Pain Psychic Conditions.—Pain after operation is an extremely common symptom and often causes much disturbance. Every surgeon knows how [{763}] individual are patients in this respect, and how much depends on the personal reaction to pain. There are men and women who have very serious lesions, from which much pain might be expected, who complain very little. There are, on the other hand, many men as well as women who complain exaggeratedly after even trifling surgical intervention. We have probably had some of the most striking examples of the influence of mind over body in these cases. Many a patient who complained bitterly of torment that made it impossible to rest has, after being given a preliminary dose of morphine hypodermically, subsequently been given less and less of that drug, until finally, after a few days, he was getting injections of only distilled water. Without their injection he was in agony. After it he settled down to a quiet, peaceful night. Very often it is noted that these pains are worse at night and there is a tendency for such patients to attract attention only at such times as may be productive of considerable disturbance of the regular order and as may call special attention to them. We used to call such conditions hysteria, though, of course, they have nothing to do with the uterus and must be looked for in men quite as well as women.
Psychoneuroses.—These neurotic conditions, to use a term that carries no innuendo with it, may affect other functions besides that of sensation. Occasionally a neurologist is asked to see a patient in whom, following an operation, usually not very serious, some paralytic symptoms have developed. There is an inability to use one or more limbs, and the suspicion of thrombosis is raised. It is rather easy, however, to differentiate thrombotic conditions from neurotic palsies. The ordinary symptoms of the psychoneurosis are present. There is likely to be considerable disturbance of sensation, with patches of anesthesia and hyperesthesia, some narrowing of the fields of vision, and anesthesia of the pharynx, sometimes even of the conjunctiva. Often there is something in the history that points to the possible occurrence of a neurotic condition. Sometimes it is extremely difficult to get such patients over the mental persuasion that is the basis of their palsy, but usually it can be accomplished by suggestion in connection with certain physical means. Electricity is often of excellent effect in demonstrating to these patients that their muscles react properly under stimulus and that it is only a question of inability to use them because of mental inhibition. Such conditions as astasia-abasia may develop quite apart from surgery, but there is always some "insult," as the Germans say, that is some physical basis for them, and so they are often considered to be surgical.
Psychic Disturbance of Function.—Besides motion and pain, other functions may be affected through the mind. After operations within the abdomen it is sometimes difficult to move the bowels when it is desired to do so. It must not be forgotten that not infrequently in these cases the patient's mental attitude of extreme solicitude with regard to his intestines is inhibiting peristalsis. Such constipation will sometimes not yield to even rather strong purgatives, and yet will promptly be bettered by something that alters the mental state. It must not be forgotten that it is in cases of neurotic constipation that pittulae micarum panis have proven particularly useful. In the chapter on Constipation there is a discussion of this subject that will often prove suggestive to surgeons.
This same thing is true with regard to post-operative urination. In women, [{764}] particularly, there may be difficulty of urination after vaginal operations, which may be attributed to some lesion of the urinary tract and yet only be due to failure of the patient properly to control muscles in these cases. As in obstetrical cases, position, the presence of others, and the mental disturbance, may inhibit urination. The subject is discussed more fully in the section on Psychotherapy in Obstetrics. Surgeons are not so inclined now to insist on absolute post-operative immobility, and even a slight change of position may enable patients to gain control over their bladders without the necessity for the use of the catheter, which always carries an element of danger with it.
The influence of the mental attitude with regard to both of these functions—intestinal and vesical evacuation—must not be forgotten. There are many persons who find it extremely difficult to bring about such evacuations in the lying position. Everything is unusual, and their exercise of the coordination of muscles necessary to accomplish these functions is interfered with. It is somewhat like stuttering and the incapacity of an individual who may be able to talk very well to close friends and yet stammers just as soon as strangers are present or he is placed in unusual conditions. It has even been suggested that there should be some exercise of these functions in the lying position before operation, in order to accustom patients to the conditions that will obtain afterwards. They thus become used to their surroundings and the newer methods required, and, above all, if there should be any post-operative difficulty, they realize that it is not due directly to the operation, but rather to the unaccustomed conditions. This proves helpful in saving them from solicitude and consequent unrest and adds to the rapidity of convalescence.
Food Craving.—When food is to be given in small quantities and there is likely to be craving for it, much can be done to save the patient disquietude and disturbance by giving small portions rather frequently, rather than distributing it over three times a day, as the routine of life sometimes suggests. When water has to be denied, small pieces of ice may occasionally be used with excellent advantage. Patients learn to look forward to breaks at the end of comparatively short intervals in their craving, and the accumulative effect is greatly lessened. It is well understood that whenever people are absolutely denied anything, they are likely to let their minds dwell on that fact and crave it much more than would otherwise be the case. If they can look forward to having even the minutest quantities of anything that they want, however, craving is much less likely to be insistent, and the state of mind is much easier to manage. In all of these cases the confidence of the patient and the lessening of neurotic tendencies by suggestion means more than most of the physical remedies that have been recommended. There are some patients who respond almost in a hypnotic way to suggestion from a physician in whom they have great confidence.
Position and Peace of Mind.—The patient's general comfort is very important for the maintenance of a favorable state of mind. It used to be the custom to keep patients rigidly in one position for days, sometimes more than a week, after operation. We know now that this is almost never necessary, and that, of course, it is most fatiguing to the patient. Keep the ordinary well person absolutely in one position, without the opportunity to change from side to side even during a single night, and there will be justifiable [{765}] complaint of tired and achy feelings as a consequence. To enforce such a state for forty-eight hours in those who are well will produce a highly nervous state, consequent upon the fatigue and soreness of muscles induced. Hence, the importance of taking every possible means to provide even slight changes of position for those who have been operated upon. A number of regular-sized pillows should be provided so that the head may be raised and lowered, and a number of smaller pillows should be at hand which can be so placed as to relieve pressure at various parts and permit the patient to make at least slight changes of position during the first forty-eight hours. After this, usually definite alterations of position may be allowed without danger. The surgeon must think of these elements in the treatment and insist on them with his nurses, or they will not be carried out. It is possible now to permit patients to sit up much sooner than before, and, indeed, in pelvic operations, this is said to be definitely beneficial by preventing the spread of any infectious material that may be present into the general peritoneal cavity, and in older people it prevents the development or, at least, greatly facilitates the dispersion of congestion or such beginning pneumonic areas from hypostatic congestion as may be present.
APPENDIX I
ILLUSIONS
A physician who wishes to use psychotherapy effectively should know something about physiological psychology, or analytical or experimental psychology, as it is variously called, because of the help that he will derive from it in understanding many of his patients' symptoms. Fortunately this branch is now being taught in some of the medical schools, and the greater requirements for preliminary training bring to the medical school men who have already had a course in this subject. The chapter on Illusions is particularly important because it affords many illustrations of how easy it is to be deceived by the senses and, therefore, how many precautions have to be taken in order to be sure that impressions produced on patients' minds that seriously disturb them may not merely be due to exaggeration of the significance of information brought them by their senses.