Signs and symptoms.

A primary spontaneous pneumothorax (PSP) tends to occur in a young adult without underlying lung problems, and usually causes limited symptoms. Chest pain and sometimes mild breathlessness are the usual predominant presenting features. People who are affected by a PSP are often unaware of the potential danger and may wait several days before seeking medical attention. PSPs more commonly occur during changes in atmospheric pressure, explaining to some extent why episodes of pneumothorax may happen in clusters. It is rare for a PSP to cause a tension pneumothorax.  Secondary spontaneous pneumothoraces (SSPs), by definition, occur in individuals with significant underlying lung disease. Symptoms in SSPs tend to be more severe than in PSPs, as the unaffected lungs are generally unable to replace the loss of function in the affected lungs. Hypoxemia (decreased blood-oxygen levels) is usually present and may be observed as cyanosis (blue discoloration of the lips and skin). Hypercapnia (accumulation of carbon dioxide in the blood) is sometimes encountered; this may cause confusion and – if very severe – may result in comas. The sudden onset of breathlessness in someone with chronic obstructive pulmonary disease (COPD), cystic fibrosis, or other serious lung diseases should therefore prompt investigations to identify the possibility of a pneumothorax.  Traumatic pneumothorax most commonly occurs when the chest wall is pierced, such as when a stab wound or gunshot wound allows air to enter the pleural space, or because some other mechanical injury to the lung compromises the integrity of the involved structures. Traumatic pneumothoraces have been found to occur in up to half of all cases of chest trauma, with only rib fractures being more common in this group. The pneumothorax can be occult (not readily apparent) in half of these cases, but may enlarge – particularly if mechanical ventilation is required. They are also encountered in people already receiving mechanical ventilation for some other reason.  Upon physical examination, breath sounds (heard with a stethoscope) may be diminished on the affected side, partly because air in the pleural space dampens the transmission of sound. Measures of the conduction of vocal vibrations to the surface of the chest may be altered. Percussion of the chest may be perceived as hyperresonant (like a booming drum), and vocal resonance and tactile fremitus can both be noticeably decreased. Importantly, the volume of the pneumothorax may not be well correlated with the intensity of the symptoms experienced by the victim, and physical signs may not be apparent if the pneumothorax is relatively small.

Tension pneumothorax.

Tension pneumothorax is generally considered to be present when a pneumothorax (primary spontaneous, secondary spontaneous, or traumatic) leads to significant impairment of respiration and/or blood circulation. Tension pneumothorax tends to occur in clinical situations such as ventilation, resuscitation, trauma, or in people with lung disease. It is a medical emergency and may require immediate treatment without further investigations (see Treatment section).  The most common findings in people with tension pneumothorax are chest pain and respiratory distress, often with an increased heart rate (tachycardia) and rapid breathing (tachypnea) in the initial stages. Other findings may include quieter breath sounds on one side of the chest, low oxygen levels and blood pressure, and displacement of the trachea away from the affected side. Rarely, there may be cyanosis (bluish discoloration of the skin due to low oxygen levels), altered level of consciousness, a hyperresonant percussion note on examination of the affected side with reduced expansion and decreased movement, pain in the epigastrium (upper abdomen), displacement of the apex beat (heart impulse), and resonant sound when tapping the sternum.  Tension pneumothorax may also occur in someone who is receiving mechanical ventilation, in which case it may be difficult to spot as the person is typically receiving sedation; it is often noted because of a sudden deterioration in condition. Recent studies have shown that the development of tension features may not always be as rapid as previously thought. Deviation of the trachea to one side and the presence of raised jugular venous pressure (distended neck veins) are not reliable as clinical signs.

Cause.

Primary spontaneous.

Spontaneous pneumothoraces are divided into two types: "primary", which occurs in the absence of known lung disease, and "secondary", which occurs in someone with underlying lung disease. The cause of primary spontaneous pneumothorax is unknown, but established risk factors include male sex, smoking, and a family history of pneumothorax. Smoking either cannabis or tobacco increases the risk. The various suspected underlying mechanisms are discussed below.

Secondary spontaneous.

Secondary spontaneous pneumothorax occurs in the setting of a variety of lung diseases. The most common is chronic obstructive pulmonary disease (COPD), which accounts for approximately 70% of cases. Known lung diseases that may significantly increase the risk for pneumothorax are  In children, additional causes include measles, echinococcosis, inhalation of a foreign body, and certain congenital malformations (congenital pulmonary airway malformation and congenital lobar emphysema).  11.5% of people with a spontaneous pneumothorax have a family member who has previously experienced a pneumothorax. The hereditary conditions – Marfan syndrome, homocystinuria, Ehlers–Danlos syndromes, alpha 1-antitrypsin deficiency (which leads to emphysema), and Birt–Hogg–Dubé syndrome – have all been linked to familial pneumothorax. Generally, these conditions cause other signs and symptoms as well, and pneumothorax is not usually the primary finding. Birt–Hogg–Dubé syndrome is caused by mutations in the "FLCN" gene (located at chromosome 17p11.2), which encodes a protein named folliculin. "FLCN" mutations and lung lesions have also been identified in familial cases of pneumothorax where other features of Birt–Hogg–Dubé syndrome are absent. In addition to the genetic associations, the HLA haplotype AB is also a genetic predisposition to PSP.

Traumatic.

A traumatic pneumothorax may result from either blunt trauma or penetrating injury to the chest wall. The most common mechanism is due to the penetration of sharp bony points at a new rib fracture, which damages lung tissue. Traumatic pneumothorax may also be observed in those exposed to blasts, even though there is no apparent injury to the chest.  They may be classified as "open" or "closed". In an open pneumothorax, there is a passage from the external environment into the pleural space through the chest wall. When air is drawn into the pleural space through this passageway, it is known as a "sucking chest wound". A closed pneumothorax is when the chest wall remains intact.  Medical procedures, such as the insertion of a central venous catheter into one of the chest veins or the taking of biopsy samples from lung tissue, may lead to pneumothorax. The administration of positive pressure ventilation, either mechanical ventilation or non-invasive ventilation, can result in barotrauma (pressure-related injury) leading to a pneumothorax.  Divers who breathe from an underwater apparatus are supplied with breathing gas at ambient pressure, which results in their lungs containing gas at higher than atmospheric pressure. Divers breathing compressed air (such as when scuba diving) may suffer a pneumothorax as a result of barotrauma from ascending just while breath-holding with their lungs fully inflated. An additional problem in these cases is that those with other features of decompression sickness are typically treated in a diving chamber with hyperbaric therapy; this can lead to a small pneumothorax rapidly enlarging and causing features of tension.

Mechanism.

The thoracic cavity is the space inside the chest that contains the lungs, heart, and numerous major blood vessels. On each side of the cavity, a pleural membrane covers the surface of lung (visceral pleura) and also lines the inside of the chest wall (parietal pleura). Normally, the two layers are separated by a small amount of lubricating serous fluid. The lungs are fully inflated within the cavity because the pressure inside the airways is higher than the pressure inside the pleural space. Despite the low pressure in the pleural space, air does not enter it because there are no natural connections to an air-containing passage, and the pressure of gases in the bloodstream is too low for them to be forced into the pleural space. Therefore, a pneumothorax can only develop if air is allowed to enter, through damage to the chest wall or damage to the lung itself, or occasionally because microorganisms in the pleural space produce gas.  Chest-wall defects are usually evident in cases of injury to the chest wall, such as stab or bullet wounds ("open pneumothorax"). In secondary spontaneous pneumothoraces, vulnerabilities in the lung tissue are caused by a variety of disease processes, particularly by rupturing of bullae (large air-containing lesions) in cases of severe emphysema. Areas of necrosis (tissue death) may precipitate episodes of pneumothorax, although the exact mechanism is unclear. Primary spontaneous pneumothorax (PSP) has for many years been thought to be caused by "blebs" (small air-filled lesions just under the pleural surface), which were presumed to be more common in those classically at risk of pneumothorax (tall males) due to mechanical factors. In PSP, blebs can be found in 77% of cases, compared to 6% in the general population without a history of PSP. As these healthy subjects do not all develop a pneumothorax later, the hypothesis may not be sufficient to explain all episodes; furthermore, pneumothorax may recur even after surgical treatment of blebs. It has therefore been suggested that PSP may also be caused by areas of disruption (porosity) in the pleural layer, which are prone to rupture. Smoking may additionally lead to inflammation and obstruction of small airways, which account for the markedly increased risk of PSPs in smokers. Once air has stopped entering the pleural cavity, it is gradually reabsorbed.  Tension pneumothorax occurs when the opening that allows air to enter the pleural space functions as a one-way valve, allowing more air to enter with every breath but none to escape. The body compensates by increasing the respiratory rate and tidal volume (size of each breath), worsening the problem. Unless corrected, hypoxia (decreased oxygen levels) and respiratory arrest eventually follow.

Diagnosis.

The symptoms of pneumothorax can be vague and inconclusive, especially in those with a small PSP; confirmation with medical imaging is usually required. In contrast, tension pneumothorax is a medical emergency and may be treated before imaging – especially if there is severe hypoxia, very low blood pressure, or an impaired level of consciousness. In tension pneumothorax, X-rays are sometimes required if there is doubt about the anatomical location of the pneumothorax.

Chest X-ray.

A plain chest radiograph, ideally with the X-ray beams being projected from the back (posteroanterior, or "PA"), and during maximal inspiration (holding one's breath), is the most appropriate first investigation. It is not believed that routinely taking images during expiration would confer any benefit. Still, they may be useful in the detection of a pneumothorax when clinical suspicion is high but yet an inspiratory radiograph appears normal. Also, if the PA X-ray does not show a pneumothorax but there is a strong suspicion of one, lateral X-rays (with beams projecting from the side) may be performed, but this is not routine practice.  It is not unusual for the mediastinum (the structure between the lungs that contains the heart, great blood vessels and large airways) to be shifted away from the affected lung due to the pressure differences. This is "not" equivalent to a tension pneumothorax, which is determined mainly by the constellation of symptoms, hypoxia, and shock.  The size of the pneumothorax (i.e. the volume of air in the pleural space) can be determined with a reasonable degree of accuracy by measuring the distance between the chest wall and the lung. This is relevant to treatment, as smaller pneumothoraces may be managed differently. An air rim of 2 cm means that the pneumothorax occupies about 50% of the hemithorax. British professional guidelines have traditionally stated that the measurement should be performed at the level of the hilum (where blood vessels and airways enter the lung) with 2 cm as the cutoff, while American guidelines state that the measurement should be done at the apex (top) of the lung with 3 cm differentiating between a "small" and a "large" pneumothorax. The latter method may overestimate the size of a pneumothorax if it is located mainly at the apex, which is a common occurrence. The various methods correlate poorly, but are the best easily available ways of estimating pneumothorax size. CT scanning (see below) can provide a more accurate determination of the size of the pneumothorax, but its routine use in this setting is not recommended.  Not all pneumothoraces are uniform; some only form a pocket of air in a particular place in the chest. Small amounts of fluid may be noted on the chest X-ray (hydropneumothorax); this may be blood (hemopneumothorax). In some cases, the only significant abnormality may be the "deep sulcus sign", in which the normally small space between the chest wall and the diaphragm appears enlarged due to the abnormal presence of fluid.

Computed tomography.

A CT scan is not necessary for the diagnosis of pneumothorax, but it can be useful in particular situations. In some lung diseases, especially emphysema, it is possible for abnormal lung areas such as bullae (large air-filled sacs) to have the same appearance as a pneumothorax on chest X-ray, and it may not be safe to apply any treatment before the distinction is made and before the exact location and size of the pneumothorax is determined. In trauma, where it may not be possible to perform an upright film, chest radiography may miss up to a third of pneumothoraces, while CT remains very sensitive.  A further use of CT is in the identification of underlying lung lesions. In presumed primary pneumothorax, it may help to identify blebs or cystic lesions (in anticipation of treatment, see below), and in secondary pneumothorax it can help to identify most of the causes listed above.

Ultrasound.

Ultrasound is commonly used in the evaluation of people who have sustained physical trauma, for example with the FAST protocol. Ultrasound may be more sensitive than chest X-rays in the identification of pneumothorax after blunt trauma to the chest. Ultrasound may also provide a rapid diagnosis in other emergency situations, and allow the quantification of the size of the pneumothorax. Several particular features on ultrasonography of the chest can be used to confirm or exclude the diagnosis.

Treatment.

The treatment of pneumothorax depends on a number of factors, and may vary from discharge with early follow-up to immediate needle decompression or insertion of a chest tube. Treatment is determined by the severity of symptoms and indicators of acute illness, the presence of underlying lung disease, the estimated size of the pneumothorax on X-ray, and – in some instances – on the personal preference of the person involved.  In traumatic pneumothorax, chest tubes are usually inserted. If mechanical ventilation is required, the risk of tension pneumothorax is greatly increased and the insertion of a chest tube is mandatory. Any open chest wound should be covered with an airtight seal, as it carries a high risk of leading to tension pneumothorax. Ideally, a dressing called the "Asherman seal" should be utilized, as it appears to be more effective than a standard "three-sided" dressing. The Asherman seal is a specially designed device that adheres to the chest wall and, through a valve-like mechanism, allows air to escape but not to enter the chest.  Tension pneumothorax is usually treated with urgent needle decompression. This may be required before transport to the hospital, and can be performed by an emergency medical technician or other trained professional. The needle or cannula is left in place until a chest tube can be inserted. If tension pneumothorax leads to cardiac arrest, needle decompression is performed as part of resuscitation as it may restore cardiac output.

Conservative.

Small spontaneous pneumothoraces do not always require treatment, as they are unlikely to proceed to respiratory failure or tension pneumothorax, and generally resolve spontaneously. This approach is most appropriate if the estimated size of the pneumothorax is small (defined as <50% of the volume of the hemithorax), there is no breathlessness, and there is no underlying lung disease. It may be appropriate to treat a larger PSP conservatively if the symptoms are limited. Admission to hospital is often not required, as long as clear instructions are given to return to hospital if there are worsening symptoms. Further investigations may be performed as an outpatient, at which time X-rays are repeated to confirm improvement, and advice given with regard to preventing recurrence (see below). Estimated rates of resorption are between 1.25% and 2.2% the volume of the cavity per day. This would mean that even a complete pneumothorax would spontaneously resolve over a period of about 6 weeks. There is, however, no high quality evidence comparing conservative to non conservative management.  Secondary pneumothoraces are only treated conservatively if the size is very small (1 cm or less air rim) and there are limited symptoms. Admission to the hospital is usually recommended. Oxygen given at a high flow rate may accelerate resorption as much as fourfold.

Aspiration.

In a large PSP (>50%), or in a PSP associated with breathlessness, some guidelines recommend that reducing the size by aspiration is equally effective as the insertion of a chest tube. This involves the administration of local anesthetic and inserting a needle connected to a three-way tap; up to 2.5 liters of air (in adults) are removed. If there has been significant reduction in the size of the pneumothorax on subsequent X-ray, the remainder of the treatment can be conservative. This approach has been shown to be effective in over 50% of cases. Compared to tube drainage, first-line aspiration in PSP reduces the number of people requiring hospital admission, without increasing the risk of complications.  Aspiration may also be considered in secondary pneumothorax of moderate size (air rim 1–2 cm) without breathlessness, with the difference that ongoing observation in hospital is required even after a successful procedure. American professional guidelines state that all large pneumothoraces – even those due to PSP – should be treated with a chest tube. Moderately sized iatrogenic traumatic pneumothoraces (due to medical procedures) may initially be treated with aspiration.

Chest tube.

A chest tube (or intercostal drain) is the most definitive initial treatment of a pneumothorax. These are typically inserted in an area under the axilla (armpit) called the "safe triangle", where damage to internal organs can be avoided; this is delineated by a horizontal line at the level of the nipple and two muscles of the chest wall (latissimus dorsi and pectoralis major). Local anesthetic is applied. Two types of tubes may be used. In spontaneous pneumothorax, small-bore (smaller than 14 F, 4.7 mm diameter) tubes may be inserted by the Seldinger technique, and larger tubes do not have an advantage. In traumatic pneumothorax, larger tubes (28 F, 9.3 mm) are used.  Chest tubes are required in PSPs that have not responded to needle aspiration, in large SSPs (>50%), and in cases of tension pneumothorax. They are connected to a one-way valve system that allows air to escape, but not to re-enter, the chest. This may include a bottle with water that functions like a water seal, or a Heimlich valve. They are not normally connected to a negative pressure circuit, as this would result in rapid re-expansion of the lung and a risk of pulmonary edema ("re-expansion pulmonary edema"). The tube is left in place until no air is seen to escape from it for a period of time, and X-rays confirm re-expansion of the lung.  If after 2–4 days there is still evidence of an air leak, various options are available. Negative pressure suction (at low pressures of –10 to –20 cmHO) at a high flow rate may be attempted, particularly in PSP; it is thought that this may accelerate the healing of the leak. Failing this, surgery may be required, especially in SSP.  Chest tubes are used first-line when pneumothorax occurs in people with AIDS, usually due to underlying pneumocystis pneumonia (PCP), as this condition is associated with prolonged air leakage. Bilateral pneumothorax (pneumothorax on both sides) is relatively common in people with pneumocystis pneumonia, and surgery is often required.  It is possible for a person with a chest tube to be managed in an ambulatory care setting by using a Heimlich valve, although research to demonstrate the equivalence to hospitalization has been of limited quality.

Pleurodesis and surgery.

Pleurodesis is a procedure that permanently eliminates the pleural space and attaches the lung to the chest wall. No long-term study (20 years or more) has been performed on its consequences. Good results in the short term are achieved with a thoracotomy (surgical opening of the chest) with identification of any source of air leakage and stapling of blebs followed by pleurectomy (stripping of the pleural lining) of the outer pleural layer and pleural abrasion (scraping of the pleura) of the inner layer. During the healing process, the lung adheres to the chest wall, effectively obliterating the pleural space. Recurrence rates are approximately 1%. Post-thoracotomy pain is relatively common.  A less invasive approach is thoracoscopy, usually in the form of a procedure called video-assisted thoracoscopic surgery (VATS). The results from VATS-based pleural abrasion are slightly worse than those achieved using thoracotomy in the short term, but produce smaller scars in the skin. Compared to open thoracotomy, VATS offers a shorter in-hospital stays, less need for postoperative pain control, and a reduced risk of lung problems after surgery. VATS may also be used to achieve chemical pleurodesis; this involves insufflation of talc, which activates an inflammatory reaction that causes the lung to adhere to the chest wall.  If a chest tube is already in place, various agents may be instilled through the tube to achieve chemical pleurodesis, such as talc, tetracycline, minocycline or doxycycline. Results of chemical pleurodesis tend to be worse than when using surgical approaches, but talc pleurodesis has been found to have few negative long-term consequences in younger people.

Aftercare.

If pneumothorax occurs in a smoker, this is considered an opportunity to emphasize the markedly increased risk of recurrence in those who continue to smoke, and the many benefits of smoking cessation. It may be advisable for someone to remain off work for up to a week after a spontaneous pneumothorax. If the person normally performs heavy manual labor, several weeks may be required. Those who have undergone pleurodesis may need two to three weeks off work to recover.  Air travel is discouraged for up to seven days after complete resolution of a pneumothorax if recurrence does not occur. Underwater diving is considered unsafe after an episode of pneumothorax unless a preventative procedure has been performed. Professional guidelines suggest that pleurectomy be performed on both lungs and that lung function tests and CT scan normalize before diving is resumed. Aircraft pilots may also require assessment for surgery.

Prevention.

A preventative procedure (thoracotomy or thoracoscopy with pleurodesis) may be recommended after an episode of pneumothorax, with the intention to prevent recurrence. Evidence on the most effective treatment is still conflicting in some areas, and there is variation between treatments available in Europe and the US. Not all episodes of pneumothorax require such interventions; the decision depends largely on estimation of the risk of recurrence. These procedures are often recommended after the occurrence of a second pneumothorax. Surgery may need to be considered if someone has experienced pneumothorax on both sides ("bilateral"), sequential episodes that involve both sides, or if an episode was associated with pregnancy.

Epidemiology.

The annual age-adjusted incidence rate (AAIR) of PSP is thought to be three to six times as high in males as in females. Fishman cites AAIR's of 7.4 and 1.2 cases per 100,000 person-years in males and females, respectively. Significantly above-average height is also associated with increased risk of PSP – in people who are at least 76 inches (1.93 meters) tall, the AAIR is about 200 cases per 100,000 person-years. Slim build also seems to increase the risk of PSP.  The risk of contracting a first spontaneous pneumothorax is elevated among male and female smokers by factors of approximately 22 and 9, respectively, compared to matched non-smokers of the same sex. Individuals who smoke at higher intensity are at higher risk, with a "greater-than-linear" effect; men who smoke 10 cigarettes per day have an approximate 20-fold increased risk over comparable non-smokers, while smokers consuming 20 cigarettes per day show an estimated 100-fold increase in risk.  In secondary spontaneous pneumothorax, the estimated annual AAIR is 6.3 and 2.0 cases per 100,000 person-years for males and females, respectively, with the risk of recurrence depending on the presence and severity of any underlying lung disease. Once a second episode has occurred, there is a high likelihood of subsequent further episodes. The incidence in children has not been well studied, but is estimated to be between 5 and 10 cases per 100,000 person-years.  Death from pneumothorax is very uncommon (except in tension pneumothoraces). British statistics show an annual mortality rate of 1.26 and 0.62 deaths per million person-years in men and women, respectively. A significantly increased risk of death is seen in older victims and in those with secondary pneumothoraces.

History.

An early description of traumatic pneumothorax secondary to rib fractures appears in "Imperial Surgery" by Turkish surgeon Şerafeddin Sabuncuoğlu (1385–1468), which also recommends a method of simple aspiration.  Pneumothorax was described in 1803 by Jean Marc Gaspard Itard, a student of René Laennec, who provided an extensive description of the clinical picture in 1819. While Itard and Laennec recognized that some cases were not due to tuberculosis (then the most common cause), the concept of spontaneous pneumothorax in the absence of tuberculosis (primary pneumothorax) was reintroduced by the Danish physician Hans Kjærgaard in 1932. In 1941, the surgeons Tyson and Crandall introduced pleural abrasion for the treatment of pneumothorax.  Prior to the advent of anti-tuberculous medications, pneumothoraces were intentionally caused by healthcare providers in people with tuberculosis in an effort to collapse a lobe, or entire lung, around a cavitating lesion. This was known as "resting the lung". It was introduced by the Italian surgeon Carlo Forlanini in 1888, and publicized by the American surgeon John Benjamin Murphy in the early 20th century (after discovering the same procedure independently). Murphy used the (then) recently discovered X-ray technology to create pneumothoraces of the correct size.

Etymology.

The word pneumothorax is from the Greek "pneumo-" meaning air and "thorax" meaning chest. Its plural is pneumothoraces.

Other animals.

Non-human animals may experience both spontaneous and traumatic pneumothorax. Spontaneous pneumothorax is, as in humans, classified as primary or secondary, while traumatic pneumothorax is divided into open and closed (with or without chest wall damage). The diagnosis may be apparent to the veterinary physician because the animal exhibits difficulty breathing in, or has shallow breathing. Pneumothoraces may arise from lung lesions (such as bullae) or from trauma to the chest wall. In horses, traumatic pneumothorax may involve both hemithoraces, as the mediastinum is incomplete and there is a direct connection between the two halves of the chest. Tension pneumothorax – the presence of which may be suspected due to rapidly deteriorating heart function, absent lung sounds throughout the thorax, and a barrel-shaped chest – is treated with an incision in the animal's chest to relieve the pressure, followed by insertion of a chest tube. For spontaneous pneumothorax the use of CT for diagnosis has been described for dogs and Kunekune pigs.

A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve is formed by an area of damaged tissue, and the amount of air in the space between chest wall and lungs increases; this is called a tension pneumothorax. This can cause a steadily worsening oxygen shortage and low blood pressure and unless reversed can be fatal. Very rarely, both lungs may be affected by a pneumothorax. It is often called a "collapsed lung", although that term may also refer to atelectasis. A primary spontaneous pneumothorax is one that occurs without an apparent cause and in the absence of significant lung disease. A secondary spontaneous pneumothorax occurs in the presence of existing lung disease. Smoking increases the risk of primary spontaneous pneumothorax, while the main underlying causes for secondary pneumothorax are COPD, asthma, and tuberculosis. A pneumothorax can also be caused by physical trauma to the chest (including a blast injury) or as a complication of a healthcare intervention, in which case it is called a traumatic pneumothorax. Diagnosis of a pneumothorax by physical examination alone can be difficult (particularly in smaller pneumothoraces). A chest X-ray, computed tomography (CT) scan, or ultrasound is usually used to confirm its presence. Other conditions that can result in similar symptoms include a hemothorax (buildup of blood in the pleural space), pulmonary embolism, and heart attack. A large bulla may look similar on a chest X-ray. A small spontaneous pneumothorax will typically resolve without treatment and requires only monitoring. This approach may be most appropriate in people who have no underlying lung disease. In a larger pneumothorax, or if there is shortness of breath, the air may be removed with a syringe or a chest tube connected to a one-way valve system. Occasionally, surgery may be required if tube drainage is unsuccessful, or as a preventive measure, if there have been repeated episodes. The surgical treatments usually involve pleurodesis (in which the layers of pleura are induced to stick together) or pleurectomy (the surgical removal of pleural membranes). About 17–23 cases of pneumothorax occur per 100,000 people per year. They are more common in men than women.

En médecine (pneumologie), un pneumothorax est une affection de la plèvre, mettant en communication l'espace pleural et l’atmosphère (accolement de la plèvre pariétale et viscérale, on parle de séreuse, elles tapissent respectivement la cage thoracique et les poumons). Le poumon s’affaisse alors avec des conséquences respiratoires et hémodynamiques parfois graves (notamment en cas de pneumothorax bilatéral ou suffoquant) et urgentes pouvant aller jusqu'à la mort.


Biography.

Early life.

The youngest of ten children, he was born at Sestri Levante, then part of the independent Republic of Genoa to Bernardo and Pellegrina Raggi Lambruschini, and baptized Emmanuele Nicolo. His older brother, Giovanni Battista Lambruschini became bishop of the Diocese of Orvieto.  Lambruschini attended a Jesuit school in Santa Margherita Ligure, and then the Oratorio di San Bartolomeo in Bordighera, run by the Order of the Barnabites. He entered the order in 1793, and after a novitiate, pronounced solemn vows in November 1794, taking the name of Luigi. He was then to Macerata for further study, took minor orders in Rome in 1797, and was ordained a priest back home in Sestri Levante in January 1799. He then taught Barnabite seminarians rhetoric, philosophy and mathematics, first in Bologna, then in San Severino Marche and, from May 1801, in Macerata.

Diplomatic career.

He attended the Congress of Vienna in 1815 as secretary to Cardinal Ercole Consalvi. As secretary of the Congregation of Extraordinary Ecclesiastical Affairs, he took part in concluding concordats with various states, including Tuscany, Naples, and Bavaria. According to Umberto Benigni, "Next to Consalvi and Pacca, Lambruschini was among the greatest diplomats of the Holy See in the nineteenth century." In 1816, Lambruschini became vice-general of the Barnabite order.  In 1819, Lambruschini was appointed Archbishop of Genoa. It was rumored that his promotion was to be attributed to the desire of Secretary of State Consalvi to remove from Rome a clergyman who, having acquired too much influence on the pope, was now an obstacle to his own plans for government. In 1826, he was named as Apostolic Nuncio to the Kingdom of France by Pope Pius VII, but was forced to flee his diplomatic post following the 1830 revolution that toppled the Bourbon monarchy and brought House of Orleans pretender Louis-Phillippe to the French throne.  He was made a cardinal in 1831, given the titular church of San Callisto on 24 February 1832. For the next four years, Cardinal Lambruschini held various curial posts until in January 1836 he was appointed Secretary of State to Pope Gregory XVI. His appointment was seen as a compromise between those who hoped for reform and the "zealanti" who wished to see dissent more forcefully suppressed; although it was said that the Cardinal was "liberal chiefly in his employment of spies and prisons".  He was the leading conservative candidate in the 1846 papal conclave. Though he received a majority of the votes initially, it was clear that he could not achieve the required two-thirds majority. He was eventually defeated by the liberal candidate, Giovanni Maria Mastai Ferretti, the Archbishop (personal title) of Imola, who became Pope Pius IX.  Lambruschini was a particularly hated figure among the masonic republicans during the 1848 Revolutions that temporarily deposed Pope Pius IX. His house was ransacked and he was forced to flee for his life, disguised as a stablehand. He returned following the Pope's restoration. He died in Rome on May 12, 1854, Rome and was buried in the Barnabite church of San Carlo ai Catinari, Rome.  He was also the uncle of the Portuguese poet and philosopher, Raul Lambruschini de Sousa Leal.

Luigi Lambruschini (6 March 1776 – 12 May 1854) was an Italian cardinal of the Roman Catholic Church in the mid nineteenth century. He was a member of the Clerics Regular of St. Paul and served in the diplomatic corps of the Holy See.

Luigi Lambruschini ("Luigi Emmanuele Nicolo Lambruschini") (né le à Sestri Levante (aujourd'hui en Ligurie, mais alors dans la République de Gênes) et mort le à Rome) est un cardinal italien du, qui fut cardinal secrétaire d'État et diplomate pontifical.


Common names.

The common names autumn crocus, meadow saffron and naked lady may be applied to the whole genus or to many of its species; they refer to the "naked" crocus-like flowers that appear in late summer or autumn, long before the strap-like foliage which appears in spring.  "Colchicum" and "Crocus" look alike and can be confused by the casual observer. To add to the confusion, there are autumn-flowering species of crocus. However, colchicums have 3 styles and 6 stamens, while crocuses have 1 style and 3 stamens. In addition, the corm structures are quite different—in colchicum, the corm is irregular, while in crocuses, the corm is like a flattened ball. "Crocus" is in the Iris Family, Iridaceae.

Etymology.

The name of the genus derives from Κολχίς (Colchis), the Ancient Greek name for the region of კოლხეთი (Kolkhida) in modern Georgia (Caucasus). Colchis features in Greek mythology as the land to which the Argonauts journeyed in quest of the golden fleece and where Jason encountered Medea. The Greek toponym "Colchis" is thought by scholars to derive from the Urartian "Qulḫa", pronounced "Kolcha" (guttural "ch" - as in Scots "loch").

Relationships.

"Colchicum melanthioides", also known as "Androcymbium melanthioides", is probably the best known species from the tropical regions. In contrast to most temperate colchicums, the flower and leaves are produced at the same time, the white flowers usually in a small corymb that is enclosed by white bracts. Close relatives such as "Colchicum scabromarginatum" ("Androcymbium scabromarginatum") and "Colchicum coloratum" ("Androcymbium burchellii") have flowers with very short stalks and may be pollinated by rodents.

Cultivation.

Temperate colchicums are commonly grown in gardens as ornamental flowers. Species found in cultivation include:  There are also cultivars and hybrids such as:-  Those marked have gained the Royal Horticultural Society's Award of Garden Merit (confirmed 2017).  In the United Kingdom, the National Collection of colchicums is maintained at Felbrigg Hall, Norfolk.

Medicinal uses and poisonous properties.

Plants in this genus contain toxic amounts of the alkaloid colchicine which is used pharmaceutically to treat gout and Familial Mediterranean fever. The use of the roots and seeds in traditional medicine is thought to have arisen due to the presence of this drug.  Its leaves, corm and seeds are poisonous. Murderer Catherine Wilson is thought to have used it to poison a number of victims in the 19th Century. The species known to contain the most lethal amount of colchicine is "C. autumnale".

Species.

The following are the species included in the genus "Colchicum". Many species previously classified in "Androcymbium", "Bulbocodium" and "Merendera" were moved to "Colchicum" based on molecular genetic evidence. "Androcymbium" is currently considered a separate genus by some.

Colchicum ( or ) is a genus of perennial flowering plants containing around 160 species which grow from bulb-like corms. It is a member of the botanical family Colchicaceae, and is native to West Asia, Europe, parts of the Mediterranean coast, down the East African coast to South Africa and the Western Cape. In this genus, the ovary of the flower is underground. As a consequence, the styles are extremely long in proportion, often more than. All species in the genus are toxic.

Colchicum (les colchiques) est un genre de plantes herbacées vivaces de la famille des "Liliaceae" selon la ou des "Colchicaceae" selon la classification phylogénétique. La World Checklist () en répertorie une centaine d'espèces. Le nom "Colchicum" est dérivé de Colchide, où la magicienne Médée habitait. Le plus grand nombre d'espèces se rencontre dans les Balkans et en Asie mineure. Le colchique est également connu sous les noms « safran bâtard », « safran des prés » ou encore, de par sa grande toxicité, « tue-chien ».


Publication history.

The character first appeared in "Fantastic Four" #45 (December 1965) and was created by Stan Lee and Jack Kirby.  As part of the 2012 rebranding initiative Marvel NOW!, Black Bolt re-joined the Illuminati.  In 2017 Black Bolt was given his own solo series, written by Saladin Ahmed and drawn by Christian James Ward.

Fictional character biography.

1960s.

Black Bolt's first appearance established the character as being a member of the Inhuman ruling class. The title "Thor" featured a back-up feature called "Tales of the Inhumans", which recounts the character's origin story. The son of King Agon and Queen Rynda, Black Bolt is exposed to the mutagenic Terrigen Mist while still an embryo, and eventually demonstrates the ability to manipulate electrons. To protect the Inhuman community from his devastating voice, Black Bolt is placed inside a sound-proof chamber and is tutored in the use of his powers. Reentering Inhuman society as a young man—having vowed never to speak—the character is attacked by his younger brother Maximus, who attempts, unsuccessfully, to goad him into speaking.  Black Bolt proved popular, and decides to leave Attilan to explore the outside world. The character reappears in a story focusing on his cousin Medusa, drives off the Hulk after the monster defeats the entire Inhuman Royal Family (Medusa, Gorgon, Karnak, Triton, and Crystal), and with the Fantastic Four battles his brother Maximus and his own group of rogue Inhumans.

1970s.

After being forced to intercede in the budding romance between his cousin Crystal and the Fantastic Four's Johnny Storm, Black Bolt and the Inhumans feature in the title "Amazing Adventures", and battle villains such as the Mandarin and Magneto. A story in "The Avengers", told in flashback, reveals how Black Bolt came to be ruler of the Inhumans and Maximus was driven mad. Black Bolt discovered his brother had secretly allied himself with the alien Kree—the race whose genetic experiments first created the Inhumans. In trying to stop an escaping Kree vessel, he overextended his sonic powers and caused the vessel to crash. The crash resulted in the deaths of several members of the Council of Genetics, including the brothers' parents, and Maximus was driven insane by his proximity to Black Bolt's use of his voice. Black Bolt assumes the title of King but is haunted by the consequences of his actions.  Black Bolt settles a quarrel between Johnny Storm and the mutant Quicksilver for the affections of Crystal, and frees the slave caste of Inhuman society, the Alpha Primitives. Black Bolt and the Royal Family aid the hero Spider-Man against the time-traveling villain Kang the Conqueror, and is forced to again battle the Hulk, teams with the Fantastic Four and the Avengers against the threat of the robot Ultron, and again allies with the Fantastic Four against the fifth-dimensional villain Xemu.  Black Bolt and the Inhumans feature in a self-titled bi-monthly series battling threats such as the villain Blastaar and the Kree, who regard the Inhumans as abominations. The character encounters the immortal villain the Sphinx—who has defeated the Fantastic Four and the Royal Family blasting him into deep space, aids Kree hero Captain Marvel in preventing a war between the Kree and Skrulls on Earth, joins with Fantastic Four member the Thing to defeat the mutated villain Graviton, and appears briefly during an announcement that Crystal is pregnant with Quicksilver's child.

1980s.

Black Bolt revisits his origins when he, members of the Royal Family, and Fantastic Four members Mister Fantastic and the Thing battle the villain Maelstrom. Maelstrom is revealed to be the son of a rival of Black Bolt's father, and—after his minions are defeated—attempts to destroy Attilan with a guided missile. Black Bolt, however, manages to defuse the missile and Maelstrom is defeated.  Black Bolt's search for a new site for the city of Attilan (eventually the Himalayas) is detailed in a back-up feature of the alternate universe title "What If". Another back-up feature in "What If?" details how Black Bolt worked with the Eternals to move the city of Attilan to the Himalayas. Black Bolt also directed the eventual move of Attilan to the moon when the pollution on Earth became too much for the Inhumans.  He is rated with other powerful Marvel characters by Spider-Man in an "out of universe" conversation with the reader. He appears in a graphic novel detailing the eventual death of former ally Mar-Vell due to cancer, He also appears in a one-shot publication featuring humorous parodies of the Marvel Universe - "Fantastic Four Roast", and aids superheroine Dazzler against the villain Absorbing Man.  An alien device abandoned on the moon causes Black Bolt, the Royal Family, and the Fantastic Four to experience nightmares until destroyed by Triton. Black Bolt is imprisoned by Maximus (who has also swapped their bodies), but he is freed by the Royal Family and the Avengers. He appears in a one-shot title detailing several of Marvel's continuity mistakes. He marries his cousin Medusa after an interrupting battle between a Kree and Skrull soldier. He appears in another "What If?" issue and a back-up tale in "Marvel Fanfare".  With the Royal Family, Black Bolt encounters Dazzler once again, appears in flashbacks in two issues of "The Avengers", attempts to subdue an erratic Quicksilver (distraught over his wife's affair), and aids the mutant team X-Factor in defeating Maximus. The Inhumans then assist the Fantastic Four against the villain Diablo, skirmish with a later version of the team during The Evolutionary War. They also appear in the first issue of "What If?"s second volume.  Black Bolt clashes with Attilan's Genetic Council when they forbid the birth of the child he conceived with Medusa. She ends up fleeing to Earth to bear her son (Ahura). Black Bolt destroys the alien symbiote that Spider-Man bonds with in another issue of "What If?", and with the Royal Family encounters the hero Daredevil.

1990s.

After another appearance in a back-up feature in the title "What If?" a story told in flashback reveals how Maximus, using a creation called the "Trikon", forced Black Bolt from Attilan. Black Bolt, however, eventually defeats the Trikon and regains the throne. After aiding the teen super group the New Warriors the Royal Family joins forces with X-Factor to stop master villain Apocalypse.  Black Bolt makes a series of brief guest appearances in several titles and his child is threatened by rogue Inhumans. He and the Royal family break away from Attilan after rescuing his son from the corrupted Genetics Council. After two more appearances in back-up features in the titles "X-Factor" and "Starblast", Black Bolt appears in several panels in two titles before starring in the one-shot publication "Inhumans: The Great Refuge" (May 1995), which details the Inhumans' ongoing battle with the Kree.  With the Royal Family, the Fantastic Four, and Doom's heir Kristoff Vernard, Black Bolt thwarts Morgan le Fay and Maximus again, battling Thor and Sub-Mariner in the process. He appears with the Fantastic Four during the Onslaught crisis. After appearing in the one-shot title "Bug" Black Bolt and the Inhumans feature in the Heroes Reborn universe, where they worship the entity Galactus and his Heralds, as gods.  The character encounters the noble savage Ka-Zar and witnesses Quicksilver reunite with Crystal before he and the Royal Family appear in a back-up feature in the "Fantastic Four" title. Black Bolt and the Inhumans then feature in a self-titled limited series which deals with the "coming of age" of a new group of Inhumans and stopping Maximus, who with both human and Inhuman allies attempts to subvert his brother's rule. After an appearance in the final issue of a "Quicksilver" limited series Black Bolt and the Inhumans team with Canadian superteam Alpha Flight.

2000s.

The character is featured—again with the Royal Family—in a third self-titled limited series that has major developments for the Inhumans. Ronan the Accuser leads the Kree in a surprise attack, capturing Attilan and forcing the Royal Family into service against Kree enemies the Shi'ar. Karnak, Gorgon, and Triton covertly join the Shi'ar Imperial Guard while Black Bolt and Medusa must attempt the assassination of the Shi'ar ruler Lilandra at a ceremony ratifying an alliance between the Shi'ar and the Spartoi. Although the attempt fails and Black Bolt manages to defeat Ronan in personal combat, the Inhuman people choose to leave with the Kree and pursue a new future. This leaves Black Bolt and the Royal Family alone to fend for themselves.  Interdimensional adventurers the Exiles also encounter an alternate universe version of Black Bolt. Black Bolt decides to attempt reintegration with Earth, and several younger Inhumans—recently exposed to the Terrigen Mists—explore Earth with mixed results, including at one stage the intervention of the Fantastic Four. The Inhumans resettle in the Blue Area of the Moon and begin to rebuild. The character also appears briefly in the mutant title "X-Statix" and a one-shot title, "Inhumans 2099", speculates on the future of the Inhumans and their role on Earth.  In the title "New Avengers", Black Bolt is revealed to be a member of a superhero council called the Illuminati. Via a retcon of Marvel continuity, the group form during the Kree-Skrull War to deal with threats to Earth. During the "Son of M" storyline, the mutant Quicksilver steals a canister of Terrigen crystals from Attilan, with Black Bolt and the rest of the Royal Family attempting to retrieve it.  Black Bolt also rejects the Superhuman Registration Act and refuses to become involved in the ensuing "Civil War." Courtesy of the hero Sentry, Black Bolt monitors the situation. In the limited series "Silent War", the US military attacks the Inhumans to prevent them from retrieving the crystals. Believing the stolen crystals should be returned to Attilan, Black Bolt issues a warning to the United States concerning further acts of aggression, and eventually launches an offensive against the nation. Gorgon and other Inhumans are captured during the attack, which prompts Black Bolt to personally head a team to rescue his subjects and retrieve the crystals. While the mission is successful, Maximus takes advantage of the situation and overthrows and temporarily incarcerates Black Bolt.  The Illuminati also collect the Infinity Gems, and—to prevent the abuse of power by the Titan Thanos and others—split the gems between themselves, vowing that they never be used in unison again. Black Bolt is given the "Reality" gem.  The character apparently suffers a setback when brutally beaten by the Hulk, on a rampage during the "World War Hulk" storyline and seeking revenge on Black Bolt for his role in the Hulk's exile from Earth. During the events of the Secret Invasion limited series it is revealed that this was not in fact Black Bolt, but rather a Skrull, who is killed in battle by members of the Illuminati. The true Black Bolt is captured by the Skrulls, who intended to use his voice as a weapon of mass destruction. The character is rescued when the heroes of Earth defeat the Skrull army and discover the location of their captured teammates.  Black Bolt, angered by the repercussions caused by the Skrull invasion, changes tactics and embarks on an aggressive campaign against all former persecutors of the Inhumans in the War of Kings limited series. At his command, the Inhumans attack the Kree and overthrow Ronan the Accuser, with Black Bolt declaring himself supreme ruler of the Kree Empire. This is followed by a preemptive strike from the Shi'ar empire, now controlled by the usurper Vulcan. Black Bolt intended to release the Terrigen Mist across the galaxy and end the war when, courtesy of the subsequent mutations, all are rendered equal, but the plan was interrupted by Vulcan, the two clashing as the bomb charged up. Although Vulcan was nearly killed by Black Bolt's voice, Black Bolt prepared to abandon his plan when Crystal pointed out that the powers produced by the explosion would only inspire more harm rather than good. However, an enraged Vulcan retained enough strength to stop Black Bolt from teleporting away with Crystal and Lockjaw, which resulted in Black Bolt and Vulcan apparently dying in the subsequent explosion of the Terrigen bomb, as Crystal only negated the Terrigen Mists within the bomb without shutting down its ability to explode.

2010s.

He in fact survived the explosion. It was revealed that Black Bolt likely represents the anomaly of the Kree Inhuman genetics program that had been predicted hundreds of thousands of years ago. The genetic prophecy was that this anomaly would bring about the end of the Supreme Intelligence. To prevent this outcome, the Kree Supreme Intelligence had ordered the destruction of all the worlds where the genetic experiments took place. Only five colonies escaped, including Earth's: these were the Universal Inhumans. After his return to Attilan, Black Bolt joined the Universal Inhumans and was presented with four new brides, one from each of the other colonies.  They returned to Earth to help defeat the last four Reeds of the Interdimensional Council. They then faced the Kree Armada, who had been ordered by the resurrected Kree Supreme Intelligence to wipe out Earth and the Inhumans. After the Kree fled in defeat, the Inhumans followed in pursuit. Guided by Franklin Richards, Black Bolt confronted the Supreme Intelligence, surviving long enough to surrender and trigger protocols forcing terms of a truce. He convinced them that the prophecy has been broken, and that he was no longer a threat. They parted ways, but Black Bolt had to agree to Ronan (Crystal's husband) returning alone to the Kree domain.  During the "Infinity" storyline, Black Bolt was visited by Thanos' Black Order in order to demand a tribute, the heads of Inhuman younglings between the ages of 16 and 22 or the annihilation of Earth's inhabitants. Using the Terrigen Codex, Black Bolt discovered Thanos used the tribute demand as a cover for his true mission: to kill his secret Inhuman-descendant son whose identity and location were unknown even by his father. After the Inhumans denied the tribute to Corvus Glaive, Thanos personally visited Black Bolt in Attilan. Finding the Inhuman city empty with only Black Bolt left, Black Bolt unleashed a powerful scream which tore down Attilan itself and activated a Terrigen Bomb which spread the Mists across the Earth. Thanos survived the attack and found Black Bolt still alive in the rubble. Thanos demanded to know the location of his son. Black Bolt refused and continued attacking Thanos with his voice until an enraged Thanos knocked him out. Black Bolt was held captive for Thanos to use his power to activate the Illuminati's anti-matter bombs to destroy the Earth. When the Illuminati arrived in the Necropolis, they found Thanos' general Supergiant, with Black Bolt under her control as she uses Black Bolt to defeat them. When Supergiant activated the bombs, Maximus appeared with the trigger. He triggered the bombs, but also used Lockjaw to transport the anti-matter bomb along with Supergiant to a distant uninhabited planet where she died in the explosion. Black Bolt was liberated and left the scene along with Maximus and Lockjaw. In the ancient location of Attilan in the Himalayas, Black Bolt hid the Terrigen Codex and made Maximus understand his survival and that of his brother were to be kept a secret. Maximus also deduced that Black Bolt was always going to activate the Terrigen Bomb irrespective of Thanos' arrival which was to herald a new age of the Inhumans. After being examined by Maximus, Black Bolt discovered with his brother that the Terrigen Bomb had greatly diminished Black Bolt's powers. Black Bolt and Maximus agreed to keep this a secret.  Using exogenetically charged waters, Maximus was able to help Black Bolt recover from the power loss he suffered after the detonation of the Terrigen Bomb.  During the "Secret Wars" storyline, Black Bolt takes part in the incursion between Earth-616 and Earth-1610. He is taken out by the Children of Tomorrow.  In the aftermath of the Secret Wars storyline, Medusa sends Nur and Auran to find Black Bolt who is forced by Maximus to use his voice against them, killing Auran. Black Bolt and Medusa end up separating over his prolonged absence from Attilan. Nonetheless, they team up to battle Kang the Conqueror for their son Ahura (Black Bolt had earlier given Ahura over to Kang for safe-keeping during the incursions). Unwelcome in Attilan, Black Bolt now runs the "Quiet Room," a nightclub that functions as a neutral zone for metahumans. At one point, a resurrected Auran steals his voice, but it is restored with the help of Sterilon.  During the "Death of X" storyline, Black Bolt is framed for the death of Cyclops.  When the truce between the Inhumans and X-Men is broken during the "Inhumans vs. X-Men" storyline, Black Bolt is subsequently ambushed by Emma Frost and Dazzler in the Quiet Room. A disguised Dazzler is able to absorb the energy from his voice and counterattack him with it. He is held captive by the X-Men in Forge's workshop in the dimension of Limbo until his rescue by Medusa and the Inhumans. He helps Medusa neutralize Emma Frost. In the aftermath, there is hope of reconciliation between the Royal couple as she joins Black Bolt in the Quiet Room.  Black Bolt and a group of Inhumans later tracked down Maximus and captured him for his trial. Black Bolt later spoke to Maximus privately.  Marvel Boy later reveals that there is still hope to restore the Inhuman race on the remains of the Kree Homeworld, so the Royal family and a couple of new Inhumans journey to space to find the secret buried on Hala.  However, they were soon confronted by two surprises: Medusa's affliction with a mysterious illness, and the revelation of Black Bolt as Maximus in disguise. Maximus had used his psychic powers and an image inducer to switch places with his brother before leaving Earth. It was Black Bolt that was imprisoned in a deep space torture prison that was meant for Maximus. Upon defeating his fellow inmate Absorbing Man, Black Bolt confronted the as-yet-unidentified jailer. When his quasi-sonic no longer worked, Black Bolt was killed and revived. Black Bolt later made acquaintances with Absorbing Man, Blinky, Metal Master, and Raava. After discovering that the Jailer is an Inhuman who was incarcerated in the torture prison and has since taken over it, Black Bolt and his fellow inmates fight the Jailer. Absorbing Man sacrifices himself so that Black Bolt can kill the Jailer and enable his fellow inmates to escape.  Black Bolt returns to Earth with Blinky. They inform Titania about her husband Crusher's heroic death. At the funeral, Blinky is kidnapped by Lash. He forces Black Bolt to surrender and injects him with a poison to prepare his blood to be used as part of a new Terrigen-type bomb that will produce new Inhumans. The pain of the process sends Black Bolt's mind towards Medusa's mind. They interact on a psychic plane and update each other. He finds out about Medusa's love for Gorgon and they determine that they cannot go back to their marriage. Instead, they will move forward and Medusa promises to find them as they get separated. Black Bolt breaks free only to succumb to the poison. Blinky tries to protect him, but turns into a monster channeling the Jailer.  After an encounter with the Progenitors, Medusa and Black Bolt meet on the Astral Plane and agreed to continue as partners and not lovers. When Medusa takes the Primagen, it restores her hair and health while also causing a backlash in the attacking Progenitor to destroy the approaching Progenitors causing the Ordinator-Class Progenitors that saw the attack from the World Farm to spare Earth from their invasion.  In the pages of "Death of the Inhumans," Black Bolt calls together the four Queens of the Universal Inhuman tribes to respond to this threat. However, the meeting goes far from as planned, as an Inhuman executioner named Vox, a Super-Inhuman created by the Kree, begins his bloody rampage across the place. When Black Bolt and his Royal Family reached the meeting place, they discover the bodies of Oola Udonta, Aladi Ko Eke, Onomi Whitemane and Goddess Ovoe, with the same three words written in their blood on a banner hanging about their corpses and eventually realized that they fell in to a trap as one of the dead Inhumans was wired with an explosive. While most of Black Bolt's group made it out alive, thanks to Lockjaw, Triton was not so lucky and was killed in the explosion. Black Bolt then sent Lockjaw to New Arctilan to retrieve his brother Maximus. After Vox subdues Karnak, Black Bolt arrives where he walks through the halls of the Kree base speaking every name of the fallen Inhumans, making it a song about death. Eventually, it comes down to just Black Bolt and Vox who's holding Karnak as a shield. Black Bolt signs to Karnak to have Vox take him instead. Vox apparently accepts the change as he teleports himself behind Black Bolt. Before Karnak’s very eyes, Vox slits Black Bolt’s throat. The Kree take Black Bolt prisoner and repair the damage done to his throat without using any sedatives or anesthesia to dull the pain which prompted them to think that Black Bolt's great power is gone when he doesn't scream and therefore the prophecy about the Midnight King is no longer a threat to the Kree. However while being transported, it turns out he still has his voice, but it's faint. After killing several Kree, Black Bolt secures a firearm and finds Ronan the Accuser alive. However, he is a prisoner of Vox and has been experimented on. At Ronan’s request, Black Bolt enables him a mercy killing. The Inhuman Royal Family and Beta Ray Bill rescue Black Bolt from Vox. When Maximus was behind the mask of Vox, Black Bolt and the Inhuman Royal Family discover that Vox is not a Super-Inhuman and is just a Kree programming. While recapping the deaths that Vox has caused, Black Bolt also recalls the prophecy of the Midnight King. Meeting up with the Inhuman Royal Family and Beta Ray Bill, Black Bolt is told by Karnak of Vox being a programming that transported his "victims" to the Kree. As Black Bolt has one more scream left, Karnak tells him to make it count. Using his sign language, Black Bolt addresses the others on how he has made mistakes in the past and apologizes to them. After holding a moment of silence, Black Bolt orders Gorgon to turn around. As Gorgon and Beta Ray Bill engage the Kree soldiers, Black Bolt, Medusa, and Lockjaw arrive at the laboratory where they find Vox-controlled Inhumans like Crystal and Lockjaw. Using a laser, Black Bolt clears the Vox-controlled Crystal and Lockjaw just because they were in his way. Entering one door, Black Bolt signs "I love you. I'm sorry" before whispering for them to run. As Medusa and Karnak fight the Vox-controlled Crystal and Lockjaw, Black Bolt confronts other Vox-controlled Inhumans like Triton. Knowing the truth about the prophecy, Black Bolt brings ruin to the Kree and unleashes his scream on the Vox-controlled Inhumans. This action frees Crystal and Lockjaw from Vox's control. Gorgon and Beta Ray Bill arrive stating that the Kree have fled and see Crystal and Lockjaw still alive. Black Bolt emerges from the room as Medusa orders Lockjaw to take them away from the Kree base. When Crystal asks where they should go, Black Bolt uses his sign language to say "home." Lockjaw then teleports them away.  Black Bolt and other heroes die helping Dr. Strange fight Galactus, but all are resurrected after the battle is won.

Powers and abilities.

Black Bolt's Terrigen-mutated physique surpasses the superhuman physique of typical Inhumans: his strength, stamina, durability and reflexes are all well above typical Inhuman or human levels. His speed and agility are also highly enhanced. He also possesses superhuman senses. An organic mechanism in his brain's speech center produces an unknown particle that interacts with ambient electrons, enabling him to produce certain mentally-controlled phenomena. The most devastating of the effects is Black Bolt's "quasi-sonic scream". Because his electron-harnessing ability is linked to the speech center of his brain, any attempt to use his vocal cords triggers an uncontrollable disturbance of the particle/electron interaction field. Because of this limitation, Black Bolt must be constantly vigilant of even the softest of utterances lest he destroy anything or anyone in his path. At full strength, his voice has the capability to destroy planets, while a whisper can rock a battleship. When Black Bolt was captured and experimented on by the Skrulls, it was shown that his "Sonic Scream" is triggered by, and at least partially dependent on, his emotional state.  The fork-like antenna worn upon his forehead helps Black Bolt control his power. He can channel his powers inward to increase his strength and speed, and can focus it through the focusing tool or his arms as concussive blasts. Black Bolt is capable of channeling all available energy into one devastating punch called his Master Blow, which renders him extremely vulnerable subsequently. By concentrating his electrons into anti-electrons, he can fly at speeds up to for a period of six hours, protected by an anti-graviton field. Black Bolt can create a nearly impenetrable force field by focusing his energy around himself, and can use his electron abilities as extrasensory probes, highly sensitive to electromagnetic phenomena, and he can also jam certain electromagnetic mechanisms. Though exhausting, he can create particle/electron interaction fields solid enough to be traversed upon.  Black Bolt also is at least partially resistant against telepathy and shares a semi-telepathic bond with those of his blood (such as the Inhuman royal family and certain others), as was evident when he was able to resist the mental abilities of his telepathically powerful brother, Maximus, and on different occasions, use his own abilities to overpower and take control of Maximus' mind. One of Black Bolt's main uses for his telepathic ability is to communicate his wishes to his wife, Medusa the Queen, who then acts as his mouthpiece to the rest of his subjects. He can also use this limited telepathy to communicate his destination wishes to the royal family's teleporting dog, Lockjaw.

Black Bolt (Blackagar Boltagon) is a fictional character appearing in American comic books published by Marvel Comics. Created by Stan Lee and Jack Kirby, the character first appears in "Fantastic Four" #45 (December 1965). Black Bolt is the ruler of the Inhumans, a reclusive race of genetically altered superhumans. Black Bolt's signature power is his voice, as his electron-harnessing ability is linked to the speech center of his brain. Speaking triggers a massive disturbance in the form of a highly destructive shockwave capable of leveling a city. Due to the extreme danger posed by this power, the character has undergone rigorous mental training to prevent himself from uttering a sound, even in his sleep, and he usually remains completely silent and speaks through sign language or via a spokesperson.

Blackagar Boltagon, alias Flèche noire (« Black Bolt » en VO) est un super-héros évoluant dans l'univers Marvel de la maison d'édition Marvel Comics. Créé par le scénariste Stan Lee et le dessinateur Jack Kirby, le personnage de fiction apparaît pour la première fois dans le comic book "Fantastic Four" #45 en décembre 1965.


Early years.

Born in County Cork, Hamilton was brought up in relative obscurity. Prior to his 20th birthday, Europe was already embroiled in the Second World War. As a result, he would spend the war years as part of the Fleet Air Arm flying Lysanders. After the war ended, he opened a car garage. During the years between the war ending and the start of the 1950s, Duncan started racing in local events. He cut his teeth in such pre-wars as the MG R-type and the Bugatti Type 35B. After racing a Maserati 6CM in 1948, Duncan graduated to a Talbot-Lago Grand Prix car.

Formula One career.

He participated in five World Championship Grands Prix and 18 non-Championship Formula One races. His best results in the non-Championship events were fourth place in the 1948 Zandvoort Grand Prix with a Maserati 6CM, third in the 1951 Richmond Trophy (ERA B-Type), second in the 1951 BRDC International Trophy (Talbot-Lago T26C), third in the 1952 Richmond Trophy (Talbot-Lago T26C) and fourth in the 1952 Internationales ADAC Eifelrennen (HWM-Alta).  That fourth place at Zandvoort, showed that he was right at home in the upper level of Grand Prix racing, especially as this was his debut at this level. After that impressive debut, things soon turned sour for Hamilton, at his last race of 1948, the RAC International Grand Prix, the first official post-WW2 British Grand Prix, he retired with oil pressure problems.  Throughout the 1949 Grand Prix season, he only suffered one retirement, however he did not finish higher than ninth, which he managed twice, both times at Goodwood. The following season, he competed in fewer Grand Prix races, while he expanded his racing experience by racing sportscars. He won the Wakefield Trophy, a minor Formula Libre race, held at Curragh in the Republic of Ireland. Hamilton performed beautifully before the Irish crowd.  In the wet, Hamilton had few peers. In his Talbot-Lago, he eclipsed even Juan Manuel Fangio at the soaking BRDC International Trophy race at Silverstone in 1951, when he finished second to Reg Parnell, but a long way ahead of Fangio who went on to win the World Championship that season.

24 Hours of Le Mans.

He was best known for his success in the 24 Hours of Le Mans endurance race, which he took part in nine times, most famously in partnership with Tony Rolt. The pair finished fourth at their first attempt in the 1950 race and sixth in 1951, both times in a special-bodied Nash-Healey coupe. Their Jaguar C-Type did not finish in 1952, but they returned with a C-Type to win in 1953. They were second with a Jaguar D-Type in 1954, losing to a much larger-engined V12 Ferrari – and by the narrowest margin in years. They came within two miles of victory, Hamilton driving a storming race in the closing stages to halve the lead of the Scuderia Ferrari of José Froilán González and Maurice Trintignant, as the track was awash following a cloudburst. When the track started to dry out, the Ferrari hung on for a narrow triumph. He failed to finish in 1955. For 1956 Hamilton partnered Alfonso de Portago in a Ferrari but again did not finish. In 1957 he reverted to a Jaguar D-Type: partnered by the American driver Masten Gregory he came sixth. His last Le Mans appearance was in 1958, when the D-Type he shared with Ivor Bueb failed to finish.  Hamilton also won the 1956 Rheims 12-hour race for Jaguar with a D-Type co-driven by Ivor Bueb. Despite the win, the factory dropped him from their 1956 Le Mans roster for speeding up and passing team-mate Paul Frère's car at Rheims when Lofty England had ordered the entire team to slow down, hence his switch to a Ferrari that year. In 1957 Jaguar did not enter Le Mans – cars and equipment had been destroyed by a fire at the factory – and Hamilton used his privately owned D-Type.

Called from the bar.

Hamilton famously won the 1953 event in a Jaguar C-Type shared with Rolt. Initially, the pairing were disqualified for practising in a Jaguar that had the same racing number as another on the circuit at the same time, but they were reinstated. Hamilton's account has become a motor racing legend: when Jaguar team manager Lofty England persuaded the organisers to let them race, both drivers were already drunk in a local bar. England said: "Of course I would never have let them race under the influence. I had enough trouble when they were sober!"  When the race was under way the team tried to sober Hamilton up by giving him coffee during the pit stops but he refused it, saying it made his arms twitch; instead he was given brandy. The alcohol must have helped when he struck a bird face first at 130 mph and broke his nose. Despite the bizarre circumstances, the duo went on to win the race and recorded the first 100 mph average speed at Le Mans, a record pace.  Both England and Rolt have denied that they were drunk.

Lucky escapes.

On one occasion in 1947, he was transporting his MG R-type to the Brighton Speed Trials, when going down a hill near Guildford, he "saw the splendid honeycomb radiator of a Bugatti in the outside rear-view mirror", so he moved over and waved it past, but the car hung back. Further down the hill, the Bugatti accelerated and drew level with Hamilton, at which point he saw there was no one in it: "The awful truth dawned on me – it was my own car, gathering speed fast." Hamilton had forgotten he was towing the Bugatti, and the story ends with a lamppost snapped in two.  A week after the 1953 Le Mans win, Hamilton drove to Oporto to prepare for the Portuguese Grand Prix. Held on the Circuito da Boavista, he was leading into the first corner of the race when he crashed his Jaguar heavily into an electricity pylon. The Jaguar cartwheeled, throwing him out of the car and into a tree. He hung there for about a minute, before falling down on the side of the circuit. Barely conscious, he moved his legs just as a Ferrari raced by, nearly taking Hamilton's left boot with it. He was taken to hospital for an emergency operation, though the medical facilities did not extend to anaesthetic; as the surgeon leant over him, Duncan was mesmerised by the increasing length of cigarette ash, as it hovered above his open chest cavity. The accident cut off the power supply to Oporto for several hours.

Retirement.

Hamilton sustained unpleasant injuries during the 1958 24 Hours of Le Mans, while contesting the lead in his Jaguar D-Type, and then he was shattered by the death of his friend Mike Hawthorn in early 1959. That tragedy finally prompted him to hang up his racing helmet and gloves in 1959, and concentrated on his garage business in Bagshot. His love and passion for the finest classic motor cars led Hamilton to establish his own company back in 1948. Since then, Duncan Hamilton & Co Limited has become an international recognised for being one of the most respected and well-connected specialists in historic cars. He co-wrote an autobiography called "Touch Wood!". Duncan Hamilton died in Sherborne, Dorset. His son Adrian Hamilton, a classic car dealer, runs his father's garage in another location today. Duncan's grandson Archie Hamilton is also a racing driver.  As Earl Howe wrote in the original autobiography foreword in 1960, though the drivers of his age were fiercely competitive, there were also "friends to meet, stories to tell and almost certainly a party to be enjoyed.". Duncan was certainly larger than life, he wasn’t just one of the most successful drivers of the 1950s, but also the man who trespassed at Brooklands, who spent the war in the Fleet Air Arm accidentally trying to drown American Admirals and who was once stopped for speeding whilst rushing to take part in a TV programme on road safety.  Hamilton is regarded as the epitome of the old school English competitor. He, and many of his contemporaries such as Hawthorn, Rolt and Peter Collins, raced mainly for the love of the sport, branding them as gentlemen drivers.

James Duncan Hamilton (30 April 1920 in Cork, County Cork, Ireland – 13 May 1994 in Sherborne, Dorset, England). His colourful and extrovert personality often overshadowed his genuine talent. After fighting in, and surviving the Second World War, he vowed to live life to the full and took up motor sport. Although adept in single-seaters, sportscars was where he enjoyed most success, winning the 1953 24 Heures du Mans, two Coupe de Paris events, and the 12 heures internationals Reims race in 1956. He retired in 1958 and ran a garage in Bagshot, Surrey for many years. He died from lung cancer in 1994.

James Duncan Hamilton, dit Duncan Hamilton, est un coureur automobile anglais né le à Cork et décédé le à Sherborne.


History.

The modern shaving brush may be traced to France during the 1750s. The French call a shaving brush "blaireau" or "badger." Quality of these brushes differed greatly, as materials used to fashion the handles varied from the common to the exotic. It was not uncommon for handles to be made of ivory, gold, silver, tortoiseshell, crystal, or porcelain. The more expensive brushes used badger hair, with cheaper ones using boar's or horse's hair. In the 1800s when the folding-handle straight razor design made it practical for men to shave themselves rather than visit a barber. A shave brush became a status symbol, and an expensive or eccentric brush was a way of asserting one's personality or even affluence. The recent rapid rise in the popularity of "wet shaving" has raised demand for high quality and custom shaving brushes.

Shave brush handles.

Modern shave brushes are similar in appearance, composition and function to their centuries-old predecessors. Although a variety of different materials are still used to fashion shave brush handles, synthetic handles of nylon, urethane or plastic are the most common even by the most expensive shave brush manufacturers. Benefits of synthetic handles include a lesser chance of breakage and resistance to damage by moisture. A limited number of consumers prefer natural materials such as wood or exotic materials such as tortoiseshell. A shave brush's handle, regardless of its material composition, rarely affects the overall performance of the brush.

Bristle Knot.

A shave brush's price is usually determined more by its bristle load than any other factor except for brushes with very exotic handles. The most expensive brushes often use exotic materials in the handle. The bristles are fixed together into a knot that is installed into the handle. The best quality brushes are hand knotted. Badger and boar brushes are the most commonly found animals used for shaving brush fibers. Badger species include the Eurasian badger and the hog badger. Badger brushes are often referred to as two band, or three band. Perhaps all badger hair fibers have three bands, but those used in the brushes conceal the lighter bottom band. Nonetheless, both types of bristle make desirable shaving brushes. Lower-quality brushes are often machine made and the bristles may be trimmed, resulting in sharp, prickly tips.  Synthetic shave brushes, most often made using nylon bristles, are available in a range of prices and gradations in quality. Comparable to traditional shaving brushes, synthetic fiber brushes can quickly create a rich lather using relatively little shaving soap or cream. The synthetic fibers dry faster than natural hair and are less sensitive to everyday use. Boar's hair brushes are relatively inexpensive, but can be of very high quality. A well-made boar brush will break in with use; the bristles begin to split at their tips, resulting in a brush that is very soft but has considerable backbone. Unlike badger hair and synthetic fibers, boar bristles absorb water, so the brush should be soaked before use.  Badger hair brushes come in a variety of grades, but there is not an industry standard that specifically defines grades of badger hair. Generally speaking, though, there are basic classifications that many manufacturers use to describe the quality of hair used in their brushes. The most common gradations of badger hair are "pure" badger, "best" badger, and "super" or "silvertip" badger. While some companies insist on using other gradations (for example, Vulfix's high-end brushes distinguish between "super" and "silvertip"), these three are commonly accepted among wet shavers and are most often used to describe the quality of a shave brush.

Pure badger.

Pure badger are badger hair brushes that use the most common hair from the underbelly of a badger, the hair which covers around 60% of a badger's body. This hair varies greatly in softness, pliability and color. Pure badger hair is usually dark in color, but fluctuates from a light tan to a near-black or silvery sheen. The hair is coarser than 'best' or'silvertip' hair due to its larger shaft. Brushes made exclusively with pure badger hair cost significantly less than finer badger hair. Most often, pure badger brush hairs are trimmed to shape, resulting in somewhat stiff, rough ends.

Best badger.

Best badger are brushes made with the finer and more pliable hairs from 20 - 25% of the badger's body. It is longer in length and lighter in color than 'pure' badger hair. A 'best' badger brush is more densely filled with hair than the 'pure' badger brush and will produce a correspondingly greater lather. However, some wet shavers argue that the variance between the quality of a 'pure' and a 'best' badger brush is negligible. Best badger and better quality brush hairs are often fit so that the ends do not have to be cut to shape.

Super badger.

A super badger brush is more expensive than either 'best' or 'pure'. While some call this hair'silvertip', it is often highly graded 'pure' hair bleached on the ends to resemble silvertip.  Though it is composed of 'pure' badger hairs,'super' is graded and sorted to such a degree that its performance is superior to that of 'best'. The brush is not prickly.  One way to determine if a brush bears a'super' or'silvertip' badger hair load is to look at the color of the bristle tips. A true'silvertip' brush has tips that are an off-white. A'super' brush on the other hand has bristle tips that are a more sterile, slightly greyed white; moreover, the light color of the tips does not extend as far down the shaft of the hair.

Silvertip badger.

Silvertip badger is the most expensive and rare type of badger hair. The tips on this hair appear white naturally, without bleaching. A "flared" bristle load results in the'silvertip' brush's fluffy appearance and lends the brush its ability to hold a large amount of water. Due to its water retention capacity, a'silvertip' brush can create well-formed shaving lather quickly and easily.  Some manufacturers such as Plisson, Simpsons and Rooney sell shaving brushes in a grade beyond silvertip. While the names these companies give this 'extra silvertip' vary, the properties remain fairly consistent between manufacturers as compared to the 'ordinary silvertip' brush. These brushes differ in appearance (the tip is whiter and extends further down the shaft; additionally, the hair under the tip is pure black as opposed to dark grey in color) and feel (the extra silvertip feels slightly firmer and less "prickly" on the face when lathering).

Sources of brush hair.

Because badgers are a protected species in North America and most of Europe, virtually all commercial badger hair comes from mainland China, which supplies knots of hair in various grades to brush makers in both China and Europe. In rural Northern China, badgers multiply to the point of becoming a crop nuisance, and village cooperatives are licensed by the national government to hunt badgers and sell the hair to processors. Procter & Gamble stopped using badger hair in its Art of Shaving products following a PETA investigation of several badger-hair farms and brush-making factories in Shijiazhuang, China, and video that showed a worker beating a badger with a chair leg before slaughtering it for its fur.  Boar bristles are available cheaply from many sources. Brushes made in China or India with boar bristle are supplied wholesale, while even the cheapest wholesale Badger brush costs at least $10; even the cost difference between badger brushes with resin handles vs. expensive horn handles shows that, except with exotic materials such as sterling silver, special woods, ivory, bone or custom materials, badger hair is the costliest element of a brush. It is common for boar-hair brushes to have part of the bristles dyed to resemble badger hair.  Brushes with nylon-only bristles are available.  Horse hair brushes are coming back, after a hiatus of nearly 100 years following an anthrax scare around World War I. Material for horse hair shaving brushes is cut from the horse's mane or tail, and the animal is not harmed.

Benefits of using a shaving brush.

A fibrous bristle load holds significant amounts of water which mix with the soap lifted from a shaving mug or scuttle. The more water a brush holds, the moister and richer a lather will be. Thicker and more emollient lather translates to less razor skipping and dragging.  Bringing a shave brush across one's skin produces a mild exfoliation. Because a shave brush is most often used with a shave soap, this effect often replaces the pre-shave routine of washing and applying lotion to the face.  A shave brush also lifts facial hair before a shave, requiring less pressure from the razor.

A shaving brush or shave brush is a small brush with a handle parallel to the bristles used to make lather from shaving soap or shaving cream and apply it to the face when shaving. Shave brushes are often decorative; antique handles are often made from materials such as ivory or even gold, though the bristle load may be composed of any number of natural or synthetic materials. The shave brush is used most often today by "wet shavers" in tandem with a single- or double-edged safety razor or a straight razor. However, this is not always the case, as shavers of all varieties may employ the tool.

Le blaireau est une brosse utilisée pour appliquer du savon à barbe sur un visage avant de le raser. Traditionnellement fabriqué en poils de blaireau, il existe aussi en soies de sanglier, en crin de cheval ou encore en poils synthétiques.