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Mental Influence In Anesthesia





Nowhere in the domain of surgery is the influence of the mind more
important than in the production of anesthesia for surgical purposes.
It is well known that intense preoccupation of mind will make an
individual completely anesthetic even for very severe injuries. In
battle men frequently are severely wounded, yet do not know it, or at
least have no idea of the extent of the wound and of the pain that
ordinarily would be inflicted by it. In the midst of panics, as
during fires, or when crowds are trying to get out of buildings
rapidly, people often suffer severe injuries and know nothing about
them. The story of the woman who lost her ear in the theater panic and
was quite unaware of it until her attention was called to it, is only
one of many striking examples. Men have been known to walk round even
with a broken leg, or with a dislocation with which it proved quite
impossible for them to move, once their mental preoccupation for
others ceased and they had time to think about themselves. Anesthetic
incidents under conditions in which great pain might well be expected
are not uncommon. It is evidently possible so completely to occupy the
mind that pain sensations cannot find their way into the
consciousness.


Pain and Diversion of Mind.--From very old times, attempts have been
made to use this power of the mind to prevent pain, and often with
some results. In preanesthetic surgery, minor operations were
performed rapidly, beginning just after the patient's attention had
been attracted to something else besides the thought of the operation.
Pain is, of course, much less tolerable and seems to the sufferer at
least to be much more severe whenever the attention is concentrated on
it. Specialists in nervous diseases, during the process of eliciting
complaints of pain or tenderness while employing movements or
manipulations, usually try to attract the patient's attention as much
as possible to something else, in order to determine just how much
genuine pain or tenderness is present. Often it is found that, while a
part of the body is complained of as exquisitely tender or it is
averred that a joint cannot, be touched or a limb moved without severe
pain, when the patient's attention is attracted strongly to something
else, deep palpations may be practiced and rather extensive
manipulations can be made without complaint. In these cases very often
the pain is not imaginary, but is slight, due to some physical basis,
and has been very much increased by the concentration of attention on
it. This part, at least of the pain, may be removed by an appeal to
the mind. The principle is valuable when there is question of minor
operations.

Surgeons have often taken advantage of this power of distraction of
attention to relieve pain in surgical manipulations. The story is told
of the French surgeon, Dupuytren, that he was called one day to see a
lady whom he knew very well in order to determine the form of injury
from which she was suffering. He found that she had a dislocation of
the shoulder, and during the manipulations, in order to make his
diagnosis, he almost inevitably inflicted considerable pain. She
complained very bitterly and told him that she understood that he was
very rough with his hospital patients, but he must not be rough with
her. He had hold of her hand at the moment, and, just before grasping
the arm in such a way as to make the manipulations necessary to reduce
the dislocation, he slapped her face and told her that she must not
talk to him while he was treating her. Needless to say, she was deeply
shocked. Before her shock had passed away, Dupuytren had completed the
reduction of the dislocation, and in her preoccupation of mind she
felt almost no pain. She remarked afterwards, however, that she had
suffered so much mental anguish from his unexpected roughness that she
was not sure whether, after all, she had been really spared in her
feelings.


Hypnotic Anesthesia.--When, in the first half of the nineteenth
century, scientific attention was seriously attracted to
hypnotism, it was hoped that this would prove an effective means of
producing anesthesia during surgical operations or at least of greatly
lessening pain. The hope was not disappointed. There was a discussion
on the subject before the Medical Chirurgical Society of London in
1840, and in 1843 Dr. Eliotson wrote a work with the title, "Numerous
Cases of Surgical Operations Without Pain in the Mesmeric State." In
1846 Sir John Forbes wrote in his Review that "the testimony as to the
value of hypnotism as an anesthetic is now of so varied and extensive
a kind as to require an immediate and complete trial of the practice
in surgical cases." At the end of that same year, ether as an
anesthetic was introduced into England, and the first case was
reported under the caption "Animal Magnetism Superseded," which shows
how much attention the previous attempts at hypnotic anesthesia had
attracted. After this, hypnotism was given up for anesthetic purposes
except by a few enthusiastic students of it. These, however, succeeded
in accomplishing much with it. Dr. Esdaile, in India, succeeded in
doing all sorts of operations under hypnotism. Dr. Milne Bramwell, in
"Hypnotism, Its History, Practice and Theory" (London, 1906), lays
down the rules for hypnosis for anesthetic purposes. They are
eminently practical.

While hypnotism can be used to produce anesthesia, it has many
disadvantages. The length of the hypnosis cannot always be arranged so
as to assure anesthesia during the whole of an operation, while in
some cases it will continue after the operation for some time in spite
of every effort on the part of the hypnotist to bring the patient to
himself. Besides, the depth of the hypnosis cannot always be assured,
and sometimes some sensation remains. Patients will groan and wince
and move, though, of course, under ether or chloroform such
manifestations may take place, yet the patient afterwards will give
every assurance that not the slightest pain was felt. In some cases,
however, even where the pain sensation is not severe during an
operation under hypnosis, it may, nevertheless, prove sufficient, when
continued for some time, to bring the patient out of the hypnotic
state.

For short operations of minor character, undoubtedly hypnosis can be
employed successfully. As we explain in the chapter on Hypnotism,
anyone can produce hypnosis who has confidence in his own power and in
whom the patient has trust. There is no need of a special hypnotist,
and there is no special faculty required. There should be some
familiarity with procedures, but any man has just as much hypnotic
power as another. The influence does not pass from the operator to the
subject, but is due to the subject's concentration of his attention so
that there is a short circuiting of association tracts within the
brain very probably, which does not permit the entrance into
consciousness of sensations through any path except one or two,
usually that of hearing, and sometimes of sight, less frequently of
other sensations.


Concentration of Attention.--In a great many cases of minor
operations, such as the opening of a boil of a small abscess, the
pulling of a tooth, the lancing of a gum, or other such procedures, a
surgeon who is confident in his own mental power over his patient can
rather easily produce a state of mind in which the discomfort of the
surgical procedure is greatly minimized. There are certain physical
helps for this. For instance, if patients are asked to breathe rapidly
and deeply for a few minutes, there is a hyperoxygenation of the
blood which seems to obtund sensibility. If patients are told of this,
and then made to breathe rapidly for a half a minute in order that
they may continue consciously their deep, rapid breathing even when
pain is noted, a state of mind is produced from concentration of
attention on their breathing in which painful sensations are greatly
obtunded. The effect is probably more mental than physical, and is
well worth while trying because of the amount of pain it often saves.


Waking Suggestion.--Without resort to hypnotism, much can be
accomplished by mental suggestion in the waking state to lessen the
pain of surgical operations and maneuvers. This is particularly true
as regards nervous persons, who will otherwise emphasize their
discomfort, and for those of lesser intelligence, children, and the
like. Esdaile's experiences in India show how much can be done in this
way. Often the hypnosis was so slight that the patients were perfectly
cognizant of everything that went on around them, yet under the
compelling influence of the assurance of Dr. Esdaile, whom they
trusted completely, they did not complain of pain nor wince even when
considerable surgical intervention was practiced, and they always
assured their friends afterwards that they had felt nothing. I know an
American physician who has an almost similar power over negroes.
Ordinarily it requires more of an anesthetic to produce
insensitiveness to pain in the negro than in a white person. By
personal assurance, by the absolute securing of their confidence, and
through their trust in him, this man is able to produce anesthesia
without the use of more than a minimum quantity of the anesthetic. He
is able to do the same thing with children, and, of course, it is well
known that mental influence over them is extremely important in
limiting the amount of anesthetic that will be necessary.


Personality of Anesthetist.--Some anesthetists by their personal
influence are able to bring patients under the influence of an
anesthetic with much less excitement and, as a consequence, with the
use of much less of the anesthetic than others. It is the same
question of personal influence that extends through all medicine. Some
men seem to have it naturally, and others not, though to some extent,
at least, it may be cultivated. Of course, it is now well understood
that, under no circumstances, should a patient be forced to take an
anesthetic. This is as true for a child as for any other patient. Only
a little management is required to secure the cooperation of even a
young child. Above all, there must be no struggling, and while there
may be a passing stage of excitement, which cannot be entirely
controlled, this can be eliminated by those who are skillful. It may
be necessary, especially in the case of children, for the little
patients to become familiar with the anesthetist. They should see him
on several occasions and should be made to feel that they know him.
The presence of a stranger is enough of itself to excite children and
make them suspicious and resentful of any manipulations. It may be
well for them to have breathed through the cone on several occasions
and to play a sort of game with it. In this way children will often go
under an anesthetic without any struggle or excitement.

It seems a little childish to suggest similar procedures with grown
patients, but even surgeons of long experience with the older methods
who have insisted on the trial being made on their patients have found
much benefit from it. Familiarity with the anesthetist and even with
the inhaler and the breathing through it on several occasions
beforehand, when no anesthetic is being administered, helps many
patients not a little. This preliminary is particularly of help with
regard to nervous patients and especially women. It is very seldom
necessary to use nitrous oxide as a preliminary to ether if this mode
of procedure is practiced.


Mental Diversion.--It is well to concentrate the mind of the patient
on something else besides his sensations. One element that is
extremely important for anesthesia is deep breathing. The patient must
then have his attention called to the necessity for deep breathing and
should frequently have the suggestion to this effect repeated in his
ear as he comes under the anesthetic. There should be some practice in
deep breathing deliberately beforehand, with the idea of accustoming
the respiratory mechanism to take deep breaths by habit even when not
entirely under the control of the will. This may be done with the
inhaler on a few occasions at least. The occupation of attention
necessary for deep breathing during the taking of the anesthetic
lessens the concentration of mind on the feelings, and actually makes
the discomfort much less. Besides, deep breathing distributes the
anesthetic over the lungs, leads to its absorption more rapidly, and
makes the irritation of the anesthetic less by diffusing it over a
larger surface. On the contrary, short, rapid breaths lead to an
intensity of irritation and much slower absorption.

Skilled anesthetists have found it of decided advantage to keep the
patient's mind fixed on something else besides the breathing. Perhaps
the easiest recommendation is that of locking the hands over the
abdomen just above the umbilicus and asking the patient to hold tight.
This gives something very definite to think about and to occupy the
mind with. I have seen patients of rather nervous organizations go
under the influence of even a very small quantity of an anesthetic
when required to hold their hands thus and when the command was
constantly repeated, "Hold your hands tight," whenever there was the
slightest sign of struggle or excitement. Where this was done
tactfully and regularly, I have seen patient after patient go into
anaesthesia without struggle or excitement and usually without any
noise or even a loud word. I realize how much the personality of the
anaesthetist means in such cases, and I feel sure that anyone who is
confident in his own power in the matter will produce a corresponding
feeling of confidence in the patients.


Fright in Anesthesia.--There seems good reason to think that
occasionally the deaths reported from anesthesia have really occurred
from fright or at least have been greatly influenced by emotional
factors. It has often been noted that these deaths occurred
particularly at the beginning of the administration of an anesthetic
and before anything like a sufficient quantity to produce a toxic
effect had been administered. In other cases it has been noted that
patients were allowed to come out partially from under the anesthetic,
and as they recovered consciousness were disturbed by some incident.
Sometimes the pain seems to act as an inhibitory agent on the heart.
In more than one reported case the patient told afterwards of hearing
very distinctly some remark that seemed to be of bad omen. In one case
in my own experience the breathing and heart stopped (though the
patient fortunately was resuscitated) as a consequence of hearing a
series of rather loud goodbyes said at the door of the elevator
leading to the operating room during the course of an operation
just at a moment when the anaesthetic influence was very much lessened
for a while. In some cases where there has been great fear of the
anesthetic which has been talked over beforehand by the patient, even
a few whiffs of the ether or chloroform have given rise to serious
symptoms from stoppage of the heart. It is evident that it is
extremely important properly to predispose such patients.

The well-known surgical warning not to make remarks during the course
of an operation that might prove disturbing to the patient, needs to
be emphasized. By a very curious psychological anomaly some patients,
though thoroughly anesthetic as regards pain, are able to hear and
understand very well remarks that are made near them. Fortunately,
such patients are few in number, but they are sometimes rather
seriously disturbed by chance observations that for the moment at
least seem to have an unfavorable bearing on their case. Besides,
certain patients sometimes have their special senses come out from
under the influence of the anesthetic before their sense of pain. They
may also hear and be disturbed. These cases illustrate very well the
place of mental influence and how much deliberate attention should be
given to this phase of the treatment of surgical cases coming out of
anesthesia, as well as while more or less under its influence.


Local Anesthesia.--In local anesthesia it has come to be generally
recognized in recent years that the personality of the operator is one
of the most important factors for success. A number of local
anesthetics have been introduced, and in some hands only comparatively
small quantities of them are needed in order to produce complete
absence of pain during operations. In other hands, however,
considerable and even toxic quantities may have to be employed and
sometimes without entire satisfaction. Infiltration anesthesia depends
for its success largely on the personal influence of the administrator
over the patient. It is extremely important that the patient should
have complete confidence and not have that confidence disturbed in any
way. For instance, he needs to be warned that he will feel the slight
prick of the needle when it is first introduced, for otherwise he will
be disturbed by even so slight a pain at the very beginning and will
magnify subsequent feelings until satisfactory local anesthesia
becomes impossible. Without thorough command over the patient and
complete trust, local anesthesia never succeeds except in very minor
operations. There are some men, however, who can do even severe and
extensive operations with comparatively small amounts of local
anesthesia. Others cannot perform satisfactorily even minor operations
with large amounts. It is the operator, his personality, and mental
influence over the patient that counts.


Vomiting After Anesthesia.--The vomiting that comes after anesthesia,
especially with ether, often constitutes not only an annoying but
sometimes a seriously disturbing complication. It must not be
forgotten that vomiting in neurotic individuals, and especially women,
may be largely due to a neurosis. In the section on Psychotherapy in
Obstetrics we discuss the vomiting that occurs in connection with
pregnancy and suggest that it is nearly always neurotic in character.
The best-known European obstetricians are now agreed in this. While
ether produces a tendency to vomit in everyone, in some the actual
vomiting is very slight or completely absent. If patients expect that
there is to be vomiting, if they are of the neurotic temperament that
not only vomits easily but has a tendency to secure sympathy by
fostering this symptom unconsciously perhaps, then the vomiting may
become even a dangerous complication. If there is no expectancy in the
matter, however, but if, on the contrary, it is made clear to these
patients before the anesthetic is administered that, while there may
be some nausea, there need be no vomiting unless they yield too
readily to their feelings, much can be done to lessen the vomiting. A
single suggestion may not mean much in this matter, but a series of
suggestions properly given beforehand, especially if the patient has
seen others vomiting after operations and is worrying about it, may
prove of excellent contrary suggestive value.

If there is no expectancy, the physician must be careful not to arouse
it by over-solicitous anxiety in the matter. A plain statement should
be made on several occasions, however, so that the patient will have
in mind a good basis for contrary suggestion when coming out of the
anesthetic. Many remedies have been suggested for this post-anesthetic
vomiting, but, just as with regard to the vomiting of pregnancy, the
most important element in all the cures that have been reported has
been the influence upon the patient's mind. Whenever we have a number
of remedies for an affection, it is almost sure that it is not their
physical but their psychic effect that is of most importance.





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