The epidural potato!

I read with great interest the editorial by Simpson and Lynch (Anaesthesia 1998; 53: 615–7). A comparison of the development and present situation of anaesthesia for ECT in the UK and in France may help to understand the specific problems associated with it. ECT was studied at the central psychiatric hospital in Paris (Sainte Anne Hospital) by Professor Jean Delay during the early years of the Second World War. He soon realised that anaesthesia was needed for the application of ECT and he secured an appointment for one of the very few physician-anaesthetists practising in France at that time, Dr Jacques Boureau. In those days, there was no formal teaching of anaesthesia in France and most anaesthetists were self-taught. Jacques Boureau, however, had received instruction from his father, a physiciananaesthetist. A first paper by Delay and Boureau was published in the Revue Médicale Française of 4 April 1945 under the title ‘L’électrochoc sous narcose’. Dr Boureau soon added a relaxant to the hypnotic he used, the first being tubocurarine on which he reported in 1954. By then he had developed an extensive practice of anaesthesia for ECT, not only providing anaesthesia but also delivering the electrical stimulation himself. This early development was therefore symmetrical with that in the UK. In the UK, the psychiatrists administered anaesthesia while in France the anaesthetists provided ECT. This latter practice was highly praised by Professor Delay’s successor, Professor Pierre Deniker, who even wondered whether psychiatrists could claim the practice of ECT for themselves. At the end of his career, Dr Boureau published a monograph describing his practice, ‘La sismothérapie moderne sous narcose et curarisation’ (Doin, Paris, 1980), in which he reported on over 100 000 cases. The evolution of the practice of ECT at Sainte Anne Hospital has been described in detail by M.-L. Meignan, in a paper to appear in the September issue of Cahiers d’Anesthésiologie 1998; 46 under the title ‘Anesthésie pour l’électroconvulsivothérapie’. Dr Meignan’s paper mentions several of the specific difficulties associated with anaesthesia for ECT not mentioned in the editorial referred to above, including the reticence of many anaesthetists to deal with psychiatric patients. Assessing the psychiatric patients’ physical condition before anaesthesia and obtaining their informed consent (a legal obligation for anaesthetists in France) is hardly possible with disturbed patients in closed wards. Taking the patient from the wards to the location where ECT is practised, combining psychiatric with anaesthetic care in the post-ECT recovery period and taking the patients back to their wards also present problems. Dr Meignan’s paper describes specific ways to get around these problems.