A 'NORMAL' PAIN RESPONSE: HYPNOSIS
Normal people under hypnosis may declare that their hand is comfortably warm when dipped in ice-cold water. Ever since its origins with Franz Mesmer in the eighteenth century, hypnosis has been the subject of an avalanche of mystical blather. The French Academy set up a commission to investigate it, with Benjamin Franklin, who was an ambassador in Paris at the time, as a member. Since this was the 'age of reason', the commission declared that mesmerism and animal magnetism did not exist because they were beyond reason. The commission was wrong. The confusion over hypnosis stems from a belief that hypnosis necessarily involves a person in a trance state induced by some hokum manoeuvres from someone with special powers. None of these are necessary. The essence of the hypnotic state is only that the subject has agreed to hand over to the hypnotist the responsibility for deciding how they will react and what they will sense.
This is a common condition of everyday life. It is called the acceptance of authority. The lawyer cross-examining a witness in court and massaging the testimony until the witness makes the required answer is a hypnotist. The parent telling the bedtime story of how the family dog is a retired ballet dancer is a hypnotist. In the traditional hypnotic setting, a form of contract is agreed between subject and hypnotist. Since this is voluntarily accepted, there is no conflict of the subject's standards and therefore the possibility of the subject acting evilly, as in the Svengali myth, is out of the question. Because the process depends on an agreed transfer of authority, the attitude of the subject will crucially depend on their personal, cultural, social, hierarchical relation to the hypnotist: 'Does this person impress?'.
Hypnosis was widely used in the first half of the nineteenth century for surgery before the days of general anaesthesia and as a substitute for rum, laudanum and physical restraint. The patient was prepared in long-repeated sessions with the hypnotist. Even so, there some horrific scenes when the patient broke through the pain-free state. A famous physician was dismissed from University College Hospital in London in 1840 when a woman broke out of hypnosis during a mastectomy. She sued both hospital and doctor. When the first general anaesthetic was administered in London, the surgeon, Joseph Lister, stepped back at the end of the operation and declared: 'Gentlemen, the Yankee trick beats the French one'. He was referring to the import of ether anaesthesia from Boston being more effective than the hypnosis associated with Mesmer in Paris.
Acupuncture during surgery has all the characteristics of hypnosis. I was invited to China in the mid 1970s to witness this fascinating phenomenon because the Chinese thought that the 'gate control' theory of pain, which Melzack and I had invented, was a Western version of their theory. With three other doctors I followed some twenty patients from the patients' ward through the operation and back. The patients, who had volunteered for acupuncture rather than general anaesthesia, had all been through a long course of training. They were at ease with the acupuncturist in a trusting, brotherly way. They had experienced many trials and, because they shared the ward with other patients, they were familiar with the whole surgical procedure. On arrival in the operating theatre, the atmosphere was relaxed and friendly with everyone greeting everyone else.
Some of the operations were difficult to assess because, in addition to needles, the patients received large intravenous doses of narcotics and often local anaesthesia in difficult areas. However, two patients calmly went through major surgical incisions without any additional medication. The question of a hypnotic explanation for the whole phenomenon arose sharply in one patient who had the femoral artery explored and cannulated before the needling started. The patient was calm and conversing. She knew that she had been assured and convinced that she was not going to be hurt even before the acupuncture.
The similarity to hypnosis increased in a much more unpleasant episode. The patient was being operated on for the removal of one lobe of his lung, which involved a wide opening of his chest while acupuncture was proceeding. The operation went well with the patient being given oxygen and some sedatives. The operation was approaching its end and the incision was being closed. As almost the last step, a drain was pushed from inside his chest through the chest wall. The man screamed and struggled to get off the table. He was held down and emitted a babble of screaming, crying and shouting. This was exactly the type of breakthrough described in the last century. I believe they had talked him through each stage of the operation and had followed the plan they had previously taught him. The insertion of the drain was not in the plan and caught him unaware, and he reacted with extreme pain.
I wish to make it absolutely clear at this point that the relief of pain by acupuncture is a real phenomenon. That should not be in question, even though it is true that it was used in its pure form on only a small minority of patients in the Chinese hospitals we visited. The majority of patients were operated on with standard Western-type general or local anaesthesia. Even for the minority who had acupuncture needles inserted, the effect was usually augmented by substantial doses of intravenous narcotics and by local anaesthesia of sensitive points. The question about acupuncture is not about whether it is sometimes effective but is about the mechanism of the action. The classical Chinese opinion that the effect results from the needles affecting a biological energy flowing in special channels has no foundation. I propose here that acupuncture anaesthesia has some similarities with hypnotic anaesthesia.
Hypnosis was used for two centuries in an air of mysticism and bafflement. In recent years, sober studies have begun to explore its real nature with three startling results. When a normal person places their hand in ice-cold water, it hurts and, as we have described, there are a whole series of reactions other than the verbal report, such as changes in the heart rate and increased blood pressure. If a well-trained, experienced, responsive subject under hypnosis is told that the water is warm, they agree that it is warm even though it is, in fact, ice cold. What happens to their blood pressure and heart rate? They react exactly as if the water is ice cold. In other words, the person is divided into separate parts. The speaking person says that the water is warm, but the body's nervous system, which handles internal regulation, detects ice-cold water and reacts correctly. This division places hypnosis on a specialized verbal plane, as we have already shown that the body normally acts as an integrated whole.
The next stage of discovery involves a further division. It starts with the work of the Hilgards at Stamford, one a professor of psychology and the other of paediatrics. Their very well-trained, responsive subjects were hypnotized and instructed so that each subject becomes two: a speaking subject and a writing subject. The speaking person was instructed that the water is warm even though it is iced, and obediently declares it warm. The writing subject, also called the 'hidden witness', had not been told the temperature and was asked to write what is felt, and writes that the water is ice cold. It is apparent that a very sophisticated game is being played in the relation between the hypnotist and the obliging subject.
This reminds us of people with multiple personalities, suffering from the Morton-Prince syndrome, who have also been shown to multiply their personalities at the suggestion of an authority figure. The discovery of this authoritarian aspect of hypnosis has led to its decreasing use by psychotherapists, who do not relish simply ordering their patients to change. Obeying orders may look very impressive at first but obedience tends to fade with time. There are an awful lot of cigarette smokers who gave up their habit after hypnosis but drifted back to smoking. The same is unfortunately true for patients treated for pain by hypnotic suggestion.
The third group of studies in relation to pain and hypnosis has been done by neurologists in Paris. They are experts in evoking pain in volunteers under strict control by electrically stimulating a nerve in the leg and precisely measuring the reflex withdrawal of the leg. In general, the stronger the shock, the stronger the pain and the stronger the reflex. They then take well-trained responsive hypnotic subjects and suggest that the pain will decrease, and the subjects accordingly report that the pain is less. They have made no suggestion about the reflex. Half the subjects who report a decrease in pain also produce a decreased reflex. However, the other half who also reported an equal decrease of pain produce a markedly increased reflex. I take this crucial experiment to amplify the variability of tactics by which we respond to painful stimuli. Even here, where one fraction of the overall response was being manipulated, the other fractions were adjusting with differing strategies. I have not set out to show that pain is a single entity with a simple bottom line. When pain strikes, the individual has many options that are intended to end the pain.
*32\219\2*
Pain Relief