By WINSLOW ANDERSON, M. D., M. R. C. P. London, etc. Professor of Abdominal Surgery and Gynecology, College of Physicians and Surgeons of San Francisco; Surgeon in Chief of St. Winifred's Hospital, San Francisco. and Consulting Surgeon to the California General Hospital, San Francisco.

The importance of lung complications, such as pulmonary hyperæmia, bronchitis, bronchial catarrh, hypostatic congestion, oedema of the lungs, broncho-pneumonia, inspiration pneumonia, pulmonary emboli and thromboses, and pneumonitis after operations, is a subject not sufficiently treated of in our medical and surgical works. When we consider that there is a mortality from lung complications in some countries of from 5 per cent to 10 per cent following major operations one must pause to reflect. This is a greater mortality than we have from all causes in appendicitis or in hysterectomies! And, we believe, furthermore, this post-operative mortality from pulmonary complications can be reduced to less than one per cent.

In 1898 Gottstein reports in Archiv. f. Klin. Chir., from Breslau, 27 cases of lung complications under local anaesthesia following 114 laparotomies, or about 15 per cent. The same writer calls attention to 119 cœliotomies under general anesthesia, with seven cases of lung complications, or six per cent.

Mikulicz, in the German Surgical Congress, 1901, cites over 1,000 cases of major operations under general anæsthesia with 7.5 per cent of pneumonia and 3.4 per cent of mortality; and in 273 cœliotomies under local anesthesia in which 12.8 per cent of cases had pneumonia with a mortality of 4.8 per cent!

*In part, from the writer's article in the Twentieth Century Practice of Medicine, Supplementary Volume.

VOL. XLVI-41

Statistics of the Presbyterian Hospital of New York, for ten years, from 1887 to 1897, are as follows (Medical Times): Ether administrations

Cases of pneumonia.

Deaths from pneumonia.

Chloroform administrations.

Cases of pneumonia....

Deaths from pneumonia...

Ether and chloroform administrations

Cases of pneumonia...

Deaths from pneumonia..

4,914

17

8

689

8

7

116

2

2

According to these figures the risk of pneumonia following chloroform administration is two and a half times. greater than from ether, facts not borne out at St. Winifred's Hospital, in San Francisco.

The Etiology of Lung Complications after Operation.In an excellent article upon the subject, Gerulanos concludes:*

1. The direct irritating action of the anesthetic on the respiratory mucous membrane, with hypersecretion. This is more marked in ether narcosis.

2. The toxic effect of the anaesthetic on the blood-vessels, producing dilatation of the vessels, hyperaemia, and oedema of the lungs, with the usual secondary effect on the heart. This is present in both chloroform and ether, and, authorities seem to think, more marked in the latter. This condition favors hypostatic pneumonia, lowers the resistance of the lung tissue to infection, which may take place (a) by inspiration, (b) by infected emboli, (c) by bacteria in the blood.

3. The inspiration of infected material from the secretions of the mouth and pharynx, or vomitus.

4. Infected or non-infected emboli from thrombosed vessels (usually veins) of the site of or in the neighborhood of the operation.

5. Chilling, fright, and shock from the operation, with or without hemorrhage, all lower the resistance of the patient and act as indirect factors in the production of the pneumonia. (Prolonged general narcosis, long exposure of the chest or peritoneal cavity, reduce the temperature.)

* M. Gerulanos in Deutch. Zeitschrift. f. Chirurg., quoted by Joseph C. Bloodgood, M. D., Progressive Medicine, Vol. IV., December 1901.

6. A general weakness of the patient lowers the resistance and acts as a very important indirect factor.

7. The restriction of respiration, and especially of expectoration, by the pain of the abdominal wound or the tight bandage.

The direct irritating action of the anaesthetic on the mucous membrane of the respiratory tract is considered. from experimental investigation not to be a very important factor.

Lindemann and Hölscher say that hypersecretion is a more important factor in that it increases the possibility of inspiration of infected material.

The toxic effect of the anaesthetic on the blood-vessels from the anaesthetic circulating in the blood is a very important factor. Lindemann in his experiments on animals with ether narcosis, demonstrated this vessel dilatation with hyperæmia and oedema of the lungs and a secondary effect on the heart. This lung cedema is present during and for a number of hours after the narcosis, and Lindemann concludes that it lowers the resistance and increases the possibility of inspiration pneumonia, and may of itself in certain individuals produce hypostatic pneumonia.

Acute Edema of the Lungs.-Hölscher practically confirms Lindemann's experiments. There is no question about the possibility of inspiration of infected material. Numerous experiments on animals have demonstrated this, and autopsy findings of material in the trachea and bronchi confirm it. (Lindemann and Hölscher.) The danger is increased when there are suppurative inflammations or wounds of the mouth and pharynx. It has been demonstrated that prolonged and proper disinfection of these cavities decreases the danger somewhat. Larger particles of infected materials, especially vomitus, in ileus, etc., are more dangerous. It is to be remembered that the inspiration of infected material during vomiting may take place without general narcosis.

Embolic Pneumonia is independent of the general narcosis, and is due entirely to the nature of the operation and the disease. This has been carefully studied by Gussenbauer and Lesshaft, Klemm and Bayer, and Fischer and Levy. In strangulated hernia and other forms of ileus, whether the gut is gangrenous or not, the mesenteric ves

sels, chiefly the veins, are frequently thrombosed beyond the seat of the constriction, and when the constriction is relieved and the gut reduced emboli may form and reach the lung. The emboli of themselves may be infected, and,' if so, produce at once in the lungs an area of pneumonia; or, if not infected, the infarct is an area of lower resist ance, and may become secondarily infected from bacteria already in the bronchi, in cases of chronic bronchitis, from infected particles or from the blood. These emboli may take place after any operation in which before or after the operation there is thrombosis of the vessels. It is not an infrequent occurrence in gynecological operations to find various infected and non-infected conditions of the pelvic organs. Embolism has been noted after Alexander's operation and operations for inguinal hernia from thrombosis of the spermatic veins. In operations for various infections of the extremities infected emboli from the seat of the infection may be loosened and reach the lungs. It has been noticed in extensive head operations (Kocher and others). On the whole, it is much more common after laparotomies. It is not uncommonly noted secondary to phlebitis of the lower extremity, which condition, we know, is more common after laparotomy. The more one studies the records of post-operative lung complications the more convinced one becomes that embolic pneumonia is the chief cause, and explains many of the cases recorded after local anesthesia.

Chilling, fright, shock, prolonged narcosis, and exposure of the chest and peritoneal cavity are commented upon by all authorities as indirect causes which should be avoided when possible. It is unnecessary to comment upon the increased danger of lung complications in greatly debilitated patients.

Czerny, quoted by Nauwerk, and others draw attention. to the possibility that the pain from the abdominal wound or the restriction of the tight bandage on the abdomen and chest greatly inhibits respiration. They find that these patients will not expectorate, and think these factors increase the dangers of lung complications, especially in debilitated patients and those having chronic bronchitis. The absolutely quiet and prolonged dorsal position of the

patient, especially when in a debilitated condition, greatly favors hypostatic congestion and its results.

All these causes acting in various combinations may produce bronchitis, bronchopneumonia, lobular pneumonia, acute oedema of the lungs, hemorrhagic infarcts, gangrene or abscess. Gangrene and abscess, fortunately, are most rare, and are due to the inspiration of large infected particles or infected emboli, which depend little, if at all, upon the general narcosis. The general narcotic acts only as a slight irritant, producing hypersecretion, and on the blood-vessels causing hyperemia and oedema by lowering the temperature, and by increasing the possibilities of inspiration on account of the muscular relaxation.

Prophylaxis.-Over some of the causes of post-operative lung complication we have some control, over others none.

The Choice of the Anasthetic to Lessen the Dangers of Post-Operative Lung Complications.-Schultz, from a careful study of 460 cases of ether narcosis and 193 chloroform narcosis, all for grave operations, finds that lung complications are less frequent after ether narcosis, and recommends it in these prolonged operations on account of its good effect upon the heart and circulation, the absence of fatty degeneration of the internal organs, and the slight injurious influence on the kidney. This question, however, does not seem to be settled.

Measures to Lessen the Possibilities of Post-Operative Lung Complications.-If the operation is of short duration and can be done under local anesthesia this should be attempted, especially if the patient is suffering with some lesion or is greatly depressed from some grave infection or disease, i. e., strangulated hernia, typhoid perforation, empyema, or operations like gastrostomy and colostomy for advanced cases of carcinoma.

When a general anesthetic is necessary it should be given with the greatest care; if possible, the narcosis should be an interrupted one, and the least possible amount of anaesthetic should be given. This partial and interrupted narcosis is the most important, and is commented upon by a number of authorities; with it it is even possible to do extensive abdominal operations, especially if the incision is a large one. Both chloroform and ether can be used in this way. It is sometimes better to begin the narcosis with