Programación del riego a partir de sensores en planta

for pain control was then considered.

At the first interview the patient appeared to be quite weak and in pain.

She was crying pitifully and begging for narcotics. She apparently did not comprehend an explanation that an attempt would be made to hypnotize her.

She was requested to close her eyes, which she finally did. This woman then responded in an excellent manner, with deep somnambulism evident in about 10 minutes as judged, among other signs, by the ability to open her eyes while remaining in trance. She was given the suggestion that she would "have much less pain in your eyes . . . you will more easily tolerate discomfort in your eyes, . . . you will not require a great amount of medicine, and you will be much more relaxed." Following the first hypnotic suggestion, she did not request narcotics again. She reported "a little hurt in the eyes, but sorta like a headache." Her previously described regression was replaced by a feeling of definite hope and cooperation.

Surgery was performed with excellent results. The patient did not ask nor require postoperative narcotics, but only aspirin on three occasions. The patient was dismissed one month later with good return of visual acuity.

It was our opinion that although this patient was never really cognizant of the meaning of hypnosis nor had any insight into its use,

she nevertheless responded in a maximum fashion.

ORGANIC PAIN

There would seem to be marked differences between pain that originates in the laboratory and the severe pain perceived, perhaps over

many months, by a patient with an organic disorder. It would seem

obvious that the experience of pain that is induced in a laboratory experiment for several minutes cannot realistically be compared with the pain manifested by patients with metastatic tumor or thermal injury covering over one-half of the body surface or severe rheumatoid arthritis. This difference in pain in clinical experimental subjects is well appreciated by Hilgard (1969).

Our own observations suggest that there is some central inhibition of pain perception, perhaps analogous to that obtained when psychosurgery is done for relief of intractable pain and perhaps related to the Melzack-Wall "gate theory," with a central hypnotic change as the "gate-closing" stimulus. In such c a s e s , according to Kalinowsky and Hoch (1961):

. . . there is no actual loss of sensory perception in any particular area of distribution of sensory pathways. What is impaired is a more complicated and not yet fully understood mental process of attachment or detachment which modifies the primary sensory perception into a secondary awareness of caring or not caring. . . . It may be mentioned that in lobotomized patients the

perception of applied pain, for example, in the usual sensitivity test to a needle.

is not only preserved but the reaction of the patient to painful stimuli is even accented.

In contrast to this, however, the hypnotized patient seems to be able to block pain reaction to discrete body areas. This can lead to

complications if the therapist is not fully aware of the limits of the area in which anesthesia has been induced, Hypnosis has been successful, for example, in decreasing the postoperative pain of defecation

fol-lowing hemorrhoidectomy- In such cases it is important to limit the suggested analgesia to the anal area rather than inducing anesthesia

"below the w a i s t . " If such a broad analgesia were inappropriately induced, the patient might not be aware, for example, of a need to urinate.

We were among the first to report the clinical observation that patients with organic pain were unusually good subjects, seemingly because of a greater motivation and need for relief. Also, in cases seen for pain relief there seems to be a greater correlation between depth of trance and effectiveness of suggestions than in such motivational uses of hypnosis as reinforcing a desire to diet. Although depth of hypnosis does not generally correlate with the effectiveness of suggestions, in the case of severe organic pain it has seemed to us that the greater the depth of trance, the more likely it is that the suggestions for pain relief will be successful. Veldesy (1967) has taken the opposite view, stating that results are inversely proportional to illness severity.

At times hypnosis may be useful in aiding in the differential

diagnosis of organic or functional pain. Although suggestions for relief may be effective in pain of either type, we have usually found that pain of organic origin tends to return more rapidly, usually within several hours after the first successful hypnotic induction. Thus, the hypnotic analgesia seems to fade at about the same rate as such chemical analgesics as morphine or meperidine. In contrast, pain of a functional origin may be relieved for days or weeks, even after the first few

inductions. With repeated hypnosis, however, the length of effective-ness may dramatically increase in either organic or functional pain. If this differential response to suggestion for pain relief is to be used to decide between these two types of pain, the distinction must be based on the length of response to the first few successful treatments. Once the patient's pain relief is hypnotically reinforced on several occasions, both organic and functional pain may be relieved for equal periods of time.

In order for hypnosis to succeed, most of the time, in the control of organic pain, reinforcement of the pain control should occur before the pain exacerbates (Crasilneck, 1979b, 1984). It is vital to reinforce the control of pain with hypnosis as soon as the patient is aware of the return of the pain. The patient should be informed of this, so that he or she will be prepared for reinforcement sessions. This may be necessary at 3- to 5-hour intervals in the first 24-hour period. However, the pain may be controlled for 6 to 8 hours on the second day, 14 to 18 hours the third day, and 24 to 28 hours the fourth day. By the end of the first week, the patient may be reinforced every third day; by the end of the second week, every fourth day; and by the end of the third week, once a week and so o n . Each patient should be taught self-hypnosis at the second session.

T h e following case illustrates the fashion in which the patient's response to hypnotic suggestions for pain relief may aid in deciding whether the pain is of organic origin (Crasilneck and Hall, 1973):

A woman hospitalized for diagnosis of an unusual pain in the left upper quadrant of the abdomen was seen in consultation after usual x-ray and laboratory procedures had failed to establish an unambiguous diagnosis. We were simply asked to give an opinion as to whether the pain was likely to be functional in nature. After the first hypnotic induction, she obtained good relief for about 4 hours, after which the pain returned. She was again hypnotized, and once more pain was greatly relieved, the effect again diminishing in a few hours. On the basis of this observation, she was considered to have most probably pain of organic origin, which was confirmed when a later exploration laparotomy revealed an unexpected tumor. Although decisions about surgical exploration should not be made on the basis of such responses alone, the

evidence of a differential response to hypnosis can be a useful clinical obser-vation, among others, to aid in difficult and crucial choices.

In most cases of chronic organic pain, we have been careful to phrase suggestions in such a manner that not all perception of pain is

blocked, For example, the subject might be told, " T h e pain will grow much less, but there will be some remnant of pain left, although the majority of the discomfort will reduce itself considerably and you will be aware of only the slightest degree of pain.'¹ It is obviously impor-tant, from a medical standpoint, to leave sufficient perception of pain so that any change in the course of the organic illness will be detectable in clinical signs and symptoms.

There are only a few conditions in which it is permissible to block all pain perception with hypnosis: during surgery, during medically attended childbirth, in fulminating arthritis attacks, and in terminal illness. Total relief of pain might also be suggested for discomfort such as that of shingles but should not be attempted in any condition in which worsening of the patient's condition might be communicated through changes in pain symptoms (Crasilneck, 1983).

There is case report (Smith and Balaban, 1983) on pain relief of a patient with systemic lupus erythematosus. Phantom limb pain is discussed by Siegel (1979).

A type of chronic pain problem that we have seen several times a year is that of the orthopedic patient who has had repeated surgery for a herniated disk, usually having had one or two unsuccessful attempts at fusion of the lower back to produce stabilization and reduce pain-Hypnosis has usually produced diminution of pain by 80 or 90 percent (based on patient's verbal estimates), lasting in most cases for several weeks but requiring periodic reinforcement.

It is obvious that in such an orthopedic patient, it would be unwise to remove all pain, since a further herniation might occur at an inter-vertebral space different from those previously treated. If all pain were removed by hypnosis, an important diagnostic clue might be obscured, and there would be greater danger of increased impairment.

There are cases in which such considerations are not important, notably in terminal cancer patients for whom hypnotic analgesia may allow a decreased amount of narcotics and a clearer, more lucid mind during their last d a y s . Even in these cases, however, some residual amount of pain perception may be desirable as an indicator of treatable complications.

All pain can be removed by hypnosis for a controlled period of time, as in surgery, tooth extractions, or delivery. In these cases the patient would otherwise be under chemical anesthesia and, in either

case, would be closely monitored for signs of change in physiological functioning. When all pain is removed for such procedures, it is important to implant the suggestion that it will return during the immediate postoperative period, when it will again be important in monitoring the patient's condition.