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SPONTANEOUS PNEUMOTHORAX
1298 of Meniere’s disease ; in 11the attacks of These results, he claimed, led to the ceased. vertigo " inescapable inference that the internal ear is not the sole ... portion of the nervous system from which the symptoms of Meniere’s disease derive [and] that these symptoms may be mediated by way of sonic and equilibratory afferent fibres in the chorda tympani." Rosen now describes 2 cases of what he believes to be Meniere’s disease, both unilateral and both with dead labyrinths on the affected side. The persistence of " Meniere attacks " despite a dead labyrinth he takes to be further evidence of some extralabyrinthine pathway by which symptoms are produced. In both cases the vertigo ceased after section of the chorda tympani. Of these 2 patients, 1 had had a fractured skull, after which " there was total absence of caloric response and total loss of hearing " on the affected side ; in the other case the symptoms developed after mumps. Both fracture of the skull and mumps are recognised causes of unilateral perceptive deafness. Fowler and Zeckelpursue the search at a higher level. They declare that " certain personality types tend to develop tinnitus and perhaps vertigo under stress." The attacks, they find, are associated with certain types of life stress, including personal antagonism, sexual abstinence in the male, sexual conflicts in the female, and death of a near relative. Fowler and Zeckel do not, however, give convincing evidence of Meniere’s disease in the 23 cases on which their report is based. In those cases where the deafness is described in detail, it is said to have been for low tones ; whereas in Meniere’s disease the loss is for high tones. It cannot be said that great strides have been made in the attack on this troublesome disorder.
in 14
cases
HALLUX VALGUS
CORRESPONDENTS, commenting on a leading article,8 have expressed the view that the badly shaped shoe is the main cause of hallux valgus. This is not the only cause-even in some peoples habitually going barefoot hallux valgus is not uncommon 9-but the evidence that shoes force the toes out of line is difficult to refute, and their deforming action is almost certainly the major aetiological factor in most cases of hallux valgus. If we accept this, what are we going to do about its’? There has long been a tendency to reverse the Victorian custom by which the foot had to fit the shoe rather than the shoe the foot. Knowles 10describes an instance of an adult with mild hallux valgus who for three and a half years wore shoes, made on a special last, which were basically triangular and had a perfectly straight inner border. Foot symptoms were immediately relieved, and the degree of hallux valgus was materially lessened. In this country Mr. Pratt 11 has been pressing for the introduction of shoes with a straight inner border. Shoes with a truly straight inner border are difficult to obtain ; but some makers 12 specialise in shoes with fairly stringent inner borders. There would be, of course, no difficulty in producing such shoes if the necessary lasts existed. The trade, through the knowledge gained by the British Boot, Shoe, and Allied Trades Research Association, is well aware of the physiological need for these shoes. But two things militate against such a change. First, it would be very expensive to change every last ; secondly, few people-and hardly any women-would buy the The pioneer manufacturer of this type of new shoes. shoe will meet a small demand from the highly footconscious ; but unless the change is introduced simultaneously throughout the civilised world, with the support 7. 8. 9. 10. 11. 12.
Fowler, E. P. jun., Zeckel, A. Psychosom. Med. 1953, 15, 127. Lancet, Feb. 14, 1953, p. 331. Kalcev, B. Ibid, 1952, ii, 937. Knowles, F. W. Med. J. Aust. April 25, 1953, p. 579. Pratt, C. A. Lancet, April 11, 1953, p. 746. For example, Messrs. Hardy and Son, 6, Baker Street, London, W.1. See Lancet, May 9, 1953, p. 956.
see no prospect of the demand not is that the new shape of shoe would It increasing. be intrinsically ugly ; in such matters it is simply a matter of what one is used to (vide men’s hats). The change could, we suppose, be introduced step by step if the trade and their designers agreed that they would .gradually make shoes with straighter and straighter inner sides. But what stimulus is there for them to follow this costly course, so much against their immediate interests ?f There is only one rapid solution. At the command of a Schiaparelli or a Christian Dior waistlines rise or fall. Cannot a shoe designer be groomed to similar stardomf Of course the trade for its part may be waiting for a lead from the medical profession; but what form should this lead take?f
of massive
publicity, we
SPONTANEOUS PNEUMOTHORAX IN the early 19th century when Itard1 first used the " word and Laennee published his pneumothorax excellent description of the conditionthe qualification Subsequently-for spontaneous " was not used. instance, in Powell’s textbook of 1893 3-this qualification was applied to pneumothoraces where no cause could be found, as opposed to those associated with pulmonary tuberculosis or other disease. But when the production of a pneumothorax became a therapeutic procedure, all other varieties, except traumatic, were grouped as 94 spontaneous," since they arise through natural processes. Unfortunately, the group name is now commonly used for a single subgroup. Thus, a recent report by DuBose and others,4 although entitled " Spontaneous pneumothorax : medical and surgical management," deals only with pneumothoraces unassociated with active pulmonary inflammation or neoplasm. Laennec knew that air could be present in the pleural cavity without any perceptible change of structure of the and it was later recognised that a pneumothorax could occur in apparently healthy people." In 1932 Kjaergaard6 defined the condition as one in which there is a pneumothorax without demonstrable cause in healthy individuals... in whom the lesion is not accompanied by fever or by [a clinically recognisablej pleural effusion." He called this " pneumothorax simplex"; others have named it "benign" or "idiopathic." Kjaergaard’s definition is no longer adhered to, and the term is now applied even to cases where a cause for the air leak has been found. For instance, Brock7 described " recurrent and chronic spontaneous pneumothorax " in 71 patients where a probable cause was discovered in all but 6 ; there were 25 with generalised or bullous emphysema, 11 with solitary or multiple cysts, 15 with small apical bullae, and others with apical scars, pleural tears, or minute subpleural air-bubbles. DuBose and others found radiographic evidence of bullous emphysema in 57 of their 73 patients. This is a surprisingly high proportion, even in a series of patients ill enough to be admitted to hospital; the frequency of radiographically detectable pulmonary abnormalities in all cases of simple pneumothorax is probably very much less. As the majority have only one mild attack, which does not warrant extensive radiographic or thoracoscopic investigation, a cause will be found in only a few ; and thus most cases will still fall within Kjaergaard’s definition. But if a lesion seems with reasonable probability to have caused the pneumothorax, it would seem worth while removing the case from the category of simple spontaneous pneumothorax and classifying it according to the cause. "
"
pleura ;
"
1. Itard, J. M. G. Dissertation. Paris, 1803. De l’Auscultation médiate. Paris, 1819. 2. Laennec, R. T. H. On Diseases of the Lungs and Pleuræ. London, 3. Powell, R. D. 1893. 4. DuBose, H. M., Price, H. J., Guilfoil, P. H. New Engl. J. Med. 1953, 248, 752. 5. West, S. Brit. med. J. 1887, ii, 393. 6. Kjaergaard, H. Acta. med. scand. 1932, 77, suppl. 43. 7. Brock, R. C. Thorax, 1948, 3, 88.
in 14
cases
HALLUX VALGUS
CORRESPONDENTS, commenting on a leading article,8 have expressed the view that the badly shaped shoe is the main cause of hallux valgus. This is not the only cause-even in some peoples habitually going barefoot hallux valgus is not uncommon 9-but the evidence that shoes force the toes out of line is difficult to refute, and their deforming action is almost certainly the major aetiological factor in most cases of hallux valgus. If we accept this, what are we going to do about its’? There has long been a tendency to reverse the Victorian custom by which the foot had to fit the shoe rather than the shoe the foot. Knowles 10describes an instance of an adult with mild hallux valgus who for three and a half years wore shoes, made on a special last, which were basically triangular and had a perfectly straight inner border. Foot symptoms were immediately relieved, and the degree of hallux valgus was materially lessened. In this country Mr. Pratt 11 has been pressing for the introduction of shoes with a straight inner border. Shoes with a truly straight inner border are difficult to obtain ; but some makers 12 specialise in shoes with fairly stringent inner borders. There would be, of course, no difficulty in producing such shoes if the necessary lasts existed. The trade, through the knowledge gained by the British Boot, Shoe, and Allied Trades Research Association, is well aware of the physiological need for these shoes. But two things militate against such a change. First, it would be very expensive to change every last ; secondly, few people-and hardly any women-would buy the The pioneer manufacturer of this type of new shoes. shoe will meet a small demand from the highly footconscious ; but unless the change is introduced simultaneously throughout the civilised world, with the support 7. 8. 9. 10. 11. 12.
Fowler, E. P. jun., Zeckel, A. Psychosom. Med. 1953, 15, 127. Lancet, Feb. 14, 1953, p. 331. Kalcev, B. Ibid, 1952, ii, 937. Knowles, F. W. Med. J. Aust. April 25, 1953, p. 579. Pratt, C. A. Lancet, April 11, 1953, p. 746. For example, Messrs. Hardy and Son, 6, Baker Street, London, W.1. See Lancet, May 9, 1953, p. 956.
see no prospect of the demand not is that the new shape of shoe would It increasing. be intrinsically ugly ; in such matters it is simply a matter of what one is used to (vide men’s hats). The change could, we suppose, be introduced step by step if the trade and their designers agreed that they would .gradually make shoes with straighter and straighter inner sides. But what stimulus is there for them to follow this costly course, so much against their immediate interests ?f There is only one rapid solution. At the command of a Schiaparelli or a Christian Dior waistlines rise or fall. Cannot a shoe designer be groomed to similar stardomf Of course the trade for its part may be waiting for a lead from the medical profession; but what form should this lead take?f
of massive
publicity, we
SPONTANEOUS PNEUMOTHORAX IN the early 19th century when Itard1 first used the " word and Laennee published his pneumothorax excellent description of the conditionthe qualification Subsequently-for spontaneous " was not used. instance, in Powell’s textbook of 1893 3-this qualification was applied to pneumothoraces where no cause could be found, as opposed to those associated with pulmonary tuberculosis or other disease. But when the production of a pneumothorax became a therapeutic procedure, all other varieties, except traumatic, were grouped as 94 spontaneous," since they arise through natural processes. Unfortunately, the group name is now commonly used for a single subgroup. Thus, a recent report by DuBose and others,4 although entitled " Spontaneous pneumothorax : medical and surgical management," deals only with pneumothoraces unassociated with active pulmonary inflammation or neoplasm. Laennec knew that air could be present in the pleural cavity without any perceptible change of structure of the and it was later recognised that a pneumothorax could occur in apparently healthy people." In 1932 Kjaergaard6 defined the condition as one in which there is a pneumothorax without demonstrable cause in healthy individuals... in whom the lesion is not accompanied by fever or by [a clinically recognisablej pleural effusion." He called this " pneumothorax simplex"; others have named it "benign" or "idiopathic." Kjaergaard’s definition is no longer adhered to, and the term is now applied even to cases where a cause for the air leak has been found. For instance, Brock7 described " recurrent and chronic spontaneous pneumothorax " in 71 patients where a probable cause was discovered in all but 6 ; there were 25 with generalised or bullous emphysema, 11 with solitary or multiple cysts, 15 with small apical bullae, and others with apical scars, pleural tears, or minute subpleural air-bubbles. DuBose and others found radiographic evidence of bullous emphysema in 57 of their 73 patients. This is a surprisingly high proportion, even in a series of patients ill enough to be admitted to hospital; the frequency of radiographically detectable pulmonary abnormalities in all cases of simple pneumothorax is probably very much less. As the majority have only one mild attack, which does not warrant extensive radiographic or thoracoscopic investigation, a cause will be found in only a few ; and thus most cases will still fall within Kjaergaard’s definition. But if a lesion seems with reasonable probability to have caused the pneumothorax, it would seem worth while removing the case from the category of simple spontaneous pneumothorax and classifying it according to the cause. "
"
pleura ;
"
1. Itard, J. M. G. Dissertation. Paris, 1803. De l’Auscultation médiate. Paris, 1819. 2. Laennec, R. T. H. On Diseases of the Lungs and Pleuræ. London, 3. Powell, R. D. 1893. 4. DuBose, H. M., Price, H. J., Guilfoil, P. H. New Engl. J. Med. 1953, 248, 752. 5. West, S. Brit. med. J. 1887, ii, 393. 6. Kjaergaard, H. Acta. med. scand. 1932, 77, suppl. 43. 7. Brock, R. C. Thorax, 1948, 3, 88.