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Recent Advances in Physical Therapy
Medica! Clinics oj North America May, 1941. New York Number
CLINIC OF DR. RICHARD KOVACS FROM THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL RECENT ADVANCES IN PHYSICAL THERAPY
A CLEARER appreciation of the physical therapy field as a whole has been the result of the present-day, large-scale, clinical employment and of painstaking research. Physicians are learning to select methods and forms of physical treatment on the basis of the physiologic principles of action instead of relying on certain makes or types of apparatus. The tendency is definitely towards simplified devices. Many of the developments in recent years, especially those in heat therapy, relate to the same basic physiologic and clinical effects, but are better adapted to certain anatomic locations or pathologic changes. THERMOTHERAPY
For the safe and efficient heating of the lower parts of the extremities, wrists, hands, ankles and feet, more extensive use is being made of conductive forms of heating. The whirlpool bath, consisting of water at a temperature of 105° to 110° F. which is kept whirling in a small tank by its own pressure or by a motor, combines gentle friction with sustained heat and also allows active exercise under water, especially in recent traumatic and arthritic conditions with swelling and limitation of motion. The paraffin bath employs melted paraffin at a temperature from 110° to 125° F., preferably controlled thermostatically; it is more useful in chronic traumatic and arthritic conditions. SHORT WAYE DIATHERMY
The original spectacular claims for specific bactericidal and antiphlogistic effects and for selective heating of this new 81 5
RICHARD KOVACS
method have not been corroborated by competent investigators. Short wave diathermy has, however, found its place as a convenient and fairly safe agent for deep tissue heating, offering the new technics of air-spaced electrodes and of coil heating or inductothermy. The latter technic is especially adaptable to the heating of an extremity or the body in toto and has become the most frequently used method for electropyrexia. A definite drawback of the technic of short wave diathermy, as employed up to the present time, has been the lack of dosage guidance, except that given by the patient's sensory response. Efforts have been made to construct dosimeters which will estimate dosage in the same manner as the milliammeter in long wave diathermy, but so far these meters have not been generally accepted for practical use. Recent investigators have endeavored to compare the results of short and long wave diathermy in traumatic, gynecologic and arthritic cases, but so far the findings are more suggestive than conclusive. The contention that short wave diathermy is preferable in acute cases, whereas long wave diathermy is more efficient in chronic cases, can be sustained by the fact that the air-spaced technic of the new method as a rule results only in mild heating, which is well tolerated and beneficial in most acute cases. Long wave diathermy with the contact-plate method produces usually more intense heating which is better suited to chronic cases. It is quite problematical whether early experimental findings indicating that heating by short wave diathermy is more intense in the depth have any practical clinical meaning, because in actual practice the heating effect depends on a number of factors. I have found coil field heating convenient in peripheral vascular conditions on account of the easy controllability of the gentle and diffuse heating effect and the avoidance of skin contact; it is also efficient for treating two knees simultaneously. Purulent infection of the skin, furuncles, carbuncles, paronychia, dental abscesses and lung abscesses have been enumerated by Schliephake and his followers as conditions in which short wave diathermy, especially of the shorter wave lengths, affords striking relief of pain and speedy resolution. Clinicians with seasoned experience emphasize on the other hand that mild heating is sedative in all suppurative processes
RECENT ADVANCES IN PHYSICAL THERAPY
817
and that in all acute conditions there exists a natural tendency for fairly quick recovery. I have reported for many years that in localized skin infection, exposure to luminous heat from a simple heat lamp, repeated several times a day, gives very marked relief and satisfactory resolution. The late Elkin P. Cumberbatch achieved similar results with carefully applied long wave diathermy. Schliephake himself advises only mild doses of short wave diathermy. Hence, definite proof of the alleged specificity of short wave diathermy in these conditions can be brought about only by comparative observation on a large series of controlled cases-and no such series has as yet been reported. In the light of present knowledge, there appear to be no specific conditions in which short wave diathermy is definitely preferable to long wave diathermy because of different clinical effects. Because of convenience of application, as already stated, its methods may be preferable in certain locations or conditions. There are now certain conclusions possible regarding the advantages of long wave diathermy over the newer method. Short wave diathermy~ as usually applied with large-size electrodes or an inductance coil, spreads its lines of force over all adjacent structures and wastes a good deal of energy. This is a drawback in treating heat-sensitive patients and in applying heat to such locations as the head or the neck where unnecessary heating of non affected parts is to be avoided. Long wave diathermy appears definitely preferable in treating accessible muscles and bursae, many of the joints and the cervical spine, because it allows better localized heating. A direct-contact plate method in short wave diathermy! has been satisfactorily employed in our clinic for two years. It includes a tube apparatus with an additional patient's circuit, in which suitable extra condensers and coupling allow energy transfer through contact electrodes. While it necessitates the return to carefully applied contact metal electrodes, this method offers three other very definite practical advantages: 1. It enables the insertion of a milliampere meter in the patient's circuit for direct reading of the output of the apparatus and a fairly accurate estimate of dosage. 2. It enables handling VOL. 25-52
RICHARD KOVACS
of the treatment cables without drawing energy from them, as they no longer form part of the treatment circuit; it also obviates the danger of a conflagration due to their overheating by crossing over each other or touching grounded metal. 3. Finally, it cuts down radio interference to a minimum because there is no superfluous scattering of energy into space. We now give preference to this method in treating most of the bursae and joints as well as body cavities and their contents; for example, the pelvic contents. FEVER THERAPY
With fever therapy the center of much interest in recent years, the methods of its administration and all possible complications have been carefully studied. Various methods of fever therapy can produce equally good results in competent hands, but the preference is generally towards cabinets in which the induction of heating is done by short wave diathermy and the temperature of the cabinet is maintained by suitable radiant heating or air-conditioning. In competent and careful hands, both of the physician selecting and supervising fever cases and the technician administering the treatment, no serious accidents are likely to happen. The personnel still remains the most important part of any therapeutic procedure. Clinical experience during the past few years has developed two ranges of therapeutic fever, mild and severe. Mild fevers from 103° to 105° F. are maintained for three to six hours and may be employed in syphilis and its various sequelae, in chorea, in mUltiple sclerosis, and in selected forms of arthritis and rheumatoid conditions. Severe fevers from 105° to 107° F. are maintained for from five to seven hours or longer and are employed chiefly in gonorrhea and its complications. Since its advent, sulfanilamide therapy has come to be preferred in the treatment of gonorrhea; however, in view of a percentage of failure even with adequate sulfanilamide therapy, fever therapy will undoubtedly continue to be an important therapeutic adjunct in certain of the more resistant cases. ELECTROTHERAPY
Galvanic Current.-The galvanic current, which is the basic current in electrotherapy, has greatly increased in use
RECENT ADVANCES IN PHYSICAL THERAPY
819
in recent years, both as a tissue alterant and in the form of electrophoresis, for the carrying of medicinal substances into the skin. It has been shown anew that such electrophoretic introduction of foreign substances into the skin is followed by diffusion, adsorption and precipitation; also, that effects on deeper tissues are possible with drugs controlling pathways between the skin and internal structures. Extensive work has been done with vasodilating drugs, such as histamine and the. choline derivatives, notably mecholyl. Favorable clinical results are being reported with both of these drugs in vascular spasm and fibrositis, neuritis, joint exudates in traumatic and rheumatoid arthritis, also in skin ulcerations. Histamine exerts a more intensive reaction and must be used for short applications only; it is generally preferred in applications to muscles; mecholyl requires more prolonged application and may exert systemic effects. Copper ionization has been favorably reported in fungous infections of the hands and feet. The recent literature brings favorable reports on the relief of migraine and headache by histamine ionization,2 of severe asthma by epinephrine ionization,3 of arthritic pain by mecholyl and histamine ionization/ of muscular spasm by aconitine ionization~ and of keloids and scleroderma by iodine ionization. 6 Low Frequency Currents.-Low frequency currents for muscle and nerve stimulation have found a promising extension of their employment. A method of inducing convulsions by means of an alternating electric current applied to the brain was proposed by the Italians, Cerletti and Bini, in 1937 and was further developed by British psychiatrists. 7 • 8 It aims to replace the more hazardous drug administration for "shock therapy" of mental disorders. This evolution is similar to the transition from the more hazardous malaria therapy to artificial fever therapy by physical means and is another proof that research workers have learned to consider physical agents alongside medicinal ones. Reports of its use are now beginning to appear in the American literature.9 • 10 Ultraviolet Irradiation.-Small and relatively inexpensive units for local ultraviolet therapy have been recently introduced and have undergone extensive clinical and laboratory testing. The thin window lampll is a mercury glow lamp emitting about 55 per cent short ultraviolet radiation, around
820
RICHARD KOVACS
2537 angstroms, and some 35 per cent infrared radiation. This lamp is employed for local treatment only and can be applied in close contact to the skin up to ten minutes without causing blistering. Our clinical experience as well as that of others has shown the effectiveness of such radiation in pyogenic infections, fungous and parasitic affections of the skin, and sluggish ulcers and wounds. The relief of pain in minor infec•tions and some ulcers after one or two treatments is often striking. The additional advantage of this application in skin infections such as impetigo is the avoidance of messy ointments. The air-cooled Kromayer lamp furnishes a radiation similar to the standard mercury vapor lamp and obviates the cumbersomeness of the water-cooling arrangement. It is efficient for treating superficial areas on contact and cavities with the aid of suitable quartz rods. UNDERWATER EXERCISES
Underwater exercises are finding increasing employment not only in infantile and spastic paralyses, but also in chronic arthritic and traumatic conditions. The partial elimination of gravity allows exercise of the weak muscles to a much larger extent; in nonparalytic cases the relaxing heat of the water helps to overcome stiffness. Such exercises can be given in the simple T-shaped device known as the Hubbard tank, which allows full extension of all four extremities; in its elaborations turbines and pumps whirl the water and quickly change its temperature. Large therapeutic pools are being built with special facilities for exercising and with motor equipment to hoist patients in and out. The question of installation must depend primarily on the number of patients actually in need of such treatment, and on the availability of skilled technical personnel. Poor or inadequate muscle training in a tank or pool is inferior to adequate training by such simple means as moving a weak limb on a smooth well powdered board or swinging it freely from a sling attached to an overhead frame. COMMENT
With the ever increasing number of new devices for physicaI.treatment, the seasoned advice of such bodies as the Coun-
RECENT ADVANCES IN PHYSIcAL THERAPY
821
cH on Physical Therapy of the American Medical Association and of physicians specially qualified in physical therapy is indispensable before the usually enthusiastically broadcast claims for each new development are accepted. The chief problem of present-day physical methods is their more general and more rational employment in the various departments of medicine. There are all too many patients who would be potentially benefited by the early and efficient use of certain well proved physical treatments in addition to their other care, who because of lack of information or indifference do not receive such treatment. Patient cooperation and more widespread education about physical therapy offer the only solution of this problem. BIBLIOGRAPHY 1. Kovacs, R.: Present Status of Short Wave Diathermy. Arch. Phys. Ther., 20: 559, 1939. 2. Ipolyi, Franz: Relief of Attacks of Migraine and Headache by Means of Histamine Iontophoresis. Fortschr. d. Therap., 16: 8-14 (Jan.) 1940.
3. Abramson, Harold A.: Comparison of Treatment of Severe Asthma by Electrophoresis of Epinephrine with Other Methods. Arch. Phys. Ther., 21: 261-266 (May) 1940. 4. Boyd, Douglas, Osborne, Stafford L. and Markson, David E.: Mecholyl Ionization in Arthritis. Arch. Phys. Ther., 20: 406--410 (July) 1939. 5. Barakin, M.: Value of Aconitine Iontophoresis. Ann. de med. phys., 32: 125-130, 1939. , 6. Nijkerk, M.: Iontophoresis in Treatment of Keloids, Dupuytren's Contracture and Scleroderma. Nederl. Tijdschr. v. Geneesk., 83: 51355140 (Oct. 28) 1939. 7. Shepley, WiIIiam H. and McGregor, F. S.: Electrically Induced Convulsions in Treatment of Mental Disorders. Brit. M. J., 2: 1269-1271 (Dec. 30) 1939. 8. Fleming, G. W. T. H., Golla, F. L. and Waiter, W. Grey: Electric Convulsion Therapy of Schizophrenia. Lancet, 2: 1353-1355 (Dec. 30) 1939. 9. Almansi, Renato and Impastato, David J.: Electrically Induced Convulsions in the Treatment of Mental Diseases. N. Y. State Jour. Med., 40: 1315 (July 1) 1940. 10. Feldman, Louis and Davis, Frederick T.: An Improved Apparatus for Convulsive Therapy. Arch. Phys. Ther., 22: 89-91 (Feb.) 1941. 11. Kovacs, R.: New Type of Mercury Glow Lamp. Arch. Phys. Ther., 19: 661, 1938.
CLINIC OF DR. RICHARD KOVACS FROM THE NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL RECENT ADVANCES IN PHYSICAL THERAPY
A CLEARER appreciation of the physical therapy field as a whole has been the result of the present-day, large-scale, clinical employment and of painstaking research. Physicians are learning to select methods and forms of physical treatment on the basis of the physiologic principles of action instead of relying on certain makes or types of apparatus. The tendency is definitely towards simplified devices. Many of the developments in recent years, especially those in heat therapy, relate to the same basic physiologic and clinical effects, but are better adapted to certain anatomic locations or pathologic changes. THERMOTHERAPY
For the safe and efficient heating of the lower parts of the extremities, wrists, hands, ankles and feet, more extensive use is being made of conductive forms of heating. The whirlpool bath, consisting of water at a temperature of 105° to 110° F. which is kept whirling in a small tank by its own pressure or by a motor, combines gentle friction with sustained heat and also allows active exercise under water, especially in recent traumatic and arthritic conditions with swelling and limitation of motion. The paraffin bath employs melted paraffin at a temperature from 110° to 125° F., preferably controlled thermostatically; it is more useful in chronic traumatic and arthritic conditions. SHORT WAYE DIATHERMY
The original spectacular claims for specific bactericidal and antiphlogistic effects and for selective heating of this new 81 5
RICHARD KOVACS
method have not been corroborated by competent investigators. Short wave diathermy has, however, found its place as a convenient and fairly safe agent for deep tissue heating, offering the new technics of air-spaced electrodes and of coil heating or inductothermy. The latter technic is especially adaptable to the heating of an extremity or the body in toto and has become the most frequently used method for electropyrexia. A definite drawback of the technic of short wave diathermy, as employed up to the present time, has been the lack of dosage guidance, except that given by the patient's sensory response. Efforts have been made to construct dosimeters which will estimate dosage in the same manner as the milliammeter in long wave diathermy, but so far these meters have not been generally accepted for practical use. Recent investigators have endeavored to compare the results of short and long wave diathermy in traumatic, gynecologic and arthritic cases, but so far the findings are more suggestive than conclusive. The contention that short wave diathermy is preferable in acute cases, whereas long wave diathermy is more efficient in chronic cases, can be sustained by the fact that the air-spaced technic of the new method as a rule results only in mild heating, which is well tolerated and beneficial in most acute cases. Long wave diathermy with the contact-plate method produces usually more intense heating which is better suited to chronic cases. It is quite problematical whether early experimental findings indicating that heating by short wave diathermy is more intense in the depth have any practical clinical meaning, because in actual practice the heating effect depends on a number of factors. I have found coil field heating convenient in peripheral vascular conditions on account of the easy controllability of the gentle and diffuse heating effect and the avoidance of skin contact; it is also efficient for treating two knees simultaneously. Purulent infection of the skin, furuncles, carbuncles, paronychia, dental abscesses and lung abscesses have been enumerated by Schliephake and his followers as conditions in which short wave diathermy, especially of the shorter wave lengths, affords striking relief of pain and speedy resolution. Clinicians with seasoned experience emphasize on the other hand that mild heating is sedative in all suppurative processes
RECENT ADVANCES IN PHYSICAL THERAPY
817
and that in all acute conditions there exists a natural tendency for fairly quick recovery. I have reported for many years that in localized skin infection, exposure to luminous heat from a simple heat lamp, repeated several times a day, gives very marked relief and satisfactory resolution. The late Elkin P. Cumberbatch achieved similar results with carefully applied long wave diathermy. Schliephake himself advises only mild doses of short wave diathermy. Hence, definite proof of the alleged specificity of short wave diathermy in these conditions can be brought about only by comparative observation on a large series of controlled cases-and no such series has as yet been reported. In the light of present knowledge, there appear to be no specific conditions in which short wave diathermy is definitely preferable to long wave diathermy because of different clinical effects. Because of convenience of application, as already stated, its methods may be preferable in certain locations or conditions. There are now certain conclusions possible regarding the advantages of long wave diathermy over the newer method. Short wave diathermy~ as usually applied with large-size electrodes or an inductance coil, spreads its lines of force over all adjacent structures and wastes a good deal of energy. This is a drawback in treating heat-sensitive patients and in applying heat to such locations as the head or the neck where unnecessary heating of non affected parts is to be avoided. Long wave diathermy appears definitely preferable in treating accessible muscles and bursae, many of the joints and the cervical spine, because it allows better localized heating. A direct-contact plate method in short wave diathermy! has been satisfactorily employed in our clinic for two years. It includes a tube apparatus with an additional patient's circuit, in which suitable extra condensers and coupling allow energy transfer through contact electrodes. While it necessitates the return to carefully applied contact metal electrodes, this method offers three other very definite practical advantages: 1. It enables the insertion of a milliampere meter in the patient's circuit for direct reading of the output of the apparatus and a fairly accurate estimate of dosage. 2. It enables handling VOL. 25-52
RICHARD KOVACS
of the treatment cables without drawing energy from them, as they no longer form part of the treatment circuit; it also obviates the danger of a conflagration due to their overheating by crossing over each other or touching grounded metal. 3. Finally, it cuts down radio interference to a minimum because there is no superfluous scattering of energy into space. We now give preference to this method in treating most of the bursae and joints as well as body cavities and their contents; for example, the pelvic contents. FEVER THERAPY
With fever therapy the center of much interest in recent years, the methods of its administration and all possible complications have been carefully studied. Various methods of fever therapy can produce equally good results in competent hands, but the preference is generally towards cabinets in which the induction of heating is done by short wave diathermy and the temperature of the cabinet is maintained by suitable radiant heating or air-conditioning. In competent and careful hands, both of the physician selecting and supervising fever cases and the technician administering the treatment, no serious accidents are likely to happen. The personnel still remains the most important part of any therapeutic procedure. Clinical experience during the past few years has developed two ranges of therapeutic fever, mild and severe. Mild fevers from 103° to 105° F. are maintained for three to six hours and may be employed in syphilis and its various sequelae, in chorea, in mUltiple sclerosis, and in selected forms of arthritis and rheumatoid conditions. Severe fevers from 105° to 107° F. are maintained for from five to seven hours or longer and are employed chiefly in gonorrhea and its complications. Since its advent, sulfanilamide therapy has come to be preferred in the treatment of gonorrhea; however, in view of a percentage of failure even with adequate sulfanilamide therapy, fever therapy will undoubtedly continue to be an important therapeutic adjunct in certain of the more resistant cases. ELECTROTHERAPY
Galvanic Current.-The galvanic current, which is the basic current in electrotherapy, has greatly increased in use
RECENT ADVANCES IN PHYSICAL THERAPY
819
in recent years, both as a tissue alterant and in the form of electrophoresis, for the carrying of medicinal substances into the skin. It has been shown anew that such electrophoretic introduction of foreign substances into the skin is followed by diffusion, adsorption and precipitation; also, that effects on deeper tissues are possible with drugs controlling pathways between the skin and internal structures. Extensive work has been done with vasodilating drugs, such as histamine and the. choline derivatives, notably mecholyl. Favorable clinical results are being reported with both of these drugs in vascular spasm and fibrositis, neuritis, joint exudates in traumatic and rheumatoid arthritis, also in skin ulcerations. Histamine exerts a more intensive reaction and must be used for short applications only; it is generally preferred in applications to muscles; mecholyl requires more prolonged application and may exert systemic effects. Copper ionization has been favorably reported in fungous infections of the hands and feet. The recent literature brings favorable reports on the relief of migraine and headache by histamine ionization,2 of severe asthma by epinephrine ionization,3 of arthritic pain by mecholyl and histamine ionization/ of muscular spasm by aconitine ionization~ and of keloids and scleroderma by iodine ionization. 6 Low Frequency Currents.-Low frequency currents for muscle and nerve stimulation have found a promising extension of their employment. A method of inducing convulsions by means of an alternating electric current applied to the brain was proposed by the Italians, Cerletti and Bini, in 1937 and was further developed by British psychiatrists. 7 • 8 It aims to replace the more hazardous drug administration for "shock therapy" of mental disorders. This evolution is similar to the transition from the more hazardous malaria therapy to artificial fever therapy by physical means and is another proof that research workers have learned to consider physical agents alongside medicinal ones. Reports of its use are now beginning to appear in the American literature.9 • 10 Ultraviolet Irradiation.-Small and relatively inexpensive units for local ultraviolet therapy have been recently introduced and have undergone extensive clinical and laboratory testing. The thin window lampll is a mercury glow lamp emitting about 55 per cent short ultraviolet radiation, around
820
RICHARD KOVACS
2537 angstroms, and some 35 per cent infrared radiation. This lamp is employed for local treatment only and can be applied in close contact to the skin up to ten minutes without causing blistering. Our clinical experience as well as that of others has shown the effectiveness of such radiation in pyogenic infections, fungous and parasitic affections of the skin, and sluggish ulcers and wounds. The relief of pain in minor infec•tions and some ulcers after one or two treatments is often striking. The additional advantage of this application in skin infections such as impetigo is the avoidance of messy ointments. The air-cooled Kromayer lamp furnishes a radiation similar to the standard mercury vapor lamp and obviates the cumbersomeness of the water-cooling arrangement. It is efficient for treating superficial areas on contact and cavities with the aid of suitable quartz rods. UNDERWATER EXERCISES
Underwater exercises are finding increasing employment not only in infantile and spastic paralyses, but also in chronic arthritic and traumatic conditions. The partial elimination of gravity allows exercise of the weak muscles to a much larger extent; in nonparalytic cases the relaxing heat of the water helps to overcome stiffness. Such exercises can be given in the simple T-shaped device known as the Hubbard tank, which allows full extension of all four extremities; in its elaborations turbines and pumps whirl the water and quickly change its temperature. Large therapeutic pools are being built with special facilities for exercising and with motor equipment to hoist patients in and out. The question of installation must depend primarily on the number of patients actually in need of such treatment, and on the availability of skilled technical personnel. Poor or inadequate muscle training in a tank or pool is inferior to adequate training by such simple means as moving a weak limb on a smooth well powdered board or swinging it freely from a sling attached to an overhead frame. COMMENT
With the ever increasing number of new devices for physicaI.treatment, the seasoned advice of such bodies as the Coun-
RECENT ADVANCES IN PHYSIcAL THERAPY
821
cH on Physical Therapy of the American Medical Association and of physicians specially qualified in physical therapy is indispensable before the usually enthusiastically broadcast claims for each new development are accepted. The chief problem of present-day physical methods is their more general and more rational employment in the various departments of medicine. There are all too many patients who would be potentially benefited by the early and efficient use of certain well proved physical treatments in addition to their other care, who because of lack of information or indifference do not receive such treatment. Patient cooperation and more widespread education about physical therapy offer the only solution of this problem. BIBLIOGRAPHY 1. Kovacs, R.: Present Status of Short Wave Diathermy. Arch. Phys. Ther., 20: 559, 1939. 2. Ipolyi, Franz: Relief of Attacks of Migraine and Headache by Means of Histamine Iontophoresis. Fortschr. d. Therap., 16: 8-14 (Jan.) 1940.
3. Abramson, Harold A.: Comparison of Treatment of Severe Asthma by Electrophoresis of Epinephrine with Other Methods. Arch. Phys. Ther., 21: 261-266 (May) 1940. 4. Boyd, Douglas, Osborne, Stafford L. and Markson, David E.: Mecholyl Ionization in Arthritis. Arch. Phys. Ther., 20: 406--410 (July) 1939. 5. Barakin, M.: Value of Aconitine Iontophoresis. Ann. de med. phys., 32: 125-130, 1939. , 6. Nijkerk, M.: Iontophoresis in Treatment of Keloids, Dupuytren's Contracture and Scleroderma. Nederl. Tijdschr. v. Geneesk., 83: 51355140 (Oct. 28) 1939. 7. Shepley, WiIIiam H. and McGregor, F. S.: Electrically Induced Convulsions in Treatment of Mental Disorders. Brit. M. J., 2: 1269-1271 (Dec. 30) 1939. 8. Fleming, G. W. T. H., Golla, F. L. and Waiter, W. Grey: Electric Convulsion Therapy of Schizophrenia. Lancet, 2: 1353-1355 (Dec. 30) 1939. 9. Almansi, Renato and Impastato, David J.: Electrically Induced Convulsions in the Treatment of Mental Diseases. N. Y. State Jour. Med., 40: 1315 (July 1) 1940. 10. Feldman, Louis and Davis, Frederick T.: An Improved Apparatus for Convulsive Therapy. Arch. Phys. Ther., 22: 89-91 (Feb.) 1941. 11. Kovacs, R.: New Type of Mercury Glow Lamp. Arch. Phys. Ther., 19: 661, 1938.