POST-OPERATIVE TREATMENT
By George A. Still
At the convention of the American Osteopathic Association held in Boston in 1918, I gave a short talk on the above subject, and during the day after I had given the lecture, two women and one man, graduate osteopaths, asked me if I really meant to convey the impression that we actually gave osteopathic treatments to recent surgical cases. I do not know whether I convinced them or not, but I do know that they convinced me that there are people practicing osteopathy who have absolutely no concept of its merits and underlying principles.
To my surprise I have found that a great many osteopaths who consider themselves absolutely “pure” are just a bit startled at the thought of handling post-operative complications by treatment. These are invariably fellows who have had most of their experience in office work, and who do not come in contact with acute cases. Still it is difficult to conceive how a man can believe that osteopathy is specific for certain diseased conditions and not for others. As a matter of fact osteopathic treatment has not proved itself more satisfactory in any field of therapeutics than it has in post-operative conditions.
The common post-operative conditions are pneumonia, pleurisy, backache and headache, nephritis, vomiting, neuritis, phlebitis.
Taking up these subjects and discussing the least serious first we would of necessity discuss pneumonia last, as it is the most serious, and is less influenced by other conditions. It will also serve to illustrate many of the details in treatment.
We will therefore briefly take up the other conditions and then discuss pneumonia more fully.
Vomiting
We believe there is no question that a good part of the prevention of anesthetic vomiting is in the preparation of the patient, including a good cleaning out of the bowels without debilitating cathartics. In other words, the vomiting is increased if the alimentary tract is loaded, or if on the other hand it has been irritated to the extent of losing its tone. Combining a careful preparation with a straight ether anesthesia and osteopathic treatment to the neck and splanchnics we have been able to eliminate any serious post-operative nausea. I do not recall a case in the last few years that vomited on the following day unless the condition for which they were operated was one that essentially in itself would cause vomiting; for instance if the patient had peritonitis and had been vomiting due to the toxic ileus. They might even vomit after the abdomen had been opened. This could hardly be called “post-operative” vomiting.
The improvement in our records in post-operative vomiting is in proportion to our increased faith and use of the osteopathic treatment. Time and again patients have told us that they had taken anesthetics before and were sick from three to five days and even a week. Invariably we have been able to surprise these patients by the fact that they were sick less than a day.
The usual treatment with bismuth sub-nitrate, cerium oxylate, sour wine and the other usual remedies were not used in any case or in any amount. No drugs whatever were employed.
Backache and Headache
There is practically no difference in the post-operative headache and the office headache. There is of course the usual multiplicity of causes, and as a matter of fact in this condition treatment can more nearly approach the ordinary office treatment, and the results are about the same. As for backache, we find that speed of operating and not keeping the patient under the ether too long has a marked influence. Also we have a four inch Seely mattress on the operating table which helps some. Treatment does the rest and does it effectively. For this complication even the ordinary nurse knows enough to give a treatment of some sort.
Neuritis
Nine times out of ten the post-operative neuritis is really a local osseous lesion, a slipped innominate, rib, vertebra, clavicle, biceps tendon or something of the sort, and responds quickly to a specific treatment.
Phlebitis
This complication usually comes on quite late after an operation and at first it is sometimes hard to differentiate it from a neuritis. Absolute rest of the involved part with lower spinal treatment gives relief, but under no circumstances should the affected part be freely moved while there is active inflammation. The reason for treatment of the lower spinal area is that practically always one of the saphenous veins is involved.
Nephritis
This complication is to a very big extent eliminated by a careful urinalysis prior to the operation, and careful preliminary treatment in indicated cases, and in other cases the postponement or if necessary complete elimination of the operation where it is not a case of life and death. Where the condition does appear we have found it the hardest of the post-operative complications to control. Indeed it is the only one that we have not found very easy to manage.
We do not vary the treatment for a post-operative nephritis from what we would use in any ordinary case of nephritis. We have observed treatment of this condition in many cases under medical management, and while we are satisfied with the osteopathic treatment comparatively we are not yet satisfied that we have it developed to its greatest efficiency.
Pleurisy
This condition in nearly every instance can be corrected with one or two treatments of a twisted rib unless it is the pleurisy of a beginning pneumonia. As far as the pain is concerned the simpler type hurts as much as the one that is going to develop a real complication. For this reason relief obtained by a single treatment often seems little short of miraculous to the patient.
Pneumonia
When I took charge of the surgical work at Kirksville, osteopathy was not used in post-surgical treatment. Post-operative vomiting was treated medically, as were other post-operative conditions, including pneumonia. Cases of a real major surgical nature rarely got an osteopathic treatment.
The idea seemed to be that osteopathic post-operative treatment had to be along the same lines as it would be for such an illness as lumbago, brachial neuritis, or ordinary pneumonia, and other non-surgical conditions where the patient could be placed for giving a treatment in a position that was not permissible following an operation, as it would work great harm to the wound.
It seemed to me that if osteopathy was effective in a case of ordinary non-surgical pneumonia, it should certainly be good for a case of pneumonia that was post-operative and that all we had to do to handle the condition was to apply a new technique of treatment that could be used on a patient who had a surgical wound. All we had to do was to so manipulate the spine that we would get the results locally, and yet handle it in such a manner as not to affect the wound.
Many laymen, and even some physicians of our own school, express surprise at the suggestion that we do much osteopathic work in the after care of surgical patients. But the fact is we have worked it out so that now, except for pain, during the immediate after effects of the operation drugs are absolutely not used in our hospital for any of the post-operative complications. The opiate immediately following the operation, is really a follow up of the anesthetic, and we use that as rarely as possible. Needless to say, there are cases such as un-united fractures, extensive adhesions, etc., where the emergency conditions positively call for some relief of the pain for a short while, but that is the only condition that we cannot control with mechanical treatment.
I am very glad that I had the confidence to give this an early trial and a thorough trial, without being afraid to leave off the drugs. The big field, however, where osteopathic treatment has won the most impressive success and proved itself a most absolute specific, is in the field of post-operative pneumonia with which I am proud to announce a one hundred per cent. success for combined osteopathic treatment in my fourteen years continuous surgical work. Not to have lost a single case is partly due to luck. In other words, with any series of serious cases, it is impossible but that there be some fatality finally.
Post-operative cases have one advantage along with their disadvantage. While they have the shock of the operation to contend with, and the weakened condition from the disease for which they were operated, still except in extreme emergency they would not have been operated on unless they had a good heart and good kidneys and a good blood pressure, so that in cases in which we are most concerned in combatting pneumonia, we usually start with a patient who has those organs in a healthy condition.
First Post-operative Pneumonia Cases Treated Osteopathically.—At the Chicago Convention in 1911, I reported the first post-operative pneumonia cases that had been treated osteopathically. I believe at that time that there had been only three cases. At that meeting I mentioned the fact that some of the doctors and some of the internes who treated those cases felt sure that they were not treating them properly because they could not get away from the idea that pneumonia needed strychnin and other drugs. One of these cases got well in three days from the developed lobar pneumonia symptoms. The results were so miraculous that the young man treating it began to doubt whether it could have been pneumonia. He could not understand how he, a senior student, could overcome this dreaded disease by merely working on the spine. He could not believe that osteopathy, a science that he had been able to learn himself, so easily could cure a condition that he had thought must be almost necessarily fatal.
One of the weaknesses of osteopathy is the fact that there is no mysticism about it. It is so simple that any person with ordinary intelligence can learn to use it, and yet it is so simple that it takes an unusual intelligence to be able to grasp the fact that it is the therapeutic discovery of the age. Many, many times I have had young internes and students cure genuine lobar pneumonia and do it with such obvious ease that it caused them to wonder, in a way, if it really could be pneumonia. It is bred in our very tissues to look for some mysticism, something impossible to understand, something supernatural, something connected with the Unknown associated with the treatment of disease and accordingly it is just human nature to find it difficult to believe, even when we see it, that a simple method of treatment can actually effect a cure.
Real pneumonia, as we understand it, is a consolidation of the lung tissues characterized by fibrosanguinous exudate into the pulmonary tissues and spaces, associated with one or more particular germs as exciting factors and proved by the physical tests and the character of the expectoration. How many cases have been cured that had not entered consolidation I do not know because up until the time of actual consolidation there may be a question as to whether or not they would have had pneumonia. I know that many cases with marked symptoms of pneumonia have failed to develop under treatment or the case has been aborted.
Pneumonia lacks a great deal of being a self limited disease. The number of cases with beginning symptoms that fail to develop is too great to be ascribed to coincidence. Of course I know that some of these might have been only pleuritis, some only neuritis, etc. However, in giving the statistics of pneumonia cures we will give only those in which pneumonia developed and showed a hardening or consolidation of the lung tissue. In these cases there can be no argument as to whether there was pneumonia.
When we have an acute condition associated with the symptoms of consolidation, we can hardly be confused as to the diagnosis. We may make a mistake in our physical findings, but hardly after a little experience, and certainly when we are sure of the physical findings there will be no trouble in naming the disease.
The Clinical Findings.—Post-operative pneumonia is a little different from the common pneumonia. It always comes on a little more insidiously. One has to watch for post-operative pneumonia more closely than he would for the attack that we may meet in ordinary practice. A patient may have considerable pain from his wound, may have some pain in the back from the position he is in; there may be headache, and an upset feeling from ether; and the pain comes in the chest. All these symptoms are forerunners of pneumonia, but the pain in the chest is not noticed until it gets quite severe. In other words, there are other things to annoy the patient as well as the attendant, and at first, this condition does not cause complaint. A strong and healthy individual who feels a pain in his pleura, which is the forerunner of pneumonia, knows it at once, because that is the only distress he has. His entire attention is attracted and he asks for a physician’s help. But in the post-operative case, the physician has to keep a look out in order to prevent a case from getting well under way before it is recognized.
As an example of this I had a case of a man who was with a party driving an automobile and they tried to cross the railroad track in front of a train. This patient I speak of was one of the survivors. He had a fracture of the femur, fracture of the skull, fracture of three ribs, and otherwise more or less bruised up. Naturally the preliminary work consisted in getting the ribs and legs attended to as well as possible and looking out for cerebral hemorrhage or meningitis.
This patient developed consolidation in both lungs in spite of regular treatment, and it precipitated on him very rapidly, partly masked by the disturbed breathing from other sources of irritation. We put him on hourly treatment, but after a few hours his condition from the injuries and the pneumonia was such that his wife asked us not to treat him any more. She put it this way, that she knew he would die in spite of all that could be done and as long as he was going to die he might as well die easy. Every time he was treated it had the effect of bringing him out of his stupor, and he would complain, and she thought it would be a kind act to let him slide off into the next world uncomplaining.
Pneumonia in a case of this sort cannot be handled with kid gloves if we wish to save the patient. We must give firm, strong treatment. Light treatment in this condition will do no good. Indeed light treatments in any sort of pneumonia are of little avail. Many times I have changed internes in a pneumonic case that was not responding and the results were immediate. That is, the turn for the better was obvious from the beginning of the good strong treatment.
The case above mentioned was treated a good part of each hour for twelve hours. He had no strychnin, no oxygen, nothing but treatments, but he got well and is now living, and aside from a limp has no evidence of either his injury or his illness.
Some cases, in private practice, may get well on a treatment a day, but I would hate to handle the kind of cases we get in that manner. I have had severe cases, especially hemorrhagic cases, where the treatment was almost continuous for hours preceding the crisis. Of course, after the crisis we can ease up. On the other hand, it is not infrequent that a few good strong early treatments, given at the beginning of a case absolutely stop it. I have seen cases where a consolidation area of the apex of the lower right lobe as large as the palm was easily outlined, and this together with the clinical symptoms would be cleared up in two or three days.
There is no possible medical method by which this can be done. Medical authorities agree that under their treatment pneumonia runs an unshortened course; in other words, a course in the individual case that has not been affected by the medication. Medically, even where the crisis occurs early, the consolidation persists for some time, but I have seen it cleared up time and again under osteopathic treatment in the length of time that could have been brought about only by osteopathic treatment.
I have previously called attention to the fact that many of the medical text books on physical diagnosis mention a point that is a very practical and very plain demonstration of the efficiency of osteopathy in pulmonary conditions. These books only mention this fact without pointing any moral or drawing any conclusions. The point is this: that frequently when a professor is having a class or a section of a class examining a case of pneumonia, they will outline the size of the consolidation at the beginning, the instructor marking it off when he makes the first examination; then after the students have examined it, by percussion, palpation, etc., possibly a dozen or twenty of them, the later students will find that the area has shrunken perhaps an inch. This fact has been frequently noted. It is said, indeed, that if careful examination is made it will always be noted.
How Manipulative Treatment Benefits
Doubtless this proved that accidental manipulations of the ribs helps clear up the congestion about the real consolidation and reduces some of the dull area. Very likely this explains some of the cases of partial or real results from spondylotherapy. Naturally, scientific osteopathic treatment would necessarily magnify such results very much.
It is a great wonder with the obvious failure of medical treatment in pneumonia, that at least some crude from of manipulative treatment has not been devised by those practitioners. We have already mentioned that the treatment of post-operative cases varies mainly in the manner of applying it. In other words, when we raise the ribs we keep the patient on his back, in treating the spinal centers we treat with patient on his back, and the physician who has no grip in his hands will not be able to treat a post-operative pneumonia to any advantage.
In these cases one has to get at the patient’s back by reaching under and the weight of the patient helps to give the treatment, but a strong grip is necessary. It is much safer for the wound to handle the patient in this way but not infrequently beginners wear their knuckles pretty nearly off before they get the finer technique; after which it is easy. In raising the ribs there is no more difficulty in treating in this position than there is with a patient who can sit up or turn from side to side and in some cases a patient can, of course, be partially turned.
Theory is all right but in these cases practice has been added to it in something over three hundred cases treated in this manner, and in this manner only. I have had no case die. None of my cases had oxygen and none of them had strychnin or alcohol unless it was a person who had used alcohol constantly or daily and in these cases I consider that the system has become sufficiently used to it that it is practically a food and that sudden withdrawal is apt to bring on delirium. It is not necessary in those cases that indulge deeply now and then, but it is advisable in those that take a small amount regularly, just as they take food. These patients are used to a constant heart stimulant and its withdrawal is also apt to be reflected in the heart action. These are the only cases in which I have ever authorized anything in the way of a chemical stimulant of the heart during pneumonia.
You will undoubtedly recall that in reading the newspaper accounts of men who are big enough and prominent enough to have bulletins in the newspapers when they are dying, that almost universally the next to the last bulletin was that oxygen is being administered. The last bulletin announces the time of death. You will also note that in case the patient lives that oxygen then is not mentioned, and a few days later the patient is all right. My observation is that the use of oxygen may attract the attention of the family, it may attract the attention of the patient, but as for any actual benefit on the patient I do not believe it is in the least helpful, and that the only treatment for pneumonia is osteopathic. I am so convinced of it that I am using only that method.
As to strychnin, some say strychnin must be given. Some say it must be given at the crisis, and others say it must be given from the inception of the disease. I do not believe the majority of cases will do as well under strychnin. I know they will not do as well under strychnin as under osteopathic treatment. I will not say they will not do as well as if under no treatment. It is possible that there would be an occasion for its use at the crisis, and I have seen such cases, and I have used it while studying medicine. I used it at the crisis, and I used it in cases where I am convinced that it helped them over the crisis, but I am also convinced now that by osteopathic treatment they would have done still better and the crisis would not have been so acute. In other words what strychnin does in favorable cases, osteopathic treatment does better in all cases.
In our post-operative cases study the charts and you will see that they do not have the acutely violent crisis that usually occurs under other treatment. They are under better control and if we can get them near the beginning, as we usually do, we can keep up the resistance so that where they would otherwise have a hard crisis they have an easy one. Instead of having a temperature of 105, pulse 165, respiration 70, or such a condition, they are more apt to run a temperature of 102, pulse 120, respiration 35 or 40 and they go through it without that suddenness and acuteness that is common under other methods of treatment.
In several instances, as an example of showing how this resistance is kept up, I had letters from boys in the camps. One letter told of a wide epidemic of severe tonsillitis. In one group of soldiers there were three osteopaths who treated all the men and this was the only group that was not sent to quarantine. This group developed sore throat and was treated osteopathically and the sore throats checked so that quarantine was unnecessary.
Among the detailed reports in the A. M. A. Journal there will be nothing about this, nor about many other instances where osteopathic treatment, given by men forced to remain in the ranks, has done things that medicine cannot do. These examples are too frequent to be coincidents. If I had had three cases of post-operative pneumonia and they had all got well, it would not be surprising. If I had ten cases and they all got well, there are medical hospitals that have been this lucky. But there are no medical hospitals in the world that can report one hundred cases or two hundred cases or three hundred with developed pneumonia and all lived. The percentage of pneumonia cases that die now in medical hospitals, is much less than formerly. But the cause of this is not vaccine, antitoxin or drugs. It is due to the fact that pneumonia cases now, like typhoid, are given very little medicine and are turned over to general nursing treatment; that is, in the best medical hospitals.
The mortality is in inverse ratio to the drugs given. The advance medical teaching is against so much drugs in pneumonia, though of course the hick doctors use it because they are practicing medicine of the by-gone age, before Andrew Taylor Still forced on the world the idea partly started by homeopathy, that the less drugs the better. Homeopathy failed in not quite discarding drugs and in not having a substitute that reproved drugs.
As a matter of interest I wish to mention that while in medical college I had the advantage of being taught surgery by the greatest surgeon that ever lived, John B. Murphy. I only wish that circumstances could have permitted me to have shown him what osteopathy could do in post-operative conditions, because Murphy was a broad minded man and no man living ever thought less of orthodox medicine and old fashioned drug treatment than Murphy.
He and the Old Doctor would have been great friends had they ever met. Murphy, whom I considered a most wonderful surgeon, and whose skill I never hope to approach, stated to me many times while a student that he lost more cases from post-operative pneumonia than any other condition and that in upper abdominal conditions like gall bladder, stomach, and similar operations, post-operative pneumonia constituted the most of his mortality.
This great man was afraid of post-operative pneumonia, while I, a much less skilled surgeon, am no more afraid of post-operative pneumonia than I am of something occurring in a distant state because with osteopathic treatment, we have eliminated post-operative pneumonia as a fatal condition.