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.