Technique of Shock Therapy

SIR,-Treatment by E.C.T. imposes severe strain on the patient, and during fits bones may be fractured or even death result from heart failure. Hobson (J. belge Neurol. Psychiat., 1947, 2, 613) refers to 20 deaths in the literature attributed to E.C.T., and of these 16 were probably due to cardiac failure. Because of these risks many patients in poor physical condition are denied the treatment that their mental illness needs. The combination of large doses of tubocurarine chloride and thiopentone is attended by the risks of shock and laryngeal spasm, and the procedure is time-consuming. So I have come to be content with the more easily managed degrees of muscular relaxation obtained by using 8 to 13 mg. tubocurarine chloride alone, the smaller of these doses sufficing for a slim and poorly nourished woman, and the larger for men of average stature and physique. In my experience one's personal assessment of the patient is an adequate guide to dosage; body weight should be taken into consideration, general health and physique, cardiovascular state, and the degree of nervous apprehension. After a time we substituted decamethonium iodide, using from 3 to 3.75 mg. in the case of men and slightly smaller doses for women; more recently still we have used " flaxedil." Immediately after giving the injection it is my custom to tell the patient it may cause a little difficulty in breathing but that this does not really matter and will be short-lived. We have found that three and a half minutes is long enough for the drug to take maximal or nearly maximal effect, anid we allow this time to elapse before passing the electric current. Since the introduction of this method none of our patients have been found to have sustained fractures. We take a number of routine precautions. Hyoscine 1/75 gr. or 1/100 gr. (0.9-0.65 mg.) is given beforehand to allay apprehension. Immediately after the fit we give 02 and C02 for a few minutes until the colour is quite satisfactory. "Prostigmin" (the effect of which is to antagonize curare) is available for use where breathing is very shallow, and ampoule; of " coramine " and adrenaline are kept ready in case of shock. One other point of interest is the result of a small series of experiments on the intensive method of giving E.C.T. Twenty-six unselected patients had a single shock at each weekly session and 26 other patients were given a second shock a few minutes after the first at each session. So far as this series can be taken as evidence, the results indicated that no benefit is to be expected from a second passage of current shortly after the first.