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American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Hypnosis in Plastic Surgery David L. Scott M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I.
a
a
Whiston Hospital Prescot , Merseyside, L35 5DR, England Published online: 20 Sep 2011.
To cite this article: David L. Scott M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I. (1975) Hypnosis in Plastic Surgery, American Journal of Clinical Hypnosis, 18:2, 98-104, DOI: 10.1080/00029157.1975.10403783 To link to this article: http://dx.doi.org/10.1080/00029157.1975.10403783
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
THE AMERICAN JOURNAL OF CLINICAL HYPNOSIS
Volume 18, Number 2, October 1975 Printed in U.S.A.
Hypnosis in Plastic Surgery
Downloaded by [Purdue University] at 15:08 17 January 2015
DAVID L. SCOTT, M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I. Whiston Hospital Prescot. Merseyside, L35 5DR England This paper reports on three years experience of the use of hypnosis at the Plastic Surgical Unit of Whiston Hospital in Lancashire, England. This therapy has primarily been used as a psychotherapeutic support for 13 patients undergoing pedicle and flap graft surgery; this resulted in a greatly improved morale and marked reduction in the total drug requirement. Ego-strengthening has been used in a few carefully selected patients with good effect, and hypnoanalgesia replacing chemical anesthesia has been used once to enable cosmetic surgery to be carried out on a post-coronary patient. The overall results have been encouraging, and it has been shown that hypnosis, even in bedridden patients, is a perfectly practical procedure in a communal ward.
There have been very few reports of the use of hypnosis in plastic surgery. The writer has traced only three articles (Kelsey & Barron, 1958; Wiggins & Brown, 1968; Wollman, 1964) concerning four patients; all underwent pedicle graft surgery. One can only presume that this use of hypnosis has been very limited clinically. For the past three years the writer has been one of the consultant anesthesiologists to the Plastic Surgical Unit at Whiston Hospital. During this period he has explored and evaluated the use of hypnosis on these patients on an increasing scale. The reader is reminded that in hospital practice in the United Kingdom a large portion of cosmetic surgery is carried out under the National Health Service; i.e., these are "free" operations. The surgeon is thus more free to choose his patients than if he were totally dependent upon fee paying patients for his livelihood. The opinions expressed here by the writer concern N.H.S. (i.e., non-private) plastic surgery. In those countries where such surgery is only carried out on a private basis some patients may present psychological problems which can affect the potential use of hypnotherapy.
REVIEW OF THE LITERATURE
Kelsey and Barron (1958) used hypnotic catalepsy as the sole means of maintaining the posture required for pedicle graft from the left hand to the right foot. The period of fixation was 28 days. Although this procedure was successful, the writer would not recommend this use of hypnosis; it seems unnecessary and the risk of the procedure coming "unstuck" is too great. Wollman (1964) used hypnosis for a similar arm to leg pedicle graft for which the patient was fixed for six weeks by means of a plaster of Paris cast. He used hypnosis primarily as a psychotherapeutic support; this patient did not require or receive medication during her fixation period and, as Wollman wrote, she was thus able to transform "the formidable experience of remaining in a fixed uncomfortable position for six weeks . . . into an exciting and competitive game in which she played the leading role." Wiggins and Brown (1968) described a similar use for hypnosis in two young patients, both suffering from gunshot wounds of the lower leg and the posture for the pedicle graft involved acute flexion of the 98
Downloaded by [Purdue University] at 15:08 17 January 2015
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knee. In both cases these writers demon- eral physical relaxation whenever necesstrated a marked reduction in the usual sary; e.g., to reduce or eliminate postural discomfort; autohypnosis also enables the medication. The writer's aims in hypnotherapy have patient to induce sleep. Limb projection been similar to those described in these lat- makes it possible for the patient subjecter two articles. tively to feel that his limbs are in a different There are few doctors carrying out hyp- position; this is of obvious value during the nosis in direct connection with surgery, fixation period (The writer has not stressed fewer still who are anesthesiologists, and the production of limb projection as part of also relatively few plastic surgical units. an hypnotic training procedure as inability The chances of all these variables coincid- to do this could cause a sense of failure. If ing are extremely remote. Furthermore, the patient has this ability, however, then knowledge of the potentiality of hypnosis in this can be beneficial). The real value of hypnosis lies in the such cases has been withheld from the plastic surgeons as the last two reports were positive outlook developed by the patient, the fact that he feels that something "speconfined to "hypnosis journals." cial" is being done for him, also the BASIC USES OF HYPNOSIS IN PLASTIC confidence engendered by his personal ability to relax profoundly and to deal with his SURGERY minor aches and pains, and also insomnia, In Pedicle and Flap Graft Surgery without having to wait for drugs to be given This is the only approach so far described - and more important, for them to work! in the literature and is probably the most important indication for using hypnosis in Supportive Psychotherapy (Egoplastic surgery. These patients often have strengthening) compound fractures of the lower leg; these Plastic surgeons are more aware of the do not unite when the bone ends are expsychological problems affecting their paposed to the atmosphere. tients than are other groups of surgeons The diverse problems include: (with the possible exception of some I. Repeated surgery, including skin gynecologists). They thus usually select grafting (the donor areas are usually paintheir patients well. They will not require ful). such therapy postoperatively. 2. Low morale and possible psychic efThere is naturally a minority who, fects due to disfigurement. through sheer persistence, finally persuade 3. The necessity to maintain a bizarre the surgeon to operate, often against his fixed posture for a period of 4 to 5 weeks, better judgement. Such patients are often causing discomfort such as muscle cramps subsequently dissatisfied with the final and joint pain. cosmetic result, but the writer feels that for 4. Insomnia (from discomfort, pain, such persons hypnotic psychotherapy is not worry, and lack of tiredness). 5. Complications of polypharmacy indicated. (hypnotics, analgesics and sedatives). Supportive psychotherapy is probably of Hypnotic relaxation will considerably more use for the mature individual who is diminish drug requirements, especially mentally stable but who finds himself or analgesic drugs. Ego-strengthening (Hart- herself suddenly in a predicament which land, 1965, 1971) is of value to boost the will necessitate cosmetic surgery. This can morale. Autohypnosis can be used for gen- be a result of an accident or maybe a medi-
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cal catastrophe (e.g., a post-stroke state re- in such patients, so adequate hypnosis quiring a face lift). Many of these individu- should be possible. als come in the category requiring pedicle or flap grafts. SPECIAL PROBLEMS OF PUBLIC WARD Finally, hypnosis may be an alternative HYPNOSIS to cosmetic surgery. The writer has had one Induction of hypnosis was carried out in such case and her story, together with a side ward where there was no telephone others, will be described later. and lessened risk of undue disturbance from outside noise. Many of these patients were Hyponanalgesia bedridden; the others were induced in a The valid use of hypnosis to replace or- chair. thodox chemical anesthesia is indeed rare The fact that under hypnosis patients betoday. However, cosmetic surgery must came less aware of other noises, which bealways be regarded as "luxury surgery," come vague and recede in intensity, was even though the individual patient may re- stressed and reinforced during the early sesgard it as far from a luxury. Life saving sions. The emphasis was on the ability of surgery may be considered in a poor risk the individual to "enter his own private patient in whom cosmetic surgery is com- world" - even on a general ward. This pletely ruled out. was essential for two reasons: (a) When the Survivors from Intensive Care Units writer was carrying out hypnosis in the (e.g., from severe coronary attacks or ward, it would be quite unsuitable for him status asthmaticus) may create a special to demand the sort of silence usual for carproblem if the patient was placed on a wait- diac auscultation. All patients would then ing list for cosmetic surgery when perfectly be listening to the hypnosis session which fit! The subsequent medical catastrophe would have rendered this public instead of will in no way diminish the individuals de- private. (b) It would be totally unreasonable for the patient to demand similar sisire for surgery. The writer has had such a patient (Scott, lence for his own autohypnosis, which he 1973). Following an intensive slimming re- could need at any time for the relief of gime a lady was left with pedunculated skin cramp, joint pains, etc. The patient had to aprons hanging from her upper arms. After be trained from the beginning to get used to being placed on the waiting list to have inducing hypnosis under normal ward conthese removed, she had a severe coronary ditions and noise. A couple of patients in the writer's pediattack, following which this operation was cle graft series had a problem with auconsidered totally inadvisable. The right tohypnosis for the induction of sleep. For side was operated under hyponanalgesia these he created a personalized tape recordalone "but this patient failed to produce this ing (cassette) which the patient could use for the operation on the other side; i. e . , the quite privately and silently by means of an same side as she had had the coronary pain ear phone. (reasons discussed in the referred article). It must be remembered that local Prehypnotic explanations All the patients treated were highly motianalgesia is not practical for all operations, and that the use of adrenalin _(to enable vated and prehypnotic explanations could more local agent to be used, and to prolong be kept to a minimum. As pedicle and flap the duration of analgesia) may be contrain- graft patients are in hospital for from two to dicated. Motivation will be extremely high three months, there was generally a patient
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with previous experience who could be introduced to a new patient; the explanations given by this experienced patient as to what hypnosis felt like and what its value was for him (or her) were almost adequate and few questions were asked prior to the induction of hypnosis. When of the same sex , such patients were placed in adjoining beds . When of different sex , temporary .. introductions " were made so that explanations could be given . RESULTS OF HYPNOSIS IN PEDICLE AND FLAP GRAFT SURGERY
From May, 1973 up to the time of writing (Feb., 1975) all patients scheduled for this surgery and admitted to the Plastic Unit of Whiston Hospital were assessed for hypnosis (Scott , 1975). There were 15 patients, 13 men and 2 women. The age range was from 17 to 67 years. Thirteen were considered suitable for hypnosis, and it was reasonably easy to induce this in all of them.
Two of the teenagers were considered unsuitable for hypnosis . One was quite dis interested, and the other had suffered multiple injuries following a motorcycle accident; these included a compound fracture of his lower leg and a brachial plexus injury with persistent causalgia which pain precluded any proper attempt at inducing hypnosis. The writer wishes to exclude two more from this series . The first was seen only 48 hours before the operation for a wrist to ankle pedicle ; this was a totally inadequate training period . Another was a middle aged dental surgeon with severe head and face bums. He initially refused hypnosis (He was probably too ill to comprehend the severity of his injury; he also subsequently admitted bias against hypnosis). The result was that he had been in the hospital for three months before hypnotic training was started, and he was already well established on drugs . There remain 11 individuals, all of
I. wrist to mid-lower leg pedicle graft in a soldier involved in an Arm y ambush . This was his most comfortable position for hypnosis - note the use of many pillow s.
FIG .
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soldier shown in Fig . I .
whom received adequate training in hypnosis . They underwent 33 operations in direct connection with the pedicle or flap transfer. None required any premedication as all were quite calm preoperatively (but this was given in error on three occasions) . None required any hypnotic drugs for sleep following training, but again one patient was accidentally given nitrazepam (Mogadon) for five nights following the operation for separation of his flap! Concerning analgesic drugs, these were not required or given following 21 of these 33 operations, and following a further 7 operations nothing stronger than dextropropoxyphene HCI (Distalgesic) tablets was given . Four patients received a single dose of pethidine (50 mg . - 100 mg.) and one
received two doses of pentazocine (Fortral), 60 mg. These results show a drastic reduction of all forms of pre- and postoperative medica tion: sedatives , analgesics and hypnotics, which confirms the results ob served by Wollman (1964) and also by Wiggins and Brown (1968). The four consultant plastic surgeons working on this unit have been encouraged by these results and give their full support to this approach. Other beneficial side effects were noted One patient, a soldier who had suffered a severe leg injury in an army ambush (see Figures I and 2), developed a urinary reten tion problem following surgery (he had had some 25 operations when he came to us for a pedicle graft!). This disappeared follow-
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ing direct suggestion under hypnosis to this concluded: "Plastic surgery no longer mateffect. Similarly postoperative vomiting ters." A recent check-up has confirmed was a problem for one of the women; this maintenance of this progress. responded equally well to direct suggestion. Another patient stopped smoking and, Case No.2 at the time of writing some two months laHousewife, born 1936. Had two children ter, was still a non-smoker. and happy family unit. Was an active tennis player and a "keep-fit" enthusiast. During EGO-STRENGTHENING CASE HISTORIES July, 1971 had a stroke due to encephalitis, and for some months could only walk with Case No.1 an aid and had an infected eye. She became Female civil servant (typist), born 1927. very depressed, and even felt suicidal Lupus vulgaris when aged 3%, which bethough never divulged this. First seen by came worse when she was 12, leaving her the writer in Jan. 1974 who anesthetised her with a severely scarred face. From the age for a face lift operation with circumoral faof 27 (1954) until 1970 she was seen by cial sling. She was given a short course of different plastic surgeons, but somehow acego-strengthening which resulted in a tual surgery had been repeatedly deferred! marked improvement in outlook, confiSeen by the writer during early 1971, and dence and even mobility; she recommenced given six sessions of simple egodriving the car again and even went to strengthening from Feb. to July of that dances and limped around! year. She used Stein's clenched fist technique (1963) a lot, which created a curious probPre-hypnosis status lem. This lady's "dominant hand" was on She had a marked inferiority complex; no the side affected by the stroke and she could one could see her without make-up (' 'I thus not clench this hand properly. She would have died"), and she would never agreed at conscious level to use the "nonanswer the door. She had virtually no social dominant hand" for Stein, which, of course life, only going out a couple of times a worked perfectly. year. She had failed a necessary qualifying This lady was also unable to close her typing exam nine times, her job now being left eye which prevented her from relaxing at risk. She had abandoned shorthand, due as well as she could. This minor problem to lack of confidence, and smoked exces- was solved by the use of sunglasses. sively (30 cigarettes/day). REFERENCES Status in October 1973 Now very confident (e.g., able to face a photographer without make-up). Passed her typing exam at the next attempt and has also passed exams for shorthand and audiotyping. Goes out a lot to theatre, concerts and even to France on a coach tour. Can stay overnight in a friend's house and accept early morning tea (i.e., without make-up). Now smokes only 3 to 4 cigarettes/day. A personal letter at that time
HARTLAND, J. The value of "ego-strengthening" procedures prior to direct symptom-removal under hypnosis. American Journal of Clinical Hypnosis, 1965, 8, 89-93. HARTLAND, J. Further observations on the use of "ego-strengthening" techniques. American Journal of Clinical Hypnosis, 1971, 14, 1-8. KELSEY, D. & BARRON, J. N. Maintenance of posture by hypnotic suggestion in a patient undergoing plastic surgery. British Medical Journal, 1958, 1, 756-757. SCOTT, D. L. Hypnoanalgesia for major surgery - a psychodynamic process. American Journal of Clinical Hypnosis, 1973, 16, 84-91.
104 D. L. Hypnosis in pedicle graft surgery. British Journal of Plastic Surgery, 1975. STEIN, C. The clenched fist technique as a hypnotic procedure in clinical psychotherapy. American Journal of Clinical Hypnosis, 1963,6,113-119. WIGGINS, S. L. & BROWN, C. W. Hypnosis with two
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SCOTT,
SCOTT pedicle graft cases. International Journal ofClinical and Experimental Hypnosis, 1968, 16, 215219. WOLLMAN, L. Hypnosis for the surgical patient: American Journal of Clinical Hypnosis, 1964, 7, 83-85.
American Journal of Clinical Hypnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujhy20
Hypnosis in Plastic Surgery David L. Scott M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I.
a
a
Whiston Hospital Prescot , Merseyside, L35 5DR, England Published online: 20 Sep 2011.
To cite this article: David L. Scott M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I. (1975) Hypnosis in Plastic Surgery, American Journal of Clinical Hypnosis, 18:2, 98-104, DOI: 10.1080/00029157.1975.10403783 To link to this article: http://dx.doi.org/10.1080/00029157.1975.10403783
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
THE AMERICAN JOURNAL OF CLINICAL HYPNOSIS
Volume 18, Number 2, October 1975 Printed in U.S.A.
Hypnosis in Plastic Surgery
Downloaded by [Purdue University] at 15:08 17 January 2015
DAVID L. SCOTT, M.R.C.S., L.R.C.P., D.A., F.F.A.R.C.S.I. Whiston Hospital Prescot. Merseyside, L35 5DR England This paper reports on three years experience of the use of hypnosis at the Plastic Surgical Unit of Whiston Hospital in Lancashire, England. This therapy has primarily been used as a psychotherapeutic support for 13 patients undergoing pedicle and flap graft surgery; this resulted in a greatly improved morale and marked reduction in the total drug requirement. Ego-strengthening has been used in a few carefully selected patients with good effect, and hypnoanalgesia replacing chemical anesthesia has been used once to enable cosmetic surgery to be carried out on a post-coronary patient. The overall results have been encouraging, and it has been shown that hypnosis, even in bedridden patients, is a perfectly practical procedure in a communal ward.
There have been very few reports of the use of hypnosis in plastic surgery. The writer has traced only three articles (Kelsey & Barron, 1958; Wiggins & Brown, 1968; Wollman, 1964) concerning four patients; all underwent pedicle graft surgery. One can only presume that this use of hypnosis has been very limited clinically. For the past three years the writer has been one of the consultant anesthesiologists to the Plastic Surgical Unit at Whiston Hospital. During this period he has explored and evaluated the use of hypnosis on these patients on an increasing scale. The reader is reminded that in hospital practice in the United Kingdom a large portion of cosmetic surgery is carried out under the National Health Service; i.e., these are "free" operations. The surgeon is thus more free to choose his patients than if he were totally dependent upon fee paying patients for his livelihood. The opinions expressed here by the writer concern N.H.S. (i.e., non-private) plastic surgery. In those countries where such surgery is only carried out on a private basis some patients may present psychological problems which can affect the potential use of hypnotherapy.
REVIEW OF THE LITERATURE
Kelsey and Barron (1958) used hypnotic catalepsy as the sole means of maintaining the posture required for pedicle graft from the left hand to the right foot. The period of fixation was 28 days. Although this procedure was successful, the writer would not recommend this use of hypnosis; it seems unnecessary and the risk of the procedure coming "unstuck" is too great. Wollman (1964) used hypnosis for a similar arm to leg pedicle graft for which the patient was fixed for six weeks by means of a plaster of Paris cast. He used hypnosis primarily as a psychotherapeutic support; this patient did not require or receive medication during her fixation period and, as Wollman wrote, she was thus able to transform "the formidable experience of remaining in a fixed uncomfortable position for six weeks . . . into an exciting and competitive game in which she played the leading role." Wiggins and Brown (1968) described a similar use for hypnosis in two young patients, both suffering from gunshot wounds of the lower leg and the posture for the pedicle graft involved acute flexion of the 98
Downloaded by [Purdue University] at 15:08 17 January 2015
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knee. In both cases these writers demon- eral physical relaxation whenever necesstrated a marked reduction in the usual sary; e.g., to reduce or eliminate postural discomfort; autohypnosis also enables the medication. The writer's aims in hypnotherapy have patient to induce sleep. Limb projection been similar to those described in these lat- makes it possible for the patient subjecter two articles. tively to feel that his limbs are in a different There are few doctors carrying out hyp- position; this is of obvious value during the nosis in direct connection with surgery, fixation period (The writer has not stressed fewer still who are anesthesiologists, and the production of limb projection as part of also relatively few plastic surgical units. an hypnotic training procedure as inability The chances of all these variables coincid- to do this could cause a sense of failure. If ing are extremely remote. Furthermore, the patient has this ability, however, then knowledge of the potentiality of hypnosis in this can be beneficial). The real value of hypnosis lies in the such cases has been withheld from the plastic surgeons as the last two reports were positive outlook developed by the patient, the fact that he feels that something "speconfined to "hypnosis journals." cial" is being done for him, also the BASIC USES OF HYPNOSIS IN PLASTIC confidence engendered by his personal ability to relax profoundly and to deal with his SURGERY minor aches and pains, and also insomnia, In Pedicle and Flap Graft Surgery without having to wait for drugs to be given This is the only approach so far described - and more important, for them to work! in the literature and is probably the most important indication for using hypnosis in Supportive Psychotherapy (Egoplastic surgery. These patients often have strengthening) compound fractures of the lower leg; these Plastic surgeons are more aware of the do not unite when the bone ends are expsychological problems affecting their paposed to the atmosphere. tients than are other groups of surgeons The diverse problems include: (with the possible exception of some I. Repeated surgery, including skin gynecologists). They thus usually select grafting (the donor areas are usually paintheir patients well. They will not require ful). such therapy postoperatively. 2. Low morale and possible psychic efThere is naturally a minority who, fects due to disfigurement. through sheer persistence, finally persuade 3. The necessity to maintain a bizarre the surgeon to operate, often against his fixed posture for a period of 4 to 5 weeks, better judgement. Such patients are often causing discomfort such as muscle cramps subsequently dissatisfied with the final and joint pain. cosmetic result, but the writer feels that for 4. Insomnia (from discomfort, pain, such persons hypnotic psychotherapy is not worry, and lack of tiredness). 5. Complications of polypharmacy indicated. (hypnotics, analgesics and sedatives). Supportive psychotherapy is probably of Hypnotic relaxation will considerably more use for the mature individual who is diminish drug requirements, especially mentally stable but who finds himself or analgesic drugs. Ego-strengthening (Hart- herself suddenly in a predicament which land, 1965, 1971) is of value to boost the will necessitate cosmetic surgery. This can morale. Autohypnosis can be used for gen- be a result of an accident or maybe a medi-
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cal catastrophe (e.g., a post-stroke state re- in such patients, so adequate hypnosis quiring a face lift). Many of these individu- should be possible. als come in the category requiring pedicle or flap grafts. SPECIAL PROBLEMS OF PUBLIC WARD Finally, hypnosis may be an alternative HYPNOSIS to cosmetic surgery. The writer has had one Induction of hypnosis was carried out in such case and her story, together with a side ward where there was no telephone others, will be described later. and lessened risk of undue disturbance from outside noise. Many of these patients were Hyponanalgesia bedridden; the others were induced in a The valid use of hypnosis to replace or- chair. thodox chemical anesthesia is indeed rare The fact that under hypnosis patients betoday. However, cosmetic surgery must came less aware of other noises, which bealways be regarded as "luxury surgery," come vague and recede in intensity, was even though the individual patient may re- stressed and reinforced during the early sesgard it as far from a luxury. Life saving sions. The emphasis was on the ability of surgery may be considered in a poor risk the individual to "enter his own private patient in whom cosmetic surgery is com- world" - even on a general ward. This pletely ruled out. was essential for two reasons: (a) When the Survivors from Intensive Care Units writer was carrying out hypnosis in the (e.g., from severe coronary attacks or ward, it would be quite unsuitable for him status asthmaticus) may create a special to demand the sort of silence usual for carproblem if the patient was placed on a wait- diac auscultation. All patients would then ing list for cosmetic surgery when perfectly be listening to the hypnosis session which fit! The subsequent medical catastrophe would have rendered this public instead of will in no way diminish the individuals de- private. (b) It would be totally unreasonable for the patient to demand similar sisire for surgery. The writer has had such a patient (Scott, lence for his own autohypnosis, which he 1973). Following an intensive slimming re- could need at any time for the relief of gime a lady was left with pedunculated skin cramp, joint pains, etc. The patient had to aprons hanging from her upper arms. After be trained from the beginning to get used to being placed on the waiting list to have inducing hypnosis under normal ward conthese removed, she had a severe coronary ditions and noise. A couple of patients in the writer's pediattack, following which this operation was cle graft series had a problem with auconsidered totally inadvisable. The right tohypnosis for the induction of sleep. For side was operated under hyponanalgesia these he created a personalized tape recordalone "but this patient failed to produce this ing (cassette) which the patient could use for the operation on the other side; i. e . , the quite privately and silently by means of an same side as she had had the coronary pain ear phone. (reasons discussed in the referred article). It must be remembered that local Prehypnotic explanations All the patients treated were highly motianalgesia is not practical for all operations, and that the use of adrenalin _(to enable vated and prehypnotic explanations could more local agent to be used, and to prolong be kept to a minimum. As pedicle and flap the duration of analgesia) may be contrain- graft patients are in hospital for from two to dicated. Motivation will be extremely high three months, there was generally a patient
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with previous experience who could be introduced to a new patient; the explanations given by this experienced patient as to what hypnosis felt like and what its value was for him (or her) were almost adequate and few questions were asked prior to the induction of hypnosis. When of the same sex , such patients were placed in adjoining beds . When of different sex , temporary .. introductions " were made so that explanations could be given . RESULTS OF HYPNOSIS IN PEDICLE AND FLAP GRAFT SURGERY
From May, 1973 up to the time of writing (Feb., 1975) all patients scheduled for this surgery and admitted to the Plastic Unit of Whiston Hospital were assessed for hypnosis (Scott , 1975). There were 15 patients, 13 men and 2 women. The age range was from 17 to 67 years. Thirteen were considered suitable for hypnosis, and it was reasonably easy to induce this in all of them.
Two of the teenagers were considered unsuitable for hypnosis . One was quite dis interested, and the other had suffered multiple injuries following a motorcycle accident; these included a compound fracture of his lower leg and a brachial plexus injury with persistent causalgia which pain precluded any proper attempt at inducing hypnosis. The writer wishes to exclude two more from this series . The first was seen only 48 hours before the operation for a wrist to ankle pedicle ; this was a totally inadequate training period . Another was a middle aged dental surgeon with severe head and face bums. He initially refused hypnosis (He was probably too ill to comprehend the severity of his injury; he also subsequently admitted bias against hypnosis). The result was that he had been in the hospital for three months before hypnotic training was started, and he was already well established on drugs . There remain 11 individuals, all of
I. wrist to mid-lower leg pedicle graft in a soldier involved in an Arm y ambush . This was his most comfortable position for hypnosis - note the use of many pillow s.
FIG .
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soldier shown in Fig . I .
whom received adequate training in hypnosis . They underwent 33 operations in direct connection with the pedicle or flap transfer. None required any premedication as all were quite calm preoperatively (but this was given in error on three occasions) . None required any hypnotic drugs for sleep following training, but again one patient was accidentally given nitrazepam (Mogadon) for five nights following the operation for separation of his flap! Concerning analgesic drugs, these were not required or given following 21 of these 33 operations, and following a further 7 operations nothing stronger than dextropropoxyphene HCI (Distalgesic) tablets was given . Four patients received a single dose of pethidine (50 mg . - 100 mg.) and one
received two doses of pentazocine (Fortral), 60 mg. These results show a drastic reduction of all forms of pre- and postoperative medica tion: sedatives , analgesics and hypnotics, which confirms the results ob served by Wollman (1964) and also by Wiggins and Brown (1968). The four consultant plastic surgeons working on this unit have been encouraged by these results and give their full support to this approach. Other beneficial side effects were noted One patient, a soldier who had suffered a severe leg injury in an army ambush (see Figures I and 2), developed a urinary reten tion problem following surgery (he had had some 25 operations when he came to us for a pedicle graft!). This disappeared follow-
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ing direct suggestion under hypnosis to this concluded: "Plastic surgery no longer mateffect. Similarly postoperative vomiting ters." A recent check-up has confirmed was a problem for one of the women; this maintenance of this progress. responded equally well to direct suggestion. Another patient stopped smoking and, Case No.2 at the time of writing some two months laHousewife, born 1936. Had two children ter, was still a non-smoker. and happy family unit. Was an active tennis player and a "keep-fit" enthusiast. During EGO-STRENGTHENING CASE HISTORIES July, 1971 had a stroke due to encephalitis, and for some months could only walk with Case No.1 an aid and had an infected eye. She became Female civil servant (typist), born 1927. very depressed, and even felt suicidal Lupus vulgaris when aged 3%, which bethough never divulged this. First seen by came worse when she was 12, leaving her the writer in Jan. 1974 who anesthetised her with a severely scarred face. From the age for a face lift operation with circumoral faof 27 (1954) until 1970 she was seen by cial sling. She was given a short course of different plastic surgeons, but somehow acego-strengthening which resulted in a tual surgery had been repeatedly deferred! marked improvement in outlook, confiSeen by the writer during early 1971, and dence and even mobility; she recommenced given six sessions of simple egodriving the car again and even went to strengthening from Feb. to July of that dances and limped around! year. She used Stein's clenched fist technique (1963) a lot, which created a curious probPre-hypnosis status lem. This lady's "dominant hand" was on She had a marked inferiority complex; no the side affected by the stroke and she could one could see her without make-up (' 'I thus not clench this hand properly. She would have died"), and she would never agreed at conscious level to use the "nonanswer the door. She had virtually no social dominant hand" for Stein, which, of course life, only going out a couple of times a worked perfectly. year. She had failed a necessary qualifying This lady was also unable to close her typing exam nine times, her job now being left eye which prevented her from relaxing at risk. She had abandoned shorthand, due as well as she could. This minor problem to lack of confidence, and smoked exces- was solved by the use of sunglasses. sively (30 cigarettes/day). REFERENCES Status in October 1973 Now very confident (e.g., able to face a photographer without make-up). Passed her typing exam at the next attempt and has also passed exams for shorthand and audiotyping. Goes out a lot to theatre, concerts and even to France on a coach tour. Can stay overnight in a friend's house and accept early morning tea (i.e., without make-up). Now smokes only 3 to 4 cigarettes/day. A personal letter at that time
HARTLAND, J. The value of "ego-strengthening" procedures prior to direct symptom-removal under hypnosis. American Journal of Clinical Hypnosis, 1965, 8, 89-93. HARTLAND, J. Further observations on the use of "ego-strengthening" techniques. American Journal of Clinical Hypnosis, 1971, 14, 1-8. KELSEY, D. & BARRON, J. N. Maintenance of posture by hypnotic suggestion in a patient undergoing plastic surgery. British Medical Journal, 1958, 1, 756-757. SCOTT, D. L. Hypnoanalgesia for major surgery - a psychodynamic process. American Journal of Clinical Hypnosis, 1973, 16, 84-91.
104 D. L. Hypnosis in pedicle graft surgery. British Journal of Plastic Surgery, 1975. STEIN, C. The clenched fist technique as a hypnotic procedure in clinical psychotherapy. American Journal of Clinical Hypnosis, 1963,6,113-119. WIGGINS, S. L. & BROWN, C. W. Hypnosis with two
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SCOTT,
SCOTT pedicle graft cases. International Journal ofClinical and Experimental Hypnosis, 1968, 16, 215219. WOLLMAN, L. Hypnosis for the surgical patient: American Journal of Clinical Hypnosis, 1964, 7, 83-85.
