Bilateral Traumatic Pneumothorax, with Recovery

Abstract

Cases of traumatic bilateral pneumothorax, with recovery, are sufficiently rare to warrant the reporting of this case. The patient, A. S., Case No. 53,975, age 13, was admitted to the surgical service July 30, 1929. Chief Complaint.—Injury to back; difficulty in breathing. Family History.—Irrelevant. Past History.—Irrelevant. Present Illness.—assisting to put up hay the patient was struck in the back by a hay fork which had been dropped from a load of hay. There were no immediate symptoms except pain. The patient was immediately started for the hospital, but before arriving, swelling of the left neck and chest was noticed. Physical Examination (three hours after injury).—The patient was a well developed and nourished lad, white. He was sitting upright in bed and experiencing considerable difficulty in breathing. There was no cyanosis. Two puncture wounds were seen at the level of the third intercostal spaces posteriorly, one on either side of the spine. Subcutaneous emphysema extended upward across the back, involving the neck and face on the left side. It was not quite so extensive on the right side. Head: Negative. Eyes: Reacted to light and accommodation—negative. Ears: Negative. Nose: Nostrils dilated with inspiration. Throat: Negative. Neck: As above. Chest: Right chest was nearly motionless. Patient was breathing with the left chest and abdominal muscles. The rate was 36. There was an expiratory grunt. The entire right chest was tympanitic; breath sounds were absent except at the base. The left chest was hvperresonant ; the breath sounds were obscured over the emphysematous areas, but were heard at the axilla and at the base. Heart: Blood pressure 90/64; apex in the fifth intercostal space 9 centimeters to the left of the mid-line. Abdomen: Negative. Extremities: Negative. Reflexes: Negative. Blood count: 4,020,000 (red); 11,600 (white); hemoglobin 75 per cent; blood Wassermann negative. Urine: Negative. Temperature: 99.6. Pulse: 100. At this time an X-ray examination of the chest showed a pneumothorax involving about two-thirds of the right side and a very small pneumothorax involving the apex of the left side (Fig. 1). There was also an extensive subcutaneous emphysema involving the soft tissues of the neck on both sides and the left axilla. The heart and structures of the mediastinum were not displaced. Progress.—The patient's condition became worse. The dyspnea increased. Respirations were 40 and were labored. There was definite cyanosis of the fingers. The subcutaneous emphysema increased and involved the entire chest anteriorly, the neck and arms. At this time (four hours after injury) 700 c.c. of air were aspirated from the right chest by reversing the bottles on the pneumothorax box. The initial reading was plus 12—plus 8; final reading was minus 8—minus 10 centimeters of water. This was followed by great improvement in the patient's condition.