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 {750} 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.{751}

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 {752} 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 {753} 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.