February 1949 35

Two Cases of Spontaneous Hmmothorax By MICHAEL WALTON

Clinical Tuberculosis Officer, Mfddlesbrough

Spontaneous haemotho rax is an unusual condition. Har tzel l (i943) records only 43 cases in the literature.

The 2 cases described here occurred dur ing the course of a year ' s work in tuberculosis in Middlesbrough, a County Borough of approx imate ly i4o,ooo in- habi tants . They are o f interest not only because they were unusual but because of" the different symptomato logy in each case.

Case I .--C. R. E., male, aged 29. Occupation, Post Office engineer. No family history of tuberculosis. He had lived a healthy life in- cluding Army service I939-45 until on I4.~.47 he was sitting at his office desk when he suddenly felt a severe pain in his left chest associated with shortness of breath and a feeling of faintness. The pain was acute over the whole of the left chest and worsened on breathing deeply. He felt faint and clammy and went home by taxi. He vomited that night repeatedly. He was seen by his doctor and given sulphonamides, propped up in bed and treated expectantly. The pain gradually eased and the dyspnoea became less. After three weeks he was allowed up and was 'downstairs' for five days when again an acute pain seized him in his left chest and he became dyspnoeic and fainted.

He was transferred to a nursing home where a diagnostic needle revealed a blood-stained

effusion in his left pleural cavity. He was transferred to Hemlington Emergency Hospital on 13.3.47.

On examination he looked pale and ill. Tempera tu re io i ~ F., pulse 9 o, regular beat of poor volume. He was orthopnoeic.

The physical signs in the chest were of dis- pIacement of apex beat. The trachea was dis- placed to the right. Diminished movement, absolute dullness to percussion with absent breath sounds and conducted sounds over the whole of the left chest. There was dullness to the right of the sternum and visible pulsation in the lower interspace adjoining the sternum on the right.

B.P. i35/85 . Blood count: 4"5 million R.B.C.s.; H.B. 95 per cent ; C . I . i . o ; 8,ooo W.B.C.s. X- r ay (fig. i ) showed complete opacity of left chest with displacement of heart and mediast inum to the right. No fluid level visible. On I4.3.47 through the 9th interspace in the axillary line 9,5 oz. of blood-stained fluid were removed and at the same time through a pneumothorax needle in the 2nd interspace in the mid-clavicular line 1,5oo ml. of air were run in leaving the final pleural pressures + 2 + 4: cm. of water, ioo,ooo units of penicillin were instilled in the pleural cavity.

Screening aider this air replacement showed a collapsed left lung with the remains of the fluid at the base and the mediastinal shift as before air replacement (fig. 2). He was nursed in the

CASE I

Fm. i Fio . 2 Fro . 3

36 T U g E

upright position and his condition quickly iraproved. Repeated spu tum examinations were negative, t-iis temperature gradually subsided by lysis and after fourteen days he had no more evening rises above 98.6 ~ .

Screening showed progressive expansion of the lung with absorption of the basal density. He was put on breathing exercises and was con- sidered fit for discharge home to convalesce on 27.4.47. H e was seen again on 3o.6.47 when there was a loud pleural rub over the left upper chest both anteriorly and posteriorly. The patient complained of occasional tightness in the chest but had no dyspnoea or palpitation.

When seen on i3 .m.47 he had returned to work and was symptom free. X-ray (fig. 3) at that time revealed some persistent shadowing in the left costophrenic angle and the lung had completely re-expanded.

Case ~. - -N. M,, male, aged ~6, Occupation, joiner. No family history of tuberculosis. War service 1939-45 , R,N. and R.A.F, He had led a healthy life until to. to.47 when he 'felt out of sorts', had headache and with diNculty could stand upright. He feIt giddy and had blindness on standing. He was dyspnoeic and next day he could not get out of bed and felt a severe pain across the lumbar region. This pain was con- tinuous and increased in severi W ,for the next few days. He became increasingly short of breath and his appeti te was poor. H e was treated for ' lumbago' but as the pain persisted and he developed a dry cough with abnormal signs in the letk chest he was transferred to hospital on 3o.w.47, On admission his tem- perature was Io~ ~ F., pulse rate I i 6 per minute.

CASE

R C L E February 1949

He was pale, orthopnoeic and anxious looking with beads of perspiration on face.

Chest.--Inspection--fixation of left chest. Pa lpa t ion--apex beat not identified. Percussion - - t r a c h e a over to right. V.F. absent over left chest. Right lung normal. Left chest--stony dullness to level of clavicle. Boxy n o t e along clavicle and above it. Auscul ation--B.S, absent over left chest. V.R. grossly diminished over left chest.

Hearl.--lncrease in dullness to the right df the sternum. Sounds muffled. B.,P. I gO/gO.

Other systems--N.A.D. Blood count : Hb, 9 ~ per cent.; R.B.C. 4"5

million; W.B.G. t4,ooo. X-ray (fig. 4) showed hydro-pneumothorax left chest with level just below clavicle. Gross mediastinal displacement to the left,

O n 3I.io.47 I2o oz. of blood-stained fluid were removed through a needle in the 9th interspace in the mid-axiliary line and through a pneumothorax needle in the 2nd interspace anteriorly in mid-clavicular line 2,800 ml. of air were given leaving the final pressures + 2 q 6 cm. of water. I oo,ooo units of penicillin were instilled into the pleural cavity. X-ray film (fig. 5), after air replacement, showed collapsed left lung. No obvious adhesions: remains of fluid in pleural cavity. The cyto- logical report--direct f i lm--no organisms-- large numbers of R.B.C.s and 1ymphoeytes present in excess of normal. No A.F.B.s seen. Culture--sterile anaerobically and aero- bically. Repeated sputum tests negative for T.B. H e was propped well up and his temperature soon became normal. His general condition improved and the lung ~'adual]y re-expanded

Fie,. 4 Fla. 5 Fic. 6

February 1949 T U B E R C L E 37

with absorption of remaining basaI density. Fig. 6 shows x-ray appearances two months after air replacement. He was discharged from hospital 5.2.48 and has been carrying on with breathing exercises and graduated exertion. While in hospital he gained 14 lb. in weight. TheE.S.R. thllandmonthlyreadings from 7o-mm. in first hour (Westergren)(uncorrected) through lO, 7, 5 to 4 on discharge.

Discussion /Etiology.--There is agreement on the patho- genesis of spontaneous haemothorax in that it occurs as a result of spontaneous pneumo- thorax which causing collapse of the lung tears vascular adhesions. On the cause of spontaneous pneumothorax it is impossible to dogmatize but the present concept is that it results fi'om the rupture of a vesicle on the surt~ce of the lung.

Kjaerga, ard (I932) grouped these vesicles into two categories, (a) those resulting fi~om scar tissue cicatrization with a healed tuberculous focus and (b) local emphysema- tons areas associated with valvular openings. The exciting cause of the rupture of the vesicle is not always apparent. In a review of 24 cases from the literature, Jones and Gilbert (*936 ) stated that at the onset of the symptoms 9 patients were at rest. In both cases reported here no exciting cause was elicited, in Case i the symptoms came on while he was sitting at his desk and in Case 2 there was no definite history of sudden onset.

PaOzology.--Autopsy findings in ~4 pub- lished cases--Hartzell (~943)--reveal that in most instances the source of bleeding is not identified but most cases show apical emphy- sematous bullae with or without pleural adhesions. The possibility of bleeding arises from both the torn lung tissue over the rup- tured bullae or from the parietal stump of the torn adhesion. According to Matson (I939) the pleural adhesions are very vascu- lar and are supplied by collaterals from the intercostal vessels. Collapse of the lung with spontaneous pneumothorax would be ex- pected materially to diminish the possibility of continued haemorrhage from the lung tissue both by reduction of the lung circu-

lation and by retraction of the tissue. It would not affect the bleeding from the parieta] stump of a torn adhesior~ and it is in this latter way that the continued fiilillg up of the pleural space occurs.

The bIood in the pleural cavity stays fluid because (as was first shown by r-['ro~sseau in ~87o ) the constant heart action defibrinates the blood and deposits the fibrin on the pleural surface.

Syrnptomatology.--The complex stated by Horst (I936) of (1) sudden onset of pain and dyspnoea, (2) temporary improvement last- ing from hours to days; (3) followed by recurrences of pain and dyspnoea and signs of internal haemorrhage corresponds to the generaily accepted pathological basis of the sudden spontaneous pneumothorax followed by the more gradual onset of signs due to intrapleural haemorrhage from the torn parietal adhesion, stump.

Case i follows this pattern closely and the interval between the onset of the first and third stages was twenty-six days.

Case 2 did not describe any definite stages of his illness but :from the onset the pain, dyspnoea and giddiness persisted.

Pain.--In Case I this was referred to the whole of the left chest and was made worse on breathing. In Case 2 the initial painwas referred to the left lumbar region and per- sisted there until after aspiration-air re- placement. In this case the adhesions are torn ir~ the lower part of the chest.

Grabfield (r92~) and Mitkhorat (I93I) reported a case in which the original pain referred to the appendix area.

Frez (I935) and Hurtzthal (~928 reported a case with pain resembling gall-bladder disease and Fischer (i92e) reported a case with pain simulating ruptured peptic ulcer.

Dysp~oea.--In Case I hppeared suddenly and following rest in bed eased off until it returned with the onset of signs of internal haemorrhage. In Case 2 the dyspnoea was of gradual onset and became worse fi'om the beginning of the illness up to his aspiration air replacement twenty-one days later.

Both cases were collapsed and anxious

38 T U B E R C L E February 1949

looking and pale. In Case I vomiting was a prominent symptom the first night but there is no record of result of abdominal examina- tion at that time. In Case 2 the symptoms of blindness, transient on attempting to stand, indicated at the outset a severe degree of collapse.

Signs.--The classical signs are those of pneumothorax with effusion but in Case i sufficient time had elapsed to allow of the absorption of the air and the signs were those of a large effusion with mediastinal displacement to the sound side. In Case 2 the presence of an air level was reflected by the abrupt change in the percussion note immediately below the left clavicle in the upright position. The mediastinum was displaced to the right.

Temperature.---Both cases were febrile due to the absorption of' the product ofhaemoly- sis and the temperature did not fail to normal for approximately fourteen, days.

X-ray examination in both cases was taken to confirm the physical findings. In Case 2 the presence of the air level was shown and after .aspiration--air replace- meri t - - the collapsed lung was seen but no obvious adhesions were visualized. No evi- dence of lur'g disease was seen.

Laboratory Findings.--ha neither case did ;he blood findings reflect clinical pictures of the ease. In neither case was there marked diminution of haemoglobin or of red cells. In Case 2 a moderate leucocytosis was present.

PIeural Fluid was examined cytologically, bacteriologically and the report was ' film shows large numbers of red cells and lym- phocytes. Culture is sterile both aerobically and anaerobically. No acid-fast bacilli seen. No red cell count or haemoglobin estimation was performed on the fluid.'

All Sputum Tests were negative for tubercle bacilli on direct smear, concentration and culture.

Sedimentation Rates were performed at monthly intervals in both cases and showed a pers{stently normal figure following the first fortnight in hospital.

z 4 of the 43 cases detailed by Hartzell (~943) were fatal. The majority of deaths occurred within the first few days of the illness and were associated with the shock, anaemia, respiratory and circulatory em- barrassment associated with mediastinal displacement. Once the initial few days are over and the positive intrapleurat pressure controls the haemorrhage the principles of t reatment are based on (i) measures de- signed to relieve the circulatory and res- piratory embarrassment, and (ii) avoidance of exciting causes for renewal of bleeding.

Good restorative measures are needed during the first few days of the acute episode.

In both cases reported here the cortdition had been present :for five and three weeks respectively. The symptoms were due to respiratory and circulatory embarrassment consequent upon mediastinal displacement together with the pyrexia due to absorption of products of intrapleural haemorrllage. In both cases aspiration and air replacement were carried out in one stage and care was taken to maintain the mediastinum in its position by leaving a positive intrapleural pressure. The gradual reabsorption of air resulted in rapid amelioration of symptoms of distress and defervescence of temperature by lysis, improvement of general condition and diminution of chest and back pain. Breathing exercises were begun as soon as the patients were fit enough.

Failure to remove the blood from the pleural cavity may result in cMcifieation and fibrosis resulting in circulatory embarrass- ment (Jones and Gilbert, z936 ).

Summary Two cases of spontaneous haemothorax have been described and the literature kas been reviewed briefly. One case conformed to the accepted pattern of acute onset, period of recovery, recrudescence of pain and dyspnoea with signs Of internal haemorr- hage and physical signs of pleural effusion. The second case developed gradually and was associated with low backache.

The cause was considered to be the same

February 1949 T U I ~ E R C L E 39

in both cases, namely, spontaneous pneumo- thorax followed by continued haemorrhage from the parietal adhesion stump. Treat- ment by air replacement in one stage was effective in these cases and their con- valescence was uneventful.

References Fischer, B. (I 9~'~) Der Gutartage. Ztsd2tklin Med., 19~,

X'IV, I, Grabfield, C. P. (z92I) Internal Clln., xxz, z and 3.

Frez, J . L. (I935) J.A.~L~,I., I.O. iv, r395. H~rtzeI/, H. C. (~94~) Ann. Int. Meal., xw% 496. Hurtzthal, L. M. (r9~8) N..E. Joum. Med., oxo, wIr~ 687. Jones, O. R., and Gilhert, C. L. (~936) Am. Re~. Tuberc.,

xxxiir, i65. Kjaergaard, I f . (Igflo) Spoataneoas Pneumotlmrax in the

Apparently Health~y. Levine and Munksgaard, Copen- hagen.

Korol, E. 0986) Am. Rev. Tuberc? xxxur, t85. Matson, R. C. (I989) Goldbergs Clinical Tuberculosls~

Ed. u, D-~'J8. Milkhorat, A. T. 0 9 3 0 Am. Gr. Surg., xm, ~I 5. Trousseau, A. (I87 o) Lectures on Clinical Mediclne.

The New Sydenham Soc~iety~ London. m, 098.

Tuberculosis Survey of a Suspected School Group J. T. NICOL ROE, Physfclan, Uxbr?dge Chest Clinic

and W. POINTON DICK, Medical Director, Middlesex Mass X-ray Unft

Following the finding that among the routine cases under the care of the Uxbridge Chest Clinic 5 were pupils at a local technical school, it was decided to mass radiograph (he remainder of the school population in an attempt to discover the source case and any other cases that might be present but uadiagnosed. Subsequent to the investiga- tion being begun in November I947, a further case was found by the Chest Clinic in'a boy who had left the school in April of the same year.

The population comprised 34~ pupils, aged 13 to I7, z 9 masters, 6 office staff and 8 domestics. O f the 342 boys who were on the school register for the year April z947, to April I948 , 9 had left before the survey began. In addition the 5 boys already found to have tubercul9sis were absent. There were thus 398 pupils available for fluorography and of these 3~o7 were examined. The sole absentee had chicken-pox.

Of the 19 masters, z8 were fluorographed. The one refusal was aged 54- and only took charge of the zst year forms in which, as will be seen, no cases were found. All the clerical staff were examined but none of the domestic staff would volunteer. The latter were all females, their ages ranging from 40 to 62.

The school consisted of a modern building with well ventilated and airy rooms. There

was an assembly hall which was used as a canteen during meal breaks. The mid-day meal was served to some 2oo boys. These were not seated according to their class and all forms were represertted.

The pupils were divided into 3 groups corresporsding with their year of entry into the school.. These groups were subdivided into classes of which at the time of the survey there were 4 in each of flie first two 'years' and 3 in the final 'year'. The population of the classes varied from 27 to 32.

Every assistance was given by the teaching staff to make the survey a success and the excellent response was in large measure due to the enthusiastic co-operation of the headmaster.

As the result of the survey a further 7 cases of pulmonary tuberculosis were found. O f these, 6 were scholars aged 15 or over, and one a master. This gives a proportion of cases among the pupils fluorographed equivalent to 18 per thousartd, a figure very similar to that of i6 per thousand found among the home contacts of tuberculous persons (Dick and Thompson, I946 ).

Table I shows the form position in the school years, April 1946-47 , and April z947-48 , of the I~ boys found to have tuberculosis. It wilI be seen that all cases at the time of diagnosis were in one of the upper five classes (see p. 4o).

*Read at a meeting of Middlesex Tuberculosis Association, May 5, ~948.