While hypnosis has been a significant medical tool through the ages, its use has been, at best, capricious. After the development and widespread use of ether, hypnosis has been mostly relegated to the role of an adjunct to chemical anesthesia. The present paper describes a case where hypnosis was used as the sole anesthetic for a septoplasty. The chronology of the surgery, hypnotic suggestion and strategies used as well as the clinician's responses are described. The paper highlights relevant clinical issues such as the hypnotic capacity of the patient, associated hypnotic phenomena, enhancing trance, and maximizing the hypnotic capacity by "meeting them where they are."

The introduction of ether in 1846 and chloroform in 1847 minimized the impact hypnoanesthesia could have had in the history of anesthesiology. In his book, Mesmerism in India, Esdaile (1902) described over 300 major surgeries that were accomplished with hypnosis as the only anesthetic. The interaction between mind and body, and the authority that one's brain can have over one's soma, is most appreciably demonstrated with the use of hypnosis as the sole anesthetic in surgery.

Peebles-Kleiger (2000) explained that hypnosis could be effective in surgery in three ways: Hypnosis potentiates the effects of analgesics and anesthesia; it facilitates postoperative healing; and it helps maintain stability of vital signs. A fourth way is the use of hypnosis as a sole anesthetic for surgery (Crasilneck & Hall, 1985).

Some past surgical uses of hypnosis include: Hemorrhoidectomy (Werbel, 1967); anorectoal surgery (Day, 1965); surgical removal of pedicle attachments (Wiggins & Brown, 1968); heart surgery (Gruen, 1972); gastrectomy (Bonello, Doberneck, Papermaster, Griffin, & Wangensteen, 1960); pulmonary infection (Jenkins & Crasilneck, 1959); neurosurgery (Crasilneck, McCranie, & Jenkins, 1956); surgical treatment of burn patients (Crasilneck, Stirman, McCranie, McCrainie, & Fogelman, 1955); and chemical peel (Wain, 1990). In most of the papers reviewed, hypnosis and similar therapeutic techniques had a positive impact on the surgery to include reduced postoperative nausea and vomiting; decreased anxiety during the procedure; fewer postoperative side effects; and quicker recovery lime.

In the past 10 years, several reports have shown that hypnosis is useful for a variety of surgical techniques, including dental surgery, breast surgery, coronary-artery-bypass surgery, endocrine cervical surgery, hernia repair, gynecological procedures, and exploratory surgery. Herod (2000) described a case that involved a woman using self-induced hypnosis instead of anesthesia during a tooth extraction. The woman remained calm throughout the procedure, and the tooth was removed without resistance or interference. Following the surgery, the woman reported feeling comfortable and confident throughout the procedure. Another paper described the effects of hypnosis during third molar extraction (Ghoneim, Block, Sarasin, Davis, & Marchman, 2000).

Williams, Hind, Sweeney, and Fisher (1994) studied the effects of positive intraoperative suggestion during major gynecological procedures. Several significant results were found in favor of the group receiving intraopcrativc suggestion compared to the group receiving no suggestion. The experimental group experienced significantly less vomiting and nausea (32% for the experimental group compared to 69% for the control group, p

Defechereux et al. (1999) found several significant advantages to using hypnosis during endocrine cervical surgery. Patients using hypnosis had significantly less days in the hospital, and less postoperative pain and analgesic consumption than did patients using general anesthesia. The group using hypnosis also reported experiencing an altered time perception during the surgery and the surgeons reported that the hypnotized patients were easier to perform surgery on. There was a significant diminishing of postoperative fatigue syndrome and surgical convalescence in the hypnotized patients. The hypnotized group also returned to work and social activities more quickly than the control group.

Another study (Lebovits, Twersky, & McEwan, 1999) compared a group using intraoperative suggestion tapes to a control group listening to a neutral tape during hernia repair surgery. Patients in the experimental group experienced significantly fewer episodes of vomiting compared to the control group in the first 90 minutes postsurgery (15% for control group vs. 4% for the experimental group, p

Meurisse et al. (1999) studied a group of patients who chose to use hypnosedation as an adjunct to a local anesthetic for bilateral neck exploratory surgery. These patients reported high levels of comfort in their recovery from surgery when using a visual analog scale.

Chronological Perspective Leading to Septoplasty with Hypnosis

The patient approached the author who was also staff at the hospital and related that because of his own anxiety he had postponed surgery for a deviated septum for several years. However, because his breathing was becoming more difficult he recognized that surgery was necessary. Initially, he inquired as to whether a desensitization approach could help decrease his anxiety relevant to the surgery. A consultation was scheduled, the patient was evaluated, and his hypnotic potential assessed. The patient was screened hypnotically by using a modified version of the Hypnotic Induction Profile (HIP; Wain, 1979).

The patient was a high hypnotic subject scoring in the range of 4 out of 5. he had both a high eye-roll and immediate arm levitation. During the history-taking the patient related he had been deeply religious as a child, a high achiever throughout his schooling, and had no previous psychiatric history. The mental status exam was normal. he had postponed the surgery for several years out of fear of being out of control because of the anesthesia. The patient is a physician and his response was based on his experiences during his residency. His wife and parents were also in the medical field, and they had discouraged him from using hypnoanesthesia.

After obtaining a history during the first session a rapid desensitization program was initiated. This entailed having the patient practice relaxation as he viewed the preparation for surgery. After the completion of the first session the patient asked whether the entire procedure could be accomplished under hypnosis. The patient was asked to discuss this with his surgeon, and he was informed that the surgeon was the one who would have to make the formal request. A week later his surgeon called the author and put forth a formal request for hypnosedation, and a follow-up appointment with the author was scheduled for the patient.

During the second session it was determined that the patient had the ability to get absorbed in a task, which is significant for achieving hypnosedation. When he was asked his preference for what he wanted to do during the surgery he responded that he wanted to watch the movie The Ten Commandments. he was instructed to go home and view the movie, which the author did independently as well.

The patient then came in once weekly for three weeks. Each session resulted in the patient's ability to drift into a deeper hypnotic state. The ceremony of induction consisted of the same words that were used during the hypnotic screening.

One: Roll your eyeballs up to the ceiling. Two: Close your eyelids. Three: Take a deep breath, hold 10 seconds, then exhale, relax your eyes relax your body and float. As you begin to float you allow yourself to drift off to the movies and you begin to feel more and more relaxed, you begin to drift off to watch the movie. As you see Charlton Heston as Moses you begin to drift off more and more, and you become more and more comfortable. You are doing very well, very nicely, feeling more and more comfortable. As you see Moses leading the people you become more and more comfortable and you can see the Red Sea. And as you do you become more and more comfortable.

During the induction the patient was able to drift off. The patient was coached into each session and was instructed to practice at least twice a day at home. A repetition of the above was continued throughout the surgery. Typically the day before surgery is scheduled the surgeon is contacted and asked if there is a desire to test the level of hypnoanesthesia to be used during the surgery.

This surgeon declined to use any stimuli near the nose for fear of causing edema to the nasal passage. Rather, after observing the patient go through a hypnotic induction where a needle was stuck into the patients forearm and there was no recognition of a noxious stimulus, the surgeon felt comfortable with what was observed. The patient was then brought out of the hypnotic state and the surgeon asked the patient his comfort level. Upon describing the absence of any discomfort the surgeon was pleased. He then informed the patient that he would see him in the morning.

The Surgery

After the patient was admitted to the ward the surgeon and the author made early morning rounds the patient asked, "Dr. W., would you mind if I don't watch The Ten Commandments! I'd rather go to the beach in Puerto Rico." Somewhat taken aback but without exhibiting any concern, I concurred and let the patient practice that he was on the beach looking at the waves and the water. However, the suggestion was made to him that he could lake along an imaginary portable VCR if he decided to watch the movie.

As the time for surgery approached we began the hypnoanesthesia while the patient was still in his room. We then wheeled him into the prep room and continued the hypnosedation. The anesthesiologist placed an IV in his arm. This procedure is part of the Standard Operating Procedure required for every patient electing to use hypnoanesthesia. Prior to going into the surgical suite the patient was again instructed on ways of communicating during the surgery. he was to raise his second finger to indicate he was uncomfortable and the third finger to indicate he was comfortable. The induction with the verbal comments described earlier in the instructions continued.

Roll your eye balls up to the ceiling.... You are on the beach looking at the water going deeper and deeper feeling more and more comfortable more and more pleasurable. The verbalization of suggestions continued with comments regarding his level of comfort. When it came time for the first incision the patient was instructed to go "deeper and deeper."

The anesthesiologist continued to monitor the patient's vital signs, which remained normal during the procedure. Periodically, the patient was asked to signal his comfort by raising one of his fingers on his left arm, which he did when requested. The surgery and hypnoanesthesia went without any complications, and at the end of the procedure the patient was brought out of the trance by reversing the induction technique. Prior to the patient being brought out of the trance suggestions that you will continue to feel more and more comfortable, you will be able to have a good night sleep and you will heal quickly and you will be able to go into trance postoperatively whenever you feel a need to increase your comfort level. The procedure went without any complications.

Upon the completion of the surgery the patient went back to his room and was met by family members. When we asked him how he felt he responded "terrific." When asked what he remembered he said that he was on the beach in Puerto Rico. The patient was again seen before we left the hospital that evening and the patient was comfortable practicing his self-hypnotic technique. At no time during or postoperatively did the patient suggest that he was uncomfortable. Again, the patient was instructed in using self-hypnotic techniques to change the packing in his nose. Many patients have described their postoperative experience as being most uncomfortable.

Hospital Chart

HISTORY OF PRESENT ILLNESS: This 31-year-old male presents with a history of nasal obstruction for many years. he had an injury at age 12 to the nose and now he has obstruction to breathing at all times. he was found to have a grossly deviated septum and a small hump on the nose, which may require removal.

PAST MEDICAL HISTORY: Non-contributory; FAMILY HISTORY: Non-contributory; SURGERY: Lipoma removed from back one year ago. No problems. DRUG ALLERGIES: None known; REVIEW OF SYSTEMS: Negative

PHYSICAL EXAMINATION: Reveals a well-developed, well-nourished 31-year-old male in no distress with normal vital signs. Blood pressure 118/74. Pulse 64. Temperature: 97.6. Physical examination is unremarkable except for the presence of a grossly deviated nasal septum to the right with total obstruction and total dislocation of the septum to the right nostril obstructing the airway. Compensatory hypertrophy of the inferior turbinates on the left side. The rest of the physical examination was unremarkable.

PERTINENT LABORATORY DATA: SMA-12 normal. VDRL non-reactive. Urinalysis: yellow, clear, specific gravity 1,022, pH 5, no glucose, blood or protein. CBC revealed 6,200 white count. Hematrocrit 44. PT 10.3 seconds, PTT 35.8 seconds. Chest x-ray - scoliosis of thoracic spine, no other abnormalities. Sinuses normal.

COURSE IN HOSPITAL: The patient was taken to the operating room on the 4th of August and had a septoplasty performed under hypnosis. Postop course was completely benign and he was released from the hospital.

FINAL DIAGNOSIS: Nasal septal deformity. SURGERY: Septoplasty With Hypnosis; DISPOSITION: The patient will be followed in the Clinic.

Clinician's Response to Surgery

There were a few times when the author recognized anxiety developing within himself. Initially waiting for the first incision to occur is always anxiety producing. In fact, upon the incision being completed, the initial tension was decreased for all in the operating room suite. This perception was confirmed when the rest of the medical staff that were present were later queried. Shortly after the surgery began, the patient began to cough and there was a mucous and blood drip into his throat. In order to help the patient adapt to the situation the concept of "trance logic" (Orne, 1959) was utilized to enhance the trance.

The suggestion, "it is only sea water" was used. Since the patient perceived he was on the beach, this suggestion was congruent with his mind set. By using the concept of trance logic-the ability to make something congruent that was incongruent-the person can accept the situation without utilizing their typical critical vigilance. As further suggestions were offered, the patient maintained his focus of being at the beach. Another perceived trying time occurred when the surgeon said he was going to use the hammer and chisel (see Figure 1). The clinician then responded by giving a suggestion that there was going to be a shield around his nose. It appeared this suggestion might not have been needed. Throughout the procedure the term "comfort" rather than "pressure" was verbally suggested to the patient.

Postoperative Phase

After the patient returned for his first postoperative check-up the patient was asked about his perception regarding the surgery. he reported "no discomfort at all." His pain was rated at "zero," and he was able to change the packing in his nose after doing his self-hypnotic technique, which was a repeat of his induction. he also reported that after his surgery he went home and began painting his house. There was also little or no swelling and only minor skin discoloration. His only memory for the surgery was being on the beach when the procedure transpired.

Hypnoanesthesia as a sole anesthetic is not for all. Only hypnotic virtuosos (highly hypnotizable) can probably use this technique as a sole anesthetic. There are many more who can use hypnosedation as an adjunct to chemical anesthesia. As described by Peebles-Kleiger (2000) and Defechereux et al. (1999), others can benefit from hypnosis as an adjunct to anesthesia. It is the virtuosos who have the wonderful gift in being able to apply their skills to controlling discomfort, healing more rapidly, decreasing their bleeding, and perhaps not needing to go to the recovery room for medical monitoring (Wain, 1979).

An amusing side effect occurs in that many of the nurses become frustrated because they don't have anything to do for these patients postoperatively. The clinician is there as a guide to support and help the patient unwrap their "gift" (Wain, 1979, 1993) and/or be a "transference figure." The patient has the "gift" to become absorbed in a task, decrease his or her critical judgment, utilize trance logic, and assimilate data rapidly. They are in a dissociative state and are able to compartmentalize events. These patients may use hetero- or autosuggestions. Their own expectations also appear to facilitate the required outcome and they learn that they can internally discipline themselves. Each patient is also taught to use self-hypnotic techniques so they can become dependent upon themselves. This patient utilized the technique postoperatively as a way of controlling his discomfort. he reported "zero" pain when changing the packing in his nose.

The patient capable of using hypnosis as the sole anesthetic for surgery is basically psychologically healthy and is relatively free of an AXIS I or AXIS II Diagnoses. This does not suggest that under specific conditions that patients with either Axis Diagnoses could not use this technique. However, a psychiatric diagnosis may interfere with the patient's ability to focus, discipline themselves, and/or trust. These characteristics are necessary for the hypnotic sedation to occur. Continuing with this frame of reference, it appears the healthier psychologically one is the greater the likelihood of a completion of a surgical procedure with hypnoanesthesia.

It is also interesting to reflect on the patient's request on the day of surgery to alter the strategy to be used during surgery. Rather than criticizing or rejecting the patients request to change the strategy, the author was able to respond in a positive manner and to meet the patient where he was rather than making it an issue. One could also speculate that he may have been testing us to see whether we were flexible enough to handle any alterations that could occur during surgery. By this author's flexibility and the surgeon's confidence in the procedure and the author, we may have communicated to the patient that we could handle the unexpected in the surgery. This may also have been an indication of the patients increased anxiety and his testing us as to whether he could really be in control and whether the technique he was to use could be successful. Perhaps if we had responded to his initial request by interpreting or questioning this procedure may have been sabotaged.

Over the years, colleagues have asked how the surgical team responds. Many surgeons, after being approached by their patient, are curious and excited. They ask countless questions and look forward to the completion of the procedure. Initially, as in the case in the above surgery, the surgery staff was not sure they could talk during surgery, and they initially responded non-verbally. However, after they were reassured that it is their operating room and they can proceed as they usually have, the staff reverted back to their normal interactions.

It is imperative to recognize that this technique should not be used simply to validate the hypnotic procedure. It must be done with the welfare of the patient in mind. The clinician who is enthusiastic about any technique must be guarded about suggesting the technique to any patient. Though we know that certain individuals possess the ability to utilize this technique, we need to guard against those who want the dramatic attention from the surgery.

This goes for both clinician and patient. It is also significant that the right person or condition be utilized for hypnotic anesthesia and not just randomly applied. The use of a hypnotic screening tool such as the Spiegel Hypnotic Induction Profile (Spiegel, 1974, 1977) or the Stanford Clinical Hypnotic Scale (Hilgard & Hilgard, 1974) can allow us to make better educated guesses about the patients' hypnotic ability. The use of hypnotic screening tools fits in well with the medical model. Again, any screening device is a probability statement. These procedures may also give credentialing committees at respective hospitals the ability to make more informed judgments about the use of hynoanesthesia.

This does not imply that other induction or screening devices are inappropriate. When looking at the scales, Spiegel suggests that only 12% can be rated at the highest-level while Hilgard's scale suggests 20%. Since these individuals are at the top of the scale they are the ones most likely to benefit from hypnosis as a sole anesthetic. Although this is a rough estimate, some of the high mid-range patients, with motivation and under the right conditions, could perhaps respond positively to the use of hypnoanesthesia for some surgeries. Many others can benefit from the use of hypnosis as an adjunct to other chemical anesthesia. Again the intervention has to be for the benefit of the patient and not the aggrandizement of the clinician.

Apr 2004