Mr. Poole's Case of Pneumo-thorax fi.om Perforation. 1S5

ART. XII.-- .4 Case of Pneumo-thorax from Perforation. By RIc~ISnD PooLs, Esq., Assistant Surgeon, 32nd Regi- ment.

PRIVATE J. Rowg, 32nd regiment, admitted into hospital at Tralee, March, 27th, 1832. He was a healthy looking lad on joining the regiment about six months ago; there was, however, slight malformation of the chest, the subclavian regions being shallo.w, the submammary cyil,adrlcal or bulging. Had an attack of pneumonia two months ago, which was treated actively, but the patient was for some time efterwards troubled with a bronchial affection, l"resentcomplaint, violent cough, dys- pncea, with thin, viscid, mucous expectoration era pale straw co- lour, and pretty copious ; no decided loss of resonance, nor any morbid sound detected in the chest, except occasional mucous tales in the lower left lobe The disease was considered bronchitic, and treated in the first instance, with antimonials, and then with the balsams ; under this plan, with milk diet, and counter- irritation, he improved very much, and regained in a great measure, a healthy look, presenting only some acceleration of pulse, occasional morning cough with scanty expectoration, and slight dyspncea.

On the 27th April, the lower portion of the right side gave a dull sound on percussion, and here file respiratory murmur became indistinct, but no aggra,'ation of the symptoms took place until the beginning of the month following, when the cough became again traublesome, and he began to look pale and unhealthy ; the pulse was still quick, and heat of skin to- wards evening considerable. On the 12th May loud bronchial breathing was detected in the mammary region of the left lung, with bronchophony, but no ronchus, the resonance continuing. unimpaired. It was inferred that some dilatation of the bron- chlaltuhes existed. OR the 21st a remarkable change took place,

186 Mr. Poole's Ca, e of Pneumo-thorax from Perforation.

the patient having been attacked with pneumonia of the lower part of the left lung, which yielded to general bleeding and large doses of the tartar emetic, not, however, before hepatization had taken place to some extent. After the signs of this latter lesion had entirely disappeared, a mucous rale persisted through the whole of the posterior portions of the lung, the anterior part giving a clear sound on percussion, until the 1st July, when file metallic tinkle was distinctly heard, and a diagnosis of pneumo- thorax made, although the respiratory murmur and a cteep gurg- ling could be distinguished in the portions of the tung, over which percussion elicited tile clearest sound. There never exist- ed any signs of an excavation, but the patient coughed up, on the 4th and 5th of the month, a large quantity of a sero-albuminous fluid, proving that a communication existed between tile lung and the sac of the pleura. From this time he sank rapidly, and expired on the 6th of the month.

./lutopsy, twelve Hours after Death.--Considerable maras- mus ; left side of tile chest, at the inferior portion, much bulged out, highly sonorous, in fact, tympanitie ; right side gave generally a dull sound on percussion : on cutting through the cartilages of the left ribs, a rush of inodorous g'as took place from the pleural cavity. The lung was found condensed, and pressed up towards the spine and back part of the ribs, to which it was bound by strong adhesions. A small quantity of a yellow eoloured serosity existed at the bottom of the cavity. The surface of the lung was covered with several loose layers of false membrane, of" a lemon colour and tough consistellce ; they were readily detached from the lung ; the lung was firm and corrugated, it was perforated by a considerable opening, which existed at the back part of the upper portion of the lower lobe, close to the adhesion with the costal pleura ; the finger could be passed by this opening into the substance of tile lung, and it was found that a small quantity of purulent matter escaped by it when the lung was pressed. The parenchyma of this lobe was thickly infiltrated with tubercular matter in a crude

Mr. Poole's Case of Pneumo-thorax fi'om Perfi,'atio~t. 187

state ; one or two points of suppuration were observed, but an- teriorly there was no excavation. On the back part of'tim lobe, however, corresponding with fl~e situation of the fistulous open- ing, existed a considerable irregular cavity, which had through this discharged its contents into the pleural sac. Tile upper lobe of this lung was quite sound, and did not contain a single tubercle, but all its bronchial tubes were much dilated, their lining membrane highly vascular, without any apparent hyper- trophy. The sac of the Hght hmg contained some serosity, but the hmg itself, wifll the exception of its lower lobe, which was thicklv studded with crude tubercles, was sound and crepitous.

Observations.--This case was clearly one of pneumo- thorax from perforation, the atmospheric air having escaped into the plcural sac by means of the fistulous opening that ex- isted in the back part of the left lung. So /at there is nothing uncommon ; but from such a case it may be readily shewn, how considerable reparation might be eflbctcd in the diseased parts, provided life could be sustained so long, by which, not merely might a stop be put to further dlsorganizatlon, but also all traces of the original mischief be completely obscured. It is, in fact, only necessary to allow the possibility of the atmospheric air that escapes into tim pleural sac producing, as in the present instance, a pleuritis with membranous exudation, some layers of which are deposited over the fistulous opening, and prevent the further entrance of the atmospheric air ; to show that this repa- tion may be effected, and to establish a rational explanation of some forms of pneumo-thorax, at present attributed to causes muchless readily assignable: we can easily understand how, under such circumstances, all traces of the fistulous opening may be completely lost, and how, after the lapse probably of years, we should in such a case discovcr nothing but a lung contracted and bound up into a certain part of the thorax by strong cellular bands, while the other portion of the pleural cavity contained nothing but inodorous gas. Such views are not altogether hypothetical, for I can only explain in this way a case I o b -

188 Mr. Poole's Case of Pneumo-thorax from Perforation.

served about four years ago, in which, the patient, a healthy young lad, dying from epilepsy, I was afforded an opportu- nity of seeing in the right side of the chest, the appearances described above. In this case, there was no contraction of the side, not" do I see, explaining it as I have now done, how such could have taken place.

In the case of Rowe, the fistula, certainly, remained open to the last, but there are several cases on record in which a fistula of the lungs has been closed. In addition to these, there are other circumstances I need not detail here, which may lead us to differ with Laennce in attributing to secretion, (exhalation), or the decomposition and putrefaction of the pleural effused fluids, the existence, in several of his cases, and particularly those in which pulmonary excavations were found, of gas in the cavity of the pleura. Andral's views on this point are evi- dently at issue with those of Laennec, for he states expressly, that in almost all instances pneumo-thorax takes place from per- foration. It appears to me also, that tile second case recorded

by Dr. Graves, in the last number but one of this Journal, stands in a very doubtful light, and I am far from concurring in the view he has taken of file impossibility of atmospheric air, intro- duced through a fistulous opening, exerting pressure on a lung sumcient to render it in a condition that might be termed "carnefied." It is known, however, that Laennec has re- stricted, with what justice I am not going to question here, this term to the inflammation of the lung under pressure. :Now, if the state of the lung in Dr. Graves' case resembled this, I can readily appreciate the value of file observation it has given rise to, but if the term is applied in this instance simply to ex- press a condition of the lung characlerizcd by compression, and absence of all crepitation, I have only to state, that in the ease of Rowe tile lung was but little crepitous, and had undergone con- densation to such an extent, as to have become remarkably shrunk, and as it were wrinkled, from the compression alone of the at- mospheric air. I have~ therefore, to repeat, that we should best-

Mr. Porter's Report of Surgical Cases. 189

sltate to admit this case as an example ofpneumo-thorax fi'om se- cretion (exhalation). The other case detailed by Dr. Graves ap- pears, however, an admirable example of this interesting lesion, and corroborates, in some measure, the views ofM. Gendrin, that an exhalation or secretion of air is t?equent in connexion with pleuritls. Gendrin appears, however, to attribute this pheno- menon to active rather than mild examples of this disease. Dr. Graves' ease appertains to flae latter.

Ar~T. XIII.--Surgical Report of Cases, treated in the 3leath Hospital during tile past Year. By WILnIA.~ HENItY Polt- ~r~a, Lecturer on Anatomy and Surgery in file School of" Anatomy, Medicine, and Surgery, Park-street, Dublin.

Tile general practice of all hospitals must be nearly file same, and as the leading characters and treatment of the ordinary forms of disease are pretty accurately understood, very detailed reports are neither necessary nor instructive, unless when adduced for the purpose of'establishing some important pathological fact, or introducing some improvement in practice. But in every establishment of this kind, particular cases will occasionally occur, not only novel in their nature, and therefore curious, but by reason of their infreqnency, di~eult and uncertain in their management. By the publication of such cases, in an authentic form, the hospital surgeon may confer the greatest benefit on his profession, for he enables the practitioner, of extensive op- portunities, who has met with similar cases, to compare the ob- servation and experience of ofhers with his own, and thereby approach the truth ; whilst to the younger practitioner, he fur- nishes a guide and assistance in the difficulties of his profession, which, though far from perfect, may nevertheless be valuable. In this spirit and with this view I have selected the following eases, each possessing its own peculiar interest, and on which I