Part 17 (1/2)

Lequeu has seen many cases of post-operative parot.i.tis, and at his suggestion Verliac and Morel investigated the condition in the laboratory. They came to the conclusion that this variety of parot.i.tis originates in the ducts of the gland.

When parot.i.tis complicates post-operative convalescence, it is almost entirely confined to septic cases: it may occur within two days of the operation or as late as the thirtieth day. It is more common between the sixth and tenth days, and its advent is accompanied by much disturbance.

The parotid swells and becomes painful and tender; the skin over it is red and often brawny. These signs are accompanied by fever, malaise, and depression of spirits. In mild cases they subside in a few days, but in severe cases rigors occur, with high fever and suppuration.

The mild cases are best treated with warm fomentations, frequently changed. If suppuration occurs, the pus will need to be evacuated by a scalpel, but incisions in a suppurating parotid gland should be carried out with careful regard to the branches of the facial nerve (pes anserinus), and the large vessels intimately a.s.sociated with it.

The surgeon need not be in a great hurry to use the scalpel in these cases, for it seems occasionally as if the skin would slough, and yet when it is incised no pus escapes. This septic parot.i.tis is deceptive in the red and brawny appearance of the skin covering the swollen gland, and the misleading sense of fluctuation. In many instances the inflammatory products escape by way of the parotid duct.

Septic parot.i.tis is an unpleasant and painful complication of an abdominal operation, but it is rarely dangerous and has only had a fatal termination in very exceptional cases.

=Thrombosis.= After operations on the pelvic organs, thrombosis occasionally occurs in the iliac, femoral, and saphena veins, accompanied by fever, pain, especially in the course of the long saphenous vein, and dema of the limb. It is noticed most frequently about the twelfth day after operation.

In some patients the thrombosis is confined to the superficial veins of the calf and thigh, but when the femoral and internal iliac veins and the a.s.sociated lymphatics are involved, the dema is of a solid kind.

Apart from the danger which ensues from the detachment of a fragment of clot and its arrest in the pulmonary artery, this complication is often very serious for the patient, for it entails a long confinement to bed, a tedious convalescence, and the dema of the limb will sometimes persist for many weeks or months, in spite of topical applications, careful bandaging, or judicious ma.s.sage.

Post-operative thrombosis was formerly fairly common after hysterectomy for fibroids and in the later stages of malignant disease of the uterus.

Its frequency after operations for fibroids was attributed to the profound anaemia in patients who had severe and exhausting metrorrhagia.

I am convinced that it is due to sepsis. In several instances I have caused the clot found in thrombosed veins to be examined bacteriologically, and pathogenic microscopic organisms have been isolated. I am also satisfied that in some cases of thrombosis of the veins of the thigh, especially those limited to the saphenous veins, the clotting spreads from the superficial veins of the hypogastrium which are infected from the abdominal incision.

=Pulmonary embolism.= In perusing the clinical histories of a series of cases of ovariotomy, hysterectomy, myomectomy, and, indeed, after almost any surgical operation, here and there a record may be read to this effect: 'The patient appeared to be doing well after the operation, when she sat up, laughed and chatted with the nurse, then suddenly fell back and died in a few minutes.'

Anything more tragic than this it is difficult to conceive, and, as a rule, after such a sad occurrence, the relatives are so distressed that they rarely permit an examination of the body. Death in such circ.u.mstances is usually attributed to embolism of the pulmonary artery.

In some instances this is an a.s.sumption, but there are many in which an embolus has been demonstrated, and a few in which the source has been detected.

Post-operative embolism of the pulmonary artery is an important matter for surgeons interested in the operative treatment of uterine fibroids, for it follows such operations more frequently than any other. In order to afford some notion of the relative liability of patients to this accident after subtotal and total hysterectomy for fibroids, I have gathered the following statistics, which are interesting as showing an extraordinary variation in the practice of different operators:--

Baldy ascertained that among 366 operations for fibroids in the Gynecean Hospital, Philadelphia, there were thirteen sudden deaths attributed to pulmonary embolism.

In the Middles.e.x Hospital between the years 1896 and 1906 (both years inclusive) there were 212 abdominal hysterectomies performed for fibroids. Three of the patients died from pulmonary embolism. Spencer, in eighty-five total hysterectomies, had two deaths from pulmonary embolism. R. Lyle, in eight cases of subtotal hysterectomy, had one sudden death.

Mallet collected the records of 1,800 cliotomies: there were six deaths attributed to embolism, and of these, three followed operations for uterine fibroids. Chas. P. n.o.ble, in forty-two v.a.g.i.n.al myomectomies, lost two patients, one from septic endocarditis, the other from embolism; in the latter case the fibroid was gangrenous.

Olshausen, from the year 1896 to the end of 1905, performed 366 hysterectomies for fibroids; twenty-seven of these patients died. Five of the fatal cases were due to embolism.

Since 1894 I have performed more than a thousand operations of various kinds for fibroids, and have lost one patient from pulmonary embolism.

This happened in 1900. The woman was forty-five years of age and profoundly anaemic from profuse and long-continued menorrhagia. Twelve days after subtotal hysterectomy she asked to be pillowed up in bed; this was done, when she suddenly slipped down the bed in agony and died in fifteen minutes. At the post-mortem examination the right pulmonary artery was found plugged with a thick clot. No thrombosed vessels were found in the pelvis.

The symptoms of pulmonary embolism may occur at any period from the hour of the operation up to the thirtieth day. In the majority of patients embolism happens about the twelfth day. The symptoms supervene with great suddenness and seem to be preceded by movement, such as sitting up, getting out of bed, and especially straining during defaecation.

Withrow tells of a patient who was attacked whilst 'putting on her clothes to leave the hospital'. She died in twelve hours. Reclus, at a meeting of the Societe de Paris, 1897, mentioned that a patient quitting the hospital, apparently convalescent from hysterectomy, fell dead in the courtyard from pulmonary embolism. In one remarkable instance a patient complained of sciatic pain fifteen days after hysterectomy. In order to afford relief the surgeon flexed the patient's thigh on her abdomen and then suddenly extended it. This dislodged a clot, and the woman was seized with the symptoms of pulmonary embolism and died in forty-seven minutes. At the post-mortem examination the pulmonary artery was found occluded with clot and the ovarian vein contained a thrombus (Byron Robinson).

It is important to note that these fatal cases of pulmonary embolism occur when they are least expected, and it is an unusual sequence in patients with obvious thrombosis of the femoral and saphenous veins.

The most constant symptoms are urgent dyspna accompanied by great distress; in some instances the patient becomes pallid and in others cyanotic. Death may follow in a few minutes; in less severe cases it is delayed several hours, the patient remains conscious, but suffers severe mental agony.

A pulmonary embolism is not necessarily fatal, for a woman after a pelvic operation may complain of sudden pain in the chest, urgent dyspna, exhibit great mental distress, and in a short time spit up sputum mixed with blood. In a few hours the urgent symptoms subside and in two or three days pa.s.s away, and the patient recovers. I have seen five examples of this mild form of pulmonary embolism after hysterectomy. One of the patients appeared to suffer from a succession of small pulmonary emboli.