Mild cases as previously mentioned are often missed entirely, the temperature, etc., being attributed to postoperative reaction.
The more severe forms grade from slight temperature, basal rales, and cough, to high temperature, dullness at one or both bases, dyspnoea and incessant cough. Any of the former states may suddenly become dramatic by reasons of shock, dyspnoea, basal dullness, heart migration and signs of impending death by onset of lobar atelectasis through bronchial obstruction.
PROPHYLAXIS.
Prevention of trouble rests with a knowledge and use of the following items:.
1. History of preexisting pulmonary disease and eradication of focal infection.
2. Pre- and post-operative isolation from respiratory cases.
3. Adequate but not excessive preoperative analgesia sparing atropine.
4. Even, rapidly induced anaesthesia with the avoidance of cyanosis.
5. Minimized surgical trauma. Elimination of massive or tight bandaging.
6. Great care about the details in the operating room, in the patients room, and in the transfer of the patient from one to the other.
7. Postoperatively, deep breathing, frequent change of posture, and adequate but not excessive sedation.
TREATMENT.
Active therapy of moderate cases consists in frequent carbogen inhalations and change of posture with the exhibition of expectorants or even nauseants to obtain coughing and thereby pulmonary ventilation. In the severe forms bronchoscopic aspiration or artificial pneumothorax should be used. Otherwise, the usual modalities useful in any pneumonia seem applicable here.
TREATMENT–HOMOEOPATHIC. Remedies particularly indicated:.
1. Ether: Bohler and Bier of Germany introduced the use of this agent in postoperative respiratory cases. Our own Dr. John Besson employs this chemical with great success.
He feels sanguine that there is a distinctly homoeopathic action although the material is given by hypo. Despite being unable to agree to its homoeopathicity we admit that it is a remedy par excellence in such states. We feel it deserves a trial at the first sign of any postoperative pulmonary complication. 3 to 5 C.C. intramuscularly once or twice in course of 24 hours.
2. Arnica. Unquestionably, modern homoeopathic surgeons neglect the pre- and post-operative use of this medicine. The mere fact that surgery of tissue, with bruising, is to take place should justify its prophylactic employment. Indications: lameness, bruised sensation, septic fever cure, local and general ecchymoses or emboli, surgery of septic fields. In the chest specifically there is pleuritic pain, presence of facial herpes, dyspnoea and bloody sputum. We must all remember to give this medicine preoperatively to every surgical case not presenting obvious indications for other drugs.
3. Phosphorus. In these conditions Phos. is especially to be thought of in surgery on patients who have long been toxic from systemic or pulmonary causes. There is evidence of anaemia, hepatic damage, and prolonged vomiting following surgery. History of previous respiratory disease is sufficient to warrant its exhibition before surgery. The other classical indications will be seen.
4. Ant. tart. Useful in weak patients where the pathology is multiple and widespread, with great bronchial hypersecretion. It is not indicated in virulent pneumococcus cases or in the massive atelectasis type.
5. Carbo. veg. and Veratrum album. These two medicines picture the shock of lobar atelectasis, the main differentiation being that Carbo. veg. presents as keynotes cyanosis, venous stasis, air hunger, but an absence of perspiration; whereas Veratrum album presents extreme diaphoresis, especially of the forehead, hippocratic countenance and other characteristic signs of rapidly impending disaster. These medicines will greatly help to control shock, but the mechanical basis for the obstruction in atelectasis must be removed by other means, as outlined above, in order to obtain successful recoveries.
6. Veratrum viride. This remedy is indicated early in sthenic patients with virulent complications. There will be evidence of widespread beginning disease but no signs of major atelectasis or shock. The arterial congestion, throbbing vessels, bright red bloody sputum, dyspnoea, and high temperature complete the picture.
7. Lachesis. Useful in cases arising from surgery on infected areas, especially of streptococcic nature. The typical left-sidedness, suffocation phenomenon, loquacious delirium, and aggravation from rest, are seen.
8. Secale. This agent is indicated in surgery on thin arterio-sclerotic individuals. A cachectic look almost amounting to shock is present with a coldness of the skin, but intolerance to heat. There is an expectoration of bloody sputum during the dyspnoea with or without cough.
Naturally any of our pneumonic remedies may be indicated. But on the basis of the pathologic picture and experience, the above medicines are most frequently needed. CONCLUSIONS.
1. Postoperative pneumonia is a result of four factors: hypoventilation, embolization, aspiration, and atelectasis. Hypoventilation is basic, but all stages show various degrees of atelectasis.
2. The surgeon is more often the etiologic agent than the anaesthetist; hence, postoperative pneumonia is a more accurate term than post anaesthetic pneumonia.
3. The choice of anaesthetic itself has little bearing on the incidence of the complication.
4. True postoperative respiratory complications develop within four days following surgery. If trouble develops later than this, the condition is probably a true pneumonia not related to surgery.
5. Prevention of these difficulties resolves to greater attention to pre- and post-operative detail and the avoidance of those factors bringing about hypoventilation, emboli, and aspiration.
6. Treatment is basically that of obtaining by any means possible the reinflation and aeration of the diseased lung areas.
7. Homoeopathic treatment is valuable and will often be life-saving. It has limitations.
SUMMARY.
We ask for the routine preoperative use of homoeopathic remedies as indicated for each patient, especially Arnica or Phosphorus. We expect hospitals and surgeons to become more adept in controlling those details contributing to postoperative pulmonary complications. We hope that the diagnosis of massive pulmonary embolism with its fatal implication will not be made without adequate x-ray study–many lives will thus be saved; and, finally, we feel confident in our similar remedies when facing pneumonic states, but also will not expect of them mechanical feats far beyond their reactive powers to accomplish.
BERKELEY, CALIF.
DISCUSSION.
DR. GRIMMER: We cant find any criticism of the selection of remedies as Dr. Redfield presented them. They are probably the best remedies in those types of cases.
Of course, there are some remedies that could be added, as the doctor has stated. His plea for the individual remedy for the individual patient is what appeals to us homoeopaths.
DR. WAGONER: I should like to make a few remarks about the use of bronchoscopy. I dont think it is being used enough in the diagnosis of other conditions, as well as postoperative complications. We find that a number of our patients who show no lesions in the parenchyma of the lung still maintain a positive sputum. Very frequently, bronchoscopy will bring out tuberculous tracheal bronchitis with ulcer.
Frequently in these intractable asthmatics, whose periodic attacks are accompanied by fever, by bronchoscopic examination we find a little atelectasis in the periphery of the lung, which promptly clears up when the mucus is aspirated from the bronchus.
DR. MOORE: There is just one comment I want to make concerning measures that we have carried on for years as essential, such as the use of atropin at a time like this, and then after years of use we finally come to the conclusion that it is a harmful agent. We have seen so much of that in medicine all the way through.
He also speaks of adhesive strips binding.
Those are two things which have been used for a long while, and now they are thrown into the discard as being not only useless, but even harmful.
DR. REDFIELD: There is one thing further I noted day before yesterday in the surgery session of the A. I. H., in which you will be especially interested. They are now using elastoplast instead of adhesive, and the abdominal respiration goes on without any difficulty.
