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The prevention of postoperative pulmonary complications
The
Prevention of Postoperative Pulmonary Complications JOHN J. FOMON, M.D.,
From tbe Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York.
genera1 trend toward increased Iongevhas resuIted in the performance of a greater number of major surgica1 procedures on patients in the older age group. This trend has been investigated and condoned by many authors and it is generaIIy agreed that eIderIy patients shouId not be denied needed surgery [2,q,6,7,9,11]. Because of a rather unique economic situation, the charity patients entering Strong MemoriaI and Rochester MunicipaI HospitaIs faI1 into the category of oIder patients, creating an idea1 situatron for f&her study of major surgery in oId patients. In addition to having a Iarge concentration of patients in this age group, conditions of operative technic and pre- and postoperative care remain fairly uniform for a given period, and thus it was recognized that an idea1 situation was present for a study of this type. Realizing, then, that the care of many oId patients under reIativeIy standard conditions created not onIy an unusua1 opportunity but aIso an added responsibiIity, a twofoId program was instituted: every attempt was to be made to prevent compIications from occurring and there was to be a continuous audit to evaIuate the methods adapted for the prevention of compIications. This report deaIs with the program onIy insofar as it related to puImonary compIications. Past experience indicated that most of the puImonary compIications were ateIectasis, pneumonia, or a combination of the two. It was aIso recognized that many oId patients, especiaIIy maIes, had chronic productive coughs with excessive tracheobronchia1 secretions that were ineffectiveIy expectorated. This situation was most often due singIy or in combination to puImonary emphysema, chronic bronchitis or diffuse miId bronchiectasis. With this informa-
T ity HE
Miami, Florida
tion as a basis, the foIIowing prophyIactic measures were undertaken. A carefu1 history and physical examination resuIted in remarkabIy accurate information about the pulmonary disorder and reserve of a given patient. This knowIedge was further impIemented by the smal1 chest film that was routineIy taken on admission and by observing the patient as he waIked briskIy down the corridor or was made to cIimb a ffight of stairs. Fluoroscopy, diagnostic bronchoscopy, bronchograms, Iaminagrams and puImonary function studies were done onIy for specific indications. Sputum cuItures were obtained at the time of admission. An unusua1 flora, such as Escherichia coIi in cases of pyloric obstruction, was an indication for specific antibiotic therapy. Antibiotics, however, were not empIoyed routinely either prior to or after operation. It was felt that such a course would be contrary to the accepted tenet that antibiotics shouId not be used indiscriminately and that the patients would be exposed to such compIications as the deveIopment of sensitivity and to staphyIococca1 enteritis [ IJ,IO]. Using the same reasoning, topica antibiotics by inhaIation were not used without specific indication. It was further reasoned that if the measures used postoperativeIy for the prevention of puImonary compIications were of rea1 value, they shouId be of much more vaIue if they couId be initiated during the preoperative period. Accordingly, part of the program was directed at Iiquefying tenaceous secretions. To this end, bronchia detergents were inhaIed by the patient three or four times a day. The Iow humidity, especiaIIy during the winter months, was combated by the continuous use of steam tents. PosturaI drainage three times a day and a regimen of turning, coughing and hyperventiIation every two hours temporariIy controIIed
Fomon the “chronic basiIar disease” of most patients. Smoking was forbidden. In a few patients who wouId not or could not raise their secretions, nasotrachea1 suction at reguIar intervaIs was necessary and bronchoscopy was rareIy indicated. Within several days, on this regimen, crepitant raIes cIeared and patients became free of cough. AmbuIation was thought to be important and patients were made to waIk prescribed distances and to spend much time out of bed. During the actuaI surgica1 procedure the anesthetists were especiaIIy aIert, maintaining tracheobronchia1 toiIet by suctioning whenever necessary and in open chest procedures by frequent inflation of the Iungs. Additiona safeguards empIoyed have been outhned by Greene [?I, who at the time was head of the division of anesthesioIogy. PostoperativeIy, vigilance was continued. Patients were made to turn every two hours in an effort to prevent dependent edema and to aid in bIood return from the Iower extremities. They were encouraged to cough at stated intervaIs. In a comfortabIe sitting position with a nurse or doctor firmIy supporting the wound, coughing was remarkabIy effective and productive. Those patients who were unabIe to raise secretions were benefited by nasotrachea1 suction. This was accompIished by expIaining the need for and outIining the procedure to the patient. Then the gauze-covered tongue was gentIy retracted by the operator and with the suction on, but with the tubing cIamped, a catheter (No. 18 pIastic Levin tubes are exceIIent) was introduced through the nose whiIe the patient “panted Iike a dog” through his mouth. Once the trachea was entered, suction was &stituted with gentIe movement of the catheter to stimuIate coughing whiIe the patient supported his own wound. Suctioning was of short duration so as not to significantIy Iower the pa&a1 aIveoIar oxygen pressure for Iong periods. During the entire procedure the p&tient was reassured. FoIIowing a short rest period, effected by cIamping but not removing the catheter, another period of suctioning was initiated. After the trachea was free of secretions, the patient’s head was turned far to the right and the catheter advanced, with the resuIt that it frequently entered the Ieft main bronchus. Suction was repeated as often as necessary in this new position and then a similar procedure was carried out on the opposite side. This maneuver was repeated frequently enough, often every two hours, to keep the 612
tracheobronchia1 tree free of secretions. Bronchoscopy was necessary rather infrequentIy for remova of retained secretions. When indicated, it was usuaIIy done on the ward without anesthesia since even topica anesthesia obtunds the cough reff ex, not onIy during the procedure but aIso during the period foIIowing bronchoscopy. Tracheotomy was rareIy necessary. HyperventiIation was part of the program and was successfu1 onIy because cooperative nurses actuaIIy insisted on patients rebreathing into a paper bag. Cirbon dioxide and carbon dioxide and oxygen mixtures were not used. Neither were any of the various machines that deIiver aIternating positive and negative pressure used routineIy. At the time of this study the rebreathing apparatus described by Schwartz and DaIe [8] was not ready for cIinicaI use. The aforementioned outIined program was made avaiIabIe with modifications to a11 patients. ObviousIy there was variation in the amount of preparation and postoperative care needed. This depended on the status of the patient and the type of surgery that was per-s farmed. In emergencies the preoperative preparation was curtaiIed and sometimes was necessarily compIeteIy omitted. CompIications were audited by entering each patient’s name in a Iedger at the time of operation aIong with the type of procedure that was performed. Any time a complication deveIoped, it was entered under one of the foIIowing headings: puImonary, cardiovascuIar, wound, genitourinary or “other.” At the time of discharge or death, the chart was again reviewed and appropriate notations made. Even the most minor comphcations tiere recorded. A wound showing miId redness was counted as a comphcation and minor degrees of ateIectasis were not dismissed. Any patient having a singIe febriIe episode to 38”~. or above was considered as having a compIication. Fever was not considered to be a normaI sequeIa of an operative procedure but a manifestation of a compIication. This concept was supported when it became evident that of the entire series onIy two instances of fever of undetermined origin were found. AIso incIuded as compIications were incorrect preoperative diagnoses, technica1 errors, headache foIIowing spina anesthesia and the like. During the study 823 procedures were performed in the operating room by the resident staff on the General SurgicaI Service. This
Prevention
of Postoperative
PuImonary
CompIications
I
100
60
W -
AGES OF ALL PATIENTS COMPLICATIONS AND DEATHS OF PATIENTS UNDERGOING MAJOR SURGERY
60
AGE
FIG. I. This graphically depicts the reIationship of age of all patients operated that deveIoped in those undergoing major upon, with the comphcations surgery.
figure incIudes the most minor as we11 as the major procedures. The Iist of the various operations and the number of times they were performed is recorded in Table I. The total here exceeds the 823 procedures that were performed. Thus, if a patient underwent cholecystectomy and subtota1 gastrectomy at the same time, it is counted as a single procedure, but on the list of operations it is Iisted in both places. On the other hand, coIostomy is considered to be part of an abdominoperinea1 proctosigmoidectomy and is onIy recorded as such. Figure I graphicaIIy depicts the reIationship of the age of a11 patients dperated upon with the compIications deveIoped by those patients undergoing major surgery. It is readiIy apparent that the peak age incidence of patients was early in the seventh decade. The second curve represents numbers of compIications and deaths and not patients. It is obvious that some patients had more than one compIication and that in most instances one or more comphcation preceded the death of a patient. The incidence of compIications roughIy paraIIeIs the age of the patients except that the peak occurred Iater in the seventh decade. The number of patients in whom various types of compIications deveIoped is shown in Figure 2. It is readiIy seen that respiratory dil%cuIties vied with wound complications. AteIectasis, in spite of efforts to prevent it, Ied the Iist of respiratory compIications and 613
was responsibIe for aImost a11 of the pneumonias that occurred. Data are not presented that aIIow for a statistica anaIysis, proving a regimen such as the one outIined decreases compIications. However, it was the definite beIief that such TABLE I OPERATIONSPERFORMED ‘~
CheestwaII....:::::::::::::::::: Pulmonary and cardiac. Upper gastrointestinal. Lower gastrointestinal. Appendectomy. .
BiIiary
24 . . .
..
Sympathectomy . Amputation. .. Hernia repair.. Biopsies and excisions. Sigmoidoscopies . ExpIoratory Iaparotomy Others. .
45 56 60
!
24
. 5: .
.
.
. ..
I20
92 37 143
was the case. There are those who wiI1 contend that the puImonary compIications are inordinateIy high as compared with their own experience, even with this program. With this in mind it is important to emphasize that the patient materia1 was such that pulmonary compIications couId be expected to be high. It is aIso necessary to point out that many cases
Fomon
60z” 0 5
50-
0 ii I 0 0
40-
k 30cc ii ,’ z
20-
io-
o-
FIG. 2. The incidence of the various types of complications compared.
of ateIectasis were of a minor nature, being manifested onIy by decreased breath sounds over the invoIved Iung fieId and invoIving so IittIe of a Iobe that it did not appear on chest fiIms. Even though minor, such degrees of ateIectasis are definite, and after instituting the various measures outIined there is definite evidence of cIearing of the ateIectasis as shown by the repIacement of the decreased breath sounds by fine crepitant raIes, indicating that once more air ig entering and Ieaving the formerIy occluded segment of Iung. Fever, if it had developed, promptIy feI1 to normaI. On continued treatment the rales disappeared and breath sounds became normaI. Unless vigiIance is constant, many episodes of ateIectasis may go unrecognized and then either cIear spontaneousIy or more commonIy deveIop into pneumonitis. One caution is exempIified by a patient who underwent puImonary resection. His emphysema and chronic bronchitis made him an ideal candidate for deveIopment of ateIectasis, and consequentIy during the postoperative period efforts at prophyIaxis were intense, so much so that moderate edema of a major bronchus deveIoped with atelectasis on this basis. Except in a few instances, pneumonia was aIways preceded by ateIectasis and generaIIy, if ateIectasis was controIIed, pneumonia did not deveIop. It is recognized that much has been written 614
that occurred are
about ateIectasis both from the cIinica1 and from the Iaboratory standpoint, and nothing in this program is origina1. Rather, it is a combination of methods that worked we11 in the prevention of ateIectasis. These measures are simpIe to carry out and effective and, therefore, are recommended. REFERENCES I. FLIPPIN, F. F. What
price antimicrobia1 therapy. Delaware State M. J., 27: 267, 1955. f 2. GLENN, F. Surgery in the aged. BUZZ. New York Acad. Med., 32: 559, 1956. 3. GREENE, N. M. Anesthetic management of patients with respiratory disease. J. A. M. A., 162: 1276, 1956. 4. HAUG, C. A. and DALE, W. A. Major surgery in oId people. Arch. Surg., 64: 421, 1952. 5. HOWE, C. Antibiotics: use versus abuse. Postgrad. Med., 19: 177, 1956. 6. LIMBRASCH, J. Experience with more than one thousand eIderIy surgical patients. Arch. Surg., 73: 124, 1956. 7. PARSONS, W. H., WHITAKER, H. T. and HINTON, J. K. Major surgery in patients seventy years of age and over. Ann. Surg., 143: 845, 1956. 8. SCHWARTZ,S. I. and DALE, W. A. Addition of dead space to produce hyperventiIation for prophyIaxis of atelectasis. S. Forum, 6: 282, 1956. g. STEWART, J. D. and ALFANO, G. S. Surgery of the elderly. J. A. M. A., 154: 643, 1954. IO. THOMSON, E. The present position of antibiotic therapy. M. J. Australia, I: 418, 1956. I I. VAUGHN,A. M., WHITE, M. S. and COLEMAN,J. M. ProbIems pecuIiar to surgery of the aged. J. Am. Geriatrics, 4: 483, 1956.
Prevention of Postoperative Pulmonary Complications JOHN J. FOMON, M.D.,
From tbe Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York.
genera1 trend toward increased Iongevhas resuIted in the performance of a greater number of major surgica1 procedures on patients in the older age group. This trend has been investigated and condoned by many authors and it is generaIIy agreed that eIderIy patients shouId not be denied needed surgery [2,q,6,7,9,11]. Because of a rather unique economic situation, the charity patients entering Strong MemoriaI and Rochester MunicipaI HospitaIs faI1 into the category of oIder patients, creating an idea1 situatron for f&her study of major surgery in oId patients. In addition to having a Iarge concentration of patients in this age group, conditions of operative technic and pre- and postoperative care remain fairly uniform for a given period, and thus it was recognized that an idea1 situation was present for a study of this type. Realizing, then, that the care of many oId patients under reIativeIy standard conditions created not onIy an unusua1 opportunity but aIso an added responsibiIity, a twofoId program was instituted: every attempt was to be made to prevent compIications from occurring and there was to be a continuous audit to evaIuate the methods adapted for the prevention of compIications. This report deaIs with the program onIy insofar as it related to puImonary compIications. Past experience indicated that most of the puImonary compIications were ateIectasis, pneumonia, or a combination of the two. It was aIso recognized that many oId patients, especiaIIy maIes, had chronic productive coughs with excessive tracheobronchia1 secretions that were ineffectiveIy expectorated. This situation was most often due singIy or in combination to puImonary emphysema, chronic bronchitis or diffuse miId bronchiectasis. With this informa-
T ity HE
Miami, Florida
tion as a basis, the foIIowing prophyIactic measures were undertaken. A carefu1 history and physical examination resuIted in remarkabIy accurate information about the pulmonary disorder and reserve of a given patient. This knowIedge was further impIemented by the smal1 chest film that was routineIy taken on admission and by observing the patient as he waIked briskIy down the corridor or was made to cIimb a ffight of stairs. Fluoroscopy, diagnostic bronchoscopy, bronchograms, Iaminagrams and puImonary function studies were done onIy for specific indications. Sputum cuItures were obtained at the time of admission. An unusua1 flora, such as Escherichia coIi in cases of pyloric obstruction, was an indication for specific antibiotic therapy. Antibiotics, however, were not empIoyed routinely either prior to or after operation. It was felt that such a course would be contrary to the accepted tenet that antibiotics shouId not be used indiscriminately and that the patients would be exposed to such compIications as the deveIopment of sensitivity and to staphyIococca1 enteritis [ IJ,IO]. Using the same reasoning, topica antibiotics by inhaIation were not used without specific indication. It was further reasoned that if the measures used postoperativeIy for the prevention of puImonary compIications were of rea1 value, they shouId be of much more vaIue if they couId be initiated during the preoperative period. Accordingly, part of the program was directed at Iiquefying tenaceous secretions. To this end, bronchia detergents were inhaIed by the patient three or four times a day. The Iow humidity, especiaIIy during the winter months, was combated by the continuous use of steam tents. PosturaI drainage three times a day and a regimen of turning, coughing and hyperventiIation every two hours temporariIy controIIed
Fomon the “chronic basiIar disease” of most patients. Smoking was forbidden. In a few patients who wouId not or could not raise their secretions, nasotrachea1 suction at reguIar intervaIs was necessary and bronchoscopy was rareIy indicated. Within several days, on this regimen, crepitant raIes cIeared and patients became free of cough. AmbuIation was thought to be important and patients were made to waIk prescribed distances and to spend much time out of bed. During the actuaI surgica1 procedure the anesthetists were especiaIIy aIert, maintaining tracheobronchia1 toiIet by suctioning whenever necessary and in open chest procedures by frequent inflation of the Iungs. Additiona safeguards empIoyed have been outhned by Greene [?I, who at the time was head of the division of anesthesioIogy. PostoperativeIy, vigilance was continued. Patients were made to turn every two hours in an effort to prevent dependent edema and to aid in bIood return from the Iower extremities. They were encouraged to cough at stated intervaIs. In a comfortabIe sitting position with a nurse or doctor firmIy supporting the wound, coughing was remarkabIy effective and productive. Those patients who were unabIe to raise secretions were benefited by nasotrachea1 suction. This was accompIished by expIaining the need for and outIining the procedure to the patient. Then the gauze-covered tongue was gentIy retracted by the operator and with the suction on, but with the tubing cIamped, a catheter (No. 18 pIastic Levin tubes are exceIIent) was introduced through the nose whiIe the patient “panted Iike a dog” through his mouth. Once the trachea was entered, suction was &stituted with gentIe movement of the catheter to stimuIate coughing whiIe the patient supported his own wound. Suctioning was of short duration so as not to significantIy Iower the pa&a1 aIveoIar oxygen pressure for Iong periods. During the entire procedure the p&tient was reassured. FoIIowing a short rest period, effected by cIamping but not removing the catheter, another period of suctioning was initiated. After the trachea was free of secretions, the patient’s head was turned far to the right and the catheter advanced, with the resuIt that it frequently entered the Ieft main bronchus. Suction was repeated as often as necessary in this new position and then a similar procedure was carried out on the opposite side. This maneuver was repeated frequently enough, often every two hours, to keep the 612
tracheobronchia1 tree free of secretions. Bronchoscopy was necessary rather infrequentIy for remova of retained secretions. When indicated, it was usuaIIy done on the ward without anesthesia since even topica anesthesia obtunds the cough reff ex, not onIy during the procedure but aIso during the period foIIowing bronchoscopy. Tracheotomy was rareIy necessary. HyperventiIation was part of the program and was successfu1 onIy because cooperative nurses actuaIIy insisted on patients rebreathing into a paper bag. Cirbon dioxide and carbon dioxide and oxygen mixtures were not used. Neither were any of the various machines that deIiver aIternating positive and negative pressure used routineIy. At the time of this study the rebreathing apparatus described by Schwartz and DaIe [8] was not ready for cIinicaI use. The aforementioned outIined program was made avaiIabIe with modifications to a11 patients. ObviousIy there was variation in the amount of preparation and postoperative care needed. This depended on the status of the patient and the type of surgery that was per-s farmed. In emergencies the preoperative preparation was curtaiIed and sometimes was necessarily compIeteIy omitted. CompIications were audited by entering each patient’s name in a Iedger at the time of operation aIong with the type of procedure that was performed. Any time a complication deveIoped, it was entered under one of the foIIowing headings: puImonary, cardiovascuIar, wound, genitourinary or “other.” At the time of discharge or death, the chart was again reviewed and appropriate notations made. Even the most minor comphcations tiere recorded. A wound showing miId redness was counted as a comphcation and minor degrees of ateIectasis were not dismissed. Any patient having a singIe febriIe episode to 38”~. or above was considered as having a compIication. Fever was not considered to be a normaI sequeIa of an operative procedure but a manifestation of a compIication. This concept was supported when it became evident that of the entire series onIy two instances of fever of undetermined origin were found. AIso incIuded as compIications were incorrect preoperative diagnoses, technica1 errors, headache foIIowing spina anesthesia and the like. During the study 823 procedures were performed in the operating room by the resident staff on the General SurgicaI Service. This
Prevention
of Postoperative
PuImonary
CompIications
I
100
60
W -
AGES OF ALL PATIENTS COMPLICATIONS AND DEATHS OF PATIENTS UNDERGOING MAJOR SURGERY
60
AGE
FIG. I. This graphically depicts the reIationship of age of all patients operated that deveIoped in those undergoing major upon, with the comphcations surgery.
figure incIudes the most minor as we11 as the major procedures. The Iist of the various operations and the number of times they were performed is recorded in Table I. The total here exceeds the 823 procedures that were performed. Thus, if a patient underwent cholecystectomy and subtota1 gastrectomy at the same time, it is counted as a single procedure, but on the list of operations it is Iisted in both places. On the other hand, coIostomy is considered to be part of an abdominoperinea1 proctosigmoidectomy and is onIy recorded as such. Figure I graphicaIIy depicts the reIationship of the age of a11 patients dperated upon with the compIications deveIoped by those patients undergoing major surgery. It is readiIy apparent that the peak age incidence of patients was early in the seventh decade. The second curve represents numbers of compIications and deaths and not patients. It is obvious that some patients had more than one compIication and that in most instances one or more comphcation preceded the death of a patient. The incidence of compIications roughIy paraIIeIs the age of the patients except that the peak occurred Iater in the seventh decade. The number of patients in whom various types of compIications deveIoped is shown in Figure 2. It is readiIy seen that respiratory dil%cuIties vied with wound complications. AteIectasis, in spite of efforts to prevent it, Ied the Iist of respiratory compIications and 613
was responsibIe for aImost a11 of the pneumonias that occurred. Data are not presented that aIIow for a statistica anaIysis, proving a regimen such as the one outIined decreases compIications. However, it was the definite beIief that such TABLE I OPERATIONSPERFORMED ‘~
CheestwaII....:::::::::::::::::: Pulmonary and cardiac. Upper gastrointestinal. Lower gastrointestinal. Appendectomy. .
BiIiary
24 . . .
..
Sympathectomy . Amputation. .. Hernia repair.. Biopsies and excisions. Sigmoidoscopies . ExpIoratory Iaparotomy Others. .
45 56 60
!
24
. 5: .
.
.
. ..
I20
92 37 143
was the case. There are those who wiI1 contend that the puImonary compIications are inordinateIy high as compared with their own experience, even with this program. With this in mind it is important to emphasize that the patient materia1 was such that pulmonary compIications couId be expected to be high. It is aIso necessary to point out that many cases
Fomon
60z” 0 5
50-
0 ii I 0 0
40-
k 30cc ii ,’ z
20-
io-
o-
FIG. 2. The incidence of the various types of complications compared.
of ateIectasis were of a minor nature, being manifested onIy by decreased breath sounds over the invoIved Iung fieId and invoIving so IittIe of a Iobe that it did not appear on chest fiIms. Even though minor, such degrees of ateIectasis are definite, and after instituting the various measures outIined there is definite evidence of cIearing of the ateIectasis as shown by the repIacement of the decreased breath sounds by fine crepitant raIes, indicating that once more air ig entering and Ieaving the formerIy occluded segment of Iung. Fever, if it had developed, promptIy feI1 to normaI. On continued treatment the rales disappeared and breath sounds became normaI. Unless vigiIance is constant, many episodes of ateIectasis may go unrecognized and then either cIear spontaneousIy or more commonIy deveIop into pneumonitis. One caution is exempIified by a patient who underwent puImonary resection. His emphysema and chronic bronchitis made him an ideal candidate for deveIopment of ateIectasis, and consequentIy during the postoperative period efforts at prophyIaxis were intense, so much so that moderate edema of a major bronchus deveIoped with atelectasis on this basis. Except in a few instances, pneumonia was aIways preceded by ateIectasis and generaIIy, if ateIectasis was controIIed, pneumonia did not deveIop. It is recognized that much has been written 614
that occurred are
about ateIectasis both from the cIinica1 and from the Iaboratory standpoint, and nothing in this program is origina1. Rather, it is a combination of methods that worked we11 in the prevention of ateIectasis. These measures are simpIe to carry out and effective and, therefore, are recommended. REFERENCES I. FLIPPIN, F. F. What
price antimicrobia1 therapy. Delaware State M. J., 27: 267, 1955. f 2. GLENN, F. Surgery in the aged. BUZZ. New York Acad. Med., 32: 559, 1956. 3. GREENE, N. M. Anesthetic management of patients with respiratory disease. J. A. M. A., 162: 1276, 1956. 4. HAUG, C. A. and DALE, W. A. Major surgery in oId people. Arch. Surg., 64: 421, 1952. 5. HOWE, C. Antibiotics: use versus abuse. Postgrad. Med., 19: 177, 1956. 6. LIMBRASCH, J. Experience with more than one thousand eIderIy surgical patients. Arch. Surg., 73: 124, 1956. 7. PARSONS, W. H., WHITAKER, H. T. and HINTON, J. K. Major surgery in patients seventy years of age and over. Ann. Surg., 143: 845, 1956. 8. SCHWARTZ,S. I. and DALE, W. A. Addition of dead space to produce hyperventiIation for prophyIaxis of atelectasis. S. Forum, 6: 282, 1956. g. STEWART, J. D. and ALFANO, G. S. Surgery of the elderly. J. A. M. A., 154: 643, 1954. IO. THOMSON, E. The present position of antibiotic therapy. M. J. Australia, I: 418, 1956. I I. VAUGHN,A. M., WHITE, M. S. and COLEMAN,J. M. ProbIems pecuIiar to surgery of the aged. J. Am. Geriatrics, 4: 483, 1956.