Hypnoanesthesia, Hypnosis and Surgery

Using hypnosis for surgery is a lost art. Haven’t you ever wondered what humans have done for thousands of years before chemical anesthetics were discovered in the 1800s? They used fainting, alcohol, or hypnosis. Or you could choose to “tough it out with nothing at all”. Reno Concierge Coaching knows how to recreate the necessary depths of hypnosis so that you may have the option to choose hypnoanesthesia instead of chemical anesthesia.

No phenomenon of hypnosis is more dramatic than analgesia, and none has more potential for clinical application. Nevertheless, hypnosis has had a hard time taking its rightful place in the standard of care for patients in pain (Kihlstrom, 2000).

What are the Origins of Surgical Hypnosis?

Think back to the 1840s, before hypnosis even had its proper name, and was still called “animal magnetism” or even “mesmerism”. Up to this time, medical and dental surgery was performed without anesthetic, for the simple reason that anesthetics were unavailable ( see also Fenster, 2001; Keys, 1963; Rushman, Davies, & Atkinson, 1996). The situation in the early 19^th century was aptly summarized by Oliver Wendell Holmes, the great American physician and jurist, with the comment that nature offers only three natural anesthetics: sleep, fainting, and death. Patients may have been given alcohol or laudanum to dull the senses, but these treatments often made them more, not less, difficult to manage. Mostly, patients were just strapped to the operating table and had to “bite the bullet” — a situation vividly portrayed by the English novelist Fanny Burney in her memoir of her own mastectomy, performed in 1810. Robert Liston, Britain’s most famous and accomplished surgeon, even scolded a patient for lacking “discipline” during surgery, and threatened to terminate the procedure unfinished.

Against this background, it was little short of amazing when John Elliotson, the revered Professor of Practical Medicine at University College, London, and his protégé James Esdaile, a medical officer for the British East India Company, each reported a large number of surgeries performed painlessly, with the mesmeric trance as the only anesthetic agent. Against the suspicion of deceit and self-delusion, Esdaile noted the simple fact that his patients referred their family and friends to his service. But he also had data of a harder kind: at a time when surgical mortality was about 40%, Esdaile’s death rate was reduced to only about 5% — an objective outcome that he plausibly attributed to the successful relief of pain with mesmerism.

Like Elliotson, Esdaile hoped that the new technique would become widely available for the benefit of the public, but he also expressed the fear “that not many of this generation will live to benefit by Mesmerism, if they wait till it is admitted into the Pharmacopoeia”. And he was right. On October 18, 1846, before Esdaile’s book could even be published, William T.G. Morton, a Boston dentist, placed an inhaler containing an ether-soaked sponge to the face of the patient Gilbert Abbot. The Harvard surgeon John Collins Warren, who himself had experimented unsuccessfully with mesmeric anesthesia earlier in his career, then removed a tumor from Abbott’s neck without the patient showing any awareness or signs of pain.

Within two years, ether, nitrous oxide, chloroform, and other chemical anesthetics were widely used in dentistry, surgery, and obstetrics. Even Queen Victoria bore her last child, Prince Leopold, under chloroform. Surgery finally had an anesthetic technique that was, in the words of Henry J. Bigelow’s authoritative report of four cases performed by Morton, “inevitable, complete, and safe”; and as an approved medical technique, mesmerism was consigned to the dustbin of history.

For the next hundred years or so, hypnosis survived mostly as a topic of laboratory investigation, and found little application in the clinic outside psychotherapy. Robert Sears and Frank Pattie performed pioneering studies of hypnotic analgesia and tactile anesthesia in the 1930s, but there were a few other experimental studies, and even fewer performed in clinical settings (Weitzenhoffer, 1953). In the meantime, advances in antiseptic practice and asepsis, regional and local anesthesia, the synthesis of nontoxic and nonaddictive substitutes for cocaine and morphine, and the introduction of muscle relaxation and artificial respiration by means of a tracheal tube, all made chemical anesthesia and analgesia increasingly “inevitable, complete, and safe”. These developments must have further reduced interest in hypnosis.

When Did Hypnosis Re-Enter Surgical Practice?

Still, hypnosis gradually crept back into medical practice — perhaps aided by its successful use in World War II, when chemical analgesics and anesthetics were not always available for the treatment of the wounded. When Jack and Josephine Hilgard surveyed the literature their review of Hypnosis in the Relief of Pain (Hilgard & Hilgard, 1975), they listed more than two dozen cases, published between 1955 and 1974, in which hypnosis had been used as the sole analgesic or anesthetic agent in surgery. But dramatic as these case reports were, the general consensus in the field was that no more than 10% of unselected patients, and probably far fewer, could tolerate such invasive procedures with hypnosis alone. Far more important, was the publication of several extensive case series, not just individual case studies, of hypnosis for clinical pain. Chief among these were Ralph August’s report of 1000 consecutive obstetrical cases and Cangello’s study of cancer pain, both published in 1961, and Davidson’s favorable comparison of hypnosis to natural childbirth, published in 1962.

Based on their review, the Hilgards estimated that approximately half of an unselected patient population could obtain significant pain relief, defined as a one-third reduction in felt pain, from hypnosis alone.  Recently, a quantitative review by Guy Montgomery and his colleagues has confirmed this conclusion (Montgomery, DuHamel, & Redd, 2000). The effect of hypnosis on pain is moderately large, even when there has been no selection for hypnotizability. Equally important, in the present context, the effect of hypnosis is even greater in the clinic than in the laboratory.

Especially given the risks to the fetus from halogenated ethers and narcotics administered to women in parturition, and the risks to cancer patients from chronic narcotic use, you would have thought that hypnosis would be a natural alternative for these kinds of patients. Nevertheless, in the succeeding quarter century, relatively few clinical studies were published, and hypnosis pretty much dropped out of the physician’s toolbox.  In retrospect, we can identify at least three reasons for this turn of events.

In the first place, hypnotic analgesia is safe, but it is neither inevitable nor complete, to use Bigelow’s terms. There are individual differences in response to hypnotic analgesia, just as there are to other hypnotic suggestions; and so the majority of patients who try hypnosis alone are still going to feel some pain. Chemical analgesia and anesthesia is the standard of care precisely because it is more reliable — more inevitable, more complete — than hypnosis.

Second, hypnosis was overtaken by new developments in anesthetic technique and medical practice. In obstetrics, for example, Caesarian section became increasingly popular among doctors, while epidural anesthesia became increasingly popular among women. The technique of conscious sedation, now extremely popular for outpatient surgery and other office procedures, allows the patient to remain awake and interact with the medical team while minimizing discomfort during the procedure and inducing amnesia for it afterward. Patient-controlled analgesia, during and after procedures, also allows patients to remain awake while enhancing their feelings of control. These are precisely the reasons to use hypnosis, but if physicians can obtain the same effects more reliably with drugs, they’re naturally going to turn to drugs.

Third, during the 1950s, just at the time that hypnosis was re-emerging in medicine, the standards for clinical research changed. Henry K. Beecher began writing about the placebo effect (e.g., Beecher, 1955), while Walter Modell wrote about the importance of randomization and controlled comparisons between treatments (e.g., Modell & Houde, 1958). It was no longer sufficient to document a new technique by presenting a case or two in anecdotal fashion, or even a large consecutive series of cases, and have other practitioners adopt it for themselves. In the current healthcare environment, in which “evidence-based medicine” is firmly established (and incidentally raising the question of just what kind of medicine we used to have), the gold standard of proof for clinical interventions involves randomized clinical trials against control groups that receive placebos, or the current standard of care. The sad fact is that there haven’t been many such studies — at least until recently.

Does Hypnosis Really Work for Surgical Pain?

Of worthwhile importance is the work of Elvira Lang and her colleagues, who have provided the most compelling demonstrations of the clinical efficacy of hypnotic analgesia. In these studies, patients who have been scheduled for a variety of invasive diagnostic and therapeutic procedures, have been randomly assigned to one of two conditions: patient-controlled conscious sedation, usually with a combination of Midazolam and Fentanyl, which is the standard of care; and conscious sedation plus a hypnotic intervention involving relaxation and counterpain imagery.

The first of these studies, published in 1996, was a small-scale study, with 30 patients randomized to hypnotic and non-hypnotic treatment groups (Lang, Joyce, Spiegel, Hamilton, & Lee, 1996).  Only 4 of 16 patients in the hypnotic condition, compared to 13 of 14 patients in the control condition, requested medication during the procedure. The hypnotic patients also received fewer drug units than controls.

Nevertheless, the hypnotized patients experienced less pain and less anxiety than the controls.

Interestingly, there were also fewer procedural interruptions due to hemodynamic instability. On every outcome variable examined, the hypnotic group was at an advantage. Unfortunately, the sample sizes in this study were too small to yield statistically significant results for the pain and anxiety ratings.

Fortunately, however, last year Lang reported a larger-scale study, with 241 patients randomized to three groups (Lang et al., 2000). In this research, all patients received standard patient-controlled conscious sedation; one-third received a standardized hypnosis treatment as well, one-third a structured attention manipulation, and the remainder were controls.  In this case, the addition of hypnosis afforded significantly greater pain relief than conscious sedation alone, especially in the latter half of the procedure.

Hypnosis also significantly decreased anxiety.  

The hypnotic group requested, and received, less medication than the controls.

There were fewer adverse events with hypnosis, and so the procedures took less time on average. On every variable, hypnosis was superior to the attentional manipulation, so hypnosis is not only efficacious; the effects are also specific to hypnosis.

These two studies, taken together, satisfy all but one of the Division 12 criteria for a “well-established” treatment (Chambless & Ollendick, 2001): there are two between-group experiments in which adjunctive hypnosis proved superior to the standard treatment; the hypnotic procedure is clearly described; and the characteristics of the samples are specified. The only remaining criterion is that the effects be demonstrated by at least two different investigators or teams. Actually, that criterion had already been fulfilled by the earlier generation of clinical studies, of the sort reviewed by the Hilgards. But in fact, there is also a series of studies by a group of Belgian investigators, using what they call “hypnosedation” as an adjunct to conscious sedation (Faymonville, Meurisse, & Fissette, 1999).

One study, for example, compared 218 cases of endocrine surgery performed under hypnosedation with 121 closely matched cases performed under general anesthesia (Meurisse et al., 1999). Interestingly, fewer than 1% of the patients in the hypnosis group required conversion to general anesthesia, requiring only local anesthetic and minimal sedation — which provides prima facie evidence for the effectiveness of hypnosis.  In terms of intra-operative outcomes — operative time, bleeding, etc. — the two groups were indistinguishable.  But all the measures of postoperative outcome significantly favored hypnosis: less pain and analgesic medication on the first recovery day, greater muscle strength, lower postoperative fatigue, shorter hospital stay, quicker return to normal activity, and greater patient satisfaction.

Unfortunately, the Belgian studies did not involve random assignment, but this should not be held against them. The principles of informed consent make randomization very difficult to achieve, and in any event there was no preselection of patients for hypnotizability, which is surely the most important potential source of bias. That is why the Lang studies, which do involve randomization, are so important. Without them, hypnosis would have to be classified merely as “probably efficacious”. Still, we could use more randomized studies, employing different kinds of surgical procedures and different diagnostic related groups, to clinch the case that hypnotic analgesia meets the fourth and final criterion as a specific and efficacious technique for the relief of clinical pain. But this “proof” has to be qualified: there is no methodologically acceptable evidence that hypnosis, all by itself, can substitute for the chemical analgesia and anesthesia that is the standard of care. Hypnosis is not an alternative to traditional medicine, but it is an effective complement to chemical anesthesia.

References

Beecher, H. K. (1955). The powerful placebo. Journal of the American Medical Association, 159, 1602-1606.

Chambless, D. L., & Ollendick, t. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716.

Faymonville, M. E., Meurisse, M., & Fissette, J. (1999). Hypnosedation: A valuable alternative to traditional anaesthetic techniques. ACTA CHIRURGICA BELGICA, 99(4), 141-146.

Fenster, J. M. (2001). Ether Day: The strange tale of America’s greatest medical discovery and the haunted men wo made it. New York: HarperCollins.

Hilgard, E. R., & Hilgard, J. R. (1975). Hypnosis in the relief of pain. Los Altos, Ca.: Kaufman.

Keys, T. E. (1963). Ths history of surgical anesthesia. New York: Dover.

Kihlstrom, J. F. (2000, November 2). Hypnosis and pain: Time for a new look. Paper presented at the Annual meeting of the American Pain Society, Atlanta, Ga.

Kirsch, I. (1994). Clnical hypnosis as a nondeceptive placebo: Empirically derived techniques. American Journal of Clinical Hypnosis, 37, 95-105.

Lang, E. V., Benotsch, E. G., Fick, L. J., Lutgendorf, S., Berbaum, M. L., Berbaum, K. S., Logan, H., & Spiegel, D. (2000). Adjunctive non-pharmacological analgesia for invasive medical procedures: A randomised trial. Lancet, 355(April 29), 1486-1500.

Lang, E. V., Joyce, J. S., Spiegel, D., Hamilton, D., & Lee, K. K. (1996). Self-hypnotic relaxation during interventional radiological procedures: Effects on pain perception and intravenous drug use. International Journal of Clinical & Experimental Hypnosis, 44, 106-119.

Lang, E. V., & Rosen, M. P. (1999). Impact of adjunct self-hypnotic relaxation on cost of IV conscious sedation during outpatient angiography: A decision analysis model. RADIOLOGY, 213P, 434.

McGlashan, T. H., Evans, F. J., & Orne, M. T. (1969). The nature of hypnotic analgesia and placebo response to experimental pain. Psychosomatic Medicine, 31, 227-246.

Meurisse, M., Defechereux, T., Hamoir, E., Maweja, S., Marchettini, P., Gollogly, L., Degauque, C., Joris, J., & Faymonville, M. E. (1999). Hypnosis with conscious sedation instead of general anaesthesia? Applications in cervical endocrine surgery. ACTA CHIRURGICA BELGICA, 99(4), 151-158.

Modell, W., & Houde, R.W. (1958). Factors influencing clinical evaluation of drugs. Journal of the American Medical Association, 167, 2190-2198.

Montgomery, G. H., DuHamel, K. N., & Redd, W. H. (2000). A meta-analysis of hypnotically induced analgesia: How effective is hypnosis? International Journal of Clinical and Experimental Hypnosis, 48(2), 138-153.

Rushman, G. B., .Davies, N. J. H., & Atkinson, R. S. (1996). A short history of anaesthesia: The first 150 years. Oxford, U.K.: Butterworth Heinemann.

Weitzenhoffer, A. M. (1953). Hypnotism: an objective study in suggestibility. New York: Wiley.