Jefferson Medical College - Clinic Yearbook (Philadelphia, PA)

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surgeons, he was again operated upon. No ulcer was found but the distal portion of the stomach removed. At the present time he is being treated by a specialist for infection of the gums. Every one of the four surgeons who operated upon this man, was a Fellow of this Association, myself, I am ashamed to say, one of them. This is not an unusual story, but I do not think we learn the lesson which these cases teach. We study our physical results, we take pains to eliminate or lessen the operative risks, but would it not be well to go into the psychologic and gastro-enterologic clinics occasionally and see some of the results of our mistakes in diagnosis and treatment? Would it not be well to have the neurologist see some of these cases before rather than after operation? Oh, I am sure that I am not wide of the mark in insisting that surgical results can be improved by a familiarity on the part of the surgeon with the various neuroses, psychoses and hysterias. I realize that many useless and harmless operations such as being done on the insane at the behest of a few unbalanced actually curing the mental disease. No insane patient is surgical operation done on his abdominal or on her pelvic hysterical patient is invariably made worse ultimately by the removal of the colon are psychiatrists with the idea of ever cured of insanity by a viscera and the neurotic and such operations, which very rightly bring discredit on surgery. It, of course, goes without saying that the insane patient and the neurasthenic, who has a real surgical lesion, should have exactly the same treatment which is given a mentally normal person. In every contact with the patient the surgeon must constantly bear in mind the effect his words and actions may have. Internes and nurses need to have this strongly impressed on them, and here example is better than precept. A perfectly normal woman was recently troubled, upset and disturbed after a colon resection for cancer by her physician who said, Now it is all out and if you don't get an obstruction, you' will be all right. Of course, with every subsequent gas pain she thought that the obstruction had arrived. A surgeon should inspire confidence, assurance and faith, and must be prepared to justify them with a sympathetic and conscientious exhibition of ability. A visit made to a patient after an operation which does not leave him cheered, comforted and more hopeful, had better never been made. It should always be realized that an indiscreet word, an anxious look or a lugubrious manner will leave the patient depressed, worried and full of fear. In the practice of surgery wisdom is as necessary as knowledge and not so easily acquired. Knowledge comes but wisdom lingers. Knowledge is proud that he has learned so much, Wisdom is humble that he knows no more. a recent address to the students of Guy's Hospital, talked on the and said among other good things, Tell the patient something that will keep his imagination from soaring into the regions of unhealthy speculation. I would only add that we should avoid saying or doing anything that would turn the mind into these unpleasant channels. We surgeons every day have to tell poor, suffering, nervous humans unpleasant and disturbing facts, but let us tell them as we would have them told to us. Lying is not necessary and is a poor policy, if for no other reason than that it sooner or later is discovered and destroys confidence. No rule can be laid down, but the patient's mental attitude and the effect upon it by what is said, must be considered. During convalescence co-operation on the part of the patient is most helpful and Ian Hay, in Human Touch, sometimes an absolutely essential element in restoring health and function. Cheering Page Nifzely-four

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That well-trained physician and neurologist of Guy's Hospital, Arthur F. Hurst says: I believe that the most common source of suggestion of hysterical symptoms is some organic disease or injury, the symptoms resulting from which are perpetuated or aggravated by autosuggestion, sometimes with the help of the unconscious hetero- suggestion, produced by the questions and the treatment recommended by the physician if he does not recognize the true nature of the condition. When thus produced, hysterical symptoms always simulate organic symptoms which preceded them more or less closely. In many cases when a certain degree of improvement has occurred in the original organic condition, a mixture of an organic basis with a superimposed hysterical element is present. I believe that this is a much more common event than is generally supposed, and that every organic incapacity tends to suggest a greater incapacity. A good surgeon must be a good diagnostician and should not operate on someone else's diagnosis. If he is not capable of diagnosing the diseases he treats, he should not treat them. In the training of the student and young surgeon, too much stress is laid on surgical technic and too little on the pathology and natural history of disease and on diagnosis. Diagnosis by exclusion is an excellent plan, but we surgeons too often make this a physical exclusion. In other words, in order to make a diagnosis of a neurosis, it should not be necessary to remove first the appendix, then the gall-bladder and then the colon. This method of reaching a diagnosis, which neurologists like to think of as being the surgical method, not only is of no value but by the time the correct diagnosis is made the patient is often beyond hope or he becomes one of the much lauded cures of Christian Science or Osteopathy. just to illustrate that I am not indulging in exaggeration, I should like to refer to the case of a nervous, but fat and healthy-looking young man, who for a number of years had been in the hands of different internists who treated him largely for mucous colitis. He was sent by his physician, who was at the end of his string, to a surgeon with a diagnosis of chronic appendicitis. This was in 1919. There was little evidence of appendicitis but there was present an incomplete hernia. This was operated upon and the appendix removed through the sac. During the next two and a half years this patient continued to complain of vague and indefinite upper abdominal symptoms and was examined and treated by a great many physicians. The surgeon who operatedrfpon him in the first instance doubted the existence of a lesion, but the patient had been to a large sanatarium where his X-ray plates were shown and explained to him as indicating undoubted disease of the gall-bladder, and he was told that operation was imperative. He was then carefully studied by a very capable gastro-enterologist who also advised operation in spite of his undoubted neurotic symptoms. His upper abdomen was opened and the gall-bladder and ducts as well as the stomach and duodenum found to be absolutely normal. These negative findings instead of being a comfort to the patient, only disturbed him the more and he sought advice of another surgeon eighteen months later. This surgeon operated and found his gall-bladder and duodenum adherent, but no other lesion, and removed his gall-bladder. This was in May, 1923. He was cured for a brief season, but his symptoms returned and later another surgeon oper- ated upon him for adhesions which were separated and the colon fixed between the duodenum and the liver. This did not relieve the situation, however, and within a year, on the advice of a distinguished internist, who thought that he might have a duodenal ulcer, in spite of the fact that he had had three previous operations by experienced .A,i' ' J ' Page Ninety-lbree

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friends tell our abdominal cases that they will not get over the effects of the operation for a year and some of them will try their best to carry out the program. Tell a patient after a fracture of the leg that he will be lame for six months, and whether he needs to or not, he will limp for the allotted time. Limps in the absence of shortening or fixation are nearly all hysterical and can be readily overcome. Not only should the surgeon know something of the neuroses, but he should be able to recognize the various manifestations of hysteria and realize their close resemblance to the symptoms of real surgical lesions. We have all known patients to undergo repeated operations for hysterical vomiting and for hysterical intestinal obstruction and then to be disappointed because further operations were refused. In the held of traumatic and industrial surgery, something more is required than a knowledge of surgery. The surgeon in this field must be able to distinguish the real sufferer, the hysterical sufferer and the malingerer, and the last is the most infrequent and the second much more common than is generally believed. Even in many cases in- volving compensation or litigation the apparent malingerer is not a malingerer at all, but suffering from hysteria the result of suggestion at the hands of friends, of fellow-workers, of his legal adviser and of partisan medical experts. This fact is pretty generally known, but do we realize how often it applies to cases in which there is no question of litigation? We must get over the idea that hysteria will always produce the physical stigmata of Charcot. Babinski and others have shown the fallacy of such an idea and that a perfectly normal person can suffer from hysteria. We surgeons can, in out own experience, amply illustrate this fact. The hysterical incapacities after operation and injury are every day occurrences, and although we may not designate them as hysterical, we prevent and cure them by suggestion and persuasion, and in doing so we are practicing psycotherapy, although we may not realize it. I shall always feel indebted to Sir William Oslet for suggesting a visit during the War to a neuropathic hospital in charge of Colonel Hurst, for here I learned in one morning a great deal about hysterical spastic palsy, which has proved of great value since. There are hundreds of men, women and children wearing apparatus or submitting themselves to repeated operations for this condition, who could be easily cured by sug- gestion. These are the patients who largely represent the cures accomplished at Lourdes, at Ste. Anne de Beaupre and at other shrines and by the bone-setters and the Christian Scientists. That these poor people get into this apparently hopeless condition is due largely to the fact that the nature of their affiiction is never properly diagnosed or because we do not know how to prevent or cure it. I saw many cases of perfectly honest British Tommies who had suffered for months, and some for years, from these palsies for which some of them had been discharged from the army as incurable, cured in ten minutes by psychotherapy. A good example is that of a sergeant who had a through- and-rhrough wound of the forearm a number of months previously and who since his arm was taken off the splint had held his fingers tightly flexed on the palm until the growing nails had made ulcers. This man in five minutes was completely extending his fingers, together and individually, much to his own astonishment and joy. Another case in civil life which illustrates very well what I want to say, was that of a young man who was sent to the jefferson Hospital from one of the towns in Northern Pennsylvania. He had had a fracture of the clavicle which a surgeon had wired and following the operation the patient had never been able to abduct the arm more than a few inches from the Page Ninely-five