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 [{759}] 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 [{760}] 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.