Hypnoanesthesia and analgesiaCLAUDIA CHANDLER, CRNACharleston, South Carolina

Hypnoanesthesia and analgesia have been shownto provide safe and effective pain relief, goodmuscle relaxation, a decreased need forpremedication, and a shorter, less complicatedpostoperative course. In this article, the authorgives a brief history and general overview ofhypnosis and its many uses.

As anesthetists, we are faced daily with the problemof providing adequate pain relief without pro-ducing harmful effects to the patient. We have awide range of chemical agents to assist us, butmany of these drugs have some side effects and arecontraindicated in certain situations.

Hypnosis is a unique clinical tool with noknown side effects. It is perfectly safe for virtuallyall patients and has a morbidity and mortality rateof zero. Hypnosis has but recently been recognizedby the medical profession as a very useful tool.

HistoryAs a method of treatment, hypnosis is ancient.

In the 4th Century B.C. Aesculapius, "the fatherof medicine," produced hypnotic sleep. It has beenused by practically every culture and race of peo-ple since then. Hypnosis has been studied exten-sively by medical practitioners through researchand experiments; however, their work was all toooften dismissed as that of quacks or charlatans,thus inhibiting the rapid growth and acceptanceof the many medical uses of hypnosis.11

Steps have also been taken to use hypnosis asan anesthetic technique. John Elliotson, (1791-1868), professor of medicine at a London univer-sity and president of the Royal Medical and Sur-gical Society, used hypnosis in the treatment ofmedical and nervous disorders and as an anes-thetic. James Braid, (1795-1860), a physician inManchester, England, scientifically studied whatwas formally called mesmerism. He renamed ithypnotism from the Greek word hypnos, meaningsleep. Braid then used this method to treat rheu-matism, epilepsy, paralysis, and neuralgia. The useof hypnosis as an anesthetic was delayed with theintroduction of chloroform. 20

The power of hypnosis to cure and to relievepain had been greatly underestimated or ignoredby the medical profession as a result of irrationalprejudice. A major breakthrough came on April23, 1955, when the British Medical Association re-ported its approval of hypnosis for the treatmentof psychoneurosis and hypnoanesthesia for the re-lief of pain in childbirth and surgery.

In 1958, the Council on Mental Health of theAmerican Medical Association recommended theinstruction of hypnosis be included in the cur-ricula of medical schools and post-graduate train-ing centers. The American Society for ClinicalHypnosis and the International Society of Clinicaland Experimental Hypnosis have established sec-tions to maintain high ethical and training stan-dards and to prevent the occurrence of abuses thatcaused hypnosis to fall into oblivion twice duringthe past century and a half. 6

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DefinitionsThe word hypnos is misleading. Hypnosis is

not sleep at all; it is simply an absolute, completestate of relaxation which is often called the trancestate."l Normal sleep is an unconscious state or astate of unawareness, whereas hypnosis is a con-scious state or state of acute awareness. In hypnosisone's awareness is increased 1,000%.

Hypnosis requires the interaction of one per-son with another person who induces the trance.It also requires the uncritical acceptance of a sug-gestion, verbal or non-verbal, deliberate or inad-vertent. 20 The patient responds to a signal fromthe hypnotist or to an inner signal which activatesa capacity for a shift of awareness and permits amore intense concentration. This shift is con-stantly sensitive and responsive to cues from thehypnotist. 22

There is nothing mysterious about hypnosis.All of us have experienced a hypnoidal state, whichis a precursor of hypnosis. This state is induced bynon-formalistic techniques such as fixation of at-tention. A good example of this is watching thewhite line on a highway and finding that you arenot aware of the landmarks you have passed oreven that time has lapsed. You get some degree ofdissociation which can merge into true sleep. Inthis state, critical thinking is reduced, enhancedsuggestibility results, and hypnosis can easily beinduced. Another good example of this state iswatching a movie. Your attention is on the screenand for a short period of time unreality becomesreality. When a need for reality thinking is ob-viated, a type of waking hypnosis occurs, as whenthe movie is over.6

Amnesia may or may not occur spontaneouslywith hypnosis. It is most often produced with apost-hypnotic suggestion. Some patients have agreat need to maintain control and will not de-velop amnesia.

Dissociation is another phenomenon that canbe experienced with hypnosis. This is the inherentability of the hypnotized subject to detach himselffrom his immediate environment. A person canbe completely dissociated and retain the capacityto function adequately. This state may be de-scribed as stepping out of self and seeing selffunction.

A clinical example of dissociation is the abil-ity to anesthetize an arm. After getting the patienttotally relaxed and ready for suggestions, one mighttell the patient he sees both of his arms in his lapwhile in actuality one arm is out by his side. Byseeing both arms in his lap, the patient has dis-

sociated the extended arm, thus he feels no painit it. 6

Another state of hypnosis is somnambulism.This is one of the deepest stages of hypnosis. Thisstate is observed in sleepwalkers who have no recol-lection of their nocturnal experience. 6

MisconceptionsThe main reasons why hypnosis has not been

more widely and rapidly accepted are misinforma-tion and misconceptions. The main fallacy is thathypnosis is a form of sleep, a state of unconscious-ness, a loss of control. This could not be fartherfrom the truth. During hypnosis, the patient isaware of everything that is going on, his sense ofawareness is acute, and he has complete control.The only resemblance hypnosis has to sleep is inthe outward appearance of the patient. He mayhave his eyes closed to facilitate concentration, andhe may look totally relaxed, as if asleep. The mostfrequent comment from a patient after beinghypnotized for the first time is, "It didn't work, Iheard everything."

A common fear of the patient is that he willsurrender his will and control to the hypnotist,but this is not true. A person's capacity to behypnotized is a subjective matter. The patient can-not be made to do or say anything he does notwish to do or say. However, if he is predisposed todo something that he has not done due to his in-hibitions, the hypnotist may be able to get him todo it under hypnosis.

The patient is aware of everything. He canmake decisions. The deeper the hypnosis, thedeeper is his concentration and attention to thesuggestions of the hypnotist. An example of thisis that of a music lover totally absorbed in hisworld of music and oblivious to his surroundings;although he is awake. He can be brought back toreality immediately if the need arises.

The next biggest concern of the patient is,"What if you can't bring me out of it?" The factis, the patient induces his own hypnosis throughhis own convictions and can dehypnotize himselfat will. If the hypnotist suggests anything con-trary to the wishes of the patient, he will spon-taneously dehypnotize himself. A person cannot behypnotized if he does not wish to be.

Hypnosis is an interpersonal relationship be-tween patient and therapist, 6 and this takes timeto develop. A well informed patient makes thebest subject.

Theories of hypnosisThe mind is extremely complex, controlling

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the body consciously by thinking, reasoning, willpower, and organized brain activity. It controlsthe body subconsciously through the central ner-vous system, memory, imagination, the ability torecall facts and experiences which affect behavior.The conscious mind is objective while the sub-conscious is subjective or automatic. The otherstate of mind is the unconscious state, when theperson is not aware of his environment.

Hypnosis works on the subconscious level. Thesubconscious accepts what the conscious says asfact. It cannot analyze what it is told. The sub-conscious mind is always aware of what is goingon even if the person is in an unconscious state.1 1

Freud states that much of a person's mental activ-ity takes place outside his stream of conscious-ness. 20

In hypnosis, ideas or suggestions are presenteddirectly to the subconscious level, which is able toaccept and act upon them more readily than whenthey are normally presented to the conscious level.Even though hypnosis works in the subconscious,there is an element of the conscious mind presentand functioning at a minimal level. This is thepatient's safety mechanism which prevents himfrom doing something he does not wish to do.

Hypnosis cannot be explained by one singlefactor because, like any behavioral process it com-bines many aspects of human thinking. There isa variety of psychological and physical factors act-ing reciprocally through the imaginative processwhich may produce the perceptual response ofhypnosis. ° The mind, if stimulated by suggestions,is capable of accomplishing remarkable thingsthrough the imagination. Emotional reactions cancause great physical and mental changes. Hypnosisuses these same phenomena to obtain desiredchanges in the patient.11

How can this work? There is considerableevidence that a dissociation of some kind plays arole in hypnosis. Phenomena such as automaticwriting, posthypnotic suggestion, somnambulisticactivity, lack of conscious awareness of painfulstimulation during hypnotically induced anesthe-sia, and hypnotically induced amnesic states allpoint to coexisting, parallel systems of awarenessor functions that exist on a dissociated level sincethey essentially contradict each other.2 0

A study done by Hilgard in 1969 shows thatpain can be reduced through relaxation, butthrough the addition of hypnosis and a suggestionof analgesia, no pain is felt. 5 Pain perceived in thetissues does not reach the pain receptors in thehigher brain centers during hypnosis. With thehigher cortical centers inhibited during deep hyp-

nosis, the reticular activating system (RAS) andother subcortical centers prevent the intrusion ofpainful impulses into awareness.

The psychological state of a patient greatlyeffects the outcome of hypnoanesthesia or anal-gesia. 6'13 Ideational processes occurring as func-tions of neocortical and limbic lobe activity reachperipheral pathways via the RAS. Thus with hyp-nosis, there is an increased alertness, vividness ofsensory imagery, and facilitation of ideomotoractivity.

NeurophysiologyTo better understand how hypnoanesthesia

works, the anesthetist first needs to understand thephysiology of pain, how the brain interprets it,and how the body responds, in addition to thepsychological factors associated with pain.

Pain pathways. Pain fibers enter the spinalcord via the dorsal roots and ascend or descendone or two segments and terminate on the neuronsin the dorsal horns of the cord gray matter. Theythen cross to the opposite side of the cord in theanterior commissure and pass upward to the brain.Most pain fibers lie in the lateral portions of thespino thalmic and spino reticular tracts. The im-pulses finally travel to the thalmus and somaticsensory cortex.

Some fibers terminate in the reticular area ofthe brain stem and excite the RAS which activatesthe central nervous system (CNS). The condition-ing impulses entering the CNS will determinewhether the incoming impulses will be transmittedas weak or strong and how much one will reactto pain.

Reticular activating system. In addition toreceiving pain impulses, the reticular activatingsystem controls thle overall degree of CNS activity.The brain stem portion controls our state of wake-fulness or sleep and the ability to direct our atten-tion toward specific areas of our conscious mind.Furthermore, the brain is the primary controllerof our orderly sequence of thoughts. The RASbegins in the lower brain stem and extends upwardthrough the mesencephalon and thalmus to be dis-tributed throughout the cerebral cortex.

The RAS has an influence on almost all sen-sory inflow via the thalmus, and influences motoroutflow as well. It participates in the vital auton-omic responses, elicits generalized inhibition ofmovement, and reduces or eliminates incomingsensory impulses at the level of the entrance to thebrain stem. Stimulation, inhibition, arousal anddepression can be experienced simultaneously in

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different areas of the RAS since it receives im-pulses from almost all parts of the brain.

Hypnosis maintains wakefulness while somedegree of cortical inhibition occurs. The RAS isan important screening mechanism for a con-tinuum of sleep, hypnosis, and wakefulness. Som-nambulism can be obtained by inhibiting themesencephalic portion of the RAS.

Limbic system. The limbic system includesthe hypothalmus, hippocampus, amygdala, and por-tions of the basal ganglia. The RAS and limbicsystem work together in behavioral functions. Thissystem is concerned with the effective nature ofsensory stimuli such as differentiating an impulseof pain from one of pleasure. The hippocampusprovides a channel through which incoming sen-sory signals can excite the appropriate limbic reac-tions. Emotions and feelings are also found here.The limbic system can facilitate or inhibit thelearning memory. It also helps to elucidate thenature of hypnosis, hysteria, schizophrenia, andpsychosomatic diseases.

The limbic system influences smooth andstriated muscles, which explains the close relation-ship between voluntary and involuntary controlof visceral functions during hypnotic behavior.The involuntary system is not as involuntary aswe tend to think, and portions of the voluntarysystem can come under noncortical control withappropriate conditioning-as in hypnosis. Controlsof the limbic system are massive and diffuse, soentire organ systems as well as the body imageappear as one whole rather than as specific musclesor movements.

The amygdaloid complex, along with the RASand intralaminar system, is capable of exerting adiffuse regulatory influence on the cortex. Thecortex is responsible for the storage, comparison,and coding of impulses which occur to provideperception, memory, and learning. The electricalactivity of the amygdaloid complex changes whenan animal is startled or, as a result of conditioning,its attention is focused on some environmentalevent. Hypnosis makes use of these phenomena.

The hippocampus has a staying effect, it keepsthe brain attentive to carrying out goal-directedbehavior and to prevent it from being shuntedhaphazardly by fluctuations in the environment. 6

Crasilneck and colleagues have described how hyp-nosis terminates each time during brain surgerywhen the hippocampus is stimulated. They suggestthat the hippocampus mediates whatever neuralcircuits are involved in hypnosis.3

By understanding this basic anatomy andphysiology, we can see how sensory imput to the

brain can be controlled, and how pain stimuli canbe diminished or eliminated in the lower centers ofthe brain (since nervous pathways from almost allsensory areas of the brain extend downward tothese lower centers). Parts of the brain can bestimulated and can exert powerful inhibition bysending descending impulses which are capable ofpreventing transmission of noxious impulses in thedorsal horn, and at different levels of the neuraxis. 2

The psychological influences on pain include:1. Early experience, perceptual factors, per-

sonality, and ethnic and cultural patterns.2. Anxiety, a very powerful factor in pain tol-

erance. High anxiety results in low pain tolerance.3. Selective attention, or orientation of the

receptor system to one source of stimulation at theexclusion of others. This can be seen in the athletewho sustains an injury during the game and isunaware of it until the game is over.

4. Motivation, possibly the strongest factor ofall. Motivation may be so strong that an injurymay be sustained and no pain felt. This probablyis due to inhibition of the transmission of painimpulses from the dorsal horn. This inhibitionmay not be sufficient to block reflex action but issufficient enough to suppress overt pain behav-ior.2, 21

Hypnosis is a part of daily behavior dynamics.Activity of an inhibited network of neuronal syn-apses, to produce altered states of awareness, canbe modified by experience through learning. Thecapacity to enter hypnosis is already built into theorganism and is merely elicited on the basis ofaltering the subject's perceptions and interpreta-tions of himself and his surroundings. 14

During hypnosis, the central nervous systemis immobilized because the reticular activity sys-tem has been deprived of data requisite to the nor-mal direction of psychic activity and response. Cer-tain signals are selected for focused arousal andamplification to the exclusion of irrelevant ones,6

demonstrated in a study by Amadeo and Yanorski(1975).1

Signs and stages of hypnosisThere are planes and stages of hypnosis which

have characteristic signs. A person usually does notstay in one stage all the time, he will fluctuate.This is called the tide theory.

In the light plane of hypnosis there are twostages. Stage one is when rapport is established,and there is a release of body tension accompaniedby flutter of the eyelids. Stage two is selective mus-cle relaxation. The patient reports a heavy or float-ing feeling, warm, tingling sensation, and complete

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cooperation and deep concentration is achieved.Twenty-five per cent of the populace will not godeeper than the light plane of hypnosis the firsttime. The patient will remember everything thatoccurs during the hypnotic session.

The medium plane has two stages. Stage threeis complete body relaxation, physical and mental.Olfactory and taste changes and aphasia can bedemonstrated. Stage four is partial amnesia. Anal-gesia is achieved along with automatic movements.Sixty per cent of the populace will reach this plane.

In deep-plane hypnosis, stage five is total am-nesia with positive hallucinations. Stage six is totalanesthesia with somnambulism. Ten to 15% of thepopulace will reach this plane.

Anesthesia can be obtained in any plane withthe help of suggestions, but it is automatic in stagesix. ,1

Clinical uses of hypnosisKroger states, "There is almost no surgical

procedure that cannot be done under hypnoanes-thesia." Approximately one in five persons canachieve a deep hypnotic state, sufficient for majorsurgery. With the careful selection of patients andimproved techniques, more could achieve thisstate. In the mid-19th Century, several thousandoperations were done under hypnosis. 6 In 1960,there were an estimated six to seven thousandphysicians and an equal number of dentists usinghypnosis in the clinical area.' s

Hypnosis has been accepted as a valuabletherapeutic adjunct to potentiate chemoanesthesia.This is useful when pure hypnosis is not appli-cable. Pain is of two types, physical and emotional.Chemoanalgesia blocks only the physical painwhereas hypnosis can block emotional as well asphysical pain. Hence, chemo- and hypno-anesthesiawork well together. 6

Anesthesia is the complete lack of awarenessof pain. Electromyographic studies show that un-der hypnosis, pain is present in the tissues butthere is no awareness of it. Since physiologic reac-tions to pain such as increased heart rate, respira-tions and galvanic skin reflexes are diminished,hypnoanesthesia is apparently genuine. There is apositive relationship between the depth of hypno-sis and the degree of induced anesthesia.

Marmer reports a case of a 42-year-old femalewho had a mitral commissurotomy. After receivinghexylcaine HC1 topically for intubation and suc-cinylcholine for muscular relaxation, she requiredno drugs intra- or post-operatively. She had totaloperative amnesia. Marmer concluded that reas-surance induced by hypnosis allays fears, anxiety,

and tension more effectively than tranquilizingdrugs. He also recommends the use of hypnoanes-thesia for the patient undergoing cardiac surgery.

Hypnoanesthesia used alone offers the greatestadvantage and safety to the heart patient. How-ever, the somnabulistic level must be reached forthis to be successful. The cords are sprayed with atopical anesthetic for intubation and insertion ofthe airway. Succinylcholine may be used for mus-cle relaxation. At the end of the operation, thepatient can remove his own endotracheal tube,and the anesthetist knows the patient is awake withgood muscle control.' 0

Pain and anxiety are interrelated. With hypno-sis, the pain threshold can be raised by 50%. Hyp-nosis and minimal chemoanesthesia will result in de-creased cardiac and respiratory depression. 10 Stress,anxiety, and fear all produce changes in the cardio-vascular and respiratory function. Uinder stress, theheart does not function normally, and this is trueeven more so under emotional stress. Atrial fibril-lation and ventricular tachycardia may be inducedby stress. These factors are especially important inthe patient with cardiac disease. If general anesthe-sia is used, it has to be in light levels, using lesstoxic agents. Thus, hypnoanesthesia is a good al-ternative. Preoperative fear is reduced, the need forpremedication is lessened, the patient is cooper-ative, and postanesthesia recovery is hastened.

Kelsey and Barron describe a patient whosefoot was to be repaired with a pedicle graft fromhis abdomen, transported via his left forearm. Un-der hypnosis, his left arm was fixed in rigid cat-alepsy against his abdomen and, with post-hypnoticsuggestion, remained there until "unlocked" by ahypnotic suggestion three weeks later at the nextoperation. From the moment of release, he hadcomplete movement of elbow and shoulder jointswithout pain or stiffness.

Lowenstein (1978) reports of two successfulcases conducted under hypnosis. One was an 11-year-old boy and the other was a six-year-old boy who hadpostoperative suture adjustments after strabismussurgery. This procedure requires a cooperative pa-tient, analgesia, facial relaxation, and immobilityof extraocular muscles. The patient must be alertand free of sedation. Hypnoanesthesia can be theanswer. A retrobulbar block may be used to sup-plement this. If this trance is disrupted during thecase, you only need to stop momentarily to deepenthe patient. Individualization is the key to success-ful hypnosis. 9

Crasilneck (1956) reports a case where a 14-year-old female with epilepsy required a temporallobectomy for control of seizures. This was done

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with hypnoanesthesia. She experienced mild painwhen the dura was separated from the bone. Thiswas a nine-hour procedure and a local anestheticwas added only twice. She also complained of painand suddenly awoke from the hypnotic trancewhen a blood vessel in the hippocappal regionwas cauterized. She was immediately rehypnotizedand had amnesia postoperatively.

Crasilneck admits that his patients are care-fully selected for hypnosis, and he stresses the im-portance of a careful psychiatric evaluation priorto hypnosis.3s

Nayyar (1962) reports a case of a 38-year-oldmale with an old gunshot wound to the rightfrontal area that resulted in the hemiplegiaand grand mal seizures. General anesthesia wascontraindicated because of needed electrocorticalgraphic monitoring of the debridement and topec-tomy. The patient was given a hypnotic suggestionfor restful sleep the night before surgery and forrelaxation to begin with the intravenous administra-tion, which was accomplished without pain. Theprocedure lasted 41/2 hours and hypnoanesthesiawas supplemented with local anesthetic and Dem-erol,® resulting in a good operative and post-operative course. 1' 2

Hypnosis can also be used for the following:obstetrics cases in both labor and delivery, burndebridement, treatment of all kinds of pain, psy-chological disorders, elimination of premedicationand facilitation of a smooth, quick postoperativeperiod. The use of hypnosis in obstetrics has de-creased fetal and maternal morbidity and mor-tality. Schafer notes that the use of hynosis in aburn unit is multifold, with pain-free dressingchanges being most beneficial.' 6 In medicine, hyp-nosis can be used to treat disorders that mightbenefit from changes in digestion, heart rate, res-piratory rate, blood pressure, peristalsis, perspira-tion, gastric secretions, skin temperature, andmenstrual cycle. 20

Disadvantages of hypnosisHypnoanesthesia is unpredictable with various

depths of anesthesia and muscle relaxation. A goodrapport and interpersonal relationship needs to beformed to have a receptive subject and a successfulhypnosis session. This takes time that may not al-ways be available. Successful use of hypnoanes-thesia also requires at least one, if not several,preoperative sessions requiring additional time andpersonnel. Increased costs can result.

All personnel who will be in contact with thepatient need to understand hypnosis and knowhow to help facilitate a successful trance. Hypno-

anesthesia can be used on only 10% of the popula-tion. Twenty per cent of the adult population canbe hypnotized if carefully selected and trained.

Certain religious or personal beliefs of the pa-tient may prohibit him from accepting hypnoticsuggestion. For example, the patient who feels thatpain in childbirth is necessary would have guiltfeelings if no pain was felt. This patient wouldnot allow the pain to be removed.

Also, if the therapist tries too hard or is irri-tating to the patient, the hypnosis will fail. Thehypnotist must know the patient and the patient'slevel of understanding. In the case of psychogenicpain, the patient may need to retain his symptomsfor a particular reason and will not part withthem.16 .19

Subject choiceSuppose you have the time to use hypnosis.

Who would be a good subject? A good choice isthe young, intelligent person with an amenablepersonality who is able to focus attention on adefined subject matter and disregard distractingstimuli. 20 A person who sleepwalks or talks in hissleep is also an excellent subject and very easilyhypnotized. These people develop spontaneousanalgesia and anesthesia, dissociation, and deper-sonalization. Hypnotically-induced suggestions be-come the convictions of the somnambulist or sleep-walker.0

Those who are not easily hypnotized are thevery young and mentally retarded because theirattention spans are so short. An older child on theother hand is very easily hypnotized due to a veryactive imagination. Hypnosis should not be used ifthe patient suffers from psychoneurotic reactionsor antisocial behavior.

StagesThere are four stages in a hypnotic session.

Induction is the first; this is the method used toput the patient into relaxation. The second isdeepening and maintenance of the relaxation. Thethird is utilization, whereby the hypnotic sugges-tion is given. Termination is the fourth stage andends the hypnotic session.

Ethical and legal aspectsThe welfare of the patient must always be the

first consideration. Hypnosis should be used withinthe limits of training and competency of the hyp-notist. The patient's rights, confidences, and de-sires must be respected. The laws of the communityand/or state in which you practice must govern.Hypnosis should not be used for entertainment or

Journal of the American Association of Nurse Anesthetists246

self-exaltation, nor should false or exaggeratedclaims be made regarding hypnosis.

The patient's permission, as well as that ofthe surgeon, must be obtained before hypnosis canbe used. The patient should be assured that he canhave a chemical anesthetic at any time. If hypnosisis used as an adjunct to chemoanesthesia, permis-sion is not necessary, since we basically use this"conscious state hypnosis" every day.1l

A leading medical malpractice insurance com-pany in Los Angeles claims, "As far as we candetermine, there has not been a physician inCalifornia sued for hypnosis, and as far as we areaware, there has only been one physician otherthan a psychiatrist sued for hypnosis in the UnitedStates."8

SummaryAlthough it is not clearly understood exactly

how hypnoanesthesia works, it has proven effectivein properly selected and trained patients. Themajor reason that hypnoanesthesia is not usedmore widely now is because it requires more timethan other methods, ultimately costs more, is nottotally predictable, and cannot be used on everypatient. There are situations, however, whenhypnoanesthesia would be the method of choiceeven in view of these disadvantages.

The major uses of hypnoanesthesia and an-algesia include minor surgery, as a replacement forpre-medications, to provide relief of postoperativediscomfort and complications, for pain relief andmuscle relaxation.

REFERENCES(1) Amadeo, M. and Yansvski, A. 1975. Evoked potentials and

selective attention in subjects capable of hypnotic analgesia.International Journal of Clinical and Experimental Hypnosis.3:200-210.(2) Bonica, John J. 1975. The nature of pain of parturitionClinics in OB and Gyn. 3:499-506.(3) Crasilneck, H.B., McCranie, E. J., Jenkins, M.T. 1956.

Special indications for hypnosis as a method of anesthesia.JAMA, 1606-1608.(4) Guyton, Arthur G. 1976. Textbook of Medical Physiology.

W. B. Saunders Co., Philadelphia.(5) Hilgard, Ernest R. 1969. Pain as a puzzle for psychology and

physiology. American Psychologist. 24:103-113.(6) Kroger, William S. 1977. Clinical and Experimental Hypnosisin Medicine, Dentistry and Psychology. J. B. Lippincott Co.,Philadelphia.

(7) Kroger, W. S., Fezler, W. D. 1976. Hypnois and behaviormodification: Imagery Conditioning. J. B. Lippincott, Philadel-phia.(8) Kroger, W. S. 1960. Techniques of hypnosis. JAMA. 675-680.(9) Lowenstein, Leonard N. 1978. Hypnosis as an anesthetic inpediatric opthalmology. Anesthesiology. 49:144-145.(10) Marmer, M. J. 1959. Hypnoanalgesia and hypnoanesthesiafor cardiac surgery. JAMA. 512-517.(11) McCoy, Louis R. 1978. Hypnosis Workshop. Durham, N.C.(12) Nayyar, S. N., Brady, J. P. 1962. Elevation of depressedskull fracture and frontal topectomy under hypnoanesthesia.JAMA. 128-130.(13) Raikor, V. L. 1978. Specific features of suggested anesthesiain some forms of hypnosis in which the subject is active. Inter-national Journal of Clinical and Experimental Hypnosis. 3:158-166.(14) Rosen, H. 1960. Hypnosis-Application and misapplica-tions. JAMA. 172:683-687.(15) Schafer, B. A. 1975. Hypnosis use on a burn unit. Inter-national Journal of Clinical and Experimental Hypnosis. 23:1-13.(16) Schafer, S. W. and Hernandez, A. 1978. Hypnosis, painand the context of therapy. International Journal of Clinicaland Experimental Hypnosis. 3:143-153.(17) Scott, D. B. 1977. Analgesia in labour. British Journal ofAnaesthesia. 49:11-17.(18) Teitelbaum, M. 1967. Hypnosis in surgery and anesthesia.Anesthesia and Analgesia. 46:509-514.(19) Trustman, R., Duboresky, S., Titley, R. 1977. Auditoryperception during general anesthesia-myth or fact? Interna-tional Journal of Clinical and Experimental Hypnosis. 2:88-105.(20) Ulett, George A., Peterson, Donald B. 1965. AppliedHypnosis and Positive Suggestion. C. V. Mosby Co., St. Louis(21) West, L. J. 1960. Psychophysiology of hypnosis. JAMA.

672-675.(22) Wicknamasekera, I. 1976. Biofeedback, Behavior Therapyand Hypnosis. Nelson-Hall, Chicago.

AUTHORClaudia Chandler, CRNA, is a graduate of Watts Hospital

School of Nursing in Durham, North Carolina. At the time thispaper was submitted at the recommendation of the programdirector Shirley S. Crump, CRNA, Miss Chandler was a seniornurse anesthesia student at North Carolina Baptist Hospital andBowman Gray School of Medicine in Winston-Salem, NorthCarolina. She recently graduated from that program and is pre-sently working as a staff anesthetist at North Trident RegionalHospital in Charleston, South Carolina. This paper was presentedto the Department of Anesthesia, North Carolina Baptist Hospitaland Bowman Gray School of Medicine on February 21, 1979.

June/1980