HISTORY
In this section, the “newer” clinical applications of hypnosis in surgery will be presented. Voltaire once said, “What is new is old, and what is old is not new.” No further proof of this adage is needed than the following:
I put a long knife in at the corner of his mouth, and brought the point out over the cheekbone, dividing the parts between; from this, I pushed it through the skin at the inner corner of the eye, and dissected the cheek back to the nose. The pressure of the tumor had caused the absorption of the anterior wall of the antrum, and on pressing my fingers between it and the bones, it burst, and a shocking gush of blood, and brain-like matter, followed. The tumor extended as far as my fingers could reach under the orbit and cheekbone, and passed into the gullet—having destroyed the bones and partition of the nose. No one touched the man, and I turned his head into any position I desired, without resistance, and there it remained till I wished to move it again: when the blood accumulated, I bent his head forward, and it ran from his mouth as if from a leaden spout. The man never moved, nor showed any signs of life, except an occasional indistinct moan; but when I threw back his head, and passed my fingers into his throat to detach the mass in that direction, the stream of blood was directed into his wind-pipe, and some instinctive effort became necessary for existence; he therefore coughed, and leaned forward, to get rid of the blood; and I suppose that he then awoke. The operation was by this time finished, and he was laid on the floor to have his face sewed up, and while this was doing, he for the first time opened his eyes.
Although it may come as a surprise to the reader, this formidable procedure was performed by James Esdaile in India before 1850!24
To undergo the knife during this period was tantamount to signing one's death warrant. Fear of pain was just as strong as fear of a fatal error by the surgeon. Many preferred death to the excruciating agony experienced during surgery. Those willing to undergo the ordeal usually screamed and struggled, which frequently affected the outcome. Some cursed, prayed, wept, or fainted. The operation invariably produced severe shock, depressive reactions, and other sequelae which delayed convalescence and wound-healing. Most operations were also a frightening procedure even for the calloused surgeon. Pain dominated the scene. Dupuytren summed up the situation for this period: “Pain kills like hemorrhage.”
Four out of every 10 people died. Yet Esdaile's mortality rate was less than 5 per cent in a total of several hundred operations, about 300 of which were major procedures. The latter were all performed under mesmeric coma (hypnoanesthesia) and included the amputation of limbs and breasts and the removal of huge scrotal tumors. Even more interesting is the fact that Esdaile noted that neurogenic shock was noticeably diminished. This is remarkable, as he was without the benefit of anesthesia, modern-day asepsis, refined surgical technics, blood transfusions, and antibiotics. The significance of his observations was not recognized until recently.
RECENT DEVELOPMENTS
Today, more than a century later, hypnosis has been accepted as a valuable therapeutic adjunct to potentiate chemo-anesthesia. However, modern-day hypnotherapists have modified the technics developed by Esdaile, Elliotson, Parker, Cloquet, and other hardy pioneers of the past century. The most significant developments in this area include the use of autohypnosis, suggestions to improve the postoperative period, glove “anesthesia,” and autogenic training. The last named technic, developed by Schultz, employs a rehearsal or a “dry run” of the intended surgery.50 This type of conditioning protects the patient against surprise, fear, and apprehension: the pain threshold is automatically raised by “blocking” the neurophysiologic paths that transmit the painful afferent impulses. No doubt a similar mechanism explains the marked difference in pain perception between most primiparas and multiparas; if one knows what to expect, the fear of the unknown is removed, and painful impulses are to some degree decreased in intensity.
In this connection, it is interesting that one of our patients (Case 1) complained of pain only when the towel clips were placed on her abdomen, prior to the skin incision. This apparently minor detail was inadvertently left out of the rehearsal. Several other patients operated on under hypnoanesthesia had similar experiences, indicating how well perceptual awareness can be organized into a variety of reactions, depending on the range of the adaptive processes.
Hypnoanesthesia has been used successfully for many other major and minor surgical procedures.12,26,30,34,40,47,54,55,56,58 Field used taped instructions for dealing with the emotional stress of surgery.25The results were attributed to patients' satisfaction rather than improved response to surgery.
Despite its effectiveness in major surgery, hypnosis will never be a substitute for chemoanesthesia, since it can be utilized in less than 10 per cent of the cases, and these must be very carefully selected.This figure may be a little high for major surgical procedures, such as laparotomies and amputations, but it is a conservative estimate if minor surgical procedures are included. Then, too, a great many individuals using hypnosis, including the author, do not report their cases unless they are medical firsts. The author recently administered the hypnosis for a vaginal hysterectomy, and near the end analgesia was given. This “contaminated” the hypnoanesthesia, and the case was not reported. The greatest use of hypnoanesthesia is to reduce the need for preoperative medication and chemoanesthesia. It also has other pre- and postoperative advantages.36,37,38
Systematic self-relaxation and self-suggestion to mitigate the discomfort following open heart surgery has been described.31 However, it has been demonstrated that encouragement and reassurance without hypnosis reduced postoperative pain.23
ADVANTAGES AND DISADVANTAGES
Since the use of hypnosis allays fear and tension, induction of inhalation anesthesia is facilitated, anoxemia is reduced, and, because of the profound relaxation, less analgesia and anesthesia are required. In some patients the traditional preoperative administration of morphine, meperdine hydrochloride (Demerol), and pentobarbital sodium often can be eliminated even in those who can enter only the light stage of hypnosis. It is believed that, even in minimal doses, most analgesic agents produce some degree of respiratory depression and lower the blood-oxygen volume. Beecher states, “Narcotics are not necessary for preanesthetic medication but their presence is actually harmful.”2 He found that in patients on placebo medication (0.6 mg. of atropine sulfate), experienced anesthesiologists could not differentiate between those who had received the narcotic and those who had received the placebo. Since this form of suggestion is so effective, obviously hypnoanesthesia would be more efficacious.
Postoperatively, hypnosis is of inestimable value when it is used in suitable patients. For instance, when surgical patients wake up, they usually are afraid to cough because of excessive pain, especially those having upper abdominal operations. In good subjects, trained to enter quickly into hypnosis, fear, and often pain, may be eradicated in a matter of seconds by posthypnotic suggestion.
Through specific posthypnotic suggestions also, the breathing and the cough reflex can be regulated readily. Because of the extreme relaxation, hypnosis also facilitates aspiration through the tracheobronchial passages; this prevents pneumonitis and atelectasis. Excessive postoperative retching usually can be decreased and, in good subjects, this annoying complication can be entirely prevented by posthypnotic suggestions.
The chief disadvantage of hypnosis is its unpredictability and its effectiveness; not every patient responds as expected. Moreover, in those that are hypnotizable, the muscular relaxation may be less than required. As emphasized in the section on dangers, it should not be employed in severely disturbed persons, zealots, or “crackpots.”
Unless the hypnotic conditioning is performed in a group, the procedure can be time-consuming; several hours of preparation may be required. However, since hypnosis is seldom utilized as the anesthetic agent per se, the unpredictability is not a deterrent—even if only partially successful, its advantages outweigh its disadvantages.
INDICATIONS AND REVIEW OF THE LITERATURE
Pharmacologic analgesia and anesthesia, with their ease of administration and effectiveness, are the methods of choice over pure hypnoanesthesia for major surgery because of their reliability. However, where there is a definitive contraindication to all types of chemoanesthesia, hypnoanesthesia is indicated.
Hypnosis, in combination with anesthesia, also can be employed routinely for the poor surgical risk as well as for the debilitated and geriatric patient undergoing major surgery. It also encourages early ambulation, acceptance of surgical deformities, as, for instance, enteric stomas, maintenance of morale during a stormy convalescent period, alleviation of bizarre types of pain and earlier intake of fluids.
The combined approach has been used by Marmer for a thoracotomy for heart disease.42 Another patient, a 42-year-old woman, underwent mitral commissurotomy after receiving only hexylcaine hydrochloride topically for endotracheal intubation and succinylcholine chloride intravenously for muscular relaxation. This patient required no postoperative narcotics or sedatives and manifested total operative amnesia. Marmer concluded that the reassurance induced by hypnosis allays fear, anxiety and tension more effectively than the tranquilizing drugs.
Doberneck and co-workers utilized hypnosis as a pre- and postoperative adjunct in the treatment of 99 surgical cases, including the post-gastrectomy or “dumping” syndrome, postoperative pain, obesity (treated before surgery to lessen the operative risk) and various bizarre forms of pain.17 Striking improvement occurred in 94 per cent of the patients with the dumping syndrome; 26 out of 32 gained an average of 5.4 pounds over an average 14-month follow-up. Posthypnotic suggestions in 31 cases before surgery significantly decreased their postoperative narcotic requirements; the patients were more cooperative and cheerful and less complaining. The relief of various forms of bizarre pain was sometimes spectacular, even occurring several times in patients who had had one to three unsuccessful cordotomies. Hypnosis was particularly effective in unexplained low back pain and pain of metastatic cancer.
Hypnosis is particularly useful for phantom limb pain9,19 as well as for the dumping syndrome.20 The gastric symptoms were present from 8 to 26 months. Two to nine hypnosis sessions were required for remission in four patients. Suggestions were directed toward reduction of tension, removing the fear of the illness, and increasing food and liquid consumption by improving the olfactory appeal of the food itself. Many investigators have used hypnosis in patients who had severe burns; the dressings could be changed without discomfort.4,27,32,42,48,52 Nutritional illnesses are generally helped by the increased caloric intake. Pain, flatulence, and anorexia often respond dramatically; skin grafting is facilitated.
Postoperative hiccoughs are often an annoying complication of surgery. Dorcus and Kirkner observed that hypnosis produced muscular relaxation and alleviated anxiety in a series of 18 cases that were refractory to all other therapies.20 Fourteen patients were permanently relieved, three were not helped, and one benefited temporarily. The author cured two refractory cases of postoperative hiccoughs—one following removal of the gallbladder and the other following a transurethral resection—in one session of hypnosis. Postoperative urinary retention often responds to hypnosuggestive therapy.11,18
Hypnosis is of value in plastic surgery and for dermabrasion.21,22,53 Patients requiring extensive suturing of facial lacerations or intermaxillary wiring of fractures of the mandible and the maxilla do not have airway problems under hypnosis. In most of these cases, a general anesthetic would be hazardous. The apposition of two widely separated areas can be maintained through posthypnotic suggestions while a tissue graft is being transferred from one to the other. Kelsey and Barron secured fixation by these means instead of a plaster of Paris cast, which is uncomfortable, causes sores, immobilizes the joint, and produces a stiffness that may require weeks of physiotherapy. Some subjects under hypnosis can be placed in bizarre postures; their limbs remain fixed until suggestions are given for their release.
Kelsey and Barron described a patient whose right foot was to be repaired with a pedicle graft from the abdomen transported via the left forearm. Under hypnosis, the left arm was fixed in rigid catalepsy against the abdomen through posthypnotic suggestions. This was so effective that it could not be moved voluntarily, nor could it be moved by attendants until it was “unlocked” by later hypnotic suggestions. The position was maintained until released at the next operation 3 weeks later. It was astonishing that, from the moment of release, movement of the elbow and the shoulder joints was full, free, and painless. A similar procedure was adopted for the transfer of the pedicle from the wrist to the forepart of the foot. The arm and the wrist were again placed in the optimal position and locked there under hypnosis. This position was maintained for 28 days, during which the patient slept sitting up! At the end of this time, the arm was unlocked by appropriate posthypnotic suggestions. Immediately, the movements of all the joints, including those of the spine and the fingers, were once again full, free, and painless. Physiotherapists and nurses were trained to reinforce the hypnosis.
A similar and more extensive report describes 13 patients who had pedicle and flap graft surgery.51 Improved morale and marked drug reduction was observed. The real value of hypnosis lies in the positive outlook developed by the patient. The associated relaxation neutralizes pains and aches; insomnia is reduced. Limb projection, if attainable, makes it possible for the patient to feel subjectively that his limbs are in a different position. This is of obvious value during the fixation period required during plastic surgery. A bilateral mammoplasty on a tense and fearful patient has been reported.44 It is believed that hypnosis is valuable for relieving the pain of injuries sustained in accidents.10,44 Hypnosis has been effective in the setting of fractures and the repair of lacerations.44 Hypnosis has been used in disguised form, especially in children, to perform minor surgical procedures.1,5,14,33 With light analgesia and hypnoanesthesia, they also react better and have smoother recoveries. Vaughn has performed an amazing number of all types of major surgery under a combination of light anesthesia and hypnosis. Several amputations of limbs were included in his series.* Bowen has reported on a transurethral resection under self-hypnosis.8 Cataract excision has been reported.49
Hypnosis is a very valuable adjunct for the relief of bizarre types of postoperative pain, such as unexplained backache and abdominal pain, and for controlling the intractable pain of the terminal cancer patient. Through posthypnotic suggestion, autohypnosis and glove anesthesia, the need for opiates is markedly reduced. More important, strong faith and the “will to live” can be exceedingly helpful.
Obstinate constipation following surgery often responds dramatically to appropriate posthypnotic suggestions. Here, too, the posthypnotic suggestions must be directed toward the subjective feelings associated with the act. Werbel1 used posthypnotic suggestions to prevent posthemorrhoidectomy pain in a series of 11 patients.57 Their course was compared with that of the same number of other patients who were not hypnotized and acted as a control group. The first group was advised that rectal pain would not be felt after the surgery, that they would have relaxed bowel movements. All were cued to enter hypnosis readily. Not a single person in the hypnotized group had severe pain, and eight claimed to have less discomfort than anticipated. Its use has been described in anorectal surgery.15
MECHANISM OF HYPNOANESTHESIA
Though the mechanism of hypnoanesthesia is as yet poorly understood, current research indicates that the pain, perceived in the tissues, does not reach the pain receptors in the higher brain centers during hypnosis. With the higher cortical centers inhibited during deep hypnosis, the reticular formation and other subcortical centers prevent the intrusion of painful impulses into awareness. This raises the adaptive responses of the organism to them (painful stimuli). Further psychophysiologic investigations are needed to elucidate the mechanisms by which hypnosis reduces neurogenic shock in surgery.
From an operational standpoint, a subject is relieved of pain when he becomes “relatively inattentive and unconcerned about all stimuli to which the hypnotist does not specifically direct his attention.” If the readiness to respond is minimized, “the sensation of pain” is no longer “painful”; it is an isolated “sensation” unaccompanied by pain.
TECHNICS FOR SURGERY
In order to reduce the surgical candidate's apprehension, the author always has a preliminary discussion with the patient, which may be as follows: “I have taught you hypnotic relaxation. You have demonstrated that you can enter into a very deep state of relaxation and be completely oblivious to all discomfort. Remember you will relax deeper and deeper with each breath you take. You also were able to achieve glove anesthesia readily. Before being taken to the operating room, you will transfer this glove anesthesia to the right side of your abdomen (or wherever the surgical field may be). You will have no more discomfort than you are willing to bear. Should you have even the slightest amount of discomfort, an anesthetic will be available upon your request—either gas, spinal, or procaine. There is no need to have the slightest anticipation because either way you will have a very pleasant experience. You can look forward to your operation without dread or anxiety. I will be present during the entire surgical procedure and will do everything possible to make you comfortable and free from tension.” When using surgical hypnoanesthesia, the patient must be watched carefully. If there is any sign of severe pain manifested by a facial flinch or a grimace, supplementary chemoanesthesia is necessary. Fewer than 10 per cent of individuals can go through an entire major surgical procedure without chemoanalgesia or anesthesia. Therefore, pain relief should not be limited to hypnotic methods, but one must use the balanced approach—hypnoanesthesia together with chemoanesthesia.
With reference to conduction anesthesia, at least half the success of local infiltration is vocal. The ideal method is the joint use of hypnoanesthesia and local anesthesia. One must continually reassure the apprehensive patient in a calm, confident, reassuring voice. Each patient must be inculcated with the idea that the hypnoanesthesia is going to help alleviate his fear and anxiety. The patient picks up this confidence, and he relaxes even further.
REHEARSAL TECHNIC
During a typical rehearsal session for abdominal surgery the patient is told, “Now your skin is being sterilized.” (At this time the abdomen is swabbed with an alcohol sponge.) “I am now stretching the skin and making the incision in the skin.” (The line of incision is lightly stroked with a pencil.) “Now the tissues are being cut. Just relax. You feel nothing, absolutely nothing. Your breathing is getting slower, deeper and more regular. Each side of the incision is being separated by an instrument.” (The skin and the muscles are pulled laterally from the midline.) “Now a blood vessel is being clamped.” (A hemostat is clicked shut.) “You feel absolutely no discomfort. You are calm, quiet and relaxed. Your breathing is getting slower, deeper and more regular. Just relax! Now I am going deeper and entering the abdominal cavity.” (For the peritoneum, suggestions of relaxation and assurances of complete pain relief are repeated several times.) “Just relax. You are getting deeper and deeper relaxed; your heartbeat is getting slower and more regular. Just relax. You feel nothing, absolutely nothing.” The viscera are relatively insensitive to cutting—one does not have to worry about pain. However, the patient has to be prepared for the discomfort produced by pulling and torsion of the abdominal organs.
The steps for closure of the peritoneum, muscles, fascia and skin are also described in a similar manner. There are really only three times when pain can be expected: when the skin is incised, when the peritoneum is incised, and when one is tugging on the viscera.
MAINTENANCE OF HYPNOANESTHESIA DURING SURGERY
The following is a verbalization for maintaining hypnosis: “All the muscles in your body are relaxed, and, with every breath you take, you will find yourself going deeper and deeper relaxed. You are doing fine. Just relax all the muscles of your abdomen and chest. You are breathing slower, deeper, and more regular. That's right. In and out … in and out. Going deeper and deeper relaxed. You feel nothing except a little pressure. The more relaxed you are, the less tension you will have, and the less tension you have, the less discomfort you will have.” Frequently there is a slight trembling of the eyelids. This often is indicative of deep hypnosis. One can use this objective sign to deepen the hypnosis, as follows: “I notice that your lids are now trembling. That's a good sign. And, as they continue to tremble, you will go deeper and deeper relaxed. You feel yourself falling, falling, deeper and deeper relaxed with every breath you take. Remember, if you want to open your eyes at any time, you may. Voices won't bother you.”
Production of catalepsy by light stroking of the skin frequently minimizes capillary bleeding, probably as the result of vasospasm. Here the law of dominant effect is put to use: a psychological suggestion is enhanced by a physiologic effect. As the region that is going to be operated on is stroked lightly, I remark: “This area is getting very stiff, cold and numb. Think, feel and imagine that there is an ice cube on your skin. Now it is getting more numb and colder. Numb and cold. Very, very cold.” This verbalization and the stroking are most advantageous where bleeding from the skin is expected.
If the hypnosis fails during surgery, one can easily switch to intravenous or inhalation anesthesia. It is always advisable to have these available for prompt use.
POSTOPERATIVE VERBALIZATION FOR DEHYPNOTIZATION
Patients are dehypnotized as follows: “You will feel just as if you have awakened from a deep sleep, but, of course, you know you were not asleep. You will be very, very relaxed. Any time in the future when I touch you on the right shoulder, if I have your permission, you will close your eyes and let your eyeballs roll up into the back of your head. Then you will count backward from 100 to zero slowly, and you will go deeper and deeper relaxed with every breath you take and every number you count. You will find that the period after your operation will be a very pleasant one. Should you have any discomfort in and around the wound, you may use the glove anesthesia which you learned to develop to “knock it out.” You will be able to relax and sleep soundly. Should you require medication for sleep, it will make you very sleepy. You will not hesitate to eat the food given to you and, as a matter of fact, you will relish every bite. You will be very, very hungry. The more nutritious food you are able to consume, the faster your tissues will heal. I am going to count to five and you will open your eyes.” Dehypnotization should be done slowly: “You will feel completely alert, refreshed, and wonderful after you open your eyes. One, you are feeling fine. Two, more alert. Three, still more alert. Four, sound in mind, sound in body, no headache. Five, open your eyes. You feel wonderful.”
Marmer and other practitioners use posthypnotic suggestions to ensure a better postoperative recovery as the patient is emerging from the chemoanesthesia.3,43,58 These are repeated again and again while the patient is in the recovery room to provide additional reenforcement.
When general anesthesia is used with hypnosis, the sense of hearing may be acute during the state of analgesia. All remarks should be guarded when in this stage, especially if heavy doses of muscle-relaxant drugs have been given with resultant controlled respiration. Some investigators believe that trauma which may adversely alter the postoperative state can be inflicted by careless remarks.
DISGUISED TECHNIC
The following disguised technic is excellent for patients requiring minor surgery. It makes use of misdirection of attention. First, a bandage or a towel is placed over the patient's eyes. I state: “You are now going to go into a deep state of relaxation. Just close your eyes. Start breathing. Breathe slowly and deeply. With each breath you take, you will feel yourself going deeper and deeper relaxed. And, if you wish to go deeper, all you have to do is start counting backward from 100 to zero. Breathe slowly, deeply and more regularly. And with each number that you count backward, and with every breath you take, you will feel yourself going deeper and deeper relaxed. Now I am inserting the first stitch.” (The needle is gently placed on the edge of the wound; no pressure is employed.) “There, the first stitch is in. You did not feel any pain, did you?” (The patient shakes his head.) “Just relax deeper and deeper and deeper, and with each breath you take, you will feel nothing. Now, here is the second stitch.” (Again one resorts to the same procedure—a hallucinated stitch.) If one maintains a steady flow of words, such as, “You are going deeper and deeper relaxed,” the individual will enter into deep hypnosis without being aware that it is being employed. After rigid catalepsy is produced, anesthesia for the entire area can be suggested. Because belief has been compounded into conviction of anesthesia, it will now be produced automatically. On numerous occasions I have been able to sew up extensive lacerations without the patient's awareness that hypnosis had been induced—all without discomfort.
CASE REPORTS
The following case reports illustrate how hypnoanesthesia, without the use of any type of analgesia or anesthesia, can be employed for major and minor surgery. All the patients were prepared by autohypnosis, glove anesthesia, and the rehearsal technic. During the rehearsal method, every detail in the surgery was fully described while the patient was under deep hypnosis. It should be emphasized that there are few indications for pure hypnoanesthesia. Nor does this author advocate an “all-or-none” approach. However, the following cases were performed under rigidly controlled conditions to demonstrate the authenticity of hypnoanesthesia. The patients, with the exception of Case 1, were selected carefully. This is an important point to consider, as it would be impossible to perform an abdominoperineal resection or lobectomy by hypnosis per se.
Case 1
Mrs. E. W., aged 18, had an extensive excision biopsy for a benign tumor of her left breast. This unselected patient was used to demonstrate the possibilities of hypnoanesthesia before a closed circuit telecast at the annual meeting of the New York State Society of Anesthesiologists in December, 1956.
I saw this patient for the first time the night before surgery and explained the advantages of hypnoanesthesia. On the first attempt, in the presence of the hospital's chief of anesthesiology, Dr. Vincent Collins, she was placed in a deep somnambulistic trance. An indirect and permissive hypnotic technic was employed. The patient was instructed in the method of developing “glove anesthesia” in her right hand and transferring this anesthesia to her left breast. After she had demonstrated satisfactorily that she could do this with ease, a number 15 needle, about 6 or 7 inches in length, was readily passed completely through the breast from the lateral to the medial border. No sign of pain was manifested, nor was there any bleeding. The patient developed a spontaneous amnesia for the entire procedure.
The next day, the surgeon, Dr. W. Mitty, removed the tumor. The start and the finish of the surgery were shown over the telecast and in the presence of a distinguished panel of anesthesiologists.
The surgeon noted the marked relaxation of the tissues, the decrease in bleeding, the complete immobility of the patient and the absence of pain or discomfort. He also stated that he could have performed more extensive surgery, adding, “I would not have believed it if I had not actually done and seen it.”
Upon termination of the surgery, the patient was alerted and had absolutely no recollection of the operation. I asked her if she was ready to undergo the surgery, and she answered “Yes.” On my telling her that the tumor had been removed, she evinced considerable surprise and incredulity. In this instance the posthypnotic amnesia was similar to Esdaile's mesmeric coma. The amnesia could have been removed; this is optional and depends on whether or not the patient wishes to remember any part of the surgical procedure. No preoperative or post-operative medication of any type was used for pain relief, and the patient made an uneventful recovery.
This case is particularly interesting because only one training session was needed, and the entire procedure and the surgery were conducted under extremely difficult conditions. On reflection, the successful outcome can be explained by the following facts: I needed a patient for the telecast demonstration of hypnosis in surgery; this was the only one available, and I just had to induce hypnoanesthesia. It was my determination and self-confidence that established the necessary rapport between the patient and myself and this increased her inherent susceptibility to hypnosis. All these factors contributed to Esdaile's successful use of mesmeric anesthesia.
Case 2
Mrs. G. D., a 28-year-old Para II, gravida II, had an elective cesarean-hysterectomy performed at the Chicago Lying-in Hospital by Dr. S. T. DeLee, without analgesia or anesthesia. This is believed to be the first such case on record.39
The patient experienced no objective or subjective discomfort. She was fully conscious and able to watch the birth of her baby, and there was no discomfort when the baby was delivered by forceps or when the uterus was extirpated. The patient made an uneventful recovery.
Case 3
Mrs. R. W., aged 27, had a subtotal thyroidectomy under hypnotic anesthesia per se. This, too, is believed to be the first such case reported. She was seen eight times; trained to enter a somnambulistic state; and exhibited all the phenomena of deep hypnosis, such as amnesia, age regression, catalepsy, disassociation, glove anesthesia and autohypnosis.
During the last training session, a complete “dry run” rehearsal of the “removal” of the thyroid was done while deeply hypnotized. That anesthesia could be produced by disassociation or glove anesthesia indicates that a subject, even in a hypnotic state, is not at all subservient to the will of the operator.
Through preoperative posthypnotic suggestions she slept for 8 hours. The next morning, the prearranged cue induced a deep hypnotic state. No trace of nervousness was discernible, although she had been extremely fearful and tense the week prior to surgery, so much so that it was necessary to reassure her that she was “not going to die.” Because of their extreme nervousness, hypnotic relaxation is particularly indicated in hyperthyroid and hypertensive individuals who require surgery.
The patient was taken to the operating room in a state characterized by profound neuromuscular relaxation. She transferred the glove anesthesia and produced complete insensibility of the neck. The entire procedure, the removal of both lobes of the thyroid, was performed without discomfort except for the period of traction on the trachea. Immediately after surgery, she sat up, talked and drank a glass of water! She was able to eat immediately and had no nausea or vomiting. The entire operation took about 70 minutes, and the patient stated, “I felt no pain at any time. I could feel only pressure and tugging at my throat. The scalpel felt like a feather being drawn across my neck.” She made a completely uneventful recovery and was not confined to bed during the 5 days in the hospital. The hospital personnel were amazed at the patient's progress; no analgesic drugs were required.
In Cases 2 and 3, not a single bleeder had to be clamped in the skin, probably because of the local ischemia induced by the rigid catalepsy usually associated with deep hypnosis. There was no sign of neurogenic shock, nor did the blood pressure fluctuate appreciably in either case! However, it must be emphasized that these patients were somnambules, and constitute a small percentage of the population. But most individuals can be hypnotized to some degree, and for these hypnosis can potentiate chemoanesthesia.
Crasilneck and Hall discuss other uses of hypnosis in surgery.13 They stress that hypnosis can decrease the need for inhalation anesthesia in the presence of pulmonary infection, that movement can be restricted during delicate surgery under local infiltration, and that patient response is a necessary factor, as in chemopallidectomy. They also describe how the electroencephalogram can be monitored during brain surgery.
Meares discusses the relief of pain of organic origin.45 He uses hypnosis to dull the critical faculties and to countercondition anxiety. He uses dissociation by autohypnosis and an atavistic regression in passive hypnosis to dull alertness to pain. He allows the patient to experience the pain in its pure form, and then conditions the patient by exposing him to increasingly severe, painful stimuli until he develops greater regression and no longer experiences pain.
CONCLUSIONS
Since hypnosis is a multifaceted tool, its effectiveness can be enhanced when it is employed in conjunction with other medical procedures. All physician-hypnotists who use hypnoanesthesia should recognize the limitations of this modality and not try to operate on every patient without careful selection, preparation, and availability of chemoanesthesia. This should promote a healthier acceptance of hypnosis, especially if its advantages are utilized judiciously.
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18. __________: The prevention of postoperative urinary retention by hypnosis. Am. J. Clin. Hypn., 3:235, 1962.
19. Dorcus, R.M., and Goodwin, P.: The treatment of patients with the dumping syndrome by hypnosis. J. Clin. Exp. Hypn., 3:200, 1955.
20. Dorcus, R.M., and Kirkner, F.J.: The control of hiccoughs by hypnotic therapy. J. Clin. Exp. Hypn., 3:104, 1955.
21. Ecker, H.A.: Medical hypnosis in maxillo-facial and plastic surgery. Am. J. Surg., 98:826, 1959.
22. __________: Hypnosis aid in plastic surgery. Factor, 6:7, January 1960.
23. Egbert, D.L., et al.: Reduction of postoperative pain by encouragement and instructions of patients. N. Engl. J. Med., 270:825, 1964.
24. Esdaile, J.: Mesmerism in India and Its Practical Application in Surgery and Medicine. Hartford, England, Silus Andrus & Son, 1850.
25. Field, P.: Effects of tape-recorded hypnotic preparation for surgery. Int. J. Clin. Exp. Hypn., 22:54, 1974.
26. Finer, B.: Experience with hypnosis in clinical anesthesiology. Särtrych Ur Opuscula Medica, 4:1, 1966.
27. Fogelman, M.J., and Crasilneck, H.B.: Food intake and hypnosis. J. Am. Dietetic Assoc., 32:519, 1956.
28. Gentry, R.W.: Hypnosis in surgery (paper delivered at Pan American Medical Association, May 10, 1960).
29. Goldie, L.: Hypnosis in the casualty department. Br. Med. J., 2:1340, 1956.
30. Grant, G.: Suggestion and hypnosis in surgery. Aust. J. Clin. Hypn., 2:6, 1974.
31. Gruen, W.: A successful application of systematic self-relaxation and self-suggestion about postoperative reactions in a case of cardiac surgery. Int. J. Clin. Exp. Hypn., 20:143, 1972.
32. Hartley, R.B.: Hypnosis for alleviation of pain in treatment of burns. Arch. Phys. Med., 43:39, 1968.
33. Hoffman, E.: Hypnosis in general surgery. Am. Surg., 25:163, 1959.
34. Jones, C.G.: Associated uses of hypnosis in surgery. Am. J. Clin. Hypn., 4:270, 1962.
35. Kelsey, J.H., and Barron, R.R.: Hypnosis in plastic surgery. Br. Med. J., 1:756, 1958.
36. Kolough, F.T.: Role of suggestion in surgical convalescence. Arch. Surg., 85:304, 1962.
37. __________: Hypnosis and surgical convalescence: a study of subjective factors in postoperative recovery. Am. J. Clin. Hypn., 7:120, 1964.
38. __________: The frightened surgical patient. Am. J. Clin. Hypn., 10:89, 1968.
39. Kroger, W.S., and DeLee, S.T.: Use of hypnoanesthesia for cesarean section and hysterectomy. J.A.M.A., 163:442, 1957.
40. Lassner, J.: Hypnosis in Anesthesiology: An International Symposium. Berlin, Springer-Verlag, 1964.
41. Le Baw, W.L.: Adjunctive trance therapy with severely burned children. Int. J. Child Psychother., 2:80, 1973.
42. Marmer, M.J.: Hypnoanalgesia and hypnoanesthesia for cardiac surgery. J.A.M.A., 171:512, 1959.
43. __________: Hypnosis in Anesthesiology. Springfield, Ill., Charles C Thomas, 1960.
44. Mason, A.A.: Surgery under hypnosis. Anesthesia, 10:295, 1955.
45. Meares, A.: A System of Medical Hypnosis. Philadelphia, W.B. Saunders, 1960.
46. Mun, C.T.: The use of hypnosis as an adjunct in surgery. Am. J. Clin. Hypn., 8:178, 1966.
47. Nayyar, S.N., and Brady, J.P.: Elevation of depressed skull fracture under hypnosis. J.A.M.A., 181:790, 1962.
48. Pellicone, A.J.: Hypnosis as adjunct to treatment of burns. Am. J. Clin. Hypn., 2:153, 1960.
49. Ruiz, O.R.G., and Fernandez, A.: Hypnosis as an anesthetic in opthalmology. Am. J. Ophthalmol., 50:163, 1960.
50. Schultz, J.H.: Some remarks about techniques of hypnosis as anesthetic, Br. J. Med. Hypn., 5:23, 1954.
51. Scott, D.L.: Hypnosis in plastic surgery. Am. J. Clin. Hypn., 18:98, 1975.
52. Schafer, D.W.: Hypnosis use on a burn unit. Int. J. Clin. Exp. Hypn., 23:1, 1975.
53. Steffanoff, D.N.: Maxillofacial surgery and hypnosis in the emergency and operating room. J. Am. Assoc. Nurs. Anesth., February 1961.
54. Tietelbaum, M.: Hypnosis in surgery and anesthesiology. Anesth. Analg., 47:509, 1967.
55. Tinterow, M.M.: The use of hypnotic anesthesia for major surgical procedures. Am. Surg., 26:732, 1960.
56. Van Dyke, P.B.: Some uses of hypnosis in the management of the surgical patient. Am. J. Clin. Hypn., 12:227, 1970.
57. Werbel, E.W.: Experiences with frequent use of hypnosis in a general surgical practice. West. J. Surg. Obstet. Gynecol., 68:190, 1960.
58. __________: Hypnosis in serious surgical problems. Am. J. Clin. Hypn., 10:44, 1967.
ADDITIONAL READINGS
Cheek, D.B.: Use of preoperative hypnosis to protect patients from careless conversation. Am. J. Clin. Hypn., 3:101, 1960.
__________: Unconscious perception of meaningful sounds during surgical anesthesia as revealed under hypnosis. Am. J. Clin. Hypn., 1:101, 1959.
Mahren, F.J.: Hypnosis and the surgical patient. Am. J. Proctol, 11:459, 1960.