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SECTION XX
PSYCHOTHERAPY IN SURGERY

CHAPTER I
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"⁵⁹ 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."

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.

CHAPTER II
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 Championére 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.