By: John Chalmers Da Costa
Source: Albert J. Ochsner. Surgical Diagnosis and Treatment. Philadelphia: Lea & Febiger, 1922.
About the Author: John Chalmers Da Costa (1863–1933) was born in Philadelphia, Pennsylvania, and trained in medicine at Jefferson Medical College. In 1907, he became head of the Department of Surgery and in 1910 became the first Samuel D. Gross Professor at the college.
Da Costa is an important figure in the history of surgery in the United States. His skills as a teacher were renowned and his book Modern Surgery: General and Operative (1894) became a classic text in medical schools throughout the country, running to ten editions (the last edition appeared in 1931). Da Costa also served as editor of the 1905 U.S. edition of Gray's Anatomy and of the English edition of Zuckerman's Operative Surgery. His association with Jefferson Medical College began in 1887, when he took up a post as assistant in the surgical outpatient department and as assistant demonstrator in anatomy, and was to last for over forty years.
During World War I, Da Costa rose to the rank of commander in the Navy. In 1919, he tended to the often-ailing President Woodrow Wilson onboard the George Washington during peace treaty and League of Nations negotiations. He also had a long-standing interest in the fire service and would often ride out with the chief of the Philadelphia Fire Department to assist injured firefighters. Da Costa was involved in psychological medicine as well, since he was a physician at the Pennsylvania Hospital for the Insane before moving to Jefferson. In the following book excerpt, his interests in insanity and surgery come together in a discussion on postoperative insanity.
Varioius states of mental disturbance may become manifest after a surgical operation. For instance: hysterical excitement, delirium, amnesia, confusion, impulses, hypochondria, mental depression, obsessions, especially morbid fears, illusions, hallucinations or actual insanity. Real insanity is rare.
It has been estimated that out of one thousand abdominal operations four will go insane. If we except from cosideration operations upon the ovaries, insanity is no more frequent after abdominal than after other operations….
The anasthetic has a certain depressing influence; in fact, it may actually seem to poison a person. The operation produces shock and loss of blood. The brilliant investigations of Crile, of Cleveland, have shown how brain cells suffer from the influence of shock and how subconscious causes of brain exhaustion are actually at work even when consciousness is abolished by ether or chloroform. Afte an operation a patient may suffer from pain, sleeplessness, worry, fear of death or deformity and from homesickness. Cases of postoperative insanity, except those due to head injury, have possessed predisposition, hereditary or acquired. The surgical operation is an exciting cause acting upon an unstable nervous system. Such patients were predisposed to insanity….
Some years ago, in a paper on the diagnosis of postoperative insanity, I made the following statement:
"The normal, stable, healthy brain will probably never go insane after an operation, unless that operation touched the brain, removed the testicles, or removed the ovaries."
The insanity may come on at once after an operation. In such a case the surgeon is apt to regard the anesthetic as causal. According to Savage, of London, in such a case the patient is insane upon waking up from the anesthetic. I have seen no such case. The usual period of the onset of insanity is from three to ten days after the operation. Acute insanities are apt to come on in a day or two. Certain insane conditions, for instance, states of fixed and limited delusions, may come on much later, even as late as two or three weeks after an operation….
The two most active exciting elements of postoperative insanity are undoubtedly fear and worry…. The immense power of fear in causing physical trouble and mental disaster is well known. Fear may be responsible for miscarriage, paralysis agitans, syncope, grayness of the hair, jaundice, diabetes, epilepsy, and other conditions.
It is well known that it can sober a drunk man, make a mother's milk poison her baby, induce catalepsy, aphasia, amnesia, and various other things.
It need scarcely be a matter of surprise that fear may cause insanity. As I have said, "An anti-operation fear may become a postoperative phobia."
I do not believe, however, that fear or that the sudden and violent manifestation of fear, we call fright, is very often responsible for postoperative insanity.
Of course, most people when they are badly frightened refuse to be operated on. I have found in my surgical experience that people usually come to the operation with calmness and courage, and some of them with actual satisfaction that the moment has come to rid them of pain, or a danger to life, or a harassing disease.
I believe worry is the most common exciting factor. Many surgical cases are terribly worried for a long period before an operation. Worry brought with it apprehension and depression, which hung upon them until they finally decided to have the operation done. Now and then a person will come to an operation expecting to die. Such prophets of evil are always bad patients. Many who, before operation expect to have terrible pain and suffering, morbidly magnify the prospect. We all know the serious condition worry may induce, how it spoils the appetite, impairs the digestion; interferes with sleep; lessens the resisting power; causes loss of flesh and frequently an actual hysterical condition. People thus worried are irritable, highly suspicious, and difficult to deal with, and not unusually are very homesick. Morbid worry is a real cause of insanity….
The treatment of postoperative insanity is to be directed entirely by the alienist. In certain cases we find the patient has been sick for a sufficient length of time to convince us that the attack of insanity is not going to be a very brief one, and we must decide whether or not to commit him to an institution for the insane. It is not possible to care for such cases in a general hospital. We must never make the mistake of sending someone to an institution for the insane when the attack is very temporary, because we wrong a man, and injure all his prospects to let him have the repute of having been a patient in a hospital for the insane, no matter how brief the time he remained there. But a prolonged attack necessitates care in a hospital for the insane.
The postoperative insanity that Da Costa refers to is now known as postoperative delirium. Derived from the Latin word meaning "off the tracks," delirium is a state of acute confusion where the person affected may suffer memory loss and hallucinations and may appear agitated or drowsy in turn. It was known to the great Greek physician Hippocrates (460–370 BCE) and described by physicians in the nineteenth century. Delirium is considered a medical emergency and, if left untreated, it prolongs hospital stays, leads to other complications, and increases the risk of mortality. With treatment, however, postoperative delirium is reversible, typically persisting for around a week.
Although delirium is most commonly a side effect of medication, there are many other causes and it is often observed after surgery, as Da Costa points out. Surveys show that between 5 and 10 percent of surgical patients suffer from postoperative delirium and figures as high as 42 percent are sometimes observed following orthopedic surgery. Older people are more at risk of postoperative delirium, although it can occur at any age.
Da Costa's theory that fear and worry are the prime causes of postoperative delirium is interesting; in fact, postoperative delirium is not well understood, but is thought to arise from a profound and reversible change in brain chemistry. He is correct to emphasize the profound interaction between mind and body, but mistaken in his earlier statement that only brain operations or those involving removal of the testicles or ovaries lead to insanity. Any kind of surgery can lead to postoperative delirium.
Sometimes a person with postoperative delirium will need to remain temporarily hospitalized for their own safety. Da Costa was correct to be concerned about the stigma of confining a person with temporary insanity to an asylum—no doubt he is drawing on his experience as a doctor in such an institution. Clearly he is trying to promote a more enlightened view of the condition. Today, postoperative delirium can be treated with a number of medications, including benzodiazepine tranquilizers, antidepressants, and melatonin. The latter can normalize sleep-wake cycles; it is believed that disruption of these cycles, arising from the disturbance in brain chemistry, may play a role in this type of delirium. Full recovery from delirium—including the postoperative kind—is common, given prompt diagnosis and treatment. But in Da Costa's day, some patients with delirium spent the rest of their lives in institutions for the mentally ill.
Lipowski, Zbigniew J. Delirium: Acute Confusional States. New York: Oxford Uiversity Press, 1990.
Porter, Roy. Madness: A Brief History. Oxford: Oxford University Press, 2003.
Thomas Jefferson University. "Notable Jefferson Alumni of the Past." 〈http://jeffline.tju.edu/SML/archives/exhibits/notable_alumni/john_chalmers_dacosta.html〉 (accessed November 18, 2005).