LESIONS of the chest following surgery and because of it occur in about 3 per cent of all operative cases. This is somewhat higher than that given in the older records and closer observation at the present time and a more complete classification of these lesions. The in the chest except embolism and pneumonia both of which frequently resulted fatally and were therefore obvious as to diagnosis.
More recently almost all known lesions of the chest have been described as postoperative complications. While pneumonia and embolism are familiar to all, other lesions that occur more or less frequently are spontaneous pneumothorax, massive and partial atelectasis, infarct, pleural effusion, pleurisy, empyema, bronchitis,and reactivating of old tuberculous process. We may also further classify pneumonia as bronchopneumonia and lobar pneumonia.
The frequency of postoperative pulmonary complications is emphasized by the fact that they frequently occur in cases in which the surgeons had every hoped and expectation of a rapid and undisturbed recovery. And the fact that the mortality percentage of the morbidity in some clinics rises as high as 50 per cent enhances the seriousness of the condition. The fatal cases are divided between embolism and pneumonia. However, more recent statistics during the past twenty years show that other lesions are more frequent or occurrence than these latter.
Postoperative pulmonary complications have been recognized since ancient times but with the increase of surgery following the introduction of anesthesia by inhalation these complications showed a marked increase and were naturally laid at the door of the anesthetic, frequently plus aspiration of vomitus and oral contents, produced sufficient irritation and injury to the bronchi and lung tissue to result in the production of the lesions under discussion. Or, secondly, it has been believed that the administration of an inhalation anesthetic resulted in a lowering of bodily resistance to infection sufficient to permit the production of these lesions.
However, with the introduction of cocaine in 1879 followed by other local anesthetics, it was quickly noticed that the incidence of pulmonary lesions was practically was marked following local anesthesia as it was following inhalation anesthesia. The remarkable this is that anesthetists have been slow to present two schools of thought have existed; one contending that etiologically these lesions were produced primarily by irritation of inhalation anesthesia, aspiration of vomitus, oral contents, etc.; and the other holding to the theory that the primary cause rested in thrombus and emboli production during and following the surgery.
Both may doubtless be primary factors in the production of pulmonary lesion but the fact that it has been shown by statistics that inhalation and local anesthesia are almost equally followed by these complications certainly discounts to some extent the claims of those who hold to the irritation of inhalation anesthesia theory.
It is well known that thrombus and embolism production occur frequently following surgery. Most frequently chest complications result from surgery of the abdomen and of the head and neck. This bears out the contention that infected emboli are the primary cause of postoperative pulmonary infection inasmuch into the lymphatics route from the abdomen into the lungs. It has also been noted that the abdomen into the lungs. It has also been noted that the lower right lobe is the most frequent site of pathology following abdominal operations.
A study of statistics from various writers and clinics tends to show that chest complications occur more frequently following operations in infected fields or fields that become infected than in those that are aseptic. One clinic reports higher per cent of morbidity following thyroid surgery under local anesthesia than under inhalation anesthesia. On the other hand, there are reports of higher morbidity following surgery on the nose and mouth under inhalation anesthesia. This may be accounted for at least partly by the slower, more careful technic employed in this type of surgery with local anesthesia as well as the lack of aspiration of blood, vomitus and oral contents. Here again the theory of transmission of infected emboli is substantiated.
In any event to anyone at all familiar with the recent literature it is difficult to ascribe the great majority of chest complications to other than thrombus and embolism formation.
Acidosis, asphyxia, chilling of the patient during and after the operation, cold wet sponges in the abdomen, exhaustion, and preexisting pathologic lesions have at various times been advanced as primary etiologic factors and while it is impossible to disprove entirely their causative effects nevertheless they cannot be substantiated as more than secondary or predisposing factors in the etiology of this type of morbidity.
The symptoms of the various postoperative chest lesions differ with the type of lesion. They all have one common symptom, however, in that all complications appear in the first three to six days and more frequently in the first three days following the operation. In all the rate and character of respiration are altered from normal and temperature and pulse rate are increased. Pulmonary embolism and infarct of the lung are frequently sudden and alarming. The patient becomes cyanotic and gasps for breath and not infrequently dies before a definite diagnosis can be made or before medical assistance can as summoned.
Other conditions are diagnosed by their characteristic signs and symptoms and with the aid of laboratory procedures such as x-ray, blood picture, etc. The various lesions should, however, be carefully differentiated in order that proper treatment may be instituted at the earliest possible moment.
Treatment will vary widely with the lesion all the way from medical to surgical and from medical to surgical and from absolute rest to frequent change of position, etc. Diet will like wise vary and as homoeopaths we should not neglect the properly selected homoeopathic remedy in all cases. This latter has sometimes been neglected and the author has been occasionally surprised at the results of even a single dose of a carefully selected remedy.
In speaking of therapy Cutler and Scott in Grahams “Surgical Diagnosis Diagnosis, :The therapy of these complications needs no particular discussion. Here again prophylaxis is the best therapy. The preceding discussions of etiology would seem to indicate that a large majority of these complications are due to defects in technical surgery.
“In our own experience the existence of acute or chronic pulmonary disease or nasopharyngeal infection has played little part if any, in the incidence of such sequelae. There are, however, investigators who have devoted much attention to this field, notably Whipple, who disagree with this statement.
The shifting from a general to a local anesthetic has proven of no benefit more has the increased perfection in giving anesthetics played any great part in aborting these conditions. The postoperative pulmonary complications seem to be the direct result of the technical performance of the operation and we can no longer blame anesthetists, cold rooms, and dormant bacteria in the pulmonary sequelae”.
W.K., aged twenty-nine. Dark complexion. Black hair. Brown eyes. Slight build. Weight, 140 lbs. Height,5 ft.9 in. Wiry muscular type. Under nourished. Anxious expression. First seen at 7 p.m., July 23, 1933, and gave the following history:.
Finally history was negative. His father was unknown. Mother died from uremia at the age of thirty eight eight. No brother or sisters. He had the usual diseases of childhood. For the past four or five years he has had stomach trouble, complaining of pain in the epigastrium which he believed was due to indigestion and which nothing seemed to relieve. He had taken various patent medicines but was never sick enough to consult a physician.
Present illness was sudden onset at about four oclock in the afternoon. Following a picnic with the usual big dinner he was suddenly attacked with a severe pain in the abdomen for which he immediately consulted a physician who administered a hypodermic and admonished him to call his own physician upon arriving home if the pain did not subside., He drove him at 7 P.M. A diagnosis of acute abdomen was made. Morphine gr.1/4 was given per hypo and he was removed in an ambulance ten miles to the Clinton at 9 P.M. The abdomen was found filled with a white was removed and a perforated ulcer of the anterior surface of the pyloric horn of the stomach was repaired surface of the pyloric horn of the stomach was prepared with purse string and Lembert sutures. The abdomen was closed with drainage.
For eight days progress was apparently uneventful when an increase of temperature and pulse were noted together with a cough with expectoration and pain in right shoulder and nape of neck. On August 9, he rate of respiration also increased and evidences of impaired breathing on the right chest appeared with muffled breath sounds and other evidences or consideration in the right chest.
On August 15, an x-ray was made which showed the right chest filled with fluid to the fourth rib anteriorly. A needle was inserted between the seventh and eighth ribs laterally and ten cubic centimeters of clear amber fluid were withdrawn for diagnostic purposes. This proved to be sterile and a recession of all symptoms followed this aspiration, which would be expected.
However, on August 27, all symptoms recurred with equal severity and the chest was again aspirated, removing fifteen cubic centimeters of fluid which was followed by no improvement in symptoms.
On September 3, he received one dose of sulphur 1M which was followed by a recession of all symptoms and he was dismissed from the hospital on September 9. His recovery continued uneventfully at home and three months later he was reexamined and x-rayed. This showed marked improvement with slight fluid residue at the base of the right lung. In the meantime he had gained twenty pounds in weight and was employed as a truck driver on the state highway.
The stomach ulcer was treated with Smithies diet which consisted of frequent feedings of a diet high in carbohydrates and low in fats and proteins. The ulcer apparently healed and he was symptom free during the entire period of observation.
Final diagnosis was: perforated gastric ulcer followed by postoperative Infarcts of the right lower lobe of the lung, pleurisy and pleural effusion. A hernia resulted in the abdominal wound due to the breaking down of the tissues by the drainage discharge and the severe cough accompanying the chest complication.