FIG. I. Nov. 24, 1921. X-Ray of the thorax showing a total collapse of the left lung with the displacement to the right of the heart and trachea.

FIG. 2. expanded approximately to two-thirds of its normal size.

Dec. 16, 1921. X-Ray of the thorax showing the left lung

FIG. 3. Dec. 26, 1921. X-Ray of thorax showing the left lung to be completely collapsed again. Apparently the pleura is adherent in the region of the seventh interspace posterior.

FIG. 4. Feb. 21, 1922. X-Ray of the thorax showing the left lung to be completely expanded. There is a pleuro-pericardial adhesion extending on to the apex of the heart.

His

distinct coin sound was made out over the entire left chest. cardiac dulness was obliterated on the left side, but on the right side the dulness extended 5 cm. from the midsternal line in the fifth interspace where the sounds by stethoscope appeared to be of a good quality. No heart sounds were audible on the left side. The abdomen showed moderate tenderness in both upper quadrants, especially the left, and moderate muscle spasm was present on both sides. The examination was otherwise negative. The diagnosis of spontaneous pneumothorax was made which was subsequently confirmed by X-ray findings (Plate 1) which showed an entire collapse of the left lung with the heart displaced to the right. No fluid was shown in the left pleural cavity. Two days later faint breath sounds were audible on the left side. The coin sound remained, but no succussion splash could be elicited. The X-ray on November 30th showed a slight expansion of the lung. On December 3d no coin sounds were made out. Four days later the left lung by X-ray appeared to be expanded approximately twothirds of its normal size. (Plate 2.) Shortly before this the heart was found to be about half-way back to its normal position, but the breath sounds were still reduced in intensity over the lower left chest and vesicular in quality. On December 24th the breath sounds were audible everywhere over the left lung, which now appeared to be completely expanded, and the heart seemed to be again in its normal position.

On December 26th he again experienced a sharp severe stabbing pain in his left chest and his pulse rate rose at this time from 60 to 120 to the minute. (Plate 3.) I saw him on the following morning when similar findings to those which he presented on admission were made out and confirmed by the X-ray. On January 8th the lung was seen by X-ray to be again expanding, but it reached only two-thirds the distance to the axillary wall. Two weeks later the left lower lobe was seen to be almost expanded to the axillary wall, but the upper lobe showed only slight expansion. On February 2d, however, the lower lobe was completely expanded and by February 21st the expansion was complete throughout the left lung. (Plate 4.) At this time a pleural pericardial adhesion was noted, extending on to the apex of the heart. He was