Jefferson Medical College - Clinic Yearbook (Philadelphia, PA)

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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

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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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sim, l , l , . A i , l , ' 5 Q. N chest wall He was supposed to have an ankylosis of the shoulder and the X ray plates were thought to show certain changes in the bones and joint which would account for the disability As massage electricity and exercise had accomplished nothing after months of use operation was advised From the general muscular rigidity whenever the patient attempted abduction and from the fact that when this was overcome by persuasion certain movements could be easily carried out a diagnosis of hysterical spastic palsy was made and in ten minutes this boy was carrying the arm up in full extension over his head Massage electricity apparatus operation all have their place but are harmful in this condition since they only prolong it and because it can be quickly cured by psychotherapy An important point is that patients should not be allowed to get into this condition and it is easily prevented. In this connection I would advise all young surgeons to read Colonel Hurst s article in the Osler Memorial Volume on 'What the War Has Taught us About Hysteria. One who doubts the effect of mind over matter should read Klauder's paper Q . A. M. A., November 28, 19251 on the Cutaneous Neuroses, in which he shows among other interesting tests, that by suggestion blisters can be made with postage stamps. The diagnostic habit needs to be cultivated by the surgeon and the young man needs to be taught that there is a something more in the art of surgery than operative skill and technic. The link between surgery and psychology is too important to be neglected. Lawrence Sterne said ofhis teachers at Cambridge that they were men of reading who .z a p : fa II ' , X . . . . - . - . . l i , . Il I WJ i u K 1 pf fi i gl thought that 'wisdom can speak in no other language than Latin and Greek,' and I sometimes think there are too many practitioners of medicine who, in making a diagnosis, depend too much on the laboratory findings and fail to recognize many perfectly patent signs and symptoms which one experienced in the att sees at a glance. The wise practi- tioner knows his Latin and Greek of the laboratories and uses them, but he does not start or stop with them. Cans: thou not minister to a mind diseas'd, Pluck from the memory a rooted sorrow, Raze out the written troubles of the brain, And with some sweet oblivious antidote Cleanse the stuff'd bosom of that perilous stuff Wliich weighs upon the heart? Page Ninety-:ix