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Massive atelectasis of the lung following pelvic fracture
vCASE
REPORT&
MASSIVE ATELECTASIS OF THE LUNG FOLLOWING PELVIC FRACTURE* HARRY 0. VEACH, nh4.s. (HARv.),
M.D.
NEW YORK ASSIVE ateIectasis of the Iung has been reported frequentIy as a seque1 of abdomina1 operations, chest wounds, and postdiphtheritic paraIysis.l ReIativeIy few cases are on record, in which this condition has however, foIIowed simpIe fracture.2 The present case beIongs to the Iatter cIass, being one of peIvic fracture foIIowed by massive ateIectasis of the Ieft lung. It aIso iIIustrates we11 the dispIacement of the mediastina1 structures to the Ieft.
M
F. T., a well-deveIoped white maIe, thirty-two years of age, was admitted to Staten IsIand Hospital March I 2,1928. He had sustained an injury from a faIIing heavy box, and as a resuIt he compIained of pain in the Ieft groin and the sacra1 region. PhysicaI examination revealed moderate tenderness in these regions, but the skin was intact and there was no sweIIing nor ecchymosis. The examination otherwise was quite negative. No Iesions were found in the head, neck, thorax, abdomen, or extremities. A roentgenogram of the entire trunk was taken on admission. This showed that the Iungs were of equal density, that the heart was 1ConsuIt the folIowing for a more extensive consideration of this subject: a. PASTEUR, W. Brit. J. Surg. I: 587-601, 1914. b. ELLIOT, T. R., and DINGLEY, L. A. Lancet, I: 1305-13o9, 1914. c. BRADFORD, SIR J. R. Oxford Medicine, II: 127-137. d. LEE, W. E. Ann. Surg., 79: 506-523, 1924. e. JACKSON, C., and LEE, W. E. Ann. Surg. 82: 364; 389, 1925, and Trans. Amer. Surg. Ass’n., 43: 723-766, 1925. j. SCOTT, W. J. M. Arch. Surg. IO: 73-116, 1925. g. CHURCHILL, E. D. Arch. Surg. I I: 489-518, 1925. 2 Cf. a. RIGLER, L. G. Minnesota Med., g: 326-333, 1926. b. EDKIN, D. K. Ann. Surg., 86: 885-889, 1927. * Submitted
norma in position and size, and that there were no fractures above the pelvis. The folIowing pelvic fractures, however, were reveaIed: an obIique fracture through the pubic crest on the Ieft side; a fracture through the inferior ramus of the Ieft pubic bone at the ischiopubic junction, and a separation of a small fragment from the inferior border of the superior ramus of the Ieft pubic bone sIightIy anterior to the iIiopubic junction. These fractures are designated by arrows in Figure I. The daiIy progress of the case may be presented as foIIows: March 12. Patient resting comfortably. Temperature at 4 P.M., 99.4’~. March 13. Temperature at 8 A.M., 98.6”~. The patient rested comfortabIy tiI1 I I A.M. when his face began to fIush and his respiratory movements became Iabored and moderately increased in rate. His puIse and temperature rose markedIy. At 12 noon, the Iatter was I OI .O’F. and it continued to rise to its maximum of 104.2’F. at 4 P.M. Examination of the chest at I P.M. showed absence of breath sounds, tIatness to percussion and absence of tactiIe voca1 fremitus on the Ieft side beIow a transverse pIane passing through the xiphisternum. At 3 P.M. these physica findings were eIicited over the entire Ieft side of the chest beneath a horizonta1 plane through the third Costa1 cartiIage. A roentgenogram taken at 3 P.M. showed a dense shadow obscuring a11 Iung markings in the lower two-thirds of the Ieft side of the chest. It also showed a definite displacement of the heart and mediastinal structures to the left (Fig. 2). The patient’s Ieucocyte count at 9 P.M. was 12,300, there being a distinct polymorphonucIeosis.
for publication 817
January
18, 1929.
818
American Journal of Surgery
Veach-AteIectasis
March 14. The cIinica1 picture remained practicalIy unchanged tiI1 r2:30 A.M., when the patient began to cough, expectorating a thick,
FIG. I. Roentgenogram of involved portion of pelvis, taken &larch 12, 1928. Fracture positions indicated by arrows.
tenacious, greyish-white mucoid sputum. It contained no bIood and was found negative for tubercle baciIIi. SeveraI hours Iater, breath sounds began to be audibIe over the Iower two-
FIG.
2.
Roentgenogram
of chest taken at 3 13.
P.M.,
March
thirds of the Ieft side of the chest. TubuIar breathing was heard at the angIe of the Ieft scapuIa and anteriorIy at the base of the Iung. At the same time, tactiIe voca1 fremitus returned.
of Lung
JUNE, r9.q
March 15. The patient continued to cough and expectorate sputum of the character described, and he was instructed to Iie on his right side to faciIitate drainage of the Ieft bronchi. The breath sounds became more nearIy normaI over the affected region of the chest. The patient’s Ieucocyte count was I I ,200 with a definite poIymorphonucIeosis. March 16. The patient continued to cough and expectorate the characteristic sputum. A second roentgenogram was taken which showed a marked decrease in the density of the shadow in the Ieft Iung, though the heart and mediastina structures remained considerabIy dispIaced to the Ieft. This picture aIso showed that the Ieft dome of the diaphragm was somewhat eIevated. (Fig. 3). Murcb 17. There was IittIe change in the clinica picture, except that the temperature was showing a definite tendency to return to normaI. The patient continued to cough and expectorate the characteristic sputum. Mud I 8. On this day, the temperature did not rise above normal. The patient coughed Iess and rested more comfortabIy than previousIy. Murcb 19. The temperature remained norma1, and the puIse and respiratory rate had
FIG. 3.
Roentgenogram
of chest
taken
March
16.
become, by this time, practicaIIy normal. Expectoration of the bIoodless, mucoid sputum ceased. March 20. The temperature remained norma1. A roentgenogram of the chest showed that
Nljw SERIES VOL. VI, No. 6
Veach-AteIectasis
the shadow on the Ieft side had practicaIIy disappeared and that the heart and media&a1 structures had returned almost to their normal position. SIight eIevation of the left side of the diaphragm, (Fig. 4).
however,
of Lung
American JOWWJof surgery
819
empIoyed, the patient being instructed to Iie on his unaffected right side and to cough freely.
stil1 persisted
Here, then, is a case of massive ateIectasis of the left Iung which deveIoped about thirty hours after fracture of the peIvis. Within twenty-four hours after the onset of this condition of ateIectasis, it began to resoIve, the patient expectorating probably from 30 to 50 c-c. in a11of mucoid, bIoodIess sputum. Resofution was progressive, with the resuIt that the temperature had returned to normal five days after the onset of the atefectasis, and the chest had returned practicaIIy to norma seven days after its onset. PosturaI treatment was
FIG.
4.
Roentgenogram
of
chest
taken
March
20.
REPORT&
MASSIVE ATELECTASIS OF THE LUNG FOLLOWING PELVIC FRACTURE* HARRY 0. VEACH, nh4.s. (HARv.),
M.D.
NEW YORK ASSIVE ateIectasis of the Iung has been reported frequentIy as a seque1 of abdomina1 operations, chest wounds, and postdiphtheritic paraIysis.l ReIativeIy few cases are on record, in which this condition has however, foIIowed simpIe fracture.2 The present case beIongs to the Iatter cIass, being one of peIvic fracture foIIowed by massive ateIectasis of the Ieft lung. It aIso iIIustrates we11 the dispIacement of the mediastina1 structures to the Ieft.
M
F. T., a well-deveIoped white maIe, thirty-two years of age, was admitted to Staten IsIand Hospital March I 2,1928. He had sustained an injury from a faIIing heavy box, and as a resuIt he compIained of pain in the Ieft groin and the sacra1 region. PhysicaI examination revealed moderate tenderness in these regions, but the skin was intact and there was no sweIIing nor ecchymosis. The examination otherwise was quite negative. No Iesions were found in the head, neck, thorax, abdomen, or extremities. A roentgenogram of the entire trunk was taken on admission. This showed that the Iungs were of equal density, that the heart was 1ConsuIt the folIowing for a more extensive consideration of this subject: a. PASTEUR, W. Brit. J. Surg. I: 587-601, 1914. b. ELLIOT, T. R., and DINGLEY, L. A. Lancet, I: 1305-13o9, 1914. c. BRADFORD, SIR J. R. Oxford Medicine, II: 127-137. d. LEE, W. E. Ann. Surg., 79: 506-523, 1924. e. JACKSON, C., and LEE, W. E. Ann. Surg. 82: 364; 389, 1925, and Trans. Amer. Surg. Ass’n., 43: 723-766, 1925. j. SCOTT, W. J. M. Arch. Surg. IO: 73-116, 1925. g. CHURCHILL, E. D. Arch. Surg. I I: 489-518, 1925. 2 Cf. a. RIGLER, L. G. Minnesota Med., g: 326-333, 1926. b. EDKIN, D. K. Ann. Surg., 86: 885-889, 1927. * Submitted
norma in position and size, and that there were no fractures above the pelvis. The folIowing pelvic fractures, however, were reveaIed: an obIique fracture through the pubic crest on the Ieft side; a fracture through the inferior ramus of the Ieft pubic bone at the ischiopubic junction, and a separation of a small fragment from the inferior border of the superior ramus of the Ieft pubic bone sIightIy anterior to the iIiopubic junction. These fractures are designated by arrows in Figure I. The daiIy progress of the case may be presented as foIIows: March 12. Patient resting comfortably. Temperature at 4 P.M., 99.4’~. March 13. Temperature at 8 A.M., 98.6”~. The patient rested comfortabIy tiI1 I I A.M. when his face began to fIush and his respiratory movements became Iabored and moderately increased in rate. His puIse and temperature rose markedIy. At 12 noon, the Iatter was I OI .O’F. and it continued to rise to its maximum of 104.2’F. at 4 P.M. Examination of the chest at I P.M. showed absence of breath sounds, tIatness to percussion and absence of tactiIe voca1 fremitus on the Ieft side beIow a transverse pIane passing through the xiphisternum. At 3 P.M. these physica findings were eIicited over the entire Ieft side of the chest beneath a horizonta1 plane through the third Costa1 cartiIage. A roentgenogram taken at 3 P.M. showed a dense shadow obscuring a11 Iung markings in the lower two-thirds of the Ieft side of the chest. It also showed a definite displacement of the heart and mediastinal structures to the left (Fig. 2). The patient’s Ieucocyte count at 9 P.M. was 12,300, there being a distinct polymorphonucIeosis.
for publication 817
January
18, 1929.
818
American Journal of Surgery
Veach-AteIectasis
March 14. The cIinica1 picture remained practicalIy unchanged tiI1 r2:30 A.M., when the patient began to cough, expectorating a thick,
FIG. I. Roentgenogram of involved portion of pelvis, taken &larch 12, 1928. Fracture positions indicated by arrows.
tenacious, greyish-white mucoid sputum. It contained no bIood and was found negative for tubercle baciIIi. SeveraI hours Iater, breath sounds began to be audibIe over the Iower two-
FIG.
2.
Roentgenogram
of chest taken at 3 13.
P.M.,
March
thirds of the Ieft side of the chest. TubuIar breathing was heard at the angIe of the Ieft scapuIa and anteriorIy at the base of the Iung. At the same time, tactiIe voca1 fremitus returned.
of Lung
JUNE, r9.q
March 15. The patient continued to cough and expectorate sputum of the character described, and he was instructed to Iie on his right side to faciIitate drainage of the Ieft bronchi. The breath sounds became more nearIy normaI over the affected region of the chest. The patient’s Ieucocyte count was I I ,200 with a definite poIymorphonucIeosis. March 16. The patient continued to cough and expectorate the characteristic sputum. A second roentgenogram was taken which showed a marked decrease in the density of the shadow in the Ieft Iung, though the heart and mediastina structures remained considerabIy dispIaced to the Ieft. This picture aIso showed that the Ieft dome of the diaphragm was somewhat eIevated. (Fig. 3). Murcb 17. There was IittIe change in the clinica picture, except that the temperature was showing a definite tendency to return to normaI. The patient continued to cough and expectorate the characteristic sputum. Mud I 8. On this day, the temperature did not rise above normal. The patient coughed Iess and rested more comfortabIy than previousIy. Murcb 19. The temperature remained norma1, and the puIse and respiratory rate had
FIG. 3.
Roentgenogram
of chest
taken
March
16.
become, by this time, practicaIIy normal. Expectoration of the bIoodless, mucoid sputum ceased. March 20. The temperature remained norma1. A roentgenogram of the chest showed that
Nljw SERIES VOL. VI, No. 6
Veach-AteIectasis
the shadow on the Ieft side had practicaIIy disappeared and that the heart and media&a1 structures had returned almost to their normal position. SIight eIevation of the left side of the diaphragm, (Fig. 4).
however,
of Lung
American JOWWJof surgery
819
empIoyed, the patient being instructed to Iie on his unaffected right side and to cough freely.
stil1 persisted
Here, then, is a case of massive ateIectasis of the left Iung which deveIoped about thirty hours after fracture of the peIvis. Within twenty-four hours after the onset of this condition of ateIectasis, it began to resoIve, the patient expectorating probably from 30 to 50 c-c. in a11of mucoid, bIoodIess sputum. Resofution was progressive, with the resuIt that the temperature had returned to normal five days after the onset of the atefectasis, and the chest had returned practicaIIy to norma seven days after its onset. PosturaI treatment was
FIG.
4.
Roentgenogram
of
chest
taken
March
20.