Consequently it is far more economic, as well as more accurate, for every physician toi prescribe pure alcohol and water, to be administered with such quantity of sugar, milk or meat-broth, as in his judgment is required. It would be a very great step in advance, if in the next revision of the Pharmacopeia, only alcohol of standard strength should be retained, to the exclusion of all fermented and distilled liquors. If these changes were adopted and carried into general practice, the result would be a more complete separation of both pharmacist and physician from connection with, or responsibility for, the sale or use of the various popular alcoholic beverages. The Annual Meeting of the Trustees of the Cleveland State Hospital for the Insane was held November 17. Dr. Eyman was highly complimented by the Trustees for his successful management of the institution. Dr. Eyman, we are happy to say, in his report recommends that a staff of consulting physicians be organized, and uses the following words: "We feel it our duty to again call attention to the desirability of a con⚫sulting staff. We have talked with a number of the most experienced physicians of the city and are led to believe that such a staff cou'd be organized without difficulty and with very little expense to the State. It does not seem that we are doing our whole duty while we neglect patients who are in need of the oculist, the gynecologist, or the specialist in any branch of medicine. It is obviously impossible for our resident staff to become expert in all the specialties. Consequently the organization of a consulting staff of non-resident physicians could not but result in great good to both the physician and the patient." This is a reform which the JOURNAL has been urging for several years as a necessary step in the progress of the modern treatment of the insane. That the reform will be yet accomplished we fully believe. The necessity for it is ever present. During the year 342 cases were admitted and 317 discharged and 70 died, leaving in the institution now 1,002. The death rate is only 5.18 per hundred and the percentage of recoveries to admissions is 41.22. The inmates during the past year have voluntarily done a great part of the labor needed in improving the institution and its grounds. The work has undoubtedly had a most excellent effect upon the inmates. New opportunities for steady employment of the insane should be afforded by the State. The per capita cost of care including officer's salaries, was $130.11. excluding officer's salaries, $124.89. For 1898 $185,300 will be required, of which $150,000 is for current expenses. For 1899 $205,800 will be needed of which $160,000 will be for current expenses and $25,000 for a new building. During the year Dr. C. B. Finfrock was made clinical assistant. The staff of assistants, Drs. Emerich, Hollister and McNamara, remains unchanged. VOL. III of Medicine FEBRUARY, 1898 No. 2 SOME OBSERVATIONS ON THE PHYSICAL SIGNS OF PNEUMOTHORAX AND ITS TREATMENT BY C. F. HOOVER, M. D., CLEVELAND Professor of Physical Diagnosis in the Medical Department of Western Reserve University, Visiting Physician to Cleveland City and St. Alexis Hospitals A CCORDING to Gaillard,1 as early as 1747 Combalusier described a case in which the doctor punctured the thorax and let out fluid, but to his surprise air rushed out of the opening and the patient recovered. In 1759 Meckel2 described a case in which the liver was depressed below the costal border, and the under surface of the right side of the diaphragm was convex. On opening the thorax, air escaped and the liver ascended into the hypochondrium. Meckel says: "This shows that air in the pleural cavity is not essential, but is detrimental to respiration, as it compresses the lung. Itard, who shortly preceded Laennec, gave a good account of the dyspnea, tympanitic percussion note, and the displacement of the mediastinum and the diaphragm. Itard said this condition often occurred in tuberculosis of the lung, and gave it the name of pneumothorax. How the air gained admission to the pleural cavity was not clear to Itard. He believed its presence was due to decomposition within a pus-cavity in the lungs. Itard also recognized two classes of pneumothorax, one in which air occupies the space of retracted lung, and the other in which air is confined in the pleural cavity under pressure and causes great displacement of neighboring organs. (Our modern treatment depends entirely upon a differential diagnosis between these two conditions). In a few years followed the work of Laennec, which marked the beginning of modern conceptions of diagnosis of thoracic diseases. Biach in 1880 published statistics showing that of 58,714 cases of phthisis there were 433, or 7%, that acquired pneumothorax. Other writers who have made estimations from smaller numbers claim as high as 5% and 13%. 1 Dr. L. Gaillard, "Le Pneumothorax," (Bibliotheque Charcot-Debore) 2 Ibid 3 E. M. Itard, These de Paris, No. 303, 1803 Read before the Akron meeting of the Union Medical Association of Northeastern Ohio, February 8. 1898 Pneumothorax may be caused by rupture of isolated tubercle or cavity without synechia of the pleuræ, emphysema, abscess of the lung, gangrene or rupture of empyema into the lung. Traumatic causes may be: Penetrating wounds of the thorax and lung; fracture of rib without wound of the chestwall; contusion of thorax without wound of the chest-wall. Pneumothorax occurs with paracentesis when air passes through the cannula during inspiration; wounding the lung; setting gas free by decomposition of an exudate; rupture of the air-vesicles by negative tension when there is suction used to draw off a pleuritic effusion and the want of elasticity of the lung does not permit it to follow the receding fluid. Efforts at coughing, parturition, defecation and emesis may be the direct causes of pneumothorax. From Biach's statistics we learn that out of 918 cases of pneumothorax, seven were due to emphysema, 65 to pulmonary gangrene, 10 to abscess of the lung, four to infarcts of the lung, and 45 to empyema. All of the conditions so far mentioned demand an opening into the pleural cavity either from the air-spaces in the lung or from the outer air. Besides these conditions there may be gas formed in the pleural cavity by decomposition of an exudate. Pneumothorax under such conditions is known as essential pneumothorax. E. Levy1 reports a case of a young man suffering from pyothorax. After repeated tappings there developed amphoric breathing, tympanitic percussion note and coin sound. There was no succussion sound. All of these signs developed seven days after the paracentesis. From the pus there was cultivated an anaerobic gas-forming bacillus that grew best in glucose-agar at the body-temperature. This bacillus is identical with the bacillus aerogenes capsulatus of Welch. The autopsy of Levy's case was performed by Recklinghausen, who expressed the opinion that the air had not gained access to the pleural cavity from the lungs. A. Biermer2 described a case of fetid pleurisy in which paracentesis was made with a silver trocar. A deposit of sulphid of silver was noticed on the trocar. The milky fluid which escaped had a strong stench, which stunk up the entire ward. On the following day there were marked signs of pneumothorax. The autopsy revealed no communication between the lung and pleural cavity. Biermer refers to Schuh and Rosenthal as having described such cases. Biermer reports no examination of the fluid in his case, but assumed sulphuretted hydrogen to have been the poisonous agent, and believed the removal of a part of the fluid permitted gas to escape from the exudation by diminishing the intrapleural pressure. I have had a similar experience with a case of fetid pleurisy. Three quarts of thick grayishyellow pus were aspirated under considerable negative tension. The pus 1 E. Levy- Arch. of Experiment, Path, und Pharmakol.. 1894-95, XXV, p. 335 2 A. Biermer-Schweiz. Zeitschrift fuer Heilkunde,1862, Vol 1, p. 307, and Vol. II, p. 101. stunk like decomposing Limberger cheese. Microscopic examination showed the pus had undergone complete decomposition, as not a single cell in a state of preservation could be found. The pus consisted of cellular debris, fat-globules and an abundance of fat-acid crystals. Bacteriologic examination demonstrated no gas-forming bacillus. Chemic examination revealed a large percentage of fat and butyric acid and a large amount of substance rich in nitrogen, the nature of which I shall elsewhere report. The left lung did not distend promptly. The heart remained in its abnormal position and the signs of pneumothorax were present. At the time, the question arose as to whether gas could have been liberated from the decompressed exudation, or air could have been admitted through the cannula. The pus frequently stopped the cannula and made it necessary to break the connection with the reservoir in order to clear the cannula. This procedure threw much doubt upon the possibility of an essential pneumothorax. With the single exception of Levy's case, I can find no instance in which the proof of an essential pneumothorax rests cn a complete clinical observation. The air of a pneumothorax may occupy the pulmonary space under a diminished negative tension, or the contained air may have a pressure equal to or greater than the atmospheric pressure. By considering for a moment the physical conditions under which the lungs occupy the chest-cavity, it will be readily seen how this great variation in pressure may occur. The lungs possess considerable contractile power, due to the yellow elastic fiber and the elasticity of the muscular tissue of the bronchial tract. The rigidity of the thorax maintains the distention of the lungs. The elastic tension of the lungs keeps the intercostal spaces retracted and holds the leaflets of the diaphragm in their position with the marked convexity of their superior surfaces. The negative tension in the pleural cavity of a dead body is as high as 8 mm. of mercury. Even under conditions which greatly impair the elasticity of the lung (as tuerculosis with moderate emphysema), I have seen the negative tension as ligh as 3 mm. of mercury. In a calf three weeks old the negative tension amounted to 10 mm. of mercury. The collapse of a lung when air is admitted to the pleural cavity during life is much more complete than when air is admitted postmortem. There are several reasons for this. During life the lungs contract, not simply because of the yellow elastic fiber, but also on account of the elasticity, and possibly contraction, of the muscular fiber of the bronchi. During life the vessels may largely expel their own contents by virtue of the contractility of the vessel-walls, and the ready flow of the lymph and blood during life. aids the elasticity of the lung to expel the fluids from their vessels. When an animal dies from disease there is generally a considerable amount of pulmonary edema. The physical conditions necessary for the production of pulmonary edema cause rigidity of the lungs. They are in an erectile state. This so-called "Lungen-starrheit" may, I think, be correctly characterized as a red emphysema. The loss of lung-elasticity under such circumstances can be readily demonstrated clinically and at autopsy. After the chest-cavity has been opened, the degree of collapse of the lungs depends upon the degree of vascular injection. The greater the vascular injection the less the lungs colapse when the chest-wall is opened. Pressure on such a lung forces a large amount of frothy serum from the cut surface. This means that a considerable amount of air has been retained in the air-spaces, as well as fluid in the vessels. The vascular injection retains the infundibula in an erectile state, thus favoring the retention of air in the vesicles, hence the term red emphys ema. If air be admitted to the pleural cavity through an opening in the chestwall and passage of air is unimpeded both during inspiration and expiration, the degree of pulmonary collapse will depend upon the relative size of the parietal opening to the size of the bronchus supplying the lung. So long as the entrance and exit of air remain the same, there cannot be a persistent positive pressure in the pleural cavity. If air gain admission to the thoracic cavity through a rent in the lung, it will pass into the cavity during inspiration because the inspiratory act opens the cleft. Directly the expiratory phase begins the size of the cleft becomes smaller and less air escapes from the pleural cavity during expiration than gains admission during inspiration. Air will accumulate in the pleural cavity until the inspiratory act no longer opens the cleft; and that will be, when the positive pressure equals or exceeds the negative tension which the inspiratory act is able to create in the pleural cavity. If, for instance, a man under such circumstances were able to aspirate through the trachea 20 mm. of mercury, the positive pressure in his pleural cavity would reach 20 mm. of mercury before air would cease to enter the pleural cavity through the cleft in the lung, during inspiration. The perfect valvular action of a cleft in an elastic wall is well illustrated by making an incision in the rubber bulb of a common medicine-dropper. Place the glass end of the dropper between the lips and blow through the tube. The air readily escapes. Now attempt to suck air through the tube; the cleft closes tightly, acting as a perfect valve. The cleft-opening is of the kind made in the lung by rupture from violence or sudden increase of the intrapulmonic pressure from coughing, or by rupture from aspirating a pleural cavity under high tension when the lung is not elastic enough to fill the space of the escaping liquid. Clinical experience shows pneumothorax under such conditions to cause much severer symptoms than when caused by an empyema making its escape through a bronchus. An opening |