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Psychotherapy In Old-time Surgery

Surgery, a name derived from chirurgy--handwork--might seem to be
dependent almost entirely on mechanical and technical skill, yet there
has always been the conviction that the patient's attitude of mind
towards an operation is almost as important a factor in the success of
surgery as the surgeon's skill.

Astrology in Surgery.--From the earliest history of surgery we, find
that astrology was mainly employed in order to determine what days
were likely to be favorable, and what unfavorable, for the practice of
such surgical procedures as were in vogue at that time. Certain
conjunctions of the planets were declared to be particularly
unfavorable, and some of them, indeed, were declared almost absolutely
fatal; others were said to be especially favorable. As astronomical
and anatomical knowledge grew, more and more details were added in
this matter. Definite portions of the body were supposed to be under
the occult influence of certain constellations. It was only with
careful reference to these constellations then that surgical
procedures or, indeed, the application of remedies of any kind, might
be undertaken. All remember the picture in old almanacs of a man with
the signs of the zodiac around him, and the indications that referred
certain of these signs and the corresponding constellations to the
different parts of the body.

Venesection and the Stars.--When venesection became a frequently
used remedy, the question of the favorable and unfavorable influence
of the stars was an important element in it. In old Babylonia, noted
for its knowledge of astronomy, which was then called astrology
without any of our derogatory meaning in the word, certain positions
of the planets were absolute contraindications for the performance of
venesection. Indeed, astrology often furnished the best possible
excuses for the failure of what were thought to be absolutely specific
remedies. When the remedies did not succeed, their failure was
attributed to their being taken at unfavorable times and not to the
remedies themselves. These astrological ideas continued to influence
medicine, and, above all, surgery, down almost to our own time.
Galileo and Kepler made horoscopes, and Mesmer wrote a thesis on the
influence of the stars on human constitutions. In fact, very few
important patients of the seventeenth and even eighteenth centuries
were treated medically or surgically without due reference to the
stars at the time. All this had a profound influence on the
patient's mind. He felt that every precaution was being taken to
preclude the possibility of failure and assure favorable results, and
he, therefore, submitted to the operation absolutely confident that so
far as human knowledge could go, everything was favorably disposed in
his regard.

Mental Influence in Old Hospitals.--It is rather interesting to
realize how much the history of medicine illustrates the profound
attention that was given in the old times to the question of the
occupation of patients' minds as an eminently helpful factor in the
treatment of disease and, above all, in convalescence. In the great
health resorts, the temple hospitals like that at Epidaurus, or even
the city hospital, the AEsculapeum at Athens, the question of
recreation of mind was evidently considered very important. At Athens,
the two city theaters, the larger one seating perhaps 50,000, and the
smaller, Odeon, were not far from the hospital. At Epidaurus, a
theater seating probably 12,000, in which the great Greek classic
plays were given; a Stadium, seating nearly 10,000, in which athletic
contests were conducted, and a Hippodrome, seating 6,000, in which
animal performances might be witnessed, were all in connection with
the temple hospital. Outdoor sleeping apartments were provided; that
is, the patients slept under a colonnade, and, in general, the mental
and physical hygiene of modern times was thoroughly anticipated. All
of this was considered particularly important for convalescents.
Patients were occupied, while in bed, with various interests. Just as
soon as they could be moved, their minds were occupied with all sorts
of interests external to themselves, and especially such as had the
readiest appeal to humanity. (See bird's-eye view, facing p. 9.)

Medieval Hospitals and the Mind.--It is not difficult to trace the
development of similar conditions in the hospitals of the Middle Ages.
While we are inclined to think of these older hospitals as surely
lacking in everything that we have developed in our modern hospitals,
they prove, on the contrary, to have anticipated most of our hospital
improvements. They were of single story construction, with large
windows high up in the wall so that there could be no drafts, with a
balcony on which patients could sit in the sun, with arrangements for
procuring privacy rather easily by means of sliding partitions, with
tiled floors, and, above all, with pictures on the walls, some of them
the products of the brush of the great artists of the old time and
which would serve to occupy patients' minds. Probably nothing is worse
for patients who are convalescing from illness or operation than to be
left to their own thoughts. Often they must not be talked to overmuch,
or permitted the exertion of conversation or of reading, yet they must
have some occupation of mind. The frescoes painted directly on the
walls of the old hospitals were eminently psychotherapeutic in this
respect, and we shall probably have to imitate them. Besides, the
patients had the opportunity every morning to hear Mass, which was
said at an altar at an end of the ward, and certain religious
exercises were conducted by the sister nurses each afternoon. How much
of consolation this was to believing patients at a time when all were
believers is rather easy to understand.

Medieval Surgeons and Mental Influence.--Some of the insistence on
this favorable state of mind for operations during the Middle Ages is
extremely interesting. One of the great surgeons of the fourteenth
century was Mondeville, whose text-book has recently been published in
both France and Germany. I have translated in "Old-time Makers
of Medicine" [Footnote 60] some of his emphatic expressions, which
show how important he deemed it to keep the patient in as favorable a
state of mind as possible before and after operations. He went so far
as to suggest that someone should be deliberately called in to tell
him jokes. He said, "Let the surgeon take care to regulate the whole
regimen of the patient's life for joy and happiness by promising that
he will soon be well, by allowing his relatives and special friends to
cheer him, and by having someone to tell him jokes, and let him be
solaced also by music on the viol or psaltery. The surgeon must forbid
anger, hatred, and sadness in the patient, and remind him that the
body grows fat from joy and thin from sadness. He must insist on the
patient obeying him faithfully in all things." He repeats with
approval the expression of Avicenna that "often the confidence of the
patient in his physician does more for the cure of his disease than
the physician with all his remedies."

[Footnote 60: Fordham University Press, 1911.]

Mondeville was but one of the great surgeons of the medieval period
who dwelt on this. It would not be hard to find corresponding
expressions in the books of such men as Guy de Chauliac, Hugh of
Lucca, Theodoric, or even earlier among the great Arabian physicians
and surgeons. Rhazes, for instance, declared that "physicians ought to
console their patients even if the signs of impending death seem to be
present, for the bodies of men are dependent on their spirits." He
considered that the most valuable thing for the physician to do was to
increase the patient's natural vitality. Hence his advice: "In
treating a patient, let your first thought be to strengthen his
natural vitality. If you strengthen that, you remove ever so many ills
without more ado. If you weaken it, however, by the remedies that you
use, you always work harm." Another of his aphorisms seems worth while
quoting: "The patient who consults a great many physicians is likely
to have a very confused state of mind." For him a confused state of
mind evidently meant a lessened tendency to recovery.

Surgical Lesions Influenced.--The King's touch in England, which so
often proved beneficial for scrofulous patients, illustrates very well
how much strong mental influence may avail even in cases where surgery
seems surely indicated. Many cases of epilepsy were also greatly
benefited by the King's touch, and, indeed, in this matter there are
probably many more cases of the cure of epilepsy, or at least relief
of the worst symptoms of the affection, reported as following the
King's touch than after operation in the modern time. In both sets of
cases we are now confident that the good effects produced came through
the minds of the patients. When, during the eighteenth century,
Mesmerism began to attract attention, investigators and experimenters
on the subject were able to show that many pains and aches could be
greatly benefited by psychic treatment. The painful conditions
following fractures and sprains proved to be particularly amenable to
mental influence exerted in this special way. As we approach the
modern time, there comes to be a definite recognition of the fact that
the mind may produce many pains and aches which seem due to purely
physical conditions that might be expected to yield only to physical
treatment. A corresponding recognition of the power of the mind to
lessen and even suppress actual physical pain is almost a corrollary
of this.

Sir Benjamin Brodie declared, as I have quoted in the section on
"Diseases of the Muscular and Articular System" that a large
proportion of the painful joint conditions that he saw among his
better-to-do patients were of the hysterical or neurotic type. Sir
James Paget thought this expression of Brodie an exaggeration, but
acknowledged that one-fifth to one-fourth of all his cases in both
hospital and private practice were due to hysteria. In those days most
of the painful conditions were considered to belong rather to surgery
than to medicine, so that these opinions represent very well the
practice of medicine in these cases during the early nineteenth

During the nineteenth century great practical surgeons, and especially
those who have taught us how to treat individual patients rather than
their diseases--for it is quite as true in surgery as in medicine that
the patient is more than his disease--have made distinct contributions
to the department of psychotherapy in surgery. Dr. Hilton's great book
on "Rest and Pain" is full of psychotherapy. His cases illustrate the
fact that when patients' minds and bodies are set at rest, all sorts
of serious conditions proceed to get better. The rest of mind, the
cessation of worry, the presence of a feeling of confidence in
recovery, is quite as important as the physical measures. Young
surgeons particularly probably could not do better than follow the
advice of the old Scotch surgical professor at Edinburgh who suggests
to his pupils that they should read Hilton's "Rest and Pain" at least
once a year.

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