85. История, гипноз и психосоматическая медицина. Д. Нэмиа (85. History, Hypnosis and Psychosomatic Medicine. John C. Nemiah)

(I should like to thank Dr. Fred H. Frankel and Dr. Peter E. Sifneos for their helpful comments during the preparation of this article)

Beth Israel Hospital, Boston, Mass., USA

In the Annuals of the past bloom the perennials of clinical medicine. Consider, for example, the travails of a fireman in the Paris Fire Department who was lifting a heavy pump in the royal prison one day toward the end of the eighteenth century. "Suddenly", he writes in an autobiographical account of his case, "I felt something snap in my low back causing severe pains". Then followed months of pain radiating along the course of the sciatic nerve-unrelieved by oxicromium plasters, beer baths, vessicatories and other approved therapeutic measures of the times. At length he underwent magnetic treatments twice a day and by the end of five weeks could "walk, run and jump without feeling any pain whatsoever". (1)

Or listen to the account of Joseph Metter, a coachman of 25, written in 1785 by his magnetiser, M. D'Esser. The patient suffered from such severe edema "from his head to the soles of his feet that he was forced by the swelling in his limbs to keep them spread out away from his body; he was unable to sit up, but lay flat on his back,... and his respiration was so embarrassed that he was scarcely able to reply when I questioned him about his illness". Magnetism was prescribed, and after the first treatment there began one of the most epic diureses in all of medical history, accompanied by copious watery stools. The patient experienced almost immediate relief of his symptoms and by the end of four weeks of daily therapy was completely cured.

If in the first patient we can recognize the symptoms of a herniated lumbar disk, the cause of the massive edema in the second is not so evident. Nor is the causal relationship between the magnetic treatments and the patients' recovery from their illnesses clear, despite their close temporal proximity, for each of them could well have experienced a natural remission of symptoms. What is of interest is that the magnetism was being used for illnesses that were primarily physical in origin.

This should, however, come as no surprise when one reflects on the origin and theoretical basis of magnetic therapy. It was Mesmer who first brought it into prominence. Borrowing his concepts from Paracelsus and van Helmont, and his practical techniques from a fellow Viennese, Father Hell, Mesmer developed what he called "animal magnetism" to a high degree of notoriety, and after his move to Paris, became the center of a bitter controversy. His theory was a simple one; just as the planets and terrestrial bodies affect one another by a "fluid that permeates everywhere", so too "these spheres likewise exercise a direct action on all the organs of living bodies (especially on the nervous system)... I gave the name of animal magnetism to that property of the animal body which makes it susceptible to the action of celestial bodies and the earth". (2)

Mesmer's theoretical formulations had practical consequences. Health, in his view, was a reflection of the proper distribution of the animal magnetic fluid throughout the body; disease resulted from blockages in the free flow of the fluid, which in turn produced organ dysfunction and the consequent symptoms of illness. Moreover, one human being could influence the quantity and flow of magnetic fluid in the body of another by the appropriate use of "magnetic passes" that overcame the blockages in the patient's organs and restored him to health. The carrying out of animal magnetic passes, in other words, had a practical therapeutic use and led to the development of a system of treatment known variously as "magnetism" or "mesmerism".

Mesmer's success with his method of treatment after he moved to Paris was meteoric, and despite the fierce antagonism of most of the medical profession, patients crowded to his clinic from all strata of society. Undaunted by the negative verdict of a Royal Commission which, after a series of carefully controlled experiments, pronounced the magnetic fluid a chimera and attributed mesmeric phenomena to "imagination",(3) Mesmer continued to practice, to proselytize and to teach. When at length he quit Paris in disgust at the opposition to his work, he left behind the legacy of a professional organization in a network of "Societes Harmoniques", which institutionalized his practices and the people he had taught to carry them out.

The Societe Harmonique de Strasbourg was a major component of this network. Its guiding spirit was the Marquis de Puysegur, an artillery officer who had undergone instruction by Mesmer and returned to his landed estates, where he brought the healing power of magnetism to the men and women who worked for him. It was Puysegur who called attention to the state of artificial somnambulism that often followed the application of magnetic passes, a phenomenon that failed to arouse Mesmer's interest, if it did not entirely escape his attention.

Between 1786 and 1789 the Societe Harmonique de Strasbourg published three annual volumes in which are reported many of the cures effected by magnetic therapy.(1) From these volumes, two facts become apparent: 1) Although some physicians employed magnetic techniques, there were a large number of laymen among the practitioners. 2) Magnetism was applied to the whole spectrum of human illnesses. Among the patients treated by it there were a goodly number who suffered from what today would be diagnosed as neurotic syndromes, but this was not recognized by the early practitioners, who included magnetism among the large armamentarium of physical measures aimed at curing physical illness. This should not be surprising if one remembers that magnetic therapy was seen as directing a physical fluid onto the patient's body with a view to affecting his physiological functions.

In the chaos of the French Revolution magnetism all but disappeared in France, and it was not until the post-Napoleonic era that it once again began to flourish. The idea that the phenomena observed by magnetists might be the result of suggestion (a psychological force) was advanced by some (Bertrand and Faria, for example), but in the main magnetizers subscribed to the theory of a physical fluid as the effective agent.

It was in this form that magnetism (or mesmerism, as it came to be called) first came to England. The seeds were carried in 1828 by an Irishman, Chevenix, who had learned mesmeric techniques in Paris, and in 1837 by a Frenchman, Dupotet, both of whom exerted considerable influence on John Elliotson. An innovative but not always tactful man, Elliotson was the first Professor of Medicine at the University of London (which he had helped to found). Impressed with what he had seen of mesmerism, he began to use it himself, and dealt with the objections of his medical colleagues by flaunting it on the wards of the University College Hospital. By 1839 his abrasive and defiant behavior had led to his resignation from the hospital staff.

Undaunted by his exile, Elliotson continued his mesmeric practice and developed a coterie of enthusiastic followers and supporters throughout England and Scotland, several of whom were vicars of country parishes. In April, 1843, there appeared under Elliotson's editorship the first issue of The Zoist. Until its demise 13 years later in 1856, the journal was dedicated to the study of "cerebral physiology and mesmerism and their applications to human welfare". "Cerebral physiology" (a euphemism for phrenology), more prominent in the early issues in the form of correlations of the measurements of murderers' skulls with lurid details of their crimes, increasingly gave way to clinical and philosophical considerations of mesmerism, and in the 13 volumes that were published, several hundred patients treated with mesmerism are described.

In these cases it is evident that the later English experience recapitulated that of the French in many regards: 1) Mesmerism generally met with scornful, unreasoning, at times, vicious opposition from the medical profession; 2) among the supporters and practitioners of mesmerism were many laymen, who used it for altruistic ends; 3) and finally, mesmerism, conceived of as a technique that acted therapeutically upon the diseased human body through physical forces, was applied along with the prevailing medical and surgical treatments of the day to patients with a wide variety of illnesses. It was not, in other words, seen (as it later came to be viewed) as an essentially psychotherapeutic measure aimed at treating psychogenic illnesses, or as a measure that could relieve the emotional components of primarily physical illnesses. The magnetists and mesmerists of the 18th and 19th centuries were not consciously practicing psychosomatic medicine in the modern sense of the term. And yet, seen from a modern perspective, they were employing psychological techniques (hypnotism, suggestion) to a wide spectrum of apparently physical illnesses. What might be learned from the reports of these earlier clinicians that would be applicable to our own interests in psychosomatic problems? What kinds of illnesses responded to their treatments? How effective was magnetism in palliating or curing physical illness?

With these questions in mind, the 13 volumes of The Zoist (4) were reviewed, with particular attention being focused on clinical reports. In the four or five thousand pages of that now foxed and crumbling journal, the magnetic treatment of several hundred patients is reported - patients suffering from a wide variety of disorders and symptoms. These may be distributed in 10 major categories: 1) Epilepsy. 2) Paralyses. 3) Abnormal movements (commonly torticollis). 4) Deafness and blindness. 5) Pain in a wide variety of distributions, especially tic douloureux. 6) "Asthma". 7)Gastrointestinal disorders, including nausea and vomiting, constipation and diarrhea. 8) Inflammations and infections. 9) "Rheumatism". 10) Finally, it must be pointed out that mesmerism was widely used to produce surgical analgesia for a variety of major procedures including amputations and the extraction of teeth.

Here certainly is a wealth of clinical experience with mesmerism, which at first glance suggests that it is an extraordinarily useful therapeutic tool for a whole spectrum of disorders. Unfortunately, upon closer inspection of the. observations, one finds most of them worthless as evidence. The majority of the case reports are so short and the clinical findings so incompletely documented that one cannot be at all certain of the diagnosis. Those patients labelled as having "asthma", for example, could well have been reporting the subjective elements of acute anxiety. There is usually nothing to differentiate between hysterical seizures and idiopathic epilepsy in those placed in the epileptic category, and the same confusion exists between hysterical and neurological phenomena in those reported to be suffering from "palsy". Indeed, at times, when the case material is extensive enough, it can be seen that some patients clearly had hysterical symptoms. Elizabeth Kell, aged 11, for example "was on the 25th of September, 1839, bitten by a cat on the back of the left hand, immediately after which she lost the use of both the hand and the arm... On the night of the 11th of June, 1840, the child awoke with a strange sensation in her head and body. This was very soon followed by the loss of her voice, and of the use of both her legs... She was not only confined to her bed for six months, but could not bear her head to be raised ever so little, so that she lay with her head in a line with her body". (5) The successful therapeutic result from mesmerism in this patient's illness was clearly effected through the removal of hysterical symptoms.

In addition to the paucity of observations bearing on the diagnosis, one is often not told of the duration of symptoms either before or after the beginning of mesmeric treatment so that one cannot be certain whether a successful outcome was the result of mesmerism, of the natural course of the illness, or of other interventions. Finally, many of the reports are made by laymen who in their enthusiastic faith in mesmerism clearly wished to see it work, and wrote accounts of its successful use that sound like testimonials to patent medicines or Christian Science healing.

In the aggregate, then, these hundreds of case reports filling as many pages provide little in the way of answering the questions asked earlier. There are three exceptions to this generalization, and we must make mention of them briefly. 1) The use of mesmerism for pain control is amply documented, and many of the patients described reported almost immediate relief of chronic, often severe pain following treatment, tic douloureux being a particularly common condition thus ameliorated. 2) Related to the control of pain in naturally occurring illness was the induction of surgical analgesia by magnetism. Here the documentation is often almost overpowering, as, for example, in the case of James Wombell described by Elliotson, (6) the report of whose painless leg amputation in mesmeric trance stretches for pages on end. 3) Finally, mention should be made of those patients treated for inflammations and infections, which include a number of cases of abcesses, infections of joints, possibly tuberculous in origin, and ophthalmias, sometimes rapidly and dramatically improved by mesmeric treatments. What makes the evidence more convincing in these patients are the facts that a chronic condition responded rapidly to the therapeutic intervention, and that the presence of an infection was readily observable and easily described, leaving the modern reader with little doubt that genuine structural changes had occurred in the symptomatic organ. A young woman, for axample, had suffered for some weeks with reddened sclerae and ulcerated eyelids accompanied by considerable pain. The latter disappeared immediately upon the first mesmeric treatment, and after five daily treatments her eyes were clear and the ulcerations gone. The patient describes the state induced by mesmerization as "the sweet tranquil feeling which always possessed my mind as 1 passed into the state of perfect and delicious repose, which is felt the moment sleep commences. There seemed to be as far as you could extend your arms, a warm, light, soothing atmosphere, encircling and isolating me in idea as completely from the outer world as if 1 were ever so distantly removed from it..." (7)

Our search into the past has not, perhaps, been so rewarding as we might have hoped, but there are still lessons to be learned from it by the modern clinician and investigator, to whom we shall turn in a moment. First, however, we must briefly trace the history of magnetism as it changed to hypnosis, and relinquished physiological for psychological explanations.

The idea that the phenomena produced by mesmerists might be best explained in psychological terms was slow to gain ground. Mention l as been made of Faria and Bertrand, who early in the 19th century formed a countercurrent in the mainstream of those subscribing to the fluidic theory, but it was not until the 1840's when Braid in England proposed that the manifestations of mesmerism were the result of ideas suggested to the subjects, that the ground was laid for modern psychological theories concerning hypnosis - the term Braid substituted for "magnetism" or "mesmerism". When the battle was finally joined between Charcot and his co-workers at the Salpetriere on the one hand, and Bernheim and Liebault of Nancy on the other, psychological theories at last triumphed over those invoking physical causation. Charcot and his group always considered hypnosis (and hysteria) a sign of degenerative disease of the brain, and viewed psychology, in the words of Charcot, as "... nothing but the physiology of the higher nervous system". (8) Although Liebault, as Chertok has pointed out (9), repeatedly flirted with the fluidic theory, and although both he and Bernheim treated many patients with physical illnesses,

Bernheim came down firmly on the side of "suggestion", a psychological concept. It was the latter theory that gained the ascendancy during the last decade of the 19th century, and psychiatrists have ever since relied mainly on "suggestion" as the primary mechanism at work in hypnotic phenomena.

It was a Pyrrhic victory that Bernheim won, however. As magnetism and mesmerism became hypnotism, and as the fluidic theory gave way to the notion that suggestion was the basis of hypnotic phenomena, the subject became more than ever suspect among those who saw no substance in "imagination", and sometimes even went so far as to attribute the effects produced by hypnotism to conscious simulation. When to this was added the rise of interest in psychoanalytic theory, and when throughout the earlier part of the 20th century psvchologically-minded psychiatrists widely adopted psychoanalytic techniques, hypnosis was relegated to the back benches of clinical practice.

In the past couple of decades there has been a resurgence of interest in hypnotic phenomena in both laboratory and clinical settings. Not only has it been used as a therapeutic method in more specifically psychogenic illnesses, but in a more limited way it has been applied to patients with physical illnesses, and as a form of surgical analgesia. Generally its use in physical illness has been limited to those conditions more narrowly conceived of as psychosomatic (10, 11), but in autogenic training it has been adapted as a treatment method for all physical diseases, covering as wide a spectrum of disorders as those treated by the earlier magnetists and mesmerists. (12)

In these modern studies we find far more convincing evidence that hypnosis can favorably affect bodily illness than was apparent in their historical predecessors, for the modern clinician has more accurate diagnostic methods to determine the pathogenesis of symptoms. But apart from providing more extensive and better-documented case reports, the clinical hypnotic investigations of modern workers are no more advanced than those of a century or more ago. For the modern hypnotist has generally not moved beyond the amassing of random case reports, and he has failed to apply to his studies newer research methods that could cast some light on the nature and therapeutic mechanisms of hypnosis. He provides no controlled studies to show whether it is indeed the hypnotic trance or some other factor that is therapeutically effective. He has not adequately assessed the role of the placebo effect of the induction procedure on those patients whose symptoms respond to his operations. (13) He has not systematically correlated the hypnotic susceptibility of his patients with their therapeutic response to trance induction. Nor has he exploited the suggestive leads of his mesmerist forebears, in exploring fully, for example, its usefulness as surgical analgesia, its possible relation to acupuncture, or its effect on inflammatory disorders. Unmindful of the fate of the empirical approach of the earlier magnetists, he is doomed to repeat their disappearance into oblivion if he continues to restrict himself to the anecdotal reporting of cases.

Finally, not nearly enough attention has been paid to the brain mechanisms underlying hypnosis, and their relation to more peripheral physiological processes. The victory of the psychological over the fluidic hypothesis has directed interest away from the neurophysiological correlates of the psychological phenomena of hypnotic trance, but this does not mean that they do not exist or that hypnosis is a psychological process only. Recent interest in the effect of relaxation techniques, bio-feedback mechanisms, and meditation has once again focused clinical and laboratory investigation on the effect of mental processes on physiological, especially autonomic functions, and Benson (14) has suggested that meditation involves specific neuronal circuits. Should not hypnosis be more systematically included within the scope of these studies, in part to determine its relation to processes like meditation and bio-feedback mechanisms, and in part to investigate its neural correlates in the light of newer neurophysiological concepts? Perhaps, to paraphrase Charcot, in the psychology of hypnosis lies the clue to "the physiology of the higher portions of the brain".

Summary

In the period immediately following its discovery, animal magnetism was employed therapeutically in a wide spectrum of somatic illnesses, sometimes with strikingly successful results. Following the recognition of the psychological nature of hypnotism (n?e magnetism), its therapeutic use was markedly curtailed and ultimately fell into general disfavor. With the current renaissance of interest in hypnotic phenomena, the opportunity is now provided for a systematic re-exploration of its possible therapeutic effect on somatic disorders and for a reassessment of its neurophysiological underpinnings in the light of modern knowledge about the functioning of the brain.

References

1. Annales de la Societe harmonique amis runis de Strasbourg, Strasbourg, 3 vols., 1786-89.

2. Mesmer, F. A., Memoire sur la Decouverte du Magnetisme Animal, Carlsruhe, Michel Maklot, 1781.

3. Rapport des Commissaires Charges par le Roi de l'Examen du Magnetisme Animal. Imprime par ordre du Roi. A Paris, de l'Imprimerie Royale, 1784.

4. The Zoist, Vols 1 - 13, 1843-56.

5. The Zoist, 1:334, 1843.

6. Elliotson, John. Numerous Cases of Surgical Operations without Pain in the Mesmeric State, H. Bailliere, London, 1843.

7. The Zoist, 3:24, 1845.

8. Charcot, J. M., Clinique des Maladies du Systeme Nerveux, Vol. II, Felix Alcan, Paris, 1893.

9. Chertok. Leon, Hypnosis, Pergamon Press, Oxford, 1966.

10. Kroger. William S. Clinical and Experimental Hypnosis in Medicine. Dentistry and Hypnosis, Lippincott, Philadelphia, 1963.

11. Mason, A. A. Medical Hypnosis, Hoeber, New York, 1960.

12. Luthe, W. and Schultz, J. H. Autogenic Therapy: Vol. II. Medical Applications. Grune and Stratton. New York, 1969.

13. McGlashan, Thomas H., Evans, Frederick, J. and Orne, Martin T. "The Nature of Hypnotic Analgesia and Placebo Response to Experimental Pain", Psychosom. Med., 31:227, 1969.

14. Beary, John F. and Benson, Herbert, "A Simple Psychophysiologic Technique which Elicits the Hypometabolic Changes of the Relaxation Response", Psychosom. Med., 36:115, 1974.