Postoperative Period

POSTOPERATIVE PERIOD encompasses the time from the moment of completion of the operation until the recovery of the patient. Simultaneously with the other two acts ensuring the success of the operation—preparation for the operation (see Preoperative Period) and the operation itself (see Operations)—proper management of the P.P. plays the most important role in the timely restoration of the patient's strength, and gross errors in care can lead to fatal consequences. Therefore, proper management of the P.P. is no less a responsible link than the operation itself. We could call the P.P. normal when the reactive changes, both from the side of the wound and from the side of individual organs, systems, and the entire organism, do not exceed the limits of a moderate reaction, natural after surgical intervention. However, a sharp boundary between 'smooth' and 'complicated' course of the P.P. cannot be found. Numerous factors of both endogenous and exogenous character can influence the operated patient. Lesion or disturbance of function of any organ affects other organs and the entire organism. Sometimes certain complications arise quite unexpectedly during what seemed to be a smooth course; sometimes immediately after the operation in the patient's condition, symptoms of what seems to be the beginning of a serious complication can be noted, but they quickly disappear and the P.P. proceeds smoothly. These facts require the surgeon's constant attention throughout the operated patient's stay in the hospital. First, even with a smoothly proceeding P.P., there are always certain complaints from patients, there are always reactive phenomena both from the side of the wound and from the general condition of the body. The degree of this reaction depends not only on the nature of the disease, the character of the operation, the degree and quality of preoperative preparation, but also on the patient himself with his physical-psychological status, with his geno- and phenotypic anamnesis, with his professional-domestic side of life. Therefore, the concept of a 'smooth' P.P. is only conditional. Second, all moments participating in the operation—the patient's psyche, anesthesia, pain with insufficient analgesia, cooling, position on the operating table (restraining), forced position after the operation, and sometimes before it, temperature, infiltrate in the abdominal cavity, the character of the operation itself, the degree of blood loss, the number of ligatures left, crushing of tissues with instruments, tampons and drains, etc.—act as agents of mechanical, physical, chemical, and biological order of changes in the body. Applying the doctrine of inflammation (see Inflammation), a 'smooth' P.P. can be called normergic, and complicated—hyperergic. In the first (normergic) state, the body's reaction is of moderate character, e.g., temperature is elevated, but not strongly (37-37.5°), metabolism is disturbed, but slightly, appetite is weak, but quickly restored, there is a shift in white blood cells, but it is not prolonged and insignificant and is interpreted as a regular reaction to the absorption of proteins, etc. The period of desensitization occurs within the generally recognized normal time limits (7-14 days—depending on the nature of the disease, the operation, and the strength of the patient). By this time, the patient is discharged from the hospital, feeling physically and mentally healthy. In the second type of P.P.—hyperergic—we have both periods, the period of sensitization and desensitization, in other words. We have a series of symptoms with the character of a sharply expressed sensitization (see Anaphylaxis). Sometimes this stage can be so sharply expressed or so prolonged that the patient's condition can be threatened with serious danger. Sometimes when transitioning to the desensitization stage, the 'recovery' phase, we will not have a 'normal' gradual transition, but we will observe decompensation, incomplete desensitization from the side of various organs or the entire organism as a whole (subfebrile temperature, shift in blood, incomplete compensation of the heart, liver, etc.). Normergic course of the P.P. usually requires only proper care, proper, if one may express it that way, 'surgical' hygiene of the P.P. The second form—hyperergic reaction of the body—requires not only attentive care, observation, and prevention, but also the application of a whole series of therapeutic measures. The latter aim sometimes to alleviate the symptoms of sensitization, sometimes, conversely, to enhance certain symptoms during the desensitization period. Otherwise, here we can get such deviations in the body from the side of various systems, which will already be interpreted as postoperative complications. These complications can take the form of new pathological conditions and require measures to be taken in relation to the entire organism (sepsis, anemia) or in relation to individual organs (metastatic abscess in the liver after appendectomy, etc.). Thus, the essence of the P.P. requires from the surgeon knowledge of: 1) methods of caring for the patient and dietary regimen, 2) methods of prevention of various postoperative complications, 3) the nature of these complications, 4) measures of influence on them. Care for the operated patient should include the totality of influences on the body, consisting of a careful preventive assessment of the condition of each organ individually and timely taking of corresponding measures to maintain or restore normal anatomophysiological relationships disturbed in the preoperative period, during the operation, or immediately after it. Care for the operated patient should be directed toward the fastest restoration of physiological condition and functions, first of all of the cardiovascular, neuropsychic, and digestive systems, on the one hand, and toward the restoration of proper metabolism—on the other. In the latter question, proper dietary regimen has not the least importance. Care for the skin should receive proper attention. A thorough examination and changing of the patient's bed are recommended, as folds of bedding, bread crumbs, sometimes secretions from the wound, unevenness of the mattress cause suffering to the patient, cause insomnia, irritate the skin, and cause a number of pathological changes from its side. Particularly attentive attitude is required to the hairy parts (head, axillary regions, inginal folds), the area of the anus and perineum. Frequent examination of these areas and the application of hygienic measures are required, especially in fatty or exhausted patients. Wiping the skin with alcohol and water, cologne, and dusting folds and folds with indifferent powders is recommended. Lack of proper skin care can lead to a series of such serious phenomena as bedsore (see), erysipelas, furunculosis. Then in the P.P. various rashes are sometimes observed. To notice them in time, give them an explanation, take measures to eliminate them, if these are more or less innocent rashes (medicinal) or to isolate the patient, if these rashes are symptoms of any infectious disease, especially in children (scarlet fever)—this is a task that can only be accomplished with constant attention to the skin. Finally, through careful skin care, the effect extends beyond it, since the significance of the skin as an organ facilitating respiration and excretion is known. In the P.P., the proper function of the skin is also extremely valuable because from it an effect (reflexively) is achieved on the most important vital centers of the medulla oblongata. Care for muscles and joints is often not included in the sum of methods of caring for operated patients. Meanwhile, the muscular apparatus, on the one hand, is directly connected with the movements of joints, on the other hand, it represents a large mass where oxidative processes occur most intensely and actively. If under normal conditions of life these processes proceed according to certain regularities, then disturbance of metabolism in the P.P. especially affects the motor organs, which for a long period are deprived of normal functions. Since the normal function of a muscle is the alternation of rest and contractions, it is natural that in the postoperative period maximum attention should be paid to the movements of various muscle groups. This factor, previously underestimated, is now winning its rightful place in surgical departments. The question of early movements, of massage of muscles, of early flexions, turns, of respiratory gymnastics, of early rising is now more and more debated and was the subject of great debates at the XXII Congress of Surgeons of the USSR (1932). Almost unanimously the position was adopted that movements should begin as early as possible. Many surgeons permit movements immediately after the operation. A certain group of surgeons occupies an even more decisive position, sending patients from the operating table after abdominal operations walking to the ward. The data of the current state of the question leave no doubt in the necessity of early movements, early turning, early rising (2-6th day) with an uncomplicated course after simple operations for appendicitis and other laparotomies, but here there must be strict individualization, strict accounting of all data concerning the patient. One cannot insist on early rising against the patient's desire. The fact that part of surgeons, especially gynecologists, who once proclaimed early rising as a principle, have now abandoned it as not having justified hopes for reduction of postoperative complications, shows that one cannot approach mechanically such a most complex biological process as the postoperative period.

Complications will occur with both early and rising if a mechanical rather than biological approach is used as the basis for the choice. Undoubtedly in recent years we have had a significant shift toward early rising, and patients leave the bed much earlier than 10 or 15 years ago. In caring for the musculo-motor apparatus, it must be remembered that after prolonged lying in bed, contractures of large joints often develop, e.g., of the knee after laparotomy; therefore, rollers or pillows should be placed under them, physical exercises should be performed, and massage should be given. To prevent the development of equinus foot, footboards should be placed at the end of the bed, thanks to which the foot can maintain the correct position. Care of the cardiovascular system should be at the center of attention from the moment of surgery until the patient's discharge. Surgery is rich in facts of disorders of the cardiovascular system at the most diverse moments: in the first hours after surgery and in the last hours before discharge from the hospital. In view of the fact that this system is affected by more diverse factors than any other, consisting of the preoperative condition of this system and factors introduced by various moments of the preoperative and operative period, systematic attention to the state of circulation must be ensured. Attention should be directed to every link of the cardiovascular system: the heart muscle, large vessels, veins, and capillaries. Only such an analysis of the state of the cardiovascular apparatus can help clarify various vascular disorders, prevent complications, and take measures regarding them. The same symptom may depend on the heart, venous congestion, paralysis or spasm of capillaries. Sometimes in caring for the patient, it is sufficient to give him the correct position, reduce compression of the diaphragm by a distended stomach or intestines, apply a hot water bottle to the legs or other parts of the body after a blood-letting operation, elevate the legs, bandage them, to achieve better results than with other, more complex therapy. Filling the vessels that have been emptied by blood loss during the operation by enteral methods (enemas, microclysms of warm physiol. solution) or parenteral methods (under the skin, into a vein), raising the cardiovascular tone with pharmacological agents (camphor, caffeine, digalen), introduction of adrenaline (1 cm³ in 500-1,000 g of physiol. solution), inhalation of CO₂ to enhance excitation of the respiratory center of the medulla oblongata, introduction of morphine for reflex (pain) irritations of the heart—such is the arsenal of means for caring for the cardiovascular system. Care of the respiratory apparatus also occupies an important place. Asphyxia can occur here, directly depending on anesthesia (see General Anesthesia). Even with 'normal' course of the P. p., a decrease in respiratory excursions is noted, as has been proven by spirometry (Korganova and others). Cooling, anesthesia, supine position, local anesthesia with reflex respiratory arrest, reflex protection from pain, decrease in respiratory excursions by the patient himself, etc.—all this creates the prerequisites for the possibility of stagnant phenomena in the lungs. Therefore, preventive measures should be directed against stagnation and the associated inflammations and edema. Care measures: uniform warming of the body, elimination of cooling factors, elevated position of the chest part (especially in elderly people) or respiratory gymnastics. compresses, cups, turning on the side, hot water bottles, diathermy of the lung area in the presence of stagnant phenomena, improvement of ventilation in the ward, elimination of reflex respiratory arrest (morphine for pain), stimulation of the respiratory center by inhalation of CO₂, rubbing the chest part of the torso, narcotics for cough. It is clear that the first preventive measure of the postoperative period in relation to the lungs will be properly conducted anesthesia, pulmonary gymnastics before the operation, as well as elimination of pain during the operation itself and to prevent embolism, careful attitude toward tissues when separating and joining them. Preventively immediately after the operation, (Bier) recommends ether intramuscularly (1 cm³), digalen, camphor. Care of the gastrointestinal tract should be applied to all its segments, starting from the oral cavity and ending with the anus. The gastro-intestinal tract sharply reacts to the act of surgery (especially in laparotomy), especially with improper or insufficiently thought-out preoperative period. Dryness in the mouth, coatings, dry tongue, violation of secretory _ch (decrease or cessation) or motor function of the digestive tube with its glands—usual companion of the P. p. Therefore, care should begin already on the operating table (careful attitude toward the oral cavity during anesthesia), reduction of the possibility of eversion and drying of the organs of the abdominal cavity and peritoneum during surgery, early introduction of fluids through the mouth; if there are contraindications to the latter, then mouth rinsing is prescribed, early exercise of the masticatory apparatus. If the patient has a tendency to spasms, constipation—stretching of the sphincter on the operating table (Raug). If the absence of HCl in the stomach is established or suspected in the patient, its introduction is recommended at 10 drops three times a day; in the presence of increased acidity, with abundant mucus—introduction of alkalis; in the presence of stagnation in the stomach—introduction of a rubber tube and stomach lavage, especially if breathing is difficult due to pressure on the diaphragm. To prevent gas retention—introduction of a rectal tube and warming of the abdomen. With increased signs of peristalsis retention—lavage of the lower part of the intestine (simple, siphon enemas), introduction of soap, glycerin (in an enema) or 15% solution of 'NaCl (100 cm³) through a Nelaton tube into the anus or 10% solution of NaCl (10 cm³) into a vein. To enhance peristalsis, pituitrin, atropine, eserine are also recommended (see Intestine, peristalsis). Care of the urinary apparatus. Attention should be paid to both the quantity (diuresis) and quality of the excreted urine. The diuresis of the operated patient should be known, and if it is insufficient, appropriate measures should be taken depending on the identified causes of decreased urine. With qualitative changes in urine (cylinders, protein, sugar, leukocytes, acetone)—corresponding diet. Since we often have delay in urination, it is recommended prophylactically to accustom the patient to urinate while lying down, and after the operation to remember this, to watch whether the patient is urinating, to apply a hot water bottle to the bladder area or to make a hot water microclysis, i.e., to take measures to prevent overstretching of the bladder. Care of the neuropsychic system. Not all patients react to surgery in the same way. In most cases, the entire set of factors that constitute and surround the act of surgery strongly affects the patient's psyche and his nervous system. The patient should find complete physical and psychological rest after surgery. He should not experience pain, as besides the direct effect on the nervous system (excitement, tears) they have an adverse reflex effect on the somatic system. Sleep strengthens the patient. There is no data to wake the patient after anesthesia. For insomnia in the P. p., all measures of sanitary-hygienic order should be taken (ventilation of the room, quiet, possible isolation from bells, noise, visits, etc.), preventive measures (comfortable position of the patient, well-made bed, rubber ring, etc.), as well as measures affecting the nervous system in the sense of reducing reflex influences on it and reducing direct sensitivity to pain (morphine, pantopon, bromural, veronal, etc.). In the first days after surgery, if the patient suffers from pain or insomnia, morphine is widely used. If the patient's psychological state is low, on the contrary, his psychological mood should be raised. In an excited state, sedatives are recommended; in a depressed state, stimulants. The patient's psyche requires very careful attention. It is necessary to ensure fulfillment of all legitimate requests and requirements of the patient, raise his mood, strive to eliminate all moments that disturb his psychological state (noise, laughter, rudeness, inattention, insensitivity), maintain his confidence in speedy recovery. 'Optimism should permeate every movement at the patient's bedside. Optimism should be maintained in the patient, in his relatives, in the caring personnel, even if the optimism at the patient's bedside is only apparent' (M. Kapis). It is necessary to ensure that the patient does not feel anxiety, fears and doubts about himself, even in the presence of threatening phenomena, especially from the side of the physician, personnel and other patients. Every operation entails a violation of metabolism. The correctness of diffusion, osmosis is violated, dysidria, dys-ionia, etc. occur. Therefore, from the moment of surgery until recovery, attention must be fixed on the rapid restoration of metabolism. Acidosis in a moderate degree is a common phenomenon in the P. p., but, going beyond the limits of moderate reaction, it can give a number of complications.

Disorders of metabolism can occur along the lines of general metabolism, water, mineral, protein, and carbohydrate metabolism; therefore, in the postoperative period, the dietary regimen must be carefully planned. The first essential condition for proper metabolism is the introduction of fluids (up to 2 liters) into the body with the addition of salts (NaCl) or sugar (glucose, regular sugar), which promotes proper blood circulation, proper excretion of products of reverse metamorphosis, proper restoration of osmotic processes and elimination of demineralization processes. In the presence of factors causing capillary porosity, swelling of the colloidal substance of cell protoplasm (prolonged infection, sepsis), the introduction of Ca in enemas, intravenously (see Calcium) is recommended. When prescribing a diet for the operated patient, one must proceed from the following considerations: it is necessary to introduce easily digestible, pleasant food for the patient, initially with the aim of inducing proper secretion and giving him a stimulus for proper nutrition. Later, a rapid transition to the patient's normal table with his usual diet is recommended. Since carbohydrate metabolism is severely impaired in the postoperative period, and the disappearance of glycogen from the liver greatly weakens its antitoxic properties, the introduction of carbohydrates (sugar, finely crushed crackers, stale bread, etc.) is recommended from the first day after surgery. Sometimes fasting, especially when caused by the disease in the preoperative period, leads to avitaminosis, which can give a number of complications from the wound and weakening of tissue reaction; therefore, the introduction of juices from fresh fruits or vegetables and berries is recommended from the first days. In the presence of weight loss and exhaustion, the diet should be supplemented with proteins and fats (butter, sour cream, cottage cheese, meat). One should not insist on forced nutrition if the patient has no appetite. On the other hand, nutrition should not be restricted if there are no indications for it. Finally, when prescribing a diet, one must take into account the state of acid-base balance, since nutrition in terms of food selection affects the oxidation or alkalization of tissues, which is not indifferent in various phases of the postoperative period and with different states of the wound. Since the first period in the process of wound healing occurs with phenomena of tissue acidosis, it is natural that maintaining this state in the body should also be reflected in the prescription of diet. Sauerbruch and Hermannsdorfer recommend in this period fish, meat, eggs, cottage cheese, butter, flour, meat extracts. In the second period, the local reaction in the area of the wound takes on an alkaline character. A shift in the reaction of body fluids in the acidic direction will adversely affect wound healing; therefore, in this period, a basic diet (milk, potatoes, vegetables, fruits) is recommended. Finally, by adding alkalis or acids (200 g of soda or 30-50 g of acid ammonium phosphate), one can also change the reaction of the medium in the acidic or alkaline direction. Care of the wound consists in observing the dressing, the bandage. Soaking, the nature of the discharge (blood, serous fluid, pus), the condition of the area around the wound (infiltration, rash, redness) should be noted. In case of intestinal distension, the dressing may compress the abdomen. Pains in the wound that do not disappear within the first two days should prompt an examination of the wound. Temperature and other general phenomena may also be a reason for examining the wound. Usually, however, if there are no indications from the wound itself or the general condition, dressings should not be frequent. Moderate soaking with blood or soaking with serous-purulent fluid does not indicate a need to change the dressing. In cases where the patient has a tendency to bleeding, with large subcutaneous hemorrhages, sometimes pressure on the wound is recommended, e.g., in the form of a sandbag (see Wounds). The blood picture is only a mirror of the shifts occurring in the body. Study of postoperative blood changes gives a clear indication of the negative phase that occurs in the body immediately after surgery. In this case, the shift in both the morphological and chemical composition of blood, with normal, uncomplicated course, is regularly equalized by the 8th day. Blood examination in the postoperative period is mandatory both in the morphological line (especially the hemogram according to Schilling) and in the chemical. These shifts are sometimes close to physiological reactions to irritation. If the blood picture changes in parallel with changes in temperature and pulse, the course of the process is correct. But sometimes we observe divergence of the curves (temperature, pulse, blood) or a sharp change in some properties of blood (decrease in coagulability, increase in viscosity, sharp decrease in Ca, etc.). This fact should be evaluated as a manifestation of an abnormal condition of some tissue or organ or the entire body (sepsis). Timely study of deviations sometimes allows, by taking necessary measures (removal of hematoma, untying of sutures, elimination of the beginning spreading infectious process from the wound, etc.) to prevent serious complications. Usually in the postoperative period, the white blood cell count changes—increase in neutrophils, decrease in lymphocytes and disappearance of eosinophils; these changes are parallel to the severity of anesthesia and the operation. Blood coagulability changes. Decrease in coagulability is sometimes a sign of hematoma, pneumonia, etc. The ratio of coagulability to viscosity is usually inversely proportional. Changes in protein fractions (albumins, globulins) also undoubtedly illustrate the physiological or pathological state of the body at a given moment. It is indicated that an increase in globulins in the blood is a harbinger of the possibility of thrombosis and embolism. The quantitative composition of blood (Hb, number of erythrocytes, their pathological forms) usually changes after operations, especially after large blood losses or exhausting diseases (stomach ulcer, malignant tumors). The development of anemias not only affects the condition of the wound but sometimes serves as a cause of an outbreak of some complication. From what has been said about the care of operated patients, it can be seen that the non-adoption of certain preventive measures or reasonable 'surgical' hygiene in relation to the patient as a whole and to various organs individually can lead to more serious violations of the function of the latter. Sometimes the accumulation and intensification of certain physiological deviations leads to so-called postoperative complications. The latter often could not have occurred if preventive measures and proper care had always been ensured and carried out in detail. These complications are extremely diverse. Taking into account the sum of numerous factors present in the operation and the individuality of the patient, it can be said that they mainly reduce to: 1) damage to the cardiovascular apparatus, 2) damage to the neuropsychic system, 3) violation of metabolism in all its forms, 4) development of infection. Various combinations of these factors give all types of postoperative complications: hemorrhages, thrombi, emboli, infarcts, pareses, paralyses of striated and smooth musculature, infection in its most diverse forms and manifestations (abscesses, gangrene, sepsis), outbreaks of latent infection (angina, diphtheria, tuberculosis, etc.). Complications arising from individual systems and organs represent new diseases that can be caused by other non-surgical factors. This new pathological form (complication) can in its seriousness prevail over the main disease (e.g., abscesses of the liver, lungs in appendicitis, intestinal obstruction, etc.). The main types of complications: 1. From the side of the wound. The wound in the postoperative period can give a number of complications depending on 1) disorders of blood circulation in it (e.g., hematoma, primary, secondary, cavity bleeding); thrombosis of veins around the wound sharply changes the course of the process; sometimes necroses are observed; 2) disorders of the nervous system around the wound (mainly pain, hyper- or anesthesia, trophic disorders); 3) infection present in the wound, introduced during the operation, specific infection (diphtheria), anaerobic in the presence of appropriate conditions, tetanus, etc. (see Infection); 4) improper suture technique (excessive tension of the edges of the wound, necrosis; improper, non-layered suturing of the wound, entrapment of the omentum, nerve, etc.). All these complications and their treatment—see Wounds. From the side of the cardiovascular system, complications can affect both the heart itself and the vessels. Most often we deal with insufficiency of the heart muscle, especially after complex prolonged operations, anesthesia or prolonged diseases. The usual postoperative decrease in blood pressure can lead to collapse, which can develop not only within several hours but also days (see Collapse). Sometimes it is confused with shock, which is also accompanied by a fall in blood pressure (see Shock). Prevention of collapse and shock is more important than therapy. Threatening symptoms in the postoperative period will be a drop in systolic pressure to 80 and diastolic to 20 mm. Half an hour of such a state makes the prognosis hopeless despite all measures taken.

Therefore, it is recommended to consider the condition of the cardiovascular and nervous systems when choosing anesthesia, the method of operation (sometimes a two-stage approach, palliative measures), to carefully stop bleeding, avoid significant blood loss, and take all measures (anesthesia of nerve trunks) to prevent reflex phenomena from the central nervous system (shock). Sometimes collapse is a symptom of bleeding, especially cavity bleeding, in which case it is necessary to open the wound and stop the bleeding (see Bleeding) and administer physiological solution or blood. Circulatory disorders in veins can lead to their obstruction, more often in the lower extremities (left side), and thrombophlebitis (pain, followed by swelling). For incipient thrombophlebitis, elevation of the extremity, cardiac medications, and appropriate diet are recommended; since changes in blood coagulability and viscosity are usually present, leeches are recommended, which give excellent results both at the beginning and during the development of the process. Finally, one of the frequent complications in the postoperative period are emboli of various organs. Mass ligation of blood vessels, changes in blood composition, severe metabolic disorders, and disturbances in cardiac activity are the main factors causing emboli. More commonly observed are pulmonary emboli (pneumonia, infarct, abscess); pulmonary artery embolism; emboli in the stomach (gastric bleeding, sometimes life-threatening) (see Embolism). The variety of complications from the cardiovascular system and their seriousness require careful selection of therapeutic measures. Complications from the lungs may follow the pattern of circulatory disorders in them (stasis, edema, pneumonia), aspiration or infection [pneumonia (see Postoperative pneumonia), pleurisy, abscess]. Diagnosis of these processes is not difficult. Therapy—see in the respective articles. Complications from the lungs often combine with disorders in the wound healing process (hematoma, suppuration, abscesses in the perinephric region, under the diaphragm, peritonitis, etc.). Statistics on pulmonary complications among various authors show the most diverse figures (2-20%). This is partly explained by the different evaluation of the phenomena. Some consider congestive bronchitis already as pneumonia, although not all objective data are present for it; sometimes pneumonia found at autopsy (hypostatic or infectious) is incorrectly considered the cause of death, when other complications are present, such as peritonitis, sepsis, or cardiac decompensation. Therefore, when pneumonia is present, the wound, general condition (blood), etc. must be thoroughly investigated. Mortality directly from postoperative pneumonia is small. Abscesses and gangrene of the lungs_:—a not frequent but possible complication with aspiration or in prolonged pneumonia in a patient weakened by the disease process and infection (sepsis). Therefore, for prolonged pneumonia, repeated fluoroscopy is recommended. Finally, one must remember about sympathetic inflammation of the lungs and pleura during operations and inflammations in the hypochondriac region (liver, spleen, etc.). Often such processes are considered independent complications, but autopsy reveals the presence of foci of suppuration, which through lymphatic pathways give the mentioned secondary pleural complications. Complications from the gastrointestinal tract are numerous. Some of them have an innocent nature, but lack of care measures sometimes makes them threatening to the health of the operated patient. Insufficient care of the oral cavity can lead to stomatitis, thrush, aphthae, parotitis (see Parotitis). Being the result of a number of etiological factors (dehydration, starvation, exhaustion, infection, etc.), these complications can be eliminated by proper care (preparation for the operation, elimination of starvation, especially dehydration in the pre- and postoperative period, oral hygiene, chewing, etc.), as well as by proper analysis of the postoperative condition of the patient and evaluation of functional deviations of individual organs. From the stomach, motor-secretory disorders are more common: paralysis, paralysis, spasms, duodenal obstruction (acute gastric dilatation) or intestinal obstruction (spasms, atony, peritonitis). Of the symptoms, vomiting is the most common. The usual companion of anesthesia (toxic irritation of the gastric mucosa or central nervous system), vomiting itself can be a harmful factor for the patient, especially after laparotomy (pain, aspiration, effect on the stability of sutures, loss of body fluids, etc.). Vomiting lasting more than 24 hours and not responding to the measures mentioned in the chapter on care often indicates irritation of the peritoneum by mechanical factors (sometimes tampons) or infectious-toxic (acidosis, peritonitis, etc.). The nature of the vomiting and its contents (mucus, liquid contents, admixture of bile, pancreatic enzymes, blood, feces) must be evaluated. Pure bile in the vomitus indicates gastric atony, admixture of pancreatic enzymes—acute gastric dilatation, fecal odor—intestinal obstruction, peritonitis; differentiation with central vomiting (see Vomiting) must be made. The measures taken must be based on determining the etiology of vomiting. Another symptom—hiccup—can occur in toxemia, irritation (incarceration of the omentum, tampon) or peritonitis. Paralysis of the stomach can take the form of complete paralysis, presenting a picture of acute gastric dilatation (see Stomach, acute dilatation), arterio-mesenteric obstruction. Here, prevention of this complication, sometimes elementary care measures (lateral, knee-chest position), stomach lavage, removal of irritating tampons, enteral or parenteral administration of fluids give more than subsequent surgical intervention (gastro-enterostomy, intestinal fistula). Analysis of postoperative gastric paralysis, differential diagnosis with peritonitis, ileus, acidosis, uremia is important. Painless bloating only of the upper part of the abdomen with the presence of intestinal activity, often normal temperature, large amounts of vomitus with admixture of all three enzymes provide grounds for correct evaluation of the pathological process. The paralytic state of the intestine (moderate meteorism)—a usual consequence of the operation, especially in the abdominal cavity, but sometimes it is a threatening symptom of peritonitis and intestinal obstruction. Therefore, if after 24 hours the signs of paralysis not only do not weaken but intensify, if auscultation of the abdomen gives a picture of complete 'silence' in the stomach (absence of peristalsis, audibility of heart sounds, sometimes even rales in the lungs, 'bubbling' in the intestine), then all measures must be taken to eliminate the phenomena mentioned above (care), and if these measures are unsuccessful, then the question must be raised about taking appropriate measures necessary for the treatment of peritonitis or intestinal obstruction (see Peritonitis, Ileus). Much less frequently in the postoperative period, diarrhea occurs. Their etiology varies: disorders of digestive and absorptive capacity of the gastrointestinal tract (coarse food, absence of HCl, improper diet, etc.), metabolic disorders, infections (septic diarrhea), trophoneurosis (ulcerative colitis)—paralysis of capillaries, ischemic necrosis of the mucosa (Bierende). (See Intestine, Diarrhea.) Complications from the liver are sometimes completely unexpected and serious; sometimes not properly accounted for in the immediate postoperative period, they manifest themselves later after the patient is discharged. The liver always reacts in the postoperative period as an organ regulating blood circulation in the abdominal cavity (stasis), as an organ involved in the removal of disintegrating red blood cells (with hemorrhages, etc.), as an organ receiving blood from the portal vein of the intestinal tract, as an organ detoxifying absorbed substances (hepatic insufficiency), as an organ sharply reacting to anesthesia (acute yellow atrophy), as an organ often infected during abdominal operations through blood and lymphatic pathways (angiocholitis, liver abscesses), and finally as an organ playing the main role in metabolism (acidosis). Complications from the liver, not reaching large proportions, are often not recorded, although they do occur. Often mild jaundice and corresponding changes in urine already indicate a pathological condition of the liver after the operation (possibly already before the operation, which had pathological deviations). Sometimes measures taken directly can prevent the development of serious phenomena, as well as protect the patient after discharge from the remote consequences of liver function impairment, which is often underestimated (see Liver). Complications from the urinary system can be of a circulatory nature (stasis, ischemia, infarction, bleeding), toxic (nephroses, nephritis), infectious (nephritis, pyelitis, cystitis, prostatitis, urethritis), can be the result of improper metabolism (salt deposition), prolonged suppuration (amyloid of the kidneys), or complete cessation of function (anuria), and finally as a result of disorders of the neuromuscular apparatus (urination disorders). The latter is the most common complication of the postoperative period, especially after abdominal operations.

Besides cases where it seems quite justified to explain this phenomenon as a reflex on the bladder from the operative site, which lies near the bladder (hemorrhoids, hernia, gynecological operations), in some cases it cannot be satisfactorily explained. The usual causal factors of retention are considered to be: unusual position, psychological influences, reaction to pain in the wound, the patient's desire to spare the abdominal press due to fear of pain, anesthesia, intestinal distension, etc. Sometimes urination is quickly restored, but sometimes for a prolonged time it yields to no measures except catheterization. In relation to the above etiological factors, the following is recommended: 1) to accustom the patient before the operation to urinate while lying down; 2) to place him on his side, if possible sitting or lying down; to urinate in the lavatory; 3) to apply local heat procedures (hot water bottle, hot water microclysis, vaginal douches); 4) drug treatment: intravenous infusion of 5-10 cm³ of 40% solution of urotropin; urotropin 0.5 four times orally, bearberry, 1% pituitrin 1 cm³, 20% potassium acetate; 5) catheterization with all precautions (see Catheterization). The sexual organs also sometimes give complications, as organs of external and internal secretion. Disorders of pelvic circulation, stagnation sometimes lead to metrorrhagias, amenorrheas, etc. Sometimes the sexual organs are the site of development of infection (epididymitis, prostatitis, orchitis, oophoritis). Sometimes we have after an operation a flare-up of old, dormant infection (adhesions, separated during appendicitis and oophoritis). The neuropsychic system, always reacting to every link in the act of operation, sometimes instead of the mild functional deviations mentioned above, gives severe complications. The latter may depend on all factors of the preoperative period (e.g. mentality in Basedow's disease), anesthesia (paralyses, pareses, peripheral and central, anesthesias, hyperesthesias, excitement, coma, shock), operation (painful, vasomotor, trophic disorders), technique of operation and dressings (pain, pressure of the bandage, hematomas, pinching or damage of a nerve, etc.), postoperative care (headaches, insomnia from noise), lack of properly organized care (excitability, increased reaction when the patient's requests are not fulfilled, failure of the service personnel to answer calls, etc., rudeness of the surrounding personnel or unexpected visits by unpleasant visitors, communication of unpleasant news), finally these complications can be caused by infectious toxic factors (meningitis, encephalitis, etc.). Finally we encounter in the P.p. with severe changes in mentality, which can lead even to suicide of patients. Most often they are expressed in the form of delirious states (exhaustion, deprivation of alcohol, infections, intoxications). Immoderate use of narcotics in the P.p. can later lead to chronic poisoning, to morphinism. In cases of beginning mental deviations in the operated patient, isolation and special care are necessary. These deviations in mentality are not uncommon in trauma patients; they are often observed after cataract operations, although no sufficient explanation of this phenomenon exists. Treatment of mental complications see below. Complications from the endocrine apparatus can also occur in the P.p. Even in general operations, not related to the endocrine apparatus, we find disorders of function of some of them: first of all the adrenal gland, very sensitive to anesthesia (fall of blood pressure), the pancreas (small diabetes of Oppel), the testicle (orchitis), the ovary (amenorrhea), the thyroid gland (trauma intensifies the initial symptoms of Basedow's disease), the parathyroid glands (tetany). The latter is usually observed after operations on goiter as a result of loss of function of the parathyroid glands. But its development can also be as a result of other operations: exclusion of the pylorus (Orth), hallux valgus (Enderlen), appendectomies, brain operations, hemorrhoids (Melchior) and others. Some authors note tetanic symptoms in a large percentage after operations (Nothmann, Starling and others). The causes of tetany are not only endogenous but also exogenous (alkalosis, disturbance of nutrition and metabolism). The main indicator is a significant shift of pH in the alkaline direction. Therapy: administration of parathyroid gland preparations, intravenous or per os infusion of calcium, transplantation of a bone as a depot of Ca (Oppel), administration of ammonium phosphate (18 g per day) with the aim of inducing artificial acidosis (see Tetany). Disorders of metabolism can also lead to a number of complications. More often they go along the line of developing acidosis, more rarely - alkalosis. Both under general anesthesia and under local anesthesia, acetonuria is observed in 85%. Clinically, dizziness, nausea, headaches, insomnia are observed, and later pareses of the gastrointestinal tract, fall of pulse, coma, sometimes death. Sometimes the picture of acidosis as a manifestation of general metabolic disturbance is not diagnosed, because the doctor's attention is concentrated on individual organs, from the side of which separate disease symptoms appear, sometimes incorrectly evaluated as primary and not as secondary, depending on metabolic disturbances (peritonitis, ileus). To the manifestations of complications from the side of metabolism should be attributed dehydration and demineralization of the patient in the P.p., which later gives a number of complications mentioned above (see Acidosis, Alkalosis, Metabolism). Disturbance of the general condition is a constant phenomenon after the postoperative status of the operated patient. Sometimes patients after the operation are quickly discharged in a state of complete physical and mental health. Sometimes, however, fatigue, weakness, fatigability, exhaustion, lack of restoration of physical and mental strength for a prolonged time are noted. Sometimes - after a successfully undergone operation, dormant processes are aggravated (tuberculosis), and sometimes symptoms of some disease which was not diagnosed appear. Sometimes after discharge of the patient, he has a subfebrile temperature, which is not evaluated uniformly by all. The apparent or existing afebrility of it gives rise to erroneous interpretations, diagnoses and therapy (e.g. bronchoadenitis, latent sepsis, thermoneurosis, allergy, etc.). The P.p., ending with the discharge of the patient from the hospital, constitutes only the first part of it. The second stage of the P.p. - the period of complete restoration of strength until returning to work (in a state of complete health) - is the stage of 'restoration' of the patient's strength. During this period, the success of the operation should be consolidated and working capacity completely restored. If suitable conditions exist, this period is conducted in a home environment, otherwise - in rest homes, sanatoriums, after which the patient should again be examined by a doctor before returning to work. The development in the USSR of rest homes, sanatoriums, prophylatoria makes it possible to properly conduct this link of the P.p. In certain cases, patronage of the patient is recommended, and in certain types of diseases and operations - study of the patient's condition at work; this makes it possible, taking into account the nature of the work, to eliminate harmful factors which can cause a recurrence of the same disease (hernia) or some complication (e.g. in stomach ulcer). Failure to take into account all the above can lead to late complications, which can occur at various periods after discharge of the patient from the hospital. They are also very diverse and can manifest themselves from the side of individual organs (heart, lungs, liver, etc.) as well as from the side of the wound and operative cavity. Irregularities of the scar, keloid, sometimes development of bone in the scar are very often accompanied by the development of adhesions and scars in the abdominal cavity. These adhesions can later give the most varied clinical picture from the side of the abdominal cavity and lead to a number of unnecessary operations (division of adhesions) or the need for emergency operations (ileus). On the other hand, the scar may turn out to be weak depending on a number of factors and serve as a site of hernial protrusion (see Postoperative hernias). If this protrusion of the viscera occurs before the adhesion of the peritoneum and aponeurosis is formed (cachexia, aplasticity of tissues, advanced age, etc.), then we will get eversion of the viscera, which can appear 2-3 weeks after discharge of the patient. These postoperative complications are common to all types of operations. But this does not exhaust their fullness. Each operation, many organs and tissues can have specific complications, which are considered in the respective articles when describing operations on individual organs.

I. Rufanov. Narcotic Paralysis-a combined concept for peripheral and central paralyses that developed during anesthesia. Central paralyses are very rare; they can develop with very severe chloroform poisoning causing degenerative changes in nervous tissue, but in most cases there are no objective data for a direct connection between central paralyses and anesthesia, either in terms of symptomatology or course. Hemorrhages, softening of the brain, underlying these paralyses, can be explained by the presence of vascular diseases. The narcotic paralyses proper refer to paralyses of individual plexuses of peripheral nerves, in which a direct connection between the paralysis and the anesthesia itself can be established. These paralyses are of toxic-traumatic origin; on the one hand, their genesis lies in trauma-pressure, stretching of the nerve trunk during prolonged anesthesia combined with an uncomfortable position of the patient's limb, on the other hand-acute intoxication with chloroform, ether and other narcotic agents. Depending on the method of injury, two groups of paralyses are distinguished: 1) paralyses from pressure on the nerve trunk, or on the nerve plexus by some external compressing object-the edge of the operating table, devices for supporting the limbs, or hands of persons assisting in the operation; an unusual body position usually favors this (e.g. Trendelenburg position of the pelvis). 2) Paralyses from stretching, pulling of the nerve trunk combined with compression of the trunk against surrounding solid tissues (bones, ligaments, etc.). This is especially common on the upper extremities-when the arm is thrown up and back for several hours; at the same time as stretching, the nerve trunk is pressed against the clavicle, individual trunks or the entire plexus are compressed between the rib and clavicle; turning the head to the opposite side also causes tension of the trunks. The clinical picture depends on the localization of the injury: most often, damage to the upper part of the brachial plexus is observed, giving a picture of Duchenne-Erb paralysis, less often the lower part of this plexus-Dejerine-Klumpke paralysis (see Duchenne-Erb paralysis, Dejerine-Klumpke paralysis); then paralyses of n. radialis, axillaris, femoralis, obturatorii, peronaei, tibialis, etc. Bilateral paralyses are described in the literature, but are very rare. The paralyses are flaccid, accompanied by changes in electrical excitability-decrease of it or reaction of degeneration. The paralyses are detected directly when the patient regains consciousness after anesthesia. After several weeks, in favorable cases, slow progressive improvement begins. Complete restoration of lost functions is possible. - Treatment-massage, electrification of paralyzed muscles. Prevention-careful and considerate attitude to the position of the patient before and during the operation.

E. Kononova. Postoperative Psychoses. According to the opinion of most clinicians, there are no independent postoperative psychoses. An attempt to isolate postoperative psychoses as a special form of disease was made by the Frankfurt psychiatrist Kleist. He considers disturbance of consciousness, lowering of intellectual processes, amnesia on the background in some cases-of an excited state with convulsive phenomena, in others-of stuporous rigidity or a helpless bewildered state to be characteristic of the clinical picture of postoperative psychosis. The onset-immediately or within the first two weeks after the operation. The course is acute, leading either to a fatal outcome or rapid recovery. Causes-poisoning by metabolic products due to the underlying disease, intensified by the surgical intervention. In the research of other authors, Kleist's observations found no confirmation (Kraepelin, Lange, etc.). Surgical intervention, causing major changes in the body, can, in the presence of corresponding predisposition, bring to life the onset or another attack of endogenous psychoses; manic and depressive phases of circular psychosis, schizophrenia (see), psychoses of involutional age, epileptic psychoses are observed. A surgical operation can serve as a provoking factor also in regard to psychoses of predominantly exogenous origin, e.g. general paresis of the insane (see), especially often in acute alcoholic hallucinations, delirium tremens, sometimes in uremic delirium. In some cases, postoperative psychoses may be the result not of the surgical intervention as such, but of ether or chloroform anesthesia. In these cases, transient delirious states are observed. Significant blood loss during major operations, especially in exhausted people, can give brief states of excitement or collapse. After operations for accidents, in amputations, castrations, etc., in predisposed persons, a more or less prolonged state of severe depression with persistent suicidal tendencies may occur. Generally, postoperative psychosis in the narrow sense of the word is a rare phenomenon. In the broad sense of the word, various reactive states, mainly depressions after operations, especially in operations on female genital organs, are often observed. The cessation of ovarian function generally does not pass without effect on the female psyche. Partial or complete removal of them usually entails changes in the mental life of a woman, prematurely causing a climacteric with its pathological course. The awareness of the cessation of generative functions in some serves as a pathogenetic, psychogenic factor of great stress. In eye operations, e.g. in cataract extraction, long stay in a dark room can give an outbreak of delirious state with bright visual and auditory hallucinations (especially visual illusions) with clear consciousness. Apparently in these cases also the participation of additional predisposing factors is necessary (old age, exhaustion of the body, constitutional peculiarities). The course of postoperative hallucinosis is favorable; recovery occurs within the nearest 1-2 weeks; the course of 'major psychoses' brought to life by surgical intervention proceeds depending on the form of the disease. In view of the fact that patients in the acute periods of psychosis continue to remain in surgical departments, the question of proper organization of care and observation acquires serious significance, since often patients show destructive tendencies and tendencies to self-mutilation and suicide. In large surgical hospitals it is necessary to train part of the middle and junior personnel specially in the care of the mentally ill. Treatment-symptomatic, in states of excitement-prolonged narcotization with veronal or luminal (they recommend in small doses), in gloomy states-opium preparations, carbonic soda baths.