Spontaneous Pneumothorax: A Study of 105 Cases

SPONTANEOUS pneumothorax is a condition in which air is present outside the lung in the thoracic cavity without obvious portal of entry through the chest wall. The term “pneumothorax” was initially employed by Itard in 1803, when he reported 5 cases, the diagnosis of which was made at autopsy. McDowell in 1856 described the first clear-cut case of spontaneous pneumothorax in an apparently healthy individual. Kjaergaard contributed his monumental work on this subject in 1932. Several hundred cases have since been reported in the literature (exclusive of figures from the military medical services). Many adjectives have been used to describe the pneumothorax. “Benign,” “true,” “real,” “idiopathic,” “simple,” and “spontaneous pneumothorax in apparently healthy individuals” are but a few of the terms. Regardless of terminology, the benign nature of the disease has been stressed by most of the recent investigators. In many medical textbooks the commonest cause of spontaneous pneumothorax is stated to be pulmonary tuberculosis. The purpose of this paper is to present a study of 105 consecutive cases of spontaneous pneumothorax observed at the Columbia-Presbyterian Medical Center, from 1930 to 1947, inclusive, to determine its possible relationship to pulmonary tuberculosis. Pathogenesis The three most important etiological agents in the pathogenesis of spontaneous pneumothorax have been considered to be (1) pulmonary tuberculosis, (2) congenital vesicles, and (3) emphysema. (1) Pulmonary Tuberculosis; Pulmonary tuberculosis has not infrequently been associated with spontaneous pneumothorax. This is apparently based on certain reports in the literature. For example, Fishberg (1932) in his textbook Pulmonary Tuberculosis, remarked that “the consensus of opinion is that the vast majority [of cases of spontaneous pneumothorax] are caused by a tuberculous lesion in the lung or pleura; it is maintained that at least 90 per cent originate thus. The rent in the pleura may be due to softening and consequent perforation of a subpleural tubercle, or to a tear in that membrane caused by tugging of an adhesion. . .. In the writer's opinion probably about 20 per cent of cases of really spontaneous pneumothoraces are not due to tuberculosis.” Rubin stated, in his textbook Diseases of the Chest, that “it was the occasional 'providential' outcome of a spontaneous pneumothorax in the tuberculous that led to the adoption of the procedure as a therapeutic measure.” Kjaergaard (1932) reported 51 cases of spontaneous pneumothorax, and was able to follow 49 of these patients from two to fifteen years. In only one of his cases did pulmonary tuberculosis develop subsequent to the pneumothorax.