A CASE OF RECURRENT PNEUMOTHORAX.

1572

Up to this time, though the fever continued, the patient appeared to be making satisfactory progress, except for the fact that on Jan. 24th she had had pain in the left groin and inner side of the left thigh, with tenderness over the left

A CASE

OF RECURRENT PNEUMOTHORAX.

femoral vein. This, however, subsided in a couple of days BY JOHN CARUTHERS SALE, M.R.C.S. ENG., and was not accompanied by any oedema. There was now no L.R.C.P. LOND. headache, the mind was quite clear, the patient was cheerful, the bowels acted well to daily enemata, the urine was normal ON June 3rd, 1906, I was called to see the patient, a wellexcept for a fine trace of albumin, and food was well taken, consisting of one and a half litres of milk and two eggs daily. developed woman, aged 21 years, by occupation a draper’s During the first fortnight of February the temperature assistant, who complained of pain in the right side of the oscillated between 98° and 100° but on the 14th it began chest and shortness of breath. The history of her illness was again to ascend, reaching 103’6°, with a slight shivering as follows. In July, 1901, she had a cough and began to The general condition remained spit up a little blood. She had never previously had a cough attack on the 20th. excellent. There was no new symptom to account for the except when suffering from an ordinary catarrh. She had rise of temperature. On the 26th a few fresh rose spots whooping-cough in childhood but bad never had pleurisy or appeared on the abdomen. During February the patient and pneumonia. There was no history of tubercle in the family In her nurses observed that she had become extensively freckled but her mother suffers from well-marked acromegaly. on the face, trunk, and limbs, the spots on the last being August, 1901, about three weeks after she commenced to stains as large as a shilling-piece. The patient declared that spit blood, whilst brushing her hair in the morning, she she had never before in her life had any freckling of the suddenly felt a sharp pain in the right side, which was skin. worse on lifting the right arm. She also had a cough, On Feb. 27th blood serum was taken and sent to the was short of breath, and could not lie on her right side. pathological laboratory of the University of Florence for When the pain came on the spitting of blood ceased. She examination of its reaction on typhoid and paratyphoid was seen by a medical man who diagnosed pneumothorax. The examinations were made by Dr. Menini, She was in bed for a month and resumed work at the shop in bacilli. assistant to Professor Lustig, under Professor Lustig’s three months, feeling quite well. She was told at the time personal supervision. The report was returned : "Agglutina- that she had not got consumption. In April, 1902, she had tion test executed March 2nd, 1907, with the blood serum of a similar attack which was not so severe. She stayed at Mrs. -. In the dilution of 1 in 100 at the temperature of home for a week but did not go to bed and did not consult a the room : Negative for the bacillus of typhoid (origin of medical man. In August, 1902, she was again taken with culture, Berlin). Negative for the paratyphoid bacillus A shortness of breath and a dry cough but on this occasion had (laboratory culture). Positive (in about half an hour) for no pain. In each of the years 1903 and 1904 she had two attacks. On three out of the four attacks she was seen by a the paratyphoid bacillus B (laboratory culture)." From Feb. 25th the temperature had been slowly falling, medical man who told her that she had pneumothorax but and on March 2nd and 3rd had not risen above 99°. On that he could discover no signs of consumption. In February, March 3rd the patient began to have pain round the upper 1905, whilst staying at a distance she had another attack part of the abdomen. This pain was very severe during the and was in bed for three weeks. The medical man who night. On the following day the temperature rose with a attended her there told her that it was another attack of slight shivering attack to 101 8°. There was great tender- pneumothorax and that her lungs were not diseased. In April, 1906, she had a further attack but not a severe ness in the right hypochondrium but the outline of the gallbladder could be mapped out, its lower edge reaching to the one. It came on just as she came downstairs. She remained level of the umbilicus. There were no jaundice and no bile at home for a week but did not consult anyone. From then in the urine. The temperature was normal on the 5th and she remained in good health until the day on which I saw remained so for ten days. The tenderness soon subsided, but her. On the night of June 2nd, 1906, she went to bed at the enlargement of the gall-bladder had not wholly dis- 12 o’clock. At 1 A.M. she awoke with pain in the right side appeared even on the departure of the patient from Florence and shortness of breath. When I saw her at 6 A.M. her conin the middle of May. On March 13th fish was allowed and dition was as follows. She was lying on her back ; her face On the 16th the temperature was rather flushed ; her respirations were 32 per minute ; on the 15th minced chicken. began to rise slightly but never above 100° and on the 28th it her temperature was 990 F. and her pulse-rate was 108. On the 19th the patient She had a slight dry cough. The right side of the chest was normal morning and evening. was up for an hour, having been continuously in bed until moved badly but was not immobile. Vocal vibrations were this date from the 26th of the preceding November. At the absent over the whole of the right chest. There was hyperbeginning of April the temperature was again irregularly,resonance all over the right side of the chest ; there was no though but slightly, raised, reaching 100’2° on the 8th anddulness at the base. On auscultation amphoric breathing 9th, and did not become regularly normal until the 19th.was heard over the whole of the right chest; the vocal r es was faint ; there was no metallic tinkling ; On the 8th and 9th there was some return of the tendernesstendresonance The heart was not over the gall-bladder and the patient was kept in bed 1the " bell sound" could be obtained. After she began to walk the left leg (displaced. She remained in bed for three weeks, at the end for three days. and thigh swelled to some extent, with pitting over the(of which time all the symptoms had subsided. The cough The swelling was not great and had already(disappeared in a week and at no time was there any tibia. become less when the patient left Florence in the middle (expectoration. In two months the patient returned to her (employment and at that time on examination her chest of May. The percussion note and CASE 2. Cat2rrlercl ,ja7tndiM " slight feveragglutination aappeared to be quite natural. reaction 7vith paratypkrlid B bacillus.-The patient, aged rrespiratory murmur were equal on both sides, the chest 21 years, who was the daughter of Case 1 and lived in the E3xpanded well, and there were no added sounds. Up to the same apartment, was taken ill with a " bilious attack on1present time--April, 1907-she has remained in good health Dec. 7th, 1906, and developed jaundice with symptoms of eind runs up and down stairs without any discomfort. She obstruction of the outflow of bile. There was slight eleva- 11as had no further cough and her lungs, on examination. tion of temperature, but never above 1000 F. The symptoms aappear to be quite healthy. According to the patient’s account she has had ten attacks rapidly subsided except the slight rise of temperature, which persisted for a week and probably longer, as the patient, 0)f pneumothorax. I think her account can be relied upon, for, feeling quite well, was allowed up and the temperature wasQ o far as I have been able to ascertain, she can invariably no longer taken. During the rest of the winter and spring dliagnose her own condition with certainty. She knows the she was in the best of health. After the blood serum of the omset accurately. There is little shortness of breath as a mother (Case 1) had given such a decided reaction with the rule, but there are usually some pain and a dry irritating paratyphoid bacillus that of the daughter was also sent for c;ough which soon passes off. Between the attacks she has examination at the pathological laboratory of the University n cough or sputum and she has never had any haemoptysis and submitted by Dr. Menini to the same tests on March 6th s’ince the first attack of pneumothorax. In each attack, so with identical results-that is, the reaction was negative f:ar as I can ascertain, there has been a complete pneumowith typhoid and paratyphoid A bacilli, but positive in a t]horax with no sign of fluid at any time during the progress dilution of 1 in 100 in half an hour with paratyphoid B of the case, yet sometimes she is very little affected, at o thers much distressed. bacilli. Possibly the size of the opening naay account for this variation, a small opening causing a Florence.

1573

gradual symptoms.

more

and therefore less

distressing development

of

apparently passed through

the

diaphragm

in its usual

posi-

tion, the stomach thence passing abruptly back again into Most of the reported cases of recurrent pneumothorax the chest through the accessory opening; the pylorus lay in an apparently healthy person have eventually turned out just below this opening ; the other abdominal contents were to be tuberculous in origin. The hemoptysis immediately normal except that the transverse colon passed in a straight preceding the initial attack seems to point to that theory line from the caecum to the diaphragmatic opening, and the in this case, but though it is now nearly six years descending colon, which was empty and contracted to the since the first attack no signs of pulmonary tuberculosis size of a man’s forefinger, passed in have developed and the patient is becoming stouter and more sigmoid flexure. robust. The largest number of attacks of pneumothorax in one person that I have been able to find is four in a case reported by Dr. D H. Gabb in the British Medical Journal of July 28th, 1888, and reprinted by Dr. Byrom Bramwell in vol. iv. of "Clinical Studies." In this case there was no sign of pulmonary tuberculosis. Since the above was written this patient has had another attack of pneumothorax, making 11 in all. The attack came on as she was walking in the street and was not attended by much distress. She insisted on going back to business in three weeks from the onset before the air was entirely absorbed and is apparently none the worse for so doing. Skegness,

a

straight

line to the

The dense adhesions, the characters of the opening, and the shape of the left lung, which was not merely displaced by pressure but had apparently grown into a hollow shell-like covering for the stomach, suggest that the hernia was not recent and not traumatic, and this, together with the unusual extent of the displacement, seems worth

recording. Bridgwater.

Medical Societies.

_________________

OPHTHALMOLOGICAL SOCIETY OF THE UNITED KINGDOM.

Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL. DISLOCATION OF THE CLAVICLE DUE TO PROMI NENT CERVICAL RIB.

Lantern Demonstrations.-Colour Vision.-Syphilitle Affeotions nf the Eye.-Rupture of the Pectinate Liganaent.-

After- Cataract. - Perinaud’s Conjunctivitis. Telangiectasis of Retinal Vessels.-Exhibition of Specimens. A MEETING of this society was held on May 25th, Mr. J. PRIESTLEY SMITH, the President, being in the chair. -

Mr. GEORGE COATS gave

a

lantern demonstration

on

the

Pathology of Rupture of Descemet’s Membrane. This was BY F. D. BENNETT, M.R.C.S.ENG., L.R.C.P.LOND. first discovered microscopically by Becker in 1875. Mr. Coats had found these ruptures in 12 of 13 cases of buphthalmos, THE following case may be of interest as I am unable to and in two of eight cases of glioma with increased tension. find a similar one recorded. were absent in four cases of high myopia. The ruptured They A boy, aged 14 years, of normal physique came before me ends were sometimes found to be flat, and sometimes curled for examination and presented the following condition. On but the rupture itself was almost always covered with up, the left side was a prominent cervical rib projecting to, and endothelium. At times extensive detachment of the memtouching, the clavicle about the centre. At first sight it pre- brane was found. Experimentally he found that the globe sented the appearance of an old fracture of the clavicle with would give way before the membrane would rupture, but if considerable callus around. During the passage of the clavicle the membrane was first scratched many features of the over the end of the rib in elevation or lowering of the shoulder rupture could be reproduced. the sternal end of the clavicle to admit of its passage over the rib was dislocated forwards and returned to its normal position immediately the bone had passed above or below the rib. Owing to the difficulty of photographing the part some x ray photographs do not show the condition as I should have wished. The lad suffered no inconvenience and was unaware of any abnormal condition. Weymouth-street, W. A CASE OF OLD-STANDING DIAPHRAGMATIC HERNIA DISCOVERED POST MORTEM. BY PENROSE

WILLIAMS, M.R.C.S. ENG., L.R.C.P. LOND.

A MAN, aged 77 years, was admitted to the Bridgwater under my care for haematemesis with a history of in swallowing and wasting of several months’ duration; he died rather suddenly within 40 hours. At the necropsy the left side of the chest from the diaphragm to two inches above the horizontal nipple line was found to be occupied by an oval cystic swelling which proved to be the stomach. Behind it was a coil of intestine consisting of the whole of the transverse colon, part of the ascending colon, and the great omentum. The heart was displaced to the right, being entirely on that side of the middle line, and completely covered by portions of the right and left lungs. The right lung occupied a normal position but the left lung was pushed upwards and to the right and was shaped to accommodate the stomach. In the diaphragm to the left of the middle line and posteriorly was a horse-shoe shaped opening, having its convexity forwards and bounded posteriorly by the chest-wall ; the margin was smooth, rounded, and thickened, and terminated behind in two I I crura,one overlapping the other; the opening admitted four fingers on the fiat, or the whole hand cone-shaped. The omentum was firmly adherent to the margin of the opening, the upper surface of the diaphragm, the chest-wall, and the left lung, and the fundus of the stomach was adherent to the left lung. The oesophagus ’

Hospital difficulty

Dr. F. W. EDRIDGE-GREEN gave an account of his observations with Lord Rayleigh’s Colour-mixing Apparatus and showed a table which brought out the fact that there were extraordinary differences in the way in which people were able to match the colours. This was not due to any physical condition present but could be readily explained physiologicallv in accordance with his (Dr. Edridge-Green’s) theory of colour vision, Dr. ALEXANDER BRUCE gave a lucid lantern demonstration of the Third Nerve Nucleus and its surrounding

parts.

Mr. SYDNEY STEPHENSON described the present position of the Spirochæta Pallida in Relation to Syphilitic Affections of the Eye. After briefly reviewing the evidence in favour of the spirochæta pallida being the specific element of syphilis he described the special researches which had been made In congenital on the eyes of man and the lower animals. syphilis the organism had been found by Stock, Peters, Rooaer, Bab, and himself. He detailed the experiments of other observers who had produced interstitial keratitis in the eyes of monkeys and rabbits with syphilitic material from man and had found spirochætæ in the lesions thereby produced. As regards clinical syphilis of the eye, the organism had been found by himself and other observers, and he expressed his belief that the presence of Schaudinn’s organism was the strongest possible proof of the syphilitic nature of any given disease of the eye or of any of its

appendages.

Dr. LESLIE BUCHANAN showed a series of lantern slides of of Invertebrates with the object of the anatomical structure a certain amount of information can be obtained as to the degree of functional activity of which the organ is capable. The preparations included sections of the eye of the octopus, the clam, the spider, the caterpillar, the house fly, the bee, and the snail. Sections of the eye of the Australian mole and of the leech were shown to illustrate the fact that loss of functional activity leads to anatomical degeneration. Dr. BUCHANAN also demonstrated a case of Rupture of

Preparations of Eyes indicating that from