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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