Embolism after laparotomy
The history of a case, which was recently in one of my wards, will serve as an introduction to this subject.
Case 1 – L.C., an unmarried woman, aged 56 years, was admitted into the Hospital on August 15th, 1908. She had suffered from two attacks of appendicitis, the first of which occurred in October 1907, and the second in July last; from this she was only just convalescent. On admission her temperature was 99.2°, her pulse 96, and there was some tenderness and rigidity in the right iliac fossa. There was no sign of abscess or peritonitis. The temperature became normal on the day following admission and, after careful preparation, the patient was given chloroform on August 19th, when I opened the abdomen, finding an appendix which had perforated at its tip and which contained a concretion. The appendix was removed without any difficulty, and there was no rough handling of structures of the abdominal wall. The wound was completely closed and healed quickly, the stitches being removed on the ninth day. The temperature once rose to 99.6° on the day after the operation, but after then remained normal to the end. At my visit on August 27th, the patient was sitting up in bed and expressed herself as being quite well. On August 28th, at 4.20 p.m., she complained of feeling faint, and, at 4.35 p.m. she was suddenly seized with acute pain in the right side of the chest, gasped for breath, became cyanosed, and while trying to show the sister the situation of the pain, she became unconscious, and died. Ether and strychnine were injected, oxygen was administered, and artificial respiration practised, but without effect. Permission for an autopsy could not be obtained.
Such is the brief history of an unexpected disaster after a simple case of appendicectomy, and it impresses upon us the fact that even the simplest laparotomy is not entirely devoid of risk.
Now, although no autopsy was allowed, there is little doubt that the cause of death was pulmonary embolism or thrombosis. This condition, fortunately, is comparatively rare (in my practice it has occurred in about 0.5 per cent of abdominal operations). It is unpreventable, since the active cause, as well as the means of prevention, are not known.
Such a case is usually considered as one of pulmonary embolism, but on reflection, it is difficult to imagine how a clot of sufficient size to suddenly and completely overload the whole or even one branch of the pulmonary artery can be detached from a small peripheral vein.
Many years ago, the late Dr. Playfair, in discussing the causes of sudden death after parturition, maintained that most cases of so-called pulmonary embolism were in reality cases of thrombosis in the pulmonary artery, or even in the right ventricle. He stated that cases presenting symptoms of pulmonary embolism before the 13th day were always cases of pulmonary thrombosis, and that only cases occurring after a longer interval could be regarded as caused by embolism. More recently Box, after making careful autopsies of several cases of so-called pulmonary embolism, has come to the conclusion that these cases are a combination of thrombosis with embolism. He considers that a clot first forms in the pulmonary artery, or in the right side of the heart, and some sudden movement causes detachment of this clot, which enters and completely plugs one or both of the pulmonary arteries. This certainly seems the probable explanation. The patient, who has been progressing favourably after an uncomplicated operation, is suddenly seized with acute pain in the right side of the chest, this is followed by a very rapid and irregular action of the heart, considerable dyspnoea and cyanosis. Death sometimes occurs within a few minutes, but the patient may survive for several hours.
The risk of death from pulmonary thrombosis, after an appendicectomy in the quiet stage, is not merely a nominal one, since three such cases have occurred in my practice, and represent a mortality of nearly 1 per cent after the operation, the death-rate from other causes being only 0.4 per cent. This risk emphasises the importance of giving a somewhat guarded prognosis even in the simplest case.
In a recent issue of the British Medical Journal, Mr. Bland Sutton referred to the occurrence of pulmonary embolism after abdominal hysterectomy, and stated that it was due to sepsis, and that its occurrence would be prevented by the use of rubber gloves by the surgeon and his assistants. In a correspondence which followed this paper, Dr. W. Duncan urged that the liability to embolism was due to the anaemia, which so frequently affects women suffering from uterine fibroids, and, in support of his view, quoted a case of a woman suffering from uterine fibroids, who died from pulmonary embolism, while in the hospital awaiting operation.
Finally, I think that the occurrence of pulmonary embolism, after abdominal operations, may be more frequent than is generally supposed, and that its apparent rarity may be due to the surgeon's natural dislike to attract attention to his fatal cases.
With regard to treatment, little can be done when the whole of the right pulmonary artery is blocked; oxygen, strychnine, and saline injections are always given, and in one case life was prolonged for 15 hours. Methods of prevention are, however, of more importance, and these include the treatment of anaemia before operation; giving excess of fluids, the use of citrates, and getting the patient up as soon as possible after an operation. At the same time lime salts, magnesium carbonate, and milk should be avoided.