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Mental Influence Before Operation

Much may be done during the preparation for operation to put the
patient in the most suitable condition for the manifestation of
healthy reaction of tissue and of normal convalescence. Many patients
do not come for operation until their health has been somewhat
impaired at least by the condition requiring operation. Not
infrequently a good proportion of this impairment of health is due not
so much to the lesion that is present as to the worry over it and the
anxiety and solicitude which its development has occasioned. If the
lesion is in connection with the digestive tract, this is particularly
likely to be true, and nutrition will often have been sadly interfered
with, not so much by direct influence of the pathological condition as
by the unfavorable mental influence developing in connection with it.
We know now that it is perfectly possible for an indigestion which is
entirely above the neck to make rather serious inroads upon the health
of the patient, by producing dislike for food or at least such loss of
appetite as leads to considerable reduction in weight. In such cases
there are often complications, such as tendencies to constipation,
that still further impair health or at least reduce vitality and
therefore hamper that healthy reaction which should occur after
operation in order to assure normal convalescence.

Accessory Neuroses.--In many of these cases, even where there is a
definite lesion present, the patient can be brought up to normal
weight, or at least his condition can be greatly improved by medical
treatment accompanied by such attention to his state of mind as
will neutralize its unfavorable influence. If he can be made to
understand that a definite effort to increase weight and to bring back
his strength will be of assistance in recovery from the operation, and
that the reestablishment of certain habits of eating and caring for
himself will do much to help in this, very desirable changes for the
better in his general health may be brought about. This is illustrated
very well by what happens in certain incurable cancer cases. The
patients often have lost considerable weight, even thirty to forty
pounds, before an operation is decided on, and then when the operation
is performed their cancer is found to be inoperable. After the
exploration the patient is not told this, but is mercifully spared and
is assured that now he ought to get better, since an operation has
been performed. Such patients have been known to gain twenty, thirty,
and in one case I believe over forty pounds as the result of the
mental influence of this suggestion and the resumption of former
habits of life to some extent at least, consequent upon the
neutralization of the unfavorable state of mind into which they had
sunk before through over-solicitude about themselves. If even the
depressing effect of the toxins of cancer can thus be overcome, it is
easy to understand how much can be accomplished when there is no such
physical factor at work.

Dominant Ideas.--As a general rule, it must be recognized that
patients may be, and indeed frequently are, besides their definite
pathological conditions, under the influence of dominant ideas which
must be recognized and as far as possible neutralized. Some of them
have persuasions with regard to food and the amount that they can eat,
others have removed many important nutritious articles from their diet
and are quite sure that any attempt on their part to take such
articles is sure to be followed by indigestion, and still others have
habits with regard to the amount and the kind of fluids that they take
at meals and between meals and, above all, the lack of fluids in their
diet which need to be overcome. Unless such ideas are counteracted
there is difficulty even in convalescence, and very often they have
brought patients into physical conditions in which whatever
pathological condition is present is emphasized by that over-attention
which the nervous system is so prone to give to even slight sensations
when the organism is in a state of lowered nutrition.

In not a few of these cases the bringing of the patient up to the
normal condition of weight and health, and the removal of the
influence of dominant ideas, will perhaps also remove many of the
indications for operation. There are many patients, and especially
such as are reasonably educated and have some leisure, who get certain
of their organs on their minds and produce symptoms or emphasize such
symptoms as are present until it seems as though an operation is the
only thing that can lift their burden of discomfort and permit them to
go on again with their work. We have all known of physicians who felt
sure that they ought to be operated on for such conditions as gastric
ulcer or duodenal ulcer, though subsequent developments in the case,
when they were persuaded to put off operation and made to reform
certain ill-advised habits, proved that no such lesion as they
suspected had ever been present. Indeed, some of these physicians and
even surgeons have insisted so much that surgical friends occasionally
have operated on them and have found nothing to justify the operation.

Some of these states in connection with discomfort of various kinds in
the abdomen have been discussed in the chapter on Abdominal
Discomfort, and some illustrations of useless operations given. We
must not forget that there is a constant stream of pathological
suggestion in the air at the present time, not only in medical
journals, but even in the secular press, and that this concentrates
the attention of patients on comparatively slight discomforts and
leads to the exaggeration of them until even an operation seems a
welcome relief for them.

Operative Persuasions.--While surgical operations are in practically
all cases mutilations, they are absolutely necessary under certain
circumstances, are often, indeed, life-saving, and there is no doubt
that they have saved mankind a great deal of discomfort. Surgeons are
agreed, however, that they are not to be performed unless they hold
out a definite promise of physical relief. It is extremely important,
then, that patients must not become persuaded of the need of an
operation in their cases unless surgical intervention is really
necessary. This is as true for physicians and even surgeons
themselves, as I have said, as it is for the general public. Women are
much more susceptible than men to operation suggestions, and since it
has become fashionable to talk about their operations, not only has
the deterrent idea of surgical mutilation been greatly lessened, but
there has actually developed in many of them a morbid fascination for
a similar experience with all its attraction of attention and promised
occupation of mind for the woman of leisure.

This phase of the necessity for favorable mental influence has been
especially emphasized in the chapters on Gynecology. Unless,
therefore, there are very definite indications, operations must not be
performed, for they will relieve, as a rule, only for the time being,
and further operations may have to be done to no purpose. Any
physician of reasonably large experience has seen such cases. Patients
get the idea of an operation as their one hope, and then nothing less
than that will produce such diversion of mind as will bring relief of
symptoms. It is important in these cases that such patients should not
have operations suggested to them. Once the suggestion takes hold,
they do not use their reserve energy in such a way as to help out
effectively other remedies that may be given. They distrust all
remedial measures, think that at most they can be only palliative, and
so do not add to other forms of therapeutics the power of
psychotherapy to cure them.

Besides the abdominal conditions, there are certain tuberculous
conditions with regard to which this seems to be particularly true. I
have seen enlarged cervical glands disappear without discharge when
patients have taken up the outdoor life, and, above all, when they
have gone out of the city and have lived the regime proper for those
in whom tubercle bacilli are growing. If such patients, however, once
become persuaded that their glands must be operated on, they are
likely to need, if not active intervention, at least the discharge of
material from their tuberculous lesions before they get well.
Operations of a radical character for tuberculosis used to be much
more popular than they are now, when we are likely to think that
nature can do more for tuberculous lesions in nearly all cases than
the most skillful surgery.

Fractures and the Mind.--In such surgical conditions as fractures and
dislocations, a change has come about in the mode of treatment, at
least in many hands, that seems entirely physical in its effect, yet
has undoubtedly exerted important psychic influences favorable
to recovery which deserve to be noted. In dislocations and fractures,
and particularly the latter, it was the custom in the past to do the
fractured limb up in bandages and then leave it until knitting of the
bones, or, in dislocations, healing of the soft tissues, had taken
place. Apparently it was forgotten that this eminently artificial
condition was not conducive to that healthy reaction of tissues for
reparative purposes which must be expected in these cases. Circulation
was not so good because of the constrictive effect of the bandages;
vitality not so high because of failure of nervous activity in
absolute immobility; the return venous circulation was somewhat
hampered because there were no contractions of muscles; and all the
conditions were distinctly unfavorable, though nature was expected not
only to maintain the health of the part, but bring about the added
functions of repair. In spite of the more or less unfavorable
conditions, nature was able, as a rule, to do so. Prof. Lucas
Championere reintroduced the older method of treating fractures and
dislocations more openly and of even using certain manipulations,
passive movements, and massage in order to encourage the circulation
and the natural vitality of the limb.

There is another phase of the influence of this mode of treatment that
deserves to be recalled. When the fracture is hidden away for many
days and the patient is not absolutely sure whether it is getting on
well or not, solicitude or anxiety is awakened in some minds that
prevents, or at least delays, normal healthy repair. It is well known
by surgeons that fractures do not heal so well after accidents in
which there has been considerable shock, or in which the simultaneous
death of a friend seriously disturbs the patient's mind. Nor do
fractures heal so well if the patient is worried about business
affairs or seriously disturbed over family matters. Among sensitive
patients, a state of mind not unlike that produced by worry or shock
may develop as a consequence of the dread that the fracture may not
heal properly, or that there may be deformity, or that when the
surgeon removes the bandages he may find it necessary either to break
it again or do something that would involve considerable discomfort.
These patients need reassurance. If the surgeon sees the broken limb
occasionally, and, by manipulation and passive movements such as may
properly be used, assures himself as to its condition, the patient's
mind is much better satisfied and that inhibition of trophic processes
which otherwise sometimes occurs is prevented.

Incisions and Suggestion.--Something of this same psychotherapeutic
influence is noted with regard to the healing of incisions when these
are not left without inspection too long. The newer surgical customs
of comparatively few dressings, so that the wound may easily be
inspected and the patient may be completely assured with regard to it,
has undoubtedly had a good influence in bringing about more rapid
repair. Air is the best environment for a healing as well as a healthy
skin, and mental trust is best for the patient's power of repair. In
vigorous individuals such repair will occur anyhow. It is in those of
delicate health, neurotic disposition, and psychoneurotic tendencies,
that reassurances are needed. Often their physical condition is such
that they need every possible aid in bringing about complete repair.
Their state of mind, then, must be noted carefully, and any inhibitory
ideas that may be present because of over-anxiety as to how the
incision is getting on must be removed. This does not mean that
patients' whims should be yielded to in the matter of
over-solicitude about their condition, but that proper care should be
taken to prevent inhibition of trophic influences through unfavorable
mental states just as far as is possible. Most surgeons of experience
do these things in the proper way by instinct from the beginning, or
by a tactful habit, which develops in their surgical experience of
adapting themselves to individual patients. It is well to realize,
however, that such mental attitudes are extremely important and must
be deliberately treated by the surgeon.

Pseudo-rabies.--Certain conditions usually treated of as surgical have
mental relations that are very interesting. There seems no doubt that
in a certain number of cases pseudo-rabies occurs; that is, persons
are bitten by a dog, become seriously disturbed over the possibility
of rabies developing, and after brooding over this for a time their
mind gives way and there is either a neurosis simulating many symptoms
of true rabies, or a state of collapse from fright in which even death
may take place. These cases are not frequent. Their occurrence is
taken by some of those who are opposed to animal experimentation as a
proof that rabies is always some such delusion, and that it is due to
the exaggeration of the significance of dog-bites by the medical
profession that the symptom complex known as rabies has come into
existence. This is, of course, nonsense, and many true cases of rabies
occur. Since, however, these other cases provide the opportunity for
argument in the matter, it is all the more necessary that they should
be recognized for what they are. When a patient has been bitten by a
dog that has not died from rabies within three weeks after the bite,
there is practical certainty that the animal did not have and could
not communicate rabies. The cases of hydrophobia with long incubation
periods are rather dubious, and the general impression now is that
there has been subsequent infection. Patients who are in the midst of
overwhelming dread of the development of rabies must be taken
seriously and their cases treated by mental influence. Suggestion,
instruction, and the neutralization of wrong ideas by reference to
authorities in the matter, must be used to overcome the unfortunate
state of mind which may, if allowed to continue and, above all, to
develop, prove serious for the individual.

Pseudo-rabies is but a type, though the most serious and perhaps most
frequent of what may be called surgical psycho-neuroses. There are
others. Imaginary syphilis is an affection that often causes worry and
trouble to patient and physician. Herpes preputialis with mental
symptoms is almost as bad. These are mental infections of various
kinds. There are many neoplastic persuasions and toxic suggestions
that must be treated with tact and firmness.

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