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Hypnosis in dentistry
HYPNOSIS
IN DENTISTRY
F. L. MARCUS~, PH.D.,*
ITHACA,
N. Y.
T
HE use of hypnosis in dentistry in the United States today is rare, and its utilization, when noted, is matter for newspaper comment despite its more than loo-year-old history. What possible future hypnotic anesthesia might have had in dental or surgical practice was cut short by the discovery of chemical anesthetics. While dentists are not professional psychologists, their interests raise legitimate and practical problems regarding the use of hypnosis in dentistry. In what ways may hypnosis be used? What per cent of the population may be hypnotized? What determines this figure ? Is hypnosis morally safe ? Is there danger of awakening from hypnotic anesthesia during operation? Do ill effects follow its use? What unique advantages does hypnotic anesthesia possessa These problems are familiar ones, but for many their context will be novel, since psychologists have little occasion to refer to the dental literature which has been reviewed for this report. In discussing the above questions, reference to more than the dental literature was of necessity required. Psychological data and work frpm medical investigators, such as Braid, Esdaile, Wetterstrand, It is hoped that the inclusion of and Petersen, will be cited where relevant. this material will indicate a sphere of application for hypnosis in the field of medicine as well as dentistry. First, it is to be noted that the articles included in the package library on hypnotism include examples of indirect suggestion and countersuggestion, as well as direct suggestion, that is, hypnosis, with which this paper is primarily concerned. Illustrations of the application of the first two types of suggestion will be given before proceeding with the main topic. Indirect Xuggestion.t-These references emphasize the elements of evasion and concealment. Rose42 reported a patient delighted with the effects of an injection of “aqua destillata,” while Hollander31 mentioned the successful use of a gas mask-minus the gas. A case similar to Hollander’s, though not in the field of dentistry, was cited by Tuckey.53 Countersuggestion.-The devices used in countersuggestion are intended to counteract the influence of fixed ideas, in this case fear of the dental situation. The main goal is to reassure the patient, calm his apprehensions, and in this way decrease the amount of chemical anesthetic required. These common-sense *Department of Psychology, Cornell fThe significance and imoortance gestion have been discussed by Wells.“-67
University. of differentiating 796
between
direct
and
indirect
sug-
Hypnosis
in Dentistry
797
procedures include the following : 1. Preparatory educational talks”‘8 66 2. Keeping instruments out of sight, and the use of praisel’ 3. Avoiding exciting colors and the traditional pictures of the doctor at the bedside of the dying patients 4. Creating an air of security and confidence by jokes and funny stories42 Use of such techniques may, according to Rose,42 result in the use of only one-fourth the usual amount of ether. Zulauf, in discussing the role of suggestion, decided : “The power of suggestion is unlimited. The dentist has been looking too long into mouths. For years his whole vision has been centered upon the teeth and only recently (1923) has he realized the inseparable relation of the dental psychical organism, a correlation beyond the power of imagination; and every learning more of their inseparable relations. “66 (Page 846.) THE
USE
OF
HYPNOTIC
mouth and field to the day we are
ANEYTFIlW.\
Xymptom Treatment.-Cases involving the use of hypnosis for the sole purpose of eliminating the pain of a toothache are described by Capern,8 Kingsbury,34 and Martin3s prior to the year 1900. The latter described a case in which, the cavity being small and the tooth needed, the patient was ordered to cease having the toothache and then awakened and told what had been done. The results were stated as follows: “In fact he would not let me leave him until he had tried ice-water and molasses and everything else at hand to try to make the tooth ache again. Three years later he told me that it had never ached afterward. ” (Page 172.) Despite such cases as this, the elimination of pain arising from tooth decay as an end in itself is obviously not advisable.” The interim use of such pain elimination pending and during the dental appointment may, however, provide welcome relief and serve a useful function. It is the opinion of the present writer, who has used hypnosis in this latter fashion, that examples of such use could be supplied by most research workers in the field of hypnosis. Operative Use.-The use of hypnosis as an adjuvant to chemical anesthetics has been advocated. Wetterstrand and PetersenS and Bernheim2 have suggested that hypnosis always be tried first, for even though the effect is slight, a smaller amount of chemical anesthetic will be required. The same point was made by Goldman in 1945 when he stressed t,he fact that anesthesia does not depend on gas-oxygen balance alone, but also on the patient’s state of relaxation. He consequently makes the following suggest,ion to the anest,hetist regarding procedure : “Your voice has the The tone is more important voice takes on the character (Page 359.)
suggestion of the hypnotist-it, is calm, slow, suggesting sleep. than the content. At about the fifth to twelfth breath your of a drone, ronducive to relaxation and comfortable sleep.“27
*Two possibilities may be mentioned where beneficial results were obtained. or originally may have been associated but the pain had persisted on a “psychic see Dunbar.’
to account for those cases, assuming their validity, The pain may either have been of hysterical origin, with some somatic condition which had cleared up, basis.” For a discussion of this latter possibility,
P. L. Marcuse References to the early use of hypnotic anesthesia alone are numerous. Elliotson15 and Braid,5 in 1843, Esdaile,21 in 1846, and Wetterstrand and Petersen,5s in 1897, are but a few who reported its successful use in extraction. A representative case is cited : “Anna L., sixteen years old. Suffered from toothache for several days and the left cheek became gradually more and more inflamed. When she came to me on the twenty-fourth of May, 1887, I noticed a hard and sensitive swelling outside of the first left molar tooth of the upper jaw; her violent toothache had originated in this carious tooth. I hypnotized her and told her during the sleep, that the pains would disappear; that she would return at five P.M. the following day and would experience no pain while I made an incision in the swelling. The toothache disappeared immediately and did not return. I made the incision the next day and she felt nothing. It was as if I cut into dead tissue, a proof of the (Page 111.) wonderful power of suggestion. “59
Similar results are to be found in reports during the past twenty-five years. Toplan, in 1920, reported the use of hypnosis on his daughter as follows: “She ‘had to have a tooth stopped. It was very bad. She had to have the pulp dealt with and the nerve removed. The dentist said to me, ‘It is very tender. Shall I put her She sat up in the chair and I said, ‘Go to sleep and do not wake under cocaine?’ up till For 20 or 25 minutes she did not take the slightest notice. He killed the nerve. I tell you.’ When he was done he was astonished. you wake up you will feel quite I said to her, ‘When comfortable. When I count 10 you wake up. ’ She said, ‘Is it over daddy?’ and I said ‘ Yes. ’ ’ ‘52 (Page 84.) *
Further successful extractions are reported by Bramwell,6 in 1921, and by Hawkes,29 in 1929. In 1933, a successful demonstration before the Northeastern Dental Association was described.@ In 1941, Wells reported two successful cases. In the first of these a cavity described by the dentist as “normally very painful” was painlessly treated. The second case involved the extraction The results are described as follows : “The of a badly decayed wisdom tooth. subject experienced no pain during the extraction, as determined by introspective report at the time of extraction, and gave not the slightest indication by muscular quiverings that he experienced any pain. “56 (Page 87.) In the above references the results were described as “most satisfactory,” or, even more enthusiastically, “no aftereffects,” “ 100 per cent perfect,” “Whether it be a minor or a major operation no other anesthetic is capable of results equal to those obtained by the application of hypnosis.“2g (Page 1948.) Despite the apparent advantages (to be described more fully later) associated with the use of hypnotic anesthesia, it is a fact of simple observation that it is rarely used today. It remains then to evaluate the reasons for its limited utilization. PROBLEMS
ASSOCIATED
Per Cent Susceptible.-Of as an anesthetic is the question susceptible so that anesthesia expected to reach the stage of
WITH
THE
USE
OF
HYPNOSIS
fundamental importance to the use of hypnosis of what per cent of the population is sufficiently may be induced ; that is, how many may be somnambu1ism.t Estimates of the percentage of
*While the case history does not indicate it, the writer feels sure that the procedure described reflects the use of a well-trained .somnambule reacting to posthypnotic suggestion. For further examples of this technique, see Wells.” TNumerous descriptions of the different stages of the hypnotic trance may be found in the literature.2a *% ss 2% 88 While the deeper stages are to be preferred, one may operate with leas pain even in the lighter stages.5
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in Dentistry
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somnambules vary from 13 per cent2 to ‘70 per centZO and from general statements of a “fair percentage”@ to a “large percentage.“21 Such discrepancies may be attributed in part to differences in techniques of induction, age, and nationality.” Technique.t-Techniques of hypnotic induction vary from hypnotist to hypnotist with regard to such aspects as the use of a fixation point, verbal content, and duration. Most procedures, however, have in common an emphasis on relaxation and sleep. The most important consideration of any hypnotic procedure, in the preliminary attempts to obtain a trance state, is its duration. Esdaile’s notesZ2 indicate that prior t,o operation a patient might be mesmerized daily for an hour and a half, over a period which might vary from a few days to a week, depending on the depth of hypnosis indicated. The importance of patience and perseverance is emphasized by Wetterstrand and Petersen in the following case : “I finally succeeded in hypnotizing a lady of about 40 after having endeavored in vain seventy times to do so, and thus alleviated her severe sufferings of more than 20 years’ standing. ‘Go (Page 3.) Wolberg64 also emphasized perseverance and stated that initially several two-hour sessions of slow systematic induction may be required to develop a satisfactory somnambulistic stage. Specific hypnotic procedures for the field of dental treatment were described by HoIlander,31 Hawkes,2g and Toplan.sz The latter advised that prior to operative procedure two to three sittings of one-quarter hour be held. Wookey6” stated that 35 per cent of patients are sufficiently susceptible for purposes of dental anesthesia after three to five visits. St,ein4B gave a corresponding figure of 15 to 20 per cent by the fifth attempt-the first yielding less than 7 per cent. Neither Stein nor Wookey indicated the length of each visit. Whether or not the patient should be informed of an impending operation represents a problem in technique. Bernheim,2 Braid,s and Wetterstrand and Petersens believed that the resulting distraction might vitiate against obtaining a sufficiently deep hypnotic state, and, consequently, concluded that the patient should not be forewarned. The auxiliary use of drugs 23,35sG4to produce somnambulism in individuals otherwise nonsusceptible represents a further extension of the problem of technique.% One procedure involves the use of drugs one-half hour prior to the hypnotic sessions to reduce the patient’s resistance. Such continuous use of drugs is not necessarily required. A posthypnotic suggestion may be given during narcosis t,o render the subject susceptible to subsequent hypnotic procedures. Failure to recognize the diverse techniques whereby hypnotic states may be induced may lead to its unwitting use. Nemoff41 reported successful elimina*Sex differences in susceptibility are not mentioned as a problem in the dental literature. Approximately the same degree of susceptibility for male and female was found by Bernhein? and Wetterstrand and Petersen.50 ~Descriptions of various techniques may be found in the following references 3 28, 8% as. 51, Me f% $Wookep described a technique which departs still further from the cu$omary hypnotic procedure. He stated that Voisin hypnotized “lunatics” by force either by \l~guse OI strait jackets or by forr%ly holding them down. until they beramr exhaustrd. was then able in many cases to hypnotize and treat them.
F. L. Marcuse tion of pain by having his patients visualize and concentrate on a black spot on the dentist’s white coat. Equally suspect was Dorland’@ “strong helpful talk” injected into the patient’s ‘ ‘ subconscious mind’ ’ which helps him ‘ ‘ mentally and dentally. ” Dorland’s categorizing of his technique as suggestion in the waking state as opposed to suggestion in the hypnotic state probably reflects a failure to recognize the existence of waking hypnosis. Age.-Many of the early writers believed that children were more susceptible than adults.*9 32 Wetterstrand and Petersen59 reported that all children between the ages of 4 and 15 years were susceptible, though to what degree was not indicated. Bernheim’s data2 indicated that 55 per cent of 7- to lCyearolds were somnambules, whereas fewer than 26 per cent in any succeeding seven-year-range fell in this category. While recent data on this problem are lacking, such a trend of increased susceptibility among children would have important implications for dental orthopedics, if verified. Nationality.-The people of India have been described as “peculiarly sensitive ’ ’ to hypnosis,*l while the inhabitants of France have been said to be more susceptible than the people of the’ United States.48 Differences, says Chandler,g are to be explained culturally. Where hypnosis enjoys scientific repute and the confidence of the populace, less resistance and, consequently, greater susceptibility are to be expected.* Religion.-Religion may constitute a practical problem in the use of hypnosis. Whether an individual volunteers for an experiment or whether a patient agrees to the use of hypnotic anesthesia may depend on his or her religious faith. , The attitude to hypnosis of the Roman Catholic Church in 1841 was revealed in correspondence between the Bishop of Lausanne and the Pope. In reply to an inquiry from the former concerning the use of animal magnetism, the Pope replied, “The Sacred Penitentiary, the premises having been maturely weighed, considers that these should be answered as it now answers-the use of magnetism, as set forth in the case, is not permissible.“21 (Page 39.) In 1938, a,,more recent indication was given-when the Apollonian, a dental journal, commented editorially on the use of hypnosis as follows: .. ‘LCatholics will be interested to note that approved moral theologians and binding decrees of the Sacred hypnotism, allowing it Hence Catholic patients when there are other prohibition are various. and spiritism, and the and false worship. “6s
Congregation of the Holy Office place a ban upon the only where it is an approved and necessary method of may not submit to hypnosis and Catholic doctors may and better anesthetics available. The reasons for this Historically the hypnotic trance has been associated Church wished to keep her faithful away from all risk (Page 174.)
general use of medical care. not hypnotize ecclesiastical with diabolism of superstition
The danger, the editorial goes on to say, is that the patient is completely and heiplessly at the hypnotist’s will and that historically the hypnotist has not been guided by a keen sense of professional obligation. Christian Science, not surprisingly, strongly condemns hypnosis. Mary Baker Eddy was convinced on the basis of her observations of the workings of *As a point of practical tions prior to attempting to conceptions has been described
procedure, it is customary to The nature induce hypnosis. by Maslow and Mitte1mann.M
clear up any existing misconcePof many of the popular miSJenness.8~ and Gerrish.%
Hypnosis
in Dentistry
801
hypnosis that : “It is not a remedial agent and its effects upon those who practice it, and upon their subjects who do not resist it, lead to moral and to physical death. ’ ‘I4 (Page 101. ) Th,e Moral Problem.-Can moral standards be transcended under hypnosis? Controversy+ over this question which has long existed among psychologists also exists among dentists, WookeyG5 presents the question as a practical problem confronting the dental practitioner who contemplates the use of hypnosis. He believes that a person will not do anything against his ‘ ‘moral sense” but conceives it possible that a suggestion which would be restrained by “moral training” in the waking state might, be carried out under hypnosis if it is in accord with innermost desires. The above distinct,ion is a dubious one. The important point is that Wookey has agreed that an act may be carried out under hypnosis which would not usually be carried out in the waking state. He mentioned a case of a will being drawn up in favor of a hypnotist as a result of hypnotic suggestion and even conceded the possibility of murderi resulting from hypnotic influence. While many hypnotists scorn the possibility of danger, how many, asked Wookey, would be willing to give a hypnotized person a real dagger and direct him to use it on the hypnotist? On the basis of his beliefs, he proposed that, for the mutual protection of patient and dentist, a third person be present during the use of hypnosis-a precaution customarily taken in experimental investigation. Additional evidence for the wisdom of this procedure is implicit in the fact that Estabrooks’” has insured himself against blackmail, while Wells x does not use women subjects in his individual experiments. Other dental practitioners who have expressed themselves on this moral question are Dorland12 and Rose,42 who denied the possibility of moral transgression under hypnosis, and Bisch” and Kingsbury,“” who affirmed the possibility. The latter mentioned a case of a dentist at Rouen in 1879 who was sentenced to ten years’ imprisonment for assaulting a client who was in a hypnotic state. The fact that hynosis can be misused by unprincipled individuals should not be interpreted as a legitimate objection to the use of hypnotic anesthesia. It should be remembered that the same criticism was raised to the use of chemical anesthetics. Bernheim’s opinion on this point was expressed as follows : “Must we proscribe a thing which may be efficacious because the abuse of it is injurious. “* (Page 415.) NATURE
OF
HYPNOTIC
ANESTHESIA
Three questions are often raised with regard to the use of hypnotic anesthesia. Is it conscious simulation ? Is it not really amnesia rather than anesthesia ? Is there danger of awakin g from the hypnotic stat,e? *For a discussion of this dispute see Well~,~~ Brenman.7 Brenman.’ and Erickson.‘” tWetterstrand *Wetterstrand and Petersen. in supporting their thesis that an honest man may be influenced to commit a crime, cite a murder charge which occurred in Kansas in 1895. The court’s decision declared “innocent a murderer who had acted under the influence of hypnosuggestion and sentenced to death the instigator to the crime.“” (Page 158.) Reference to the case as reviewed and sustained in the Superior Court?’ indicated that the condemned man “counseled and incited McDonald to commit the murder.” (Page 136.) However, the court record also raises some doubt, in the present writer’s mind at least, as to the validity of considering that hypnosis, intentional or unintentional, played a part in this particular crime.
F. L, Marcuse Conscious Simulation.-The answer to the first question of conscious simulation must of necessity involve discussion of the feasibility of the control experiment. In connection with clinical procedures, Wells56 believed this to be either impossible or absurd. While Wells’ statement is generally true, instances are to be found in both Esdaile and Braid’s cases which approach the requirements of a control experiment. In Esdaile’s case hypnotic anesthesia was used in a tumor operation “without her feeling it.” Four months later a similar operation was performed on the same patient due to a return of the tumor. The second operation, which may be thought of as the control operation, was described as follows: “She has been mesmeriseddaily for two hours but without effect. I therefore operated on
poor
her
to-day, aa we could old woman screamed
she continued in the
spare no more time for her, others requiring equal attention. miserably the whole time, crying that I was murdering her; greatest pain for hours afterwards.“21 (Page 76.)
The and
Esdaile’s emphasis in discussing this case concerned the possibility of conscious simulation. If the successful results of the first operation resulted from the patient’s shamming insensibility, why, he asked, did she not act similarly in the second operation ? Especially since she had had practice and now knew what was expected of her.+ In a further extension of this same argument Esdaile raised the problem of how to account for the increasing number of patients coming to him at the hospital. He answered this question very succinctly as follows : “I only see two ways of accounting for it : My patients, on returning home, either say to their friends similarly aYEcted, ‘ Wah! brother, what a soft man the doctor Sahib is! He cut me to pieces for twenty minutes, and I made him believe that I did not feel it. Isn’t it a capital joke? Do go and play him the same trick; you have only to laugh in your elbow, and you will not feel ,the pain.’ Or they say to their brother sufferers, ‘Look at me; I have got rid of my burthen (20, 30, 40, 50, 60, or 80 pounds, as it may be), I am restored to the this, I assure you, the doctor Sahib did use of my body, and can again work for my bread: of these hypotheses best explains when I was asleep, and I knew nothing about it. ’ . . . Which the fact my readers will decide for themselves. “21 (Page 237.)
Braid’s case similarly pointed to the same conclusion, of the hypothesis of conscious simulation.
that is, the poverty
“A lady had abscess connected with disease of the orbital process of the frontal bone, had the matter discharged by small puncture, the wound closed by first intention and again opened, as required, by the lancet. She experienced so much pain on each occasion as to induce me to hypnotize her, after which she made no complaint, although I durst not carry it far owing to the state of the brain. On one occasion I was anxious to ascertain how she would feel by operating wdthozlt hypnotizing, when the result was so distressing as to induce me always in future to hypnotize her, before such operations, and then all went on well.“5 (Page 252.)
Elliotson,15 in 1843, discussed a case in which an extraction was reputedly performed with the patient shamming anesthesia. He concluded that such indifference was impossible. *This case as well as other clinical data put a strain on current theories which regard hypnotic behavior as “meaningful goal-directed striving. its most general goal being to behave like a hypnotized person as this is continuously deflned by the operator and as this is understood by the subject”” (page 503). or which regard anesthesia as resulting from “an imaginative focusing on a situation which is associated with the desired condition.“1 (Page 115.)
Hypnosis
in Dentistry
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Even in the laboratory situation where the nature of the tests of anesthesia tend, though not necessarily, to be less severe, a conclusion similar to that found for clinical data is reached. Sears’ study concluded that: “Voluntary inhibition of reaction to pain does not present a picture even remotely resembling the reaction under true hypnotic anesthesia.“46 (Page 22.) Amnesia.-Hull raised the question concerning the possible confusion between amnesia and anesthesia, by discussing the following case reported to him by M. H. Erickson : IL The patient, an adolescent girl, whimpered and flinched decidedly while the tooth was being extracted. Upon being dehypnotized, however, the subject professed a complete amnesia for the trance proceedings, and smilingly expressed surprise when told that her teeth were out, even though at the time her mouth was very bloody from the effects of the recent ordeal. ’ ‘3s (Page 252.)
Hull felt that in situations such as the above, amnesia rather than anesthesia is indicated. He consequently expressed some doubt of Esdaile’s assertion that, his patients remained perfectly quiet during operation. Reference to Esdaile’s own reports, rather than the secondary sources on which Hull appears to have relied, reveals that Esdaile never claimed that all or even a majority of his patients remained perfectly quiet during surgical procedure.” However, it does not follow, as will be shown, that this indicates the validity of Hull’s contention. Examples of cases similar to Erickson’s and described by Esdaile as “disturbed trances’ ’ follow : L’Towards the end of the operation he moved and cried out unintelligibly, but on the fall of the mass became perfectly tranquil, and did not awake till after he had been coverecl with a clean sheet, and all tracts of the operation removed. Nothing had disturbed his sleep, he said, he felt just as usual, had no pain anywhere.“*2 (Page 45.) ((This man was also disturbed before the end of the operation but did not awake till after he had been covered with a clean sheet. He was not aware that anything had happened to him. “2s (Page 49.)
Analysis, by the present writer, of eighteen major operations described by Esdailez2 reveals only seven that fall into the “perfectly quiet” category. This group included those who “lay like a corpse throughout” as well as those who showed some “slight contractions of the toes and face.” Six of the remaining cases belong to the “disturbed trance” category illustrated above. Esdaile pointed out that the movements that might occur during the “disturbed trance” were never purposive, that is, no attempt to avoid the cutting end of the knife is made. The patient stems to have no idea of the source of his discomfort. Esdaile’s explanation of the movemeuts that occur is that the spinal nerves rather than the brain are involved and that as a result there is no consciousness of sensation. This muscular irritability might be eliminated by prolonged hypnotic treatment, but there is little value in doing this, since the patient suffers no more in “disturbed trances” than when there is not a “quiver of the flesh.” Both these catcgorics, in Esdaile’s opinion, represent painless operations, for, “If a man has had no apprehension of an operation, and knows not that it has been performed when he awakes, what is this to be *Bernheima
similarly
stated
that
absolute
insensibility
is the
exception.
P. L. Marcuse As a practical man, I am quite satisfied if called if not a painless operation? my patients assure me that they feel no pain, especially when every look, word, and action correspond with their statements. ’ Q* (Page 4.) In summary then, two points are to be made regarding Hull’s contention that hypnotic anesthesia is more likely amnesia. In the first place, operations under hypnotic anesthesia in which the patient remains “perfectly quiet” do occur. In the second place, the existence of “disturbed trances,” on which Hull rests his argument, does not necessarily point to amnesia, but in light of the above discussion may still indicate anesthesia.* Danger of Aw&ening.,The final question concerning the danger of awakening from the trance state represents, for obvious reasons, a most important problem for the clinician. Conklinlo believes that an individual may awaken from the trance state as a result of severe nervous stimulation incident to the operation, and Hays warns of the “possibility of the patient awakening unexpectedly and dying from the shock of the operation. ‘vO (Page 607.) Cases illustrating the possibility of awakening are to be found in both Wetterstrand and Petersen5s and Esdaile.21* 22 An example from the case reports of the latter follows : “8th.-Deeply entranced, his legs were raised in the air and thrown down on the bed several times, the hair and the tumor exposed “1Oth.-He had granted that he was in I almost made up my it would not be broken, as usual I proceeded little advantage from
of
his beard was plueked out; his left nipple was severely pinched, and testis squeezed without disturbing his sleep. been for two days in the most satisfactory state, and I took it for the same state to-day. He shrunk on the first incision, however, and mind to desist but trusting that though the trance migh be disturbed, and that he would retain no recollection of his apparent suffering, with the operation. But he very soon woke up completely and had his mesmeric trance.“22 (Page 47.)
In the report previously referred to22 of eighteen major operations performed by Esdaile, five of the patients woke up completely during the course of the operation. In another report covering a different time period, Esdaile2’ stated that of seventeen major operations, three were imperfect in that the patient Esdaile attempted to account for three of the awakened during the operation. eight failures, on the basis of the fact that they had been subjected to a cold draught, which in his opinion was capable of arousing the deepest somnambule. ,However, further cases of awakening, about which he offered no explanation, occurred even after suitable temperature precautions were taken. the failure, in the one case they Wetterstrand and Petersen5s attributed cite, to the inadequate depth of hypnosis that existed. WelF similarly attributed failure and, as well, success in hypnotic research to the depth of hypnosis obtained. If the operation is successful, the subject and the technique are satisfactory; if the individual awakens then the subject and/or the technique are unsatisfactory. In the writer’s opinion such an explanation is open to the criticism of post hoc reasoning. The question of whether we can eliminate indi*Wells” also quotes and discusses the Erickson successful attempt to produce hypnotic anesthesia. failure, Esdaile, on the basis of the postoperative mentioned by Wells) -would probably have considered
case, but he considers it merely an unThough Wells considered the case a amnesia which was present (though not it a success.
Hypnosis
in Dentistry
805
viduals likely to awaken during the course of the operation can be effectively investigated only on the basis of controlled experimentation with adequate t,ests for estimating varying depths of hypnosis. While the accuracy of such prediction would probably be high, available data indicate that it would not, be perfect. The preoperative description of the patient mentioned above, which appeared to indicate somnambulism, is a case in point,. Data on two of the other cases in which the patient awakened revealed similar preoperative pictures, while in t,he remaining five cases no information of the prior degree of susceptibility was given. Is a patient as likely to awaken from the effects of a minor operation as from a major one? Dorland12 raised the question in regard to extraction, and concluded that there are no grounds for fear that a patient will awaken during minor surgery. Hays,30 who warned against the use of hypnotic anesthesia in major surgery,* believed in its use in minor operations, especially dentistry. IIJ,
EFFECTS
The question of ill effects following or concomitant with the use of hypnosis is frequently raised. A variety of objections may be considered under this heading. Dificulty in Awaken&y.-Difficulty in awakening from the hypnotic trance is frequently mentioned but seldom encountered. The present writer met the problem in one subject, in the course of a three-year period of work with hypnosis. Loud verbal statements and shaking were of no avail, so the subject was allowed to sleep it out-a matter of three hours. Early in the next hypnotic session, suggestions concerning the awakening procedure were strongly emphasized and no further difficulty was encountered. Kraines commented on this problem as follows : “Only in rare and extremely unstable persons will the hypnotic sleep continue very long. (In intractable cases, a subconvulsive dose of metrazol [2 to 3 C.C. intravenously] will be effective in awakening the patient.) “G (Page 233.) Hu113” said that the problem presents no real difficulty, while Estabrook? stated that he has never encountered this situation. HypersuggestibiEity.-Two forms in which this problem has been presented are : the danger of reducing the limen of susceptibility to such an extent that merely witnessing the hypnotic procedure may induce the trance state,“” and the involuntary appearance of a trance.2, 51’ In both cases, according to the authors who raised the problem, a single suggestion during hypnosis prevented further occurrences. In similar fashion, adequate protection for susceptible subjects against being hypnotized “against their will,” or by other hypnotists is easily given.2t 56 Sporatnneous Disturbances.-EsdaileZ2 reported cases of patients who on awakening from the hypnotic state were unable to see “for a good while after.” Schultz44 and Erickson’” have reported the appearance of spontaneous disturbances in different sensory modalities, resultin g from experiment,ation during the hypnotic state, or the hypnotic state itself. Such occurrences are rare and with ‘Vi& supm.
806
P. L. Murcu.w
adequate prior knowledge may be forestalled or immediately removed by suggestion on rehypnotizing the subject. In general, reports dealing with the problem of possible ill effects associated ‘with the use of hypnosis are in agreement with conclusions such as the following : “I have extracted questioned the patients “I have induced that anybody suffered
in all about forty teeth, myself, but the results were hypnosis about sixty thousand any bad effect afterward.“59
tried my best to discover defects, and most satisfactory.“s (Page 163.) times and I have never seen or heard (Page 116.)
More recently, Erickson discussed such possible detrimental effects of hypnosis as alterations of personality, hypersuggestibility, development of escape mechanisms, and weaking of perceptual powers in distinguishing between reality and unreality. His conclusion regarding such dangers was expressed as follows: “In summary then, the literature offers little credible information concerning possible detrimental effects of eFperimenta1 hypnosis, although replete with dogmatic and opinionated denunciations founded on outworn and untenable concepts of the phenomenon. . . . The author’s own experience based upon several thousand trances on approximately three hundred individual subjects, some of whom were hypnotized at least five hundred times each over a period of four to six years, reveals no evidence of such harmful effects.“ir (Page 326.) CONTRAINDICATIONS
AND
INDICATIONS-HYPNOTIC
ANESTHESIA
Possible contraindications to the use of hypnotic anesthesia have been indicated in the foregoing discussion. Of the problems discussed, the most important is probably the relatively small number of individuals sufficiently susceptible within a reasonably short period of time. With regard to the time factor, WookeyS made three points. First, the subsequent ease and rapidity of inducing anesthesia must be kept in mind. Secondly, the use of hypnosis is more feasible for younger dentists whose practice does not yet take up all their time. Thirdly, in some instances the dentist may be able to enlist the help of a hypnotist. Indications for the use of hypnotic anesthesia may be considered under two headings : its advantages over chemical anesthetics, and its utilization when contraindications to the use of chemical anesthesia exist. The specific advantages which make hypnosis “an ideal anesthetic” have been listed by Stein48 in 1930 and by Hollander31 in 1932. Some of these attributes are : anesthesia can be localized, salivation can be controlled, bloodless fields of operation can be produced, mouth props and gags are unnecessary, postoperative pain and nausea may be eliminated, no abstinence from food is required prior to the operation, nervous apprehension may be removed, and the patient can be placed in any position without risk. Wookey, in discussing the uses and limitations of hypnosis in dental treatment, concludes: ’ ‘Whatever may be said to the contrary, anesthesia whether of the general or local variety is not a pleasant process, whereas hypnosis possesses no more discomfort than falling asleep and the awakening gives a very agreeable feeling of well being.“65 (Page 567.) The danger of using anesthetics, local or general, when contraindications to their use exist, is testified to by the reports of fatalities.16y 45y67 Among the pre-
Hypnosis
in Dentistry
807
disposing factors mentioned were : kidney disease, degenerated heart muscle, acute endocarditis, and nervous excitement leading to secondary complications. In a number of other papers+ 37143~47, 48p51163168 are described “bad risks” in the use of local or general anesthesia. In addition to the conditions already described were : chronic catarrh, sinusitis, bronchial affections, psychological fear of nose piece and nervous disorder.” The question arises as to whether a local anesthetic may be used when a general one is inadvisable, and vice versa. In regard to this question, it may be mentioned that dental practitioners themselves are not completely agreed either on the respective merits or on the indications for the use of general or local anesthesia.36T 6o Cases in which hypnotic anesthesia has been successfully used when contraindications to chemical anesthesia existed have been reported by BramwelJ6 Hollander,31 and Hawkes.29 Bramwell’s case involved an extraction in a patient suffering from anemia and valvular disease, while Hawkes reported the removal of the entire lower and upper sets of teeth in a person with valvular regurgitation-with “ perfect results. ” CONCLUSION
The different functions of hypnosis in dentistry and the problems associated with its use, as revealed in the available literature, have been reviewed and evaluated. On the basis of this report, the writer would argue that the existence of contraindications to the use of chemical anesthetics represents a minimum argument for a more serious scientific study of hypnosis and hypnotic anesthesia.t The writer is indebted to Miss T. Gilman for assistance in the preparation of the manuscript. Thanks are also due to Dr. 0. K. Champlin of Ithaca, New York, and to the Library Bureau of the American Dental Association for the loan of their package library on hypnotism. This package is described in a letter from the librarian as “including all of the articles indexed in the dental literature in the English language during the past 15 years, with the exception of three. ” The articles from the package library are indicated in the bibliography by asterisks. REFEREKCES
1.
Arnold, Magda B.: On the Mechanism of Suggestion and Hypnosis, J. Abnorm. & Social Psychol. 41: 107-128, 1946. 2. Bernheim, H.: Suggestive Therapeutics, cd. 2, New York, 1889, G. P. Putnam’s Sons. 3 y Bisc,Ty$ted by C. A. Herter.) . Psychotherapy, INTERNAT. J. ORTHODONTIA 11: 547-549, 1925. 4: Blankz?ortj MI; Why We Don’t Know Much About Hypnosis, J. Abnorm. & Sorial Psychol. 26: 390-394, 1932. 5. Braid, J.: Neurypnology, London 1843, J. & A. Churchill. 6. Bramwell, J. M.: Hypnotism: Its History, Theory and Practice, ed. 3, London, 1921, Rider & Company. 7. Brenman, Margaret: Experiments in the Hypnotic Production of Anti-social and Selfinjurious Behavior, Psychiatry 5: 49-61, 1942. 8. Capern, T.: Curative Powers of Mesmerism, London, 1851, J. B. Bailliere et fils. 9.* Chandler, F. W.: The Psychologic Aspect of Anesthesia: With Special Reference to Pressure Induction. Anesth. & Analg. 4: 375-376, 1925. *There are many remedies on the market for the extremely nervous or neurotic patient. Thorn51 however, warned against the use of “premeditation” because of the danger of producing drug-forming habits. He stated that it is to be avoided unless “absolutely neeessary.” tProgress in our knowledge of hypnosis has been hampered by short-sighted and illinformed groups who have been in a position to directly or indirectly prohibit research in many of our large universities. Blankfort’s article,’ “Why We Don’t Know Much About Hypnosis,” and Stein’s paper.48 “Hypnotism To-day” (1930) give evidence of this.
808 10. 11.” 12.” 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.* 29.* 30. 31. 32. 33. 34. 35. 36. 37. 38.” 39. 40. 41.” 42.” 43. 44. 45. 46. 47. 48. 49.
P. L. Marcuse
Conklin, E. S.: Principles of Abnormal Psychology, New York, 1935, Henry Holt & Company. Denny, R. E.: Use of Suggestion in the Practice of Dentistry, Dent. Reg. 72: 278282, 1918. Dorland. J. W.: Hvonotic Theraoeutics and Modern Dentistry, “I Dental Cosmos 63: I 810-813, 1921. “_ Dunbar, Flanders H. : Emotion and Bodily Changes, ed. 2, New York, 1938, Columbia University Press. Eddy, Mary B.: Science and Health With Key to the Scriptures, Boston, 1917, Christian Science Publishing Society. Elliotson, J.: Numerous Cases of Surgical Operations Without Pain in the Mesmeric State, London,. 1843, J. B. Bailliere et fils. Elliotson, J. : Mesmerism in India, London, 1850, J. B. Bailliere et fls. Erickson,Social M. H.: Possible Detrimental Effects of Exoerimental Hypnosis, J. Abnorm. & 27: 1932. L -Psychol. 321-327, Erickson, M. H.: An Experimental Investigation of Possible Anti-social Use of Hypnosis, Psychiatry 2: 391-414. 1939. Erickson, M. If.: Hypnotik Investigation of Psychosomatic Phenomena. I. Psychosomatic Interrelationships Studied by Experimental Hypnosis, Psychosom. Med. 5: 51-58, 1943. Erickson, M. H.: Hypnosis in Medicine, M. Clin. North America 28: 639-652, 1944. Esdaile, J. : Mesmerism in India, London, 1846, Longmans, Green & Co. Esdaile, J. : Record of Cases Treated in the Mesmeric Hospital November, 1846May, 1847, Calcutta, 1847, Ridsdale. Estabrooks, G. H.: Hypnotism, New York, 1943, E. P. Dutton & Co., Inc. Friedlander, J. W., and Sarbin, T. R.: The Depth of Hypnosis, J. Abnorm. & Social Psychol. 33: 453-475, 1938. Gardner, B. 5.: Extraction of Teeth; Emphasizing the Advantages of Local Anesthesia in Difficult Cases J. A. D. A. 18: 105-110, 1931. Gerrish, F. H.: The Therapeutic Value of Hypnotic Suggestion, J. Abnorm. & Social Psychol. 4: 99-119, 1909-1910. Goldman, J. D.: Better and Safer Gas-Oxygen Anesthesia for Exodontia, Dental Items Interest 67: 358-372. 1945. Griffiths, H. H.: Psychology in Dentistry, Wis. Dent. Rev. 12: 103-107, 1936. Hawkes, L. A.: Hypnotism as an Anesthetic, Oral Hygiene 19: 1948-1950, 1929. Hays, H. M.: Hypnotism, Its History, Nature and Use, Popular Science Monthly 67: 590-607, 1905. Hollander, B. : Hypnosis and Anesthesia, Dent. Surg. 29: 239-244, 253-257, 1932. Hull, C. L.: Hypnosis and Suggestibility, New York, 1933, D. Appleton-Century Company, T-^ .LJlG. Jenness, A. : Hypnotism, In J. MeV. Hunt, Editor, Personality and the Behavior Disorders, New York, The Ronald Press Company, Vol. I, pp. 466-502, 1944. The Practice of Hypnotic Suggestions, Wood’s med. surg. Monogr. Kingsbury, G. C.: 12: 261-398, 1892. Kraines, S. H.: The Therapy of the Neuroses and Psychoses, Philadelphia, 1943, Lea & Febiaer. A Boon to Dentist and Patient, Dental Items Levy, I. R., and Langa, H. : Analgesia: Interest 67: 1084-1088, 1945. Mackay, R. P. : Points of Contact Between Dentistry and Neurology, J. A. D. A. 24: 1647. 1654, 1937. Maller, J. W.: Child Psychology as Applied to Orthodontia, INTERNAT. J. ORTHODONTIA 15: 585589, 1929. Martin, E. H.: The Use of Hypnotism in General Practice, Med. Rec. 58: 170-173, 1900. Maslow, A. H., and Mittelmann, Bela: Outline of Abnormal Psychology, New York, 1941, Harper & Brothers. Nemoff, I.: Patient’s Attitude, Dental. Cosmos 67: 398-405, 1925. Rose, W. 8.: Dental Psychics, Dental Cosmos 53: 1253-1262, 1911. Rovenstine, E. A. and Hershey, 8. G.: The Utility of Apomorphine in Clinical Anesthesia, Dig. Treatm. 9: 873-874, 1946. Schultz, I. H.: Gesundheitsschadigungen nach hypnose, Halle a.S, 1922, Carl Marhold. Accidents During Administration of Local Anesthesia, J. A. D. A. 14: 1177Schultz, L.: 1182, 1927. Sears, R. R.: An Experimental Study of Hypnotic Anesthesia, J. Exper. Psychol. 15: l-22, 1932. Seldin, H. M.: General Anesthesia in Dental and Oral Surgery, J. A. D. A. 23: 1040. 1044, 1936. Stein, M. R.: Anesthesia by Mental Dissociation, Dental Items Interest 52: 941-947, 1936. Stein, M. R.: Hypnotism To-day. Scient. Monthly 31: 86-88, 1930.
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Suggestion and Auto-suggestion in Its Relation to Dentistry, Dent. Summ. 1916. 51. Thorn, L. W.: Control of Pain in Operative Procedures, J. A. D. A. 26: 1777-1785, 1939. 52.* Toplan, B.: Hypnotic Suggestion in Dental Practice, Dent. Reg. 74: 82-85, 1920. 53. Tuckey, C. L.: Psycho-therapeutics; or Treatment by Hypnotism, Wood’s med. surg. Mononr. 3: 721-795. 1889. 54. Wells, W. ii.: Experiments in Waking Hypnosis for Instructional Purposes, J. Sbnornr. 6; Social Psycl~ol. 18: 389404, 1924. 55. Wells, W. R.: Hypnotizability Versus Suggestibility, J. Abnorm. & Social Psychol. 25:
50.”
Stone,
in Dentistry
W. F.:
36:
87-92,
436-449. 5fi.
Wells,
1%‘. R.‘:
1931.
Experiments
in the
Hypnotic
Production
of
Crime,
J. Psychol.
11:
(X-192,
1041. 57.
58. 59. 60. 61. 62.” 63. 64. G5.* 66.” 67. 68.” G9.
Wells,
W. R.: The Hypnotic Treatment of the Major Symptoms of Hysteria: A Case Study, J. Psychol. 17: 269-297, 1944. Wells, IV. R.: A Basic Deception in Exhibitions of Hypnosis, J. Abnorm. & Social Psychol. 41: 145153, 1946. Hypnotism and Its Application to Practical m’etterstrand, 0. G., and Petersen, H. G.: Medicine Together With Medical Letters on Hypno-suggestion, etc. (translated by H. G. Petersen). New York. 1897. G. P. Putnam’s Sons. White, C. M.: The’Use of Nitrous O&de and Oxygen for Cavity Preparation and Other Dental Procedures, Dental Items Interest 67: 776-779, 1945. White. R. VV.: A Preface to the Theorv of Hvonotism. J. Abnorm. & Social Psvchol. 36: “I 477. 505, 1941. Talking to the Dental Patient, Oral Hyg. 24: 694-502, 1934. Whitmer, C. A.: The Psvcholoeical Annroach to the Nervous Dental Patient. Dental Wildman. C. W.: Items Interest 67: 691-692; 1945. *I Hypnoanalysis, New York, 1945, Grune and Stratton. Wolberg, L. R.: Uses and Limitations of Hypnosis in Dental Treatment, Brit. D. J. Wookey, E. E.: 65: 562-568, 1938. Suggestions as a Factor of Success in the Practice of Dentistry, Dental Zulauf, A. F.: ltems Interest 45: 841-858, 1923. Cases (Anon.) Dent. Surg. 29: 502-503, 539-531, 546, 1932. Editorial (Anon.), Apollonian 8: 173-174, 1933. Reports of the Supreme Court of the State of The State of Kansas v. Anderson Gray. Kansas 55: 135-146, lS96.
IN DENTISTRY
F. L. MARCUS~, PH.D.,*
ITHACA,
N. Y.
T
HE use of hypnosis in dentistry in the United States today is rare, and its utilization, when noted, is matter for newspaper comment despite its more than loo-year-old history. What possible future hypnotic anesthesia might have had in dental or surgical practice was cut short by the discovery of chemical anesthetics. While dentists are not professional psychologists, their interests raise legitimate and practical problems regarding the use of hypnosis in dentistry. In what ways may hypnosis be used? What per cent of the population may be hypnotized? What determines this figure ? Is hypnosis morally safe ? Is there danger of awakening from hypnotic anesthesia during operation? Do ill effects follow its use? What unique advantages does hypnotic anesthesia possessa These problems are familiar ones, but for many their context will be novel, since psychologists have little occasion to refer to the dental literature which has been reviewed for this report. In discussing the above questions, reference to more than the dental literature was of necessity required. Psychological data and work frpm medical investigators, such as Braid, Esdaile, Wetterstrand, It is hoped that the inclusion of and Petersen, will be cited where relevant. this material will indicate a sphere of application for hypnosis in the field of medicine as well as dentistry. First, it is to be noted that the articles included in the package library on hypnotism include examples of indirect suggestion and countersuggestion, as well as direct suggestion, that is, hypnosis, with which this paper is primarily concerned. Illustrations of the application of the first two types of suggestion will be given before proceeding with the main topic. Indirect Xuggestion.t-These references emphasize the elements of evasion and concealment. Rose42 reported a patient delighted with the effects of an injection of “aqua destillata,” while Hollander31 mentioned the successful use of a gas mask-minus the gas. A case similar to Hollander’s, though not in the field of dentistry, was cited by Tuckey.53 Countersuggestion.-The devices used in countersuggestion are intended to counteract the influence of fixed ideas, in this case fear of the dental situation. The main goal is to reassure the patient, calm his apprehensions, and in this way decrease the amount of chemical anesthetic required. These common-sense *Department of Psychology, Cornell fThe significance and imoortance gestion have been discussed by Wells.“-67
University. of differentiating 796
between
direct
and
indirect
sug-
Hypnosis
in Dentistry
797
procedures include the following : 1. Preparatory educational talks”‘8 66 2. Keeping instruments out of sight, and the use of praisel’ 3. Avoiding exciting colors and the traditional pictures of the doctor at the bedside of the dying patients 4. Creating an air of security and confidence by jokes and funny stories42 Use of such techniques may, according to Rose,42 result in the use of only one-fourth the usual amount of ether. Zulauf, in discussing the role of suggestion, decided : “The power of suggestion is unlimited. The dentist has been looking too long into mouths. For years his whole vision has been centered upon the teeth and only recently (1923) has he realized the inseparable relation of the dental psychical organism, a correlation beyond the power of imagination; and every learning more of their inseparable relations. “66 (Page 846.) THE
USE
OF
HYPNOTIC
mouth and field to the day we are
ANEYTFIlW.\
Xymptom Treatment.-Cases involving the use of hypnosis for the sole purpose of eliminating the pain of a toothache are described by Capern,8 Kingsbury,34 and Martin3s prior to the year 1900. The latter described a case in which, the cavity being small and the tooth needed, the patient was ordered to cease having the toothache and then awakened and told what had been done. The results were stated as follows: “In fact he would not let me leave him until he had tried ice-water and molasses and everything else at hand to try to make the tooth ache again. Three years later he told me that it had never ached afterward. ” (Page 172.) Despite such cases as this, the elimination of pain arising from tooth decay as an end in itself is obviously not advisable.” The interim use of such pain elimination pending and during the dental appointment may, however, provide welcome relief and serve a useful function. It is the opinion of the present writer, who has used hypnosis in this latter fashion, that examples of such use could be supplied by most research workers in the field of hypnosis. Operative Use.-The use of hypnosis as an adjuvant to chemical anesthetics has been advocated. Wetterstrand and PetersenS and Bernheim2 have suggested that hypnosis always be tried first, for even though the effect is slight, a smaller amount of chemical anesthetic will be required. The same point was made by Goldman in 1945 when he stressed t,he fact that anesthesia does not depend on gas-oxygen balance alone, but also on the patient’s state of relaxation. He consequently makes the following suggest,ion to the anest,hetist regarding procedure : “Your voice has the The tone is more important voice takes on the character (Page 359.)
suggestion of the hypnotist-it, is calm, slow, suggesting sleep. than the content. At about the fifth to twelfth breath your of a drone, ronducive to relaxation and comfortable sleep.“27
*Two possibilities may be mentioned where beneficial results were obtained. or originally may have been associated but the pain had persisted on a “psychic see Dunbar.’
to account for those cases, assuming their validity, The pain may either have been of hysterical origin, with some somatic condition which had cleared up, basis.” For a discussion of this latter possibility,
P. L. Marcuse References to the early use of hypnotic anesthesia alone are numerous. Elliotson15 and Braid,5 in 1843, Esdaile,21 in 1846, and Wetterstrand and Petersen,5s in 1897, are but a few who reported its successful use in extraction. A representative case is cited : “Anna L., sixteen years old. Suffered from toothache for several days and the left cheek became gradually more and more inflamed. When she came to me on the twenty-fourth of May, 1887, I noticed a hard and sensitive swelling outside of the first left molar tooth of the upper jaw; her violent toothache had originated in this carious tooth. I hypnotized her and told her during the sleep, that the pains would disappear; that she would return at five P.M. the following day and would experience no pain while I made an incision in the swelling. The toothache disappeared immediately and did not return. I made the incision the next day and she felt nothing. It was as if I cut into dead tissue, a proof of the (Page 111.) wonderful power of suggestion. “59
Similar results are to be found in reports during the past twenty-five years. Toplan, in 1920, reported the use of hypnosis on his daughter as follows: “She ‘had to have a tooth stopped. It was very bad. She had to have the pulp dealt with and the nerve removed. The dentist said to me, ‘It is very tender. Shall I put her She sat up in the chair and I said, ‘Go to sleep and do not wake under cocaine?’ up till For 20 or 25 minutes she did not take the slightest notice. He killed the nerve. I tell you.’ When he was done he was astonished. you wake up you will feel quite I said to her, ‘When comfortable. When I count 10 you wake up. ’ She said, ‘Is it over daddy?’ and I said ‘ Yes. ’ ’ ‘52 (Page 84.) *
Further successful extractions are reported by Bramwell,6 in 1921, and by Hawkes,29 in 1929. In 1933, a successful demonstration before the Northeastern Dental Association was described.@ In 1941, Wells reported two successful cases. In the first of these a cavity described by the dentist as “normally very painful” was painlessly treated. The second case involved the extraction The results are described as follows : “The of a badly decayed wisdom tooth. subject experienced no pain during the extraction, as determined by introspective report at the time of extraction, and gave not the slightest indication by muscular quiverings that he experienced any pain. “56 (Page 87.) In the above references the results were described as “most satisfactory,” or, even more enthusiastically, “no aftereffects,” “ 100 per cent perfect,” “Whether it be a minor or a major operation no other anesthetic is capable of results equal to those obtained by the application of hypnosis.“2g (Page 1948.) Despite the apparent advantages (to be described more fully later) associated with the use of hypnotic anesthesia, it is a fact of simple observation that it is rarely used today. It remains then to evaluate the reasons for its limited utilization. PROBLEMS
ASSOCIATED
Per Cent Susceptible.-Of as an anesthetic is the question susceptible so that anesthesia expected to reach the stage of
WITH
THE
USE
OF
HYPNOSIS
fundamental importance to the use of hypnosis of what per cent of the population is sufficiently may be induced ; that is, how many may be somnambu1ism.t Estimates of the percentage of
*While the case history does not indicate it, the writer feels sure that the procedure described reflects the use of a well-trained .somnambule reacting to posthypnotic suggestion. For further examples of this technique, see Wells.” TNumerous descriptions of the different stages of the hypnotic trance may be found in the literature.2a *% ss 2% 88 While the deeper stages are to be preferred, one may operate with leas pain even in the lighter stages.5
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somnambules vary from 13 per cent2 to ‘70 per centZO and from general statements of a “fair percentage”@ to a “large percentage.“21 Such discrepancies may be attributed in part to differences in techniques of induction, age, and nationality.” Technique.t-Techniques of hypnotic induction vary from hypnotist to hypnotist with regard to such aspects as the use of a fixation point, verbal content, and duration. Most procedures, however, have in common an emphasis on relaxation and sleep. The most important consideration of any hypnotic procedure, in the preliminary attempts to obtain a trance state, is its duration. Esdaile’s notesZ2 indicate that prior t,o operation a patient might be mesmerized daily for an hour and a half, over a period which might vary from a few days to a week, depending on the depth of hypnosis indicated. The importance of patience and perseverance is emphasized by Wetterstrand and Petersen in the following case : “I finally succeeded in hypnotizing a lady of about 40 after having endeavored in vain seventy times to do so, and thus alleviated her severe sufferings of more than 20 years’ standing. ‘Go (Page 3.) Wolberg64 also emphasized perseverance and stated that initially several two-hour sessions of slow systematic induction may be required to develop a satisfactory somnambulistic stage. Specific hypnotic procedures for the field of dental treatment were described by HoIlander,31 Hawkes,2g and Toplan.sz The latter advised that prior to operative procedure two to three sittings of one-quarter hour be held. Wookey6” stated that 35 per cent of patients are sufficiently susceptible for purposes of dental anesthesia after three to five visits. St,ein4B gave a corresponding figure of 15 to 20 per cent by the fifth attempt-the first yielding less than 7 per cent. Neither Stein nor Wookey indicated the length of each visit. Whether or not the patient should be informed of an impending operation represents a problem in technique. Bernheim,2 Braid,s and Wetterstrand and Petersens believed that the resulting distraction might vitiate against obtaining a sufficiently deep hypnotic state, and, consequently, concluded that the patient should not be forewarned. The auxiliary use of drugs 23,35sG4to produce somnambulism in individuals otherwise nonsusceptible represents a further extension of the problem of technique.% One procedure involves the use of drugs one-half hour prior to the hypnotic sessions to reduce the patient’s resistance. Such continuous use of drugs is not necessarily required. A posthypnotic suggestion may be given during narcosis t,o render the subject susceptible to subsequent hypnotic procedures. Failure to recognize the diverse techniques whereby hypnotic states may be induced may lead to its unwitting use. Nemoff41 reported successful elimina*Sex differences in susceptibility are not mentioned as a problem in the dental literature. Approximately the same degree of susceptibility for male and female was found by Bernhein? and Wetterstrand and Petersen.50 ~Descriptions of various techniques may be found in the following references 3 28, 8% as. 51, Me f% $Wookep described a technique which departs still further from the cu$omary hypnotic procedure. He stated that Voisin hypnotized “lunatics” by force either by \l~guse OI strait jackets or by forr%ly holding them down. until they beramr exhaustrd. was then able in many cases to hypnotize and treat them.
F. L. Marcuse tion of pain by having his patients visualize and concentrate on a black spot on the dentist’s white coat. Equally suspect was Dorland’@ “strong helpful talk” injected into the patient’s ‘ ‘ subconscious mind’ ’ which helps him ‘ ‘ mentally and dentally. ” Dorland’s categorizing of his technique as suggestion in the waking state as opposed to suggestion in the hypnotic state probably reflects a failure to recognize the existence of waking hypnosis. Age.-Many of the early writers believed that children were more susceptible than adults.*9 32 Wetterstrand and Petersen59 reported that all children between the ages of 4 and 15 years were susceptible, though to what degree was not indicated. Bernheim’s data2 indicated that 55 per cent of 7- to lCyearolds were somnambules, whereas fewer than 26 per cent in any succeeding seven-year-range fell in this category. While recent data on this problem are lacking, such a trend of increased susceptibility among children would have important implications for dental orthopedics, if verified. Nationality.-The people of India have been described as “peculiarly sensitive ’ ’ to hypnosis,*l while the inhabitants of France have been said to be more susceptible than the people of the’ United States.48 Differences, says Chandler,g are to be explained culturally. Where hypnosis enjoys scientific repute and the confidence of the populace, less resistance and, consequently, greater susceptibility are to be expected.* Religion.-Religion may constitute a practical problem in the use of hypnosis. Whether an individual volunteers for an experiment or whether a patient agrees to the use of hypnotic anesthesia may depend on his or her religious faith. , The attitude to hypnosis of the Roman Catholic Church in 1841 was revealed in correspondence between the Bishop of Lausanne and the Pope. In reply to an inquiry from the former concerning the use of animal magnetism, the Pope replied, “The Sacred Penitentiary, the premises having been maturely weighed, considers that these should be answered as it now answers-the use of magnetism, as set forth in the case, is not permissible.“21 (Page 39.) In 1938, a,,more recent indication was given-when the Apollonian, a dental journal, commented editorially on the use of hypnosis as follows: .. ‘LCatholics will be interested to note that approved moral theologians and binding decrees of the Sacred hypnotism, allowing it Hence Catholic patients when there are other prohibition are various. and spiritism, and the and false worship. “6s
Congregation of the Holy Office place a ban upon the only where it is an approved and necessary method of may not submit to hypnosis and Catholic doctors may and better anesthetics available. The reasons for this Historically the hypnotic trance has been associated Church wished to keep her faithful away from all risk (Page 174.)
general use of medical care. not hypnotize ecclesiastical with diabolism of superstition
The danger, the editorial goes on to say, is that the patient is completely and heiplessly at the hypnotist’s will and that historically the hypnotist has not been guided by a keen sense of professional obligation. Christian Science, not surprisingly, strongly condemns hypnosis. Mary Baker Eddy was convinced on the basis of her observations of the workings of *As a point of practical tions prior to attempting to conceptions has been described
procedure, it is customary to The nature induce hypnosis. by Maslow and Mitte1mann.M
clear up any existing misconcePof many of the popular miSJenness.8~ and Gerrish.%
Hypnosis
in Dentistry
801
hypnosis that : “It is not a remedial agent and its effects upon those who practice it, and upon their subjects who do not resist it, lead to moral and to physical death. ’ ‘I4 (Page 101. ) Th,e Moral Problem.-Can moral standards be transcended under hypnosis? Controversy+ over this question which has long existed among psychologists also exists among dentists, WookeyG5 presents the question as a practical problem confronting the dental practitioner who contemplates the use of hypnosis. He believes that a person will not do anything against his ‘ ‘moral sense” but conceives it possible that a suggestion which would be restrained by “moral training” in the waking state might, be carried out under hypnosis if it is in accord with innermost desires. The above distinct,ion is a dubious one. The important point is that Wookey has agreed that an act may be carried out under hypnosis which would not usually be carried out in the waking state. He mentioned a case of a will being drawn up in favor of a hypnotist as a result of hypnotic suggestion and even conceded the possibility of murderi resulting from hypnotic influence. While many hypnotists scorn the possibility of danger, how many, asked Wookey, would be willing to give a hypnotized person a real dagger and direct him to use it on the hypnotist? On the basis of his beliefs, he proposed that, for the mutual protection of patient and dentist, a third person be present during the use of hypnosis-a precaution customarily taken in experimental investigation. Additional evidence for the wisdom of this procedure is implicit in the fact that Estabrooks’” has insured himself against blackmail, while Wells x does not use women subjects in his individual experiments. Other dental practitioners who have expressed themselves on this moral question are Dorland12 and Rose,42 who denied the possibility of moral transgression under hypnosis, and Bisch” and Kingsbury,“” who affirmed the possibility. The latter mentioned a case of a dentist at Rouen in 1879 who was sentenced to ten years’ imprisonment for assaulting a client who was in a hypnotic state. The fact that hynosis can be misused by unprincipled individuals should not be interpreted as a legitimate objection to the use of hypnotic anesthesia. It should be remembered that the same criticism was raised to the use of chemical anesthetics. Bernheim’s opinion on this point was expressed as follows : “Must we proscribe a thing which may be efficacious because the abuse of it is injurious. “* (Page 415.) NATURE
OF
HYPNOTIC
ANESTHESIA
Three questions are often raised with regard to the use of hypnotic anesthesia. Is it conscious simulation ? Is it not really amnesia rather than anesthesia ? Is there danger of awakin g from the hypnotic stat,e? *For a discussion of this dispute see Well~,~~ Brenman.7 Brenman.’ and Erickson.‘” tWetterstrand *Wetterstrand and Petersen. in supporting their thesis that an honest man may be influenced to commit a crime, cite a murder charge which occurred in Kansas in 1895. The court’s decision declared “innocent a murderer who had acted under the influence of hypnosuggestion and sentenced to death the instigator to the crime.“” (Page 158.) Reference to the case as reviewed and sustained in the Superior Court?’ indicated that the condemned man “counseled and incited McDonald to commit the murder.” (Page 136.) However, the court record also raises some doubt, in the present writer’s mind at least, as to the validity of considering that hypnosis, intentional or unintentional, played a part in this particular crime.
F. L, Marcuse Conscious Simulation.-The answer to the first question of conscious simulation must of necessity involve discussion of the feasibility of the control experiment. In connection with clinical procedures, Wells56 believed this to be either impossible or absurd. While Wells’ statement is generally true, instances are to be found in both Esdaile and Braid’s cases which approach the requirements of a control experiment. In Esdaile’s case hypnotic anesthesia was used in a tumor operation “without her feeling it.” Four months later a similar operation was performed on the same patient due to a return of the tumor. The second operation, which may be thought of as the control operation, was described as follows: “She has been mesmeriseddaily for two hours but without effect. I therefore operated on
poor
her
to-day, aa we could old woman screamed
she continued in the
spare no more time for her, others requiring equal attention. miserably the whole time, crying that I was murdering her; greatest pain for hours afterwards.“21 (Page 76.)
The and
Esdaile’s emphasis in discussing this case concerned the possibility of conscious simulation. If the successful results of the first operation resulted from the patient’s shamming insensibility, why, he asked, did she not act similarly in the second operation ? Especially since she had had practice and now knew what was expected of her.+ In a further extension of this same argument Esdaile raised the problem of how to account for the increasing number of patients coming to him at the hospital. He answered this question very succinctly as follows : “I only see two ways of accounting for it : My patients, on returning home, either say to their friends similarly aYEcted, ‘ Wah! brother, what a soft man the doctor Sahib is! He cut me to pieces for twenty minutes, and I made him believe that I did not feel it. Isn’t it a capital joke? Do go and play him the same trick; you have only to laugh in your elbow, and you will not feel ,the pain.’ Or they say to their brother sufferers, ‘Look at me; I have got rid of my burthen (20, 30, 40, 50, 60, or 80 pounds, as it may be), I am restored to the this, I assure you, the doctor Sahib did use of my body, and can again work for my bread: of these hypotheses best explains when I was asleep, and I knew nothing about it. ’ . . . Which the fact my readers will decide for themselves. “21 (Page 237.)
Braid’s case similarly pointed to the same conclusion, of the hypothesis of conscious simulation.
that is, the poverty
“A lady had abscess connected with disease of the orbital process of the frontal bone, had the matter discharged by small puncture, the wound closed by first intention and again opened, as required, by the lancet. She experienced so much pain on each occasion as to induce me to hypnotize her, after which she made no complaint, although I durst not carry it far owing to the state of the brain. On one occasion I was anxious to ascertain how she would feel by operating wdthozlt hypnotizing, when the result was so distressing as to induce me always in future to hypnotize her, before such operations, and then all went on well.“5 (Page 252.)
Elliotson,15 in 1843, discussed a case in which an extraction was reputedly performed with the patient shamming anesthesia. He concluded that such indifference was impossible. *This case as well as other clinical data put a strain on current theories which regard hypnotic behavior as “meaningful goal-directed striving. its most general goal being to behave like a hypnotized person as this is continuously deflned by the operator and as this is understood by the subject”” (page 503). or which regard anesthesia as resulting from “an imaginative focusing on a situation which is associated with the desired condition.“1 (Page 115.)
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in Dentistry
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Even in the laboratory situation where the nature of the tests of anesthesia tend, though not necessarily, to be less severe, a conclusion similar to that found for clinical data is reached. Sears’ study concluded that: “Voluntary inhibition of reaction to pain does not present a picture even remotely resembling the reaction under true hypnotic anesthesia.“46 (Page 22.) Amnesia.-Hull raised the question concerning the possible confusion between amnesia and anesthesia, by discussing the following case reported to him by M. H. Erickson : IL The patient, an adolescent girl, whimpered and flinched decidedly while the tooth was being extracted. Upon being dehypnotized, however, the subject professed a complete amnesia for the trance proceedings, and smilingly expressed surprise when told that her teeth were out, even though at the time her mouth was very bloody from the effects of the recent ordeal. ’ ‘3s (Page 252.)
Hull felt that in situations such as the above, amnesia rather than anesthesia is indicated. He consequently expressed some doubt of Esdaile’s assertion that, his patients remained perfectly quiet during operation. Reference to Esdaile’s own reports, rather than the secondary sources on which Hull appears to have relied, reveals that Esdaile never claimed that all or even a majority of his patients remained perfectly quiet during surgical procedure.” However, it does not follow, as will be shown, that this indicates the validity of Hull’s contention. Examples of cases similar to Erickson’s and described by Esdaile as “disturbed trances’ ’ follow : L’Towards the end of the operation he moved and cried out unintelligibly, but on the fall of the mass became perfectly tranquil, and did not awake till after he had been coverecl with a clean sheet, and all tracts of the operation removed. Nothing had disturbed his sleep, he said, he felt just as usual, had no pain anywhere.“*2 (Page 45.) ((This man was also disturbed before the end of the operation but did not awake till after he had been covered with a clean sheet. He was not aware that anything had happened to him. “2s (Page 49.)
Analysis, by the present writer, of eighteen major operations described by Esdailez2 reveals only seven that fall into the “perfectly quiet” category. This group included those who “lay like a corpse throughout” as well as those who showed some “slight contractions of the toes and face.” Six of the remaining cases belong to the “disturbed trance” category illustrated above. Esdaile pointed out that the movements that might occur during the “disturbed trance” were never purposive, that is, no attempt to avoid the cutting end of the knife is made. The patient stems to have no idea of the source of his discomfort. Esdaile’s explanation of the movemeuts that occur is that the spinal nerves rather than the brain are involved and that as a result there is no consciousness of sensation. This muscular irritability might be eliminated by prolonged hypnotic treatment, but there is little value in doing this, since the patient suffers no more in “disturbed trances” than when there is not a “quiver of the flesh.” Both these catcgorics, in Esdaile’s opinion, represent painless operations, for, “If a man has had no apprehension of an operation, and knows not that it has been performed when he awakes, what is this to be *Bernheima
similarly
stated
that
absolute
insensibility
is the
exception.
P. L. Marcuse As a practical man, I am quite satisfied if called if not a painless operation? my patients assure me that they feel no pain, especially when every look, word, and action correspond with their statements. ’ Q* (Page 4.) In summary then, two points are to be made regarding Hull’s contention that hypnotic anesthesia is more likely amnesia. In the first place, operations under hypnotic anesthesia in which the patient remains “perfectly quiet” do occur. In the second place, the existence of “disturbed trances,” on which Hull rests his argument, does not necessarily point to amnesia, but in light of the above discussion may still indicate anesthesia.* Danger of Aw&ening.,The final question concerning the danger of awakening from the trance state represents, for obvious reasons, a most important problem for the clinician. Conklinlo believes that an individual may awaken from the trance state as a result of severe nervous stimulation incident to the operation, and Hays warns of the “possibility of the patient awakening unexpectedly and dying from the shock of the operation. ‘vO (Page 607.) Cases illustrating the possibility of awakening are to be found in both Wetterstrand and Petersen5s and Esdaile.21* 22 An example from the case reports of the latter follows : “8th.-Deeply entranced, his legs were raised in the air and thrown down on the bed several times, the hair and the tumor exposed “1Oth.-He had granted that he was in I almost made up my it would not be broken, as usual I proceeded little advantage from
of
his beard was plueked out; his left nipple was severely pinched, and testis squeezed without disturbing his sleep. been for two days in the most satisfactory state, and I took it for the same state to-day. He shrunk on the first incision, however, and mind to desist but trusting that though the trance migh be disturbed, and that he would retain no recollection of his apparent suffering, with the operation. But he very soon woke up completely and had his mesmeric trance.“22 (Page 47.)
In the report previously referred to22 of eighteen major operations performed by Esdaile, five of the patients woke up completely during the course of the operation. In another report covering a different time period, Esdaile2’ stated that of seventeen major operations, three were imperfect in that the patient Esdaile attempted to account for three of the awakened during the operation. eight failures, on the basis of the fact that they had been subjected to a cold draught, which in his opinion was capable of arousing the deepest somnambule. ,However, further cases of awakening, about which he offered no explanation, occurred even after suitable temperature precautions were taken. the failure, in the one case they Wetterstrand and Petersen5s attributed cite, to the inadequate depth of hypnosis that existed. WelF similarly attributed failure and, as well, success in hypnotic research to the depth of hypnosis obtained. If the operation is successful, the subject and the technique are satisfactory; if the individual awakens then the subject and/or the technique are unsatisfactory. In the writer’s opinion such an explanation is open to the criticism of post hoc reasoning. The question of whether we can eliminate indi*Wells” also quotes and discusses the Erickson successful attempt to produce hypnotic anesthesia. failure, Esdaile, on the basis of the postoperative mentioned by Wells) -would probably have considered
case, but he considers it merely an unThough Wells considered the case a amnesia which was present (though not it a success.
Hypnosis
in Dentistry
805
viduals likely to awaken during the course of the operation can be effectively investigated only on the basis of controlled experimentation with adequate t,ests for estimating varying depths of hypnosis. While the accuracy of such prediction would probably be high, available data indicate that it would not, be perfect. The preoperative description of the patient mentioned above, which appeared to indicate somnambulism, is a case in point,. Data on two of the other cases in which the patient awakened revealed similar preoperative pictures, while in t,he remaining five cases no information of the prior degree of susceptibility was given. Is a patient as likely to awaken from the effects of a minor operation as from a major one? Dorland12 raised the question in regard to extraction, and concluded that there are no grounds for fear that a patient will awaken during minor surgery. Hays,30 who warned against the use of hypnotic anesthesia in major surgery,* believed in its use in minor operations, especially dentistry. IIJ,
EFFECTS
The question of ill effects following or concomitant with the use of hypnosis is frequently raised. A variety of objections may be considered under this heading. Dificulty in Awaken&y.-Difficulty in awakening from the hypnotic trance is frequently mentioned but seldom encountered. The present writer met the problem in one subject, in the course of a three-year period of work with hypnosis. Loud verbal statements and shaking were of no avail, so the subject was allowed to sleep it out-a matter of three hours. Early in the next hypnotic session, suggestions concerning the awakening procedure were strongly emphasized and no further difficulty was encountered. Kraines commented on this problem as follows : “Only in rare and extremely unstable persons will the hypnotic sleep continue very long. (In intractable cases, a subconvulsive dose of metrazol [2 to 3 C.C. intravenously] will be effective in awakening the patient.) “G (Page 233.) Hu113” said that the problem presents no real difficulty, while Estabrook? stated that he has never encountered this situation. HypersuggestibiEity.-Two forms in which this problem has been presented are : the danger of reducing the limen of susceptibility to such an extent that merely witnessing the hypnotic procedure may induce the trance state,“” and the involuntary appearance of a trance.2, 51’ In both cases, according to the authors who raised the problem, a single suggestion during hypnosis prevented further occurrences. In similar fashion, adequate protection for susceptible subjects against being hypnotized “against their will,” or by other hypnotists is easily given.2t 56 Sporatnneous Disturbances.-EsdaileZ2 reported cases of patients who on awakening from the hypnotic state were unable to see “for a good while after.” Schultz44 and Erickson’” have reported the appearance of spontaneous disturbances in different sensory modalities, resultin g from experiment,ation during the hypnotic state, or the hypnotic state itself. Such occurrences are rare and with ‘Vi& supm.
806
P. L. Murcu.w
adequate prior knowledge may be forestalled or immediately removed by suggestion on rehypnotizing the subject. In general, reports dealing with the problem of possible ill effects associated ‘with the use of hypnosis are in agreement with conclusions such as the following : “I have extracted questioned the patients “I have induced that anybody suffered
in all about forty teeth, myself, but the results were hypnosis about sixty thousand any bad effect afterward.“59
tried my best to discover defects, and most satisfactory.“s (Page 163.) times and I have never seen or heard (Page 116.)
More recently, Erickson discussed such possible detrimental effects of hypnosis as alterations of personality, hypersuggestibility, development of escape mechanisms, and weaking of perceptual powers in distinguishing between reality and unreality. His conclusion regarding such dangers was expressed as follows: “In summary then, the literature offers little credible information concerning possible detrimental effects of eFperimenta1 hypnosis, although replete with dogmatic and opinionated denunciations founded on outworn and untenable concepts of the phenomenon. . . . The author’s own experience based upon several thousand trances on approximately three hundred individual subjects, some of whom were hypnotized at least five hundred times each over a period of four to six years, reveals no evidence of such harmful effects.“ir (Page 326.) CONTRAINDICATIONS
AND
INDICATIONS-HYPNOTIC
ANESTHESIA
Possible contraindications to the use of hypnotic anesthesia have been indicated in the foregoing discussion. Of the problems discussed, the most important is probably the relatively small number of individuals sufficiently susceptible within a reasonably short period of time. With regard to the time factor, WookeyS made three points. First, the subsequent ease and rapidity of inducing anesthesia must be kept in mind. Secondly, the use of hypnosis is more feasible for younger dentists whose practice does not yet take up all their time. Thirdly, in some instances the dentist may be able to enlist the help of a hypnotist. Indications for the use of hypnotic anesthesia may be considered under two headings : its advantages over chemical anesthetics, and its utilization when contraindications to the use of chemical anesthesia exist. The specific advantages which make hypnosis “an ideal anesthetic” have been listed by Stein48 in 1930 and by Hollander31 in 1932. Some of these attributes are : anesthesia can be localized, salivation can be controlled, bloodless fields of operation can be produced, mouth props and gags are unnecessary, postoperative pain and nausea may be eliminated, no abstinence from food is required prior to the operation, nervous apprehension may be removed, and the patient can be placed in any position without risk. Wookey, in discussing the uses and limitations of hypnosis in dental treatment, concludes: ’ ‘Whatever may be said to the contrary, anesthesia whether of the general or local variety is not a pleasant process, whereas hypnosis possesses no more discomfort than falling asleep and the awakening gives a very agreeable feeling of well being.“65 (Page 567.) The danger of using anesthetics, local or general, when contraindications to their use exist, is testified to by the reports of fatalities.16y 45y67 Among the pre-
Hypnosis
in Dentistry
807
disposing factors mentioned were : kidney disease, degenerated heart muscle, acute endocarditis, and nervous excitement leading to secondary complications. In a number of other papers+ 37143~47, 48p51163168 are described “bad risks” in the use of local or general anesthesia. In addition to the conditions already described were : chronic catarrh, sinusitis, bronchial affections, psychological fear of nose piece and nervous disorder.” The question arises as to whether a local anesthetic may be used when a general one is inadvisable, and vice versa. In regard to this question, it may be mentioned that dental practitioners themselves are not completely agreed either on the respective merits or on the indications for the use of general or local anesthesia.36T 6o Cases in which hypnotic anesthesia has been successfully used when contraindications to chemical anesthesia existed have been reported by BramwelJ6 Hollander,31 and Hawkes.29 Bramwell’s case involved an extraction in a patient suffering from anemia and valvular disease, while Hawkes reported the removal of the entire lower and upper sets of teeth in a person with valvular regurgitation-with “ perfect results. ” CONCLUSION
The different functions of hypnosis in dentistry and the problems associated with its use, as revealed in the available literature, have been reviewed and evaluated. On the basis of this report, the writer would argue that the existence of contraindications to the use of chemical anesthetics represents a minimum argument for a more serious scientific study of hypnosis and hypnotic anesthesia.t The writer is indebted to Miss T. Gilman for assistance in the preparation of the manuscript. Thanks are also due to Dr. 0. K. Champlin of Ithaca, New York, and to the Library Bureau of the American Dental Association for the loan of their package library on hypnotism. This package is described in a letter from the librarian as “including all of the articles indexed in the dental literature in the English language during the past 15 years, with the exception of three. ” The articles from the package library are indicated in the bibliography by asterisks. REFEREKCES
1.
Arnold, Magda B.: On the Mechanism of Suggestion and Hypnosis, J. Abnorm. & Social Psychol. 41: 107-128, 1946. 2. Bernheim, H.: Suggestive Therapeutics, cd. 2, New York, 1889, G. P. Putnam’s Sons. 3 y Bisc,Ty$ted by C. A. Herter.) . Psychotherapy, INTERNAT. J. ORTHODONTIA 11: 547-549, 1925. 4: Blankz?ortj MI; Why We Don’t Know Much About Hypnosis, J. Abnorm. & Sorial Psychol. 26: 390-394, 1932. 5. Braid, J.: Neurypnology, London 1843, J. & A. Churchill. 6. Bramwell, J. M.: Hypnotism: Its History, Theory and Practice, ed. 3, London, 1921, Rider & Company. 7. Brenman, Margaret: Experiments in the Hypnotic Production of Anti-social and Selfinjurious Behavior, Psychiatry 5: 49-61, 1942. 8. Capern, T.: Curative Powers of Mesmerism, London, 1851, J. B. Bailliere et fils. 9.* Chandler, F. W.: The Psychologic Aspect of Anesthesia: With Special Reference to Pressure Induction. Anesth. & Analg. 4: 375-376, 1925. *There are many remedies on the market for the extremely nervous or neurotic patient. Thorn51 however, warned against the use of “premeditation” because of the danger of producing drug-forming habits. He stated that it is to be avoided unless “absolutely neeessary.” tProgress in our knowledge of hypnosis has been hampered by short-sighted and illinformed groups who have been in a position to directly or indirectly prohibit research in many of our large universities. Blankfort’s article,’ “Why We Don’t Know Much About Hypnosis,” and Stein’s paper.48 “Hypnotism To-day” (1930) give evidence of this.
808 10. 11.” 12.” 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28.* 29.* 30. 31. 32. 33. 34. 35. 36. 37. 38.” 39. 40. 41.” 42.” 43. 44. 45. 46. 47. 48. 49.
P. L. Marcuse
Conklin, E. S.: Principles of Abnormal Psychology, New York, 1935, Henry Holt & Company. Denny, R. E.: Use of Suggestion in the Practice of Dentistry, Dent. Reg. 72: 278282, 1918. Dorland. J. W.: Hvonotic Theraoeutics and Modern Dentistry, “I Dental Cosmos 63: I 810-813, 1921. “_ Dunbar, Flanders H. : Emotion and Bodily Changes, ed. 2, New York, 1938, Columbia University Press. Eddy, Mary B.: Science and Health With Key to the Scriptures, Boston, 1917, Christian Science Publishing Society. Elliotson, J.: Numerous Cases of Surgical Operations Without Pain in the Mesmeric State, London,. 1843, J. B. Bailliere et fils. Elliotson, J. : Mesmerism in India, London, 1850, J. B. Bailliere et fls. Erickson,Social M. H.: Possible Detrimental Effects of Exoerimental Hypnosis, J. Abnorm. & 27: 1932. L -Psychol. 321-327, Erickson, M. H.: An Experimental Investigation of Possible Anti-social Use of Hypnosis, Psychiatry 2: 391-414. 1939. Erickson, M. If.: Hypnotik Investigation of Psychosomatic Phenomena. I. Psychosomatic Interrelationships Studied by Experimental Hypnosis, Psychosom. Med. 5: 51-58, 1943. Erickson, M. H.: Hypnosis in Medicine, M. Clin. North America 28: 639-652, 1944. Esdaile, J. : Mesmerism in India, London, 1846, Longmans, Green & Co. Esdaile, J. : Record of Cases Treated in the Mesmeric Hospital November, 1846May, 1847, Calcutta, 1847, Ridsdale. Estabrooks, G. H.: Hypnotism, New York, 1943, E. P. Dutton & Co., Inc. Friedlander, J. W., and Sarbin, T. R.: The Depth of Hypnosis, J. Abnorm. & Social Psychol. 33: 453-475, 1938. Gardner, B. 5.: Extraction of Teeth; Emphasizing the Advantages of Local Anesthesia in Difficult Cases J. A. D. A. 18: 105-110, 1931. Gerrish, F. H.: The Therapeutic Value of Hypnotic Suggestion, J. Abnorm. & Social Psychol. 4: 99-119, 1909-1910. Goldman, J. D.: Better and Safer Gas-Oxygen Anesthesia for Exodontia, Dental Items Interest 67: 358-372. 1945. Griffiths, H. H.: Psychology in Dentistry, Wis. Dent. Rev. 12: 103-107, 1936. Hawkes, L. A.: Hypnotism as an Anesthetic, Oral Hygiene 19: 1948-1950, 1929. Hays, H. M.: Hypnotism, Its History, Nature and Use, Popular Science Monthly 67: 590-607, 1905. Hollander, B. : Hypnosis and Anesthesia, Dent. Surg. 29: 239-244, 253-257, 1932. Hull, C. L.: Hypnosis and Suggestibility, New York, 1933, D. Appleton-Century Company, T-^ .LJlG. Jenness, A. : Hypnotism, In J. MeV. Hunt, Editor, Personality and the Behavior Disorders, New York, The Ronald Press Company, Vol. I, pp. 466-502, 1944. The Practice of Hypnotic Suggestions, Wood’s med. surg. Monogr. Kingsbury, G. C.: 12: 261-398, 1892. Kraines, S. H.: The Therapy of the Neuroses and Psychoses, Philadelphia, 1943, Lea & Febiaer. A Boon to Dentist and Patient, Dental Items Levy, I. R., and Langa, H. : Analgesia: Interest 67: 1084-1088, 1945. Mackay, R. P. : Points of Contact Between Dentistry and Neurology, J. A. D. A. 24: 1647. 1654, 1937. Maller, J. W.: Child Psychology as Applied to Orthodontia, INTERNAT. J. ORTHODONTIA 15: 585589, 1929. Martin, E. H.: The Use of Hypnotism in General Practice, Med. Rec. 58: 170-173, 1900. Maslow, A. H., and Mittelmann, Bela: Outline of Abnormal Psychology, New York, 1941, Harper & Brothers. Nemoff, I.: Patient’s Attitude, Dental. Cosmos 67: 398-405, 1925. Rose, W. 8.: Dental Psychics, Dental Cosmos 53: 1253-1262, 1911. Rovenstine, E. A. and Hershey, 8. G.: The Utility of Apomorphine in Clinical Anesthesia, Dig. Treatm. 9: 873-874, 1946. Schultz, I. H.: Gesundheitsschadigungen nach hypnose, Halle a.S, 1922, Carl Marhold. Accidents During Administration of Local Anesthesia, J. A. D. A. 14: 1177Schultz, L.: 1182, 1927. Sears, R. R.: An Experimental Study of Hypnotic Anesthesia, J. Exper. Psychol. 15: l-22, 1932. Seldin, H. M.: General Anesthesia in Dental and Oral Surgery, J. A. D. A. 23: 1040. 1044, 1936. Stein, M. R.: Anesthesia by Mental Dissociation, Dental Items Interest 52: 941-947, 1936. Stein, M. R.: Hypnotism To-day. Scient. Monthly 31: 86-88, 1930.
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Suggestion and Auto-suggestion in Its Relation to Dentistry, Dent. Summ. 1916. 51. Thorn, L. W.: Control of Pain in Operative Procedures, J. A. D. A. 26: 1777-1785, 1939. 52.* Toplan, B.: Hypnotic Suggestion in Dental Practice, Dent. Reg. 74: 82-85, 1920. 53. Tuckey, C. L.: Psycho-therapeutics; or Treatment by Hypnotism, Wood’s med. surg. Mononr. 3: 721-795. 1889. 54. Wells, W. ii.: Experiments in Waking Hypnosis for Instructional Purposes, J. Sbnornr. 6; Social Psycl~ol. 18: 389404, 1924. 55. Wells, W. R.: Hypnotizability Versus Suggestibility, J. Abnorm. & Social Psychol. 25:
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87-92,
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1%‘. R.‘:
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Experiments
in the
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of
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11:
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1041. 57.
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W. R.: The Hypnotic Treatment of the Major Symptoms of Hysteria: A Case Study, J. Psychol. 17: 269-297, 1944. Wells, IV. R.: A Basic Deception in Exhibitions of Hypnosis, J. Abnorm. & Social Psychol. 41: 145153, 1946. Hypnotism and Its Application to Practical m’etterstrand, 0. G., and Petersen, H. G.: Medicine Together With Medical Letters on Hypno-suggestion, etc. (translated by H. G. Petersen). New York. 1897. G. P. Putnam’s Sons. White, C. M.: The’Use of Nitrous O&de and Oxygen for Cavity Preparation and Other Dental Procedures, Dental Items Interest 67: 776-779, 1945. White. R. VV.: A Preface to the Theorv of Hvonotism. J. Abnorm. & Social Psvchol. 36: “I 477. 505, 1941. Talking to the Dental Patient, Oral Hyg. 24: 694-502, 1934. Whitmer, C. A.: The Psvcholoeical Annroach to the Nervous Dental Patient. Dental Wildman. C. W.: Items Interest 67: 691-692; 1945. *I Hypnoanalysis, New York, 1945, Grune and Stratton. Wolberg, L. R.: Uses and Limitations of Hypnosis in Dental Treatment, Brit. D. J. Wookey, E. E.: 65: 562-568, 1938. Suggestions as a Factor of Success in the Practice of Dentistry, Dental Zulauf, A. F.: ltems Interest 45: 841-858, 1923. Cases (Anon.) Dent. Surg. 29: 502-503, 539-531, 546, 1932. Editorial (Anon.), Apollonian 8: 173-174, 1933. Reports of the Supreme Court of the State of The State of Kansas v. Anderson Gray. Kansas 55: 135-146, lS96.