 
 May and (Jebhart.* , 
 
 A male, a't. Ul, stal.l.e.l lumselt twiee in the cardiac region, witli a 
 dagger wh'ieh had been prevh.usly used on another f..r a similar purpose. 
 The wounds were aj.parently trilling, and healed .piiekly, but the tem- 
 perature remained elevated and ^igns of fluid developed m the lett 
 pleura, and on aspirating a .luaiitity of cl.mdy and markedly ha^morr- 
 hagie exudate was drawn oiV. A fortnight after the w.)un.l oeeurred 
 evidence of pneumothorax was distinct. The gas when drawn olf lit 
 with a bluish flame. 
 
 I'ericardial exudation deveh.ped, and in spite of incisions into both 
 the pleura and pericardium, the patient died. 
 
 The autopsy confirmed the diagnosis, tlie anatomical diagnosis read- 
 ing :— Subacute, h i.led, purulent pleurisy and pericarditis, following 
 
 a stab in the left siu^. 
 
 The bacillus coli and staphylococcus pyogenes were found in the exu- 
 date. Careful analysis of the gas from the pleura showed that it con- 
 sisted of CO.,, II, & N, but no 0. The presence of a gas (II) not con- 
 tained in atmospheric air proves clearly the production of gas in the 
 
 pleural cavity. 
 
 In all of tliese four cases the proof that gas was evolved by bacteria 
 is very conclusive, and it may therefore he accepted that such an event 
 occasionally occurs. That such cases are rare is evident by the very 
 scanty literature on the subject, but like other rare conditions, it may he 
 more frequently found if looked for. 
 
 In two cases the bacillus aerogenes capsulatus was present, and in two 
 
 f May and (Jebhart, Uelx>r Pneumothorax durch Giisbildeads Bakterion, Deuf 
 Arch, fur Klin. Med., Bd. 01, p. ;i2;i 
 
"■"""H*" 
 
 rn iltvol- 
 
 'hlTU WllH 
 
 ifitis wiiH 
 
 liii. an<l a 
 
 •0 was no 
 pneuuio- 
 iiiiiiil and 
 luclinii ill 
 tlio a!)()vu 
 lently dis- 
 ^riiliH! ciil- 
 jblk-alioii. 
 
 >ii, witli a 
 r purpose. 
 t the tem- 
 n the left 
 y haimorr- 
 l occurrutl 
 iwn olf lit 
 
 into both 
 
 nosis read- 
 !, following 
 
 in the exu- 
 ,hat it con- 
 I) not con- 
 gas in the 
 
 by bacteria 
 ?h an event 
 jy the very 
 s, it may be 
 
 and in two 
 Lterion, Deuf 
 
 the b.icillUH coll. With our pn-m-nt hiv ..y kiiowlclgo on thn Huhj.;cl it 
 i8 dllliciilt to t;,lahliHli rtatisractonly any dia^'imslir points. It sviU lu' 
 noiuni, howrv.T. that in thiw ol' tho lour casi-n thcro was alulominal 
 dihi-uHi-. and in the r.'ii.aininK one u rijrin swiiy to have Ihhmi a wouiul 
 infection. In Nichols" case I lie evidence of alidoininal distsisi! (appon- 
 diciliHl N.as dislinct diring life, in Levy's case there was tul.en;ulo.sii 
 of the I (.litoneiiin, di.seovered only at the autopsy, and in my own the 
 snlxliaphraKniatic ahscesn was doubtless infected by the bacillus coli 
 froM the intestine. The freiiueiicy with which the abdominal organs 
 are alfected by the bacilUis capsulaturf uerogenes, and the constant 
 presence of the gas-pnubicing bacillus coli in the large intestine, are in 
 accord with the clinical features of three of the recorded cases, and where 
 there is evidence of ab.loniinal dimise with subse.pient pneumothorax, 
 the p(.ssibilily of the jjiodiiction of gas by bacteria is worth bearing in 
 uiimi. 'i'he onset of the condition .seems commonly to be gradual, and 
 not abrupt, as is usual in pneumothorax. 
 
 May lays much stress on a chemical analysis of the gases. He points 
 out that a cavity may become infecte.l by air-producing bacteria,, and 
 ye'i. the pneumothorax be due to communication with the external air. 
 The presence of a gas in the cavity, not found in atmospheric air,'may 
 therefore be regarded as a proof of its zymotic cliaracter. 
 
 In May's case hydrogen was present in sullicient quantity to burn, and 
 this ,simple test, if con.4antly present, may serve to replace the more 
 elaborate method of chemical analysis. It may he remarked that the 
 bubbles of gas produced by the bacillus capsulatus aerogcnes are also 
 inllammable. 
 
 In conclusion, it may be now accepted :-(l) That pneumothorax 
 may in exceptional cases result from gas-producing bacteria, and that 
 the bacillus coli or bacillus capsulatus aerogcnes may be the organism 
 concerned, {-i) That the presence of hydrogen or other gases not found 
 in the atmosphere is conclusive proof of this condition being induced by 
 gas-producing bacteria (May).