Spontaneous Pneumothorax in the Previously Healthy

Abstract

The many reported cases of spontaneous pneumothorax since 1932, at which time Kjærgaard first collected and carefully analyzed 51 cases, all substantiate his claim that this is a distinct diagnostic entity, not related to tuberculosis or other chronic disease of the lung, and has a good prognosis. As early as 1884 it was recognized by West that pneumothorax might occur suddenly in the previously healthy who had no evidence of tuberculosis or other lung disease either before or after the attack. Osler's teaching that tuberculosis was the cause of spontaneous pneumothorax in 77 to 86 per cent of cases, a theory which he based upon the autopsy reports of Brach (1880) and Drasche (1899), still clouds the thinking of clinicians, despite the fact that the study of living pathology, particularly through roentgen examination, has clearly shown that tuberculosis is rarely associated with this clinical condition. Spontaneous pneumothorax in the previously healthy is primarily a disease affecting young adult males. The most startling demonstration of this is furnished by the data of Schneider and Reissman, who reported from an induction station in the 2nd Service Command that approximately 1 man in 500 of draftee age gave a verified history of spontaneous pneumothorax. Previous estimates, made by authors reporting from college dispensaries, cite an incidence of 1 per 1,000 male students. The comparative incidence of spontaneous pneumothorax in the apparently healthy to spontaneous pneumothorax associated with pulmonary disease will vary greatly depending upon the type of patients seen and whether hospital or general office practice is considered. Of the 60 patients studied by the author, approximately two-thirds were ambulatory office patients and one-third were hospital patients. During the years (1915–46) that these 60 cases of spontaneous pneumothorax in the apparently healthy were gathered, 5 cases of spontaneous pneumothorax in patients having tuberculosis were found. Thus, the non-tuberculous form in this brief series is twelve times as common as the tuberculous form. This is approximately the ratio reported by Kjrergaard and others making comparison studies. The extensive investigations of Kjrer-gaard and the excellent analytical work of Ornstein and Lercher have summarized the factual knowledge of the cause of spontaneous pneumothorax in an apparently healthy lung. The latter authors believe that it occurs from rupture of a thinned-out sub-pleural bleb which has formed as the result of a break in the elastic layers of the alveoli due to persistent over-distention of the apical portions of the lung produced by exertion. That the subpleural bleb is a common finding is attested by the fact that anatomists have referred to it in descriptions of “normal” anatomy (Cunningham, Miller). There should be no confusion, however, between these emphysematous blebs which are the precursors of pneumothorax and the clinical entity of pulmonary emphysema.