[Reprinted from The Medical News, February 24, 1894.] 
A CASE OF RUPTURE OF THE LUNG, UNASSO- 
CIATED WITH FRACTURE OF THE RIBS, 
WITH EARLY SUBSEQUENT 
RECOVERY. 
Emerge7icy Hospital, (Washington, D. C. 
Service of JAS. KERR.JVbD., M.Ch., 
ATTENDING SURGEON. 
Reported by W. L. PYLE, A.M., M.D., Resident Physician. 
The mechanism of this rare and fatal form of injury 
has been very aptly described by M. Gosselin. It is 
due to a sudden pressure exerted on the thoracic wall at 
the moment of full inspiration, there being a spasm of 
the glottis or obstruction of the larynx ; in consequence 
of which the lung bursts. An extravasation of air 
occurs, resulting in the development of emphysema, 
pneumothorax, etc. Subsequently pleurisy, pneumonia, 
or even pus in the pleural cavity often results. Hemo- 
ptysis is a possible, but not a marked symptom. The 
mechanism is identical with that of the bursting of an 
inflated paper bag when struck by the hand. 
M. Gosselin reports two cases terminating in recovery. 
Dr. John Ashhurst, Jr., reports having seen three cases, 
all of which terminated fatally before the fifth day ; he 
has collected the histories of thirty-nine cases, of which 
twelve recovered. Dr. Otis has collected reports of 
twenty-five cases of this form of injury from military 
practice exclusively. These were generally caused by a 
blow on the chest, by a piece of shell, or other like 
missile. Among the twenty-five cases there were eleven 
recoveries. As Dr. Ashhurst very justly remarks, this 
injury appears more fatal in civil than in military life. 2 
That so severe a form of injury should show such a 
rapid and continuous recovery as in the case here cited 
is without a doubt extraordinary, and would seem to 
make it worthy of report. 
Lewis W., ten years old, white, born in Maryland, 
and living now in the District of Columbia ; was brought 
in by the Emergency Hospital ambulance on the after- 
noon of November the ioth, with a history of having 
been run over by a hose-cart of the District Fire Depart- 
ment. The boy was in a state of extreme shock, 
having a weak, almost imperceptible pulse ; his respira- 
tions were shallow and rapid, and his temperature sub- 
normal. There were no signs of external injury about 
his thoracic cavity, and no fracture of the ribs could be 
detected, although carefully searched for; there was 
marked emphysema ; the neck and side of the face were 
enormously swollen with the extravasated air; the tissues 
of the left arm were greatly infiltrated with air, which 
enabled us to elicit the familiar crepitus of such infiltra- 
tion when an attempt at the determination of the radial 
pulse was made. Consciousness was never lost. There 
were several injuries to the face and scalp; and there 
was hemorrhage from the nose and mouth, which was 
attributed to the fact that the patient had fallen on 
his face, striking both nose and lip. This was confirmed 
subsequently by the absence of any evidences of hemo- 
ptysis during the whole period of convalescence. The 
saliva was not even blood-streaked ; therefore it can be 
said with verity that there was no hemoptysis. 
The first indication in this, and in all similar chest-in- 
juries, is to limit the amount of thoracic expansion. To 
effect this, the chest was securely strapped with over- 
lapping bands of adhesive plaster, extending nearly 
around its whole circumference, and a muslin binder was 
applied. Hypodermatic injections of strychnin and 
whiskey were resorted to, and hot-water bottles applied, 
the patient being wrapped in blankets. It was soon found 
that the respirations were easier, and the pain less marked 3 
when the patient was propped up in bed by several pillows, 
than in the dorsal position. To further control respira- 
tion, morphin sulfate in doses of one-sixteenth grain 
was given at sufficient intervals to keep the rate below 20. 
Shortly after admission the patient reacted to the 
stimulating treatment, his pulse became stronger, and all 
evidences of threatened collapse disappeared. He rested 
well the first night and complained of no pain, then or 
subsequently. The improvement was continuous. The 
temperature remained normal until the evening of the 
fifth day, when it rose to 102.20, and again on the evening 
of the sixth to 102.30. This rise was apparently without 
significance, as the patient at no time seemed disturbed 
by it. On the eighth day the temperature again reached 
the norm and has since remained there. 
The advisability of thoracic puncture and superficial 
scarification of the infiltrated tissue to relieve the emphy- 
sema was considered; but realizing that such emphysema 
was not in itself dangerous and that the patient’s con- 
dition constantly improved under treatment, these proced- 
ures were not employed. The wisdom of this decision was 
demonstrated by the continued absorption of the air and 
diminution of the emphysema until the ninth day, when 
it was entirely absent from the tissues. A slight pneumo- 
thorax, however, remained. On the ninth day the chest 
was again carefully examined for evidences of a fracture, 
but the result of this second examination was again nega- 
tive ; leaving no doubt but that the case was one of rupture 
without fracture. There developed a slight, dry cough 
on the fifth day, which, however, soon subsided without 
any further treatment. The diet was exclusively of milk 
for a week, when light diet was substituted. The bowels 
were kept open daily by salines and enemata. 
The boy is apparently well now, suffers no incon- 
venience, and has left the hospital, safe from danger and 
apparently free from any pulmonary embarrassment. 
He uses well-developed diaphragmatic breathing which 
is fully sufficient.