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Early Movement, Early Rising, and EarlyDischarge

THE LANCETLONDON : : SATURDAY, JAN. 13, 1951

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WHEN a method has been practised for over fiftyyears, it can scarcely be considered new and revolu-tionary. But the number of surgeons who favoured

early ambulation has until lately been small-toosmall. Only gradually have we returned from post-Listerian complacency to physiological sanity. LISTER’sfollowers, reared on the teaching of bacteriology andimmunity, seemed to look on Nature as an amiablehalf-wit who must be prevented from ruining theiroperations. It took the impact of a world war ona generation not yet steeped in orthodoxy to bringback the outlook of HUNTER, and indeed of LISTERhimself,that Nature’smethods, perfected over millions ofcenturies, are always purposeful and nearly always right.For the past thirty years at any rate most surgeons

have believed that the less an operation is allowed tointerfere with the normal tenor of a patient’s life the

quicker and the more complete will be his recovery.Those who pass from belief to action-and it is a bigstep-permit their patients after operation to assumeany attitude in bed they prefer, make them breathedeeply and move their arms and legs as soon as theyare conscious, encourage them to sit on the edge ofthe bed to urinate and on a commode to defaecate,and urge them to get out of bed when the spirit movesthem, the sooner the better. But this advance in

practice, like all advances not conducted on the

parade-ground, has been on an uneven front. Some runahead, perhaps too far. In 1946 LEITHAUSER, whoseearly experience seems to have been among colleaguessomewhat behind the times, suddenly saw the light,and, like many repentant converts, rushed ahead ofthe preacher. Not merely did he push patients outof bed as soon as they were conscious ; he pushedthem out of hospital as soon as they could totter.Others still lag behind. One surprising fact emergingfrom the papers we published last week by Dr.GOODALL and by Dr. PAYLING WRIGHT and her

colleagues, is the extent to which conservative

practices still linger. Dr. GOODALL states that " inthe great majority of wards studied, the normal

practice still approximates much more closely toa traditional than to an early ambulation regime."Taking an average of 155 patients in general surgicalwards, he found that only about 30% were fullyambulant in contrast to nearly 50% who might havebeen. Dr. WRIGHT’S paper deals largely with gynae-cological cases, but it is interesting to note that in 3of the 4 gastrectomies and all the 3 hernia operationsincluded in her series the patients were still in bedafter ten days.When should a surgical patient become ambulant

-i.e., walk round the ward ? Surely not as soon

as he recovers from the anaesthetic. He can be hustledout of bed at this stage by the taunts, exhortations,and hot-gospelhng of house-officers, sisters, andphysiotherapists ; but how he hates it ! Naturaldesires are a sure guide to procedure in most things

-certainly in the selection of diet and the choicebetween activity and rest. The chief need in theimmediate postoperative period is that the process ofhealing in recently divided and resutured tissuesshall not be prejudiced. The arrest of capillaryhaemorrhage, the sealing of spaces, the knitting ofgaps by fibroblasts, and the bridging of incisions byepithelial cells-all these require rest, complete anduninterrupted, to the injured part, though to that

part alone. This can be attained only by rest in bed,while deep breathing and leg exercises are carried outunder the supervision of the physiotherapist. Afterfour days the wound is safe against lesser strains,and it will be protected from major ones by nociceptivereflexes that do not reach the level of conscious pain.The worst strains to which a recently repaired surgicalwound can be subjected are those of coughing and theuse of the bedpan. On the fourth day the sensible andcooperative patient welcomes the first steps to a chair,and Dr. WRIGHT shows that it is physiologicallywise for him to do so, since he has arrived at the

point where further recumbency would lead to venousstasis. The main danger of the postoperative periodis venous thrombosis, of which venous stasis is

undoubtedly a major cause, and the infarction andembolism that may follow. Of interest in this con-nection is Dr. WRIGHT’S observation that whereasthe average rate of flow in the veins of arms and

legs, as measured by the transit of radioactive salinesolution, was accelerated in both her groups duringthe first four days, it was considerably slowed afterthat time in the non-ambulant group and did notreturn to normal till after three weeks, whereas inthe ambulant group it was above the preoperativerate during the whole of this period.

Dr. GOODALL points out that a policy of earlyambulation, adopted universally, would add 10-20%to the effective capacity of a hospital and would reducegreatly the call on nurses’ time ; though it wouldalso necessitate an increase in basins, water-closets,and day space. But he does not suggest, as doesLEITHAUSER who records an average stay of 1’9

days in hospital following interval appendicectomy,that patients, having been got up, should be got out.It is essential to good surgery that a patient shouldremain under constant skilled supervision until thechance of any systemic or local complication is wellpast-i.e., for a minimum period of ten days in almostany surgical condition serious enough to demand

hospital treatment. A visit to a clinic where earlydischarge is the rule quickly reveals that it leads togreater waste of beds, for the second and subsequentadmissions take more bed-days and involve more

paper work than retention till the patient is well.

Hasty discharge also leads to increased morbidity,and often to a lamentable end-result.

Laboratory Study of Starvation in VolunteersIN the last decade the reappearance of famine on a

grand scale in many parts of the world has providedall too much material for studying the reactionsof man to gradual starvation. But because famineconditions are never ideal for accurate observations,such first-hand descriptions often lack scientificprecision. These considerations led Prof. ANCEL KEYSand his colleagues of the University of Minnesota tostudy semi-starvation in volunteers under laboratory