PNEUMOTHORAX. 291 



tienls soon began to complain of severe pain in the region of the lower 

 ribs, which is to be attributed either to the strain upon the diaphragm, 

 or else to the pleurisy which is excited by the escape of air, and of the 

 contents of the vomica into the pleura. If the patient be not very 

 anaemic already, marked signs of engorgement of the right side of the 

 heart, which is deprived of half its efferent channels by compression 

 of the vessels of the lung, soon are added to the above symptoms. 

 The patient becomes cyanotic and dropsical ; swelling of the face and 

 extremities is often observable from the very commencement. The 

 pulse is small, the urine scanty, the skin cool, partly because the left 

 side of the heart receives blood from one lung only, and hence is not 

 completely filled, partly in consequence of the collapse which accom- 

 panies bursting of a vomica into the pleural sac, and other serious in- 

 juries, such as the perforation of ulcers of the stomach. 



Some patients die in a few hours, or even sooner, from the com- 

 bined effects of want of breath and collapse. In other instances, death 

 does not take place for days or even weeks. The collapse then sub- 

 sides, the patient grows warm again ; but the dyspnoea continues, and 

 grows worse, as the pleuritic effusion increases, and pushes the heart 

 and mediastinum more and more against the sound lung. The cyano- 

 sis and dropsy also increase. The patients finally succumb to pul- 

 monary cedema and to insufficient decarbonization of the blood, or 

 perhaps die of the consecutive pleurisy, exhausted by fever and by the 

 profuseness of the effusion. 



Recovery from pneumothorax is rare. When it occurs, the pneu- 

 mothorax first changes into a simple pyothorax, the liquid exudation 

 accumulating in the chest, and so augmenting the pressure upon the 

 air contained in the pleural sac, that it is diffused among the adjacent 

 vessels. Then, if circumstances favor, the effusion itself may be reab- 

 sorbed, and, if meantime the orifice of the perforation be closed, the 

 lung may expand again. I treated a patient in Magdeburg, who, 

 after lying for weeks in a condition of the utmost misery, so that hei 

 death was daily expected, so far recovered in the course of three 

 months as to marry, and to carry on a somewhat extensive business. 

 In other cases, a wide communication forms between the pleural cav- 

 ity and some large bronchus, which still remains patulous in the com- 

 pressed lung, and from time to time but only when the patient 

 assumes particular attitudes (as has been related in a very interesting 

 case in Bomber g*s clinic, reported by Henoch) a part of the liquid 

 contents of the cavity which has entered the bronchi is discharged by 

 coughing. When the perforation of a cavity causes the admission of 

 air into a space which has been enclosed in old and firm adhesions, 

 or where an empyema nas pointed into the lung, and where air lias 



