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CHAPTER III
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.

CHAPTER IV
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,"⁶⁰ 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."

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.