122
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MARCH, 1975
The Use of Hypnosis in Anesthesiology* CAPT CLYDE W JONES, MC, USN. Chairman, Departmnentt of' Ansthesiologv, Naval Regional Medical Cemter; Sami Die,go, Calili)rnia
In the development of the science of pain relief, hypnosis played a most important historical role, and has much to offer in contemporary anesthetic practice. Unfortunately, hypnosis has become identified with the mysterious and occult, but when these misconceptions are dispelled, hypnosis can, when used by trained personnel, be of significant value to medical practice in general and to the practice of anesthesiology in particular. Before chemical anesthesia was discovered (1844,46) hypnosis represented the only available method of pain relief, beyond traditional and questionable administration of alcohol and other drugs of limited value. HISTORY
Hypnosis was practiced in many forms in primitive times. Medicine men, witch doctors, and religious leaders of many primitive cultures and nations used hypnotic techniques without realizing it. Ceremonial rites of many types were used to induce a sleep-like state, or the religious or royal healer used merely the laying on of hands to effect miraculous cures. Some view the ancient religious rite of exorcism as a form of hypnosis. The most celebrated proponent of what is now known as hypnosis was Franz A. Mesmer, who described animal magnetism. A 1766 graduate of the University of Vienna, Mesmer claimed that he had the power to transmit the "harnessed powers of the cosmic energies", which he did by the use of a magnet, thus banishing pain and suffering. When several thousand patients flocked to him to receive the cosmic energies, he performed mass healings by transferring the energy from the magnet to a wooden rod and thence to the multitude by *The opinions or assertions in this paper aire those of the author aind atre not to be construed ais official or reflecting the views of the Navy Department or the Naivati Service at large
waving the rod at groups of patients simultaneously. Finally, Mesmer claimed that the healing force emanated from his own body and was conferred by the laying on of hands. This theory of animal magnetism was believed by such luminaries as Marie Antoinette and Lafayette. A commission exposed Mesmer as a fraud in 1784. Serving on this commission were Benjamin Franklin and the celebrated French surgeon, Dr. J. Guillotin. Somnambulism, an off-shoot of mesmerism, was started by one on Mesmer's pupils, Count Maxine du Puysegur. This technique, in which the patient, in a trance-like state obeyed commands, spread to other parts of Europe. In the British Isles, James Esdaile and John Elliotson of Edinburgh explored the use of hypnosis as a means of relieving surgical pain. When leading surgeons in Europe were skeptical, Esdaile journeyed to India to further his knowledge from certain Indian castes, familiar with this procedure. Though successful in a few operations, hypnosis, a term coined by James Baird of Manchester, was not generally successful in Europe or the U.S.A. In Nancy, France, the Nancy School was founded, where physicians from all over the world came for instruction in hypnotic techniques. In World War I and World War II hypnosis was used in cases such as battle fatigue, again leading to its use in anesthesia and in the post-operative management of pain. Organized medicine was slow to accept this controversial form of therapy. In 1955, the British Medical Association officially endorsed the teaching of hypnosis in medical schools, and subsequently the American Medical Association followed suit. Yet few schools offer such courses even today. In 1958, the AMA had nine consultants investigate the clinical
Vol. 67, No. 2
Hypnosis
use of hypnosis. They concluded: 1. Physicians and dentists may use hypnosis as an adjunct to other techniques only in areas of their individual professional competence. 2. Knowledge of the complex nature of the phenomena of hypnosis is essential. Instruction should be broad-based and not limited merely to induction techniques. 3. High-level research is to be launched to unravel the unknown and controversial aspects of hypnosis. 4. The use of hypnosis for entertainment purposes is vigorously condemned.
DEFINITION AND THEORIES
A complete and precise definition of hypnosis is difficult to construct. Most definitions are descriptive more than explanatory. However, if complete understanding of our techniques was a prerequisite to their use, many medical modalities of treatment would have to be abandoned. Hypnosis may be regarded as a temporary state of altered attention in a subject which may be induced by another person or the subject himself, in which there is concentration and suggestibility of superlative degree. A variety of manifestations may appear in response to verbal or other stimuli during this state. Alteration of awareness and memory, anesthesia, muscular relaxation, fatigue, alterations in taste and other senses, etc. may be induced and removed during this hypnotic state. The field of awareness is restricted to a narrow area, thus allowing extreme intensity of concentration. The hypnotist merely directs the utilization of the subject's abilities of concentration and suggestibility to lead him into the hypnotic trance. Despite many theories to explain hypnosis, its true nature remains a mystery. Because of this, many people have associated hypnosis with the supernatural and the occult. Novels and movies have treated the subject in this fashion, even linking it with the subject of reincarnation. This mystique which surrounds hypnosis is largely responsible for its slow acceptance by organized medicine. Some of the theories advanced to explain hypnosis are: conditioned reflex theory, disassociation theory, hysteria theory, role-playing theory, regression theory, psychosomatic theory, hyper-suggestibility theory and many others. There are some people who are poor hypnotic subjects: a) those who lack the ability to concentrate, and those with short attention
123
spans: b) some mentally disturbed persons; and c) highly intelligent people who refuse to concentrate or to accept the idea of hypnosis. We may classify people according to hypnotizability and the depth of trance states obtainable. Modifying factors such as exhaustion, tension, fear, pain, and worry may alter one's hypnotizability index. There are several tests designed to screen and classify subjects as to hypnotizability. People roughly fall in the following categories: Depth Not hynotizable Light trance Medium trance Deep trance Very deel) trance
Applroximate Percentage 10 25 35 20 10
These categories are rough estimations, based on the impressions of many workers. It is to be remembered that the depth of the trance is not the most important factor, but the extent of the rapport and cooperation existing in that special relationship between patient and hypnotist. MISCONCEPTIONS
There are many misconceptions about hypnosis, despite the fact that spontaneous hypnotic trance occurs in almost everyone, such as when day dreaming, watching TV., listening to lectures, and so forth. Some of the popular misconceptions are: Hypnosis is a sleep state. Far from being a sleep state hypnosis is a state of intense concentration, though the field is narrowed. Closing the eyes limits distraction and improves concentration. Good subjects can be hypnotized without closure of the eyes. Hypnosis is, then, a waking state of extreme concentration and suggestibility. The will is surrendered in hypnosis. The myth of the surrender of the will in hypnosis has been made popular by the movies-e.g. "Dracula". The hypnotist merely directs the subject's concentration just as an orchestra leader directs. The will of the subject remains his own. This is an unfounded fear. Hypnosis requires a weak mind.Since hypnosis requires great concenration, those who concentrate best are generally the best subjects. The weak minded are therefore not the best subjects.
124
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Hypnotizability is synonymous with gullibility. Hypnotizability is not the same as gullibility. Again it must be emphasized that the hypnotist does not have any mental mastery over the subject, nor does he preempt the patient's thought. He merely directs the concentration. The power of the hypnotist (male vs. female). A hypnotist does not have to be a strong personality, making males better hypnotists than females, nor, conversely, are women better subjects than men because of their sex. The power of the hypnotist is limited to the cooperation of the subject, irrespective of sex. Hypnosis is dangerous. Hypnosis as used in medical context is not dangerous. Trust and cooperation are the sine qua non of hypnosis. An unscrupulous hypnotist could theoretically trick a subject into doing something unethical or improper, but that hardly means that there is anything intrinsically dangerous in hypnosis. Possibility of not being dehypnotized. Some people are of the opinion that a hypnotist may be unable to dehypnotize a subject. Since the hypnotist has no power over the subject, spontaneous termination of the trance will occur if the hypnotist fails for any reason. Such misconceptions and fears can render the patient's concentration less than optimum, and thus a poorer hypnotic subject. It is essential that these fears and misconceptions be explained away before hypnosis is induced. To achieve good results the subject must be unencumbered by fear, worry, or mistrust. The rapport between hypnotist and patient must be one of confidence, trust and ease. ACUPUNCTURE AND) HYPNOSIS
When acupuncture anesthesia came to the attention of the Western World a few years ago, some critics were quick to point out, "this is a variation on the theme of hypnosis." Chinese acupuncturists were equally quick to assert that acupuncture has been used successfully in animals, thus destroying the hypnosis theory. It is the feeling by knowledgeable workers in the field, that though acupuncture is not identical with hypnosis, the best acupuncture patients scored highest on hypnotizability profiles and vice versa. Many therefore conclude that these two modalities utilize the same or
MARCH, 1975
very similar neuro-physiological pathways. INDUCTION OF HIYPNOSIS
As a prerequisite to induction of hypnosis the subject's mind must be placed in a receptive posture, the field of consciousness must be restricted to a narrow area, and suggestions must be given to the subject in a manner that full acceptance can be achieved. There are many methods of achieving these objectives, by fixing the eyes on an object, the use of lights, hypnodisks or the pendulum. Most hypnotists use a combination of the above plus vocal suggestions or the voice alone. After preinduction explanation and relaxation a rapid induction by use of the voice alone can be achieved in a large percentage of patients. Once the trance has been induced it can be deepened by a variety of techniques including post-hypnotic suggestion. The depth of the trance can be tested and demonstration of profound muscular relaxation and catalepsy, and skin anesthesia will reinforce the confidence of the patient and allow more profound trance states to develop. USE OF HYPNOSIS IN MEDICINE
Hypnosis has many uses in medicine generally, and in anesthesiology in particular. It may be used: a) as a tool to study some human problems such as "conflict" which results in anxiety and tension; b) in rehabilitation; c) in appetite control and in the control of smoking and other habits; d) as an adjunct to psychiatric management; and e) in the management of headache, allergies, impotence, colitis, alcoholism, speech problems, hyperemesis gravidarum, and many others. USE IN ANESTHESIOLOGY
In anesthesiology, hypnosis can be an exceedingly valuable tool. It is not a substitute for chemical anesthesia, but is used as an adjunct to conventional anesthetic techniques. Pain, in man, can be separated into two components: first, the physical stimulus which causes the pain; and second, the total emotional response to the pain. The secondary anxiety, muscle tension, and apprehension compound the physical symptoms and inten-
Vol. 67, No. 2
Hypnosis
sity of the pain. In reducing or eliminating these secondary modifiers of pain, hypnosis serves one of its most valuable roles in anesthesiology. It does not make the pain disappear, but it aids in the reprocessing of pain perception to a less annoying level by blocking neurophysiologic paths. Other uses of hypnosis in anesthesia include: 1) Conditioning the patient against fear, surprise and apprehension. The operating room scene may be rehearsed. This results in a more tranquil patient, leading to smoother induction and management of the anesthetic. This is preferred to drug-induced tranquility in an anxious patient. 2) To assist induction of anesthesia. 3) As sole anesthetic in minor surgery, and occasionally in major surgery. 4) To treat post-op hiccoughs, nausea, and other problems. 5) To ease post-op tension, fear, pain, fear of coughing and thus decrease the need for analgesics-usually by posthypnotic suggestion. 6) In pain states of all kinds, including phantom limb. 7) To assist patients who must be treated by immobilization with appliances, or in uncomfortable or bizarre positions (e.g. body casts, pedicle grafts). 8) To improve overall attitude toward the total surgical experience. Though hypnosis takes times, the experienced hypnotist can use the time available more efficiently. Intra-operatively we, as anesthetists, have a significant opportunity to enhance our credibility with the patient. A suggestion of drowsiness and relaxation, supported by a small dose of Pentothal and a test dose of curare, makes a believer out of the most incredulous skeptic. The suggestibility of such a patient receives a boost from this judicious intravenous therapy. SPECIAL CASES
At the Naval Regional Medical Center, San Diego, we have put the technique of hypnosis to special use in the management of scoliosis by Harrington rod fusion. Because of the possibility of compression of the vascular
125
supply to the cord or compression of the cord itself, when the cord is straightened by action of the rod, it is useful if the surgeon can rule out this problem or take corrective measures before changes become irreversible. For this reason, it is desirable for the patient to be able to carry out certain voluntary movements of the lower extremities on the operating table soon after the rod is tightened into position. Waiting for return of consciousness in the recovery room would be too long a time for effective corrective measures to be accomplished if such vascular compromise went undetected. To solve this problem, the technique of hypnosis has been utilized. The patients are admitted a week or more before surgery, and while the pre-operative workup and studies are being performed, the anesthesiologist works with the patient. Hypnotic trance is induced on several occasions, after a thorough explanation of the technique of hypnosis and the specific objectives to be achieved. Not only is the importance of the intra-operative tests emphasized, but the success of hypnosis in the management of pre-operative apprehension, immediate post-operative pain and discomfort, and the long range immobilization and decreased activity attendant to the surgical management of this condition are presented. The patient, under hypnosis, is familiarized with the operating room situation, and a group of lower extremity voluntary movements, designed to test whether cord compression is present, rehearsed in random sequence. Posthypnotic suggestions relative to post-operative pain and discomfort aretalso given at this time. The number of sessions varies depending on the patient's hypnotizability, the better subjects generally requiring fewer sessions. On the day of surgery anesthesia is induced with I.V. Pentothal and/or Valium, and maintained with I.V. narcotics, relaxants, and nitrous oxide and oxygen by endotracheal tube. When the Harrington rod is placed and straightened as desired, the surgeon notifies us. With 15-20 minutes lead time, the patient can be dependably awakened on the table and the tests performed on the instructions of the (Concluded on page 175)
Vol. 67, No. 2
Medical History
and heroine. In June 1914 President Scarborough of Wilberforce University wrote: "Dr. Susan McKinneySteward, our resident physician for a number of years, has been faithful in looking after the young people in need of medical attention. I am very glad to commend her and her services, and to say that to have such a woman connected with the institution, where there is a large attendance of girls, is indispensable".5 After her death, as part of her eulogy, the Green County (Ohio) Statistics, printed ". She was one of the best known women of her race, and for years exerted a remarkable influence for good, in and about Wilberforce, where she had been practicing her profession since
1898.... "5 To Dr. McKinney-Steward's family one highlight of her career has been recorded as a dramatic and commemorative episode. It was a housecall by train and ship from Ohio to Haiti in 1897 to deliver her first grandson, Louis Holly. Now after 104 years Brooklyn, her native city, has written its epitaph-the Dr. Susan Smith McKinney Junior High School. (Fig. 1). LITERATURE CITED
1. New York Times, February 18, 1901 2. Bulletin of the Medico-Chirurgical Society of the District of Columbia, Inc., Vol. 6, No. 1, p.3, January 1949.
175
3. McKINNEY, W. S., Personal communication, December 23, 1974. 4. STILES, -. History of Kings County, Long Island Historical Society in Brooklyn. 5. McKINNEY, W. S., Personal communications, December 20, 1974 6. Eighth and Twentieth Annual Announcements, New York Medical College, 1870 & 1882. 7. Medical and Surgical Register of the United States. R.L. Polk & Co., 1890. 8. The Brooklyn Directories, 1871 to 1896. 9. STATISTICS, Green County, Ohio, 1918. 10. LYONS, MARITCHA. Woman In Medicine (Intro-
duction). 11. Negro Heritage Library, Volume I. 12. BROWN, HALLEYE Q. Homespun Heroines and Other Women of Distinction. 13. OTTLEY, ROI and WILLIAM G. WEATHERBY.The Negro in New York. 14. New York World-Telegram & Sun, May 9, 1960. 15. Transactions of the Homeopathic Medical Society of the State of New York, Volume XXXI. 16. Catalogues of the Long Island College Hospital, Brooklyn. (in Library of the Medical Society of the County of Kings and Academy of Medicine). 17. New York Daily News, September 26, 1974. 18. New York Times, September 29, 1974. 19. New York Amsterdam News, October 4, 1974. 20. New York Voice, October 4, 1974. 21. New York Recorder, October 4, 1974.
(Jones, from page 125)
anesthesiologist-hypnotist. In over one dozen cases we have had 100% success. Two patients moved other parts of the body during the test, but without complication. Anesthesia is then reinduced and continued. In no case did any patient remember the intra-operative tests. It is my feeling that a mature, cooperative, patient could carry out these tests without the benefit of prior hypnosis. However, reliable and consistent results, without panic on the table, can best be achieved by this technique. We have also been impressed by the general reduction in post-operative pain in these patients. I have continued the hypnotic sessions until discharge of the patient, directing attention to the prolonged period of recuperation and the immobilization and wearing of appliances. The strong motivation to improve their physical appearance on the part of these patients, mostly teenage girls, reinforces their cooperation. We have been impressed by the high percentage of good subjects in this group. Long term followup of these patients has
shown excellent progress, almost without exception. SUMMARY
The history of hypnosis and its contribution to medical practice has been traced, and the many myths and misconceptions surrounding it explained. That an exact definition is still difficult, and that its neurophysiological mechanism still perplexes us, has been revealed, notwithstanding the many areas of medicine to which it can be applied. Hypnosis is not a magic cure-all, but is one of the tools of medical management, which judiciously applied within the bounds of its limitations, and with intelligent and expert selection, can offer much to broaden the scope of medical techniques. Stripped of the many myths which surround it, and placed in proper perspective, hypnosis is seen as a complex phenomenon, but far from mysterious and occult. The field of anesthesiology, due to its concern with the likewise complex matter of pain and its relief, can make good use of hypnosis as a supplement to its many techniques.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
MARCH, 1975
The Use of Hypnosis in Anesthesiology* CAPT CLYDE W JONES, MC, USN. Chairman, Departmnentt of' Ansthesiologv, Naval Regional Medical Cemter; Sami Die,go, Calili)rnia
In the development of the science of pain relief, hypnosis played a most important historical role, and has much to offer in contemporary anesthetic practice. Unfortunately, hypnosis has become identified with the mysterious and occult, but when these misconceptions are dispelled, hypnosis can, when used by trained personnel, be of significant value to medical practice in general and to the practice of anesthesiology in particular. Before chemical anesthesia was discovered (1844,46) hypnosis represented the only available method of pain relief, beyond traditional and questionable administration of alcohol and other drugs of limited value. HISTORY
Hypnosis was practiced in many forms in primitive times. Medicine men, witch doctors, and religious leaders of many primitive cultures and nations used hypnotic techniques without realizing it. Ceremonial rites of many types were used to induce a sleep-like state, or the religious or royal healer used merely the laying on of hands to effect miraculous cures. Some view the ancient religious rite of exorcism as a form of hypnosis. The most celebrated proponent of what is now known as hypnosis was Franz A. Mesmer, who described animal magnetism. A 1766 graduate of the University of Vienna, Mesmer claimed that he had the power to transmit the "harnessed powers of the cosmic energies", which he did by the use of a magnet, thus banishing pain and suffering. When several thousand patients flocked to him to receive the cosmic energies, he performed mass healings by transferring the energy from the magnet to a wooden rod and thence to the multitude by *The opinions or assertions in this paper aire those of the author aind atre not to be construed ais official or reflecting the views of the Navy Department or the Naivati Service at large
waving the rod at groups of patients simultaneously. Finally, Mesmer claimed that the healing force emanated from his own body and was conferred by the laying on of hands. This theory of animal magnetism was believed by such luminaries as Marie Antoinette and Lafayette. A commission exposed Mesmer as a fraud in 1784. Serving on this commission were Benjamin Franklin and the celebrated French surgeon, Dr. J. Guillotin. Somnambulism, an off-shoot of mesmerism, was started by one on Mesmer's pupils, Count Maxine du Puysegur. This technique, in which the patient, in a trance-like state obeyed commands, spread to other parts of Europe. In the British Isles, James Esdaile and John Elliotson of Edinburgh explored the use of hypnosis as a means of relieving surgical pain. When leading surgeons in Europe were skeptical, Esdaile journeyed to India to further his knowledge from certain Indian castes, familiar with this procedure. Though successful in a few operations, hypnosis, a term coined by James Baird of Manchester, was not generally successful in Europe or the U.S.A. In Nancy, France, the Nancy School was founded, where physicians from all over the world came for instruction in hypnotic techniques. In World War I and World War II hypnosis was used in cases such as battle fatigue, again leading to its use in anesthesia and in the post-operative management of pain. Organized medicine was slow to accept this controversial form of therapy. In 1955, the British Medical Association officially endorsed the teaching of hypnosis in medical schools, and subsequently the American Medical Association followed suit. Yet few schools offer such courses even today. In 1958, the AMA had nine consultants investigate the clinical
Vol. 67, No. 2
Hypnosis
use of hypnosis. They concluded: 1. Physicians and dentists may use hypnosis as an adjunct to other techniques only in areas of their individual professional competence. 2. Knowledge of the complex nature of the phenomena of hypnosis is essential. Instruction should be broad-based and not limited merely to induction techniques. 3. High-level research is to be launched to unravel the unknown and controversial aspects of hypnosis. 4. The use of hypnosis for entertainment purposes is vigorously condemned.
DEFINITION AND THEORIES
A complete and precise definition of hypnosis is difficult to construct. Most definitions are descriptive more than explanatory. However, if complete understanding of our techniques was a prerequisite to their use, many medical modalities of treatment would have to be abandoned. Hypnosis may be regarded as a temporary state of altered attention in a subject which may be induced by another person or the subject himself, in which there is concentration and suggestibility of superlative degree. A variety of manifestations may appear in response to verbal or other stimuli during this state. Alteration of awareness and memory, anesthesia, muscular relaxation, fatigue, alterations in taste and other senses, etc. may be induced and removed during this hypnotic state. The field of awareness is restricted to a narrow area, thus allowing extreme intensity of concentration. The hypnotist merely directs the utilization of the subject's abilities of concentration and suggestibility to lead him into the hypnotic trance. Despite many theories to explain hypnosis, its true nature remains a mystery. Because of this, many people have associated hypnosis with the supernatural and the occult. Novels and movies have treated the subject in this fashion, even linking it with the subject of reincarnation. This mystique which surrounds hypnosis is largely responsible for its slow acceptance by organized medicine. Some of the theories advanced to explain hypnosis are: conditioned reflex theory, disassociation theory, hysteria theory, role-playing theory, regression theory, psychosomatic theory, hyper-suggestibility theory and many others. There are some people who are poor hypnotic subjects: a) those who lack the ability to concentrate, and those with short attention
123
spans: b) some mentally disturbed persons; and c) highly intelligent people who refuse to concentrate or to accept the idea of hypnosis. We may classify people according to hypnotizability and the depth of trance states obtainable. Modifying factors such as exhaustion, tension, fear, pain, and worry may alter one's hypnotizability index. There are several tests designed to screen and classify subjects as to hypnotizability. People roughly fall in the following categories: Depth Not hynotizable Light trance Medium trance Deep trance Very deel) trance
Applroximate Percentage 10 25 35 20 10
These categories are rough estimations, based on the impressions of many workers. It is to be remembered that the depth of the trance is not the most important factor, but the extent of the rapport and cooperation existing in that special relationship between patient and hypnotist. MISCONCEPTIONS
There are many misconceptions about hypnosis, despite the fact that spontaneous hypnotic trance occurs in almost everyone, such as when day dreaming, watching TV., listening to lectures, and so forth. Some of the popular misconceptions are: Hypnosis is a sleep state. Far from being a sleep state hypnosis is a state of intense concentration, though the field is narrowed. Closing the eyes limits distraction and improves concentration. Good subjects can be hypnotized without closure of the eyes. Hypnosis is, then, a waking state of extreme concentration and suggestibility. The will is surrendered in hypnosis. The myth of the surrender of the will in hypnosis has been made popular by the movies-e.g. "Dracula". The hypnotist merely directs the subject's concentration just as an orchestra leader directs. The will of the subject remains his own. This is an unfounded fear. Hypnosis requires a weak mind.Since hypnosis requires great concenration, those who concentrate best are generally the best subjects. The weak minded are therefore not the best subjects.
124
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Hypnotizability is synonymous with gullibility. Hypnotizability is not the same as gullibility. Again it must be emphasized that the hypnotist does not have any mental mastery over the subject, nor does he preempt the patient's thought. He merely directs the concentration. The power of the hypnotist (male vs. female). A hypnotist does not have to be a strong personality, making males better hypnotists than females, nor, conversely, are women better subjects than men because of their sex. The power of the hypnotist is limited to the cooperation of the subject, irrespective of sex. Hypnosis is dangerous. Hypnosis as used in medical context is not dangerous. Trust and cooperation are the sine qua non of hypnosis. An unscrupulous hypnotist could theoretically trick a subject into doing something unethical or improper, but that hardly means that there is anything intrinsically dangerous in hypnosis. Possibility of not being dehypnotized. Some people are of the opinion that a hypnotist may be unable to dehypnotize a subject. Since the hypnotist has no power over the subject, spontaneous termination of the trance will occur if the hypnotist fails for any reason. Such misconceptions and fears can render the patient's concentration less than optimum, and thus a poorer hypnotic subject. It is essential that these fears and misconceptions be explained away before hypnosis is induced. To achieve good results the subject must be unencumbered by fear, worry, or mistrust. The rapport between hypnotist and patient must be one of confidence, trust and ease. ACUPUNCTURE AND) HYPNOSIS
When acupuncture anesthesia came to the attention of the Western World a few years ago, some critics were quick to point out, "this is a variation on the theme of hypnosis." Chinese acupuncturists were equally quick to assert that acupuncture has been used successfully in animals, thus destroying the hypnosis theory. It is the feeling by knowledgeable workers in the field, that though acupuncture is not identical with hypnosis, the best acupuncture patients scored highest on hypnotizability profiles and vice versa. Many therefore conclude that these two modalities utilize the same or
MARCH, 1975
very similar neuro-physiological pathways. INDUCTION OF HIYPNOSIS
As a prerequisite to induction of hypnosis the subject's mind must be placed in a receptive posture, the field of consciousness must be restricted to a narrow area, and suggestions must be given to the subject in a manner that full acceptance can be achieved. There are many methods of achieving these objectives, by fixing the eyes on an object, the use of lights, hypnodisks or the pendulum. Most hypnotists use a combination of the above plus vocal suggestions or the voice alone. After preinduction explanation and relaxation a rapid induction by use of the voice alone can be achieved in a large percentage of patients. Once the trance has been induced it can be deepened by a variety of techniques including post-hypnotic suggestion. The depth of the trance can be tested and demonstration of profound muscular relaxation and catalepsy, and skin anesthesia will reinforce the confidence of the patient and allow more profound trance states to develop. USE OF HYPNOSIS IN MEDICINE
Hypnosis has many uses in medicine generally, and in anesthesiology in particular. It may be used: a) as a tool to study some human problems such as "conflict" which results in anxiety and tension; b) in rehabilitation; c) in appetite control and in the control of smoking and other habits; d) as an adjunct to psychiatric management; and e) in the management of headache, allergies, impotence, colitis, alcoholism, speech problems, hyperemesis gravidarum, and many others. USE IN ANESTHESIOLOGY
In anesthesiology, hypnosis can be an exceedingly valuable tool. It is not a substitute for chemical anesthesia, but is used as an adjunct to conventional anesthetic techniques. Pain, in man, can be separated into two components: first, the physical stimulus which causes the pain; and second, the total emotional response to the pain. The secondary anxiety, muscle tension, and apprehension compound the physical symptoms and inten-
Vol. 67, No. 2
Hypnosis
sity of the pain. In reducing or eliminating these secondary modifiers of pain, hypnosis serves one of its most valuable roles in anesthesiology. It does not make the pain disappear, but it aids in the reprocessing of pain perception to a less annoying level by blocking neurophysiologic paths. Other uses of hypnosis in anesthesia include: 1) Conditioning the patient against fear, surprise and apprehension. The operating room scene may be rehearsed. This results in a more tranquil patient, leading to smoother induction and management of the anesthetic. This is preferred to drug-induced tranquility in an anxious patient. 2) To assist induction of anesthesia. 3) As sole anesthetic in minor surgery, and occasionally in major surgery. 4) To treat post-op hiccoughs, nausea, and other problems. 5) To ease post-op tension, fear, pain, fear of coughing and thus decrease the need for analgesics-usually by posthypnotic suggestion. 6) In pain states of all kinds, including phantom limb. 7) To assist patients who must be treated by immobilization with appliances, or in uncomfortable or bizarre positions (e.g. body casts, pedicle grafts). 8) To improve overall attitude toward the total surgical experience. Though hypnosis takes times, the experienced hypnotist can use the time available more efficiently. Intra-operatively we, as anesthetists, have a significant opportunity to enhance our credibility with the patient. A suggestion of drowsiness and relaxation, supported by a small dose of Pentothal and a test dose of curare, makes a believer out of the most incredulous skeptic. The suggestibility of such a patient receives a boost from this judicious intravenous therapy. SPECIAL CASES
At the Naval Regional Medical Center, San Diego, we have put the technique of hypnosis to special use in the management of scoliosis by Harrington rod fusion. Because of the possibility of compression of the vascular
125
supply to the cord or compression of the cord itself, when the cord is straightened by action of the rod, it is useful if the surgeon can rule out this problem or take corrective measures before changes become irreversible. For this reason, it is desirable for the patient to be able to carry out certain voluntary movements of the lower extremities on the operating table soon after the rod is tightened into position. Waiting for return of consciousness in the recovery room would be too long a time for effective corrective measures to be accomplished if such vascular compromise went undetected. To solve this problem, the technique of hypnosis has been utilized. The patients are admitted a week or more before surgery, and while the pre-operative workup and studies are being performed, the anesthesiologist works with the patient. Hypnotic trance is induced on several occasions, after a thorough explanation of the technique of hypnosis and the specific objectives to be achieved. Not only is the importance of the intra-operative tests emphasized, but the success of hypnosis in the management of pre-operative apprehension, immediate post-operative pain and discomfort, and the long range immobilization and decreased activity attendant to the surgical management of this condition are presented. The patient, under hypnosis, is familiarized with the operating room situation, and a group of lower extremity voluntary movements, designed to test whether cord compression is present, rehearsed in random sequence. Posthypnotic suggestions relative to post-operative pain and discomfort aretalso given at this time. The number of sessions varies depending on the patient's hypnotizability, the better subjects generally requiring fewer sessions. On the day of surgery anesthesia is induced with I.V. Pentothal and/or Valium, and maintained with I.V. narcotics, relaxants, and nitrous oxide and oxygen by endotracheal tube. When the Harrington rod is placed and straightened as desired, the surgeon notifies us. With 15-20 minutes lead time, the patient can be dependably awakened on the table and the tests performed on the instructions of the (Concluded on page 175)
Vol. 67, No. 2
Medical History
and heroine. In June 1914 President Scarborough of Wilberforce University wrote: "Dr. Susan McKinneySteward, our resident physician for a number of years, has been faithful in looking after the young people in need of medical attention. I am very glad to commend her and her services, and to say that to have such a woman connected with the institution, where there is a large attendance of girls, is indispensable".5 After her death, as part of her eulogy, the Green County (Ohio) Statistics, printed ". She was one of the best known women of her race, and for years exerted a remarkable influence for good, in and about Wilberforce, where she had been practicing her profession since
1898.... "5 To Dr. McKinney-Steward's family one highlight of her career has been recorded as a dramatic and commemorative episode. It was a housecall by train and ship from Ohio to Haiti in 1897 to deliver her first grandson, Louis Holly. Now after 104 years Brooklyn, her native city, has written its epitaph-the Dr. Susan Smith McKinney Junior High School. (Fig. 1). LITERATURE CITED
1. New York Times, February 18, 1901 2. Bulletin of the Medico-Chirurgical Society of the District of Columbia, Inc., Vol. 6, No. 1, p.3, January 1949.
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3. McKINNEY, W. S., Personal communication, December 23, 1974. 4. STILES, -. History of Kings County, Long Island Historical Society in Brooklyn. 5. McKINNEY, W. S., Personal communications, December 20, 1974 6. Eighth and Twentieth Annual Announcements, New York Medical College, 1870 & 1882. 7. Medical and Surgical Register of the United States. R.L. Polk & Co., 1890. 8. The Brooklyn Directories, 1871 to 1896. 9. STATISTICS, Green County, Ohio, 1918. 10. LYONS, MARITCHA. Woman In Medicine (Intro-
duction). 11. Negro Heritage Library, Volume I. 12. BROWN, HALLEYE Q. Homespun Heroines and Other Women of Distinction. 13. OTTLEY, ROI and WILLIAM G. WEATHERBY.The Negro in New York. 14. New York World-Telegram & Sun, May 9, 1960. 15. Transactions of the Homeopathic Medical Society of the State of New York, Volume XXXI. 16. Catalogues of the Long Island College Hospital, Brooklyn. (in Library of the Medical Society of the County of Kings and Academy of Medicine). 17. New York Daily News, September 26, 1974. 18. New York Times, September 29, 1974. 19. New York Amsterdam News, October 4, 1974. 20. New York Voice, October 4, 1974. 21. New York Recorder, October 4, 1974.
(Jones, from page 125)
anesthesiologist-hypnotist. In over one dozen cases we have had 100% success. Two patients moved other parts of the body during the test, but without complication. Anesthesia is then reinduced and continued. In no case did any patient remember the intra-operative tests. It is my feeling that a mature, cooperative, patient could carry out these tests without the benefit of prior hypnosis. However, reliable and consistent results, without panic on the table, can best be achieved by this technique. We have also been impressed by the general reduction in post-operative pain in these patients. I have continued the hypnotic sessions until discharge of the patient, directing attention to the prolonged period of recuperation and the immobilization and wearing of appliances. The strong motivation to improve their physical appearance on the part of these patients, mostly teenage girls, reinforces their cooperation. We have been impressed by the high percentage of good subjects in this group. Long term followup of these patients has
shown excellent progress, almost without exception. SUMMARY
The history of hypnosis and its contribution to medical practice has been traced, and the many myths and misconceptions surrounding it explained. That an exact definition is still difficult, and that its neurophysiological mechanism still perplexes us, has been revealed, notwithstanding the many areas of medicine to which it can be applied. Hypnosis is not a magic cure-all, but is one of the tools of medical management, which judiciously applied within the bounds of its limitations, and with intelligent and expert selection, can offer much to broaden the scope of medical techniques. Stripped of the many myths which surround it, and placed in proper perspective, hypnosis is seen as a complex phenomenon, but far from mysterious and occult. The field of anesthesiology, due to its concern with the likewise complex matter of pain and its relief, can make good use of hypnosis as a supplement to its many techniques.
