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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