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Mental Influence After Operation





Every surgeon feels the necessity of having his patients as quiet and
restful as possible after operation. Any unfavorable mental influence
will surely hamper the curative reaction of tissues and delay
convalescence. We all know how fear blanches tissues, and anxiety
causes hyperemia, and how solicitude with regard to any part of the
body interferes with the normal control of the sympathetic nervous
system and sets up vasomotor disturbances. Either a lessening or
surplus of blood in a particular part interferes with the normal and
healthy curative reaction of tissues. The patient's mind should
therefore be as much as possible diverted from attention to the part
that has been operated on in order to leave nature to pursue its
purposes without disturbance. For this, of course, pain must be
relieved and every possible measure taken that will add to the comfort
of the patient. In spite of the fact that opium may interfere with
certain natural processes, it is always useful after severe
operations, because it represents the lesser of two evils. The pain of
itself would produce more detriment than does the opium which relieves
the pain. There are, of course, other anodynes which may be used and
that have less disturbing sequelae. In this matter, routine is
unfortunate, for individual patients react very differently to opium
and its derivatives, the disturbing effect upon the mind being greater
than the quieting effect on the body. Many patients stand the coal-tar
derivatives much better because of their lack of effect on the mind.


Removal of Worries.--Worries of all kinds not associated with the
operation must have been thoroughly removed beforehand and must not be
allowed to obtrude themselves afterwards until convalescence is
well established. Business is quite another matter. Whenever it does
not imply worry but only means occupation of mind and distraction of
the attention of the patient from himself, it may very well be
permitted, after only a comparatively brief interval after operation.
Within a few days a business man may certainly be allowed to dictate
letters for an hour or so, and an author may even be allowed to
dictate notes of some of the fancies that came to him during
anesthesia. When a man has the opportunity to look forward to even a
short interval during the day when he can do something that is useful,
it serves as an excellent distraction for many hours beforehand and as
a satisfactory memory for hours afterwards.


Pleasant Visits.--It used to be the custom to keep visitors from
patients after operation much longer than is at present the custom.
There has come the realization, however, that short visits from
pleasant friends may mean much for the patient. It is hard to make the
selection, for certain friends and especially relatives disturb and
annoy rather than help the patient. Anyone who shows much solicitude
and, above all, fussy over-anxiety, must be excluded, no matter how
nearly related he or she may be.


Psychic Conditions of Hospitals.--The atmosphere of the hospital must
all conduce to peace and quiet of mind. It is surprising the
differences that may be noted in this respect. I have been in a
hospital where only a dozen of operations were done a week and have
scarcely ever been there without hearing complaints of pain and
discomfort that were surely disturbing to others. On the other hand, I
have been in a hospital where twenty capital operations a day were
done, and have heard no complaint, and at nine o'clock at night have
found in it the peace of a religious community. I knew that it was all
due to the personality of the surgeons and their lack of power in one
case to impress their patients' minds and a very marvelous power in
the other of impressing patients favorably. The success of many a
surgeon in a material way depends on this power to impress his
patients. It is they who send others to him, and in general there is a
feeling that if he cannot cure them no one can.

Of course, it is extremely important that circumspection should be
employed as regards chance remarks that may be seriously
misinterpreted and prove unfavorably suggestive. Patients should not,
as a rule, be allowed to see their own charts whenever there are
disturbing developments in pulse and temperature. During dressings the
conversation should be cheerful, distracting to the patient, and
should not contain remarks that may be disturbing. The surgeon and his
assistants must know how to control their expressions so as not to
reveal any solicitude that may be occasioned by the patient's progress
or by the state of his wound when these are not satisfactory.


Surgeon's Visits.--Practically every time that a surgeon visits a
patient after operation there is something that the patient has to ask
or have explained. A good deal depends, as far as regards the comfort
and peace of mind during the interval until the coming of the surgeon
again, on the satisfaction derived from the surgeon's explanation. He
should be prepared, therefore, to answer in such a way as will leave
no haunting doubts in the patient's mind. Some patients are very prone
to find unfavorable suggestions in even simple expressions of the
physician. He must be prepared for this, therefore, and be sure
to say nothing that can possibly be misunderstood. In spite of this,
at times patients will draw unfavorable inferences and then the nurse
should have the confidence of the patient sufficiently to set the
matter right or at least to give reassurance that will keep the
patient's anxiety from disturbing until the next visit of the surgeon.
All of this seems trivial from a certain standpoint, but even surgery
is as yet an art and not a science. Art depends on personality and the
influence of it and the power to express itself. The personality of
the surgeon must be felt in the patient, and the more he can make it
felt the better the convalescence and the less discomfort even though
there should be more of pain. The amount of pain actually felt depends
on how much of it gets above the threshold of consciousness.

Almost any surgical patient, especially if he has gone through a
serious convalescence, will tell you how much good the visits of his
physician used to do him, though a glum and over-serious surgeon may
have exactly the opposite effect. Sometimes busy surgeons neglect to
visit their patients daily, and nearly always this has an unfortunate
effect. In serious cases, the seeing of the surgeon several times a
day, when it is well understood that his visits are not due to
over-anxiety with regard to the patient, may hasten convalescence
materially.


Comfort, Mental and Physical.--Everything must be done to make the
patients as physically comfortable as possible. It must be well
understood, however, that comfort lies much more in variety and
response to feeling than in any continuous condition. Patients will
have little complaints and there must be always something novel to do
for them. This does not necessarily imply medicine or even troublesome
external applications, but the rearranging of bed clothing, the use of
a hot-water bag or of an ice bag, the relief of pressure, sometimes
mild applications of pressure, the lifting of the head, slight
turning, even small changes of position and the like. Whenever a
patient can be relieved by some means so simple as these external
trifling remedial measures, confidence is awakened that the discomfort
they feel is not due to any serious condition, but is only such achy
tiredness as comes from confinement to bed. Without relief afforded in
this way, they are likely to let unfavorable suggestion accumulate
until their dread of something serious may inhibit convalescence or at
least interfere with sleep and greatly enhance their discomfort
generally. It is the state of mind that develops as a consequence of
continued trifling discomforts and not the physical results of those
discomforts that must be carefully looked to in post-operative
patients.


Nursing.--In the general management of patients after operations it
would be eminently helpful to the surgeon if surgical nurses were
supposed to read at least once a year, Florence Nightingale's "Notes
on Nursing," [Footnote 61] written half a century ago, and if the
surgeon himself should have read it through once at least and dip into
it occasionally afterwards. In her chapter on Noise there are many
remarks that I should like to quote, but the whole chapter is so
valuable that it is hard to know where it stops, and so only a few
expressions may be given here. For instance, "Never to allow a patient
to be waked intentionally or accidentally, is a sine qua non of all
good nursing. If he is aroused out of his first sleep he is almost
certain to have no more sleep." "The more sleep patients get the
better will they be able to sleep." "I have often been surprised
at the thoughtlessness (resulting in cruelty, quite unintentionally)
of friends or of doctors who will hold a long conversation just in the
room or passage adjoining the room of the patient, who is either every
moment expecting them to come in, or who has just seen them, and knows
they are talking about him." "Everything you do in a patient's room
after he is 'put up' for the night increases tenfold the risk of his
having a bad night. Remember, never to lean against, sit upon, or
unnecessarily shake or even touch the bed in which a patient lies."

[Footnote 61: American edition, Appleton, N. Y.. 1860.]

Miss Nightingale, as might be expected, insists emphatically on the
state of the room, the arrangement of the furniture and the
cheerfulness of surroundings as important factors for the cure of
patients. One of the most important elements is, of course, the nurse.
She must be gentle, patient, quick to understand, often ready to
anticipate wishes, and always as noiseless as possible. Slowness may
be neither gentle nor noiseless. Patients, particularly men, often
grow impatient at the slowness with which things are done for them.


Chattering Hopes.--There is scarcely an element of mind in the
patient's environment that Miss Nightingale has not thought of and
touched with very practical wisdom. She deprecates, as does anyone who
knows anything about the care of patients, the "chattering hopes" of
those who try to cheer patients by simply telling them that they ought
to be more cheerful, that of course they will get well and that they
must not be anxious. She says: "I would appeal most seriously to all
friends, visitors, and attendants of the sick to leave off this
practice of attempting to 'cheer' the sick by making light of their
danger and by exaggerating their probabilities of recovery."
Cheerfulness and kindness towards the sick are one thing and foolish
attempts at encouragement not founded on good reasons quite another.


Variety of Thoughts.--From the chapter on Variety the following
quotations show the very practical character of Miss Nightingale's
persuasion as to the value of influencing the patient's mind:

"To any but an old nurse or an old patient the degree would be quite
inconceivable to which the nerves of the sick suffer from seeing the
same walls, the same ceilings, the same surroundings, during a long
confinement to one or two rooms." "The nervous frame really suffers
as much from this lack of variety as the digestive organs from long
monotony of diet." "The effect in sickness, of beautiful objects, of
variety of objects, and especially of brilliancy of color is hardly
at all appreciated."

As Miss Nightingale insists, flowers are remedies of great value for
the ailing and especially for those who are confined to their room for
a long period. She pleads for having the bed placed near a window in
order that they may see out into the fields and the scenery around
them, to which I would add with emphasis, and so that, if it is
possible, they may see the occupations of human beings. Miss
Nightingale adds: "Well people vary their own objects, their own
employments many times a day; and while nursing (!) some bedridden
sufferer then, they let him lie there staring at a dead wall without
any change of object to enable him to vary his thoughts." Quite
needless to say, variety is more important for the ailing than the
well.


Pain Psychic Conditions.--Pain after operation is an extremely common
symptom and often causes much disturbance. Every surgeon knows how
individual are patients in this respect, and how much depends on
the personal reaction to pain. There are men and women who have very
serious lesions, from which much pain might be expected, who complain
very little. There are, on the other hand, many men as well as women
who complain exaggeratedly after even trifling surgical intervention.
We have probably had some of the most striking examples of the
influence of mind over body in these cases. Many a patient who
complained bitterly of torment that made it impossible to rest has,
after being given a preliminary dose of morphine hypodermically,
subsequently been given less and less of that drug, until finally,
after a few days, he was getting injections of only distilled water.
Without their injection he was in agony. After it he settled down to a
quiet, peaceful night. Very often it is noted that these pains are
worse at night and there is a tendency for such patients to attract
attention only at such times as may be productive of considerable
disturbance of the regular order and as may call special attention to
them. We used to call such conditions hysteria, though, of course,
they have nothing to do with the uterus and must be looked for in men
quite as well as women.


Psychoneuroses.--These neurotic conditions, to use a term that carries
no innuendo with it, may affect other functions besides that of
sensation. Occasionally a neurologist is asked to see a patient in
whom, following an operation, usually not very serious, some paralytic
symptoms have developed. There is an inability to use one or more
limbs, and the suspicion of thrombosis is raised. It is rather easy,
however, to differentiate thrombotic conditions from neurotic palsies.
The ordinary symptoms of the psychoneurosis are present. There is
likely to be considerable disturbance of sensation, with patches of
anesthesia and hyperesthesia, some narrowing of the fields of vision,
and anesthesia of the pharynx, sometimes even of the conjunctiva.
Often there is something in the history that points to the possible
occurrence of a neurotic condition. Sometimes it is extremely
difficult to get such patients over the mental persuasion that is the
basis of their palsy, but usually it can be accomplished by suggestion
in connection with certain physical means. Electricity is often of
excellent effect in demonstrating to these patients that their muscles
react properly under stimulus and that it is only a question of
inability to use them because of mental inhibition. Such conditions as
astasia-abasia may develop quite apart from surgery, but there is
always some "insult," as the Germans say, that is some physical basis
for them, and so they are often considered to be surgical.


Psychic Disturbance of Function.--Besides motion and pain, other
functions may be affected through the mind. After operations within
the abdomen it is sometimes difficult to move the bowels when it is
desired to do so. It must not be forgotten that not infrequently in
these cases the patient's mental attitude of extreme solicitude with
regard to his intestines is inhibiting peristalsis. Such constipation
will sometimes not yield to even rather strong purgatives, and yet
will promptly be bettered by something that alters the mental state.
It must not be forgotten that it is in cases of neurotic constipation
that pittulae micarum panis have proven particularly useful. In the
chapter on Constipation there is a discussion of this subject that
will often prove suggestive to surgeons.

This same thing is true with regard to post-operative urination. In
women, particularly, there may be difficulty of urination after
vaginal operations, which may be attributed to some lesion of the
urinary tract and yet only be due to failure of the patient properly
to control muscles in these cases. As in obstetrical cases, position,
the presence of others, and the mental disturbance, may inhibit
urination. The subject is discussed more fully in the section on
Psychotherapy in Obstetrics. Surgeons are not so inclined now to
insist on absolute post-operative immobility, and even a slight change
of position may enable patients to gain control over their bladders
without the necessity for the use of the catheter, which always
carries an element of danger with it.

The influence of the mental attitude with regard to both of these
functions--intestinal and vesical evacuation--must not be forgotten.
There are many persons who find it extremely difficult to bring about
such evacuations in the lying position. Everything is unusual, and
their exercise of the coordination of muscles necessary to accomplish
these functions is interfered with. It is somewhat like stuttering and
the incapacity of an individual who may be able to talk very well to
close friends and yet stammers just as soon as strangers are present
or he is placed in unusual conditions. It has even been suggested that
there should be some exercise of these functions in the lying position
before operation, in order to accustom patients to the conditions that
will obtain afterwards. They thus become used to their surroundings
and the newer methods required, and, above all, if there should be any
post-operative difficulty, they realize that it is not due directly to
the operation, but rather to the unaccustomed conditions. This proves
helpful in saving them from solicitude and consequent unrest and adds
to the rapidity of convalescence.


Food Craving.--When food is to be given in small quantities and there
is likely to be craving for it, much can be done to save the patient
disquietude and disturbance by giving small portions rather
frequently, rather than distributing it over three times a day, as the
routine of life sometimes suggests. When water has to be denied, small
pieces of ice may occasionally be used with excellent advantage.
Patients learn to look forward to breaks at the end of comparatively
short intervals in their craving, and the accumulative effect is
greatly lessened. It is well understood that whenever people are
absolutely denied anything, they are likely to let their minds dwell
on that fact and crave it much more than would otherwise be the case.
If they can look forward to having even the minutest quantities of
anything that they want, however, craving is much less likely to be
insistent, and the state of mind is much easier to manage. In all of
these cases the confidence of the patient and the lessening of
neurotic tendencies by suggestion means more than most of the physical
remedies that have been recommended. There are some patients who
respond almost in a hypnotic way to suggestion from a physician in
whom they have great confidence.


Position and Peace of Mind.--The patient's general comfort is very
important for the maintenance of a favorable state of mind. It used to
be the custom to keep patients rigidly in one position for days,
sometimes more than a week, after operation. We know now that this is
almost never necessary, and that, of course, it is most fatiguing to
the patient. Keep the ordinary well person absolutely in one position,
without the opportunity to change from side to side even during a
single night, and there will be justifiable complaint of tired
and achy feelings as a consequence. To enforce such a state for
forty-eight hours in those who are well will produce a highly nervous
state, consequent upon the fatigue and soreness of muscles induced.
Hence, the importance of taking every possible means to provide even
slight changes of position for those who have been operated upon. A
number of regular-sized pillows should be provided so that the head
may be raised and lowered, and a number of smaller pillows should be
at hand which can be so placed as to relieve pressure at various parts
and permit the patient to make at least slight changes of position
during the first forty-eight hours. After this, usually definite
alterations of position may be allowed without danger. The surgeon
must think of these elements in the treatment and insist on them with
his nurses, or they will not be carried out. It is possible now to
permit patients to sit up much sooner than before, and, indeed, in
pelvic operations, this is said to be definitely beneficial by
preventing the spread of any infectious material that may be present
into the general peritoneal cavity, and in older people it prevents
the development or, at least, greatly facilitates the dispersion of
congestion or such beginning pneumonic areas from hypostatic
congestion as may be present.





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