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

century.



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.