Anton Mesmer and Mesmerism

Healers of varied traditions have used suggestive therapies throughout history. The origin of medical hypnosis is generally attributed to Anton Mesmer, a Jesuit-trained eighteenth-century physician, who believed that health was determined by a proper balance of a universally present, invisible magnetic fluid (Figure 15-1). Mesmer’s early method involved application of magnets. He was an important medical figure at the Austrian court, but he fell into discredit when a scandal occurred around his care of Maria Paradise, a young harpsichordist whose blindness appears to have been a form of conversion disorder.

Figure 15-1 Franz Anton Mesmer.

(From www.general-anaesthesia.com/people/anton-mesmer.html.)

Mesmer reestablished his practice in Paris and employed a device reminiscent of the Leyden jar, a source of significant popular interest in the Age of Enlightenment. His patients sat around a water-containing iron trough–like apparatus (a bacquet) with a protruding iron rod. He was a colorful figure who accompanied his invocation for restored health with the passage of a wand; there was no physical contact with his patients. Susceptible individuals convulsed and were pronounced cured. An enthusiastic public greeted Mesmer’s practice and theory of “animal magnetism.” However, medical colleagues were less impressed. The French Academy of Science established a committee, led by Benjamin Franklin, the American ambassador to France, who was an expert in electricity.¹ The committee found no validation for Mesmer’s magnetic theories, but determined that the effects were due to the subjects’ “imagination.”

The work of one of Mesmer’s disciples, the Marquis De Puyseguer, brought a new approach to the practice of Mesmerism. The method involved induction of a somnambulistic state associated with posttrance amnesia.

James Esdaile, a nineteenth-century Scottish physician, was the first to take advantage of this somnambulistic state induced by Mesmerism to relieve surgical pain. Esdaile served as a military officer in the British East India Company, and took care of primarily Indian patients in and around Calcutta between 1845 and 1851. Over this period, Esdaile performed more than 3,000 operations (including hundreds of major surgeries) using only Mesmerism as an anesthetic, with only a fraction of the complications and deaths that were commonplace at the time. Many of these operations were to remove scrotal tumors (scrotal hydroceles), which were endemic in India at the time, and which in extreme cases swelled to a weight greater than the rest of the individual’s body (Figure 15-2). Before Esdaile’s use of Mesmeric anesthesia, surgery to remove these tumors usually resulted in death, due to shock from massive blood loss during the operation.²

Figure 15-2 Massive scrotal hydrocele.

(© TDR/WHO/Crump.)

Although Esdaile’s technique was clearly effective in many cases, it was controversial enough that, as in Mesmer’s case a century earlier, a committee was appointed and sent to India to observe Mesmeric anesthesia firsthand and to evaluate its efficacy. Esdaile performed six operations for scrotal hydroceles for the committee (which consisted of the Inspector General of hospitals, three physicians, and three judges). He carefully selected nine potential patients by attempting to induce a “Mesmeric trance” using the customary technique of passing his hands over their bodies for a period of 6 to 8 hours; as a result, three of the patients were dismissed when it was found that they could not be mesmerized even after repeated attempts over 11 days. Another three calmly faced the surgery, but when the first incision was made signaled severe pain by “twitching and writhing of their body, by facial expressions of severe pain, and by labored breathing and sighs.” The remaining three patients demonstrated to the committee “no observable bodily signs of pain throughout the operation.” Nevertheless, the committee dismissed Esdaile’s technique as a fraud and stripped him of his medical license.

Early Applications of Hypnosis in Medical Practice

Early in the nineteenth century some surgeons advocated the use of this new procedure for pain reduction in the operating theatre. James Braid, a British surgeon, called it “hypnosis” after the Greek root for sleep. Some questioned its apparent utility, and thought it was “humbug.”

The prominent French neurologist Jean Martin Charcot studied hypnosis at the Salpetriere in Paris, where he worked with a large population of women who suffered from hysteria. Charcot linked hypnosis with hysteria and considered it an expression of neuropathology. Janet’s concept of dissociation followed.

A prominent internist, Hippolyte Bernheim, studied hypnosis at a French school at Nancy. He worked with a country doctor known as “Pere Liebeault” for his pro bono work with patients who agreed to undergo hypnosis for therapeutic purposes. The Nancy School found hypnosis to be a normal phenomenon that operated through suggestion.

Hypnosis in Psychiatric Practice

Sigmund Freud studied with Charcot, and also at Nancy.³ He was a skilled hypnotist, but he came to believe that it had an unwanted impact on transference and it was therefore incompatible with his psychoanalytic method. Instead, Freud substituted his method of free association.

Eriksonian hypnosis, named for its founder, Milton Erikson, is a counterpoint to Freud’s earlier position. Erikson advocated strategic interactions with his patients that employed use of metaphor and indirect methods of behavior shaping. While hypnotizability is generally considered to be an individual trait, Erikson believed that the efficacy of hypnotherapy depended on the skill of the therapist.⁴

Theoretical Perspectives on the Hypnotic State

Theorists have debated the view of hypnosis as an altered state of consciousness. Alternatively, researchers have focused on social factors and on role-playing capacity as an explanation of the phenomena associated with hypnosis.

Martin Orne’s⁵ work at the University of Pennsylvania identified the demand characteristics (based on a hierarchical relationship) of interaction between the hypnotist and the subject. He used sham hypnosis as an effective research tool. Orne also addressed the memory distortion that can occur with hypnosis and exposed its lack of validity for courtroom procedures, and he defined “trance logic” as a willing suspension of belief that highly hypnotizable subjects readily experience.

Ernest Hilgard⁶ and associates postulated the “neodissociation” theory of hypnosis. Hilgard saw hypnotic process as an alteration of “control and monitoring systems” as opposed to a formal alteration of conscious state. He differentiated between the unavailability of a truly unconscious process and the “split off” but subsequently retrievable material involved in dissociation.

David Spiegel⁷ has pointed to absorption, dissociation, and automaticity as core components of the hypnotic experience. Absorption has been found to be the only personality trait related to an individual’s ability to experience hypnosis. Table 15-1 contains several items from the Tellegen absorption scale to illustrate the characteristics of this trait.⁸

Table 15-1 Sample Yes/No Questionnaire Items from the Tellegen Absorption Scale

Effects on Physiological Function

Hypnotic suggestion has been found to produce changes in skin temperature in some subjects. Immunological change has been evident in some studies of hypnosis and allergy and in the successful treatment of warts. Changes in evoked sensory potential have also been observed with hypnotic subjects.⁹ In addition, a few studies have found improved wound healing with hypnosis. However, these phenomena are not necessarily specific to the hypnotic process.

Measurement of Hypnotic Susceptibility

Reliable measurement of hypnotic susceptibility is available with several scales (including the Stanford Scales and Harvard Group Scales of Hypnotizability).¹⁰ These scales begin with the induction of hypnosis by reading the subject a script similar to that contained in Figure 15-3.

Figure 15-3 Sample hypnotic induction script used in rating hypnotizability.

Next, subjects are administered a series of test suggestions, graded from easy to difficult, similar to those shown in Figure 15-4, and their objective and subjective responses are scored as present or absent. Finally, a total score is computed and compared with published norms for each scale. Across scales, approximately 10% to 15% of subjects fall into the “high hypnotizability” range, another 15% to 20% fall in the “low hypnotizability” range, and the remainder fall in an intermediate range.

Figure 15-4 Example item in a series used to assess hypnotic responsiveness.

Moderate levels of hypnotizability are important for clinical efficacy, although the level of hypnotic responsiveness does not ensure therapeutic success.

The Tellegen Scale of Absorption correlates with hypnotic responsiveness.⁸ Absorption refers to a process of concentration and a narrowing of attention. Clinical observations of absorption (e.g., in competitive sports and other forms of performance) may be a clue to a patient’s hypnotizability.

Frankel and Orne¹¹ found that hypnotizability was generally greater among patients with monosymptomatic phobias. Patients with posttraumatic stress disorder (PTSD) and dissociative states generally have higher levels of hypnotizability.

Neuroimaging studies have found an association between high hypnotizability and mechanisms of attention (including a recent finding of increased volume of the anterior corpus callosum in highly hypnotizable subjects who are most adept at hypnotic anesthesia).^12,13 There is also similar activation of limbic circuits in hypnosis and in the recall of traumatic events.¹⁴ Patients with trauma early in life are typically good hypnotic responders.

Recent studies in Israel have found a relationship between high hypnotizability and polymorphisms of the catechol O-methyltransferase (COMT) gene on human chromosome 22¹³; this gene controls enzymes involved in dopamine metabolism, which is thought to be involved in the ability to focus attention effectively.

Measurement of Hypnotic Depth

Measurement of hypnotic depth is a subjective process that does not correlate with clinical utility.

Customary Clinical Use

Hypnotherapists commonly use direct suggestion for relaxation, followed by instruction in self-hypnosis. Sessions may be recorded for home use. Suggestion under hypnosis is commonly used for habit disorders, for reduction of a variety of somatic symptoms, and for smoking cessation. As a tool for smoking cessation it offers no general advantage over other forms of suggestion, but it may have specific appeal to some smokers.

Joseph Wolpe^17,18 applied hypnosis or progressive muscle relaxation to facilitate systematic desensitization. Arnold Lazarus¹⁹ demonstrated the importance of patient expectation by randomizing phobic patients to one of these two techniques. There was a significant tendency of patients to respond best to their treatment of preference.

Hypnosis has continued as an adjunct to behavior therapy. Surman²⁰ proposed a modification of systematic desensitization termed postnoxious desensitization, especially applicable to performance anxiety. The approach begins with assumption of ultimate mastery about the phobic event. To date there have been no clinical trials. Some investigators have found that hypnosis improves the efficacy of behavior therapy for treatment of depression and other conditions. Hypnosis is also applicable to covert sensitization, a technique that may accompany treatment of habit disorders and tobacco dependence.

Hypnosis for memory retrieval has sometimes provoked controversy because of the subtle influence and unintended covert suggestion of the hypnotist. For example, theoretical bias of the hypnotherapist may lead to erroneous production of traumatic memories. For similar reasons, courtroom applications of hypnotically-retrieved information are of questionable validity. Skillful hypnotic recall of conscious experience can, however, be useful in helping patients improve a sense of safety and control. Such efforts involve a cognitive-behavioral effort to facilitate a “top-down” influence for the reduction of emotional arousal.

Pain Management

A “top-down” cognitive-behavioral approach to pain management may prove helpful for adaptation to traumatic events.²¹ Moreover, hypnotherapy can promote the use of imagery to modify perception of the painful experience. For example, pain may be coupled with a specific color (e.g., red) and comfort with a second color (e.g., blue or green). One can next encourage the subject to imagine a change in the color coupled with pain reduction.

Direct suggestion under hypnosis can allow for induction of “glove-hand anesthesia.” The patient can be instructed to place the hand that is “asleep” over the area of perceived pain, and to experience that area becoming “anaesthetized.”²² This type of approach requires a high level of hypnotic susceptibility.

Hypnotherapy is especially applicable to children because of their relatively strong capacity for imagination and for suspension of belief. It is therefore a useful intervention in painful conditions and medical interventions.

Surgical Care

Intraoperative use of hypnosis is of more than historical importance. Some anesthesiologists use hypnoanesthesia as an adjunct to routine intraoperative care. Hypnosis has been used as sole anesthesia for cesarian sections, and in one report, by Marmer,²³ it was used for heart surgery (along with local anesthetic for passage of an endotracheal tube). Other obstetrical uses of hypnosis have also been described.

Preoperative hypnotherapy is effective for surgical phobias related to endotracheal intubation or for fear of undergoing anesthesia.

Surman²⁰ has used postnoxious desensitization as a routine intervention for transplant patients with preoperative anxiety. Formal studies have found preoperative hypnosis to be of benefit in pediatric surgery and in adults undergoing a wide range of procedures. Various studies have found improvement in postoperative nausea and vomiting,²⁴ in the management of pain, and in physical and psychological well-being, and some have reported reductions in postoperative recovery time.^16,22

Medical and Dermatological Uses

Hypnosis has had successful application for anxiety reduction among general medical patients. It has proven useful in reducing the adverse effects of anxiety and airway resistance among asthmatics. Several studies have demonstrated its efficacy in irritable bowel syndrome.²⁵ Some claims have been made that it reduces bleeding in hemophiliacs and that the impact of Rasputin on Czar Nicholas and his wife was a product of his success with their son’s episodic hemorrhages.

Dermatological applications for hypnosis abound; the technique can help reduce pruritus and scratching for some patients. The efficacy of hypnosis for the treatment of warts has been well studied, though its mechanism remains unproven.^26,27

An excellent handbook that includes suggestions and inductions for a wide variety of clinical uses is William Kroger’s Clinical and Experimental Hypnosis in Medicine, Dentistry, and Psychology²⁸; although it was last updated in 1977, this volume still contains an unmatched wealth of information for the beginning practitioner of hypnosis.

The Cochrane Collaborative

The University of Maryland’s Center for Integrative Medicine is the site of the Cochrane Collaborative Complementary Medicine Field, which maintains a database of contacts.

The Society for Clinical and Experimental Hypnosis

The International Journal of Clinical and Experimental Hypnosis is a source of excellent research articles and theoretical discussion about the field of hypnosis.

The American Society of Clinical Hypnosis

The society offers training programs in several cities. The American Journal of Clinical Hypnosis is a valuable clinical resource for practical information related to the medical uses of hypnosis.