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DISEASES OF THE NERVOUS SYSTEM
-1. Berger, 1". M., Boclcelheide, V., and Tarbell,
1'. S.: The Pli:trmattilogtcal Properties of Sonic
2-subst it at cd-I -livdroxymetliyt - 1, 3 - dioxolanes.
lOs: 5G1-562, 19-is.
5. Uoine.,, CL .1.: Management of the 1Icnopause
The Else of Diinetliyla 310 in Certain Symptoms
ld-MOntl1 Study. .tllnlicul Tiiiirs, January, 1953.
Li. Boioes, U. .1.: The Use of Diniethylyn in the
Management t1 Certain Symptoms of Menupause. It 1. St. Med. f. 23 :11, 1951.
7. Boiiies, 0. J., and Horiisc1ial, S. : Dimethylanc
in the Treat went of Dysmenurrltca. Del. St.
JUe,j J., 23:183-185, 1951.
S. Btiines, C. J., and Ilorosclialc, S.: Tension States
Helated to tJLeiipatIoii;il Stress -Use of Diioeth3'lane ill Management. hid. Mcd. unit Siiiy, 22:
Fiectroshoek
A/au U'f1 £&`r volt 1
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228-230, 1953.
iCissen, M. D., and Fortnum, V. G.: Dimethylane
in Post-alcoholic Tension States. Am. Proc. aaid
Dig. of Tn'utnicnt, 5:32-35, 1951.
10. Vivino, A. E., and Ritter, ii: Treatment of Dysmenorrhea with a Dioxolane. Mcii. Annals of
.D. 0., 22:117-119, 1953.
11. ICissen, M. fl., Yasktn, H. E., Robertson H. F.,
and Morgan, D. FL : A New Adjuvant in Postalcoholic Psychomotor Agitation. Quart. J. of
51w/irs on Alcohol, 12 587-591, 1951.
12. Committee on Nomenclature and Statistics of
the American Psychiatric A ssoein Lion: Di agnostie and Statistical Manual: 1i cutal U isorders,
Washington, 11 C., American Psychiatric As
sorintion Mental Hospital Service, 1952.
9.
Without Muscle Relaxants
J. M. RADZ1NSKI, M.D.
The pitt-pose of this article is twofold: 1
evaluate critically some of the methods
now being used in combating complications
iii elect roshoek therapy and 2 to show tllat
shock tiletapy without muscle relaxants is
reasonably safe not only ill healthy individ
uals but ill a great variety of 1001' physical
risks. The latter point especially requires
t'larilieation on medico-legal groullds because
Pf illtillltttiolls by some users of relaxant
drugs that non-enlployloent of tilese latest
"advances'' iii electroshock technique bortiers on negligence on the part of the thetato
-139
Aside from the question of error of ohset-ration, the incidence of fractures appenis
to depend on three fat'toi s: 1 the condition
of the siteleto-muscular system of the a
tient, 2 type of restraint, 3 Severity of
convulsion. The last, in turn, is dependent
on the type of etlt1-ellt used. Since in gun
eral psychiatric practice patients of.ail phys
ical types and states come for treatment,
thei-e remain but two factors to consider,
lestla iiit and tile type of current. Restraint
may be effected either by mechanical or
chemical methods.
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DISEASES OF THE NERVOUS SYSTEM
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NtVEMIIFI:
tive current the greater the likelihood of its iites each. There was one fracture in this
being felt and subsequently dreaded by the series involving the ilght transverse proc
iatieii. I recall during ny experimentia- ess of the fouuth cervical vertebra. Another
tiOl Viih ``softer'' currents how one young patient developed a mild aspiration 11CUUlemale iatieni lieVer did forgive me for in- Iii;i.. A third aspirated a small antuint ui
ilicting 111011 her temples the sensation of vomitus al-id subsequently developed atahe
``a blow with a baseball bat.''
tasis of the right lung. "Prompt bronchial
The intolerable subjective discomfort `is- asplratlop, inflatiqn of the ataleetatic lunfx
pOJ
ifi6WiS tI?ritii resulted iii coitiplett'
sociated with soft electrical
led to the introduction of narcotizing and disappearance of the symptoms and X-nv'
paralyzing drugs. The first Preparation used findings in 24 hours."
cxtensi'ely in the forties was D tubo-curaBoth curare and its synthetic equivalcpt
rine. Because of the sensation of suffocation affect the vital respiratory function. Tiit
associated with the paialytic stage, it was ellicacy of these drugs depends on premed i
found necessary to narcotize the patient cation with atropin and an intravenous jar
with pentothal. Although soon after the biturate-anothcr respiratory depressant
introduction of curare alarming reports of Oxygen must bc available for controlled res
deaths and near deaths began to appeal' in lfhtion. Air passages must be kept clea r
of mucus etc. Thus all operational chain, Ilt
the literature, A. E. Bennett, a pioneer
the field, as late as 1918 expressed strong stronger than its weakest link, is forged to
guard against the iatrogenic complications
approval of the curare technique.
It became clear, however that tile safety of respiratory arrest, atalectasis, aspiration
margin of curare was too narrow for com- Jj1eumonia and circulatory collapse.
One cannot but note with misgivings the
fort particularly in view of the fact tha#
growing
tendency among sonic tlierapisb:
some individuals show a hypersensitivity to
towards
hazardous
polyphaimacv. At tiiiics
the drug. Even with adequate oxygen inearer psychiatrist seeks to
it
seems
that
the
take, some patients died, either because of an
unfavorable central action of curare or from tempt fortune by skirtin at the brink ol
areatl
a complicating bronehospasm and circula- disaster. Let me cite an example: A
patient
yrs.
disturbed male
28
old receive I
tory collapse from a histamine-like etect.
preeedina
on the day
his last hCl sOD ingnis
Quest for safer relaxants brought on the
of rfhoraziile 200 of it IM. Next momma ii,
market such synthetic preparations as fiaxeis given an inhalation of nitrous oxide Jt'i
dyl and syneurine. These also were found see. followed
by inhalation ol CC: ill 70'
to be dangerous. W. S. Maclay,4 in an cxoxygn duration unspecified. This we'
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DISEASES OF THE NERVOUS SYSTEM
:ilWays been to avoid ha i'ni-----nil nonTc. Iiiiertercnee with the vit'd fthrctions of lespi-.
lion and circulation is justified oniy as a
life saving measure. Outside of certain psyeliiatrie emergencies, such as extreme excite
went leading to exhaustion or an irrepres
sible suicidal urge, the role of shock theraly
;s mainly i.o shorten the course of a psycho
sis or to lender a disturbed patient more
tractable. it still remains to be proved
whether in the schizophrenic group more paients recover with ECT than would evenma lly get well by other methods. Moreover,
`the relatively Jienkpi nature of electroshock
omplieat ions ien' ters dubious any need of
placing the `it al functions in jeopardy.
The tlietry that the pentotlial-Aneetine
cehniqtie is easier on cardiac and otherwise
debilitated patients is likewise open to cjuesion. Debilitated individuals in consequence
cf their wasted musculature have milder
seizures than others. As for the lightened
strain on the circulation with Anectine, there
are indications I hat the opposite may actu
ally be U ue. Studies by William L. Holt and
associates with Flaxedil and Anectine show
a marked liucluation in blood pressure from
a a initial drop to a secondary rise with
l'laxet lii and a somewhat smaller fluctuation
with Anectine. Bitt more arrhythmias were
ionnd with the latter. One patient on Flaxvdil registered a drop in systolic pressure
ft-am 150 nun 11g. to 70 mrn.-a near catas
I rophic effect.
Many workers have rightly expressed the
`pinion that muscle rclaxunls have substiat ccl `qual, if not greater, hazards in the
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electroshock at the APA meeting in Chicago
1953 the discussants who had used such
combinations reported that when the patient
dies "he goes out like a light."
The exact dynamics of spinal compres
sions which have been responsible for much
of the relaxant controversy remain uncer
tain. One theory is that the fracture oc
curs as a result of a sudden flexion of the
upper spine during the initial phase of the
eonvulsion. Another theory is that the uppci' thoracie spine, the neck and the skull are
compressed downwards by the longitudinal
spinal musculature delivering a "hammer
type" blow to the joint surfaces of the ver
tebral bodies.' The "wedging'' of the cornpressed vertebral bodies is explained by the
simultaneous operation of bot Ii processes.
It is doubtful whether the contraction of the
relatively weak upper spinal musculature
alone would be sufficient to crush a vertebra.
It is more likely that the massive lumbosaeral flexors and the abdominal muscles by
tending to approximate the pubis to the xiplioid process indirectly contribute the de
cisive force in the crushing action. Why
fractures occur in the upper dorsal spine has
been explained by the more delicate struc
ture of the vertebral bodies in that area and
by their relative immobility. It has been
shown that of all the dorsal vertebrae, the
fifth is the least movable and the most read
ily crushed expei'iinentally. It, therefore,
may be regarded as the center of dorsal vul
nerability and as the fulcrum from which
the two ends of the spine extend cephalad
and caudad as levers. Powerful flexor action
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DISEASES OF TIlE NERVUIJS SYSTEM
j ranged in age from 16 to 85 yrs. There has
been 110 fatality.
One gets the impression while observing
these patients after treatment and watching
the healthy glow of their flushed faces that
they benefit not only from the central action
of the current but from the stimulating met
abolic effect of the convulsion itself. The
muscle soreness of which many previously
inactive patients complain following treat
ment is the same healthy soreness that nor
ma! persons find not unpleasant after vig
orous exercise.
During the past two years, 233 patients
received a total of 1643 treatments, Among
them there were 29 with organic cardiovas
cular disease. Their clinical diagnoses con
firmed by EICG were as follows:
L
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HyperLensive hearl disease
6
Coronary insuhlicieney
in
IntravenLrieular ilocic
3
Frequent. aurieuiar and `enOicuiar exirasystoles 3
Old indaretions
3
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iiitnd stenitsis
Auricular fibrillation
Only those cases were included in the hy
pertensive group whose systolic pressut e was
persistently 200 mm. Hg. or more. One 59
yr. old depressed male had a pressure of
260/150. He received 12 ECT with recovery.
Another patient, a 27 yr. old female, had
advanced chronic rheumatic valvular disease
bordering on decompensation and with an
ricular fibrillation. Cardiac patients were
sible to obtain pre- and 1ost-treatnlent X
rays in 87 ot' these cases. Among them wer
23 repeaters with a history of one or moi
courses of ECT. There were 61 new cases,
The results of this study are summarized in
Table 2.
The incidence of fractures discovered III
the repeaters was 39 in the new patients
9.5
The difference in these figures is moro
striking when we consider that in the old
cases there were 2.6 compressed vertebra:
per fracture patient in the new the ratiq
was 1.7. Thi.'ee of the six new cases hat!
only a mild degree of compression consisting
of cupping of the dorsal surfaces with a
slight decrease in the height of the vertebral
bodies. The compression in the remaining
three was moderate according to the classi
fication described by Newbury and Ettcr.
The number of old cases is too small to have
a significant statistical value though thes
patients were selected only on the basis of
recurrence of the psychosis. Perhaps the
high rate of comi nessions f und among' tliei ii
is due to the facL that they had been treated
with a machine giving an nstantanefls
of current, In the present series an appa
ratus with a glissao_current was, used.
None of the patients with old conipressionz
suffered any backache or any changes in the
X-ray findings following their most recent
ECT.
Among the 64 new patients there were
five, aged 62 to 67 with advanced osteoar
thritic changes in the spine, one with a
,
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DISEASES OF TilE NERVOUS SYSTEM
*143
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[lie contour of the pelvis without being rig would he be willing to trade for one fatality
idly unyielding. The belt is fastened with traceable to a relaxant drug? Oii the sub
:iecreasing tight ness from above downwards ject of risks associated with cardio-vascular
allow Some flexionof the thighs without * disease, it appears that if a patient can tol
Janger of bruising the thigh muscles. At crate ECT combined with a barbiturate-re
[lie cephalic end of the spine, the head is held laxant- cocktail,, he can take itThtraighFff
:1 rmly anti under traction to counteract the well A certain irreducible minimum of car
`ilUOtliler type" effect of the contraction of diac deaths will occur under any circum
Llie longitudinal spinal muscles. Fig. 1.
stances because the existing clinical and lab
oratory methods cannot predict accurately
an impending coronary accident.
The use of a foam rubber belt is described
which appears to aid in decreasing the mcidence and severity of spinal compressions.
1
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The foam rubber belt has been found use
iil not only in limiting pelvic Ilexion during
lie seizure but as an eliect lye restraint durthe post-seizural excitement. It is less
a the field of returning Consciousness than
list and ankle restraints. In patients with
ierniae or recent abdominal scars, it serves
is an adequate abdominal support.
Based
the
series
listed
above,
the
belt
`a
appears to
educe the frequency and severity of corn
iressious.
Suinmui'y ulu?fl ionciitsiwt
rillie subject of electroshock therapy has
icen reviewed
the point
the
view
`pS'
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1. Cossa, P.: Letter from France. Ant. J. Psjjcldat.,
103:-i, p. 433, Jan. 19-17.
2. Kalinowsky, L. B. : Shock Treatments, Psycho
surgery. New York, Urns t' f SHot too 1952.
3. Eeiuiiett, A. B. : 1lisconeeptioiis Conicrning I-iazaids of Curaiization vith Electric Shock. Ths.
Nrri,. System. 9:219-221, July, 19-18.
Maclay, V. S.: Death Due to Treatment. Proc.
Royal Soc. Mci!., 16:13-20, Jan, 1053.
5, Wilson V. P,, and Nowill, W. K. : Suceinyicholine Chloride in Elect ioshot'lc Therapy. Arch.
Ncurol. £ Psyclilat., 71:122-127, Jan. 1951.
6itz C.L Pulwrnyt, D., Mills, Jr.: Death
Folhns'i ng Elcctrocoi ivi ilsi ye Therapy. A re/i.
q, era!. Q P-sue/il:!., 75:103, 1ny, 1956.
7. 1-Jolt, W. L., MeCandloss, F. I., Jacoubian, J.,
momil Mebod, A. A. IC. : A Comparison of `Anectine'' Succi nvlchol inc alit! ``Flnxedyl'' Effects on
Blood Pressure, Pulse and Respiration in 30 Car
diac and -10 Other Patients Given Ele.ctro-eon`ii]sivc Therapy. Con flu Ia Ni-nrolu'yiea, 13:315,
Sept. 1953.
S. Salan, I., and Carnuichel, L. JU. : Hazards of Cu
rare. J.A.M.A., 135:215, 1018,
9. 1"orrcger, ft.: Fatalities Following Curare. LA.
M.A., 112 :131.1-13'lS, April 29, 1050.
10. Parsons, B. H., Enact, S. H., ICealing, J. U.,
Ict
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