PULMONARY lobectomy is now firmly established as a curative operation in certain cases of bronchiectasis, yet despite the advances in technique and anasthesia that have been made during recent years, it is still an operation which carries a mortality of from 10 to 20 per cent. It is true that this figure represents a considerable improvement on the earlier results, for Graham (1923) collected the cases reported up to that time and found a total mortality of 52 per cent, but, even so, it is one which it should be possible to lower yet further. Another disturbing factor is that it does not seem possible to forecast which case will go wrong, for, as will be shown later, the mild case without a large amount of sputum is almost as likely to develop one of the most serious complications, i.e., massive collapse of the upper lobe, as is the case with gross disease and much sputum.
The present research was undertaken in an attempt to assess the causes of the post-operative complications of lobectomy and to determine whether any of the aetiological factors could be overcome. The clinical material studied was provided by the cases operated on by Mr. Tudor Edwards and Mr. Price Thomas at the Brompton Hospital between I929 and 1938.
It is proposed, first, to give a short account of the post-operative complications of lobectomy and then to proceed to a consideration of the aetiological factors involved.
I. Shock.-This is usually proportional to the extent and vascularity of the adhesions which require to be separated at the operation. It may be overcome by the judicious use of rectal or intravenous saline and of blood transfusion during and after the operation. It led to a fatal outcome in a few of the early cases, but is no longer regarded as a likely cause of death. So-called pleural shock has not been encountered on opening the pleura, and it has been suggested that this phenomenon is really due to air embolism. The manipulation of the hilum of the lobe may also result in shock, and O'Shaughnessy (1936) and other workers have consequently advised the injection of novocain subpleurally around the hilum before the tourniquet is applied. The anzesthetic records at the Brompton Hospital, however, show that as a rule the application and tightening of the tourniquet have very little effect on the blood-pressure and pulse, whether spinal or inhalation anzsthetics are being used (Figs. I, 2). 2. Reactionary Haemorrhage.-Reactionary hamorrhage may occur from adhesions, or more rarely from the hilar stump. The latter should not occur with *Being the substance of a Hunterian Lecture delivered before The Royal College of Surgeons of England on February 6, 1939.