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Postoperative massive atelectasis of the lung
POSTOPERATIVE MASSIVE ATELECTASIS OF THE LUNG CASE REPORT
GEORGEB. BADER, M.D. NEW YORK CITY
p FAeTbIrEuNa rTy
V. V., aged twelve years was a d m i t t e d to the hospital service on 22, 1932, with the diagnosis of acute appendicitis and peritonitis. The s y m p t o m s of appendicitis h a d existed f o r 2 days previous to admission d u r i n g which time he had been given epsom salts and milk of m a g n e s i a b u t with p r o m p t emesis. H i s t e m p e r a t u r e on admission was 101 ~ F. His blood count was W.B.C. 16,250, with a differential of 92 per cent p o l y m o r p h o n u c l e a r s a n d 8 per cent lymphocytes. I~[e w a s p r o m p t l y operated upon. The a p p e n d i x w a s f o u n d to be retrocecal, g a n g r e n o u s and r u p t u r e d at its tip with f r e e p u s in the r i g h t lower
Fig. 1.
Fig. 2.
Fig. 1 . - - F o u r days Posloperati~/e. Note the dense shadow on the left si.de of the chest with the disappearance of the cardiac image and the mediastinal contents from the right side of the chest. Th~ intercostal spaces on the right are more widely separated than those on the left due to compensatory emphysema. Fig. 2.--Five days Dostoperative. Note the increased aeration in the left upper lobe, the elevation of the diaphragm on the left and the widening of the intercostal spaces on the right side. quadrant. The incision was r i g h t rectus, 5 centimeters in length, and cigarette d r a i n a g e was instituted. The anesthetic was open drop ( e t h e r ) and. the narcosis w~ts not unduly prolonged. The operation lasted 30 minutes. The child w a s placed in the Fowler position, postoperative, a f t e r p a t i e n t had recovered f r o m anesthesia. There was nothing" in the previous history except p n e u m o n i a 6 years ago and tonsillectomy a n d adenoidectomy 4 years ago with u n e v e n t f u l recovery. The tuberculin skirl test was negative and no pathology was f o u n d in the chest before the a p p e n d i x operation, F r o m the Pediatric Service at St. Vineent's Hospital, New .York City. 726
B~-DEI~:
POSTOPERATIVE ~,IASSIVE ATELECTASI~ OF LUNG
727
R e q u e s t f o r a c o n s u l t a t i o n t h e first d a y p o s t o p e r a t i v e because of r e s p i r a t o r y difficulty r e v e a l e d s i g n s i n d i c a t i v e of an a c u t e b r o n c h i t i s , r~les d i s s e m i n a t e d t h r o u g h o u t the chest, t{e p r e s e n t e d the c l i n i c a l a s p e c t of a p o s t o p e r a t i v e pneumonla, with rapid labored breathing. The child w a s seen a g a i n f o u r d a y s p o s t o p e r a t i v e a t w h i c h t i m e he a p p e a r e d to be v e r y m u c h worse. H e w a s dyspneic, c y a n o t i c a n d t h e l e f t chest w a s prae-
~'ig. 3. Fig. 4. Fig. 3 . - - N i n e d a y s postoperative. Note the progressive increase in a e r a t i o n of the left lung. The c a r d i a c i m a g e is still to the left. Fig. 4 . - - E i g h t e e n days postoperative. A e r a t i o n of the left lower lobe extends to t h e base on. this date.
Fig. 5. Fig. 6. Fig. 5 . - - T w e n t y - s i x d a y s postoperative. Lung" expansion is n e a r l y complete. Fig. G.---~ifty-eight clays postoperative. Shows compiete e x p a n s i o n of t h e left lung. The h e a r t occupies its n o r m a l position w i t h the r e t u r n of the c a r d i a c i m a g e on the right. The left d i a p h r a g m presents a n o r m a l r e l a t i o n s h i p to the r i g h t a n d the i n t e r c o s t a l spaces are s y m m e t r i c a l in w i d t h on the two sides.
728
THE JOURNAL OF PEDIATRICS
tically immobile. He had signs in the left chest which wore interpreted as fluid, the breath sounds over the left side anteriorly and posteriorly being greatly diminished a n d with diminished tactile fremitus. No r~les were heard over this area. A t the extreme apex of the left upper lobe, however, there was loud bronchial b r e a t h i n g with rMes. A n x-ray picture was taken at once which revealed what is seen in Fig. 1. Thereafter a series of pictures was taken which show the progress to complete recovery. (Figs. 1 to 6.) Temperature continued nine days. This and the slow disappearance of the shadow in the left chest were attributed to a small a m o u n t of fluid. A thoracentesis was done, however, without success except for a few drops of blood which were reported sterile. I n this instance no special t r e a t m e n t was instituted. Recovery is apparently complete after 57 days. CONC'LUSION I believe this condition is sufficiently u n u s u a l to w a r r a n t a t t e n t i o n and although apparently rare in children or perhaps rarely recognized, I suggest t h a t the condition be anticipated in all instances of so-called postoperative pneumonia.
GEORGEB. BADER, M.D. NEW YORK CITY
p FAeTbIrEuNa rTy
V. V., aged twelve years was a d m i t t e d to the hospital service on 22, 1932, with the diagnosis of acute appendicitis and peritonitis. The s y m p t o m s of appendicitis h a d existed f o r 2 days previous to admission d u r i n g which time he had been given epsom salts and milk of m a g n e s i a b u t with p r o m p t emesis. H i s t e m p e r a t u r e on admission was 101 ~ F. His blood count was W.B.C. 16,250, with a differential of 92 per cent p o l y m o r p h o n u c l e a r s a n d 8 per cent lymphocytes. I~[e w a s p r o m p t l y operated upon. The a p p e n d i x w a s f o u n d to be retrocecal, g a n g r e n o u s and r u p t u r e d at its tip with f r e e p u s in the r i g h t lower
Fig. 1.
Fig. 2.
Fig. 1 . - - F o u r days Posloperati~/e. Note the dense shadow on the left si.de of the chest with the disappearance of the cardiac image and the mediastinal contents from the right side of the chest. Th~ intercostal spaces on the right are more widely separated than those on the left due to compensatory emphysema. Fig. 2.--Five days Dostoperative. Note the increased aeration in the left upper lobe, the elevation of the diaphragm on the left and the widening of the intercostal spaces on the right side. quadrant. The incision was r i g h t rectus, 5 centimeters in length, and cigarette d r a i n a g e was instituted. The anesthetic was open drop ( e t h e r ) and. the narcosis w~ts not unduly prolonged. The operation lasted 30 minutes. The child w a s placed in the Fowler position, postoperative, a f t e r p a t i e n t had recovered f r o m anesthesia. There was nothing" in the previous history except p n e u m o n i a 6 years ago and tonsillectomy a n d adenoidectomy 4 years ago with u n e v e n t f u l recovery. The tuberculin skirl test was negative and no pathology was f o u n d in the chest before the a p p e n d i x operation, F r o m the Pediatric Service at St. Vineent's Hospital, New .York City. 726
B~-DEI~:
POSTOPERATIVE ~,IASSIVE ATELECTASI~ OF LUNG
727
R e q u e s t f o r a c o n s u l t a t i o n t h e first d a y p o s t o p e r a t i v e because of r e s p i r a t o r y difficulty r e v e a l e d s i g n s i n d i c a t i v e of an a c u t e b r o n c h i t i s , r~les d i s s e m i n a t e d t h r o u g h o u t the chest, t{e p r e s e n t e d the c l i n i c a l a s p e c t of a p o s t o p e r a t i v e pneumonla, with rapid labored breathing. The child w a s seen a g a i n f o u r d a y s p o s t o p e r a t i v e a t w h i c h t i m e he a p p e a r e d to be v e r y m u c h worse. H e w a s dyspneic, c y a n o t i c a n d t h e l e f t chest w a s prae-
~'ig. 3. Fig. 4. Fig. 3 . - - N i n e d a y s postoperative. Note the progressive increase in a e r a t i o n of the left lung. The c a r d i a c i m a g e is still to the left. Fig. 4 . - - E i g h t e e n days postoperative. A e r a t i o n of the left lower lobe extends to t h e base on. this date.
Fig. 5. Fig. 6. Fig. 5 . - - T w e n t y - s i x d a y s postoperative. Lung" expansion is n e a r l y complete. Fig. G.---~ifty-eight clays postoperative. Shows compiete e x p a n s i o n of t h e left lung. The h e a r t occupies its n o r m a l position w i t h the r e t u r n of the c a r d i a c i m a g e on the right. The left d i a p h r a g m presents a n o r m a l r e l a t i o n s h i p to the r i g h t a n d the i n t e r c o s t a l spaces are s y m m e t r i c a l in w i d t h on the two sides.
728
THE JOURNAL OF PEDIATRICS
tically immobile. He had signs in the left chest which wore interpreted as fluid, the breath sounds over the left side anteriorly and posteriorly being greatly diminished a n d with diminished tactile fremitus. No r~les were heard over this area. A t the extreme apex of the left upper lobe, however, there was loud bronchial b r e a t h i n g with rMes. A n x-ray picture was taken at once which revealed what is seen in Fig. 1. Thereafter a series of pictures was taken which show the progress to complete recovery. (Figs. 1 to 6.) Temperature continued nine days. This and the slow disappearance of the shadow in the left chest were attributed to a small a m o u n t of fluid. A thoracentesis was done, however, without success except for a few drops of blood which were reported sterile. I n this instance no special t r e a t m e n t was instituted. Recovery is apparently complete after 57 days. CONC'LUSION I believe this condition is sufficiently u n u s u a l to w a r r a n t a t t e n t i o n and although apparently rare in children or perhaps rarely recognized, I suggest t h a t the condition be anticipated in all instances of so-called postoperative pneumonia.