CONVULSIVE THERAPY IN SCHIZOPHRENIA

131

DR. L. A. FINIEFS AND DR. H. GILLIES : SCHIZOPHRENIA

I wish to thank Dr. A. Pool, medical superintendent of the West Riding Mental Hospital, Wadsley, for permission to publish this case, and Sir Arthur Hall, consulting physician to the hospital, for his valuable advice and assistance. REFERENCES

Paget, J. (1876) Lancet, 2, 715. Schrijver, D. (1932) Zeit. ges. Neurol. Psychiat. 141, 645. Hartfall, S. J. (1931) Lancet. 2, 68. Hann, R. G. (1910) Brit. med. J. 1, 135. Slander, K.H. (1933) Arch. Psychiat. 98, 546. Smith, L. H. (1928) J. nerv. ment. Dis. 68, 578. Van Eeden, J. H. (1928) Jb. Psychiat. Neurol. 46, 53. Kaufman, M. R. (1929) Arch. Neurol. Psychol. 21, 828. Rutherfurd, W. J. (1931) Lancet, 2, 350. Wyllie, W. G. (1923) Brain, 46, 336.

INDUCED EPILEPTIFORM ATTACKS AS A TREATMENT OF SCHIZOPHRENIA BY L. A. FINIEFS, M.D. Paris, M.R.C.S.

Eng.

DEPUTY MEDICAL SUPERINTENDENT, THREE COUNTIES HOSPITAL, ARLESEY, BEDS.

PSYCHIATRISTS have long recognised that in certain mental disorders improvement sometimes follows " shocks." In 1929 Nyiro and Jablonsky, reviewing the reports of the Budapest-Lipotmezo Mental Hospital, observed that in a number of schizophrenics remissions had followed attacks of epilepsy. In 1930 Muller reported two cases of catatonic schizophrenia which recovered after having epileptiform fits. These observations and the results of his own experiments prompted von Meduna (1934) to evolve a form of treatment by inducing fits artificially. He first tried intramuscular injections of camphor in oil but these had to be discontinued because of the large dose required. Eventually, pentamethylentetrazol, known as Cardiazol (Knoll), proved to be more practical and effective.** He has since treated a large number of recent as well as chronic cases of all forms of schizophrenia, irrespective of antecedents, with very good results. No fatality, complications, or late sequelae were observed. His conclusions are that the best results are obtained in early cases with 6-12 months of psychosis and in those that responded with strong fits to the minimum dose of cardiazol. A thorough physical examination is essential, before treatment: it must include complete examination of urine, and estimates of blood sedimentation-rate, blood-urea, blood-sugar, and blood pressure. All febrile conditions and pulmonary, cardiovascular, and renal diseases are absolute contra-indications. The technique is simple. All previous medication, especially of sedatives, should be discontinued for a few days beforehand. Cardiazol is supplied in ampoules of 1-1 c.cm. solution, each containing 0-1 g. of cardiazol in 1 c.cm. It is injected intravenously once or twice a week, with at least two clear days between each injection. The patient, having had an enema the previous evening and no morning meal, is kept in bed and injected at 8 A.M. The initial dose should be 0-5 g. of cardiazol and if this dose does not produce a fit, it should be Bincreased at the following injection by 0-1 g. until the fitproducing dose is reached. This is then repeated at subsequent injections. The highest dose reported is 1 g. The fit occurs -lg-Iminute after the injection, lasts for about 2 minutes, and has all the dramatic appearance of a grand mal attack. At the onset of the fit, the tongue should be protected by placing * Cardiazol is a rapidly acting circulatory and respiratory stimulant. It has come to be used in the convulsion therapy because in sufficiently high doses it excites the central nervous system, and as it contains no paralysing component it induces convulsions with safety.

The patient a wooden wedge between the jaws. remains dazed afterwards for a short time and restlessness may follow, but this is temporary and should not be controlled by sedatives. More often the patient falls asleep, and he should remain in bed for the rest of the day. Food should not be given for 4-5 hours after the fit because there may be vomiting. No other complications have been met with. The number of fits required varies considerably, the average however being 30. Remissions have been obtained with as few as 4 but in general if no mental change is noticed after 20 fits the treatment is stopped. Epileptiform fits occur in hypoglycaemic coma during treatment with high doses of insulin, and although dangerous to life because of the status epilepticus that may set in, they are generally believed to have a beneficial effect on the mental condition. James, Freudenberg, and Cannon (1937) report that they have induced occasional epileptiform fits by injecting cardiazol into some of their patients undergoing high-dosage insulin treatment, on days when insulin is omitted; for the cardiazol fits are less dangerous than those of hypoglycsemia and may be used as a supplement. Induced epileptiform fits, either alone or in combination with insulin coma, have been used at the Three Counties Hospital for several months with fairly good results. Although no imposing figures of recoveries can yet be produced and the treatment is very active and somewhat rough, no ill effects have been observed in carefully selected healthy young patients. The method appears especially beneficial in early psychoses especially the stuporose and catatonic. I am indebted to Dr. N. McDiarmid, medical superintendent of Three Counties Hospital, for permission to carry out this treatment and to publish this paper. REFERENCES

James, G. W. B., Freudenberg, R., and Cannon, A. T. (1937), Lancet, 1, 1101. Meduna, L. von (1934) Arch. Psychiat. Nervenkr. 102, 233. (1937) Die Konvulsionstherapie der Schizophrenie, —

Halle a.S.

Müller, G. (1930) Allg. Z. Psychiat. 83, 237. Nyirö, P., and Jablonsky, S. (1929) Orv. Hetil. p. 196.

CONVULSIVE THERAPY IN SCHIZOPHRENIA BY HUNTER GILLIES, M.B.

Glasg.,

D.P.M.

ASSISTANT MEDICAL OFFICER, WEST HAM MENTAL HOSPITAL ; CLINICAL ASSISTANT, WEST END HOSPITAL FOR NERVOUS DISEASES ; AND PSYCHIATRIC CLINICAL ASSISTANT, PRINCE OF WALES’S HOSPITAL, LONDON

SINCE 1934

Meduna of Budapest has been schizophrenia by the administration He believes that there is a of convulsive drugs. biological antagonism between schizophrenia and epilepsy, and that the production of major con-

treating

cases

von

of

vulsions

can cause remissions. In a series of 110 he has secured remissions in 54 cases whose duration varied from less than six months to more than five years. Experience of the so-called insulin shock treatment of schizophrenia has shown that the hypoglycsemic convulsion is therepeutically useful, and it is reasonable to suggest that any major fit, however caused, will have a good effect.

patients

METHOD

At first Meduna used camphor by intramuscular injection, but he later found the proprietary drug, Cardiazol, more suitable for the production of fits. In small doses this drug is a respiratory and

132

MR. GISSANE AND MR. SCHULENBURG: STAB WOUND OF THE HEART

circulatory stimulant, its chemical name being pentamethylentetrazol. (It is also known in the United States as Metrazol.) The solution that I have used is of 10 per cent. strength, and is prepared according to the following formula: cardiazol powder 1-0, di-sodium phosphate 0-01, distilled water ad 10-0. The solution may be sterilised by heating for thirty minutes in a water-bath at 100° C. The solution is best prepared daily. The patient is in bed, and the stomach should be empty. The initial dose is 0-5 g. cardiazol powder in solution-i.e., 5 c.cm. of the 10 per cent. solution. The injection is made into the veins at the elbow, and I The epileptic fit use a needle of 0-90 mm. diameter. comes on almost instantaneously, often with a premonitory cough. Usually the convulsion is a typical major epileptic fit, but I hve seen fits composed of tonic spasm only, and also mental convulsions in The only attention necessary the form of furor. the fit to is restrain violence, and to insert during a soft tampon between the jaws, which never fail to open and allow time for this procedure. It is essential that the injection be made quickly, and Meduna advises a rate of 1 c.cm. per second. In the same patient I have injected 9 c.cm. slowly and failed to produce a fit, whereas the next day the rapid injection of 5 c.cm. at once resulted in a convulsion. If the initial dose of 5 c.cm. does not produce a convulsion, the dose is increased next day by 1 c.cm. and so on. However, with increased skill it is usual to find that 5 c.cm.. suffices with most patients. As the solution is somewhat irritating care must be taken to make sure that the needle is truly within the vein. After the fit the patient may or may not have a short period of coma ; in any case rest in bed for some five hours is advisable. Mental improvement may occur after two or three fits, or may be delayed until some 15-20 fits have been produced. Meduna advises that the treatment be continued until 20 fits have been produced, whether there is improvement or not. ILLUSTRATIVE CASE

to hold a sensible conversation with her. In addition her hallucinations diminished markedly. However, she was still apathetic. Up to the present she has had only 7 fits induced and further improvement is at least likely. Even though this improvement should disappear, the case is still of interest as showing the effect exerted by the cardiazol fit on schizophrenic insanity. POSSIBLE ILL EFFECTS

Meduna believes that the convulsions alter the humoral environment so that it becomes unfavourable for the development of schizophrenia. These views, however, are still speculative, and it may later be found that the good effects are solely due to a non-specific stimulation of cerebral cells that had become functionally inactive. In a series of 1000 induced convulsions Meduna has seen no serious complications. He quotes the results of renal and electrocardiographic investigations as follows : "... the cardiazol convulsions exert no deleterious and certainly no permanent influence on a healthy system, particularly not on the circulatory system." In my own short experience of some 60 induced convulsions, the only ill effects seen have been slight and short-lived attacks of vomiting, transient attacks of moderate tachycardia, and the occasional thrombosis of the injected veins. In the present state of our knowledge, however, it would be in the highest degree unwise to apply this treatment to any patient who showed signs of organic disease. With these provisos, it may be said that the cardiazol convulsion is no more dangerous than the idiopathic epileptic fit. For Dr. J. Ham

book I

am

A PENETRATING STAB WOUND OF THE HEART OPERATION ; RECOVERY BY WILLIAM GISSANE, Ch.M.

some

On admission the patient was in a state of resistive stupor, which persisted until September, 1935, when she began to talk. Her utterances were nonsensical and have continued thus. A mental examination on Feb. 9th, 1937, showed no apparent dementia. She understood questions, and so far as her incoherent state allowed she was cooperative and her responses usually contained the correct answer. However, usually she spoke nonsense, and made use of neologisms. In answer to the question, " " she replied, " The Holy Martyr What is your name ? of the world. They forged my name. Ki-nacki-ki-nookiki-nacki. Miracles of the blessing of the pure air. They said, holy ki-nacki-ki-teeren, they said. You can understand what I’m saying." The principal clinical features were the absurd incoherence, the silly smiles and grimaces, and the general religious tone of her utterances. She was also aurally hallucinated. From Feb. 10th, 1937, until April 23rd she was treated by Sakel’s hypoglycaemic method. Neither during nor after her ten weeks of this treatment did she show any improvement mentally. The insulin treatment was directed to the production of daily periods of coma, and once she had a major hypoglycsemic convulsion. On May 22nd the cardiazol treatment was begun, and after the second induced convulsion mental improvement was noticed. She no longer uttered the nonsensical phrases described above, and it was possible

indebted to Knoll Ltd. of Welbeck-street.

Reference.-Meduna, L. von (1937) Die Konvulsionstherapie der Schizophrenie, Halle a.S.

A woman, aged 33, was admitted to hospital on April 19th, 1935. She had become depressed a few days after the death of her father, which took place

three weeks before admission. Her sister had been a patient in the hospital on two occasions.

permission to publish this report I am indebted to Harvey Cuthbert, medical superintendent of West Mental Hospital. For a translation of Meduna’s

Sydney,

F.R.C.S. Eng. and Edin. SENIOR ASSISTANT MEDICAL OFFICER AT ST. JAMES’ HOSPITAL,

LONDON;

AND

BÖDO SCHULENBURG, M.B. Cape Town, F.R.C.S. Eng. FORMERLY ASSISTANT MEDICAL OFFICER AT THE HOSPITAL

SINCE Rehn published his original case of a successful operation on a stab wound of the heart in 1897 Yet, in many such injuries have been reported. this country, the injury is still an extremely rare one ; the habits of our countrymen have not changed since Guthrie wrote in 1848: "London, the great metropolis of the British Empire, with its two millions of inhabitants, has been nearly exempt from injuries of the heart-sensible people not being disposed to stab each other, whilst madmen try to kill themselves in a different way." The report of a case with its radiological and electrocardiographic records appear to be of interest. A man, aged 23, was stabbed in a fight on July 31st, 1936. He collapsed " through inability to get his breath

"

and

unconscious for

short period. Seen by one of the injury he was then quite conscious but in a state of collapse. He was pale, cyanosed, us

was

twenty minutes after

a