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Early postoperative ambulation
EARLY POSTOPERATIVE AMBULATION* ARKELL
M.
VAUGHN,
M.D.,
WESLEY R.
ANTHONY
T.
C.
METZNER,
GUZAUSKAS,
M.D.
AND
M.D.
Chicago, Illinois
I
NTEREST in earIy ambulation has been aroused among surgeons since Leithauser and Bergo’s’ revivaI of the subject in 1941. Like a11 new procedures, the penduIum of enthusiasm is apt to swing too far in one direction at first and then too far in the other direction Iater. But in the course of a few years it settIes down to a norma tempo. A great amount of enthusiasm for the procedure has been stimuIated in the past severa years in civiIian practice by the shortage of nursing care and hospital beds. In an attempt to evaIuate the procedure in our general surgica1 service at Mercy Hospital, the senior author aIIowed IOO selected private surgical patients to arise on an average of 2.3 days foIIowing various surgica1 procedures. There were eight compIications in six patients but no deaths in this series, the results of which are pubIished eIsewhere.2 Since these were selected cases without a contro1 series, we decided to enIarge the series and incIude an equa1 number of contro1 cases. During this period the senior author was seized with an acute attack of appendicitis requiring an emergency appendectomy. He arose on the first postoperative day and made persona1 observations which have assisted him in evaIuating the procedure. This paper is based on 135 earIy ambuIatory patients compared with 135 Iate ambulatory patients undergoing major surgica1 procedures of simiIar magnitude. EarIy ambuIation is not a new procedure. Dr. Ephraim McDoweI13 who performed the first successfu1 Iaparotomy in the United States in 1809 found his patient, Mrs. Crawford, up making her bed on the fifth postoperative day. In 1899 Dr. EmiI
J. Ries4 of Chicago advocated early ambuIation for his gynecologic patients. His patients arose from bed twenty-four hours to six days foIlowing vagina1 cehotomy. Observations recorded by him compare favorabIy with those of the present day, especiahy in reIation to bowel habits, appetite, earIy return of peristaItic sounds and diminished incidence of urinary retention. EarIy ambuIation was not popular in the United States foIIowing Ries’ articIe. However, since the Iate twenties articIes have appeared from European cIinics stressing its vaIue. The American Iiterature has numerous articIes upon the subject since Leithauser’s article in 1941.““‘~ There is no common definition for early ambuIation at present. IndividuaI standards as to time and physica energy have been set by various investigators. Newburger5 defines earIy postoperative ambuIation as follows: “A daiIy postoperative continuation of bodiIy activities, incIuding waIking (not just being pIaced in a chair), seIf-care in matters of toiIet, dressing, feeding and even actual gymnasticsdirected toward an uncompIicated and rapid convaIescence.” We have arbitrariIy set no Iater than the third postoperative day as the time Iimit for arising and actuaIIy waIking in this series. PHYSIOLOGY Normal thoracic motion and puImonary activity are restored by earIy ambuIation. The normaI vita1 capacity of the Iungs is restored and at the same time an increased negative pressure is produced in the Iarge venous vesseIs in the chest. Lowering of the
* From the Stritch SchooI of Medicine of LoyoIa University and Mercy Hospital, Chicago, III.
November,
I 950
523
Vaughn
524
et aI.-Early
diaphragm also aids in producing an increased negative pressure. This increased negative pressure in the chest augments the return venous flow and should theoreticaIly aid in preventing thrombosis in the extremities. In Iike manner, fuIl aera-
Ambulation postoperative days. (Tables I and II.) We attempted to maintain constant, as nearIy as possible, the type of operation and the atIe of the patient in our controI series so &at there- was inadvertentIy a smaI1 variation in the sex incidence.
TABLE ONE
HUNDRED
THIRTY-FIVE
AMBULATORY
Average Day of Ambulatior
St2X Types
I
EARLY
1
IMalt
I
Female
Male
Female
Thyroidectomy..
_.
Femoral.
28
I.7 2.08 2.6
33
2.7
44.9 2
3 4 16 1”
7 ,9
43.5
44.5
24.7 19.9 53 40.6
34.8 23.3 5”
22.-
32.5 68
;;
,4 3 . 2
3 t
36
z. 17 2
t&the1teriza-
tions
I .j
;
3
2
2. I 2.: I ,.:
2
*
44.4 5,
3
roo.4°F. IO, .PF. IO, .3%. 100.9%.
I.4 1.4 I .q 1.2
,“0.5%. I”“. 4%. 10,. 2%. IO,%.
1.9 2 2.1
I.,
L”0.7°F.
2.8
0
4.5 5.6 4.4
0
2
0
0
0
0
4.9 4.’ 4 4.3
0
3 0 2
3
;,
I 0 0 0 0
101
.6%. IO, .ZOF.
I.3 I
4.7 6
0 0
,0,.5%. 100.7%. IO,%. 102%. IO,%.
I I
I.5 ,.3 I I
IOI°F. 100°F. IoO*F. 101
.WF.
I
5.2.3 5
r
z
I
47
4,
6,
I I
I
42
I
65
34 55
3
3 I.2
2 2
. . . . I
3 2 I
0 0 I 0 0
4.5 2.7 7 10 xft hospital with temperature elevated
I.
78
57
-
2
35.5
36.4
2.02
-
tion of the Iungs and puImonary motion Iessen the possibIe occurrence of ateIectasis. SkeIetaI tone is restored earIy and muscular activity Iikewise increases the return venous ffow. By earIy ambuIation we hope to maintain a reIativeIy norma vasomotor baIance. CLINICAL
I
3 2. I
-
or average
2.
3
26
5
and cIosure of chole fist&.
.
45
4 I
post&o]
2.I
s I
1
Vagotomy Transthoracic Transabdominal. Transabdominal with gastroenterostomy Mastectomy.. Bowel obstruction.. Lumbar sympathectomy.. Pelvic Iaparotomy.
IVumbcr ol I?atients with tZomplications
Total
Day of Return t” Normal
_13 10
Ch0Iecystectomy..
Cholecystectomy and appendectomy Oophorectomy.. Appendectomy Acute......................... Interval. Gastroenterostomy Hysterectomy.. Herniorrhaohv Indirect &ui”al.. Direct inguinal., Umbilical.. . I ncisiona1.
-
Da:
‘Vial c
--
Total
Temperature Maxi,num Elevation
ol’ Cases Female
Cholecystectomy dochoduodenal
PATIENTS
OBSERVATIONS
In order to contribute toward the evaIuation of this procedure earIy ambuIation was empIoyed in 135 seIected patients on our genera1 surgical service at Mercy HospitaI and 135 comparabIe patients were kept non-ambulatory during the earIy
101
.PF.
-
-1
2. I
-
I
.~
1.5
loo.8°F.
-
0
4 _
0
.16
4.53 -
-
In summarizing the two series (Table the average day of ambuIation was approximateIy the second postoperative day in the earIy ambuIation cases as compared with aImost tI;e ninth postoperative day in the contro1 series. It is of interest to note that the average maximum temperature of the patients was entireIN uninfluenced by earIy ambuIation in our two series. We observed, aIso, that the average maximum temperature eIevation occurred during the latter haIf of the first postoperative day in both series and that the Iatter half of the fourth postoperative day was the average day of return to normaI III)
American
Journal
of Surgery
Vaughn
et al.-Early TABLE
ONE
HUNDRED
THIRTY-FIVE
Average Age
AMBULATORY
Average Day of Ambulation
IMale
--
Fe-
Male
Female
42.6
13 10 2
2 I
4
*
IO
13 21 I
8 I
8 1
16 3
I 2
Vagotomy Transthoracic. .................. Transabdominal. ................ Transabdominal with posterior gas troenterostomy ................ Mastectomy ....................... Bowel obstruction .................. Lumbarsympathectomy ............ PeIvic Iaparotomy ................. Cholecystojejunostomy .............
I
51.5
43.9 42.5 45
54
3
25.4 21.3
17.9 34
49
I
1 1 I
1.8 1.9
4.5 4.8 4
3 II 0
39
37.6 40
7
40 54.5 .
62
39
39 52.7
36.0
2.06
10 8
:xpired 8th postoperative day
November,
1950
35.0
1
8.8
3.5 2.0
II 3
0 I ,oI.~~F.
8.8
8.8
cl 3 0 0 2 0
?.8
100.6%. 102.0°F.
1.5 3 4 z 2 7
7.6 5 4 7
100.8%.
1.85
4.9
IO1 .OOF. 101.4°F.
32
-
III
I
I
Day of Maximum T emperature EIevation
I-Number
Day of Normal Temperature
1.5
4.53
IO
7
1
Ambulation
/
1
/
of
Patients with CompIications
Total Catheterizations
I 100.8”F.
/
7 I 0 0 0
3.5 5 5
CHART
Average Maximum Temperature
2.
1.1 2.3 2.0
IOO. 4%.
II
Non-early
1351
6.5
55
34.4
2 0
4 8.7
-,
I 2.02I
1
Ioo.4°F.
8.8 8
8.5
33
I
.4%.
9
45.8
35.6
I 00
0
z
-
Average Day of Ambulation
35.5 36.4
9.2 7.4 9
4 ‘9
. . .
23 35 72
49
0
I 00.4%.
.
TABLE
‘35
tions
7.4
40.3
SUMMARY
5;
:athe.
4.2 5.6 5.7 5.5
-
7t
NOP ma1
Jumber of ‘atients with Zompli:arions
Total
1.9 1.7 2.3 I.5
9.1 10
_
FemaIes. Males.
0
100.8%. 10, .6%. 100.8~~. 100.9%.
8.1
2 5
86
Age
Day
hy
Flerur to
6.6 12.9 9 9
ZI.2
I
2
_.
Average
Level
I
1t
_
I ,caI ....................... u mb’l’ Incisiona ....................... Femoral. .......................
Total Number of Patients
Temperature Maximum Elevation
-
Thyroidectomy. ................... Cholecystectomy ................... Cholecysrectomy and appendectomy. ..................... Ooph orectomy Appendectomy Acute .......................... Interval ............. , .......... Gastroenterostomy. ................ Hysterectomy Subtotal. ....................... Herniorrhaphy Indirect inguinal., ............... Direct inguinal.. ................
or average..
PATIENTS
-
of Cases Female
Total
425
II
NON-EARLY
Sex Types
Ambdation
(
Vaughn
526
et aI.-EarIy
temperature in both series. It may be noted from the summary chart (TabIe III) that there is onIy a minima1 favoring of the early ambuIation series in this respect. These findings are at variance with the report of Schafer and Dragstedt* who observed
-
Thyroidectomy Female 37 yr. Cholecystectomy Female 52 yr. Female 40 yr.
. .
ing confirms the observations made by Ries4 in 1899 and is at variance with findings recorded by Canavarro’O who found the number of catheterizations equal in his Iarger series of 401 cases with the same number of controk.
TABLE IV COMPLICATIONSIN 135 EARLY AMBULATORYPATIENTS -iAteIectasis or I ‘neumoniti (Postoperative Day)
Types of Cases
AmbuIation
PuImonary EmboIism (Postoperative Day)
ThrombophIebitis (Postoperxtive Day)
Phlebothrombosis (Postoperative Day)
!
Wound Infection (Postoperative Day)
Other Complications (Postoperative Day)
-Io
0
0
0
0
7th
0 0
Thyroid
storm
I st
0
0
0
0 0
5th 0
0 0
0 0
14th 0
0
0
0
11th
0
o
0
4th
0
0
0
0
5th
2nd 0
0 0
0 0
0 5th
0 0
2nd
0
0
0
0
2nd
14th
0
0
0
14th
6th
0
0
0
0
0
0
Reaction to penicillin 1st
2nd
0
0
0
0
0
0
0
0
0 0
Aqpe&ymy n Female 2 I yr . Female 19 yr. .I Acute MaIefoyr... Hysterectomy Female 40 yr. InguinaI herniorrhaphy Male6yr...... Vagotomy Transthoracic MaIe 52 yr. Male 50 yr. _. TransabdominaI Male 51 yr... Transabdominal with gastre enterostom? Y MaIe 25 yr. .’ Mastectomy FemaIe 57 yr. Bowel obstruction MaIe34yr..... Lumbar sympathectomy Male 55 yr.. . Pelvic laparotomy FemaIe 42 yr. . .
lowered maximum temperature and earher return to normaI temperature in a series of 103 earIy ambuIatory patients. There were seven catheterizations in the early ambulatory group as compared with thirty-two in the controI series. This find-
joth
-I
~
~
0
Nausea throughout in hospita1
course
i
There were eighteen complications in sixteen patients in the early ambuIatory group (TabIe IV) as compared with fortyfour comphcations in twenty-three patients in the controI group (TabIe v); or I 1.9 and 17 per cent, respectiveIy, of the American
Journal of Surgery
Vaughn
et al.-EarIy TABLE
COMPLICATIONS
A
.telectasis or PI leumoniti! ( Postopera tive Day)
Types of Cases
Thyroidectomy Female 32 yr.. Female 41 yr.. Female
AMBULATION
1
Phlebotl uombosis ( Postopera tive Day) -
CASES
Wound Infection Postopertive Day)
Other Complications (Postoperative Day)
‘haryngitis 3rd ‘eripheral neuritis I st; psychosis 1st 1hoIecystitis 1st; auricular fibrillation; depression 2nd
0 0
0
2nd 0
Cholecystectomy and appendectomy MaIe54yr..... Oophorectomy Female 23 yr. . Appendectomy Interval Female 19 yr. Female 27 yr. Male 15 yr.. . Male 31 yr.. . Herniorraphy Incisional Female 55 yr. Vagotomy Transthoracic Female 39 yr. Transabdominal Male62 yr...
0
0
Cerebral embolism; expired 2nd kin disruption 4th .eft brachial artery embolus 2nd sknin disruption 3rd
0
1st
0
0
0
tvisceration
0
0
0
0
0
0
0
0
0
10th
8th
4th 0
‘haryngitis 14th lystitis 4th
0
0
0
0
0
0
0
0
0
0
0
5th
0
0
0
0
9th
1st
0
0
0
6th
0
0
0
0
0
7th
0
1st
0
0
0
5th
2th
0
0
0
0
11th
0
0
8th
Cardiac pulmonary congestion and effusion 2nd; wound dehiscence 8th
.
0
4th
.. .
0
Urticaria 9th; pharyngitis 9th; bilateral pleurisy 16th Shock 1st Psychosis 1st and 2nd
Female 44 yr Male 37 yr.. . Transabdominal with gastro enterostom: Female 6o yr.
Female 50 yr. Female 70 yr.. Cholecystojejunostomy Female 70 yr.
Thrombophlebitis (Postoperative Day)
0
.
v
NON-EARLY
11th
MaIe36yr..... Female 64 yr.
Mastectomy Female 44 yr..
3
P‘ulmonary Embolism ; Postopera tive Day)
134
0
58 yr.
Cholecystectomy Female 49 yr. Female 59 yr..
-
IN
327
Ambdation
.
November, 1950
21st
13th 0
0
I
2th 0
I
0
0
7th
0
0
60th
0
0 0
4uricular librillation 3rd and 5th; regional pericarditis 3rd; superficial dehiscence 5th; cardiospasm 7th
Expired
8th
Vaughn
528
et al.-Early
patients in these groups had complications. Our statistics, however, indicate that of those patients having complications, the earIy ambulatory probabiIity is that patients wiII have approximateIy onIy one whereas Iate ambuIatory compIication patients wiI1 have approximateIy two compIications. An interesting observation was that there were three cases of puImonary emboIism, two of thrombophIebitis and two of phIebothrombosis in the earIy ambuIatory group as compared with one thrombophlebitis, one puImonary emboIism and no phlebothrombosis in the Iate ambuIatory group. There were no dehiscences, disruptions nor eviscerations and onIy four wound infections in the earIy ambuIatory group while there were three dehiscences, one disruption, one evisceration and eIeven wound infections in the contro1 group. OnIy one-haIf as many patients (four) had pulmonary compIications of ateIectasis or pneumonia in the early rising group as in the Iate rising group (eight patients). There were no deaths in the earIy ambuIatory group but there were two in the contro1 group, giving 0.73 per cent mortaIity for the entire two series. SURGICAL
TECHNIC
EMPLOYED
AI1 patients in both series were operated upon under genera1 or spina anesthesia. Sodium pentothal induction has been routinely empIoyed for genera1 anesthesia and curare used as necessary in both series for reIaxation. IntratracheaI anesthesia was empIoyed for the transthoracic procedures. The incisions were transrectus, pararectus, transverse and McBurney’s in the abdomen, and intercosta1 in the chest. Standard herniorrhaphy and radica1 mastectomy incisions were empIoyed. Catgut suture materia1 was used throughout except for skin cIosure. PIain No. o, was used for the doubIed, continuous, peritoneum, interrupted No. I chromic for the fascia, pIain No. o for the subcutaneous tissues and interrupted black siIk for the skin.
AmbuIation ADVANTAGES
OF
EARLY
AMBULATION
The foIIowing advantages are noted in the Iiterature and aIso were noted from our persona1 experiences : ( I ) increased wound heaIing; (2) reduction of wound infection, dehiscence and evisceration; (3) Iowered incidence of nausea, vomiting and abdomina distention; (4) earIy return of vasomotor balance; (5) earIier return of normal function of bIadder and bowel; (6) maintenance of norma muscIe tones; (7) psychologic effect on the patient’s morale and menta1 status; (8) acceIeration of convaIescence and reduction of compIications; (9) earIier return of working abiIity; (IO) economic saving to the patient and hospitaI; and (I I ) nursing care reduced which is especiaIIy desirabIe in this day of scarcity of nurses. CONTRAINDICATIONS
FOR
EARLY
AMBULATION
The contraindications for earIy ambuIation are : (I ) prolonged bed rest previous to surgery; (2) cardiac insufficiency; (3) recent coronary occIusion; (4) shock; (5) severe anemia; (6) hemorrhage or fear of hemorrhage; (7) suspected presence of thrombi or emboIi; (8) suppurative conditions such as peritonitis, pancreatitis and choIangitis; (9) insecure anastomosis, copious tamponade and di&uIt hernia repair; ( I o) avitaminosis ; (I I ) hypoproteinemia; and (I 2) severe abdomina1 distention. COMMENTS
At present we believe that good judgment must be exercised and each case individualized. EarIy ambuIation has its merits but in our experience it has not reduced the incidence of puImonary emboIism, phIebothrombosis and thrombophIebitis (three conditions for which earIy ambuIation was strongIy advocated in the past few years) as it was earlier hoped it wouId. There does seem, however, to be an improvement in wound healing and tensile wound strength by earIy ambuIation. This observation is supported experimentaIIy by American
Journal
of Surger_c
Vaughn
et aI.-Early
the work of Newburger and Kimbarovsky (cited by Leithauser),j who demonstrated that activity rather than immobihzation in experimental animaIs increased wound heaIing, and by the dog experiments of Royster, McCain and Sloan, l3 who reported actua1 measured tensile strength 5 to IO per cent stronger in the wounds of the exercised animaIs than in the contro1 immobiIized animaIs. Drye14 has demonstrated by human experiments with intra-abdominal baIIoons that early ambuIation does not increase abdomina1 tension significantly to be deleterious to the wound and pressures at Ieast five times as high are observed with such common invoIuntary acts as coughing or vomiting. There is noted aIso an appreciabIe difference in the number of wound infections in the two series, onIy four being among the earIy ambuIation cases as opposed to eIeven among the Iate rising cases. This might be attributed to better circulation in the wound area, assuming there is Iess opportunity for a bacterial growth-stimuIating medium as a stagnating vascuIar bed is eliminated. We aIIowed onIy certain patients with indirect inguina1 hernias to arise early and no patients with direct hernias when the study began. However, since the report of BIodgett and Beattie,15 who showed a Iower incidence of recurrence of direct hernias in earIy risers than non-earIy risers, we have aIIowed seIected patients with direct hernias to arise early, with no recurrences to our knowIedge to date. Our persona1 experience was an emergency appendectomy for an acute phIegmonous appendicitis. Ambulation was on the first postoperative day and incIuded waIking to the bathroom. A great dea1 of sharp abdomina1 pain was experienced upon the initial arising. This, however, diminished with each arising. A ScuItetus binder was found to be invaIuabIe and has been used on a11 our earIy ambulatory patients. WhiIe the skeIeta1 tone of the muscIes appeared to be we11 maintained, it
November, 1950
AmbuIation
529
was noted that one month and more Iater fatigue was very pronounced upon the Ieast exertion. At present we do not ambuIate a11 our patients early. The contraindications, age, type of patient and operative procedure influence our judgment. Most patients have to be urged to arise the first time but from then on many are rather desirous to continue earIy ambuIation. Some patients, however, are reIuctant even to attempt the procedure and resist repeated attempts at earIy arising. If patients do not arise during the first three days, we do not attempt to ambuIate them before the eighth to tenth days. SUMMARY I. One hundred thirty-five earIy ambuIatory cases from a private genera1 surgica1 service are compared with 135 simiIar but Iate ambuIatory cases. 2. EarIy ambuIation is defined as actua1 waIking by at Ieast the third postoperative day. The average was 2.06 days postoperativeIy in this series. 3. The average day of ambuIation for the contro1 group was 8.8 days postoperativeIy. 4. The average maximum temperature postoperativeIy was exactIy the same in both series, 100.8~~. 5. Very IittIe difference was noted between the two groups as to the time of occurrence of the maximum temperature and the day of return to norma temperature. 6. OnIy seven catheterizations were required in the earIy ambuIatory group whereas thirty-two catheterizations were required in the contro1 series. 7. EIeven and nine-tenths per cent of the earIy ambuIatory patients and 17 per cent of the Iate ambuIatory patients deveIoped complications but there were more than twice as many individua1 complications in the late ambuIatory group. 8. There were no deaths in the earIy ambuIatory group but two deaths in the control group. 9. PuImonary emboIism, thrombophIe-
Vaughn
530
et aI.-EarIy
bitis and phIebothrombosis were more prevalent postoperativeIy in the earIy ambulatory group. I o. Wound infections, dehiscences, disruptions and eviscerations were much more prevaIent compIications in the Iate ambuIatory group. I I. Pulmonary complications such as ateIectasis and pneumonia were twice as common (eight to four) in the Iate ambuIatory group. 12. The advantages and contraindications of earIy ambuIation are summarized. 13. The Scultetus binder affords a great amount of comfort, support and feeling of security to the early ambuIatory patient. 14. Catgut sutures are not a contraindication to earIy ambuIation. 15. According to this series the main advantages that can be anticipated by employing earIy ambulation judiciousIy in selected cases are apparentIy Iimited to reduction of the foIlowing: number of catheterizations, wound infections, disruptions and eviscerations, and incidence of postoperative complications, including pulmonary compIication (but not puImonary emboIi in this series). REFERENCES I. LEITHAUSER, D. J. and BERGO, H. L. EarIy rising
and ambuIatory activity after operation. Surg., 42: ro86rog3, 1941.
Arch.
AmbuIation 2. VAUGHN, A. M., GUZAUSKAS, A. C. and LAGORIO, F. A.. JR. Earlv ambulation in the sureical natient.. Illinois hi. J., 92: 337-340, 1947. 3. HAGGARD, W. D. Surgeon of the wiIderness: Ephraim McDoweII. Surg., Gynec. CT Oh., 58: 415, 1934. 4. RIES, E. J. Some radical changes in the after treatment of celiotomy cases. J. A. M. A., 33: 454456. 1899. 5. NEWBURGER, B. Postoperative care: early waIking; influence of exercise on wound heahng in rats. Surgery, 13: 692-695, 1943. 6. NIXON, J. W. Early postoperative walking. Soutb. M. J., 37: 682-687, 1944. 7. LEITHAUSER, D. J. Confinement to bed for only twenty-four hours after operation. Arch. Surg., 47: 203-215, ‘943. 8. SCHAFER. P. W. and DRAGSTEDT. L. R. EarIv rising, following major surgical operations. Surg., @rec. & Obst., 81: 9397, 1945. o. BURCH, J. C. and FISHER, H. C. Early ambuIation in abdomina1 surgery. Ann. Surg., 124: 791-798, 0
I
d
1946. IO. CANAVARRO, K. A review of 401 cases of early ambulation. Bull. New York Acad. Med., 22: 264-269, r 946. I I. CANAVARRO, K. EarIy postoperative ambulation. Ann. Surg., 124: 180-181, 1946. 12. Mendelsobn, S. N. Early walking after major gynecoIogic surgery. Am. J. Surg., 71: 614619,
1946.
13. ROYSTER, H. P., MCCAIN, I. and SLOAN, A. Wound healing in early ambuIation. Forum on Fundamental Surgical Problems, 33rd Annual CIinicaI Congress, Am. CoII. Surg., New York, September 9. ‘947. 14. DRYE, J. C. Study of intra-abdominal pressure in humans. Forum on FundamentaI SuraicaI Problems, 33rd Annual CIinical Congress, Am. COIL Surg., New York, September I I, 1947. 15. BLODGETT,JAMES B. and BEAT~IE, EDWARD J. The effect of early postoperative rising on the recurrence rate of hernia. Surg., Gynec. w Obst., 84: r * 716-718, 1947.
American
Journal of Surgery
M.
VAUGHN,
M.D.,
WESLEY R.
ANTHONY
T.
C.
METZNER,
GUZAUSKAS,
M.D.
AND
M.D.
Chicago, Illinois
I
NTEREST in earIy ambulation has been aroused among surgeons since Leithauser and Bergo’s’ revivaI of the subject in 1941. Like a11 new procedures, the penduIum of enthusiasm is apt to swing too far in one direction at first and then too far in the other direction Iater. But in the course of a few years it settIes down to a norma tempo. A great amount of enthusiasm for the procedure has been stimuIated in the past severa years in civiIian practice by the shortage of nursing care and hospital beds. In an attempt to evaIuate the procedure in our general surgica1 service at Mercy Hospital, the senior author aIIowed IOO selected private surgical patients to arise on an average of 2.3 days foIIowing various surgica1 procedures. There were eight compIications in six patients but no deaths in this series, the results of which are pubIished eIsewhere.2 Since these were selected cases without a contro1 series, we decided to enIarge the series and incIude an equa1 number of contro1 cases. During this period the senior author was seized with an acute attack of appendicitis requiring an emergency appendectomy. He arose on the first postoperative day and made persona1 observations which have assisted him in evaIuating the procedure. This paper is based on 135 earIy ambuIatory patients compared with 135 Iate ambulatory patients undergoing major surgica1 procedures of simiIar magnitude. EarIy ambuIation is not a new procedure. Dr. Ephraim McDoweI13 who performed the first successfu1 Iaparotomy in the United States in 1809 found his patient, Mrs. Crawford, up making her bed on the fifth postoperative day. In 1899 Dr. EmiI
J. Ries4 of Chicago advocated early ambuIation for his gynecologic patients. His patients arose from bed twenty-four hours to six days foIlowing vagina1 cehotomy. Observations recorded by him compare favorabIy with those of the present day, especiahy in reIation to bowel habits, appetite, earIy return of peristaItic sounds and diminished incidence of urinary retention. EarIy ambuIation was not popular in the United States foIIowing Ries’ articIe. However, since the Iate twenties articIes have appeared from European cIinics stressing its vaIue. The American Iiterature has numerous articIes upon the subject since Leithauser’s article in 1941.““‘~ There is no common definition for early ambuIation at present. IndividuaI standards as to time and physica energy have been set by various investigators. Newburger5 defines earIy postoperative ambuIation as follows: “A daiIy postoperative continuation of bodiIy activities, incIuding waIking (not just being pIaced in a chair), seIf-care in matters of toiIet, dressing, feeding and even actual gymnasticsdirected toward an uncompIicated and rapid convaIescence.” We have arbitrariIy set no Iater than the third postoperative day as the time Iimit for arising and actuaIIy waIking in this series. PHYSIOLOGY Normal thoracic motion and puImonary activity are restored by earIy ambuIation. The normaI vita1 capacity of the Iungs is restored and at the same time an increased negative pressure is produced in the Iarge venous vesseIs in the chest. Lowering of the
* From the Stritch SchooI of Medicine of LoyoIa University and Mercy Hospital, Chicago, III.
November,
I 950
523
Vaughn
524
et aI.-Early
diaphragm also aids in producing an increased negative pressure. This increased negative pressure in the chest augments the return venous flow and should theoreticaIly aid in preventing thrombosis in the extremities. In Iike manner, fuIl aera-
Ambulation postoperative days. (Tables I and II.) We attempted to maintain constant, as nearIy as possible, the type of operation and the atIe of the patient in our controI series so &at there- was inadvertentIy a smaI1 variation in the sex incidence.
TABLE ONE
HUNDRED
THIRTY-FIVE
AMBULATORY
Average Day of Ambulatior
St2X Types
I
EARLY
1
IMalt
I
Female
Male
Female
Thyroidectomy..
_.
Femoral.
28
I.7 2.08 2.6
33
2.7
44.9 2
3 4 16 1”
7 ,9
43.5
44.5
24.7 19.9 53 40.6
34.8 23.3 5”
22.-
32.5 68
;;
,4 3 . 2
3 t
36
z. 17 2
t&the1teriza-
tions
I .j
;
3
2
2. I 2.: I ,.:
2
*
44.4 5,
3
roo.4°F. IO, .PF. IO, .3%. 100.9%.
I.4 1.4 I .q 1.2
,“0.5%. I”“. 4%. 10,. 2%. IO,%.
1.9 2 2.1
I.,
L”0.7°F.
2.8
0
4.5 5.6 4.4
0
2
0
0
0
0
4.9 4.’ 4 4.3
0
3 0 2
3
;,
I 0 0 0 0
101
.6%. IO, .ZOF.
I.3 I
4.7 6
0 0
,0,.5%. 100.7%. IO,%. 102%. IO,%.
I I
I.5 ,.3 I I
IOI°F. 100°F. IoO*F. 101
.WF.
I
5.2.3 5
r
z
I
47
4,
6,
I I
I
42
I
65
34 55
3
3 I.2
2 2
. . . . I
3 2 I
0 0 I 0 0
4.5 2.7 7 10 xft hospital with temperature elevated
I.
78
57
-
2
35.5
36.4
2.02
-
tion of the Iungs and puImonary motion Iessen the possibIe occurrence of ateIectasis. SkeIetaI tone is restored earIy and muscular activity Iikewise increases the return venous ffow. By earIy ambuIation we hope to maintain a reIativeIy norma vasomotor baIance. CLINICAL
I
3 2. I
-
or average
2.
3
26
5
and cIosure of chole fist&.
.
45
4 I
post&o]
2.I
s I
1
Vagotomy Transthoracic Transabdominal. Transabdominal with gastroenterostomy Mastectomy.. Bowel obstruction.. Lumbar sympathectomy.. Pelvic Iaparotomy.
IVumbcr ol I?atients with tZomplications
Total
Day of Return t” Normal
_13 10
Ch0Iecystectomy..
Cholecystectomy and appendectomy Oophorectomy.. Appendectomy Acute......................... Interval. Gastroenterostomy Hysterectomy.. Herniorrhaohv Indirect &ui”al.. Direct inguinal., Umbilical.. . I ncisiona1.
-
Da:
‘Vial c
--
Total
Temperature Maxi,num Elevation
ol’ Cases Female
Cholecystectomy dochoduodenal
PATIENTS
OBSERVATIONS
In order to contribute toward the evaIuation of this procedure earIy ambuIation was empIoyed in 135 seIected patients on our genera1 surgical service at Mercy HospitaI and 135 comparabIe patients were kept non-ambulatory during the earIy
101
.PF.
-
-1
2. I
-
I
.~
1.5
loo.8°F.
-
0
4 _
0
.16
4.53 -
-
In summarizing the two series (Table the average day of ambuIation was approximateIy the second postoperative day in the earIy ambuIation cases as compared with aImost tI;e ninth postoperative day in the contro1 series. It is of interest to note that the average maximum temperature of the patients was entireIN uninfluenced by earIy ambuIation in our two series. We observed, aIso, that the average maximum temperature eIevation occurred during the latter haIf of the first postoperative day in both series and that the Iatter half of the fourth postoperative day was the average day of return to normaI III)
American
Journal
of Surgery
Vaughn
et al.-Early TABLE
ONE
HUNDRED
THIRTY-FIVE
Average Age
AMBULATORY
Average Day of Ambulation
IMale
--
Fe-
Male
Female
42.6
13 10 2
2 I
4
*
IO
13 21 I
8 I
8 1
16 3
I 2
Vagotomy Transthoracic. .................. Transabdominal. ................ Transabdominal with posterior gas troenterostomy ................ Mastectomy ....................... Bowel obstruction .................. Lumbarsympathectomy ............ PeIvic Iaparotomy ................. Cholecystojejunostomy .............
I
51.5
43.9 42.5 45
54
3
25.4 21.3
17.9 34
49
I
1 1 I
1.8 1.9
4.5 4.8 4
3 II 0
39
37.6 40
7
40 54.5 .
62
39
39 52.7
36.0
2.06
10 8
:xpired 8th postoperative day
November,
1950
35.0
1
8.8
3.5 2.0
II 3
0 I ,oI.~~F.
8.8
8.8
cl 3 0 0 2 0
?.8
100.6%. 102.0°F.
1.5 3 4 z 2 7
7.6 5 4 7
100.8%.
1.85
4.9
IO1 .OOF. 101.4°F.
32
-
III
I
I
Day of Maximum T emperature EIevation
I-Number
Day of Normal Temperature
1.5
4.53
IO
7
1
Ambulation
/
1
/
of
Patients with CompIications
Total Catheterizations
I 100.8”F.
/
7 I 0 0 0
3.5 5 5
CHART
Average Maximum Temperature
2.
1.1 2.3 2.0
IOO. 4%.
II
Non-early
1351
6.5
55
34.4
2 0
4 8.7
-,
I 2.02I
1
Ioo.4°F.
8.8 8
8.5
33
I
.4%.
9
45.8
35.6
I 00
0
z
-
Average Day of Ambulation
35.5 36.4
9.2 7.4 9
4 ‘9
. . .
23 35 72
49
0
I 00.4%.
.
TABLE
‘35
tions
7.4
40.3
SUMMARY
5;
:athe.
4.2 5.6 5.7 5.5
-
7t
NOP ma1
Jumber of ‘atients with Zompli:arions
Total
1.9 1.7 2.3 I.5
9.1 10
_
FemaIes. Males.
0
100.8%. 10, .6%. 100.8~~. 100.9%.
8.1
2 5
86
Age
Day
hy
Flerur to
6.6 12.9 9 9
ZI.2
I
2
_.
Average
Level
I
1t
_
I ,caI ....................... u mb’l’ Incisiona ....................... Femoral. .......................
Total Number of Patients
Temperature Maximum Elevation
-
Thyroidectomy. ................... Cholecystectomy ................... Cholecysrectomy and appendectomy. ..................... Ooph orectomy Appendectomy Acute .......................... Interval ............. , .......... Gastroenterostomy. ................ Hysterectomy Subtotal. ....................... Herniorrhaphy Indirect inguinal., ............... Direct inguinal.. ................
or average..
PATIENTS
-
of Cases Female
Total
425
II
NON-EARLY
Sex Types
Ambdation
(
Vaughn
526
et aI.-EarIy
temperature in both series. It may be noted from the summary chart (TabIe III) that there is onIy a minima1 favoring of the early ambuIation series in this respect. These findings are at variance with the report of Schafer and Dragstedt* who observed
-
Thyroidectomy Female 37 yr. Cholecystectomy Female 52 yr. Female 40 yr.
. .
ing confirms the observations made by Ries4 in 1899 and is at variance with findings recorded by Canavarro’O who found the number of catheterizations equal in his Iarger series of 401 cases with the same number of controk.
TABLE IV COMPLICATIONSIN 135 EARLY AMBULATORYPATIENTS -iAteIectasis or I ‘neumoniti (Postoperative Day)
Types of Cases
AmbuIation
PuImonary EmboIism (Postoperative Day)
ThrombophIebitis (Postoperxtive Day)
Phlebothrombosis (Postoperative Day)
!
Wound Infection (Postoperative Day)
Other Complications (Postoperative Day)
-Io
0
0
0
0
7th
0 0
Thyroid
storm
I st
0
0
0
0 0
5th 0
0 0
0 0
14th 0
0
0
0
11th
0
o
0
4th
0
0
0
0
5th
2nd 0
0 0
0 0
0 5th
0 0
2nd
0
0
0
0
2nd
14th
0
0
0
14th
6th
0
0
0
0
0
0
Reaction to penicillin 1st
2nd
0
0
0
0
0
0
0
0
0 0
Aqpe&ymy n Female 2 I yr . Female 19 yr. .I Acute MaIefoyr... Hysterectomy Female 40 yr. InguinaI herniorrhaphy Male6yr...... Vagotomy Transthoracic MaIe 52 yr. Male 50 yr. _. TransabdominaI Male 51 yr... Transabdominal with gastre enterostom? Y MaIe 25 yr. .’ Mastectomy FemaIe 57 yr. Bowel obstruction MaIe34yr..... Lumbar sympathectomy Male 55 yr.. . Pelvic laparotomy FemaIe 42 yr. . .
lowered maximum temperature and earher return to normaI temperature in a series of 103 earIy ambuIatory patients. There were seven catheterizations in the early ambulatory group as compared with thirty-two in the controI series. This find-
joth
-I
~
~
0
Nausea throughout in hospita1
course
i
There were eighteen complications in sixteen patients in the early ambuIatory group (TabIe IV) as compared with fortyfour comphcations in twenty-three patients in the controI group (TabIe v); or I 1.9 and 17 per cent, respectiveIy, of the American
Journal of Surgery
Vaughn
et al.-EarIy TABLE
COMPLICATIONS
A
.telectasis or PI leumoniti! ( Postopera tive Day)
Types of Cases
Thyroidectomy Female 32 yr.. Female 41 yr.. Female
AMBULATION
1
Phlebotl uombosis ( Postopera tive Day) -
CASES
Wound Infection Postopertive Day)
Other Complications (Postoperative Day)
‘haryngitis 3rd ‘eripheral neuritis I st; psychosis 1st 1hoIecystitis 1st; auricular fibrillation; depression 2nd
0 0
0
2nd 0
Cholecystectomy and appendectomy MaIe54yr..... Oophorectomy Female 23 yr. . Appendectomy Interval Female 19 yr. Female 27 yr. Male 15 yr.. . Male 31 yr.. . Herniorraphy Incisional Female 55 yr. Vagotomy Transthoracic Female 39 yr. Transabdominal Male62 yr...
0
0
Cerebral embolism; expired 2nd kin disruption 4th .eft brachial artery embolus 2nd sknin disruption 3rd
0
1st
0
0
0
tvisceration
0
0
0
0
0
0
0
0
0
10th
8th
4th 0
‘haryngitis 14th lystitis 4th
0
0
0
0
0
0
0
0
0
0
0
5th
0
0
0
0
9th
1st
0
0
0
6th
0
0
0
0
0
7th
0
1st
0
0
0
5th
2th
0
0
0
0
11th
0
0
8th
Cardiac pulmonary congestion and effusion 2nd; wound dehiscence 8th
.
0
4th
.. .
0
Urticaria 9th; pharyngitis 9th; bilateral pleurisy 16th Shock 1st Psychosis 1st and 2nd
Female 44 yr Male 37 yr.. . Transabdominal with gastro enterostom: Female 6o yr.
Female 50 yr. Female 70 yr.. Cholecystojejunostomy Female 70 yr.
Thrombophlebitis (Postoperative Day)
0
.
v
NON-EARLY
11th
MaIe36yr..... Female 64 yr.
Mastectomy Female 44 yr..
3
P‘ulmonary Embolism ; Postopera tive Day)
134
0
58 yr.
Cholecystectomy Female 49 yr. Female 59 yr..
-
IN
327
Ambdation
.
November, 1950
21st
13th 0
0
I
2th 0
I
0
0
7th
0
0
60th
0
0 0
4uricular librillation 3rd and 5th; regional pericarditis 3rd; superficial dehiscence 5th; cardiospasm 7th
Expired
8th
Vaughn
528
et al.-Early
patients in these groups had complications. Our statistics, however, indicate that of those patients having complications, the earIy ambulatory probabiIity is that patients wiII have approximateIy onIy one whereas Iate ambuIatory compIication patients wiI1 have approximateIy two compIications. An interesting observation was that there were three cases of puImonary emboIism, two of thrombophIebitis and two of phIebothrombosis in the earIy ambuIatory group as compared with one thrombophlebitis, one puImonary emboIism and no phlebothrombosis in the Iate ambuIatory group. There were no dehiscences, disruptions nor eviscerations and onIy four wound infections in the earIy ambuIatory group while there were three dehiscences, one disruption, one evisceration and eIeven wound infections in the contro1 group. OnIy one-haIf as many patients (four) had pulmonary compIications of ateIectasis or pneumonia in the early rising group as in the Iate rising group (eight patients). There were no deaths in the earIy ambuIatory group but there were two in the contro1 group, giving 0.73 per cent mortaIity for the entire two series. SURGICAL
TECHNIC
EMPLOYED
AI1 patients in both series were operated upon under genera1 or spina anesthesia. Sodium pentothal induction has been routinely empIoyed for genera1 anesthesia and curare used as necessary in both series for reIaxation. IntratracheaI anesthesia was empIoyed for the transthoracic procedures. The incisions were transrectus, pararectus, transverse and McBurney’s in the abdomen, and intercosta1 in the chest. Standard herniorrhaphy and radica1 mastectomy incisions were empIoyed. Catgut suture materia1 was used throughout except for skin cIosure. PIain No. o, was used for the doubIed, continuous, peritoneum, interrupted No. I chromic for the fascia, pIain No. o for the subcutaneous tissues and interrupted black siIk for the skin.
AmbuIation ADVANTAGES
OF
EARLY
AMBULATION
The foIIowing advantages are noted in the Iiterature and aIso were noted from our persona1 experiences : ( I ) increased wound heaIing; (2) reduction of wound infection, dehiscence and evisceration; (3) Iowered incidence of nausea, vomiting and abdomina distention; (4) earIy return of vasomotor balance; (5) earIier return of normal function of bIadder and bowel; (6) maintenance of norma muscIe tones; (7) psychologic effect on the patient’s morale and menta1 status; (8) acceIeration of convaIescence and reduction of compIications; (9) earIier return of working abiIity; (IO) economic saving to the patient and hospitaI; and (I I ) nursing care reduced which is especiaIIy desirabIe in this day of scarcity of nurses. CONTRAINDICATIONS
FOR
EARLY
AMBULATION
The contraindications for earIy ambuIation are : (I ) prolonged bed rest previous to surgery; (2) cardiac insufficiency; (3) recent coronary occIusion; (4) shock; (5) severe anemia; (6) hemorrhage or fear of hemorrhage; (7) suspected presence of thrombi or emboIi; (8) suppurative conditions such as peritonitis, pancreatitis and choIangitis; (9) insecure anastomosis, copious tamponade and di&uIt hernia repair; ( I o) avitaminosis ; (I I ) hypoproteinemia; and (I 2) severe abdomina1 distention. COMMENTS
At present we believe that good judgment must be exercised and each case individualized. EarIy ambuIation has its merits but in our experience it has not reduced the incidence of puImonary emboIism, phIebothrombosis and thrombophIebitis (three conditions for which earIy ambuIation was strongIy advocated in the past few years) as it was earlier hoped it wouId. There does seem, however, to be an improvement in wound healing and tensile wound strength by earIy ambuIation. This observation is supported experimentaIIy by American
Journal
of Surger_c
Vaughn
et aI.-Early
the work of Newburger and Kimbarovsky (cited by Leithauser),j who demonstrated that activity rather than immobihzation in experimental animaIs increased wound heaIing, and by the dog experiments of Royster, McCain and Sloan, l3 who reported actua1 measured tensile strength 5 to IO per cent stronger in the wounds of the exercised animaIs than in the contro1 immobiIized animaIs. Drye14 has demonstrated by human experiments with intra-abdominal baIIoons that early ambuIation does not increase abdomina1 tension significantly to be deleterious to the wound and pressures at Ieast five times as high are observed with such common invoIuntary acts as coughing or vomiting. There is noted aIso an appreciabIe difference in the number of wound infections in the two series, onIy four being among the earIy ambuIation cases as opposed to eIeven among the Iate rising cases. This might be attributed to better circulation in the wound area, assuming there is Iess opportunity for a bacterial growth-stimuIating medium as a stagnating vascuIar bed is eliminated. We aIIowed onIy certain patients with indirect inguina1 hernias to arise early and no patients with direct hernias when the study began. However, since the report of BIodgett and Beattie,15 who showed a Iower incidence of recurrence of direct hernias in earIy risers than non-earIy risers, we have aIIowed seIected patients with direct hernias to arise early, with no recurrences to our knowIedge to date. Our persona1 experience was an emergency appendectomy for an acute phIegmonous appendicitis. Ambulation was on the first postoperative day and incIuded waIking to the bathroom. A great dea1 of sharp abdomina1 pain was experienced upon the initial arising. This, however, diminished with each arising. A ScuItetus binder was found to be invaIuabIe and has been used on a11 our earIy ambulatory patients. WhiIe the skeIeta1 tone of the muscIes appeared to be we11 maintained, it
November, 1950
AmbuIation
529
was noted that one month and more Iater fatigue was very pronounced upon the Ieast exertion. At present we do not ambuIate a11 our patients early. The contraindications, age, type of patient and operative procedure influence our judgment. Most patients have to be urged to arise the first time but from then on many are rather desirous to continue earIy ambuIation. Some patients, however, are reIuctant even to attempt the procedure and resist repeated attempts at earIy arising. If patients do not arise during the first three days, we do not attempt to ambuIate them before the eighth to tenth days. SUMMARY I. One hundred thirty-five earIy ambuIatory cases from a private genera1 surgica1 service are compared with 135 simiIar but Iate ambuIatory cases. 2. EarIy ambuIation is defined as actua1 waIking by at Ieast the third postoperative day. The average was 2.06 days postoperativeIy in this series. 3. The average day of ambuIation for the contro1 group was 8.8 days postoperativeIy. 4. The average maximum temperature postoperativeIy was exactIy the same in both series, 100.8~~. 5. Very IittIe difference was noted between the two groups as to the time of occurrence of the maximum temperature and the day of return to norma temperature. 6. OnIy seven catheterizations were required in the earIy ambuIatory group whereas thirty-two catheterizations were required in the contro1 series. 7. EIeven and nine-tenths per cent of the earIy ambuIatory patients and 17 per cent of the Iate ambuIatory patients deveIoped complications but there were more than twice as many individua1 complications in the late ambuIatory group. 8. There were no deaths in the earIy ambuIatory group but two deaths in the control group. 9. PuImonary emboIism, thrombophIe-
Vaughn
530
et aI.-EarIy
bitis and phIebothrombosis were more prevalent postoperativeIy in the earIy ambulatory group. I o. Wound infections, dehiscences, disruptions and eviscerations were much more prevaIent compIications in the Iate ambuIatory group. I I. Pulmonary complications such as ateIectasis and pneumonia were twice as common (eight to four) in the Iate ambuIatory group. 12. The advantages and contraindications of earIy ambuIation are summarized. 13. The Scultetus binder affords a great amount of comfort, support and feeling of security to the early ambuIatory patient. 14. Catgut sutures are not a contraindication to earIy ambuIation. 15. According to this series the main advantages that can be anticipated by employing earIy ambulation judiciousIy in selected cases are apparentIy Iimited to reduction of the foIlowing: number of catheterizations, wound infections, disruptions and eviscerations, and incidence of postoperative complications, including pulmonary compIication (but not puImonary emboIi in this series). REFERENCES I. LEITHAUSER, D. J. and BERGO, H. L. EarIy rising
and ambuIatory activity after operation. Surg., 42: ro86rog3, 1941.
Arch.
AmbuIation 2. VAUGHN, A. M., GUZAUSKAS, A. C. and LAGORIO, F. A.. JR. Earlv ambulation in the sureical natient.. Illinois hi. J., 92: 337-340, 1947. 3. HAGGARD, W. D. Surgeon of the wiIderness: Ephraim McDoweII. Surg., Gynec. CT Oh., 58: 415, 1934. 4. RIES, E. J. Some radical changes in the after treatment of celiotomy cases. J. A. M. A., 33: 454456. 1899. 5. NEWBURGER, B. Postoperative care: early waIking; influence of exercise on wound heahng in rats. Surgery, 13: 692-695, 1943. 6. NIXON, J. W. Early postoperative walking. Soutb. M. J., 37: 682-687, 1944. 7. LEITHAUSER, D. J. Confinement to bed for only twenty-four hours after operation. Arch. Surg., 47: 203-215, ‘943. 8. SCHAFER. P. W. and DRAGSTEDT. L. R. EarIv rising, following major surgical operations. Surg., @rec. & Obst., 81: 9397, 1945. o. BURCH, J. C. and FISHER, H. C. Early ambuIation in abdomina1 surgery. Ann. Surg., 124: 791-798, 0
I
d
1946. IO. CANAVARRO, K. A review of 401 cases of early ambulation. Bull. New York Acad. Med., 22: 264-269, r 946. I I. CANAVARRO, K. EarIy postoperative ambulation. Ann. Surg., 124: 180-181, 1946. 12. Mendelsobn, S. N. Early walking after major gynecoIogic surgery. Am. J. Surg., 71: 614619,
1946.
13. ROYSTER, H. P., MCCAIN, I. and SLOAN, A. Wound healing in early ambuIation. Forum on Fundamental Surgical Problems, 33rd Annual CIinicaI Congress, Am. CoII. Surg., New York, September 9. ‘947. 14. DRYE, J. C. Study of intra-abdominal pressure in humans. Forum on FundamentaI SuraicaI Problems, 33rd Annual CIinical Congress, Am. COIL Surg., New York, September I I, 1947. 15. BLODGETT,JAMES B. and BEAT~IE, EDWARD J. The effect of early postoperative rising on the recurrence rate of hernia. Surg., Gynec. w Obst., 84: r * 716-718, 1947.
American
Journal of Surgery