1 100 6561 http://exhibits.library.stonybrook.edu/mfp/files/original/e06d90c86c34900cbfbc862c755d6567.pdf 15ada951bb078ffb8bea42b5be5e0745 PDF Text Text IV: 10/113/60 Experieeutel Peyehietrie Presreue et niiieide neepitni A The Review veeieue prostate in the Department at Experineetei W Psychiatry have been devoted to en undereiending e: the node at W‘iherepiu “tie: or thrush undies or hreiu taxation. the principal techniieel have been edepted tree deeoriptive peyehieiry, uenrepeyehoiexy, electreeeeeyheiecrephy, linguietiee, phereeeelour, end eeeielecy. In initial etudiee It reaction were round cenvuleive iterepy. ehenzee in brain it reiete beth to iepreveuent retinge end to pro-treatment peyuhelecic variables. in our enderetendin; e: ceevuieive therepy develeped, e centre: neerephyeieiezio-edeptive view e: eaeetie therepiee eeerted ( ). In this Suuka» view psychiatric treeteente ereﬁtherepeutieeiir exteetive to the degree that brein function in nee-trebly’eitered. While ehense in brein tenetien neeeeeery to: behavioral change, the irpe e: edeptetiee, it however, veriee depending upon pre-treeinent peyoheleuiigend eeeieiecieag charecterietiee er the subject. Thee, the node at eotien ie not eeen ee eiiher 'ercenic' er 'peyehelexie' bet tether ee the intereotion at both eepeete in the individeel. further, while behevierei change in �-2- ralatad to chanson in brain function; and the adaptiva pattarn to paynhologiéﬂoharaatariatic!t praotraatnant avalaationa at 'inprovaaant'; baing spacial typan at avalnatian or ahanga, ara darivativa Jadgnanta baaad an start and tanily anpaatatiana and talarannaa. Thin hypothaaia was dovalapad and anatainad in a aariaa at atudiaa at onnvulaiva therapy. concurrant atndiaa of insulin tuna indicatad that behavioral changa hora, too. van ralatnd to tha anaat and dacraa o: prolancad cana a: rapaatad aaiauraa - than. bainx tho nanraphyaialogiélnhanaa nanixantatiana at principal prolansnd in thin thanany. Tho node at action of tha nan paychetroyic asanta anpraaaad within thin hypothaaia ( aganta would III all. ). It ran anxgaatad that thaaa b. attactiva to the dasraa that tho: indnaad paraiatant chanxaa in brain fanaticn' and that tha typa a: bahavioral raaponaa vanld ha ralatad to tha type at brain nhanza, and to pranorbid pnyehaloxigﬁ(para¢nality) pattarna. rho praaant proxrann in tha Bogart-ant an. danisnnd to atndy than. ralatianahipa in datail. Canvnlaiva Tharazz Prooana or variaua anaanraa at brain tnnatian, tha anannt of slow vat. activity in tho alantronncnphalacran and cantabnlatory and �-3H dontal languago pottorno attor aaohorbital ( ) oonottivo indiooo in oonvaloivo thorany oohaoeto. voro tho aoot In tho firot oxporioont, improvooont ratings ooro round to ho oorrolatod dirootly with tho appoaranoo or high dogrooo o: ohango indicoo ( ). 1n thoao rhooo oboorvationo woro tootod in a douhlo-hlind study in which pationto rotorrod for olootroohock woro randoaly ao~ aignod to coorooo or oithor oonvuloivo or auboonvoloivo thorapy undo: poutothal pronodioation. nigh dogrooo o: nourophyoiologie ohango ooro oboorvod only in tho aonvoloivo group; improvonont ratoo significantly highor in this group; '02. and than oubconvnloivo oohjooto uoro ro-troatod by convuloivo appliaationo, tho improvoaont rota was oinilar to tho original convaloivo group. In tho oihconvnloivo troatod oahjoota, oonoidorahlo anonnto o: oloetrieol corront paoaod hotwooh tho hitouporal oloetrodoo. It woo ooncludod, thorotoro, that tho thoropoutio agont total oloctrioal curront, or no, but an all woo not tho or nono quality aahitootod by tho grand nal ooiouro. rho otgniticaneo or tho grand nal ooiouro was turthor olahoratod 1n otudioo of tho inhalant convuloont, hoxatluorodtothylothor (Indoklon). 31-11ar dogrooo o: olootrographio ohaugo, iayrovoaont ratoo, typo: o: bohavtoral �‘hV, change and ohanxee in neuropeyohologio teak behavior were obaerved in the inhalant and in electrically treated :ronpa. It nae anon apparent, however, that not all anbjeote aaniteetin; high decreea of physiologic ohanga were rated on 'inproved'. In a deeoriptive typelogio atndy, rive patterne were doeoribed, eaperioally teraed ‘enphorio', 'hypoaanio', 'eoaatiaetien’, ’paraneid-Iithdraval', and 'panio'. While the tirat adaptive aedea were ratod ae 'nnoh inproved', the aeen ae ‘uniapreved' or 'verae‘ ( two or latter theae two were ). In etndiee of peyoholegio variablea, it nae reported that patiente rated ae 'anoh inproved' and ’reoevered' frequently aanireeted peraenality patterne similar to that deeoribod by Heinatein and Kenn ( ) an the explicit verbal denial personality. In language patterna, they expreeeed the language of denial, when dittnae brain change denial, was indnoed, exhibiting anoh aepeote an niniaiaation, diaplaoenent, oliohee,|g§g. aere treqnontly than unimproved enhaeote. high I Stale eoore ( Other indioee related to favorable ontoeae were ), and Rorschach deterninante or color, abeent aoreaent and abaent torn-oeler ( ). alao, :avorable ontoeae nae aaaooiated tith lea In thin population, educationalaohieveaont �and revels: birth ). ( Antlehellner lea and Convalelve there Seeking a way EEG slew wave eae given te eucaent the degree at peet-oeaveleive activity, an inn-anneal: at antlehelinercle cenpoand, diethaaine, vex-1e“ “sea at the eemalelve therapy preeeee. Contrary to expectatlene, diethaaiae eaueed an iaaedlate and entrained decreaee in EEG alerting. Patleitl with dental language patterae rellnxqalehed than; Instead of euphoria and well being, the eibjeete were irritable, anxieue and expreeelve a: nre-treateeet patterne. In eubjeete prior to cenvuleive or drug therapy, elethaalne induced exciteaent, tenelen, anxiety and lllaeery eeaeatlene. Sabaeqeent etadlee with ether eentral antlohelinerglo oeapeeade (VII-2299, JB-318,336, beeaetyaine) abated behavleral and electrezraphle patterns alaalar te diethaelae. Stellar deeynohrenieatien a! peet-eenvulelve EEG aleeing wee aleo noted with central eynpathealaetie hallucinogene (euphetaaine, aeeoallne, LSD-25). and baa been reported re: antihietaainee (dephanlydraalne). Theee obeervatlene led to the eaageetlea that an increaee in central ehellnergie activity eae a biocheaieal haste tor the eenvalelve �therapy process ( ). Pszshotrogic Drugs and During EEO this period,the drugs aroused interest. node of action of newer psychotropic Following the concepts derived from convulsive therapy, the neurophysiologis ohenges induced by drugs were tested within the experi-ents in an EEG Ill. experimental setting or acute setting. It was observed that phenothiasines (shlorprolasine, pronssine, triflnepronasine) induced isation and a shitting o: the spectra: to the ERG synchron- slow frequencies; leprobanate and barbiturates , en increased synchronisation and a shift of spectra: to fast frequencies; reserpine, an inoreased slowing with synchronisation at low dosages, and desynchronisatien at higher levels. Inipraaine induced desynohrenisation with a shift of frequencies to the slow bands. Other experinental oonpounds tested included phenyltoloxaline (Bristol), Deaner and (liker), wx-21h9 (Wyeth) and its vsrions BL-HlBB and oongeners trenquel (nerrill). For eaoh, no consistent electrographis.patterns energed. It teens use suggested that psychopharnaoelogio agents provide a ‘lr eliciting a variety or nenrephysielogio patterns in �.7contreet to the eingle pattern of induced oonvuleione. Furthermore, the typo of neurophysiologie alteration, ee reflected in synchrony and Iroquoooy petterns, or hehoviorel edoptetion. elow :roqnonoieo wee Inoreoein; EEG related to epooirio types EEG eynohrony and e shift to or. oeeooieted with trenquillisetion, eedetion deoreeeiog ogitotion; while deeynohronisetion and e end shift to test frequencies in eeeooieted with oxoitenent, illusions, end delnlionol idoetion. These observations orooeaeietont with hypotheeoo or Hikler ( ). The merit of such teohaiqoeo for the eeeey or psychotropic agents hoe been doeorihod ( ). new �-8Pszchcpharaacologz Evaluation Prograa The present pregraa, instituted in October 1959, is based these studies and is on designed to answer the following questions: Is there s relation between aeasurable alteration in brain function and behavioral change with psychotropic drugs on chronic administra- tion? Are there pre-treatasnt clusters of psychiatric, physiologic and psychologic variables related to the type of behavioral adanptation? - to the type and degree of physiologic change? Method: is an initial approxiaation, fixed a double-blind, dosage rendoa assignment drug study was undertaken. Based on clinical experiences with various psychotropic coapounds, three classes were selected on the basis of their patterns of :30 response. ‘The selected agents were those eith predoainent desynchronicing patterns; synchronising and slowing; or niniaal or no effect. Patients referred for drug therapy, after medical examination, and after all other medications have been discontinued are randoaly assigned to one of three classes of compounds. Patients are predoainantly middle class, urban, with high educational attainment. Hillside Hospital is a non-profit, philanthropic supported psychiatric institution, admitting voluntary �.9patients for extensive psychotherapentic treatment. of stay is seven months. are prescribed by Kean duration Convulsive and psychotropic drug therapies star! psychiatrists on referral to the Department. All treatment is adninistered by Departaental start, so that the experinentsl variables or drug dosage, route of administration, assignsent to groups, 333. are readily controlled. All patients in the hospital are available for study. all patients receive After a testing period, ho cc of medication daily tron individually labelled bottles. increased in fixed weeﬂy etepe until a nsxiaua at date, 1&0 the study period. Dosages are After weeks. reotestinz occurs. two weeks on maximum dosage, To h liquid subjects have been referred, and 110 have completed Preliainary analyses of the data are new in progress 0 avieral Chan e5 In a survey or the behavioral adaptations of patients receiving phenothiazines er iaipranine, various clusters at behaviors were developed. The typology was based on the pre~treatasnt psychiatric the treatnent reepenee and profile. In the present study, various measures of behavioral change are under study. Therapist referral questionnaires and six week evaluatione; therapist and �-10- patient two Clyde Heed Scales; Lorr Scale evaluations in interview by research psychiatrist, and Lorr ward scales; patient eelta ratings including the Johns Hopkins synpten check list and the Chicago Attitude Scalee are ancnget the neaenres being explored. lenropezchelcgz: Paychelcgic tasks are viewed both as change variables and predictive variablee. In convulaive therapy, changee ), tactile perception in aencry tasks ( ), crr ( ( or figuree ( ), rignre ground tasks ) have been ( ), Recheler«3ellevne ( and tachietcecopic recogniﬂcn , ) related to the degree of induced neuro- For each task, the degree or decrement in physiologic change. taek pertornance has been positively correlated with the amount of EEG slowing. lollcwing treatnent completion, with the return of physiologic indicee to pre-treatnent levels, performance in these peychclcgic taaka also returns to prewtreatnent levels, or higher a betternent of performance ascribed to practice eitect. Denial scores on interview ( ), Rorechack deterninante ), 1 ), auditory feedback ( ),and perception of the visual upright ( ) have been viewed ae predictive indices of the behavioral changes following nor. various tasks are new ﬁbeing Scale scores ), language patterns after ancbarbital ( ( ( Theee asseeeed with paychctrcpic agents. �.11. In the convulsive therapy studies; the lieetreencezhalogrsghzs degree of EEG slowing was measured by counting the consecutive waves in selected samples. were studied, it was When the more subtle changes or druggeftects necessary to apply less tediens techniques. Electronic frequency analysis was introduced in August 1959. By asasurenent e! the pen deflection for various frequencies free 3 to 33 cps in ten second epochs, rapid aeasnreaent of apparently saall changes in total activity and and frequency spectra are not obtained applied. Other physiologic variables include the response of £30 to intravenous chlerprcnasine; blood pressure response to sechelyl; EKG; radioactive iodine uptake, and analyses or various blood and urine element ordinarily conceived ac protective of the patient'e welfare. �Pnzghuliggualtion: rollcving thy studios at syntgotio Iguanas. pattorns ( ) in oonvnlntvo thnrspy, 0th.: anpoctu or Innguagc cﬁndind for worn their ralatiou as 1361... st «hung. in intrnporlonll with nonltdurabln nun: .xplarctlou attnr bcinvior. attic, (1T3) thn‘ typewtokoa-rutio augxoltod 11:;«1-t19 nounurOI, or connoautivo 33-pin: a: dyldic apcoch 1.: bu A useful lunar. tppliud to writing toxta or tho Hull. ran had previously buon hung. nmlu ¢ individuals, Jute intuit-d ﬂat the two index (dyad) at a ounnunieutioa an: sicniriuant not. portal tho ltttc at tho intaraction than snnlytcn or ltplrt‘. Innplnn or the participantl. tpplytn; ‘htv technique to couralsivo tiara»: pntiunta, august: in ran nonn and atnndnrd deviation worn rclntod both to tn. dogroo 0: induced use slow vuvo nctivity and to lyutaatic lan‘unxa puttorns obtained in indop-ndoat structurod iutcrvicvnc Bpocch boa... new. rupctttivc (lovarod nag: 223) and Iowa vurttblc in connocutivo canplou (inoronnod standurd dovistion) ( ). �In tnttrvidvt tutor. &nd aft-r 8h. intravunoul administration of coutrully .ctivo ngcnta, 11-11;: chtnguu rare obaorvtd. Axtntu with a prcdauinnnt lynehronisatiou ptttorn tn. on EEG uxhibttod n docroaao tn tutu 218 and inarcuao in Itnndtrd deviation or soorcs,vh11n ataynchroniliag compounds olicitcd grnttnr variability in apooch pa‘torus (lﬂOrOll. in and accrual: 13 varidbility at conntnntivo 133 noun) neuron (doeronlo 1n It;adnrd dcvistion). 0th.: 1:33:33. nasuuroo under study includu dintronln r0110: quottontl, colt-rotoronco, tad potion. It 1- aucxoutod are potont tuchaxquos to: and poyuholusie ultorttioa 1n tuna. and that than. paycholinsutstte nut-urns ﬁho operational unnlyiun a: phylialogta crises: at payohopharnuoologic acunta C ). �aotiolg‘io Studio: 2h. cuncral prdbiun 0: tbs rolatiuu at liaitl tautarl to choico tad rocuitu o: parchiatrio troutucnt. and tho Ipoeitic prdblun at tho rolnticn at it... taatars pittcrnn, within tun instieutioa. and to a cutie: at population ), uduoatiun, ago. place a: birth In on: tinny ( utmdioa. 13d ta in. rorcrrul learn .3 tau California I nail. var. nixnitieuntly rciatod to thc type .1 thnripr roe-iv'd ind tho utiliuntion o! ndaunctiv. hoapittl nitric... ndnantod hid paiinntl uh. var. old-r, poorly Than, night: I acorou und warn tar.i;n-horn, pnrtieuinrly Einicrn lnropo, utro ngat 11301: to be rotorrtd fur oloctro— shook. Thou. rnlntianahipl were pro-nail: iudupondcut a: diagnnlol. within tho crunp at cloctrolhock putiontl, rottrrnl {or In rclltod to 36? vac .100 g cocond Iﬁuuy at this tin. tor in... factora. group ( ). durstioa or hospituliaation, dilohurxu ovuluutina and dincnoa¢n wars :0lniod to the can. 000111 taetcru. Fur «suspic, patiunta hoapituliuod tar Sh. Ihnrtolt patina var. oidoat, had thi icast oducution, war. nest likely to hivc and had in. high I again boon tornign born scar... titular, nativoaborn, str- �uduoatod, lunar 1 real. Ilﬁrl pttiontn v'ro hospltnllscd tho lnagost. Inn's rolttsonuhipl bald trnu within tronincnt typo and had thn rithln diutunaﬁao 31330. On allohurxo, .14.: pttttutu not! tavurubli rttlngo. In not, valiant. rutad ti rooovcrod or IIOh luprovnd htd thq hlxhott F scarce, lunat odnuuttou :ad var. acct likaly to ho rarclxn born. In a study at patlont rtrulal a: 30!, 01:11.: ro- lutlonlhtpu wort obncrvcd ( ). that. rolgtlounhlpi If. no! undo: ntndr in tho out-pttlantxdopartnoat, sad in a trlw hospital cunpnrattvc Itaay. In tn. lnttor Itudr. th- population! or thrco hunptlalc in which :11 thrupltu are equally arullnbla to all p¢tluata, - sonniugor roundatlau lllplttl (Ippir-cltll, Protoltant), nascaohau-ttn unnttl Xcslth c ntnr (lavdroclnao Catholla) and 3311314. noopltll (nlddln-clnnn Jalluh) boin; alaoaacd. It but Etna postulntod that lhunc rcl:t1¢ulhlpl rctlact tho tntlncncu at .00131 bunksround on plynhologlcnl pronoun, nah u hubltul undo: at axprcsslon. tho putt-tn a: nontal action tr. undo: Ir. ”turn or Th. onutwibution emulation um 0: than. tactorc to antaru tho tad patsont-thtrnpttt lllnsal, atlﬁr. �Exporinuutal Plyohiatrio Progr;ul nt Hillside ﬁespitnls A Max Review rink, H.D. the Depurtneut of Experimental Psychiatry, Kill-id. Hospital, Glen Oaks, 1.1., l.I. From V: 11/60 �v: 11/22/50 Experimental Psychiatric Prograns at Hillside hospital: A Review various programs in the Department of Experimental Psychiatry have been devoted to an understanding or the node of action or psychiatric therapies through studies or brain function. The prin(ipnl techniques have been adapted tron descriptive psychiatry, nenropeychelcgy, electroencephalography, linguistics, pharaacology, and sociology. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pro-treatment peyohologic variables. is our understanding or convulsive therapy developed, a general neurophysiologicadaptive view of soaatic therapies emerged ( l ). In this view psychiatric treataents are therapeutically effective to the degree that brain tnnction in measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation, however, varies depending upon pro-treatment psycholozic and sociologic characteristics of the subject (2). Thus, the node of action is not seen as either 'orgenic’ or "psychologic' but rather as the interaction of diffuse neurophysiologic changes and adaptive mechanisms. further, while behavioral change is related to changes in brain function, and the adaptive pattern to pre-treatnent psychologic characteristics, evaluations of 'inprovenent', being special types of evaluation of change, are derivative Judgments based on start and {anily expectations and tolerances (2). The �-2... amine series "or studies of convulsive therapy. concurrent etudiee of ineulin ccna indicated that behavioral change here, too, was related to the onset and degree e: prolonged cone or repeated seizures - these being the principal aanitestatiens or prolonged neurophysiologic change in thie therapy (3,h). The node of action or the new psychotropic agente was also expressed within this hypothesis (5,6). It use suggested that these agents weuld be effective to the degree that they induced persistent changes in brain function and that the type or behavioral response would be related to the type of brain change, and to preeorhid peycholegic (personality) patterns. the present prograne in the Department are designed to study these relationships in """""'m. hypS‘iEiSii‘ﬁ; a.‘+‘¢i3§.ia'gua‘ .. .. «'WIfahlr‘ehnebtn ”1.5"; detail. GOHVVLSIvg IBERAP! PROCESS or various neaeuree of brain function, the aecuut or slow wave actiéity in the electroencephhlcgraa (7,8) and contahulatcry and denial language patterns atter anoberhital (9,10) were the sensitive nest indices (11) in convulsive therapy subjects. In one experieent, improvement ratings were correlated with the appearance of high degrees or change in these indices (7,10). These observations were thsted in a double-blind etudy in which patients referred for electrcehcck were randomly assigned te ceureee of either convulsive or subccnvuleive therapy under pentothal prenedication. High degrees of neurophyeiclcgic change were observed only in the cenvuleive group; improvement rates were significantly higher in this grog); and when snbconvulsive subjects �-3- epplicetiene, the inprevcnent rete wee sieiler tn the originel convulsive group (2). In the enbccnvnleive treeted subjects, ceneiderehle emanate er electric current pessed between the bitenperel electrodes. It sppeered that the therepeutic egent use not the totel electrical current, ger es, but en e11 or none quelity eenitested by the grend eel seizure (8,12). the significsnce cf the grend eel seizure wee exenined in studies of the inhalant ccnvnleent, hexetlnorodiethylether (Indoklon). Sieiler degrees at electrogrephic cheese, iepreveeent retes, types at hehevicrel change end cheeses in nenrepsychclegic tesk behevier were observed in the inhelent end in electricelly treated groups (13). It wee seen epperent thet net ell subjects lenitccting high degrees 0: physielegic chenge were reted es 'iepreved'. In e descriptive typelegic etndy, rive petterns were described, eepirieelly tereed 'enphcric', 'hypeeenic', 'seeetieetien', bereneidovithdreeel', end 'penic'. While the first tee of these edeptive nodes were reted es 'nuch inpreved', the letter two were seen es 'uniepreved' er 'ecrse' (It). In stndiee of psychelcgic veriebles, it wee reported thet peticnts reted es 'ench improved' end ’reccvered' frequently menitested perecnelity petterns siniler to thet described by Heinetsin end Kehn es the explicit verbel deniel personelity. In lengnege petterns, petients expressed the 'lengnege or deniel', when diffuse brein chenge wee induced, exhibiting such aspects es explicit deniel, nininisetien, displeceeent, cliches, etc. eere frequently then nniepreved subjects. Other indices releted to revereble were re-treeted by convulsive �4,ontooae were high 1 Scale ecore (15), and Rorechach deterrinante or color, absent movement and abeent torn-color (16,17). In thie population, also, favorable outcome wee aeeociated with low educational echievenent and foreign birth (18). ilfICXOLIEERGIO courovlnc one GGIVVLSIVE 2323‘?! Seeking a way to augment the degree of poetoconvnleive activity, EEG anticholinergic compound, diethasine, was given intravenously at variene stages of the convulsive therapy proceee (19). Contrary to expectations, dietharine caused an innediate and sustained decrease in EEG slowing. Patiente with denial language patterns relinquished then. Inetead of euphoria nelow wave and well being, tho on ethecte irritable, anxione and expreeeive of pre-troataent patterne. In subjects prior to convulsive or drug therapy, diethaoine induced excitement, tension, anxiety and were illusory sensations. Snbeequeht etndiee with other central anticholinergic coapounde (WIH-2299, JB-318,336, benactycinc) ehoued behavioral electrographic patterne eiailar to dicthasine. Similar deaynchrenination of poetaoonvuleive EEG cloning wee also noted with central eyapathoniaetic hallucinogene (amphetamine, neecaline, LSD-2S), been and hae reported for antihietaainoe (diphenylhydraaine). These obeervatiene led to the suggeetion that an increaee in central cholinergic activity wae a biochemical basic for the convulsive therapy proccoe (20). and PSIOROERGPIG DRUGS AND EEG this period, the node of action of newer psychotropic aroused interest. Following the concept: derived from During drnge convuleive therapy, the nenrephyeiologic changes induced by drnge �-5- tested within the sane acute experimental franework of the EEG setting. It was observed that phencthiacinee (chlcrpronazine, proaasine, triftuopronanine) induced EEG synchronisation and a shifting of the spectra: to the slow frequencies; neprebanate and barbiturates, an increased synchronization and a shift of spectrum to fast frequencies; reserpine, an increased slowing with synchrono isatien at low dosages, and desynchronizaticn at higher levels (5,6). Inipraaine induced desynchronisatien vith a shift of frequencies to the slow bands (21). Other experinental oerponnds tested included BL-H188 and phenyltolexaaine (Bristol), Deaner and its various cengeners (hiker), wr~21h9 (Wyeth) and frenqnel (Merrill). For each, no consistent electrographic pattern was recorded. It was suggested that psychepharnacclogic egents provide a means for eliciting a variety of neorophysiclogic patterns in contrast to the single pattern of induced convulsions. Furthernore, the type of neurophysiologic alteration, as reflected in EEG synchrony and frequency oatterns, was related to specified types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquillisaticn, sedation and decreasing agitation; while desynchronieation and a shift to fast frequencies was associated with excitement, illusions, and delusional ideaticn (6,20). These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychotropic agents have already been reported (6). were V �-6PSYCHOPHARHACOLOGI EVALUATION PROGRAM besed on present progree, instituted in October 1959, is these studies end is designed to ensver the following questions: Is there e reletion between eeesureble elteretien in brsin function end behevierel chenge with psychotropic drugs on chronic edninistretion? Are there pre-treetnent clusters of psychietric, physiologic end psychologic veriehles releted to the type of behevierel edsptetien? And, ere such clusters related to the type end degree of physiologic ohenge?Method: is en initiel epproxinetion, e double-blind, fixed dosege rendon eseignnent drug study wes underteken. Besed on our clinicel experiences with verious psychotropic coeponnds tree 195k to 1959, three clessss were selected on the besis of their patterns of EEG response.' the egents selected were those with either predoeinent desynohronising petterns, synchronising end slowing, or mini-e1 or no effect. Petients referred for drug therepy, etter nedicel exeeination, end etter ell other eedicetions heve been discontinued ere rendonly essigned to e conpennd in one of these three cleeses. Petients ere predominently middle eless, urhen, with high eduoetionel etteinnent. Hillside Hospitel is e nonnprﬂtit, philenthropie supported psychietric institution, ednitting volantery petients for extensive psychetherepentic treatment. The noen duration or stey for petients is seven months. Convulsive end psychotropic drug therepies ere prescribed by stetf psychietrists The �.7. referral to the Departaent. All treatment is administered by Departaental start, so that the experimental variables of drug dosage, route of adainistration, assignment to groups, 232' are on readily controlled. All patients in the hospital are available for study. After a testing period, all patients receive he so of liquid aediestion daily tron individually labelled bottles. Dosages are increased in fixed weekly steps until a aaxiaua at h weeks. After two weeks on maxiaua dosage, ro~testing oeeurs. Io date, 1&0 subjects have been referred, and 110 have eonpletod the study period. Preliainary analyses of the data are new in progress. Behavioral Change: In a survey of the behavioral adaptations of patients reeeiving phenothiasines or iaipraaine during 1958-59, various clusters of behaviors were developed. The typologies were based on the treataent response and on pre—treatnent psychiatric profiles. In the present study, the typologies are being tested, and various measures of behavioral change are being studied. These include therapist referral questionnaires and six week evaluations, therapist and patient Clyde Hood Scales; Lorr Scale evaluations in interview by two research psychiatrists, and Lorr Ward Scales; and patient sel£~ratings including the Johns Hopkins syaptoa check list and the Chicago Attitude Scales. lenrogszehelegx: Psycholozie tasks have been viewed both as ehanze variables and predictive variables. In convulsive therapy, changes in aenory tasks (22), tactile perception (23,2h), WeehslerBollevne (13), CF! (13), figureagronnd tasks (25): and taehistoseopie recognition of figures (26) were related to the degree or induced 0% �.8neurophyeiolegic change. for each task, the degree of decrement in tank portornance was found to be positively correlated with the enount of EEG cloning. Following treatnent completion, with the return or phyeiologic indicee to pre-treatnent levelo, performance in these paychologic tacks aloe returned to pro-treatment levels, or higher - e hetternent of performance ascribed to prectice effect. Denial ecoree on interview (27), Rorschach determinante (16,17), I Scale coerce (15,17), language patterne after anoberhital (28), auditory teedheck end perception of the vienal upright have been viewed as predictive indicee of the behavioral chengee following 36!. Thole veriene tasks are now being eeeeeeed with psychotropic egente, for their capacity to chenge with verione agents, or their capacity to predict change. Electroencephelogrephze In the convnleive therepy etndiee, the degree of RIG cloning nae neaenred by counting the consecutive waves in selected eenplee (7). When the more subtle changes or drug effect- are etndied, it ie neoeeeary to apply leee tedious techniques. Electronic frequency enelyeie wee introduced in inguet 1959. By neaenrenent of the pen deflection for vaﬁione frequenciea from 3 to 33 ope in ten eecond epoche, repid eeeenreeent of apparently enall chengee in total activity and frequency epectra are new obtained and epplied. Other phyeiologic variablee etndied in thie progren include the reepenee er era to intravenous ohlorprenaeine; bleed preeeure reeponee to neoholyl; the EKG, radioactive iodine npteke, end analyeee o: varioue blood and urine elenente. E 5 �PSIGROLIHGBISIIGS series of studies in the Departnent have been devoted to ternal lenguege patterns. Following the etudies of syntactic lenguage petterns (28) in convuleive therepy, other espects of lenguage were studied for their relation es indicee or chenge in interpersonal behavior. darts; otter considerable exploretion with verious linguistic neesures, nuggested thet typeutoken-retioe (2!!) of consecutive senplos or dyadic speech nay be e enetnl index (29,30). While 213 hed previously been applied to written texts or the language senples of indiriduels, Jeffe indicated that the two pereon eonnunicetion (dyed) wee e acre significent index of the etete of the interaction then enelysee or concrete eenples of the participants. Ayplying this technique to convulsive therapy petionte, changes in 21! neon end etenderd deviations were releted both to the degree of induced ERG slow ueve ectivity end to syntactic lenguege petterne obteined in independent structured interviews. Speech heeene more repetitive (lowered nean 113) and nkre verieble in consecutive eenplee (increesed etenderd devistion)§(31). In Another interviews hetero end otter the intrevenous edeinistretion or centrelly ective egente, einiler chengee were observed. Agente with e predominent synchronization pettern on the EEG exhibited e decreese in mean or: and increase in standard deviation of scores, while deeynchronieing conpounde elicited greater variability in speech petterne (increase in TTR neon) end decreeee in veriehility of consecutive eoorss (decreeee in etenderd devietion) (32). Other lengnege neeeures studied included dietrese~relie£ quotients, self—reference, and elteretion in tense end person. �«10- It was luggontod that then. psycholingukatic nonsuroa tr. techniques for the opcrational annlyaoa or physidlagic and psychologic ctr-eta of psychopharuteologic ugcnts (32). potent �.11 .3001030910 STUDIES In the course or these psychiatric programs, considerable interest wee engendered in the tenily organization to which patients returning. Also, the general problem of the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to the referral patterns led to a eeriee of pepnletion studies. In one study (33), education, ego, place or birth and score on the California I scale were significantly related to the type or therapy received and the utilization of addonotive hospital services; Thus, patients who were older, poorly educated, had higher P scores and were foreignhorn, particularly Eastern Europe, were most likely to he referred for electroshock. These relationships were present independent of diagnoses. Within the group o: electroshock patients, the tire for referral for BC! was also related to these factors; In a second study (18), duration of hospitalization, discharge evaluation and diagnoses were related to the eaae social factors. For example, patients hospitalized for the shortest period were oldeet, had the least education, were most likely to have been foreign» born and had the higher 1 Scale scores. Younger, native-born, more educated, lower 1 Scale score patients were hospitalized the longest. these relationships held true within treatment type and within diagnostic close. On discharge, older patients had the nest favorable ratings. In 30?, patients rated as recovered or much improved had the highest 1 scores, least education and were most likely to he foresighorn. In another study or patient refusal of nor, similar relationships knee observed (3h). were �Theee reletionehipe ere new under etudy in the Out-Petient Depertnent, end in e tri—hoepitel conperetive study. In the letter etudy, the population: or three hoepitele with preveiling differing cliente, in which e11 therepiee ere equally eveileble to e11 petiente, - Kenninger Peundetion Hoepitel (upper-ollee, Proteetent), Hheeeehueette lentel ﬂeelth Center (leverceleee, Getholio) end Hilleide noepitel (niddle-eleee, Jewieh) ere being eeeeeeed. It hee been postulated that theee reletionehipe reflect the influence of eociel beckgrouud on peychologicel processes, such ee hebituel petterne of eennunieetien and nodes of expreeeion. The contribution of these factors to the pattern or mental illneee, end the petient-therepiet interaction ere under etudy. �-13SEHMAB! . on. Dopartnontal programs are a clustor of intsrrslatsd studios toonssod about common population sonplos. Within Hillside Hospital, rosoaroh laboratories in Bioohonistry, and in Hsdieino are aotiro; and other laboratorios in psychodynanic psychiatry aro boing dovolopod. In this Dopartaont, various disciplinos aro participants,rsprssonting a gradual growth of six ysars. Furthsr growth and tho dirsotions o: ensuing studios sro dopondsnt on tho results of tho studios doscribod bars; as wall as tho growing institutional avaronsss that roooaroh is an intogral part or the hospital's operation and budgots - as such as troatnont and staff training. �”lh‘ Reterenaea Authors at the {alleving references include the following staff nenbere: Hex Pink, Hex Pollack, Robert L. Kuhn, Joseph Jette, xertin 3. Green, Eric Kerp, Hyman Karin, Doneld F. Klein, George Ireuthener, Arnold G. Blnnberg, Ittheniel S. siegel, Abrehen Keplen end Henry 1. J. Hillside Reap. 113, 19583 3. J. lééa 18h6, 1958) A Go., 325, 19593 J. Letkewite. 2. Die. Harv. 8:1. 12: Eilleide Heepitel‘gt 13h, 1955) h. J.A.H.A. Q} 197, 19571 5. Pszehozhernecolegz Frontiers, Little, Brown 6. Heuregazehozherneeologz, Eleerier, hhl, 1960; 7. A.H.A. Arch. Neural. Psychiet. 1Q: 516, 19573 8. Die. Kerr. 5:3. 12: 227,19583 9. J. Hillside Heep. g. 3, 1955; 10. Arch. lenrol & Peychiet. 1g. 23, 1956. 11. First Int'l can . leurol. Sc1., Pergenon, 613, 1959: 12. Jeur. Herr. Kent. Die. $29: 117. 19603 13. A.H.A. Arch. Gen.Paychiet. (in press); lh. Unpublished nenneerﬁﬁtg 13. Jenr. Herr. & ' Bent. Die. ggg: 187, 1960; 16. J. leurepeyehiet. 1: 2&2, 19603 1?. Jour. lerv. Kent. Die. ggg. 2h3, 19593 18. A.H.A. Arch. Gen. Psychiet. 1; S65, 1959: 19. A.H.A. Arch. laurel. & Peychiet. ﬁg: 20. EEG Clin. Neurophyeiel. 15¢ 359, 1960. 380, 19583 21. Gened. Psych. Aeeee. J. A: 1668, 19591 22. Cent. Neural. 23. J. Hillside Hoep.‘§: 2&1, 1957; 1g: 88, 19563 2k. Am. J. Psychol. 13: 38h, 19593 25. A.H.A. Arch. Neural g: 5&7, 19601 26. Free. 1? Int. Pezehel., lerth-Hellend, 238, 1959; 1%. J. Heuropeyohiet. 1} hS. 19593 28. Pezehezethelegz of Guaranieetien, Grnne & Stretton, 126, 19583 29. J. Hillside Heep. g; 207, 1957; 30. Psyehiet. 3;. 2&9, 1958. Gong. �.1531. Jour. lorv. Hunt. D13. 120: 235, 19603 Pazchiutric Drug Thorazz, 0.6. that‘s, 29, 19603 3b. Unpublished Hannueript. Boap. g: 216, 195?) 32. ngnnieu at 33. J. Hillsid- �lap-rtnaltal Fuyuhtutrac 2701:... at 3:11:14. luapitcls A title: In: fink, Fran tau ntpnrtuaut ”’F‘ul. 91“ “kl. 7!: U I, 1;!50 K.B. a: sxpurtnuutnl Psychiatry, 1111.14. 10.1.; '0’. �/ [, ‘e VI //y 11/22/60 layoviunntal ruyuhtutrto Procrnnn u‘ [1113140 loapltnlu A Icvtou It. Virtoun program: 1: an. nupartnant of xxpcrtnantal Payoh‘airy 531‘ but: dcvutod to an underttnndtn: of tho sad. at ﬂl‘itl at payuh1n$r1¢ thnruptta through studina at brtiu tunetiun. rho principal inshnign¢¢ invo boon adapted {ran doneriptiv. plyuilutry.vnanrapiyuhology, oloetronnotphnlocrnphy. lingututtcl, phuruaaolﬂtyg and socinlocy. 1n chungoa brats convululvu thcrtpy, at initial attain: functian nova round ta rtlatc both to ovuluution- o: inpruvaucnt In ptywholaciéﬁznrinblca. Al 0‘? undarnttudtnu and to pru~tr¢3tncut or eonvulaivw thcrupy dovelupad, a genera: nouroyhynialozic1 ( usergnd slanttw ). In this via: thorapxos a! vita udtpttvc uiif‘i‘rxplnttonlly thy dogtoo to ottactivo troutueutn payihtntrtu this brain function 13 uncuurahly nl‘nrnd. will. Chung. in brain function 1- noatnsary tar bchuvtorul ch:u¢o, the twp. or nd:p$¢tton, paywhologiédnna hurtvnr, vnrtoo «avoiding upon pro-‘rontncnt Itoiuloxliﬂcharactnrtutio: 02 sh. cuhdoot (2). Thus, tho use. or uotlcn 1. not soon as ulthar 'oralnle' or *poynhologic' but rathcr and chaugua of nourophyaiologio distant tan lattruaticn a. adnptivo 3008331.... turthcr, uh$lo bohtvtirtl chins. 1a rnluted to ohnngns in brain ttnottaa,‘nnd the nanptivt patio!» t0 prt-triatuont psychologte thirtetcricttot, 07:1nat10nu a: ’1Iprovcunat', but»: npuottl $79.! or uvlzuntiou or chnnxo, arc atrtvutivs stagnant. hated an :tatt and £1.11: oxpootutions and inlcrtaonu (2). �n2- ?hiu hypothuain Ill dovulopca and nuntstncd an a £021.! a! ntuditl qt cunvulstvn thnrnpy. ctncurrcnt aﬁudios a: tuuulia can. tnd1¢utod taut hohsvtor¢1 chant. horn. too, wua.r¢1ntod to tn. lutot ind accrue or piniongut can: a: ropaatod stature. - that. b.1uc tho prinaxpul manifestations at proloncod nonrcrhysioloctcaﬂ an that»: (ink). chm: in It: made if aoStoa of tho new pcyahotropio «goat; vac also nithta thin hypothesis (5,6). It nan ouggontod that ﬁhouo tgan%a would ho affectivc to tho 403:0. that ghoy induced paratatant ch:ugau 1a brgtn fanatian and that the typo at bchaviur;l rampaano Inuld to rolttud to tho typo or brain ohaagc, and to prcaorbtd payohologit (paruunultﬁr) patturnt. Tho prisont pruxruan in tin Btpartltat ‘20 4331¢u§d to study th.ue volitianuhipt in unprosuud _d¢tti1. E E III 13‘ £88 a: turtou: nanutrnn at brain tunusiaa, thc alount a: slaw var. atttvity ta ta. cinctrcunoupphagzrin (1,8) tad contcbulutary and 60.1.1 Inasmuch pattora: nttur unobarbital (9.10) not. thu unit uoaca‘:vc that... (11) 1a .0I7‘101VD thorny: subjects. In on. naportnont, tapruvclnnt ratings wire ctrruxttod with the upponrnacc .1 itch dgcrooa or change in thou. inexact (7.10). dtnbin-bltnd 1a 1n abnorvntiana tkntot a a‘udy ”‘2. it... Itiuh patiohta rotorrod for clootrguhock var. rand-n1: nustgncd to court‘s o: otthor ocnvulutvu 0r aubconvulttvo therapy under anurophytlologiénchaagt pqntothnl prcnodtonttal. nigh dugrtul or v!ra obuarvod only in tun convulitvn grnupg inprcvon-nt rutct varnixuitiouutly higher in this ﬁriﬁtj and vhaa subconvuluiv: nubjoeto �U). * v.20 ru-trontad by couVIInivo upyliuutiona, ﬁlo tuprovcnnnt rut. um: lintzsr to the orictual convtlaivt group (2). In the anboouvulaivo treated Inhannta, uuuutdar;b1¢ Quaint. or altntria «arrout yauaca hotuocu tho hitanporul cluotrodoc. It Ipptﬂrtd that the thorupautic taunt wan not tho total cloatrle.1 currunt, aggugg, but an :11 or non. quality nan££.ctnd by thc grand In: lotuuru (8,12). Th. algnittenuao at ﬁhc grand In! I'liir. van~cxan1uod in etudiat of tho inhalant aouvnlsnnt, insurlugrodtothylcth¢r (13692105). ﬁinilur 4.3!... of alsetro~ graphic ehsngc, ﬁngvovwnaut tutti, typos or bghgviortl ahtugo and changes In nourvysyuholoxtiﬂgatk bahavivr nﬁro observcd in tic tnhallnt tn ulcatrieally treatud groups (13). It at. anon npyaroat $hat act :11 tubjaats Ianiroatins high tugraou or physiologxc chnngo warn rttod ts '1npravod'. Ia a dcsaripttva typolngtn study, :31. ptttarna wire doacrihad, impartcnlly turned 'ouphnrlu', 'hypounnio', 'sonlttnatiuu', $0!!ﬂ.1£¢'1‘hdtlﬂl1'. and 'punlo‘. ﬁhtlo the ttrat tun of than. udnpt11¢ .04.: nor: rttud I. 'nugh taprovod', ¢ho latter two were noun as 'Iuinprovvd' or 'uoraa' (1%). In station a: ysyuh01031£#VIrinb1on, it run vaportod that pctxnnta rntcd as 'I‘ch improvud* and 'reaovurad' frequently ltnituntcd puruonnltky puttcrut liuillr ta that diaeribod by ﬁctuutnin and Ink: is ﬁhu laplacit vorbal 4.31.1 pornonality. 'In 1!:zunxo ynﬁtoras, patiantn capraastd thu 'lnazuugu a: doninl', than ditthln brain ohnagc In: Indueca, txhiblttus anon napocﬁa an txpltctt dintsl, Izaiuisataun, ditylne¢noat, cliches, g§g&_uorc traqu.ntly thug untuwravcd cubaoctu. Other 134130: taint-d to tnvorsblo and �.3. hash I 5341. acct. (15), and Roruuhaeh dotarnintnts «Olav, nbsaut novunaat and nbaont t-rn-calor (16,17). In thia popu1&tttn, also, :avurablo outatuu at. taaoctntod with 10v uduaattgnnl uahxuvannnt tad {truism birth (18). tutu... it?! at sitting a way to nuancat tun digit. of pentatonvulitvu :39 $1.! utvu nitzvity, ta anttahozanorciu coupltnd, «totEutzno, was giro: tutrnvonoualy at various :tngos or tht ccavulutvc thor‘py - proutll (19). doa$r¢ry to oxyaetntiaal, ditthnlinc eaunod In lunadiatd and «attained ¢aer¢aan in EEG cloning. Patiunta with donstl lagging. putt'ruu rulaaqntshad than. Inttcud or atphorin aha wall hasng, thc lubjoota vat. irritqblc, anxious and prrO181V. or pramtrnatnnnt patterns. In aubaastv prior ta eonvulaiva a: drug thnrapy, diothantnu andueod uxaitanont, tan-ion, anxiety and illusory nontatsunc. ﬁuhaoqncht ntndica with 9th.: «antral antioholinurutc ae-paunda (VII-8299. 33-318,336g hanaotyttno) aboucd behavioral sad cloctrogruvhlc pattarau elitist to daoth‘xino. atnilnr datynahrontnnttau o: postuconvulaivt 330 niacin; was ‘10. notod with «Mt-'11 amnion-tutu: hunuinnuo (nphounno, «suntan, nan-as). Ind ht: been rcpur‘od for tatihiatantnoa (diphunyihylrauinc). that. thiarvaticnu 10d $a tut mugxultion thtt «a incrtano 1n coutrnl ottltnargia activiiy VQI a btoahouscal haul: for thy convulaivc ttorapr greats: (26). rsmgonauo nma an no During this parted, tho mod. 0: sctlaa cf ucv¢r psychotrepic drug. trout-d intnrnst. rollcving tho caaouptc doravca tron ' J2 otavulntvu ‘harupr, thu nc‘rophgwiologio outage: inanood by drug. �.5... f tutti! I1th1n tun 3.x. aautc oxpcrinautu1 trunnuork at th. E39 usttinx. It It: thaurvod thtt phonothitslnos (ohlorpronasiac, any. prangnlnc, tritanaprolaaxna) :nduood axe ayauhrontauttou and a oh£tt1ng of tho upcetrun to tho .10! frequaaotts; Improbaghtc cad barbiturates, an incrouuud IyuchrnaxsatSOB and a shirt 0: spoctrnn to inst (recitation; roanrpiuo, an Inorouood ulcvtns with Iyaohrouw inattua at . dying... and douynchronisatioa at night! 10'010 (5,6). 2.133.313. tainted ﬁctynohrtnisnttua with a ah1:% ct :rcquauaicu fa the a!” but: (21). ”‘ng Gina: expirtnnatal annpounda tul‘cd inaludod nz~uxaa and phtnyaioltlslino (ariatol), nectar tad its variant aoneaaors (33:99), wtatlh9 (37"h) and trﬁnquol (lorrill). tor cash, an I0|tiutcut olnctrucraphia putters it. recordta. psyuhoyhnrtnollaciéwazoats wgu that staccatod It pruvtd. u nearaphyuiolotiéﬂpat§cran u for of 1a nasal eliciting varicty ctutraat t¢ tho sags}: psttura or induced scavalnionu. furthtrnouroyhyntolugidJtlttrttion, sh. a! type .02., I: rotlon$ad in as: aynohrcny and IFC‘ICRGI ynttcrna, nun rolnt.‘ to apoottiud typo: a: behavioral stuptntsdn. InorOtttuc nae aynchrony tad a shirt GO aluu fvnqncactou aura nauoatttud with trangutlltzn‘tua, notation uni docrnﬁatng agitatious stilt angynohraatua£tua and a shirt tn tu't tragucncloa It: antacxntta with excitouaut, tlluuionu. tad dolnntcntl ilcatton (6.20). than: aha-trutionu are conclt‘aut with hypothaloa o: Hitler. 2h. advantagon at are tuchntquco tn: the 300.7 or not payuhntropzc ugcntu haw. nlroady b¢0u reportcd (6). low �2h. presuut progrnn, instttnﬁod in Outabcr 1959. 1a banal an sh... attitua and in 6.113304 £0 .3380? $8. I’llavinc quantlultu In £3.90 t rolutlon hotutcn Innuurublo altovtttua in 53:13 tunc‘ian and bohnvtoral «hung. with payuho- airbus. unnaatatrttian? 120 that. proeﬁrtntnoatfqlua§oru gt paynhxatrao, ptyctulcciéinnd ptyuhmlc¢1£&variahzoa rolgtud to in. tropic drugs an typa 0: hohnviornl adiptntttn? And, art such cluntora rolntod to the typo and 403200 at phyutologle ohuuxo?# ‘gggaggs AI ua.1n1t1n1 ayproxinattcn, a doublnuhlind, sized Gonna. random Isntgnncnt drug study clinical In. undertnktn. luccd on our varitu' piyuhctropto coup-sud; tron 195k to 1959, thrco clan... unto 0.100%04 an tho 5‘31! or that: patﬁnrun or 310 ro‘ponao. tho slant. scloutnd wit. that. rich oxpcrzoncoa with caﬁhcr proloninan‘ dunynuhrouiutax pattcrnu, Irhahrontutng and nlyvinc, or nintnal or no errant. Pattoutu r-rorrud in: drug therapy, IItOf nudist: tun-auntaon. and art-r :11 other nodicntiouu hay. boon diucoattuucd are randomly usutgacd to ‘ compound.1n an. or that. ‘hrio «lacs... Pa‘icnto are pvodonlnnuﬁly Ilddlo eluot, urban, utﬁh high oiiontaonnl :t‘linlont. 1111.14. 80-pita1 1a a nou-pritit, philanthtopie supported psychiatric tnutttutton, .duitttng voluntary pattoutn {or txtonntvn puyuhothurcpoutie troitntut. fin loan duration or its: fer patients in novon months. convuiaivc and puychotropao drug thnrnpics It. pronortbud by star: payuhxntriota �.1. A11 thc trlatnnut in aduluintorad by to naparﬁutu‘. rottrrll Da’artniatul stuff, no that the axpcraanutal vartthlta or drag daoaco, rant. 0! adutaictrnttua, aaotguunut to groupu, 333, &r¢ roadtly controllod. 111 patiantu in thc hoapttal arc «v.113blu for titty. Attor‘a tutti»: ptrtod, 111 puticnt: rocuivc he so or liquid ‘nndtogttoa daily tron 1nd:vtd:ally inhallcd bettlco. Dos;¢o: at: incrcnscd in ttxnd tOIIII atop: tutti a u.x:uun at h ucnku. Artur tun wank: on nixtnau 4.111., ro—tnatlnx ¢o¢ura. to dn‘o, 1&0 vuhjaoto but. hon: rtturtod, and 110 have outplatod tn. study period. Proltniunry analyst: of tho data At. an: in on prozroau. Ichuvigral GhlI‘Oi In a tutti: u: tho bnhnviorul adnptnstonu of pt‘tuuta rcaoiviag pitucthiasiutl or inipruutua during 1958-59, variauc clustorn at bchnvtora var. duvolopad. 1h. typalocton wore but-d on tho trontatut rcapiaat and on pr0~trlntauut ptyuh1&tr1c protilus. In $3. pruncut sitar, tho typoloxint at. being tested, and variant scalarot at behavtoral ahtug. at. being atudtod. It... inaluac thorlyitt ritorrnl quortiouuairoc I1: cvaluntiono) therapiat tad puts-at Glyn. Road s¢nlang burr aoglu .valuntiona 1n int¢rviov by two rnutnrch psychiatrtnta. and Lorr Hard Scale.) and puttout unit—ratings 15013413: ‘ho Johan toutinl symptul about lint and the stints. Attstnda 50:10:. boon both vtcvod I‘Vl tank. as Psycholnglc lutrggangglogzg thing: vsrtnhlou sud pradlcttvo variablou. In convulsivo thorgpy, chingo¢ in Inner: tanks (22), tactile paraoption (23,2h), wcohnlcro Bolltvu‘ (13). err (13). flatro‘3rocnd talk. (25). ‘nd tachlntQUQOptu recognition a! figure: (26) war. relatcd to thy Court. or induocd and ﬂ‘Ok am �neurophyutczogaggihnngu. In: 9.03 tack, tn. dcxroo at docruuont tn rouui ta b. poatttvny ocrr'lutod with the ‘llk vortoruuncn nus assist a! :36 closing. lollewaac trout-oat aonalation, with the rotur: a: phybitloxialiaaauca t. prootroatnnnt lovnln, performing. payahologidﬁkasku in than: also raturnud to pro-trontnont lcvuln, or higher ~ a buttarntnt 02 purrornnnco ascribed to practi¢o afloat. Donia: start. on interviﬁw (27), aoroohach dotorl1nuntn (16,17), r 8.11. Idﬂvit (15,17), ltngunzu pntﬁarns attnr tnobnrbttal (28), andatary toodbuck and porcuption if the 11:ua1 Iyrscht have bcan v10v0d a: prcdlattvu attains at tho hchavioral outages following 362. fhauo vurinuo tank. are at: being Isa-anon with paychctropio :.£?:1.1p agon$s, alpncxty capacity to prudiot chaago. t. cling. wl‘h vurtona anout319igfﬁhotr §;I¢§ronniqggg;o‘gughzg In tn. convulttvn therapy ntndlnt. the intro. of as» slaving was latsurod by counting tho oonncauttv. wave- 1» lolcotad :unpi:a (7). lab.» ta. not. nubtlchohuazoo at uttoetl arc ltudiod, it in uooclaury to gyply lula'ttdionn toohntquoa. Iltctroulc Iroqutncy nnnlrlia wt: introduacd 1h Angint 1959. 8y nauaurounat 0: th. pun doticetion for vaﬁﬂoal rrnquoneius Iran 3 ta 33 8?! 1n ttn ataoaa epochs, rapid nanuurcnnat o: upptrintly nlnll august. in total activity nnd troguoncy aptctrl arc new obtatnnd drug tad applied. ethn- play-1.1.316" in thin program include tha rtlpautn I: :36 to iatrnvontua chlorpronnsinzj blood protauro reapnunu to the nut, pullout!" 1041” mute, and a: turtouv blo.d and urin. elegantl. man" “at“ ”any” “an“ w: 9! 115‘ 8 �tho atadlco in napnrtuont hurt beta dovctoa .: to torn;1 1.33133: puﬁtcruu. iylzoving it. stutits ct syntactic lung‘tgu pattern: (:8) tn asavulitvo ihsrapy, uﬁhor capogts at 11:51:30 vuru Ituaxod for tkcir r01:$£on an iudSQIa of change in intovpornonnl bohtvtor. .Jattc, urtnr oonoiiertblc omnlorutian with Various linguistic consecutivn or that suggcitaa typo~tokoa~rtttol (I?!) lilltrit, ho t 1nd»: (19.30). man. «mm: at and“ apneh it! hid prtvionoly §ncn npplicd tn urittua $311: or en. 1:ngungo nanplou of indivﬁdulil, 3.1!. indicated that the two pcrnou cou~ nuatcttton (47") was 1 nor. liznitignnt indox at tho itttn at tho interacting than auulylou or i¢paratu snnpxoa of tho ptrtitiplutl. tpplying than toohutque ﬁt convulltvu shtrnyy patients. chanson 13‘!!! noun and atundnrd «aviation. var. r01¢tnd both to in. deavco or induced 3:3 ulot wire aat1viti and to uyutnet1c lunxttxo pattern. ob$ttnca 1n indopondtut atruatnral interviouu. apauah 5.01:. no»: rupo‘tttvc (lowered noun If!) and nor. vartnhlo in coautcutivu nunplon (in-ruaI04 utnndurd d¢v1at10n) (31). In intarvtawl but-r. and alter tho mutrtvvaonu aduanlatrtttoa at ecutrally activa astutu, 31:11:: Ihlngil Int. obnurvod. taint. with n yrcdouinant lynchruatxgtion pnttorn on tn. £86 oxhibitcd a 4.120ntt in net: 191 cud inﬂfilti tn itandnrd duvxatioa o: necros, viii. dotynchrouising ealputuda 01101106 groatcr variability in tyccch pattcrus (1:090... in RI! Inna) tad dtcrunan in v.r1ub111%y of coauoeutiva scorn. (duorouun 1n ntandnrd deviatian) (32). 6th.: languaga notnnrnl atudiod includod diatroccurolior quttt¢ata, uclt-rutcruncc, and alttrntion 1n tunnu and paracn. Antﬁhar 30:10. m tutu �.19. nu: sagsoaﬁcd that ﬁt... yuywhcltnxutstta Inaiurcs tgo pa‘cat incantqutl for sh: operational unnlytns o: phyaiologig%und yi:¢h¢1¢¢1€?£ttactn a: ycychopharanaolugse taunt: (32). It �aggggaggzc $233133 It ta. court. at ‘ thou. plyuhta%r1e protraaa, comaidartblo InﬁnrOtt Ian unguudarcd in at. tantly organisation to which pttttnto turn rcturntnc. Also, its ginornl problem at tho ralntiou or stein! M chase. and a: pnychutric treat-out, and the Ipttifia prathn a! the rnlutiau of thtli factor. in tht rarogrul puttarna lad to a aortic at papulatian studsus. In on: study (33). ﬁduaattua. ﬂgi, plus: ct birth cud score on tho Galltarnia r Iallc wort ticnttioaatly ralctad to the may. at therapy rocoivod und the utilatniton at adainottva hotpttnl aortic... rhui, pgttont; aha var. older, pearl! uduantcd, had hishar I neuron And aura tarnishhnru, ptrtiuularlyranstnrn invent. wart neat ltkuly to be 90:0rfﬂd tar ¢ls¢trouhooh. that. rclationahlpl worn proaont indopiadont or atlxntnoa. within tic sunny 3: cluo‘ronhack patiuntu, $3. tins for rotttrnl for 3a: 3:: ulna rolntnd to ﬁhoau factora. In t nocand ntud: (18), dnru‘ton a! harpitnliantion, discharge uvnluattan and asucnoun: vova rolniod ta tho Ian. social flotara. fur uxauplo, patient: harpitlltuna for it. uhortcnt ported EOE. oldest, had in. lcaaﬁ education, v¢ro punt llkcly ta hnvc baou farcicaioru and had the hiahﬁr t ﬁnal. user‘s. Younger, uttivowborn, not. nénuatod, lava: ! 89.10 a¢oro yuttonta worn hospit.11sod thu taunt-t. I)... rnlntinanhipl htld trnc within troutlant typt and within diagnoatic 0131!. on dinohargt, 014.: patients had tan unit tavorablc ratings. In :61, patients rated as renovated or sunk improvod had tho highoat r 3.0!... lasat aduantion and war. moat 113.1: ta b. rurattg* born. In anoﬁhcr study or p;t1cat textual a: new, 01.11;: rolattun~ ships tutu obsorvad (3h). an». nun: �.12“ ‘ thc under antarctiout in study not volatiiauh1pa If. It... Dtpnrtutnt, and in I triuhtnpttnl coupura‘tvo study. In tho 133%.: utuﬂy, tho pcpn1n%1ona at ﬁbre. haupttclu uttk provatltac dittcvtng $0 .11 pttaoutt, :11 wits! aquully in thoruptcs arc I'lillhlt cltuutu, - Ionian:- muauw Iowan (mu-«nu, run-mu, hunk» nottn lontil ﬂunl‘h cantor (lowiroclnns, ctthnlta) ‘34 ltllllio loaptt&1 (naddzcvcliuu, icwioh) It. ﬁning tanouacd. It ha. bcon thy rotlooﬁ antlntnco .2 social rolutiandhtpt it... ha011ruund on payth.lo¢1all prrcanuou, such ll habitual pnttnraa or contagiouttun and gods: of «sproutioa. {ha cantrthlﬁton 0! than. tnotara to tho patﬁorn o: ncaﬁal 111303., and thy ptticIt-thnrtpiot intoruottou are undo: atnﬁy. postultttd that �.13- may; it. nipnr$uoat:1 99032.3: are a oluutar a! interrolntod studios tocuunod about cannon pnpulntauu annplcu. within ltllltdo Iblpttnl, restart! ltboratoricu 1a niaehauiltry, and in nadtctno if. aattVQ; and 0th.: inbnrntorina 1a puyuhodyulnto puynhtntry Ar.hmaac aqvolcpud. In tat; Dtpnrtnont, various diacipllnoo tr. vartttayaats,roprtuoatzn: a gradual cravth a: :1: 33.3.. tartan: grcuth and t8. ﬂirtation. a: tanning 31341.. tr. dapoudont .a tau rostlta at tho attain. dotcrahtﬁ hart; no will a: th§ (rowing £Il$1titt¢ll1.nilrin031 that ruaonrch in an tutogral part of thy httpitul't opcrnttcu and budgu‘n . II that ll trcntnnat and otutt training. �~13:- kahuna” fauna: uni-cue“ that“ m £0.11.ng rut: hum" m rink, ﬂu hunk. “but 1.. tum, Jinnah um, Int-u I. Erna, 3”,. Km, In" mu, ma: 3'. £1.13. Guru Imam, ”and a. auburn. “that“ 8. 33.301, abun- Inn: at! nary J. Mint“... Aim" at tho J. “11.1“ lap. 93 197, 1957; .3. J. mun. Hospital at 1958; 2. Ms. 3.. .113. In". 81.. 3:2: h. 4.1.11.1. 1.1m... Iron 131;. 1955; h 5. ms h “mule 1min”, a c... .325. 1339; 6. ¢h02m00§2u. naval". Mal, 19603 7. Add. not. loan)... a 1-31.31». ﬂ: $16, 1957: 0. Mn. In". an. '33: ”7.19563 9. J. i111.“- llup. g: 3, 1955: 19. Arab. 18116, 1958; ”my; 1.956. :3, rennin. t ﬁt 11. nm In“). 3” In“ 1. Sci. , Penman, 613. u. “an Em. that. 31!. 122' 117. 19691 13. 1.3.1:. Int-.1 Mm“. 1959) arch. Gun. pan); ﬁnalist“ autumn 15. Jar. low. but. ml. ms 15?, 1960: 16. a. lunpuehut. 3,: an, 1960; 1?. am. it". lat. M... m; 11:). 1959: 18. Mid. Arch. on. ”want. .13 555. 1959; 19. Add. Auk. Int-1. I: "youth £9: no. 1958; 21. g: (in 1h. can“. 8!, 1,563. usual. can Emlyn“. 9,3: 359. uni. Anna. 3. A: 1668, 1959: to. no 13. 3. Hanna. luv. g: 1950. 2:. 21:1, 1957: car. lmol. 2h. a. J. luau: g: Shh 1m; 8&. 17.19%: Gong. 238, 1959] 901350;” law-mama, m, 335. 4. 28. 19593 lmopoychiu. u. chhgzﬂhclaa at y «1-. 35.11.14. Buy. 5 1953; 126, Gun 29. Mutton, cwuuia, g: 207. 19573 30. urchin. 3.2») 2139, 1958. 1?} 381:. 19593 25. MILL. Arch. �. «150 ‘1-.. O 3'1. :"9: ‘.".¢ "”‘o ﬁt‘t > ‘ ‘ hip. g: 216, 195'!) g 31:. w! ”5’ 1,69} M', uranium-a Mnuonph 3.6; 2’. 196°, 3!. W 33. ‘¢ 31.11.14. �Experimental Psychiatric Programs at Hillside Hospital: A Max Review Fink, MnD. the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, L.I., N.Y. From VI: 1/61 �Experimental Psychiatric Programs at Hillside Hospital A Review various programs in the Department of EXperimental Psychiatry have been devoted to an understanding of the mode of action of psychiatric therapies through studies of brain function. The principal techniques have been adapted from descriptive psychiatry, neuropsychology, electroencephalography, linguistics, The pharmacology, and sociology. In initial studies of convulsive therapy, changes in brain function were found to relate both to evaluations of improvement and to pre~treatment psychological variables. As our understanding of convulsive therapy developed, a general neurophysiologicadaptive view of somatic therapies emerged (1). In this view psychiatric treatments are seen as therapeutically effective to the degree that brain function is measurably altered. While change in brain function is necessary for behavioral change, the type of adaptation, however, varies depending upon pre—treatment psychological and sociological characteristics of the subject (2). Thus, the mode of action is not seen as either "organic" or "psychologic" but rather as the interaction of diffuse neurophysiologic changes and adaptive mechanisms. Further, while behavioral change is related to changes in brain function, and the adaptive pattern to pre-treatment psychologic characteristics, evaluations of 'improvement’, being special types of evaluation of change, are derivative Judgements based on staff and family expectations and tolerances (2). �-2This hypothesis was developed and sustained in a series of studies of convulsive therapy. Concurrent studies of insulin coma indicated that behavioral change here, too, was related to the onset and degree of prolonged coma or repeated seizures - these being the principal manifestations of prolonged neurophysiological change in this therapy (3,h). The mode of action of the new psychotropic agents was also eXpressed within this hypothesis (5,6). It was suggested that these agents would be effective to the degree that they induced premorbid psychologic (personality) patterns. The present programs in the Department are designed to study these relationships in detail. CONVULSIVE THERAPY PROCESS 0f various measures of brain function, the amount of slow activity in the electroencephalogram (7,8) and confabulatory and denial language patterns after amobarbital (9,10) were the most sensitive indices (11) in convulsive therapy subjects. In wave one experiment, improvement ratings correlated with the appearance of high degrees of change in these indices (7,10). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to courses of either convulsive or subconvulsive therapy under pentothal premedication. High degrees of neurophysiological change were observed only in the convulsive group; improvement rates were were �-3- significantly higher in this group; and when subconvulsive subjects were rc-treated by convulsive applications, the improvement rate .was similar to the original convulsive group (2). In the subconvulsive treated subjects, considerable amounts of electric current passed between the bitemporal electrodes. It appeared that the therapeutic agent was not the total electrical current, per sez but an all or none quality manifested by the grand mal seizure (8,12)o significance of the grand mal seizure was examined in studies of the inhalant convulsant, hexafluorodiethylether (Indoklon). Similar degrees of electroThe graphic change, improvement rates, types of behavioral change and changes in neuropsychological task behavior were observed in the inhalant and in electrically treated groups (13). It apparent that not all subjects manifesting high degrees of physiologic change were rated as 'improved’. In a descriptive typologic study, five patterns were described, empirically termed 'euphoric', 'hypomanic', 'somatization', 'paranoid-withdrawal', and ‘panic'. While the first two of these adaptive modes were rated as 'much improved', the latter two were was soon seen as *unimproved' or 'worse' (1h). variables, it was reported that patients rated as 'much improved' and 'recovered' frequently manifested personality patterns similar to that described by Weinstein and Kahn as the explicit verbal denial personality. In language patterns, patients expressed the 'language of denial', when diffuse brain change was induced, exhibiting such aspects as In studies of psychological �-h- explicit denial, minimization, displacement, cliches, 222. more frequently than unimproved subjects. Other indices related to favorable outcome were high F Scale score (15), and Rorschach determinants of color, absent movement and absent form-color (16,17). In this population, also, favorable outcome was associated with low educational achievement and foreign birth (18). ANTICHOLINERGIC COMPOUNDS AND CONVULSIVE THERAPY Seeking a way to augment the degree of post-convulsive slow wave activity, an anticholinergic compound, diethazine, EEG was given intravenously at various stages of the convulsive therapy process (19). Contrary to expectations, diethazine caused an immediate and sustained decrease in EEG slowing. Patients with denial language patterns relinquished them. Instead of euphoria and well being, the subjects were irritable, anxious and expressive of pre-treatment patterns. In subjects prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety and illusory sensations. Subsequent studies with other central anticholinergic compounds (WIN-2299, JB-318,336, benactyzine) showed behavioral and electrographic patterns similar to diethazine. Similar desynchronization of post-convulsive EEG slowing was also noted with central sympathomimetic hallucinogens (amphetamine, mescaline, LSD-25), and has been reported for antihistamines (diphenylhydraminc) These observations led to the suggestion that an increase in central cholinergic activity was a biochemical basis for the convulsive therapy process (20). �PSYCHOTROPIC DRUGS AND EEG During this period, the drugs aroused mode of action of newer psychotropic interest. Following the concepts derived from convulsive therapy, the neurophysiological changes induced by drugs were tested within the same acute experimental framework of the EEG setting. It was observed that phenothiazines (chlorpromazine, promazine, trifluopromazine) induced EEG synchronization and a shifting of the spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (5,6). Imipramine induced desynchronization with a shift of frequencies to the slow bands (21). Other experimental compounds tested included BL-M188 and phenyltoloxamine (Bristol), Deaner and its various congeners (Biker), WY-21h9 (Wyeth) and frenquel (Merrill). For each, no consistent electrographic pattern was recorded. It was suggested that psychopharmacological agents provide a means for eliciting a variety of neurophysiological patterns in contrast to the single pattern of induced convulsions. Furthermore, the type of neurophysiological alteration, as reflected in EEG synchrony and frequency patterns, was related to specified types of behavioral adaptation. Increasing EEG synchrony and a shift to slow frequencies were associated with tranquillization, sedation and decreasing agitation; while desynchronization and a shift to fast frequencies was associated with excitement, illusions, �and delusional ideation (6,20). These observations are consistent with hypotheses of Wikler. The advantages of EEG techniques for the assay of new psychotropic agents have already been reported (6). �97PSYCHOPHARMACOLOGY EVALUATION PROGRAM _______an.._________.__u~m._______. present program, instituted in October 1959, is based on these studies and is designed to answer the following questions: Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? Are there pre-treatment clusters of The psychiatric, physiological and psychological variables related to the type of behavioral adaptation? And, Method: As an are such clusters related to the initial approximation, a double-blind, fixed dosage random assignment drug study was undertaken. Based on our clinical experiences with various psychotropic compounds from l9Sh to 1959, three classes were selected on the basis of their patterns of EEG response. The agents selected were those with either predominant desynchronizing patterns, synchronizing and slowing, or minimal or no effect. Patients referred for drug therapy, after medical examination, and after all other medications have been discontinued are randomly assigned to a compound in one of these three classes. Patients are predominantly middle class, urban, with high educational attainment. Hillside Hospital is a non-profit, �-8- philanthropic supported psychiatric institution, admitting voluntary patients for extensive psychotherapeutic treatment. The mean duration of stay for patients is seven months. Convulsive and psychotropic drug therapies are prescribed by staff psychiatrists on referral to the Department. All treatment is administered by Departmental staff, so that the experimental variables of drug dosage, route of administration, assignment to groups, 323. are readily controlled. All patients in the hospital are available for study. After a testing period, all patients receive no cc of liquid medication daily from individually labelled bottles. Dosages are increased in fixed weekly steps until a maximum at h weeks. After two weeks on maximum dosage, re-testing occurs. To date, 1ho subjects have been referred, and 110 have completed the study period. Preliminary analyses of the data are now in progress. Behavioral Change: In a survey of the behavioral adaptations of patients receiving phenothiazines or imipramine during 1958-59, various clusters of behaviors were developed. The typologies were based on the treatment response and on pre-treatment psychiatric profiles. In the present study, the typologies are being tested, and various measures of behavioral change are being studied. These include therapist referral questionnaires and six week evaluations; therapist and patient Clyde Mood Scales; Lorr Scale evaluations in interview by two research psychiatrists, and Lorr Ward Scales; and patient self-retina including the Johns Hopkins symptom check �-9- list the Chicago Attitude Scales. Neuropsychology: Psychologic tasks have been viewed both as change variables and predictive variables. In convulsive therapy, changes in memory tasks (22), tactile perception (23,2h), WechslerBellevue (13), OFF (13), figure-ground tasks (25), and tachistoscopic recognition of figures (26) were related to the degree of induced neurophysiological change. For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiologic indices to pre-treatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher - a betterment of performance ascribed and to practice effect. Denial scores on interview (27), Rorschach determinants (16,17), F Scale scores (15,17), language patterns after amobarbital (28), auditory feedback and perception of the visual upright have been viewed as predictive indices of the behavioral changes following ECT. These various tasks are now being assessed with psychotropic agents, for both their capacity to change with various agents and their capacity ts predict change. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (7). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques. Electronic frequency analysis was introduced in �August 1959. By measurement of the pen deflection for various frequencies from 3 to 33 cps in ten second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are now obtained and applied. Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure reaponse to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. �-11PSYCHOLINGUISTICS series of studies in the Department have been devoted to formal language patterns. Following the studies of syntactic language patterns (28) Another in convulsive therapy, other aspects of language were studied for their relation as indices of change in interpersonal behavior}. Jaffe, after considerable exploration with various linguistic measures, suggested that type-token-ratios (TTR) of consecutive samples of dyadic speech may be a useful index (29,30). While TTR had previously been applied to written texts or the language individuals, Jaffe indicated that the two person communication (dyad) was a more significant index of the state of the interaction than analyses of separate samples of the participants. Applying this technique to convulsive therapy patients, changes in TTR mean and standard deviations were related both to the degree of induced EEG slow wave activity and to syntactic language patterns obtained in independent struuctured interviews. Speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (increased standard deviation) (31). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents with a predominant synchronization pattern on the EEG exhibited a decrease in mean TTR and increase in standard deviation of scores, while desynchronizing compounds elicited greater variability in samples of speech patterns (increase in TTR mean) and decrease in variability �-12- of consecutive scores (decrease in standard deviation) (32). other language measures studied included distress-relief quotients, self-reference, and alteration in tense and person. It was suggested that these psycholinguistic measures are potent techniques for the operational analyses of physiological and psychological effects of psychopharmacologic agents (32); �SOCIOLOGIC STUDIEE In the course of these psychiatric programs, considerable interest was engendered in the family organization to which patients returning. Also, the general Problem of the relation of social factors to choice and results of psychiatric treatment, and the specific prohlem of the relation of these factors to the referral patterns led to a series of population studies. In one study (33), education, age, place of birth and score on the California F scale were significantly related to the type of therapy received and the utilization of adjunctive hospital services. Thus, patients who were older, poorly educated, had higher F scores and were foreignborn, particularly in Eastern Europe, were most likely to be referred for electroshock. These relationships were present independent of diagnoses. Within the group of electroshock patients, the time for referral for ECT was also related to these factors. In a second study (18), duration of heapitalization, discharge evaluation and diagnoses were related to the same social factors. For example, patients hospitalized for the shortest period were oldest, had the least education, were most likely to have been foreign-born and had the higher P Scale scores. Younger, nativeborn, more educated, lower F Scale score patients were hospitalized the longest. These relationships held true within treatment type and within diagnostic class. On discharge, older patients had the most favorable ratings. In ECT, patients rated as recovered or much improved had the highest F scores, least education and were most likely to be foreign-born. In another study of patient were �refusal of similar relationships were observed (3h). These relationships are now under study in the Out-Patient Department, and in a tri-hospital comparative study. In the latter study, the populations of three hospitals with prevailing differing clients, in which all therapies areenually available to all patients, - Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lower-class, Catholic) and Hillside Hospital (middle-class, Jewish) are being assessed. It has been “postulated that these relationships reflect the influence of social background on psychological processes, such as habitual patterns of communication and modes of expression. The contribution of these factors to the pattern of mental illness, and the patient-therapist interaction are under study. ECT, �SUMMARY Departmental programs are a cluster of interrelated studies focussed about common population samples. Within Hillside The HOSpital, research laboratories in Biochemistry, and in Medicine are active; and other laboratories in psychodynamic psychiatry are being developed. In this Department, various disciplines are participants, representing a gradual growth of six years. Further growth and the directions of ensuing studies are dependent on the results of the studies described here; as well as the growing institutional awareness that research is an integral part of the hospital's operation and budgets - as much as treatment and staff training. �~16- References Authors of the following references include the following staff members: Max Fink, Max Pollack, Robert L. Kahn, Joseph Jaffe, Martin A. Green, Eric Karp, Korin, Donald F. Klein, George Krauthamer, Arnold G. Blumberg, Nathaniel S. Siegel, Abraham Kaplan and Henry Hyman J. Lefkowits. 1. J. Hillside Hosp. 6: 197, 1957; 2. Dis. Nerv. Sys. 12: 3. J. Hillside Hospital h: 13h, 1955; 113, 1958; h. J.A.M.A. 166: 18h6, 1958; 5. Psychopharmacology Frontiers, Little, Brown 6. Neuropsychopharmacology, Elsevier, hhl, 1960; 7. A.M.A. Arch. Neurol. & Psychiat. 18: 516, 1957; 8. Dis. Nerv. Sys. 12: 227, 1958; 9. J. Hillside Hosp. A: 3, 1955; 10. Arch. Neurol & Psychiat. 16: 23, 1956. & Co., 325, 19593 11. First Int'l Cong. Neurol. Sci., Pergamon, 613, 1959; 12. Jour. Nerv. Ment. Dis. 129: 117, 1960; 13. A.M.A. Arch. Gen. Psychiat. (in press); 1h. Unpublished manuscript; 15. Jour. Nerv. Ment. Dis. 129: 187, 1960; 16. J. Neuropsychiat. l: 2h2, 1960; 17. Jour. Nerv. Ment. Dis. 128: 2h3, 1959; 18. A.M.A. Arch. Gen. Psychiat. l: 565, 1959; 19. A.M.A. Arch. Neurol. & Psychiat. 82: 20. EEG Clin. Neurophysiol. 13: 359, 1960. 380, 1958; J. g: 1663, 1959; 22. J. Hillside Hosp. 6: 2hl, 1957; 21. Canad. Psych. Assoc. 16: 88, 1956; 23. Conf. Neurol. 2h. Am. J. 25. A.M.A. Arch. Neurol. g: 5&7, 1960; Psychol. 13: 38h, 1959; 26. Proc. XV Int. Cong. Psychol., North-Holland, 238, 1959; 27. J. Neuropsychiat. l: h5, 1959; 28. Psychopathologx of �-17- m Communication, Grune ' & Stratton, 126, 19583 29. J. Hillside Hosp. 6: 207, 1957; 30. Psychiat. g3: 2&9, 1958. 31. Jour. Nerv. Ment. Dis. 130: 235, 1960; Psychiatric HOSp. Drug Therapy, C.C. Thomas, 29, 1960; 6: 216, 1957; 3h. Unpublished Manuscript. 32. ngamics of 33. J. Hillside �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, M.D. Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume X ' Nos. 3-4 ° July-Oct. 1961 . �EXPERIMENTAL PSYCHIATRIC RESEARCH AT HILLSIDE Review and Prospect MAX FINK, MD. The dedication of Hillside Hospital as a Research Institute has been a dream of many of its students—a dream that may achieve realization in this decade. Dr. Tarachow was an early proponent of this view; and both in his sponsorship of the Journal, and in his encouragement of research studies, he presaged this development. He was also the inadvertent sire of the research studies in experimental psychiatry. While I was a resident in psychiatry in 1952, we collaborated in a study of the relation of the early separation of child from a parent to the adult choice of neurosis. Reviewing the hospital records of ﬁve previous years we concluded that there was, indeed, a relation— neurotic patients with obsessional neuroses had a signiﬁcantly, greater incidence of separation than patients with hysterical neuroses (2). This report was the beginning of the patient population studies described here. Since 1954 the various programs in experimental psychiatry have been devoted to an understanding of the mode of action of the psy- chiatric therapies of the hospital. The techniques have been adapted from descriptive and dynamic psychiatry, neuropsychology, electro— encephalography, linguistics, pharmacology, and sociology. This report reviews these studies and presents support for the creation of a Research Institute at Hillside. PAST STUDIES In our early studies of convulsive therapy, instituted with the 1 From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. The studies reported here have been aided by the Board of Directors Research Fund; the National Institute of Mental Health (Grants M-927; MY-2092,-27l5, ~4798; MF-12,033); Foundations Fund for Research in Psychiatry (FFRP 56-151); Kaufmann, and Dazian Foundations; and numerous pharmaceutical concerns including Geigy, Bristol, Wyeth and Smith, Kline 8: French Laboratories. 159 �160 MAX FINK aid of a grant award of the National Institute of Mental Health, evaluations of patient improvement were shown to be dependent both on changes in brain function and on psychological factors. As our understanding of convulsive therapy developed, a general neurophysiologic-adaptive view of somatic therapies emerged (6). A change in brain function was seen as a necessary condition for behavioral change, with the type of change varying, depending upon psychological and sociological characteristics of the subject (22, 25). Thus, the mode of action was not seen as either ”organic” or “psychological” but rather as the interaction of neurophysiological changes and individual patterns of response and behavior. This hypothesis was sustained in studies of convulsive and insulin coma therapies (21, 22); and the mode of action of the new psychotropic agents was expressed within this hypothesis. It was suggested that psychotropic drugs would be effective to the extent that persistent changes in brain function were induced; and that the type of behavioral response would be related to the type of brain change, and to individual premorbid psychologic (personality) patterns (6, 28, 40). l. Convulsive Therapy Process: Seeking a measure of altered neurophysiological change that was sensitive and suitable for repeated retests, various measures were studied including changes in the face-hand test (1, 10, 13, 35), memory tests (17, 35), amount of slow-wave activity in the EEG (16, 23) and confabulatory and denial language patterns after amobarbital (3, 15). The latter two, EEG and amobarbital tests, were the most sensitive indices of change in convulsive therapy subjects. In one experiment, clinical ratings of improvement were correlated with high degrees of change in these indices (15, 16). These observations were tested in a double-blind study in which patients referred for electroshock were randomly assigned to either convulsive or subconvulsive therapy. High degrees of electrographic slow-wave activity and positive amobarbital tests were observed only in the convulsive group; improvement rates were signiﬁcantly higher in this group, and when subconvulsive subjects were retreated by convulsive applications, the improvement rate was similar to the convulsive group (22). In subconvulsive applications, considerable electric current passes between the electrodes. It was postulated that the therapeutic agent was not the total electrical current per se, but the “all or none” quality manifested by the grand-mal seizure (9, 23, 42). The signiﬁ- �EXPERIMENTAL PSYCHIATRIC RESEARCH 161 cance of the grand-mal seizure was examined in a comparative study of the inhalant convulsant, hexaﬂuorodiethylether (Indoklon), and electrically induced seizures. Similar degrees of electrographic change, improvement rates, types of behavioral adaptations, and changes in neuropsychological task behavior were observed in both the inhalant and in the electrically treated groups (49). However, not all subjects manifesting high degrees of physiological change were evaluated as “improved.” In a descriptive typologic study, ﬁve adaptive modes were described, empirically termed “euH H phoric,” “hypomanic,” “somatization, paranoid-withdrawal,” and “panic.” While the ﬁrst two patterns were rated as “much improved,” the latter two were seen as “unimproved” or “worse” (50). In studies of psychological variables, it was reported that patients rated “much improved” and “recovered" frequently manifested personality patterns akin to the explicit verbal denial personality type (37). These patients expressed the “language of denial” more frequently than unimproved subjects, exhibiting such aspects as explicit denial, minimization, displacement and clichés (27). Other psychological indices also related to favorable outcome included high F Scale score (42), Rorschach determinants of color, absent movement and absent form-color (30, 45), and low educational achievement and foreign birth (31). 2. Anticholinergz'c Compounds and Convulsz've Therapy: Seeking a way to augment the degree of postconvulsive EEG slow-wave activity, an anticholinergic compound diethazine, was given intravenously at various stages of the convulsive therapy process (20, 24). Unexpectedly, diethazine caused an immediate and sustained decrease in EEG slowing, which was associated with marked changes in language and mood. In patients with denial language patterns (27), these could no longer be elicited. Instead of euphoria and wellbeing, the subjects became irritable, anxious, and complaining. In subjects prior to convulsive or drug therapy, diethazine induced excitement, tension, anxiety, and illusory sensations. Subsequent studies with other central anticholinergic compounds and sympathomimetic hallucinogens showed behavior and electrographic patterns similar to diethazine. These observations led to the suggestion that an increase in the cholinergic activity of the central nervous system was the biochemical basis for the convulsive therapy process (38). 3. Psychotropic Drugs and EEG: Following these studies, the neurophysiological changes induced by drugs were tested within an �162 MAX FINK acute experimental EEG setting. It was observed that phenothiazines induced EEG synchronization and a shifting of the frequency spectrum to the slow frequencies; meprobamate and barbiturates, an increased synchronization and a shift of the spectrum to fast frequencies; reserpine, an increased slowing with synchronization at low dosages, and desynchronization at higher levels (18, 26, 28, 40). Imipramine induced desynchronization with a shift of frequencies to the slow bands (33, 34). Each active psychotropic compound was thus shown to have a characteristic frequency pattern. Various other experimental compounds were also tested, and for these no consistent electrographic pattern was recorded. These compounds have since been shown to have either no or very limited clinical psychotropic activity. The absence of behavioral change with these compounds lent further support to the assumption that brain change is a necessary condition for the action of psychotropic drugs. These observations suggested that psychopharmacological agents provide a means for eliciting various types of altered brain function in contrast to the single pattern following convulsive therapy. Furthermore, the type of neurophysiological alteration, as reﬂected in EEG synchrony and frequency patterns, was found to be related to speciﬁed types of behavioral adaptation. The advantage of EEG techniques for the assay of new psychotropic agents and the technical merits of electronic frequency analysis were assayed and described (47, 52). 4. Insulin Coma Therapy: In our insulin coma studies we con- firmed earlier observations that persistent alterations of brain function were related to prolonged coma and spontaneous seizures; and saw in this relationship support for a neurophysiologic-adaptive hypothesis. With the availability of the new psychotropic agent chlorpromazine, a controlled chlorpromazine-insulin coma study was undertaken in September, 1955. As patients were referred for insulin coma they were randomly assigned to courses of either oral chlorpromazine for at least three months in doses adjusted to fall short of toxicity; or insulin coma, induced by a standard technique at least ﬁfty times in each patient. While a number of minor differences were noted in comparing the two therapies, the results at time of discharge showed no statistical difference in the effectiveness of both treatments. Neither treatment seemed to affect the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management (21). Concurrently, following the suggestion by the Creedmoor workers that �EXPERIMENTAL PSYCHIATRIC RESEARCH 163 divided insulin doses were superior to single insulin doses, Blumberg and Laderman (39) essayed this problem and demonstrated no signiﬁcant merit to the multiple-dose technique. (In 1958, following the general conﬁrmation of these observations, insulin coma therapy was discontinued at Hillside). 5. Neuropsychology: Various psychophysical tests were adapted from neuropsychology, where their signiﬁcance in brain-damaged subjects had been demonstrated. The early studies assessed these tasks as indices of altered brain function (35), and measured the range of performances of psychiatric patients, who are generally assumed not to be brain-damaged. Thus, memory function was assessed on immediate recall, after various interpolated learning tasks (17, 35), as well as during convulsive therapy (17). Tactile perceptual tasks were ﬁrst examined in the clinical population (1). Later, with more sensitive electrical tactile stimuli, Korin (10) observed the range of thresholds in different body parts, the changes with altered brain function (10), and the inﬂuence of set (instruction) on performance (36). We also studied the perception of embedded geometric ﬁgures (43), tachistoscopic presentation of embedded color ﬁgures (55), perception of the visual upright (55), critical ﬂicker frequency (49), and interference in reading time by delayed auditory feedback (55). For each task, the degree of decrement in task performance was found to be positively correlated with the amount of EEG slowing. Following treatment completion, with the return of physiological indices to pretreatment levels, performance in these psychological tasks also returned to pretreatment levels, or higher—a betterment of performance ascribed to practice effect. Concurrently, assessment of various psychological measures as indices predictive of behavioral change during convulsive and drug therapies led to studies of the Rorschach determinants (30, 45), California F Scale scores (30, 42), language patterns after amobarbital (27), denial scores on interview (37), and the perception of the visual upright and auditory feedback (55). 6. Psycholinguistics: Concurrent with the syntactic language studies (27), analyses of other language patterns were undertaken, both in a search for more objective indices of behavioral change and to gain experience in the technical problems of tape analysis for psychotherapy research. An index of variability in the vocabulary of speech, the type-token ratio (TTR) of consecutive samples of dyadic speech, was extensively studied (7,41, 44, 46, 56, 57). In convulsive therapy patients, signiﬁcant changes in TTR mean �164 MAX FINK and standard deviations were related both to the degree of induced EEG slow-wave activity and to syntactic language patterns obtained in independent structured interviews. It was noted that speech became more repetitive (lowered mean TTR) and more variable in consecutive samples (41). In interviews before and after the intravenous administration of centrally active agents, similar changes were observed. Agents which produced predominant synchronization patterns on the EEG were related to a decrease in mean TTR and an increase in the standard deviation of scores, while desynchronizing compounds elicited greater variability in speech patterns and decrease in variability of consecutive scores (44). Other language measures studied included distress-relief quotients, self-reference, and alterations in tense and person. It was suggested that these psycholinguistic measures are useful techniques for the operational analyses of physiological and psychological effects of psychopharmacological agents (44, 46). 7. Brain Damage and Schizophrenia: Following his studies at Ittleson Center, Pollack reviewed the relationship between age of hospitalization, intellectual functioning and prognosis in schizophrenic children and adults. He noted that initial hospitalization in childhood and adolescence was related to I. Q. scores in the subnor— mal range, deviant performance on psychomotor tasks, and more frequent ratings of “unimproved” at hospital discharge than was initial hospitalization as an adult. The early and insidious onset of the behavioral syndrome “schizophrenia” was thus related to brain dysfunction (54). Findings suggest that different subgroups of schizophrenia may be classiﬁed on the basis of neuropsychological deviancy. 8. Sociological Studies: Considerable interest in the family organization to which discharged patients were returning, the relation of social factors to choice and results of psychiatric treatment, and the specific problem of the relation of these factors to treatment referral patterns led to a series of population studies. In one study (8), education, age, place of birth, and score on the California F Scale were signiﬁcantly related to the type of therapy received and the utilization of adjunctive hospital services. In a second study (31), duration of hospitalization, discharge evaluation, and diagnosis were related to the same social factors, while in a study of patient refusal of ECT, similar relationships were observed (51). These observations suggested a comparative interinstitution study, and among three hospitals the relationships between social class and other demographic variables (age, sex, education) to the clinical �EXPERIMENTAL PSYCHIATRIC RESEARCH 165 variables of patient classiﬁcation (diagnosis), duration of hospitalization, selection of therapy, and discharge evaluation have been assessed. Three teaching institutions were selected in which all therapies are equally available to all patients—Menninger Foundation Hospital (upper-class, Protestant), Massachusetts Mental Health Center (lowerclass, Catholic), and Hillside Hospital (middle-class, Jewish). In such a comparison we have found the differences in designations of treatment, diagnosis, and discharge evaluation so marked as to make comparisons difﬁcult. While many relationships between social variables and clinical variables were observed in each hospital, no social variable was found related to the clinical variables in every hospital (53). In an outpatient department study, sex, age, and marital status were found to be related to the acceptance and rejection of patients and failure to complete the application process (55). These observations in population samples led to concurrent studies of staff attitudes in the selection of therapy (ll, 12). In a series of ward observation studies, Kaplan and Lefkowits indicated the signiﬁcant role of staff attitudes (especially nursing personnel) in the referral for subjects for somatic therapies, and in the transfer of patients from one ward to another. (To study the inﬂuence of staﬂ attitude on patient selection for drug therapy, we requested one ward be designated as a “no-movement” unit. This was adopted in September, 1959 and shortly thereafter by the whole hospital.) PRESENT STUDIES During the period of the convulsive therapy studies, many new psychotropic compounds were assessed clinically (5, 21), electrographically (34, 40, 48), and psychophysically (48). The present psychopharmacology evaluation program, based on these studies, was designed to answer the following questions: 1. Is there a relation between measurable alteration in brain function and behavioral change with psychotropic drugs on chronic administration? 2. Are there pretreatment clusters of psychiatric, physiological, and psychological variables which are related to the type of behavioral adaptation? 3. Are such clusters related to the type and degree of physiologi- cal change? As an initial approximation, a double-blind, ﬁxed dosage, ran- �166 MAX FINK dom assignment drug study was undertaken. Based on our clinical experiences three types of compounds were selected on the basis of their EEG patterns. In this study, 203 subjects were referred, and 149 have completed the testing program, from October, 1959 to July, 1961. l. Behavioral Change: In a survey of the behavioral adaptations of patients receiving various psychotropic compounds during 195859, a behavioral typology based on the treatment response and on pretreatment psychiatric profiles was developed (55). In the present study, the typologies are being tested, and various measures of behavioral change studied, including therapist ratings, self-ratings, and various ward observation scales. 2. Neuropsychology: Psychological tasks have been viewed both as indices of behavioral change and as predictive guides in convulsive therapy. Each of these tasks and a selected group of motor tasks are now being assessed for both their capacity to reveal change with various drugs and their capacity to predict change with the drugs in this program (48). 3. Electroencephalography: In the convulsive therapy studies, the degree of EEG slowing was measured by counting the consecutive waves in selected samples (16). When the more subtle changes of drug effects are studied, it is necessary to apply less tedious techniques (48), and electronic frequency analysis was introduced in August, 1959. By measurement of the pen deﬂection for various frequencies from 3 to 33 cps in ten-second epochs, rapid measurement of apparently small changes in total activity and frequency spectra are obtained (52). Other physiological variables studied in this program include the response of EEG to intravenous chlorpromazine, blood pressure response to mecholyl, the EKG, radioactive iodine uptake, and analyses of various blood and urine elements. 4. Data Analysis: To analyze the data generated in this study, we have sought the aid of complex statistical methods and computational facilities. Analyses of covariance, correlation matrices, factor analyses, and discriminant function analyses are computations now in progress with these data at the NIMH Psychopharmacology Service Center’s Biometric Laboratory in Washington. THE NEXT STEPS Favored by a national research climate and a cooperative hospital staff, these studies have proceeded vigorously. The assets for research in this setting have been great—a selected, intelligent patient popula- �EXPERIMENTAL PSYCHIATRIC RESEARCH 167 tion resident from six to twelve months, without individual economic limitation of hospital stay; a sophisticated administration tolerant of controlled studies; and approval of a Board of Directors who desire “research” as an institutional function. As Dr. Lewis Robbins noted in his ﬁrst hospital report in 1959, a specialty hospital can make little impact on the mental illness problems of the community by treatment alone. The successful treatment of 350 patients a year is but little comfort to the 40,000 resident patients in the state hospitals of Long Island. Nor will the annual training of twenty or thirty physicians in the arts of psychotherapy do much to help these unfortunates or the many thousands of ambulatory mentally ill resident in the nation. No, a therapeutic goal alone is salutary but inadequate to our needs. As he proposed, the answer may lie in the dedication of a “research hospital,” as it is here that a specialty hospital can truly excel. The charter has been written in the Board’s assertion of research as a hospital goal. With the assets of an exemplary therapeutic facility, such rededication can provide the stimulus for the continuous study of the cause of mental illness and of methods of therapy. Such dedication would provide the stimulus for comparative and controlled assessments of different therapeutic techniques. Continued study is urgently required of the selection of patients for various therapies; the application and mode of action of the therapies; and the role of social and milieu factors in supporting the effects of our therapies. Assessments require a meaningful classiﬁcation of subjects. The behavioral variables alone, which are the basis of our present diagnostic schemata, are unsatisfactory. Study is urgently required of the applicability of social and demographic variables; psychological task performance proﬁles; typologies based on behavioral response to deﬁned stresses or drugs; and physiological reactivity measures. Such classiﬁcations are also essential for any biochemical, physiological, or evaluative study to provide homogeneous samples and comparable controls. Assessments also require meaningful indices of evaluating change. Present global “improvement” ratings and socialization measures are inadequate. Whether the intervening variable be milieu therapy, psychotherapy, drug therapy, or time, the criteria of behavioral change require deﬁnition. The applicability of rating scales, language tasks, self~ratings, psychophysical change scores, family assessments, etc., require study and evaluation. Recent studies of psychotic subjects have provided the suggestion �MAX FINK 168 that there is a neurologic factor in a group of the schizophrenias. The high incidence of electrographic and neurologic dysfunction, the lack of behavioral response to all therapies, and the relentless course of the illness suggest an “organic” involvement in this cluster. Such a substrate must be clearly sought by the application of biochemical, neurophysiological, and epidemiological techniques to various clusters of young psychotic subjects. These are broader views of some of the questions studied in the programs in experimental psychiatry of the past seven years. These programs, and the contemporary projects in biochemistry and in medicine, provide models of bootstrap studies undertaken with limited support. A dedication of Hillside Hospital as a Research Institute will provide the needed focus and impetus for the scientiﬁc and humanitarian forces of the community to join in a common endeavor to resolve the problems of the mentally ill. Acknowledgment: Participants in these programs include the present members of the Department of Experimental Psychiatry: Ira Belmont, Martin A. Green, Abraham Kaplan, Eric Karp, Donald F. Klein, John C. Kramer, Max Pollack, and Arthur Willner. Former associates included Karl Andermann, Joseph Jaffe, Robert L. Kahn, Hyman Korin, George Krauthamer, Nathaniel Siegel; and Research Fellows Barre Alan, Fred Coleman, Harold Esecover, Stanley Friedman, Henry J. Lefkowits, and Robert Shaw. The cooperation of Arnold G. Blumberg of the Department of Medicine in the present program is gratefully acknowledged. The reports listed here are the result of the collaboration of these workers and the professional staffs of the hospital who gave unstintingly of their time and their good-will. REFERENCES (1) ' This Journal, 1:21, 1952; (2) ibid., 2:67, 1953; (3) ibid., 4:3, 1955; (4) ibid., 4:134, 1955; (5) ibid., 5:67, 1956; (6) ibid., 6:197, 1957; (7) ibid., 6:207, 1957; (8) ibid., 6:216, 1957; (9) ibid., 6:229, 1957; (10) ibid., 6:241, 1957. (13) Neurology, 4:211, (15) ibid., 76:23, 1956; 1956; (18) EEG Clin. (20) ibid., 10:207, 1958. (21) ]. Am. Med. Assn., 166:1846, 1958; (22) Dis. Nero. Sys., 192113, 1958; (23) ibid., 19:227, 1958; (24) Arch. Neurol., Psychiat., 80:380, 1958; (25) ibid., 80:73, 1958; (26) Neurology, 8:682, 1958; (27) Psychopathology of Communication, New York: Grune 8c Stratton, 126, 1958; (28) Psychopharmacology Frontiers, New York: Little, Brown, 325, 1959; (29) Proc. XV Int. Cong. Psychol, North Holland Publ., 238, 1959; (30) J. Nero. Ment. Dis., 128:243, 1959. (31) Arch. Gen. Psychiat., 1:565, 1959; (32) EEG Clin. Neurophysiol., 11:398, (11) This Journal, 10:84, 1961; (12) ibid., 10:97, 1961; 1954; (14) Arch. Neurol., Psychiat, 72:233, 1954; (16) ibid., 78:516, 1957; (17) Conf. Neurol., 16:88, Neurophysiol.,9:180,1957; (19) ibid., 10:162, 1958; �EXPERIMENTAL PSYCHIATRIC RESEARCH 169 1959; (33) ibid., 12:243, 1960; (34) Canad. Psychiat. Assn. ]., 4:1668, 1959; (35) Proc. Int. Cong. Neurol. Sci., Pergamon, 613, 1959; (36) Am. J. Psychol., 72:384, 1959; (37) J. Neuropsychiat., 1:45, 1959; (38) EEG Clin. Neurophysiol., 12:359. 1960; (39) Am. ]. Psychiat., 116:839, 1960; (40) Neuro-Psychopharmacol., 1:441, Elsevier, 1960. (41) J. Nerv. Ment. Dis., 130:235, 1960; (42) ibid., 1302187, 1960; (43) Arch. Neurol., 2:547, 1960; (44) Dynamics of Psychiatric Drug Therapy, Springﬁeld: Thomas, 29, 1960; (45) J. Neuropsychiat., 1:242, 1960; (46) Am. J. Psychother., 15:46, 1961; (47) Neuro-Psychopharmacol., 2:30, Elsevier, 1961; (48) ibid., 2:381, 1961; (49) Arch. Gen. Psychiat., 4:259, 1961; (50) ibid., 5:30, 1961. (51) ]. Nerv. Ment. Dis., 132:153, 1961; (52) Medicina Experimentalis (in press); (53) VA Conf. Psychopharmacology (in press); (54) Arch. Gen. Psychiat., 2:652, 1960; (55) Unpublished manuscript; (56) Psychiatry, 21:249, 1958; (57) Comparative Psycholinguistic Analysis of Two Psychotherapeutic Interviews. New York: Int. Univ. Press, 1961. ° Due to the length of this Bibliography, it is presented in an abbreviated form. ��IIIIIIII, IIII III IIIII, IIIIII I mill‘iﬂﬁl IIIIIIIIII IIIII 3,963.4. 16"”1WI m3 “It W “WI IIII. 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Round in At‘ttudou Pros-nu, tbs troutnont Stat! rink, 3.: lab}. on lbnnnru; 1321:0300: on ’uynhophnrnnaologia hut-wt, AH, ensue, my. link, 3.: BilB‘lIiOl a: Ptythologicnl and ltoohcnietl Synthosou Occurring Duran: 10907097 tron Parana-cl, by lagoon, 8., Andornnnn, K.: It“. ABA, III. rank, n.: laurophyuiologic«Adaptive 1:0! or canvulutvo rhorupy Bound table on 'luarophyutological chin... with iloetroconvulsivo rhurapy', ARA, chioaao, ”by. rank, u.a chn1runn, coat. on Ila tad Eula: Paychcpharnnaoloxy. World CongrOII of Plyuhlutry, Houtrutl, Juno. rink, u.: 336 troqnoucy tad rnynhotropio Bras Activity, nautuchn Arbuitoaunoxnschttt tit luurnpnychopharnukolozio, hub-r: , Supt. rank, n.: In. convulsive thorapy Press-a, Itstoru nil-our: Paynhtntrtc Sacioty, at. tonic, ectobar. rink, 1.: Ila and lulnn rayohophlauaaolony, 2.1a notioutl Ioaosrch contoronoo, lovonhor. :14 lohuvtor, link, n.2- Plyohotrtplc Brunt, train Function ancona county 8.010%: a: Icurology 33¢ Puychintry, Duct-bar. �Q .2“ 5195.9’ and :39 r11okcr rruqnaaay 3.: critical x»rp 3911:511Sty ; Study, Sulturl Payohaiuztcnl Lauoutu‘tul, Pundnlphu , lurch. 11.13, 3.: rypolou at thnviorsl Gunman with Ph¢ngthtuuiao ﬁndicntlan, Gout. nu auhtsophrcutn, at. Elisabeth' a lcupztal, J;n., W‘shingtan. Pollack, n.:' 3.1. a: ltur01&¢tea1 Dyntunotlon 1n tho childhood schizophraninn, Lynx. arthapuyohiatric Auioc., 8.3., Burah. in Pollack, n.: scatnl £Ipo¢ta of Paytltnirtc Ironinout YA V1 Aunnnl Problcnn, Hothtdologia loupst‘la: first nsonareh can:., Bantinuaﬁt, Karen. “ or Sinnlﬁantous StimulaPullnck, H.s attordcrcd Pgraopt1¢n ttou a: rsoc-aad Hand: A Ravine and thaory, Sac. 3101. Payohtnt., Atlantic Gity, Juan. 810301, 1.: Diagnosis and truatnon‘ 1n Thrao Pnywhtntrto noapitala, An. Saelologtcal Lss¢o., 8%. Louis, Aug. �\ PUBLICATIONS OF DR. MAX FINK 1950 1. 2a. Subdural Hematoma Developing During Hospitalization, Amer. J. M. 1950 Dr. (With Green). 107: 381-383, Pszchiat. Patterns in Perception of Simultaneous Tests of Face and Hand, Trans. Amer. Neurol Assoc. 72: 250, 1950 (with Drs. _' Ereeni. & Arch. Neurol. ibid, Pszchiat. ﬁg: 355-362, 1951. M.B. Bender and M. .... 3. 1952 Test as a Diagnostic Sign of Organic Mental Syndrome, Neurologz, 2: h6-58, 1952 (with Drs. M.B. Bender and M. Green}. Tactile Perceptual Tests in the Differential Diagnosis of 1952 21-31, Hillside J. Hosp. 1: Disorders, Psychiatric (with Dr. M.B. Bender). A Clinical Evaluation of Carotid Angiography, Conf. Neurol. 13: 181-195, 1952 (with Dr. J.M. Stein). Exosomesthesia, or Displacement of Cutaneous Sensation into 1952 Amer. Assoc. 1Q: Neurol. Trans. Space, Extra-personal .B. Ben er . (with Drs. M.F. Shapiro an & 1952. h81-h90, Neurol. Arch. éﬁ: ibid, Pszchiat. .... Order of Dominance in Cutaneous Perception, Trans. Amer. Neurol. Assoc. 7h: 238-2h0, 1952 (with Drs. M.B. Bender and M. Green}. Patterns of Perceptual Organization with Simultaneous Stimuli, Arch. Neurol. & Ps chiat. 13: 233-255, l95h (with Drs. M.B. The Face-Hand '- Bender and M. areani. 1953 8. 9. HeDeielopment of Perception of Simultaneous Tactile Stimuli in 1953 (with Dr. M.B. 27-3h, 3: Neurologz Normal)Chi1dren, Bender . Perception of Simultaneous Tactile Stimuli by Mentally Retarded Adults, J. Nerv. Ment. Dis. 117: h3-h9, 1953 (with Drs. M.B. Bender and M. Green). �-210. 11. Spinal Fluid Findings Following Cerebral Angiography, Neurol— ( 1953 with Dr. J.M. Stein). 137, ogz'g: A Statistical Study of a Psychoanalytic Hypothesis: Absence of a Parent as a Specific Factor Determining Choice of Neurosis J. Hillside Hosp. 3: 67-71, 1953 (with Dr. S. Tarachows. 12. 13. Effects of Barbiturates on Perception, Trans. Amer. Neurol. Assoc. 15: 1953 (with Drs. M.B. Bender, P. Bergman and M. Nathanson). Homosexuality with Panic and Paranoid States (Case Report) J. Hillside Hosp. 3: 16h-19o, 1953. l95u Standardization of the Face-Hand Test, Neurology, h: 211-217, l95h (with Dr. M. Green). 1955 Test in Patients with Mental Illness, J. Hillside Hosp. 3: 3-13, 1955 (with Drs. R.L. Kahn and E.A. Weinstein}. Delusional Reduplication of Parts of Body after Insulin Coma Therapy, J. Hillside Hosp. A: 13h-1h7, 1955 (with Drs. R.L. Kahn and D. Graubert). The Amytal 16. 195 O\ 17. 18. 19. Relation of Amobarbital Test to Clinical Improvement in Electroshock, Arch. Neurol. & Ps chiat. 16: 23—29, 1956 (with Drs. R.L. Kahn and E.A. Weinstein). Evaluation of High-Dose Reserpine Therapy for the Relief of Anxiety, J. Hillside Hos . g: 67-77 (April) 1956, (with Drs. M. Wachspress, 1.5. Blumberg and J.S.A. Miller). Relation of Changes in Memory and Learning to Improvement in Electroshock, Conf. Neurol. lé’ 88-96, 1956 (with Drs. H. 20. Korin and S. Kwalwasser). Denial of Blindness Following Cerebral Angiography, J. Hillside Hosp. 5: 238-2h5, 1956. �-321a. Quantitative Studies of Slow Wave Activity Following Electroshock, EEG. Clin. Neuro hysiol. 8: 158 (abst) web.) 1956 (with Dr. §.E. Kahn). Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A.M.A. Arch. Neurol. & Psychiat. 18: 516-525, 1957 (with Dr. 5.5. Kahn). 1957 22a. Clinical Response to Megimide, EEG. Clin. Neurophysiol. 2: 180, 1957 (with Dr. M. Green). Clinical and Electroencephalographic Effects of Megimide in Patients without Cerebral Disease, Neurology 8: 682-685, EEG and 1958, (with Dr. A Green). Unified Theory of the Action of Physiodynamic Therapies, J. Hillside 26. M. Hosp. é: 197-206, 1957. Perception of Embedded Figures After Induced Altered Brain Function, Amer. Psychol. lg: 361, 1957 (with Dr. R.L. Kahn). Social Factors in Selection of Therapy in a Voluntary Mental Hos . g: 216-228, 1957 (with Drs. Hospital, J. Hillside R.L. Kahn and M. Pollacﬁ}. Role of Stimulus Intensity in Perception of Simultaneous Cutaneous Electrical Stimuli, J. Hillside Hosp. é: 2h1-250, 1957 (with Dr. H. Korin). 1958 27. Changes atholo grune & 28. 29a. in Language During Electroshock Therapy, in Psycho- of Communication, Ed. Hoch, P. and Zubin, gtratton, 1958, {with Dr. R.L. Kahn). J., Lateral Gaze Nystagmus as an Index of the Sedation Threshold, EEG. Clin. Neurophysiol. 12: 162-163, 1958. Effect of Diethazine on EEG and Significance for Theory of EEG. Clin. Neurophysiol. 19: 207-208, Therapy, Coggulsive 19 . Effect of Anticholinergic Agent, Diethazine, on EEG and Behavior: Significance for Theory of Convulsive Therapy, A.M.A. Arch. Neurol. & Psychiat. 82: 380-387, 1958. �-uidem, Biol. Psvchiatr THE-195. 29c. New 30. 31. ‘ 32. 33a. b. Bha. b. YorE, ed. Masserman, , J., Grune & Stratton, Experimental Studies of the Electroshock Process, Dis. Nerv. Sys.. 12: 113-118, 1958, (with Drs. Kahn and Green}. Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. 166: 18h6-1850,1958 (with Drs. R. Shaw, G. Gross, and E.§. Coleman). Electroencephalographic Correlates of the Electroshock M. 1958 Green). Dr. Nerv. (with Dis. 227, Bye. l2: Process, Experimental Studies of Convulsive and Drug Therapies in Theoretical Implications, A.M.A. Arch. Neurol. Psychiatry: & 1958 (ﬁEtE‘ﬁ?§T'§TE?'EEEE‘ 80: 733-73h (abst.), PSﬁchiat. an . . reEK). Alteration of Brain Function in Therapy, in Ps & N. Brown Co., Ed., Frontiers, Kline, Little, cho harmacolo y BosEon, 1958, Pp. 325‘3320 Effect of Anticholinergic Compounds on Post-Convulsive EEG Behavior, EEG. Clin. Neurophysiol. lg: 776 (abst.). Effect of Anticholinergic Compounds on Post-Convulsive EEG and Behavior of Psychiatric Patients, EEG. Clin. Neurophysiol. 13: 359-369, 1960. and 1959 35. 36. 37a. b. Effects of Diffuse Altered Brain Function on Perception, in Proc. XV Int. Con . Psychol., North Holland Publ., Amsterdam, [959, PP. 238-259 (with ﬁrs. R.L. Kahn and H. Kojéﬁ)..lk~u-Al Diff rences in Psychological Factors Affecting Individual Jwﬁfgvﬁt Behavioral Response to Convulsive Therapy, 2h3-2h8, 1959 (with Drs. R.L. Kahn and M. Po ac 128: Significance of EEG Pattern Changes in Psychopharmacology, EEG. Clin. Neurophysiol. 11: 398 (abst.) 1959. EEG and Behavioral Effects of Psychopharmacologic Agents, Neuro-Ps cho harmacolo y, ed. Bradley, P., Elsevier, REE-HES, T950. Amsterdam, 38ayr / Electroencephalographic and Behavioral Effects of Tofranil: Canad. Psych. Assoc. J. h: 1668-1713., 1959. v.9w. �-5; (abst.), 38b. Idem, EEG. Clin. Neurophysiol. 13: 2h3-hh 39. Relation of Tests of Altered Brain Function to Behavioral Change Following Induced Convulsions, The First International Con ress of Neurolo ical Sciences (III: EEG, Clinical Neuro— and EEIIepsyi, Pergamon,‘fondon, 1959, pp. STE-519 physiology W a n and H. Korin). ran 1960. . a of Set in the Perception of Simultaneous Tactile Stimuli, Am. Jour. Psychol. 13: 38h-392, 1959 (with Dr. H. The Role Korin). Personality Factors in Behavioral Reaponse to Electroshock l: J. Neuropsychiatrz Therapy, Kahn . h5-h9, 1959 (with Dr. R.L. Wm: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental HOSpital: Duration of Hospitalization, Discharge Ratings and Diagnosis, A.M.A. Arch. Gen. Ps chiat. """ _1_: 565-571., 1959 (with Drs. R.L. and M. Pol ac . 1960 h3. Efficacy of Divided and Single Dose Schedules in Insulin Therapy, Coma J. Am. P8 Drs. A.G. BlumEerg and hh. h5. h7. h8. 1960 (with Eaderman). in Verbal Transactions with Induced Altered Brain Function, JNMB-IBO: 235—239, 1960 (with Drs. J. Jaffe and R.L. Kahn).: S;uw.UUub‘Jua'but Drug Induced Changes in Intervi w Patterns: Linguistic and Neurophysiologic Indices, in ‘__Dynamics of Psychiatric Drug Therapy, ed. G.J. Sarwer-Foner, C.C. Thomas, Springfield Changes 9“ pp. h6. 116: 839-h0, chiat. %. ’ Jaffe 1960, (With Drs. Jo Social Attitude (California and R.L. Kahn). Scale) and Convulsive Therapy -JNMB 130: 187-192, 1960 (with Drs. R.L. Kahn and M. Pollack). 5.“,"wllua-Du‘ Figure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 3: 5h7~551, 1960 (with Drs. R.L. Kahn and M. PollacES. F Prognostic Value of Rorschach Criteria in Clinical Reaponse to Convulsive Thera 1960 2h2-2h5, J. Neuropsychiatrz y, l: Kahng. (with Dr. R.L. r .2” //£ .'V ' '.. / «n: Ln 1 I aré/a /->" -'- f, 4' _.” ‘. a“ ’34 45.114.” 7;” gay” n)/m / (j " 6.. ff) ,1"? ' "'4 K p (1 ‘ H y ,y /" m; «1" (rm *4 I 3 . , w V if“. r 51:3 ‘ /7w,« 5mm... x {5" ‘ ‘*' 4'" /‘ (a 3.1;,' A A.' g ”z " e, p/fivJ’J‘ “l ' W. “if 3 f/ a 3 (f ‘- , / ’5 K £9 / 3%» u �- 1961 h9. Modification of Psychotherapeutic Transactions by Altered Brain Function, Amer. J. Psychother. 1E: hé-SS ( with R.i. Kahn). Neuropsychologic Response Patterns of Some Psychotropic Drugs, Neuro-Psycho harmacology 3: 38l-38h, ed. E. Rothlin, Elsevier, Amsterdam (with M. Pollack, E. Karp, G. J. Jaffe, SO. H. Esecover and Krauthamer and D.F. Klein). 51. Problem of Antagonists to Psychotropic Drugs, 30-320 ibid, Inhalant-Induced Convulsions, A.M.A. Arch. Gen.Psychiat. h: 259-266, (with R.L. Kahn, E. Karp, M. Pollack, M.A. Green, B. Alan and H.J. Lefkowits). 53. Behavioral Patterns in Convulsive Therapy, A.M.A. Arch. Gen. Psychiat. E: 30-36, (with R.L. Kahn). Sh. Sociopsychological Characteristics of Patients Who 132: Refuse Convulsive Therapy, Jour. Nerv. Ment. Dis. —' """"“"“"""""""" M. 153-157, (with Pollack). SS. EEG Techniques in Study of Psychotropic Drugs, Acta of on Techniques for Study of Psychotro ic Int'l Meeting Drugs, Soc. Tipografica Modense, Modena, 1951. Withdrawal Symptoms Following Discontinuation of Imipramine Therapy, Amer. J. Psychiat. 118: 5h9-SSO (with J.C. Kramer and D.F. Klein}. 52. Experimental Psychiatric Research at Hillside: Review and Prospect, J. Hillside HOSEital 19: 159-169, 1961. Prediction of Individual Patient Response to Convulsive Therapy, VA Coo erative Chemothera y Studies in Psychiatry é: 317-325, 1951. Social Aspects of Psychiatric Treatment in Three HospiVA Coo erative Chemotals: Methodological Problems, 202-205, 1951 (with Studies in thera Psychiatry é: M. PoElack, N. Siegel and R.L. Kahn). Quantitative Electroencephalography and Human Psychopharmacology: Frequency Spectra and Drug Action, Medicina Experimentalis i: 36h-369, 1961. '7 -.\,A.-r-w, . -ﬁm... , _. ,, .1 . um.» . .4 m A~ a ‘R .1.” �1961 c" h9. Modification of Psychotherapeutic Transactions by Altered Brain Function, Amer. J. Psychother. 15: h6- SS ( with J. Jaffe, H. Esecover and R. f. Kahn).“ Neuropsychologic Response Patterns of Some Psychotropic Drugs, Neuro-Psycho harmacology 2: 381- 38h, ed. E. Rothlin, Amsterdam (with M. Pollack, E. Karp, Elsevier, G. Krauthamer and D. F. Klein). Problem of Antagonists to Psychotropic Drugs, 30'320 ibid, Inhalant- Induced Convulsions, A. M. A. Arch. Gen.Psychiat. h: 259- 266, (with R. L. Kahn, E. Karp, M. Pollack, M. A. Green, B. Alan and H. J. Lefkowits). 53. Behavioral Patterns in Convulsive Therapy, A.M.A. Arch. Gen. Psychiat. E: 30-36, (with R.L. Kahn). 5h. Sociopsychological Characteristics of Patients Who Refuse Convulsive Therapy, Jour. Nerv. Ment. Dis. 132: 153-157, (with M. Pollack). 55. 56. Techniques in Study of Psychotropic Drugs, Acta of Int’l Meeting on Techniques for Study of Psychotro ic Drugs, Soc. Tipografica Modense, Modena, 1951. Withdrawal Symptoms Following Discontinuation of Imipramine Therapy, Amer. . Psychiat. 118: Sh9—SSO (with JKlein}. EEG J. C. Kramer and D. F. CriticalEEGFlicker Frequency and EEG Alpha: A Reliability Clin. Neuro hysiol. (with E. Karp and Study, M. Pollack}. ‘ Neurophysiologic-Adaptive View of Convulsive Therapy, J. Neuropsychiat: Disordered Perception of Simultaneous Stimulation of Face and Hand: A Review and Theory, Biological PsychiaM. IV: (with Pollack). try, Factors Associated with the Selection of Applicants for Out- Patient Psychiatric Treatment, Social Issues. (with The N. Siegel and R. L. Kahn). �1962 I..— 61. 62. Critical rlicker Frequency and Alpha: EEG Olin. lenroghzeio1., __c Study, EEG and x. Pollack). A Reliability 1962 E. Karp (with , of Action of Convaleive Therapy: The Neurophysioe logic-Adaptive View, J. Neurogezchiats, ;; 231-233, 1962. The node Disordered Perception of Simultaneous Stimulation of Pace and Hand: A Review and Theory, Biolo icel Pe chiatr , IV Ede Jo 6h. Hortil, Ch‘pe 31, (With He P011.Ck)e Tachietoeoopic Perception After Induced Altered Brain Function: Influence of Hental Set, J.l.H.D., : , 1962, (with 1!. Pollack, 11.1.. Kahn and E. Kerp). Psychiatric Reaction Petterne to Inipraline (Torranil), 1962 D.F. Au. Jour. Pezchiat., __: (with Klein). , 66. Behavioral Reaction Patterns with Phenothiasinee, A.M.A. 1962 D.F. Arch. Gen. Pczphiat., __: (with Klein). , Quantitative Electroencephalography and Hanan Peychopharaacology. II: Drug Patterns, in EEG Correlate of Behavior, ed. 6. Glaser. 68. Iniprenine an an Adjunct to Phenothianine Therapy, Cong. Pezchiatrz, __c , 1962 (with J.c. Kramer end D.F. Klein). �69. Motivation in Psychotherapy, (with 70. H. Co . Po ohintr , z , 1962 Siogol). Rating Sooloo as Bohoviorol cpango Hoaauroo in Payohophorna1962 cology, v.1. Coon. Chonothor. St. in Pozchiat., 1: , (with DJ. Klein) . ��1. 195“ ~- 1 ‘ .3)... Standardlzatlm of the Faee=~Hand Test, 1H1 . 1. . . ~..‘-.~-:- 1- _. 1.1,..1 "9:“ .1: (mthM. _Neumlog:’21'1=12'17*,~ if} ‘ -.1955 ; 157° 1.'i That 1n Patlents w1th Mental Illness, J1 .axld . (With . R9 Ed A01m; 126111). Kahn Ly} of ‘Deltslmal Redupllcatlm of Parts Insuhn after «)1...’ R1 13911147 Kahn L1 D1 and (mth H0321“; i151 Coma Therapy, - . ' A I ' . - .3 . of ' Relatmn E17 1 ' 1 ~ . . f;-';tal ____ 19.1 mmlxla 201 . Denlal S1. _ = ' of Bhndness Pollowmg Cerebral Angh , cal .2231 1”” 'bo ‘ ’ Response ' ; to Meglmde, ﬁle ”j 1197:206 r 213-1 f; '1' ; 1. . 1... =1. ‘ 3. 1 1 1 ’ 3 , of Megumde in Patlents mthout (mth M1 Greenl1 »"."I_phalog'aph1c Effects Cerebral Insease, Neum'Ly 18;". 682-685, A Umfled Theory of the Aenm of PhysL; . 231 5.; ‘ 1957? - . «11 ‘ . 1 111111111311, .. J1 ,~ » 1 . . ; . 1 1 1. _ . Percep'aen of Enbedded ﬁgures After Induced Altered Iram hmctlon, Arlen -_Ps »12 361, (with R1 L1 Kahn)1 ‘“‘ﬁf_= _ . , 1 . E ' '1 2511 i 1 261: Soclal Factors 1n Selectman of - 3 17'.“- ‘3 " 3 , ‘ Quantltauve Studlee 80f Slow Wave Act1v1ty Follcmno Electroshock, 158 (Feb1) Absmct (with R1; L1 Kahn)1 . :,li .‘7 ' Evaluatlcm Of High-Dose Fez-35': Therapy for the Rehef of Annety, J1;;H:LlJ.81de_ M1. A1 G1.B (mth (Apml), Wadxspress, .1 3057515 57.77, 'Relatlcn of Changes 1n Learnmg to Improvement in Electroshodt, and ("3.11.12 'arld '85:." K' waSSer) (mm Hﬁ 88"96 '18” - 5? ~1 Test to Chnlcal Improvement 1n Bleetmshock,‘ Arch New?“ Psichlat1; Chmagoﬂﬂe23-29, (w1th R1 L1 Kahn and E1 A1 Welnsteln) 1 . 1955 ' .” ‘ lay an . a Voluntary kntal Hospltal, J 1 H11151de:. "i 3 �, _ j, . ,R-Pwmmgw;wwﬁssuu 955.3,umnm'», a. . . ,_ . hock ' fef'lheor‘y sP: Con " '- 4 ,l 5x2 Therapy, Po Koch and Jo Zubin (Edltors), {Gr-me s‘ Stmtton, New. .p 125-139, '1; wt, methazme, on EEG and Behavmr- SIgmfIcance unease . , g3; 380-387 . Q Q . ‘ :1:- . . ,s \‘..:- '- 1‘s u.“ I, ILJMMJI-L‘LL . ,' ' a . . : u QL‘_=A-uzca-m‘:& :‘ﬁ'u was '.Q“ ‘ ,.Q.- .ijhV‘. 19 227 ' , . ‘ (w1‘th ’Ms I ‘n)s, .“v Q Bwemnental Studles 'o‘f Oonvuls1ve and Drug Theraples In Psyclua} 'Inphcanons, Arch Neurol“ Psychlato, meaty, 80 733-734Abstract, (mth Alterauon 1:, of Emu Functlon in Therapy, Em s C00, mule, :uezs Effect of ArrtIcholmec No pp‘325-332 1959., and BehaVIor of 19600 359=339. "101ﬁ12 as an Post-Oonvu131ve Psyehla' a'ilfie Panents , Electr-éeneeﬂ f: ,. L EEG 1959 I ‘ ' 35-0) I as "Effects In Proc. ‘XV Into Kalm Ro and 238-239 Austerdam), L; Holland, pp Amt}: en Percepuon, 1:0 BehaVIoral Response IndIVIdual DIfferenees In Rio Psyduologleal Factors Affectmg Ls Ka‘r-m and 'Convulswe Therapy, J]° new mento msquzsjzuaszua (szth Mo was of mffuse Altered Bram thctlm Pode) 9 , I. \ SIgnIeranoe of EBG Pattern Changes In Psychhanralogy, Neum 111.551010» 11k. 398 Abs ' . H ' 1: ��1951 (tmued) ' M031”Kahn)e 1 is Who Refuse Cmvulswe Therapy, Somyeheloglcal maractemstlcs of Patlents M, Pollackh J3, mm n‘ento (mth 153457 2132 Tea‘zmqmu 1:: Study of Psyebopm Draws, 3x3, £13.,”31103 EEC 360: _; 7" 1 ‘ 5;; ' ‘EJS'EID . : '- Masque ‘ * _, one Pollemng mcontlnuauan C46 51‘9‘9550 (With - 159631:sta . insauz, E . Ele ' 60;; E Jo - ..-. _ ,. . :é'. « ,1 I ’* « :1 E? 1629; i. /63 1 Eggs ijhActlm elol wlswe of _N_:;3:3c::ruat13 23133233 The Mode (21": gist}; ‘ .j.-_. 650 - ilj. 1%.th 31,-- Mp 362-36 J o , : . 1 . _ ;~' , A 1:29 Fa Klemh " ' The NemphysmloglesAdaptlve View, . of Face and Hand: A ;{~i‘;:"_‘"fw5at':0n‘ " 7'" : “22"430, (Wlth Mo Renew " Press, Inc;..,_ (Elenmn "(-2 . 0n: Pellack, 3 rehens Inﬂuence Of Ra Lo Kat-1n ~3PM1;]th4!a“.179-173 (szth 1 1"*0. Reactim Pattems 1:0. Im:.jjf;":;i‘:: 2132:4138, (mth ‘ Rehablllty Study, Electroence’ho M‘. Pollack). and Karp 'Z‘iiMy: -i; _‘ _ 3'4“ 3...»... i: '7 -5' . ’ , 1 . 2 :Tadustoscoplc Perception After Induced Altered Brain Mental Set, :Lonerve '65:) KIM)9 "‘ ' Alter-o ' 80u63 (nth E0 and Theory} «Jo-worn" 3 ~ 3111- 'Dlsordered Perceptmn Of 51ml1‘1_‘{-Ifi; E61!» ' F0 sane-3690 "anneal Fucker Frequency and EG Alpha New York)Chapta E Impnamme Therapy, and 13-0 -» : - 1962 . 2* dMe- «maﬁa -Quant1tauve Spectra and Drug Acum, Mada . g 61 off. _, Expemnental Psychlatmc Research at Hlllslde Renew and Prospect, Ja Hlllszlde _ Ej’V j:.at £118 ‘ r ;-;- +2 {j - ’“V Nu and Slegel)‘, ��Publications - 1963 and Human Psychopharmacology, (Abstracts, 1961 Meeting, Mbntreal), Electroenceph. clin. Neurophysiol. lg; 133-137. 7/~ EEG 72. Multiple Item Factors as Change Measures in Psychopharmacology, Psychopharnacologia M: #3-52, (with D. E. Klein). 13‘ Quantitative Electroencephalography in Human Psychopharmacology II: Drug Patterns, In: G. Glaser (Editor) EEG Correlates of Behavior, (Basic Books, New York), pp l77~197. 74; Comparative Studies of Chlorpromazine and Imiprandne, I: Drug Discriminating Patterns, In: P. B. Bradley (Editor), NeuroPs chopharnacolo , Vol. III, (Elsevier Publ. Co.), (With KL—Pollack'rD-r—EizKlein, A. G. Blumberg, I. Belmont, E. Karp, (In Press) J. C. Kramer and A. Willner). Vii Comparative Studies of Chlorpromazine and Imipramine, II: Psychological Perfornance Profiles, In: P. B. Bradley (Editor), Neuropsychopharmacology, Vol. III, (Elsevier Publ. Co.), (with M. Pollack, E. Karp, I. Belmont, and A. Willner). (In Press) wia’ and Human Psychopharmacology, III: Changes on Acute and ChronicnAdministration of Chlorpromazine, Imipagmine and Placebo (Saline), :W. P. Wilson and G. A. Ulett (Editors), Applications Quantitative 76. SS (In Electroence ofHEEG‘andWHumaﬁ"Psychopharmacology, h. Bibliography clin. Neurophysiol., Supplement 23, (in preparation), (With L. 77, * “ﬁg. 7" .. EEG w» Bouthilet E. Cromwell, and M. Brown). and Im1pram1ne of Chlorpromaz1ne on Perceptual Analytic Effects Ability, Perceptual Responsivity and Memory as Revealed in Rorschach Responses, J. nerv. ment. Dis., (with I. Belmont, M. Pollack and A. Willner). (In Press) �Nm~£xpcrim1ts1 B. ‘9. 1. BookRevimdeattm 23m" use, 33 W W3 Diffcmtial Trcctmnt and R. D. Win: and w. Simon, 1:. c. sispringficld. Illinois); 1959." 121-122. in Schizoplmmic. m. Revicwqé' Amh. Experimental Studies of the Mode of Action of Electroccnvulsivs Therapy Jun-Otto. Ottosoon (Editor) . get; pm KIWI c ("ET—MW, {swam Scam. 6'39 PM The i A Symbol Wo_ ” V“ .. 3"me m 1 clin. .3. Will J. Hillside (Bateugf’: “' R. 001m 1956. 111.7. Home 8101. 1952, Psychiatry H. Bruin (Editor), Pittsbm‘gh‘ﬁ 1961. ENG. 11093., 1962, 31;: Review“? .. W Doomtraliutim of Psychiatric Services and Ccntinuity Milbcnk of Md, 1961, CmL3thliM Pictorial Fund, Na York. 1982. Ravi“. ”of mm of. mm: cad m._ War, 1963, 3.: Jm» Intmticncl Dicticnm ' ’ in Clinical Medicine, harm KUniv. Pittsb‘n‘gh Press, on 0 (Esmgfyﬂwkgaﬁi 1361. E: :52. MMMHMNWNL '15.!) Psychic Graphs-M. of Pour “yﬂxginsgiﬁwﬂmiﬂﬁ V 78-79. ”W, Us 1;)“, C. C. Homology and WWW, cog, . a“ Wit: for Electra; Indicgtdgrs QumtiStctua cmvulc wk 'Ihcmpy. latter to the tar. {an};m. of ﬁg. 23: 292-293. P " mm Mt m, Emmi/1953. in of Inubmctim to Physical chiam,"w: Scrgcnt and E. Slctcr ”"W, An» 4 ' a; 1983*; and Wilkins new, 1mm“ (In mas) Review-dahntcl Mitch. ' , Cap 42.: ! ”1/ @3234 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource [Hillside] Hospital annual report (folder title). Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-008 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1960 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Experimental Psychiatric Programs at Hillside Hospital - A Review (several). Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/037717b3a94f66da3e9b2761caa9f3e2.pdf e23ad26e74d9d730dd0ebac94c7bdd05 PDF Text Text January 8, 1960. KIHORAIDUH 1803: 20: SUBJECT: Medical Director DOpartnent of Experimental Psychiatry Salary Scales for Professional Staff Over the past few years we have attenpted to establish reasonable salary scales based upon the conception of full tine work at the institution, without outside professional activity. By adninistrative pressures, a policy of equating Job positions both within the institution and between institutions has been grafted onto the full tine concept. This latter has been nade an integral part of the salary scales despite the awareness that so-called equivalent workers within the institution were not "full tine,’I and that institutional salaries are often different because of the nador.fringo benefits. Continuation of these fictions lakes further growth of this unit extrenely difficult. we are severely handicapped in recruitment; and the staff is restive, considering the opportunities they have elsewhere. We cannot provide university affiliation with graduate students as a source of new personnel; nor have we established an identification for staff persons with I the institution. For these reasons, among others, the following revisions of salary scale and work standards are reconnended for this Department, to be effective July 1, 1960. A. General Principles. 1. All appointments in Associate or Senior Associate categories are to be node on a full tine basis. �-22. All income tron ancillary eorvicee to accrue to the aeeeoroh Fund of the Hillside Hospital. 3. For Aoaooioto and Senior iseociate stat: neoboro ‘ aro in apeoial training toward graduate degree or oertitioatee, no enae to 83000 per anon: tor tour yoare lay bo approved by the Hadioal Director on roooaaondation o: the Director or the Dopartwho loot. h. aebbotioala Salary nay be paid up to .1: loathe after (it. years service and up to one year after oight yearoerrioa in the Dopartnont for etudy at another laboratory or ioatitotien. In the event that ouch eabbatioal in approved, travel and relocation expeneaa up to 3 looo nay be reqneetod. 5. Mentorohip in proteeaiooal eeoietiee and malpractice insurance oorerago to to providod by the Departnont. B. azeoifio Soolea 1e Pchhiﬂt’ye o. For accredited Alerioan Board or Peyohiatry, recent $13,000 - $20,000 with $1000 inoreaent, to 827,500; b. For :raduetoe, eligible for exaninatiooe, .16'000 ‘ .18,000a o. tor lellove (hth or 5th year) $12,000 “ ; ’1h3000 2. Payohelegy. a. Senior Reeearoh atatf ~ 31h,000 - $20,000 Ph.D. and ten or lore yoare orperienoe. .b. Pazaoaroh Aeaoeiate - $10,000 - $15,000 .D. o. Roeearoh iseietanae - $8,000 Phono G‘ndid.t..o ~ $10,000 �ca. 4. Roooorch Follow - $5,000 - $7,000 a. Job Sgociticotioa. 1. For itou la, b, ond to, b, o, tho doooriptiono in monotondun or ootobor 30. 1958, opply. i 2. For itolo 1n ond 24: ohoonto In tho or groduoto oohool otriliotion, tho troininc or our oqn otorr 1o Iondotory. With tho potontiol oupport of (routing ooonoioo oloo dooirono or providing troiaing tundo, thooo rongoo oro onggootod,'ond itouo oiil bo roquootod ‘in tho noxt budgot. 10. Poychiotriota Cooplotion or throo yooro in psychiatric rooidoacy, ond dooirono or otndyiatdhring hth ond 5th yoor. 2d. Ph.D. oondidoto or H.A. ooudidoto. Eorly in coroor, without thooio, would roquoot tnndo to pornit ouch oooiotont to oporoto within tho loborotorioo. \ Roopoettully onbnittod, IX ‘n, oo �\ Departaent of Experimental Psychiatry « April It, 1950. Director SUBJECT: Salary Scales fer Pretessienal Start. Correction of acne dated January 8, 1960. Here stands except for specified revisiens receanended: HEEORLIDUH Page 1. Page 2. T0: Medical General Princigles. 1. All appeiutsents er presetiens te senior Research Associate are made en a 'full'~tell-tiae basis. Appeintaents in ether categeriee are "fellotine" according to established standards of the Hospital. 2. All inceae Irea ancillary services of "full" full-tine start to accrue to the Research Fund of A. Eillsids Hospital. 3’ h, 5. B. 'tCte Sgecitic Scales 1. Psychiatry (a) Sr. Research Asaeciate: en agreeaent with the Medical Directer (b) Research Associates for accredited Aaerican Beard or Psychiatry, recent $18,000 . $20,000, with $1,000 increaent, to $27,500; for greauates, eligible for exasiuatiens, $16,000 - $18,000. (0) tellers: (hth & 5th year) - $12,000 - $1h,000 2. Psychology (a) Sr. Research Asseciate: stat. (b) Research Associate: Ph.D. and esperinental ,» experience $9,000 - $1h,000 (c) as. Research Assistant: x.i. or equivalent, three years experience, and candidate for Ph.D. at accredited university - $7,000 - 39,000 — (d) Research Assistant er Pelbw: H.i. or one year experience - $5,000 - $7,000 �Pug. 3 0. Job Sgociticatiana: while specificatians at 10/30/58 would apply, following changes arc rnqnvatnd. In original docignntion, Rcuoarch Lsaociata in Psychology was limited to Ph.D. and thrus ynnra or oxporicnec. this in hurdansonn, and :11 Ph.D. appointinbo designated 'Aaaociatc.' Assistant dasignation be subdividad to Sonia: Rnaonreh tall-tint and Roacurch Aaaintaut, as abovo pornittinx tho nmploynont or trainees 1nd aundidat-a, with origiu;1 cpcoificutiona applying. Roapodlully submitted, ‘EE§“FIEEI"HTET”~’"' 31:13 ��Pg. 1 Dr. Fink To: Director, Research in Emerimental Psychiatry Prom: Accounting Dept. Re: Report of Expenditures .131; 1 - October 21: 1960 HOSPITAL SUBSIDIZED RESEARCH 1960-61 Ebcperience To Date 25, We 8, 331e 3,167. 363. Dudet Salaries BC Assoc. 8c arises: Fink in Social Psychology Siegel Psycholinguistic Technician Secretary Medical Equipment Office Equipment Travel Supplies Social Security Director's Kolodny Podrid 118. ' Blue Cross Expense Account & Income from Nassau County Net Expenses cc: Hr. Bachrach h85. 1,500. Total Expenses Less: 3,120. 2 ,172. 2 , 890. 3,1t00o 3.1100. (67.) 920. 600. 119. 161. 237. 10,120. 12,796. 3,120. 1214. h0,000. 12 ,672. �Dr. Fink Director, Research in Experimental Psychiatry Pg. 2 GRANT biz-2115 5% to 12/31/61 Grant approved for $65,886. to 12/31/61 Supplemental Grant 16 2 O. approved for Amount applicable to 1960-61 6 151%: h1,058.* 1960-61 Budget quaerience Grant Balance 6/30/60 32,105- 3h,699. Additions: Amount applicable to 1960-61 1.12158 .* m, _ Starting Balance Salaries & Additions 8. nses: ese ssoc. n sychiatry Sr. Assoc. in Ehtp. Psychology Assoc. in Exp. Psychology Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary Klein Pollock (Gittelman (Bel-"nut Karp (Krauthaner (Andermnn Kclodny Mosquera Bowie Podrid To Date 73,1463. 3h,699. 16,1416. 5,667. 10, 92°. 7,500. 2 ’ 500. 2 ,500. 8,500. 2,931. h.l.10. 1,1426. 7,333. 3,360- 291. 1,123. 1.80. MM Supplies Iviedical Equipment Office Equipment Social Security 8: Overhead Blue Cross Travel Total Eutpenses Unexpended Balance cc : Mr. Bachrach 2,500. 382. 1,928. 101. 1196. 9,681.. 2,7hh. 563. 72,9330 20,8270 13,372. �1“ Director, Research in Experimm Psychiatry Dre mm Pg. 3 181-2092 Great. terminates 12/31/60; expenditurepicked up by Great III—2715 Supplement. mm m0 Starting Behnce 5 Additions We:PWIC" Salaries & Sr. Assoc. in Me Repairs to quipnent 800111 Security Overhead Tom & Blue Crone WW3 Wed We 6,&7e 7,h35e To Date 0 Additions Behave cc! Hr. Mhrech Wk be 1960-61 Bidet " 6/30/60 te 6,667. 7,h35. 5,667e 11,333. 130. 870. 1:3. 628. 6,667. 5,7080 0 7014. 1,727. �Pg. 1 ”MaDr. Fink To: Director, Research in kperimental Psychiatry Fran: Accounting Dept. Re: Report of Expenditures .1an 3 .. 393mm; 30, 1260 HOSPITAL SUBSIDIZED RESEARCH 1960-61 W'Lec Salaries nses: & Assoc. in Social Psychology Psycholinguistic Technician Secretary Medical Equipment Office Equipment 'l‘revel Supplies Social Security Director's Blue Cross Expense Account & Total Expenses Less: Income from Nassau County Net muses cc: Mr. Bachrach Experience Bidet Fink Siege). Kolodny Podrid 25,000. 3,120. 2 ,172. 2,890. To Date . 10, 338. 3,958. 5&6. 730. 1,500. 118- 3,h00- 3,1400. 920. 600. (55a) 173. 22h. 290. 10,120. 16,2014. 3,120,. 177. 130,000. 16,027. gm �M Director, Research in Experimental Psychiatry Dr. ( ' GRANT Pg. 2 111-27}; 1/1/61 to 12/31/61 Grant approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant approved for Amount applicable to 1960-61 W Grant Balance 6/30/60 Additions: Amount applicable to 1960-61 Starting Balance Salaries 8: ese uses: ssoc. n sychiatry Sr. Assoc. in Eng). Psychology Assoc. in up. Psychology Asst. in Assoc. Psychology Exp. Psychology Ebcp. in Psycholingzistic Technician E.E.G. Technician Secretary Secretary Klein Pollock (Gittelman Social Security a: Overhead 1960-61 Budget Experience 32,1105. 3h,699. 311,699. 16 ,hlé. 7,083. (Belmont Karp (Krauthamer 10,920. 7,500. 3,500,, (Andaman 8.500. 3,6140. Kolodny Hosquera h.h10. 1,783. 1,h06. 3 , 360. Bowie 2.500. 382. 1,928. Blue Cross Total Expenses Balance 5 d .- cc: n .n ﬁ.w ,...,..— I I Illll 291. 1:80. 165. 607. 3,130. 72,933. 26,185. 675: -IIIM' 530. ,. -Nv “A. 3,125... 9.681;. Travel "I'fn'expended To Date 73.h63. 7,333. Podrid Supplies Medical Equipnent Office Equipmnt h1,058.* 1413958 .* Additions 8. l "851%? 6 2 O. 8,51)» �..o~’ Drcl'ink Director, Research in mm Psychietry mm Pg. 3 III-2092 «when: 12/31/60; «podium» to be picked up by Great 141-2715 Suppl-lent Went 1960-61 Met Great Balance - 6/30/60 6.667. Belem. & mm» W Selene: I: Expense” 8r. Assoc. in Exp. Psychology S plies ‘greee Social Security Overhead Total To DI“ 7,105, 0 Additions mm Experience a Blue heme Wed Behme Pollock 6.661. 7,155, 5.567. S,h17. 130- SS. 725. 870. 785. 6,667. 6,982. 0 1:53. �' To: Dr. Fink Director, Research in Prom Accounting Dept. Re: Report of 119 Pg. 1 M mm herinentel Psychiatry nditures to December 31, 1960. A -._A -4tm ,.._ Assoc. in Social Psychol Paycholinguietic Technician Secretary Medical Equipment Office Equipment Travel Supplies Social Security ctor'e Tom Blue Croce Expense Account a: mews Less: Income from Nassau County Net Expenses Pink Siege]. Kolodnv Podrid 25, 000. 3,120. 2,172. 2,890. 112.3335. 14,750. 739. ”5. 1 500. ,118. (SS“ ) 3 ,hOO. 3,hoo. 920. 600. 233° 290’ 1‘3ng ”’566. 3.129.. 265. 130,000. ' ‘ ' �Dr. Fink Director, Research in Experimental Psychiatry GRANT Pg. 2 111-2715 approved for $65, 886. 1/1/61 to 12/31/61 Supplemental Grant approved for 1/1/61 to 12/31/61 Grant 1’20. ﬁg. Amount applicable to 1960-61 1960-61 Budget quaerience Grant Balance 6/30/60 32,105. 313,699. Additions: Amount applicable to 1960-61 1413958.!- ‘ Starting Balance Salaries & nses: Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician E.E.G. Technician Klein Pollock 16,h16. 7,333. 8,500. Karp 10,920. 7,500. h,soo. 8,500. 31,3338. h.h10. 2,”.0. (61th (Belmont (Krauthaner (Aniormann Kolodny Hosquera 3,350- Podrid Supplies Medical Equipmnt Office Equipmnt Social Security 3h,699, Bowie Secretary Secretary 8: Overhead 2,500. 382. 1,928. Blue Cross Trml Total kpenses Unexpended Balance _ I cc : Hr. Bachrach To Date 73,h63. Additions & ese ssoc. n sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology _ hl,058.* ' I II. 3,750,. 291. 1,689. EEO. 278. 697, 9,68,4- 31,116. 72.933. 31,1170. 631. My 530- 3,229, Mum �Dr. Fink Director, Roam): in Experimental Psychiatry mm Pg. 3 31-2092 mus 12/31/60; Grunt picked up by Grant 141—2715 Wt. exp-Mite": to he 1960-61 that Balance - 6/30/60 ' 6,667. 3mm. 6 Additions W Salute: & Enema: $‘o To Date 71:35. 0 Additions Starting Met We “3°C. in m. won-m Supplies Social Security Overhead & 311:. Total. Expenses Unmanned Balance cc: Hr. Bum-ad: areas Wk 6,667. 71:35. 5,6670 6 Q a 130. 870. 63‘. 91-2. 6,667. 8,2138. 0 (813.) �W P80 1 W Dr. Fink To: ‘ Director, Research in Experimental Psychiatry Fran: Accmnting Dept. Re: Report of Menditures 1961 HOSPITAL SIBSIDIZED RESEARCH Salaries ec Assoc. & uses : in Social Psychology Psycholingulatic 'Dechnicien Secretary Medical Equipment Office Equipmnt Travel Supplies Social Security 8: Blue Cross Director's Expense Account Total Expenses Leas: Income from Nassau County Fink Siegel Kolodny Podrid 25,000. 3,120. 2,172. 2’890’ lb 181 5,5112. l ' ’912' D 220.0 _ 1,500. 118. 3,)400o 3,h00. 920. (SS ) 2714' 600. 397‘ 387: 10,120. 22,858. 34L 265. . l __________________________________._____———-——--——--—Net Expenses cc : Mr. Bachrach h0,000. 22,593 �Dr. Fink ‘ _.. ., Director, Research in 'hcperimental Psychiatry GRANT Pg. 2 IKE-2715 1/1/61 to 12/31/61 Grant approved for $65 ,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0. approved for ‘B'iﬁi'ﬁ Mount applicable to Grant Balance 6/30/60 1960—61 .m Additions: Amount applicable to 1960-61 Starting Balance Salaries & Additions nses: ReseF-ch Issac. In Psychiatry Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology . 1960-61 Budggt Experience 32,1105. 3h.699. ulzostm 20,529. 73,h63. 55,228. 16,h16. 7,333. 9 ,917. 1,083. 10,920. 7:500- 5,500, h,375. 8,500. 5,056., 291. To Date 8: Asst. in Ebcp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician W E.E.G. Technician Secretary Secretary Supplies Medical Equipment Office Equipment Social Security a Blue Cross Overhead Klein Pollock (Gittelman (Belmont Karp (Krauthamer (Ardemenn Kolodny Hosquera me Podrid 14,1th3 9 360. ‘ Total Ehcpenses Unexpended Balance Mr. Bachrach 2 ,517. 1, 972 ¢ 1:80. Cartolano 13s 2 ,500. 382. 1.928- 99681“ Travel cc : b1,058 .* 281;. 920. 5,009. 979. 72:933- 38,396. 530- 16 ,832. . �Pg. 1 Dr. Fink To: Director, Research in Experimental Psychiatry From Accounting Dept. Re: Report of Ehcpenditures 1: 1260 - Februagz 28I 1961 ng HOSPITAL SUBSIDIZED RESEARCH Salaries & 80 menses: Social Psychology Psycholinguistic Technician Secretary Assoc. 111 Medical Equipment Office Equipment Travel Supplies Social Security Director's Blue Cross Expense Account 8: Total Memes less: Income from Nassau County Net mpenses cc: Mr. Bachrach Fm Siegel Kolodny Podrid 25, m0 3,120. 2,172. 2,890. 1 500. ,118. 3,h00. 3,h00. 12,33: 1’09; ,, J £1455: 180' 13h. 61. 525. 920. 600. 1:17. 53:12“ 26,238. 3,120. “3,955. 10,000. 2 3 ,283. " ; 4-; A 3*) 7’ . �\ Dre Fink Director, Research in ﬁrperimental Psychiatry GRANT Pg. 2 PIX-273:5 1/1/61 to 12/31/61 Grant approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant approved Amount Grant Balance 6/30/60 Salaries & Eggnses: ese esoc. sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Earp. Psychology Asst. in Ech. Psychology Assoc. in Earp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary Electronics Technician Supplies Medical Equipnent Office Equipment Social Security 8: m Overhead Klein Pollock (Gittshnan (Belmont (Krauthamer (Andermann Kolodny Mosquera Podrid Cartolano Unexpended Balance cc : Hr. Bachrach Experience To Date 3h,699. M* 203529. 73,1163- 55,223. 16 hlbe 71333- 11 o 3:333. 10 920. 6 500. 3500- 5,765. 7:500- 5:000. 291. hyhloe 2.895. 2,255. 3’36“ 2480. ho. \a ’38:. 500. 295. 1,92 e\~\...1 9’68hN-h 5,3533.. Travel Total Ebnpenses 111,058.?!- 32’h05- 2 Blue Cross 11:15: 1960-61 Budget Additions 8: 16 230. applicable to 1960-61 Additions: Amount applicable to 1960-61 Starting Balance for 15029. 72,9330 [6,852. �Pg. 1 W MEMORANWH Dre Fink To: Director, Research in Merinontal Psychiatry From Accounting Dept. Re: Report of Ebcpenditnres 195] 3] 12m lamb 1. 3 Jul: W RESEARCH SUBSIDIZED HOSPITAL Salaries Assoc. uses: 6: in Social Psychology Psycholinguiatic Technician Siegel m Kolodny Secretary Medical Equipment Office Equipment Travel Supplies Blue Cross Expense Account Social Security Director's . Total Expenses less: Net Expenses 7’125' 1 500. 180' 3,1400. 151: 1’ 335‘ 1:681: ’118. 920. 600. . Income from Nassau County Donation of Paychiatropic Drugs 3,120. 2,172. 2,890. 3,h00. 8: Experience To Date 1960-61 Budget »» ~ x... ,, . 110‘ 626. 1117: 10,120. 2951.0. 3 ,120. 2,955. 2 :295: h0,000. 21:390. to Hospital ______________________________...——————————--- cc : Hr. Bachrach �Dre Fink Director, Research in farperimental Psychiatry GRANT Pg. 2 m~271§ 1/1/61 to 12/31/61 Grant. approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0. approved for T511137 Amount applicable to 1960-61 1_‘_‘_____ Grant Balance 6/30/60 Additions: Amount applicable to Starting Balance Salaries Essen 1960—61 Additions 3. nses: Issac. In Psychiatry Assoc. hp. in Psychology Exp. Psycholog Psycholinguistic Technician E.E.G. Technician Bud eet Experience To Date 32,1105. 3h,699. hl,058.* 20.5293 73,h63. 55,228. 16 ,h16. 12,750. M327. (Belmont Karp (Krauthamer 10, 920. 7,500. 7 , 5142 .. (Amiermann 8,500. 6,1173, Kolodny Mosquera , 7,333. h,h10. 3,360. & Overhead Blue Cross Travel Total Expenses Unexpended Balance Hr. Bachrach 5,625. 291. 3,272,, 2,592. 1:80. 93. Castolano Supplies Medical Emaipment Office Equipment Social Security Klein Pollock (Gittelman Em; Podrid Secretary Secretary cc : 1960-61 8c Sr. Assoc. in Exp. Psychology Assoc. in Exp. Psychology Asst. in h1,058.* 2,500. 382. 1,928. 9.968140" 3760 1,376. 6,1173n 14100" 72,933. 52,770.» 530. 2,158. �P30 1 Dr. Fink To: Director, Research in Emoriuontd Psychiatry W1 Fran: Accmnting Dept. Re: Report. of Expenditures w—WW m HOSPITAL wnsmxzm RESEARCH M Salaries ac Assoc. & gases: Fink in Social Psychology Siegel Psycholinguistic Technician Secretary Kolodmr Mics]. Equipusnt 1960-61 merience 25gme 19,7950 1,500. 180. 33’4me 5939 3,120. 2,172. 2,890. 118. Office Equipmnt bIVOI Supplies Social Security & Blue Cross 7,917. 1,57h. 1,906. 711, 3shme 920. 600. 163689. Total Expenses 1.3.120. 33, 308. less: Incaus 3,120. 2 ,955. Director's Expense Account from Nassau County Donation of Psychotropic Drugs to Hospital Net kpenses ~ 41;] cc: Hr. Backrest: 1417. 2: 295: 150,000. 28 ,058. �Dre Fink Pg. 2 Director, Research in "apex-mental Psychiatry GRANT ' a... 141-271; . $65,886. for Grant. approved 12/31/61 1/1/61 to 1/1/61 to 12/31/61 Supplemental Grant 2 0 6 1 . for approved 121115: Mat applicable to 1960-61 1960-61 Budget ... ’41, 058 .* Experience To Date Grant Balance 6/30/60 32,)405. 314,699 Additions: Amount applicable to 1960-61 glIOSBJ 111,058s 73,1163. 75,757. Klein Pollock 16,2116. lh,167. (30130111: 10,920. 7,500. 8,583. 6,250. 8 ,500. 7 , 181. Starting Balance & Additions Salaries &ﬁsoc.uses: In Psychiatry Sr. Assoc. in Exp. Psychology Hem Assoc. in hp. Psychology Asst. in Exp. Psychology Assoc. in Exp. Psychology Psycholinguistic Technician EOEOG. WWW Secretary Secretary 7,333. (Gittelmn Karp (Krauthatner (moment: Kolodny m W ughloe 3,360. HOWE 5,1111. 291. 3,6509 2,353.. LBO. 93o Oastslano ' Supplies pursuant Office Equipnnt 2.500. 382. 1,928. Medical Social Security 8: Overhead Blue Cross 9.681;. Travel Total MEMOS Unexpended Balance cc: Mr. Bechrach . 169. 1,5711. 7,366. $139.91 72,9330 593,458: 530. 16 ,299. ' �I [1W W Iu' [44/ : ~--—; I C. I / 1/ / ’W W K4444” ' LI“I X { ~//‘/. / I/L/ I I / 1 I, d — / / 7’ 'V e - ‘1 .__ �2.7 f 444/ Ms/ ,1. r a M dv //'. / .4 — ’ M1 h. 1 a... / 41%;»! / ’, [14,.” I If:/- (I t». AI'VA‘;_727 44' w W / .4 / / 4’15] / 5;! 1% ’ / {i I 440/ a a/ ”M7142: 72ﬁ;4h.&¢ igv M (A I» r], «Ac/47% ’ 3 I / (5300 if 1’ C II» a» W ﬁwm) 72. 13/ / one 53¢: 39 ace �5—0 90¢ �1/3/61 Dopartnont or lxpsriaantal Psychiatry 1961-62 Bndgot, Propoood I. 1960-61 Indgst (-ovsrhsad) $118,882 a. Inorsasos in salariss, annual inorsnsnts b. Additions in prograns: 1. Psycholingnist - to ba aotivatsd 2. Sociologist to tho proxraa 3, £80 technician Statistical tsohnioian, g.. Elootronio oqnipnsnt é. o. s. Status rslatinx to lndgst John [razors Irt. tron fallowship status to Rasaaroh Associats 9/1/61; snbjoot to approval of g. or‘g. Donald Klein: continnss as Isa. Assoc. but is to ba grant (Kh798) supported. that tho dittorsncs in It is axpsctod salary iton on grant and an lsvsl nay ha up to $7500. Grant providss 85000 additional for sscrotaria1 and othar sxpansss. Sabbatieal ~ lax link: 9/15/61-8/1/62 Visiting Soiantist support is roqnsstad. rhara is no salary ohangs during yaar. Amount is $15,000 par annnn. Expanss III. W %,650 1 000 Changas in 0. Souroas of Support (-ovsrhoad) a. Approved: 1961-62 1. HI2715 . ha P01161118: 2, nh798 rotal 0 12,000 170,732 12,000 182,732 72,231 - (323,000) out. 3. Visiting Soiontist c. To bs Raqnastads h. Snpplonantary H12715 126,282 10,000 10,000 6'800 tins tins llaetronios spacialist, II. 7.300 “17,000 13,500 30,000 r¢/~ gh,g§o �$0,000 a. Board or Daroetorl 1. it would Ilk the Board to apprevo I grant 0: $h0,000 to: {var ytara; with an lpyortunity to carry tarvnrd unoxpondod can: far 2 yn;rs. 2. WI wanld also ask for a credit tranltor tron operating budget funds of value of psychotropic drugs (to $10,000) roecivod in the progran. In 1959. the ' vulno was ontinntod as O11,000. Inconn Eutinato: 182,731 Exponae Estinatcs 182,732 ��V WWW—WM...‘ r L ///~/ 5 ”A Z 3%” ' IBKOO >3, W? + ' ————-'_f"——' I 23, We ’3 ’ (00 ‘ 2.00 ..—— I ~ I I v ’ 2“ 3f?” = ��May 5, 1961 Hrs. Croghan Departnent of Experieental Psychiatry Heme: Iron: Subject: Budget '1. In reviewing find budgetery expenses to date, I the following in the Beapitelised Subsidized Research: Expenditures 7/1/60 ¢ 3/31/61 $29,5h0 Less my credits (Nassau County) 5,250 (Drugs) Estimated Expenses nets sonths 3 $2h,290 I Salaries (3&00 x 3) Social Secutity Travel Other 10,200 300 1,000 _ 200 net: Less credit for teeching 900 Research Associete in Psychiatry (Klein) app. Secretary I! (Podrid) app. hSOO 82g $5,325 my calculations are in error, please call as. Thank yen. a Sincerely yours, HTzOP 11,100 35,990 ax n , . �5. 1961 May HOIO! Mrs. Croghan Irons Dapartaont of Expsriaantal Psychiatry Subdaota Budxat 1. In roviaviag a: budgstory oxpsusaa to data, I find tho following in tho lospitalisad Subaidisad Rasaaroh: nxpandituras 7/1/60 ~ 3/31/61 $29,5h0 Lass credits (lasoau county) 5,250 (Drug-v) __.______ not: $2h,290 lotiaatad xxoonsos 3 months salarios (JhOO x 3) 10,200 Social secuoity Traval ethar 300 1,000 200 not: Lass oradit for teaching 2. 11.100 35,990 200 I: this is iha approxiaatsly would you oorraot, ploasa assign following sxpandituras to this account, tron Grant l1-2715, attentiva April 1? nosoaroh Associats in Psychiatry (Ilain) app. ASOO Saoratary (Podrid) app. “33: I: ay calculations aro in Thank you. 85,325 error, ploaso call as. Sinosraly yours, IIsOP ax n , . . �Prcptlod ltdgot 1961-6! nevi-ad 5/22/61 Doparinont .: tsp-rtnonttl Plyuhtltry annuity: Exponloo 1961-62 $156,hh0 Inoolo warns _ Eonpttal eruditl 108,870 1.510 116.;50 lot Unuubcidisod ltloarch 8 ko,ooo �5/22/61 Bspcrt-sct ct lxpssissntsl Psychistry Prcpcscd 1961-62 ludxst (lsvtssd 5/22/61) Exp-uses: 1. Blrsctcr 2. Assoc. 1n rsychistry .AQE‘o/B. Assoc. 1n Psychistry h. is. Assoc. Expos. Psychology 5. Assoc. in lxpsr. Psychslcgy 6. Assist. in Expos. Psychslcgy ,rswo'7. Assist. in lxpsr. Psychc1cxy 8. Assoc. in Sosisl rsychclcgy 1960-61 1961-62 Apprsvsd hsqusst (3. link) 25,000 25.000 16,h16 17'500 Sllcta) lrsnsr) . 13.000 Pcllsck; lslncnt 10.920 1.500 Ksrp) . Villas!) 2'004' b‘; 1h,000 11,000 8.100 73200 (9) 9,500 10,000 (d) I,$oo 1,h20 (s) Elbsqusrs) lss) h:h10 k,aoo 3.600 (I) ) 12. rsychslingsistis rsshntc1sn élslcdn Psdridg 13. soot-tar: (Ibssclnsn) 1h. alcrkotyptst 1,172 3,360 2,890 2.300 - 2.700 3:500 16. [quip-cut (attics, nsdicsl 11. frsvsl 18. acrylics 19. nircctsr's Prstcsstscsl lxysnsss b.5oo 3,h00 3,hoo 3.000 3,600 3.000 3,31h 3.500 9. Assoc. 1s lxpcr. Psychology 33:6) Andsrssan) 8:. ”Eu/11. no lcchsicisn, Jr. 10. ans fschnicisn, AﬂE‘VlSs fcchnicsl Assistant 20. Social Bcccrisy/llns Gross (lcs) (sst.) 21. msrhssd «- 600 11.01;]. 20211 $129,923 33h80 (t) 600 11,200 kg 2,8h0 1 $156,hho �-2. Bopartnont at lxporincutal Prychiatry lxyoulon 1961~62 lacunae 0&56ikk0‘ ﬂ?{5.3,qzelo 1. warns 31.2115 (62) - 1/1/61»12/61 (1/2) Iroaght toﬁvurd (03%.) (1/2) (ca) - 1/1/62o12/62 h1,oso k,oeo 32.000 w 87,059 2. warns x.h795 natinutod 8.1.2: 1k,26h n.710 pr. 0701‘. 2.8!!6 21,820 (a) 3. 2cc¢htn¢ (But. he hrs. .181!!!) h. Bra: rrnnlror (13%.) ' 1,000 (k) 3,570 (1) 4E=4HHhIHHap6Iadtﬁ-GIaI-é-otalG~9010htt§rttt+jhﬂﬁﬂy4hér W ”3 Vs'ro lot lxpouaoa (Haunt-111104 lcncuroh) 3 ha,ooo �lgtoot Sagportod, in art, by l~h798, aa Garcon Iavoaticator, otfoctivo 1/1 61. Bixtoroaoc in inooao will to aooignod tron l1-27159 (b) loplncoo 3.). [loin in nx-avzs. In continuing onporvioion of la! prozroa would roqnoot continuation of clinical onpyott a! l/h otat: poychiatriot iton. low appointacnt, ottoctivo 9/1/61 at $8,500 for air nontho, $9,000 thoroottor. loo appointaont, to ho aado 9/1/61, at oatinatod $12,600 pot annna. ippointnont onco 9/1/61. Will not ho roplacod onlooBiroctor rocoivoa II! Vioiting acioatiat award. (t) (a) (h) (1) (3) (k) (1) Ion aypointnont to porait hoopital~uido onrvoyw plannod attor 9/1/61. low poaition to: ototiotioal ani onporviaory :nnotiono. lollovo a roooanondatioa at Aaoiotont idniniotrator, Hr. Bavio, tollowinc a Job convoy Icy 1961. evorhoad allcvoaoo on l1-2715. avorhood allowanoo on l-h798. n~h198 allowo $18,!1h for oalary ani roooarch cooto; $2,0h6 for ovorhood. rho-o'itoao aro applicablo to tho prograa. It aloo allovo Oh.838 opooitiod oo training cooto. Ihilo Dr. Kloin nay not ntilioo tho on: in tho conin; yoar, it nay not to nood for othor pnrpoooa without oxprooo provioion. It ia onticipatod that thio on: will to rotnrnod to tho warns. Incono ootinato boood on continuation of coarooo in Biological Paychiotry and in noooarch lothcdology. lininal oatiaato balod on 1959-60 and 1960.61 oxporionco. loqnoot continuation ot clinical crodit-tor clinical oorvicoo, followingll960-6l oxporionco. ‘ �5/!!I61 a.“ nupnrtuont at prorannatal Parnhtu‘vy ttovonod 19§1~62 nudgit (3011804 5/22/61) 196o~61 lupus-0.: 1. Blrootor H. fink) 2. assoc. 1a rnynhxntry x1013) J. Assoc. in Ptyuhtutvy tranor) Assoc. 8!. 8390!. Psycholtcy (Pollack) g. A‘s... in super. Psyuhnlocy (not-oat) . 6. Acoiut. 1n Savor. Puyehalogy Earp) 7. Alutlt. 1a Payah01n¢7* Willa-r) or. 8. Autos. 1: 3.0 :1 Payuholocy luv; 9. Assoc. in Expor. Psyuholncy Ila Ap’rovod 8:. Inna ' 15.133131», m 330 ruahaictna, Andlrllll) on) 25.000 15.h16 - 13.000 10,9:0 7.500 - . 8,500 10. 11. 1!. 13. 1h. 15. 47. ll! Pﬂytholtsgutattc rochniotna {301.43 ) 50ar¢$ary roarid Clark. 10% ftnuatlnan) rlahnie Lnatutaat 30v) . 2,112 16. 11. 18. 19. Equtpuunt (otttc..n¢di¢n1) traval Suppltca Dtruator‘c !rottultonnl lap-anon 800131 80¢n31$7llluo 0:03: (00‘) h.500 3.h00 3,hoo to. no: 21. Ovarhoau "f ﬁg?! {VFW 4‘ anf‘ <\ \J, a\. iﬂﬂﬂt 3,360 2,890 - $00 3.31h 11.0h1 $129,923 ‘155 0500 �“531.1190 Inna-0i 1. um :::: um 'mzz-wzzx . _ W , 01.059 I. um: MM “mm am “.000 10.850 3. latching (83%.) h. um.) S. m Wu- clilttti crolit (xerox/h 500 5.00.0 (a) Itttr plyth$n3rtnt1;‘ggg lit lliilill (I) (lhlniltltsod tinnitus) (a) \ W W ‘ 1505000 �(o) (d) (o) (f) (s) (h) sappurtod, in part, by u~h198. ll carter Invoc‘tcntcr. ottaottvt 7/1/61. Dittoronco in incon- v111 be assigned S!!! IY~2715. Inpltaoa 5.1. Xi'an in ur~2715. In contanuzn; unparttnion a: no: progran would mounts: aonttnuttton at tho 1/8 nt‘tt poynhxntrtlt. lav appcxntunut. «rtagtavo 9/1/61 at :0.500 for at: nontha, $9,000 ‘hnrunttur. lav appatatnnnt, t- be and. 9/1/61, nﬁ outiuttad $12,000 par gonna. Appointncnt and. 9/1/61. 3111 not he rnplnood talus: ntvactnr rﬁcctvbl III Vitittuc Scientiut award. luv appointuant.to pcrult hoapxtllavado survey: planatd utter 9/1/61. New position for azntintloni and aupnrviaurr tunotlcnt. Fallout 3 risen-audition of Assistant idlinistr¢‘ar. pr. navio, (allowing a Job I‘TVII law 1961. on continuation or court.- in Inc... ontinnto bland and non-arch nothodoloay. Bioloctonl Payohtutry (1) Kin1nnl catiunto based anti-stat. on 1959~60 and 1960~61 ' (3) noqscnt continuation or clinical credit for 01131301 suvvtauu. failurtuc 1960~61 o:pnr1¢n¢¢. �HILLSIDE HOSEFRHL WEGE & SALARY SCALES Scale # HIRING RATE SERVICE-MERIT INCREMENTS "‘if""‘i?“”"“"§"" MERIT INCREMENTS “ﬁf“"“‘3¢‘”"‘ l 185 193 201 209 217 225 2 205 21h 223 232 2&1 250 3 225 235 225 255 265 275 ,h 250 ‘261 272 283‘ 29h 305 5 275 2877 233' 311f 323‘ 335 6 305 318 331' 324, 357 370 T 320 355 320 385 hoo 215 385 200 his h30 nus 8 376 �9113 TITLES ﬁrm GRADES AND HOURLLRATES F0 a JON-PROFESSIONAL PERSONNEE #h #5 $250-$305 $275-$33é GRADE MONTHLY RANGE myTITLES ﬂed hr A JOB - $l¢55hr Accounting Clerk Busboy File Clerk §_; $1.32 hr Cook‘s Helper Housekeeping Dictaphone Operator II Asst. Gardener Counter Aide Leadman (days) Dishwasher 'Linen Asst. DriYBr [Store Keeper Haniyman Kitchen Man Maid C Room " $1.032 :Cook IV hr Clerk Iypist Mimeographer Receptionist Stenographer Telephone Operator B 'Porter Potwasher - $l.h5 hr Housekeeping Leadman(Nights) "Night Cook Linen Clerk watchman Painter N.B, All hourlz rates Room A - $1.71 hr Chief Telephone Operator Dictaphone Operator OPD Receptionist CaShier Seoretary,IIj Cashier B "' $1960 hI‘ Cook C III - $1.50 hr Licensed Practical Nurse Psychiatric Aide Maintenance Mechanic include 1 me§l_p§rﬂggz_§t_the rate of $10.00 per month I A - $1.8833 Jr. Laboratory Technician �SUPERVISORY & EWIEESSIONAL PERSOBYlé FOR RATES HOURLY AND GRALEE WITHIN TITLES JOB #6 GRADES , $37 $3110 - $h15§ $370 MONTHLY RANGE $05 - JOB TITLES A- $2.080 A- $2.31 Asst. Office Manager Bookkeeper Pay Master B- $2.02 Assistant Bookkeeper Registered Nurses ‘ hr hr A - Charge Nurse Supervisor $1.9h hr Asst. Superintendent Grounds Asst. Dietitian Gardener Housekeeping Supervisor 0- $1.82 hr Dental Hygienist N.B. All hourlz rates include 1 meal per day at the rate of $10.00 per (Nursing) Chef . Psycholinguistic Technician 8: §h10 ~ $510 $2.h2 hr Sr. Laboratory Technician Bldgs $1M $2.19 hr Executive Secretary B" #9 #8 #7 month �JOB TITLES WITHIN GRADES #2 #1 $15 - $235 , $1.20 hr. HOURLY RATE Ass't AND HOURLY RATES FOR NON—PROFESSIONAL PERSONNFL m $215 1§g§g Cook IV Gardener Busboy Counter Cleaner, File Clerk Housekeeping Cook's Helper Counter Aide II _ Man I Housekeeping Leadman Cashier Clerk-Typist Boiler Dictaphone Operator Chief Telephone Operator (days) Ass't. Leadman (nights) Maintenance Mechanic Dishwasher Linen Driver Psychiatric Aide II Painter Handyman Storekeeper Receptionist KitchenvMan ward Clerk Stenographer Maid Room II Mimeographer linen Attd‘t Room Room Supervisor Psychiatric Aide I Secretary II Cook III Dictaphone Operator Senior Telephone Operator Night Cook Porter Poiwasher *(Licensed Practical Nurses at_one incresent higher) *Watchman N.P. All rates include one meal per day at the rate of $10.00 per month. * Not included in Schedule A ' $235 - $31.5 Assistant Chef Accounting Clerk Housekeeping *Gateman . -, BET??? :. 9‘19? .51 s- 39.5.} Secretary I Jr. Laboratory. Technician � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource [Hillside] hospital budgets. (1/2) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-011 Date A point or period of time associated with an event in the lifecycle of the resource 1960-1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Proposed Research request budgets; letters; report of expenditures Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/ec4afc36e7130461e6211b8cf229b80f.pdf 15614c0aba92d94b8e5d0589849ccd08 PDF Text Text $57” 4’13 /?é,/~(22 ‘ may JUN HILLSIDE HOSPITAL Glen Oaks New 21 1961 York June 12, 1961 MEMORANDUM Victor Leventritt, Chairman, Medical Affairs Committee TO k Mr. M. FROM : Maurice Bachrach, Administrator WWW” SUBJECT: Proposed Research Request Budget for July'l, 1961 to June 30, 1962 income and the of proposed expenses Attached hereto is a presentation been has carefully Each 1961/62. request departmental research for for each schedule for There a is Robbins well myself. as reviewed by Dr. as Research Department. After the expenses are given for each department, we have Shown applicable and potential income from various sources that each of end At departmental the each department. for have been designated This the is "net deficit". shown the have department's we schedule, income that for designated less the for department, expenditure total department. will find the entire deficit picture which gives the from various income estimated each the of departments, for net deficit research the total to which Trustees applicable are the than sources other The research net departments". all and research "net deficit, program actual $53,250; our at was projected the for present year deficit Budget Research 1961/62 Request The $58,12h. estimated at expenditure is from this $h,250 of decrease net $h9,000, of a net deficit a projects actual from this year‘s decrease and $9,12h a Budget year's Request On page h you experience. �-2- June 12, 1961 HILLSIDE 1109131111, M wwnwm‘m 001. I Col. II - 1961/62 TENTATIVE REQEARCH BUDGET 1960/51 Budget I. 001. III 1951752" 1950731 Request Budget Experience est.) (2 mos. 001. IV Overage 001 III over 001. RE§EARCH IN EXPERIMENTAL PSYCHIATRY EXPEN§ES: l2 3 . . . 1 . Director . 7 . 8 . 9 . 1o. 11. 12. 13. 11. 19. 16. 17. 18. 19. 20. 21. 22. 1,500 3,100 3,100 3,113 2,163 600 600 600 3,311 11,011 2,817 10,126 25,000 17,000 3r. Assoc. Exper. Psychology 13,000 10,920 7,500 13,000 10,667 7,500 9,500 8,500 1,110 9,500 8,597 1,105 2,172 3,360 2,890 2,251 3,127 2,356 Assoc. in Psychiatry v - n n Assoc. EXPer- Psychology 6 . ‘Asst. Exper. Psychology S 25,000 17,500 9,000 11,000 13,331 8,100 7,218 10,000 1,120 1,800 3,600 2,185 3,192 2,710 1,500 3,000 3,600 3,000 25,000 16,116 u n (NEW) 11 Assoc. in Social Psychology Assoc. Exper. Psychology E.E.G. Technician, Sr. E.E.G. Technician Jr. (NEW) Psycholinguistic Technician Secretary Clerk Typist Technical Ass't. Equipment Travel supplies (office (NEW) & Medical) Director's Professional Expenses Training Expenses gocial security Overhead & Blue Cross Research in enses115351%§%151'9§23515177'7“' Total - - - - - — 251 1,838 3,500 11,010 - 1,081 9,000 1,000 2,111 (A) (B) (0) (B) 600 (C 7,218 (E) 500 (F) (7,080)(G) 390 (c) 3,600 (H) 313 (C) 132 (C) (150) 1,500 (I) (1,500) 200 (100) 1,838 (J) 186 2,999 ' 129,923 licable & Potential Income Researcﬁ in ExperimenEEI Psychiatry 122,839 7 159,797 29,871 A 23.'ﬁ?§7”565113 ﬁSEIEE‘EEFFTEE“"‘72,101 21. Drugs 25. Nassau County 26. Potential Income Total Applicable PotentiEI Income - 3,120 11,102 & Net Deficit, Research in EggerimenEEI PsycHIatry 78,000 1,800 - 111,708 5,089 - . 12,307 (K) 5,089 (L) (3,120)(M) (11,102)(N) 89,923 82,800 119,797 29,871 10,000 10,039 10,000 0 I �Memorandum re: preposed Research Budget June 12, 1961 ans-u. II. RESEARCH IN BIOCHEMISTRY 001. EXPEN‘EES: I 1960/61 Budget 27. 28. 29. 30. 31. 32. 33. 3h. .35 . 36. 3?. 38. 39. 80. Director 3r. Biochemist 3r. Biochemist Biochemist Biochemist Jr. Biochemist Jr. Biochemist 13,500 8,786 8,hlh 5,000 21, 500 8,168 h,000 gecretary (%) 1,680 Diener 1, 250 Laboratory Equipment 2,000 §upplies 7,000 Travel 1,000 3ocial Security & Blue Cross 2,h80 Overhead 2,h75 Col. II I96076I Experience (2 mos. 13,500 8,783 8,820 5,000 21,170 8,131; 3,972 1,692 1, 250 1,677 7,89h 1,000 1,776 h,2Bh est.) 001. III I96I752 Request Budget 13,500 9,883 1,816 5,300 8,600 8,868 h,h00 1,7h8 Col. IV Everage Col III over 001. I 697 (0) (6,998) 300 100 308 800 68 (o) (0) (0) 5,800 6,200 1,000 2,000 3,200 3,800 (Q) 300 (950) (800) 725 66,289 67,152 63,815 (2,83h) Applicable & Potential Income Research in Biocﬁemist MET—‘41:: 13"".9. Hea th service ET 82. Potential Income 18,162 26,087 111,317 - 37,900 6,515 19,738 hh,2h9 h1,317 hh,815 22,000 25,835 19,000 7,000 2,066 1,000 3,000 PatentiaI (19,572) & Woe Income h3. Net Deficit- Research in ems ry III. 166 (3,000)(R) MEDICAL DEPARTMENT RESEARCH EXPENQEE: 88. 85. 86. 87. 88. 1:9. Research Assoc in Medicine Research Associate Nurse-Technician supplies Travel & Publications 3ocial 3ecurity & Blue Cross w - 3,000 900 800 1160 - h,000 3,108 (7,000) 8,000 108 100 139 1,000 245 I425 (200) (35) 6,250 8,733 (3,027) - 200 Total Expenses - Medical Dept Research (0) (h80) Total E enses - Research in Biocﬁemlstry Total Applicable (O) 11,760 �Memorandum -h- re: proposed Research Budget £31. I 1960/61 Budget Applicable ,0. & Potential Income June 12, 1961 Col. II I95575I" Experience (2 mos. Est.) Col. III I§5I752 Request Budget Col. IV Overage III Col over 001. 1,510 5,000 u,000 8,733 h,223 (5,000) _2,510 h,000 8,733 (777) 2,250 2,250 - Net Deficits Forwarded §E§earc 1n . syc iatry Research in Biochemistry Medical Dept. Research h0,000 22,000 2,250 h0,039 25,835 2,250 h0,000 19,000 - (3,000) (2,250) Total Deficits 6h,250 68,12h 59,000 (5,250) 1,000 2,000 1,000 2,000 1,000 1,000 8,000 7,000 8,000 10,000 10,000 (1,000) 58912:: Egauw (E: 250) 51. 1c Potential Income . . Total Applicable PotentIaI Income .ervzce - & 52. Net Deficit Medical. Dept. ﬁesearcﬁ Unrestricted Research Income Henry Kaﬁfmann MemoriaI Funa scheuer Research Fund Contributions - Other than Trustees Total Unrestricted Research Income 11,000 NET RESEARCH - I DEFICIT; III‘DEEERTMENT§"‘“‘ 53, 250 (2,2SO)(31,_ - - (1,000) - _ �-Memorandum - - re: proposed Research Budget ane 1 1961 BUDGET COMMENTS I. RESEARCH IN EXPERIMENTAL PQYCHEgTRY EXPENSEB: projects total expenditures of $159,797, an increase of $29,87h over the approved budget for 1960/61. This increase is made up of the The Request Budget following items: Note A: Line 2-Associate in Psychiatry (Dr. Donald Klein)--Increase-----------—-—--$l,08h This increase represents tﬁo factors: a. Annual increment of $500 as of July 1, 1961 in accordance with stated increment plan. b. Salary adjustment made during the year in order to accurately reflect Dr. Klein's actual qualifications and experience. Note B: Zine §--Associate in Psychiatry (Dr. John Kramer)--Increase—---------------$9,000 During the current budget year Dr. Kramer divided his time between the research and clinical programs, being in charge of the Electro Shock Therapy services on the clinical side. He received part of his remuneration from the Operating Budget and the remainder of his salary was made up by a United 3tates Public Health Service Fellowship. His Fellowship terminates geptember, 1961 so that $9,000 of his total salary of $13,826 should be charged to the Research Budget. Note C: Line 5-- Senior Associate in Experimental Ps hole --------------------------- ncrease---~---------—-—-$1,000 Line 6--Assistant in Experimental Psychology (Eric Karp)—-Increase --------- $ 600 Line 10--EEG Technician Senior .................... Increase ................. $ 390 £§§§_}2--PS cholinguistic Technician -------------- Increase ----------------- $ 313 Line 13--‘Secretary-------------------------------- Increase----------—------$ 132 These repreEEnt regular increments for these positions. Note D: fine 5--Associate in Experimental Psycholo (Dr. Ira Belmont)--Increase---$2,hlh This increase represents two factors: Full year employment for 1961/62 against part year employment for 1960/61; increment from $12,500 to $13,500 as of September 1, 1961. �"Memorandum -6- re: prOposed Research Note E: Line 7--Assistant Budget June 12, 1961 erimental Psychology (NEW)--increase --------------- $7,2h8 personne? itEm grows out of two related factors in E This new in the program. 1. The volume of work in Experimental Psychology during the current year has risen to a point where it places a great strain on the two incumbents. In order to complete the number of psychological tests and experiments essential to the program it is necessary to add personnel able to do this work. This however would not require a full time worker. 2. This factor is related to the information given below in Line 11 which states that we have made a definite policy decision to make encephalographic studies of every patient admitted to the Hoapital instead of a selected sample of patients. This program of encephalography for each patient necessitates a corresponding increase in the number of associated psychological tests which are made concurrently with each encephalograph in order to complete the picture which we are seeking. These two added work loads qualified psychologist. will amply use the full time of a Note F: $ 500 Kelman)----increase (Dr. 8--Associate -----------in roial Psycholo Line or y the fact that the e 1 erence is accoun e new incumbent has higher qualifications than the present incumbent. Note G: Lin' e §--Associate in ppo n ment en 3 erimental Psycholo ugus , . w (Dr. Karl Anderman)-decrease--$7,080 Note H: fine IluEEG Technician Junior (NEW) -------------- increase ----------------- $3,600 The purpose of this new position is to enable the department to make complete encephalographic and associated psychological examinations of every admitted patient. At the present time we are making encephalograph studies on only a portion of the population related to our drug investigations. much found have we a however, these of studies, In the course been have we than abnormal of encephalograms incidence higher It has therefore been decided that it would be valuable and informative to make of instead each on patient study encephalographic a full selected patients in order to learn whether this high incidence of abnormal encephalograms will hold for the total patient population. In order to achieve this, it is necessary to add this position in to referred services additional psychological the well as as led to expect for our patient population. Line 7 above. �“memorandum -7- Note re: proposed Research Budget June 12, 1961 I: fine IS--Teohnical Assistant (NEW) ---------------- increase ----------------- $h,500 This positioﬁ‘is Being added in order to relieve higher paid professionals, psychiatrists and psychologists from statistical work and to provide a coordinating function in the department in the development of more efficient methods. This will give the top professionals more time and opportunity for the use of their higher skills. Note J: Eine 50~~Training Expenses ------------------------ increase ----------------- $h,838 Cost for didactic psychoanalysis, special courses, etc., for Dr. Donald Klein (Line 2 of budget); this expenditure is covered in full by United gtates Public Health Service‘Grant. Note K: line Income------ ------------~--~--a_~--increase—-------—--------$h2,307 Represents approximately $16,000 of additional funds for a con— tinuation grant from the United States Public Health 3ervice and $26,000 from the same source for a Career Investigation Grant to cover Lines 2 and 20 of the budget. 23--USEHS Note L: fine 25--Drugs ------------------------------------increase ----------------- $ 5,089 This {tam is for psychotropic drugs which the Hospital receives free of charge due to our extensive research studies. The cost of these drugs which the Hospital would normally purchase are charged to the Operating Budget and credited to the Experimental Psychiatry . Budget. Note M: Line 2S—-Nassau County---------------------------- decrease----------------- $ 3,120 Research projects supported by Nassau County have been completed and not renewed. Note N: Line 26--Potential Income ------------------------- decrease ----------------- $1h,h02 For I96I752 there are no pending grants or any other sources of potential income to be noted. II. REiEARCH IN BIOCHEMISTRY EXPENSES: Note 0: EIﬁes 58 and 30 through 3h------------------------ increase ----------------- $1,869 AII these increases totalling $1,869 are in accordance with the stated increment policy of the Hospital. the Line P: 29--§enior Biochemist------------------------decrease ----------------- $6,998 Kppointment ends August 31, 1961 �{Memorandum -8- Note re: prOposed Researdh Budget June 12, 1961 Q: ITEE‘36--Laboratory Equipment ------------------ ---increase ----------------- $3, 800 This expenditure is Toor one item of equipment covered Uhited States PUblic Health Service in full by Grant. a Note R: TEEE-E3--Net Deficit: Research in Biochemist ----decrease --------- - ------- $3,000 The decrease shown is the difference between the current year's budget and the budget for 1961/62. It should be noted that there is a decrease of $6,835 from our actual experience III. MEDICAL RESEARCH Note 3: Line §§--Net Deficit: Medical De Research-~decrease ---------------- $2,250 ent ¥or E? accountéd This decrease is the fact that Dr. Arnold Blumberg's full salary is carried in the Operating Budget as Hospital Internist and Employee Physician. All other expenses of this project are covered by a Federal Grant. �Memorandum OFFICE 01" 113E Frm The Mlmm June 30, 1961 Dr. Fink To: 1961-62 Mdget Re: is etateunt of the budget allowance for your departnnt for 1961—62; this is sent to you for your guidance The attached a during the coming year. If you have any queationa whatsoever, please feel free to see me about this femlation; I do not hear you I will assure that all of the figures and procedures are accepted by you. 1133130 Mel. if Ira �”7;” a Q ray—o“ meE 1961-62 WEARCH IN WTAL Salaries and Director Assoc. " nses " Sr. Assoc. Exper. Psycholoy Assoc. Exper. Psycholoy Asst. Exper. Psycholog I (new) I Assoc. in Social Psychology Assoc. Exper. Psycholog ' E.E.G. Technician, Sr. 15.3.0. Technician Jr. (new) Psycholinguistic Technician Secretary Clerk Typist 1961-62 Reguest (Kramer) 25,000. 17,500. 9,000. 25,000. 17,500. 9,000. (Belmont) (Karp) 13,33h. 8,100. (Fink) (Klein) (Pollock) "’ (Kellen) (Andersen) (Hosquera) (Kolo (Podrid Director's Professional Expenses Training Expenses Social Security & Blue Cross Overhead Research in Total nses ZﬁﬁeriggnEEE Egichiatii Potential Income licable & Research in EggngESEtal Pszghiatgz 3. Public Health Service Drugs Hess au County Potential Income Total tent Net licable Deficit Research in ﬁrﬁntg 111,000. 114,000. 7,2148. 7:2h80 Psichiat'i 1 r ,Afyc ﬂy}. ‘3 .. jar ~M" Deferred* 13, 33h. 8,100. 10,000. 10,000. h,800. 3,600. 2, h85. 3,h92. h,800. 3,600. 2,h85. 3,192. 2,710. 1,1120. 2,7110. 11,500. 1,1120. 11,500. 3,000. 3,600. 3,000. 600. 3,000. 3,600. 3,000. 600. h,838. 3.500. 1h,0h0. 3.500. 1h,oho. 159.797. 159,797. 11h,708. 11h,708. 119.797. 119.797. , 240,000. 110,000. . 5,0890 & ncome "? \ Approved 1961-62 Budget Technical Ass't (new) Equipnent (office & medical) Travel Supplies U. BUDGET \\\ {Lu [7/1, PSICHIATRI in" Psychiatry A HOSPITAL /' :1 11,838. 5,0890 cc: Dr. Fink Dr. Robbins Acctg. Dep . *These items requested may be restored to the budget during 1961-62 additional funds become available. if �Duﬂelmh C1707 9L“! v714x14 C 5. /£j>ur5r‘pf ~ "‘50 zaﬁ/ "‘.’U.'>V'“ ,I‘ June 12, 1961 HILLSIDE HOSPETAL TENTATIVE REsEARCH BUDGET Col. I. I - 1961/62 C01. II 1960761 1960/61 Budget Experience (2 mos. est. Col. III 195I75§* Request Budget ) Col. IV Overage 7001 III over Col. I RESEARCH IN EXPERDMENTAL PSYCHIATRY EXPENgES: 1 . 2 . Director Assoc. in Psychiatry 25,000 16,116 25,000 17,000 1 . 9r. Assoc. Exper. Psychology 13,000 7,500 13,000 10,667 7,500 9,500 8,500 1,110 9,500 8,597 1,105 n . 3 5 . 6 . 7 . 8 . u Assoc. Exper. Psychology “Asst. Exper. Psychology " (NEW) Assoc. in aocial Psychology Assoc. Exper. Psychology 1.13.0. Technician, Sr. E.E.G. Technician Jr. (NEW) Psycholinguistic Technician 9 . 10. 11. 12. 13. 9ecretary Clerk Typist '. 15. Technical Ass't. 16. 17. 18. 19. Equipment Travel supplies (office - & Medical) enses- Research in Ezgerzmeniéz Psychiagry licable & Potential 2'3. 21. Drugs 25. Nassau County 26. Potential Income Total Applicable FofenEIaI Income PS 0 rvice 3,113 2,163 600 600 - 1, 500 3,100 3,100 251 - - 1,838 3,500 11,010 2,817 10,126 . 1,081 9,000 1,000 2,111 (0) (D) 600 (C) 7,2118 (E) 500 (F) (7,080)(G) 390 (c) 3,600 (H) 313 (C) 132 (C) (150) 1,500 (I) (1,500) 200 (100) 1,838 (J) 186 2,999 129,923 atry 72,101 - 122,839 78,000 1,800 - 159,797 111,708 5,089 29,871 12,307 (K) 5,089 (L) (3,120)(M) (11,102)(N) - - 89,923 82,800 119,797 29,871 10,000 10,039 10,000 0 3,120 11,102 & Net Deficit, Research in EggsrimenfEI Psychiatry (A) (B) ' “Fawn .n erimen esearc U:.:S:.::m%c§ Income 7,2113 10,000 1,120 1,800 3,600 2,185 3,192 2,710 1,500 3,000 3,600 3,000 2,251 3,127 2,356 600 Expenses Training Expenses 30cia1 Security & Blue Cross 3, 311 Overhead 11,011 Total - 2,172 3,360 2,890 - (NEW) Director's Professional 20. 21. 22. An 10 920 25,000 17,500 9,000 11,000 13,331 8,100 ‘ �WWW Memorandum ~S- re: proposed Research Budget June 12, 1961 BUDGET COMMENTS I. RESEARCH IN EXPERIMENTAL PQYCHIATRY EXPENSEB: projects total expenditures of $159,797, an increase of $29,87h over the approved budget for 1960/61. This increase is made up of the The Request Budget following items: Note A: Line 2-Assgciate in Psychiatry (Dr. Donald Klein)--Increase-~~---—---—-~---$l,08b This‘fhcrease represen s we ac ors: a. Annual increment of $500 as of July 1, 1961 in accordance with stated increment plan. b. Salary adjustment made during the year in order to accurately reflect Dr. Klein's actual qualifications and experience, Note B: tine §--Associate in Psychiatry (Dr. John Kramer)~-Increase----------------$9,000 During the current budget year Dr. Kramer divided his time between the research and clinical programs, being in charge of the Electra Shock Therapy services on the clinical side. He received part of his remuneration from the Operating Budget and the remainder of his salary was made up by a Uhited States Public Health Service Fellowship. His Fellowship terminates September, 1961 so that $9,000 of his total salary of $13,826 should be charged to the Research Budget. Note 0: Line ﬁ~~§enior Associate in Experimgital Psycholo Drtéﬂax PoIIaCE--—-------------------—-::— ncrease ----------------- $1,000 Line 6--As§istant in;§§perimental Psychology (Eric Karp)--Increase 600 $ --------- Line lO--EEG Technician Senior-------------------- Increase ----------------- $ 390 Line 12--Psycholinguistic Technician -------------- Increase ----------------- $ 313 Eine 13--Secretagy -------------------------------- Increase--------~------~-$ 132 These repres§nt regular increments for these positions. Note D: fine §--Associate in Experimental Psychology (Dr. Ira Belmont)--Increase---$2,hlh This increase represents two factors: Full ytar employment for 1961/62 against part year employment for 1960/61; increment from $12,500 to $13,500 as of 3eptember l, 1961. �Memorandum -6- re: proposed ?esearch Budget June 12, 1961 Un- Note E: Line 7--Assistant erimental Psychology (NEw)--increase--------------- $7,2h8 personne§ item grows out of two related factors in E This new in the program. 1. The volume of work in Experimental Psychology during the current year has risen to a point where it places a great strain on the two incumbents. In order to complete the number of psychological tests and experiments essential to the program it is necessary to add personnel able to do this work. This however would not require a full time worker. 2. This factor is related to the information given below in Line 11 which states that we have made a definite policy decision to make encephalographic studies of every patient admitted to the Hospital instead of a selected sample of patients. This program of encephalography for each patient necessitates a corresponding increase in the number of associated psychological tests which are made concurrently with each encephalograph in order to complete the picture which we are seeking. These two added work loads qualified psychologist. Note F: will Line 8-~Associate in gocial Psycholc The difference is new incumbent has present incumbent. amply use the (Dr. full time of a Kelman)----increase--------~---$ at the iac accounts or y e higher qualifications than the 500 Note G: fine §--Associate in §%perimental Psychology (Dr. Karl Andermagl—decrease--$7,080 Kppointment en s ugus , /a . the H: Line I1--EEG Technician Junior (NEW) -------------- increase ----------------- $3,600 The purpose of this new position is to enable the department to make complete encephalographic and associated psychological examinations of every admitted patient. At the present time we are making encephalograph studies on only a portion of the population related to our drug investigations. In the course of these studies, however, we have found a much higher incidence of abnormal encephalograms than we have been led to expect for our patient population. It has therefore been decided that it would be valuable and informative to make a full encephalographic study on each patient instead of selected patients in order to learn whether this high incidence of abnormal encephalograms will hold for the total patient population. In order to achieve this, it is necessary to add this position as well as the additional psychological services referred to in Line 7 above. �Memorandum -7- Note re: proposed Research Budget June 12, 1961 I: EEEE'I§--Technical Assistant (NEW) ---------------- increase ----------------- $h,500 This position is Being added in order to relieve higher paid professionals, psychiatrists and psychologists from statistical work and to provide a coordinating function in the department in the development of more efficient methods. This will give the top professionals more time and opportunity for the use of their higher skills. Note J: Tine 20--Training Expenses ------------------------- increase ----------------- $b,838 Cost for aiHEE'icfEEychoanalysis, special courses, etc., for Dr. Donald Klein (Line 2 of budget); this expenditure is covered in full by United §tates Fublic Health Service‘Grant. Note K: Line 23"‘USH‘I9 In00me-----n-m-'~~—--——---ou—-~-.._..-a-increase—-—---—-—--------$b2,30'? Represents approximately $16,000 of additional funds for a continuation grant from the united States Public Health 3ervice and $26,000 from the same source for a Career Investigation Grant to cover Lines 2 and 20 of the budget. Note L: Line §E--Drugs ------------------------------------ increase ----------------- 3 5,089 This item is for psychotropic drugs which the Hospital receives free of charge due to our extensive research studies. The cost of these drugs which the Hospital would normally purchase are charged to the Operating Budget and credited to the Experimental Psychiatry Budget. Note M: Line §S--Nassau County---------------------------- decrease----------------- $ 3,120 Research projects supported by Nassau County have been completed and not renewed. Note N: Line 26-—Potential Income ------------------------- decrease ----------------- $lh,h02 For I95I752 there are no pending grants or any other sources of potential income to be noted. �T’Heﬁo ﬁranluh desk of 'L.ING.BE ‘ L Jun 21, 1961 to: Dr. Fink: of June 30, 1961, the changes you requested will be reflected in your net expenses. As will net expenditure of h0,000. at that time. we 114% show a M ”(M (L/ao/o/ 6’35? �Pg. 1 To: I Dr. Fink Director, Research in Experimental Psychiatry Fran: Accounting Dept. Re: Report of Expenditures 1 60 - H 31 1961 HOSPITAL 50331012110 ”Lac Fink Siege], Secretary Podrid Salaries 0 uses : Assoc. in Social Psychology Psycholinguistic Technician maize}! Kolodny Medical Equipment 113. Expense Account Total Expenses 1333: Income from Nassau County ' Donat i on of Psych 0 room Dru g s Net Expenses cc: Mr. Bachrach t 3,120. 2,172. 2,890. 1,500, Office Equipment Travel Supplies Social Security & Blue Cross Director's 25,000. to Hospital . 23,753' $33.?- :1 12, 3 . 18%. ES. 3’1“». 3 , hog. 920. 600. 1,0 . 2 38 . 143,120, 37,109- 3,120. 3:35;9 . {5%. 7 ' W, 0. ho,ooo, 31,859. �.1 Dr. Fink Pg. Director, Research in hcperhnental Psychiatry GRANT 2 141-2715 1/1/61 to 12/31/61 Grant. approved for $65,886. 1/1/61 to 12/31/61 Supplemental Grant 16 2 0 . approved for with: Amount hl,058.* 1960.61 to applicable hperience 1960-61 Budget . To Date ,. Grant. Balance 6/30/60 32,1105. 311,599- Additions: Amount applicable to 1960-61 1431053 -* bl 053. Starting Balance Salaries & ese nses: ssoc. n sychiatry Sr. Assoc. in Exp. Psychology Assoc. in Em. Psychology Asst. in Exp. Psychology Assoc. in 73,u63. Additions & Exp. Psychology Psycholinguistic Technician E.E.G. Technician Secretary Secretary 16 ,h16.~- \ Klein Pollock (Gittehnan 675. 6’8?” ’ 9’ 8,500. 7 ’ 890. 291. luhlo. 3,360. mm»... RM V . h 028 9,8112. " ’ 7'93: 106. ' Sspplies 2:5“). Medical Equipment Office Equipmnt Social Security 9 . 7.500. (Andermann Kolodny Mosquera Castalano ’ 10,920.-~r (Krauthamer % 15 583 6,1914.’ 7,333. (Belmont Karp v-1... 75 , 797 . 8: Overhead 382. 1,928. Blue Cross 9,681» " 1-1519‘ ,1 729. 3’ 259 1:100. “Iravel ”933' Total Expenses Unexpended Balance 530' - is 3!“an cc: Hr. Bachrach " Em 66,085. 9,672. if)? w, a 5, X“ I 3 41.3 6 7 3"? �Pg. 1 W m Director, Research in Ehperimsntsl Psychiatry To: Dr. From: Accounting Dept. Re: Report of Menditures J1EE}. HQ] .. 5323 39 mm HOSPITAL SUBSDIZED RESEARCH Experience To Date 1961-62 Budget SALARIES Fink Kramr 2% 6’25° Equipment Travel supplies 3. S. & Blue Cross Director‘s Expert“ Accmmt TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES CC: Hr. Baohroch $313“ ' 3 233‘ 5 350 “65 5,089. 5 335 h0,000. 1 g �Pg. 2 To: Dr. Fink Director, Research in hperinantal Psychiatry cam 141—2715 Mariana To Date Grant Balance 6-30-61 ’ Addition: Starting Balance and Additions _S__ALARIES Klein Pollock Belmont Karp Andermann Kolodmr Mosquera Zoller & Schniman Cartolano xrlmr EXPENSES Winner Goldaclmidt Supplies Equipmant Travel S. S. 8: Blue Cross Overhead TOTAL EXPENSES UNEZPENDED BALANCE 00: Hr. Bachrach Sept. 30, 196; 6,810 .57 20 529, 2 72 .. 1,000. 3 ,500, 3,203, 2,025. 1, 771. 619. 1,133. 625. ho. 2 ’2500 610. 263. 133, 1,01h. 301. 2 ,676, 21,168. 6,201,, ., .. __ ..__.. ._.... �av~ ﬂh T6: Dr. Fink Director, Research in Mammal Psychiatry W Experience to Date 3.21;. 302 1961 Grant Balance 6-30-61 Additions -’\ Starting Balance and Additions SALARIES Klein Podrid 3,500, 861. EIPENSES 8.8. 8: Blue Cross W @1135 0 Supplies row. Emmszs mm ,. 8,166. p.500.) BALANCE « W 00: Hr. Bachrach 5" 64“ ”‘5 27’? 6‘ ﬂex/4’" ﬁb (I M / . �d To: . .‘Dr. Fink Director, Research in Experimental Psychiatry (RANT HI-hl98 to Date Sept. 30, 1961 Grant Balance 6-30-61 Additions ___6.ééé..________.____..___ Starting Balance and Additions M Klein Podrid 6.666. 3.500. 861. EXPENSES S.S. & Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC: Mr. Bachrach 78. _______7_13‘_____________________ �"\ Pg. 1 x To W Dr. Fink Director, Research in Marianna]. Psychiatry From: Accounting Dept. Re: Report of Expenditures July 1 - October 31: 1961 HOSPITAL SUBSIDIZED RESEARCH Ebcperience ' To Date 1961-62 Budget SALARIES Fink Kramer 8.331.. EXPENSES Equipment Travel Supplies Blue Cross Director's Expense Account S. S. & TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES 00: Hr. Bachrach 221;. 116. 13. 8,990. 1 “55 5,089. I 525. 140,000. �Pg. 2 To: Dr. Fink Director, Research in hperimental Psychiatry GRANT 141-2715 Experience To Date Oct. 31, 1961 Grant. Balance 6-30-61 July Oct. Additions . Starting Balance and Additions §5_LARIES ""‘"""" Klein Pollock Belmnt Karp Andermann Kolodny Mosquera Zoller- Schnirmn Cartolano Kramer Winner GOIdBChEidt EXPENSES 6,810.57 20,529. 20,529. 147,901.57 1, 333. 14,666. M333, 2,700. 1,771. 906. 1, 510. 879. ho. 3,000. 1, 277 . 550. Supplies we“ 3'“ S. S. Blue Cross Overhead & '7 215. 6 . l’iog. 3,568. TOTAL EXPENSES 2Q UNEXPENDI BALANCE 19.,hﬂs.._______________ 00: we mach mg. _... �.M W Pg. 3 Dr. Fink To: Director, Research in Experimental Psychiatry W herience to Date - Grant Balance 6-30-61 July Additions Oct. Starting Balance and Additions W October 31, 1961 6 666. 6:66h. 13,330. Klein Pcdrid h,667. 1,280. Travel 111;. EXPENSES 8.5. & Blue Cross Supplies Overhead TOTAL WSES UNEXPENDED BALANCE CC: Hr. Bachrach 10?. 15. 950. 7 ,133. 6,197. _ ��Pg. 1 ‘ EEEQEEEEE! To: Dr. Fink Director, Research in Emerimental Psychiatry From: Accounting Dept. Re : Report of Ehcpenditures July 1 to November 30: 1961 HOSPITAL SJBSIDIZED RESEARCH Experience To Date 1961-62 Budget SALARIES Fink Kramer 10,u16. EXPENSES Equipment Travel Supplies 808. 205. 53. Blue Cross Director's Expense Account S. S. 8: TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPHWSES CC 3 “re BacmaCh 235 11,767 . hég, 5,089. 10 302, 130,000. 1 __ , �Pg. To: 2 Dr. Fink Director, Research in Khmerﬂwntal PSyChiatry GRANT 141-2715 Merience To Grant Balance 6-30-61 July Additions Oct. Starting Balance and Additions SALARIES Klein Pollock Belmont Karp Andermann Kclodny Mosquera Zoller- Schnirman Cartolano Kramer EXPENSES Willner Gold schmidt 6,816.57 20,529. 20,529. h7,901.57 1,666. 5,333. 5,1633,375. 1 , 771 , 1,117. 1 , 888 . 1,111. ho, 2 ,250. 1 , 9&3 . 83 7 . Supplies 108. Equipment Travel S. S. G: Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC 3 Mr. Bacmactl Date 1 . ’2?“ 11,1160- 3h 0h] 13,352.. ‘ ___-.- �To: Dr. Fink Director, Research in maximum Paychiotry mum HI-h 98 Exporience to Date Grant July Oct. Edam. 6-30-61 6 666. 61661;. Additions Starting Balmco and Additions p.330. SALARIES Klein Podrid 5,833. 1,575. Travel 209. 138. EXPENSES 5.3. a: Blue Gross mm: Overhead MAL MSES mm MCE 00: Mr. Bachrach 2?. 1,181. 8,969. 5361. �Pg. 1 To: Dr. Fink Director, Research in Experimental Psychiatry From: Accmmting Dept. Re: Report of icpenditmrea Jug: 1 to December 31I 1961 HOSPITAL SUBSIDIZED RESEARCH Experience To Date --__ 1961—62 Budget SALARIES Fink 12, 500. Kramer w Equipment Travel Supplies 629. 318 Blue Cross Director's Expense Account S. S. 8: 2683, 13,797. TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES . 5,089. 2 ,295. 11,502. ho,ooo / 2K CC: Mr. Bachrach ; 1' a.) ,7“. ‘ .1 " .. �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT tax-2715 Experience Tb Date Grant Balance 6-30b61 July Oct. Additions Starting Balance and Additions SALARIES Klein Pollock 20 ,529 . 20,529. WI 901. 2 , 000. 7,000. 6,583. Belmont Karp Andermann Kolodny Mbsqnera Zoller - Schnirman 1,771. 1, 327 . 2,255. 1, 310. Kramer 3,000. Cartolano Willner EXPENSES 6,8h3.57 Gold schmidt Supplies those. hO. 2 ,652 . 1 , 1214 , 1108 . Equipment Traﬂel S. S. 8: Blue Cross Overhead 1 . ’23; 5,352. TOTAL EXPENSES 1 000 UNEXPENDED BALANCE ﬁIQQ], CC: Mr. Bachrach _ �To: Dr. Fink Director, Research in Experiments]. Psychiatry GRANT “1:5198 Meme to Date Grant Balance 6-30-61 July Oct. Additions Starting Balance and Additions W MNSES my) BALANCE cc: Mr. Bschrsch 13,330, 7,000. 1,870. Travel 350. 171. Overhead “FUSES 6,6611. Klein Podrid S.S. & Blue Cross Supplies TOTAL 6,666. . ho. ____J_’),L2)J_.________________,__ 102855. 2.2.15, �Pg. 1 Dr. Fink To: Director, Research Wu“). 1!: From: Accounting Dept. W62 Psychiatry Report of Expemﬂtures Re: . HOSPITAL w SUBSIDI- RESEARCH Experience To Date Fink 11bit”- Kramer 750. 21h. 333. Schnimn W" chin Equipment Travel Supplies S. S. gig" 1 ,1h9. Blue Cross Director's Ehpense Account & 359. TOTAL EXPENSES mss Donation of Psychotropic Drugs NET EXPENSES CC: Mr. Bachrach 1961-62 Budget m , 213 2 225 5,089. 15 213 1.0.000. �Pg. To: Dr. Fink Director, Research in Emperimental PsyChiatry GRANT MY-2715 Experience Tb Date W 6 ,8h3. 57 Grant Balance 6-30b61 Oct. Additions Starting Balance Jan. and Additions 68,906. Klein Pollock 2,000. 8 ,083. SALARIES Belmont Karp Andermann Kolodny Mosquera Zoller Cartolano Kramer EXPENSES Uillnnr Goldldhnidt Supplies Equipment Travel S. S. & Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC: 20,529. 20,32 3. Mr. Bachrach 7, 628. h:6730 1,771. 1,522. 2,633. 1’3h3. 3,000. 3. 3061,389. 938. 3,315. 1,h37o 839. 6,100. 50 0h}. 2 �Pg. 3 To: Dr. Fink Director, Research in Mex-mental Psychiatry GRANT DIX-£1798 Experience to Date Additions July 6,666. Jan. 6,66h. Starting Balance and Additions 19 . 8 8. SALARIES EXPENSES Klein Podrid 21%;, Travel 350. Bur SOS. & Blue Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC : Mr. Bachrach 60. Cross 2%. 0. 1, 3, 12 555, Lugs», �Pg. 1 To: Dr. Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Ehcpenditures July 1, 1961 to February 28, 1962 HOSPITAL NBSIDIZED RESEARCH Experience To Date 1961—62 Budget SALARIES Fink Kramer Schnimn 2% Klein Equipment Travel Supplies Blue Cross Director's Expense Account S. S. & TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPENSES CC : Mr. Bachrach 15,371. 1,500. 1428. 666. M0. 1,329. 232. ['22 21,858. 2 1225 5,039. 19 5§2° h0,000. _ _. �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT 141.2715 Merience Date To Grant Balance 6-30-61 Additions 6,810.57 July - Jan. 62 ,062. Starting Balance and Additions SALARIES "" ' 68,906. Klein Pollock 2,000. 9,166. 8,673. 5,296. 1,771. 1,716. 3,000. 1,316. 66. 3,000. 1,694. Belmont. Karp . Andermann Kolodny Moequera Schnirman mm Cartohno Dramer Goldachmidt EXPENSES Willner Supplies Trave1 s. s. a. Overhead TOTAL EXPENSES UNEXPENDED BALANCE cc: Mr. Bachrach 3 , i460 . h, 2 95 . t 1 ) 1:353’1‘.. Blue Cross 7,01h. ‘4 ’ 9. 13,},62. �To: Dr. Fink Director, Research in Ewerimental Psychiatry GRANT DIX-M98 Mama to Date Grant Balance 6-30-61 Additions July - Jan. . -—————l9-,991+.——-——————————————. .___J.2;22L_.____.____.____.. Starting Balance and Additions SALARIES Klain Podrid EXPENSES 9 11 . falls» 2 Baer 212 . Travel 5.8. & Blue Cross Supplies TOTAL EXPENSES UNEXPENDED BALANCE CC: Mr. Bachrach 350- 319. 11h. 1h,h22. __§,_S7_g_._________________ �Pg. 1 MEMORANDUM To 3 Dr 0 Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Expenditures Jnl3Al..l£ﬁl.tn.laznh.31,—1262 HOSPITAL SUBSIDIZED RESEARCH __ ...____~_._.._w-. __ Iii“ hramer Schnirnan Klein Experience To Date 1961-62 Budget 18,307. 2,250. 6h2. 1,000. EXPENSES Equipment Travel Supplies Blue Cross Director's Expense Account S. S. LESS r CC: & Donation of Psychotropic Drugs 4...: Mr. Bachrach 1 052. 1:971. 302. 509 ‘__~.w_____ 2' ““2 23 713. 5,0§3:~*WWM . 513,960. �Pg. 2 To Dr. Fink Director, Research in Experinental Psychiatry GRANT Mir-2715 Merience To 6,813.57 Grant Balance 6-30-61 Additions July - Jan. §2 m2 Starting Balance and Additions SALARIES 68 Qgé Klein Pollock 13:33: gm“ A”? ndermam Kolodm' Mosquera w! Krmr Ichnirnn Cartolano Winner EXPENSES Goldachmidt Supplies Eq‘li t Travel S. S. 8: Blue Cross Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC 0 Mr. Bachrach Date 9,718. 5,919. 1 771. 1:911. 3,353. 1,310. 66 000: ﬁz6Sg. 1’36 . h,326o , i’gﬁ’ , 0 7,927. E] 555 ‘ �PSe 3 To: Dr. Fink Director, Research in herimental Psychiatry GRANT MI-h798 aperience to Date Chant Balame 6-30-61 Additions July to Jan. Starting Balance and Additions w EIPENSES 1‘1““ Podrid Baer Travel S.S. & Blue Cross Supplies Overhead TOTAL MSES UNEXPENDED BALANCE CC: Hr. Bachrach __J.9..22lL.__.__._.—_______ :2 22!: 10,173. 2,686. 352. I495. 397, 188. _____2.135.______________. 16,136. 3 68. �M Pg. 1 To: Dr. Fink Director, Research in Ehcpermental Psychiatry From: Accounting Dept. Re: Report of Ebcperaditures __EﬂaLJg—lﬁél_tn_hp=il_30,—1962 HOSPITAL sussmxzm RESEARCH Experience To Date _.._...._.__. 1961—62 Budget SHARES Fink 20,2m4. Kramer Schnirman 3,000. 81h. 1, 308.. Klein §§E§E§§§ Equipment Travel Supplies S. S. & Blue Cross Director's Manse i’éﬁi: 3% Account $99. TOTAL EXPENSES LESS Donation of Psychotropic Drugs NET EXPENSES CC 3 29 Hr. Bacm‘aCh ‘ . 2 8] 2 295 22 186 5,089. 140,000. __ _ �Pg. 2 To: Dr. Fink Director, Research in Experimental Psychiatry GRANT Mir-2715 Emerience To Grant Balance 6-30-61 Additions 6,816.57 July - April Starting Balance and Additions SALARIES Klein P°11°°k 29%“ ”P Andaman KOlOdW Mosquera MmSchnirman Kramer Willner Gold schmidt EXPENSES - Supplies Egamt 8“]. So So & Blue Cross overhead TOTAL EXPENSES UNEXPENDED BALANCE 00: Mr. Bachrach Date 8 3 , 065 . _.__...__..__. 52 292 1%??? 10,762. 6 , suz . 1 ’ 7 71 . 2 ’ 105 . 3 ’ 736 o 13%;: 3 , 000 . S . 3%; 2 o7 . , 1 12 O 3,315. 2 1468 1,h23. ’ O 8 ’ 8h0 . 52 212 22 5 3? . �Pg. 3 Dr. Fink 'Mmqum—‘m To: Director, Research in Ebzperimental Psychiatry GRANT PIX-M98 Experience to Date Grant Balance 6-30-61 Addiu‘ms July to April ‘ Starting Balance and Additions —-4515S8~————————————26 658 SALARIES K331“ 1. 2:9g9. 11 2 PM?“ EXPENSES Baer T 371“ 1 Sgt“; Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE CC : Mr. Bachrach ﬂit . 188 . 2 312 18,072. 8 ~86 �’ To: Pg. 1 Dr. Fink Director, Research in Experimental Psychiatry From: Accounting Dept. Re: Report of Ebcpenditmrea Jugs! 1I 1961 - Max 2]“ 1262 HOSPITAL SIBSIDIZED RESEARCH Emerience To -.....___ Date 1961-62 Budget SALARIES Fink 22,179. 3,750. Kramer Schnirman W 1 , 028 . Klein 1,558. Equipment Travel supplies 8. S. & Blue Cross Director's Ishcpense Account TOTAL EXPENSES IESS Donation of Psychotropic Drugs NET EXPENSES U4872,032. 356. 519 22 262. Mr. Bachrach ho,ooo. 30.6%; * Transfers from Grants MY 2715 and MY 1:798 as per your to be entered on books as of June 30, 1962. CC: 5,089. 2 225 memo of 5/23/62 - �Pg. 2 To: Dr. Fink Director, Research it: Write; GRANT Psychiatry rib-2755 Ehcperience To We Grant Additions 6-30-61 LPN-1;! ~ . April """"" 89,909 . Klein Pollock 2,000 12,h16. 11,808. Behnont Kerp Andemm Kolodny Mos ere my: Certoleno Schnirman ramer 1mm. Travel S. S. 8: Blue Cross 2,601. 1,600. 9,753. Overhead UNEXPDJDED BALANCE 00: he WW 92. Supplies Gold schmidt EXPENS$ MOMS. 1,3}43 . Willner Equipment TOTAL 7,165. 1,771. 2,330. 3 ’ 000 , 6 , O36 . K EXPENSES 6,810.57 £33,063. Starting Balance and Additions SALARIES Date 2 A1; , 72 120, 11.112 . �To: Dr. Fink Director, Research in Mex-mental Psychiatry GRANT PIE-M98 Emerience to Data Grant Balance him Additions . Starting Balance and Additions _ 26,658 . 26,658, SALARIES Klein Podrid EXPENSES B8 er 12 ,36". 3,2h2_ 37h . Travel h9h. S.S. & Blue Cross Supplies Overhead TOTAL EXPENSES UNEXPENDED BALANCE 00: Hr. Bachrach 2481;. 188. g 692 12 256 g 202 �July 10, 1961 H830 re: ﬁre. Groghan Front Dr. Pollaak nleaae aet aaide the annual increaent approved for July 1, 1961 for retirement or other annuity pnrpneee attentive Jnly 1, 1961. I understand that the neniea withheld rill be nade available to me at my raqneet. Thank ynn. Would ynn Sincerely yours, Hrszp 33E FoIIacE, 55.5. �July 10, 1961 HERO To: Mrs. Croghan From: Dr. Klein please set aside tho annual increment approved for July 1, 1961 for retirement or other annuity purposes effective July 1, 1961. I understand that the monies withhold will be made available to no Would you at my requoab. Thank you. Sincerely yours, Drtgp I on . o n, . �g .I Wm [bur/m. a; !‘ ll L~O-h-b-C-* .0i ' 604’. a") “wt 6 ? 0 u-' ......... " ﬁ WW 4:~-5‘."4‘I-.0J.I«----'Q.OD.I'.II'.--.l“lC u-ov -.... n _ )J’ 4 I I! A / ” ll , I , 1 ”I. II i II II ‘ II II II II ll ‘ i "W“ II II || . ll ll ll r/. 03 nu». a A. V ['2411/ /€/ - �L\.‘\I-"-\ \y Q. �July 13, 1961 HERO To: Era. Dorothy Groghan Front Dr. rink Max Subject: Aaaignaout of salary Itaaa, 1961-62 Plaaao aaoign tho salary itaaa in tho Departaont of Exporirontal Psychiatry aa tolloval (a) lon-Govoroaant 1. Director 8. Social Psychologist 15. Toohnioal Aaaiatant (b) Dr. Fink To ho appointad To be appointod: H. NY-2115 2. 3. h. 5. 7. 9. 10. Payohiatriot (shooo) Lazoc. 8r. Expar. Psychology Aoaoo. Aoaiataut_ '” * ' - 0.1. Kloih John Kranar Pollack Dal-out Ira V Eric Earp Arthur Willnorﬁ streettvum9f6t-w Assoc. Expor.'Payoho1ogy Karl Andoraanui Ends 9/1/61 EEG Technician Hrs. Haaaah-Hooquora EEG Taohnioian ll. - Hrl. Ilano Goldoohaidtr Bagino 9/61 12. Poyoholinguiotio Toohoioian - Hrs. Joan Koloday 1h. Clark Typiat - 32f. fygiawzollor Max ‘ . (o) NI-h128 y 2. Payohiatriat 13. Soorotary . - D.F. Klltn - Hrs. Gloria Podrid Sinooroly youro, ﬁtter - ﬂax FIBEI 3.5?“ �July 19, 1961 HERO To: Hre. Croghen From: Dr. Ire Beleont pleeee set eeide the annual increment approved for Sept. 1, 1961 for retirement or other ennuity purposes effective July 1, 1961. I understand that the monies withheld will be made available to me Would you at my toque-t. Thank you. Sincerely yours, 1331p Ire EeImonE, 55.5. �Novenber 27, 1961 MEMO To: Mrs. Dorothy Groghan From: Dr. Max rink Subject: Revision of Salary Assignments, 1961-1962 Budgot. 2nd half, Please assign tho following salary itoms in tho Department of Exporinontal Psychiatry offectivo Jan. 1, 1962 to Juno 30, 1962 as follows: (a) Nen-Govornmont 1. Director - Dr. H. Pink 3. Psychiatrist ,- John Kronor (O$9000/annlb 8. Social Psychologist - To be appointod 1h. clerk Typist ”Us Do schnirlm '15. Technical Assistant - To be appointed (b) HI-2712 7 ' -21rPoychtatrist7**“‘““m“““‘””m““““”3“DTFT“ttetn“tO$kooo/annuo 8r. Assoc. lxper. Psychology - ﬂax Pollack 5. Assoc. I I - Ira Bolnont Assistant I 'I 3 I Assoc. Expor. Psychology EEG Technician EEG Technician Psycholinguistic Technician (c) HI-h798 C}. Psychiatrist 13. Socrotary - Eric tarp Arthur Willner To be appointed Hrs. Hannah Hosquera Hrs. Ilana Goldsohnidt Hrs. Joan Kolodny - D.F. Klein (Total loss $h000) - Hrs. Gloria Podrid Sincerely yours, Mllgp HIE'TIEEI'HTET' �MIMOIANDA ,“ �[13/ Memorandum From The OFFICE OF THE ADMINISTRATOR December 20, 1961 To: Dr. Arnold Blumberg v’Dr. Max Fink Dr. Harry Goldenberg 1962-63 Budget Re: I am working on the budget for the fiscal year - July 1, 1962 to June 30, 1963. Attached please find budget'forms with expense categories pertinent to your department. The first column shows the budgetary allowance for the current fiscal year; in the second column, kindly indicate the appropriation you feel will be needed for the 1962-63 fiscal year. You may append any data or schedules which you feel will be of assistance. For each item of salary and expense contemplated for 1962-63, kindly indicate in the appropriate column the source of support for the expenditure. Before you make your please confer with for next year. Thank you MB:DC Enclosure M:- 7254' final determinations for purposes of this budget, Dre Rebbins for your cooperation. as to your plans and budget prospectives �~T0: DEPARTWNT 0F MERIMENTAL PSYCHIATRY HILLSIDE HOSPITAL �L F; , . a , ,3 ,.. L: ....q. a a; mg 3. :m.‘ :2,‘ ,Fman .3, .35 n 1 a.»v. GM ,r I. , 4 Ahrwwm. a. H..4. H. ”a?” mh. 4 .3. . A». Vt. 1 can , H k ”21., ‘5‘.» K 3.: , _, L f. L H ‘ , . . l , f. : . , hm H 1+ ..'I {IIIII i'l'l'll «Inlgilillﬂllwll it‘ll-Illlllllllllllll «I'll'llll.wu,llllll"l “EIIIIIIII! .flllllllll I'lllnlll .,II|l|IIl|I:|-|lll|l.lll. IIIII'III...,.Illlll'l. Ill'lllll. «IIIIIIII! «ill-I'll! ,Illl'llllw ‘llllllllll .Ill'l'llllll ll! ‘ - , IlinllA ¢ A x . , 1, I x I.“ l z. , M I“ 1 . / , i. f lI < . . 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Y 5,. “lllll'lll'l'l'll IIIIIIIIIIIIIII , .. ‘ , \ I_ I ...... �ﬂFfBB’. 5% WA: I’wa N ”/7 ' x . ‘M. ”#7 11,1111; ’ ” 47%? 6’7? / Wu” 6/ ”F A203 /&:W - ��, . 31-. . _ km. Auoc. he. who . rod-aha up». an. .‘ kt" A“ ', Pooh-log , 7 m . Assoc. uni-w inn—- ~ rm ‘ roam Sea-our; mm. Club-mm . (ml-Ad» and run). nun-1) mun mat-01"! Put-utensil. Train“ up»... (0:. we; W W 3001.). & nu. an” ”7.”,— 4, an. 13.331» moon. 5,100. m7 :3: . A 7,50. 10.000. " 1.1.20. . Wu g b.000. 3.600. ' ' . 4.. (W) Us A .m‘ m. 2:12. n «a 2.1.65. 3,132. 2,1“. £500. . 3.000. 3,600. 3.000.. . w . ' - n4.) Cron- ‘ ~ . 3.500. ”MM. 7 ' 0.3. Public -. . a' m mm Hula; 1. M. 15,833. it"s-nu Tom lupus-a muscu- ram mu Scum-u . - . pun—L44 ’ lquimt (arm. .- lug-n ' 2.3.0. Yeoman, Jr. tholjnzuhuo . nrp . Auoc. 1n Soom’ V“ Bel-nut mug hpor. mm 3.x.o. rochucim, 8r.' . . We i ' 1.13.100. G tea! 8'!“- �81'. Anna. E190! Psychology Pollack Assoc. Bqu‘r. 3.01% Anya-.313)». p n new. in lung. 'E.E1.G. metal": thlby I a m W4 ‘ _ 30016. m1! . _ ~ Pmbloq Exp". thploq .7 Tahitian, Sr. E.E. a. nemoimn, Jr. Hams " ‘ ~ 1 mar-onngmtio technician ‘Stcutuy_ HINHW. ’ =j smm inert-Typist“ ' - . fwd/h‘wﬁﬁ $92:me mun) if Equip-Ont w-mia ”PM” ' . ’ ‘ ' W Wantor'a Prozac-10nd ruining Enigma (hasnun) "__Se¢1n «Emu Gm Wt! 1' ‘ m 'j: 2/1/11 " . .m in (/5: WW3: )7 * _ ‘ J47_-' r5“ ' ' ‘ �H1llside Hoqpitii 1962—63 Salaries Director & Budget - Research in Experimental Psychiatry Assoc. Exper. Psychology Asst. Exper. Psychology . Kramer . ’Pollock » Belmont ' Karp Assoc. in Social Psychology Assoc. Exper. Psychology E.E10. Technician, 3r. E.E.G. Technician, 4ﬁdhlﬂr Moaquera Jr. ,(L14‘.ALaQ»‘ (office and Medical) Training Expenses (Dr. Klein) Social Security & Blue Cross thioaw Total Expenses Anglicable & Potential Inca-o U. 5. Public Health Service «Mr—“whoa”, Ire.“ lions 7/4/4. a. 5».«~ " ﬁfe" . Fﬂclv 1“ 7 4/0 3 Director's Professional Expenses r. r- lbowr Scott/‘nual (éI‘M) 7 ?"',4]; : 3"” 47;: r: 417. Supplies W m-~.— C) agaao. Podrid 1‘rawel «- v 5-» [9‘100 ,.r, n.. ' A/vi Kolodny . mm. Drugs Request Anderman Psycholinguistic Technician Sacretnry Clerk-Typist ~Teohnioa1 Asst. gout/”‘4‘“ m... Budget .37 Klein Nil/Mr Overhead $1.1¢¢1Lc.z 1962-63 Egggnees Associate in Psychiatry n. I Sr. Assoc. Exper. Psychology Equipment 1961-62 F‘s-u ‘44. 7‘9 JI-A ?,h85. 3,h92. 2,7h0. h,500. 3,000. 3,600. 3,000. 6) >640 J 70 / 39/4. 7~fec — , /.(on Juo, 300 "' IOOo h,838. 3,5001h,ouo. V! 3! .3'00 [76yj'h' loco 153,797. /?3/:9. 113,708. 5,059. [4U .43 2! as. �” V‘r/‘f/ f‘ﬁf/ �7-5- H ”I ‘ I0“ V. .4 . ll . Mﬂzr Th ﬂ e, [ll—Yr» I ‘ . ll ll I! I Corr/biz} o‘7 ' I ‘ * - . ‘ " ~ “W ﬂﬂanoa‘ 1 t 1.- 6110 Q Afﬂéeméudz" ,, , .V 7!!) 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Requiaitione dated: 11/61 ﬂax rink - expenaee 12/61 Max Fink - expenses 12/20/61 Max naailton 2/8/62 L.I. stenotape Co. (Royal Typita) 2/8/62 Joint Purchasing (aupplies) 9.75 b0.61 50.00 53.20 h6.55 W. ."' �oemnmtm or: arm» mcmm HﬂLﬂDEPKNFgﬂL Gumcnﬂhl99' May 23, 1962 MEMO To: Mr. M. ﬁachrach From: N. Subject: to MY Pink, M.D. Adjustment of Expenditures MY 2715 and July 1, 1961 - June 30, 1962 MI L798 Please reassign following expenditures assigned 2715 to “non-government”. 1. a. Salary of Jan. 1, 1962 - June 30, 1962 Jen. 1, 1962-Mey 31, 1962 Goldschmidt, Ilene 2. Please reassign expenditures charged HY h798 by transfer to “non—government" of the following items: a. Gloria Podrid Charge 2/5 to MY h798 7/1/61 - data lolodny, Jeen " 3/S/to Non-Govt. b. Mrs. Gertrude Beer Charge ell salary to Non-Govt. c. Requieitione dated: Fink - expenses Fink - expenses 12/20/61 Hex Hamilton 11/61 12/61 Mex Max 9.75 h0.61 50.00 53.20 2/8/62 L.I. Stenotape Co. (Royal Typite) 2/8/62 Joint Purchasing (supplies h6.55 Hex FInE, M.D. �6/11/62 Brain Function and Bohavior Rososrch Progoct Bud‘otagz Rocoonggggtiono -- 1262 ~ 62 - Rovisod 6/11/62 Following discussions or 5/22 and 23, a hudgst rooosnondation for oightoon months support was prosontod which did not lost tho Radical Diroctor's approval. In ossonco, it provided for an oxponditurs or $53.h10 for the first six months; $63,183 for tho next twolvo; and of those suns, 325.750 from Hillsido Hospital and $90,8h3 (including $9583 ovorhsod) from tho u.s.9.n.s. In lino with tho discussion of 6/11/62, tho following rovissd budgot is prosontcd for consideration. 1. It is tho intsntion of tho Director of tho Dopartnont or Exporioontal Psychiatry to resign fro- hia prsaont pooition' on July 1, 1962 to continue os Principal Invsstigator (Consultant) of tho Brain Function and Bohavior Rosoarch ProJoct (H! 2715) to Doc. 31, 1962. For this poriod, to Doconhor 31, 1962 his ssrvicos will ho conponsasod on a consultant stipond basis, tron funds providod by tho Board of Directors of Hillsido Hospital. 2. It is roconnondod that Dr. Belmont, boginning 10/1/62, bo continuod on a flat too stipond basic at an ostblishod rats oqnivalont in ootivity to ono day pot wash. 3. It is roconnondsd that tho following adjustnonts ho nadc in Dcpartnontal hudgsts to accomplish tho rsquostod soparation of tho Dopartaont into constituont unite. �-2- s. the expenses and activities of Dr. Donald Klein he continued under the direct supervision of Dr. Robbins, providing such secretarial and data processing services as his project may require. b. in EEG technician salary be provided by the hospital at a rate of $5,000/annuu for full tile. 1 would suggest 2/5 tine; but this should be based on s reconaendation of tho hospital Neurologist. For the period that Dr. Kramer is available, he will continue to read the records; but provision should be node for others to do this. 0. Dr. Kroner to continue in the sane relationship to end or 1962 continuing supervision or 30!, at Dr. Robbins' K! h798 and pleasure. 0. Present budgets (to 6/30/62) he re-ellocated to show estimated expenditure of approximately $30,000 in Board support, allowing the following a a) Estinsted balance 6/30/69 nr 2715 2000 Incone 2nd half 1962 h2001 stupoo 5. Budgets for six nonths 1962 and 12 nonths 1963, corrected for social security, blue cross and statistical expenses are shown on next page. These provide, exclusive or principal investigators 7/1/62 - 12/31/63 3h,260 Overhead 1/1/63 - 12/31/63 5,100 $38,960 50.500 �-36. Requeet 0.8.P.H.S.t $hh,000 a. 196? Income Expendituree 38.960 5.000 app. - carried forward b. 1963 50,500 -._.£&99_ hS.Soo Overhead 6.8gg $52,325 7. With theee adjust-cute, the budget ie reconnended inclueingt a. Continuation request or I! 2715 be aubaitted to U.S.P.R.s., requeeting the aaount of 52,325 to retain at Hillaide ﬁoapital for 1963 and the balance (app. 31.000) he made available for application of continuation at the Mieeouri Iuetitute or Paychiatry. b. iproval for transfer of EEG analyser and tape eyeten ee requeeted h/l/62 be approved. 6. Board of Directors approval tormfunde or 12,500 for period 7/1/62 - 12/31/62 aa continued aupport of Principal Investigator (Coneultant) on baeis outlined above. In the event coneultent tine 1- required in 1963, expenses and ccnaultation teee are to be paid by Hilleide Hoopital through {undo provided by the Board of Directore. A contingency fund in the amount of 86000 ie eugteeted for thia activity. a. U.3.P.H.s. be requested to approve Dr. Hex Pollack ea oouinveetigator. �7/1/62 - 12/31/62 1/63 - 12/63 1. Staff Psychiatrist I. Pollack, 8:. Res. Assoc. taper. Peychol. John Kroner, 3,956 - I. Bel-out 7,500 3,582 15,000 'Earn, Consultant 750 Res. Ass't. Expor. Fsychol. A. "illner, Res. Assoc. Expos. Psychol. B. Hosquereﬂ, EEO Technician 3. b.350 h,700 1,000 1,700 1,h57 1,315 0. Podrid, secretary Dr. schnirnanhe, secretsry J. Xolodny, technician 351 BC (OPP) 3,000 8,700 , 9,h00 2,000 3,800 ~ 2,600 950 Travel Supplies Conputaticn c Consultation ‘ Carried forward Net Overhead u.s.r.n.s. Total ' Board support Total Budgets: 18 nos. uspns Board 500 600 900 1;560& 1,200 1,800 1,500 3h,260 50,500 3h,260 5,000 u5,500 5.100 38,960 6,822 $2,325 12,599 16,000) $109,785 91,285 12,500 (¢ $6000 contingency). Notes 0 H. Hosquere: tins s 380 resesrch i and as ties statistician, clinicel EEO services recouaended by Allows one es Secretary-typistc Prograa (it sill Neurologist). not require second typist 1963. �6/11/62 I! Brain Function and Behavior Research Proaect Budgetarz Reconnendetions -- 1962 - 63 - Revised 6/11/62 Following discussions or 5/22 and 23, a budget reconnendation for eighteen months support was presented which did not nest the Medical Director's approval. In essence, it provided expenditure of $53,h10 for the first six nonths; $63,183 for the next twelve; and of these suns, $25,750 from Hillside hospital and $90,8b3 (including $9583 overhead) from the U.3.P.H.3. In line with the discussion of 6/11/62, the following revised budget is presented for for an consideration. 1. It is the intention of the Director of the Department of Experimental Psychiatry to resign from his present position on July 1, 1962 to continue as Principal lnvestigator (Consultent) or the Brain function and Behavior Research Project (M! 2715) to Dec. 31, 1962. 1962 December to 31. his services period, this will be cenpensaeed on a consultant stipend basis, tron funds provided by the Board of Directors or Hillside Hospital. 2. It is recon-ended that Dr. Belmont, beginning 10/1/62, be continued on-e flat fee stipend basis at an estblished rate equivalent in activity to one day per week. 3. It is recommended that the following adjustnente be node in Departmental budgets to accomplish the requested sepsraticn or the Departnent into constituent units. For �-2- a. activities of Dr. Donald Klein he continued under the direct supervision or Dr. Robbins, providing such secretarial and data processH! h798 and the expenses end ing services as his project require. b. in EEG technician salary be provided by the hospital at a rats of $5.000/annuu for full time. I would suggest 2/5 time; but this should be based on a reconnendation of the hospital Neurologist. For the period that Dr. Kramer is available, he will continue to read the records; but provision should be made for others to do this. c. Dr. Kramer to continue in the same relationship to end of 1962 continuing supervision of ICT, at Dr. Rohbins' pleasure. h. Present budgets (to 6/30/62) he re-allocated to show may estimated expenditure of approximately $30,000 in Board support, allowing the following: a) Estimated balance 6/30/6? NY 2715 2000 Income 2nd 5. half 1962 h2°?Z, thhpoo Budgets for six uonths 1962 and 12 months 1963, corrected for social security, blue cross and statistical expcnaes are shown on next page. These provide, exclusive of principal investigator: 7/1/62 - 12/31/63 Overhead 1/1/63 - 12/31/63 3h,260 - 3.100 838,960 50.500 �-36. Request U.S.P.H.s.s s. 1962 - Income Expenditures $bh,000 38.960 5,000 spp. - csrried forward b. 1963 * 50,500 §IOOO hS’SOO Overhead 6:825 $52,325 7. With these sdJustsents, the budget is recossended inelusing: s. Continustion request of I! 2715 be submitted to J.S.P.H.S., requesting the ssount or 52,325 to rensin st Hillside Hospitsl tor 1963 end the bslence (spp. 31,000) be nsde evsilsble for spplicstion of continuation at the Missouri Institute of Psychiatry. b. Aprovsl for transfer of EEG snslyser end tspe system so requested h/l/é? be approved. 0. Bosrd of Directors spprovsl forfﬂunds or 12,500 for period 7/1/62 - 12/31/62 ss continued support of Principal luvsstigstor (Consultsnt) on basis outlined above. In the event cousultsnt tine is required in 1963, expenses end oonsultstion tees sre to be psid by Hillside Hospitel through funds provided by the Bosrd of Directors. A contingency fund in the slount or 36000 is suggested for this sotirity. d. 0.8.9.3.8. be requested to spprove Dr. Hex Pollock ss eo-investigstor. �7/1/62 - 12/31/62 1. 1/63 - 12/63 Staff John Kraser, Psychiatrist Pollack, Sr. Res. Assoc. Bxper. Psychol. 1. Belmont Consultant I. tarp, Res. Ass't. Exper. Psychol. A. "illner, Ree. Assoc. Bxper. Psychol. H. Hosquerae, EEG Technician 0. Podrid, aecretary at. Schnirneneﬁ, secretary J. Kolodny, technician as, no (app) Travel Supplies Computation & Consultation H. ' ’ 3,956 - 7.500 3.582 15,000 750 3.000 b.350 8,700 h.7oo 1,000 1,700 1,h57 1,315 9,hoo 2,000 3,800 950 1,500 600 1,200 1.800 1,200 11500? Carried forward ,, Net ' . Board Support 03935 Board 50,500. 5,000 _., 3h,260 hS.Soo h,zoo 6,825 38,960 52,325 12,500 $6,000) 51,h60 58,325 Overhead Total Budgets: 18 nos. 9,600 900 3h,260 Total U.8.P.R.S. - $109,785 91.285 12,500 (+ $6000 contingency). Notes e i tine as research and i time as clinical statistician, EEG services (if reconaanded by Neurologist). so Secretary-typist: Prograa will not require second typiet 1963. H. Hosqueras Allows one EEG �Juno 12, 1962 Dr. Lowis L. Robbins, Hodioal Diractor Hr. Horbsrt Bookind, Prosidsnt, Board or Dirootors ﬁillsido Hospital Olon Oaks, !.!. Dsar Dr. Robbins and Hr. Bookind: It is with rogrst and with tondnsos for my stimulating and exciting ysars at ﬂillsids that I submit this lattsr of rosignation as Dirsotor of tho Dopartssnt or Exporiasntal Psychiatry stractivo Doooubor 31, 1962. I an aura you will ho ploaosd to know that tho prograss hora havo lad to tho invitation to ostahlish a rosoaroh and training program in a now cantor, tho Missouri Instituto of Psychiatry at St. Louis; as wsll as my appoint-ant as Rsssarch Protoosor of Psychiatry at Washington Unirsrsity School of Hodicino. I look back at thoss ysara with ploasurs, for I havo loarnod such and hats round snthusiastio and dodioatod co-worksrs. I as aratotul to tho contidonoo sxprosssd in my initial appointasnt by Dr. Israol strauss, and to tho Board or Diroctor's support during thoso yoars. During tho nsxt tow aonths, I should liko tho opportunity to coaplots as such o: my progras as possiblo hora, and for this roason hays askod to continua as projaot dirsotor or ths USPH3 grant H12715. is soon as tho studios hora psrait, I shall lsavs to ossuas my now dutiss in St. Louis. with my boot porsonal rogards, and assurancos of loyalty, I roaain. Rospoctfully yours, Hrsgp . ﬂax M IInE, 5.5. �HEHORAHDUH June 12, 1962 to: Dr. L. Robbins FROM: Hex Pink, M.D. With the disapproval of the proposed 18 nonth budget for the Brein Function and Behavior Project, and without a to submit the satisfactory alternative, I an conetreined enclosed letter of reeignation, dated Deco-her 31, with a recommended budget for the expenditures under HI-2715 during the renainder ot the grant period. I an dating the roaignation as of this time to permit the oonpletion of e major port or the progren. It in my intention to continue thie program of studies or the relation of brain function to behevior et the Hieaonri Institute of Poy‘ ehiatry, beginning early in September. For e treneition period or e few nonthe, while aone onelyeeo end write-up are in progress here, the continuation progrene will be eetabliehed there. AI noon on my tine is predoninantly in St. Louie, I will resign fully from the program here. I truet this is satisfactory to you. Roapeotfnlly yonre, Krzdto one. or M n , . . �June 12, 1962 Proposed Budget, Brain Function and Behavior Research Project Jnly 1, 1962 - December 31, 1962 Estimated Balance, 6/30/62 MY2715 Income 6/30-12/31 12,000 h2,007 $Sh,000 Expenditures l.2. Prin. Investigator Psychiatrist (Kramer) 3. Psychologist (Pollack) h. 5. 6. -7. 8. 9. 10. 11. 12. 13. lb. 15. ” EEG 12,500 3,956 7,500 3,582 (Belmont) 750 (Karp) '' (Willner) Technician (Moequara) Secretary (Podrid) (Schnirnan) Technician (Kolodny) Soc. Sec., Blue Cross Travel Supplies Cowputation and Consultation 0,350 h,700 2,000 1,700 1, h57 1, 315K ' Overhead 950 600 900 , ’ 1,500 h,700 $52,h60 Balance carried forward 1963 $ 1,5h0 �June 12, 1962 Proposed Budget, Brain Function and Behavior Research Project July 1, 196? - December 31, 1962 Estimated Balance, 6/30/62 H12715 Income 6/30-12/31 12,000 h2,oo7 $5h,000 Expenditures l.2. Prin. Investigator Psychiatrist (Kramer) 3. Psychologist (Pollack) h. So 6. 7. a. 9. 10. 11. 12. 13. lb. 15. (Belnont) 'I I . (Earp) (willner) ' £30 Technician (lacquers) Secretary (Podrid) (Schnirnan) ' Technician (Kolodny) Soc. Seo., Blue Cross Travel Supplies 12,500 3,956 7,500 3,582 750 13,350 ‘ h,700 2,000 1,700 1.h57 1,3155 . ' ‘ Computation end Consultation Overhead 950 600 900 1,500 ht7°° 3 2 h60 Balance carried forward 1963 ' 3 1,5h0 �June 1?, 1962 Propoeed Budget, Brein Function end Behevior Reeeeroh Project July 1, 196? - necenber 31, 196? V Settleted Belence, 6/30/62 HYZTIS Income 6/30-12/31 . 12,000 g2.oov $5h,000 Expenditures 1. Prin. Inveetigetor 2. Paychietriet (Ire-er) 3. Psychologist (Pelleok) * L. (Beleont) R S. 6. 7. 8. 9. 10. 11. 12. 13. 1b. 15. '' I (Earp) (willner) Technicien (Hoequere) Secretary (Podrid) (Schnireen) \ Technicien (Koladny) Soc. Sec., Blue Cross Trevel Supplies Coeputetion end Consultetion EEG ' Overheed 12,500 3.956 7.500 3.582 750 h,350 h.700 2,000 1,700 1.h57 1.315f 950 600 900 1,500 5&12Q 2 Belence carried toruerd 1963 h60 a 1,5h0 �glidilibﬂl Jan. 12, To. 1962 Dr. In Robbins ---.~-- -----”.-.-.with tho disapproval at the prchIod 18 nouth budget fur the Brain function and lohnvlnr Proaout, and without a tntlntuatory altornativc, I am eenstrainod to submit the with a Isolated lattar at rculznatlon, datod noun-bowII~5115 Jl roast-andod budgot for the Impoudlturuu and-r during tho ronnlndor or the grist porlud. I :m attlng rollcu:tlan In of ﬁhln #1:. to paralt the ounplo‘lon of a IIJOr part at in. progral. It 1- Iy intanllon to uoatlano tutubotavlor proxruu of It‘dlou of tho ralatlon or brain Pay— I1UIOIF1 tho or functlun $0 InstitutIt ohlntrr. bout-nan; early in Boptunhor. It: a truulttlou 902106 at I ran monthl, will. aqua analyacn and write-up are in prograan bars, the oonﬁlnnntlou prouru-l will be octablilhnd tiara. At noon an my tin. la produuiu:ntly 1a 3%. L§!1l. I will route: tall: from the progrum hcrc. I ‘rlnt til: 1. natiltlctozr to you. BprQoSShlly yours, ti. nmu “.0 n , . . �MEMORANDUM DEPARTMENT OF EXPERIMENTAL PSYCHIATRY June 1h, 1962 To: Mr. Bechrsch FROM: Dr. Hex Fink ..‘.~.“‘..--.-.“enclosed budget dated June 12, 1962 for 6 months under project support by MY-2715 is contingent upon the adjustments euthorised in my memorandum of 5/23/62, 3 copy or which is enclosed. The estineted belence or $12,000 for 6/30/62 may be in error by 10%, and if so, can be corrected by using the belenoe, or adjusting expenditures to conform with reality. Also, it is probable thst lines 1, 2 ere overestimeted. I have also indented this grent fully for Mrs. Mosquere (line 7). After Hrs. Croghen hes made the adjustments of 5/23/62, if she will give me e true balance, I will revise this budget statement. The Thenk you HFsdts for your cooperation. Sincerely yours, ﬁe: Fink, 5.5. �MEMORANDUM DEPARTMENT OF EXPERIMENTAL ?SYCHIATRY June 1h, 1962 T0: Mr. Bachrach FROM: Dr. Max Fink enclosed budget dated June 12, 1962 for 6 months under project support by MY-2715 is con— tingent upon the adjustments authorized in my memorandum of 5/23/62, a copy of which is enclosed. The estimated balance of $12,000 for 6/30/62 may be in error by 10%, and if so, can be corrected by using the balance, or adjusting expenditures to conform with reality. .Also, it is probable that lines 1, 2 are overestimated. I have also indented this grant fully for Mrs. Mosquera (line 7). After Mrs. Croghan has made the adjustments of 5/23/62, if she will give me a true balance, I will revise this budget statement. Thank you for your cooperation. The Sincerely yours, ﬂaw MF:dts Max Fink, M.D.' �MEMORANDUM DEPARTMENT OF EXPERIMENTAL PSYCHIATRY July 20, 1962 Pollack Co-Investigator M. Fink, M.D. T0: Max FROM: MI-2715 Project In answer to your question of 7/19, I plan to complete my active participation at Hillside on September 15 and shall request “vacation” time as terminal leave. For the past year I have accrued 16 days as of 9/1/62, and have carried forward 15 days from 1960-61. If my calculations are correct, my salary should be paid to October 26. Effective on your return from Europe in September, I believe you should assume full responsibility for the expenditures and management of MY-27lS. Until I leave for Europe, and in your absence, I shall continue to carry out these responsibities. I shall notify NIMH as to the transfer of responsibility as of September 15, and have notified Mr. Bachrach as attached memo indicates. In the event that you balieve my consultation will be of service to you, I shall be pleased to come to N.Y. However, reimbursement for expenses should be borne by the grant here. Good Hrtdts luck! Max Fink, M.D. �do ’ MEMORANDUM k DEPARTMENT OF EXPERIMENTAL PSYCHIATRY July 20, 1962 T0: Mr. Bachrach FROM: Max Fink, H.D. Principal Investigator, permit you to MI-2715 Project exact budget estimate for MI-2715 for 1962-1963, I should like to bring the following to your attention. At the completion of my duties in Europe I shall return to Hillside and complete such reports as may be necessary. This should be done by September 15. I shall ask that I complete my service on these programs as of that date, subject to reimbursement for accrued leave. is of September 1, 1962 accumulated leave time will be 31 days, which will be requested as terminal leave. Until September 15 I shall continue to exercise responsibility for the project activities, but shall relinquish these To make a more that date. Parenthetically, I would suggest a prudent bookkeeping measure for your consideration. is you know, the office of Director of the Department has never been supported by government funds. It is prudent to combine this course until the final termination of the office. As a record fully as of matter, if you exercise the prerogatives of your position you could so reassign items in MI-2715, and non-government for 1961-62 as to "carry forward” in non-government a sum necessary for the position. In the revised budget estimate you are planning to submit to NIMH, the item of principal investigator need no longer appear. Thank you for your cooperation. HF:dts ﬁax Fink, H.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource [Hillside] hospital budgets. (2/2) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-001-0-010 Date A point or period of time associated with an event in the lifecycle of the resource 1961-1962 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Proposed Research request budgets; letters; report of expenditures Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/035fb0f29ed47985e9b4395a43cb14d0.pdf 4db2ed7f8f4aec275baaa2efc8c24ad0 PDF Text Text Seventy Years an Experimentalist in Neurology and Psychiatry Max Fink, M.D. Professor of Psychiatry and Neurology Emeritus, State University of New York at Stony Brook. First Publication in Archives: May 28, 2017 Updated April 18, 2021 11 Buttonfield Lane South Hadley, MA 01075 Tel. 631.637.1730 fink.max@gmail.com maxfink55@gmail.com max.fink@stonybrook.edu max.fink@stonybrookmedicine.edu max.fink@sunysb.edu max.fink@optimum.net Metrics: April 18, 2021 Pages: 100 Words: 38,107 The ultimate court of appeal is observation and experiment, and not authority. Thomas H. Huxley 1 �Introduction Inducing seizures to relieve severe behavior disorders-- electroshock, ECT -is a much prejudiced treatment that is undergoing a renaissance after eight decades of experience. Usage is increased to varying degrees worldwide. But raucous attacks by public critics and psychologists claiming treatments cause brain damage and memory losses are ever common. But assured safety and remarkable efficacy, even guides to specificity in illnesses, brings the intervention within a successful medical tent. Introduced for the relief of the imagined Kraepelinian diagnosis of schizophrenia, recent decades has defined catatonia (and its varieties of mutisms, manias, motor rigidities) and melancholia (depressive psychoses) as more specific systemic disorders that are rapidly and effectively relieved. How was the treatment discovered? And why was it rejected by the professions? Why the public stigma in the face of efficacy and specificity? How has the practice and the science of the treatment evolved? The author, well on his way for full training in conventional neurology and psychiatry is asked to oversee the seizure therapies in hospitalized severely psychiatric ill. He takes on the task of improving the science and increasing public and professional acceptance are highlighted in this personal story of an experimentalist physician. These pages cite my education as a physician with qualifications in neurology, psychiatry and psychoanalysis. From the beginning, I studied patients, their physiology and symptoms, and applied different interventions, often in a Random Controlled Trial. When I entered the profession, research studies in man was an accepted practice. In recent decades, bars to such studies have been increasingly applied, leading to focus on studies in animals and other surrogates. Over my professional career my interests focused on the treatment of induced seizures (electroshock, ECT), the effects of substances that altered brain functions (psychopharmacology, EEG), and the systemic behavior syndromes of catatonia and melancholia. The records of my studies are archived at the Stony Brook University Library. 1 2 �Contents Introduction for Readers Book One: Inducing Seizures as Treatments 2 Ending Insulin Coma Optimizing ECT Procedures The EEG as Index of Efficacy Modifying seizures: Muscle relaxants and sedatives Are subconvulsive treatments effective? Are chemical induced seizures as effective as electrical? Is Isoflurane anesthesia a replacement? Acetylcholine and Anticholinergic Drugs Neuropsychological Tests and EEG Slowing 9 11 13 15 16 17 17 18 The differences Electrode Placements make, Again Multiple ECT. MMECT ECT in Systemic Medical Illnesses Optimizing Treatments ECT in Schizophrenia Clozapine and ECT Seizures and Brain Fluphenazine CORE Study: ECT in Depressed Inpatients Persisting Stigma: Memory Loss and ECT 19 20 21 23 24 25 26 26 28 Creation of Induced Seizures as Therapy Immediate Rejection by the Profession First APA Task Force onECT Out-Patient ECT Commission Stigma persists: Public Joins Attack Church of Scientology and Malpractice Legal Suits Media Attacks: Madness with Jonathan Miller Active Defense: A Beautiful Mind 30 31 34 34 35 36 36 38 Book Two: After ECT Research Hiatus, Renewed Studies Book Three: Electroshock in the Public Eye 3 �Book Four: The Enigma: How do Seizures Affect Behavior? Seizures as systemic reflexes Neurophysiologic adaptive theory Cholinergic theory Neuroendocrine hypothesis Conferring in the search for mechanism 40 41 42 43 46 The Teaching Case Catatonia as a type of Schizophrenia? But Catatonia is not Schizophrenia In contrast, Catatonia is Treatable Is NMS a Form of Catatonia? The Drive to Official Definition Sedative Verification Test Many Faces of Catatonia Delirious mania Toxic serotonin syndrome Pervasive Refusal Syndrome Toxic encephalitis: NMDAR Receptor Self-injurious behavior in Autism DSM Classification Debates Catatonia Textbook, ACTA Supplement 50 51 52 53 54 56 56 57 57 59 59 60 62 62 64 What is next? Dexamethasons Suppression Test Melancholia Textbook, History 66 66 67 EEG Introduced to Hillside Hospital EEG in Psychopharmacology Grey Walter Analyzer Digital Computer analysis of EEG IBM 1800 analysis system Lessons learned: Putative Drugs Classified Association-Dissociation Controversy Pharmaco-EEG Paradigm 69 71 71 71 73 74 76 78 Book Five: The Road to Catatonia Book Six: Melancholia: Medical Model of Diagnosis Book Seven: Studies in Electroencephalography 4 �Book Eight: A Medical experimentalist is Created Medical School Experiences 1942-1945 Neurosyphilis and CSF Osteomyelitis, Barbiturates Interneship Penicillin in Empyema Residency Percutaneous Carotid Angiography Face-Hand Test 79 79 80 Early Life Family Affairs Dalliance with Psychoanalysis Military Career, Ship's Surgeon Perigrinations Books Published, Edited 85 87 87 89 93 93 Book Nine: Biography Appendices 81 82 83 94 5 �Book One: Inducing Seizures as Treatments My academic arc in electroconvulsive therapy began unexpectedly on January 2, 1952 as I enrolled for the fifth year of residency training in neurology and psychiatry at a hospital reputed to use classic psychoanalytic principles to treat hospitalized severely ill. I arrived on a clear winter day with another new recruit, to meet the Directors of this 170-bed multi-building Hillside Hospital caring for voluntary psychiatric in-patients, for up to a year, mainly at public cost. That morning I was assigned to the electroshock and insulin coma treatment services. In my previous years, I had no experience with either treatment. I received my M.D. degree from New York University School of Medicine on June 12, 1945, followed by nine-month interneship and 20 months service in the US Army Medical Corps. During the succeeding four years I studied in neurology and psychiatry residencies, attended a school of psychoanalysis, and sought a final year in psychoanalytic psychotherapy at an inpatient hospital in the Long Island farmland, with accredited training psychoanalysts on its faculty. I accompanied the Associate Medical director to a 2-story building that housed the electroconvulsive (ECT) treatment unit. One by one, five patients lying on a wheeled stretcher under sheet restraints were brought into a treatment room, a rubber bite-bloc placed between their teeth, two stimulating electrodes applied at the temples, protected by two aides, a seizure induced with currents delivered from a Medcraft alternating or a Reiter polyrhythm current device with the energy set according to estimates of what was needed to induce a full grand mal seizure. As the electric currents were applied, the neck and back arched, the body became rigid, followed by rhythmic muscle movements and breath holding. The patient became cyanotic with light blue lips. After a minute, the muscles relaxed, deep breathing followed, cyanosis waned, and color returned as the patient was moved to a recovery room, cared for by aides for 15 to 20 minutes until able to get off the stretcher and walk to the ward for shower, dressing and breakfast. Durations of the elicited seizures varied in length from 30 seconds to a few minutes, occasionally requiring termination by intravenous injections of amobarbital. Observing a full grand mal seizure in each patient jarred me. The previous week and for years before I had been taught by my neurologist teachers that seizures were dangerous to patients and must be stamped out. Every teacher had emphasized the need to fully inhibit seizures to avoid tooth, limb, and spine fractures, tongue-biting, confusion, injury from falls, and death. Much was made of the newly developed anticonvulsant phenytoin (Dilantin). 6 �And now, we were deliberately inducing grand mal seizures! This antithesis has plagued my professional life and the lives of neurologists who, to this day, are unable to accept the evidence that benefits in behavior accrue to repeated induced seizures in severely depressed, manic, catatonic, delirious, and psychotic patients. As I learned how to treat patients safely I realized the remarkable benefits of inducing seizures, and such treatments became an interest for the remainder of my professional life. After introduction to ECT that first morning, we crossed the hall to the insulin coma treatment unit, a well-lit air-conditioned suite with a large nursing staff. Filled with cries, coughs, grunts, and groans of patients in various stages of stupor, coma, drowsiness and confusion, and some suffering a seizure. They had come to the treatment unit in loose-fitting pajamas at 6 in the morning and had been injected subcutaneously or intravenously with measured doses of insulin. For the next three to five hours they were repeatedly tested for vigilance and response to commands as they lost consciousness; their tendon and pupillary reflexes disappeared, breathing became stertorous, and intense sweating soaked the bedsheets. After a measured hour, the stupors were ended by 10% glucose solution administered either by nasogastric tube or by intravenous injection. The change from unconsciousness to consciousness and to talking with the aides occurred rapidly, within 10 to 30 minutes. On awakening, each patient was taken to shower, dress, and within an hour was eating breakfast. Most were famished and ate everything put before them. Insulin coma treatments, like the ECT sessions at the time, were unsafe. Fractures of teeth and limbs occurred and confusion persisted for hours after treatment. During 1/5 of the ICT treatments, at least one unscheduled seizure emergency occurred each morning. For the patients who had shown little change in behavior during the course of insulin comas, seizures were induced electrically in the midst of the coma. This combination of ECT and coma was common for the severely psychotic patients, an implicit recognition that the seizure was the therapeutic feature of the coma treatments. Occasionally, consciousness did not return despite repeated doses of glucose. Stupor persisted with sweating, fever, elevated blood pressure, and rapid heart rates. We had no understanding of why a state of persistent coma occasionally occurred nor how to relieve it. Many experimental means were tried. Relief from the stupor occurred slowly over days of intensive nursing care. Two patients died in stuporous coma during the six years that I managed the service. By early afternoon, the ICT and ECT treated patients were in individual and group treatment sessions, participating in occupational activities, playing musical instruments and games, and meeting with relatives. I frequently tested their skills in chess and checkers, finding the skills of many better than my own despite their morning seizure or coma. It was remarkable to see a patient in coma, unresponsive 7 �to verbal, sensory, or painful stimulation and an hour later chatting with staff, drawing, and playing games. Older patients, though, were more often confused and fatigued, spending a good part of their post-treatment day in their rooms or their beds. For the next three months, I supervised both the ECT and ICT services, with ECT three times weekly and ICT every morning. My afternoons were spent in individual therapy sessions with patients, meeting families, attending staff conferences about individual patients and classes with attending physicians. By mid-year I had learned that ECT effectively reduced suicide thoughts, relieved negativism, aggression, depressed and manic moods. Of the hospital populations, the patients treated with electroshock improved the most. They became more cooperative and responsive, no longer expressing morbid thoughts and threats of self-harm, sleeping and eating better, and interacting more normally with their families, other patients, and staff. The outcomes with insulin coma were less well defined, and the risks much greater, but yet, greater percentages of patients so treated were rated improved than after psychotherapy. ECT treated patients typically improved rapidly; many returned home, with few transferred to the local Creedmoor State Hospital for lack of improvement. By contrast, few insulin coma treated patients returned home after a year's residence; most continued in chronic care. A 5-year follow-up study of 314 patients admitted to the hospital in 1950 reported a mean hospital duration for ECT-treated patients of 5.0 months, for psychotherapy-treated patients 6 months, and for ICT-treat patients 6.5 months. With ECT, 76% were rated as recovered or much improved compared to 53% for psychotherapy and 33% with ICT. Admittedly, the selection of treatments and the diagnostic labels were not random but dictated by the opinions and beliefs of the Attending physicians and by the preference for trials of psychotherapy before assignment for ECT or ICT. 2 The teachers used social and symptom guidelines for diagnosis and treatment. The younger, more literate, and better educated patients with phobias, obsessions, compulsive rituals, and anxiety states were assigned a diagnosis of psychoneurosis and valued as participants in psychotherapy; the more aggressive, over-active, and psychotic patients were labeled schizophrenic, with ICT or ECT the recommended treatments; while the elderly, poorly educated patients, often immigrants, were seen as depressed and referred for ECT. 8 �Ending Insulin Coma Therapy The introduction of Largactil (chlorpromazine) to Hillside Hospital in the fall of 1954 set in motion the demise of insulin coma therapy. Developed in France as a sedative, to reduce excitement and psychosis of the psychiatric ill, it first underwent safety and efficacy trials at various New York State hospitals. At an open meeting organized at Creedmoor State Hospital in Queens in 1954, I heard one researcher after another -- Herman Denber, Nathan S. Kline, Sidney Malitz, Sidney Merlis, Anthony Sainz, and John Whittier -- report reduced excitement, aggression, and mania, lesser disorders in thought, fewer injuries to patients and staff members, fewer fires set, fewer mattresses trashed, and fewer windows broken with chlorpromazine use. At the end of the sessions representatives of the Smith, Kline and French pharmaceutical company offered 25mg samples for clinical trials and I enrolled. As the dosing and risks of chlorpromazine were poorly known, the Hillside hospital administration decided that referrals for this experimental treatment were best prescribed and supervised by the ECT/ICT physicians. For the first trials we selected the most disturbed and least cooperative patients in one study unit. Patients became more responsive, less aggressive, less manic, and more cooperative. Soon, nurses from other units asked to enroll their patients. Initial reluctant staff attitudes changed quickly and our enthusiasm for chlorpromazine added to the voices encouraging its use from France and Canada. But soon one patient and then another developed jaundice. Other study centers reported similar toxicities. Our patients were examined for systemic liver disease, but no explanation for the jaundice was found. Our initial enthusiasm for chlorpromazine trials was inhibited, but the strength of the benefits encouraged continued trials. Within a year, such toxic reports became less frequent (there had been a contaminant in the initial batch, it turned out) and soon motor rigidity, tremors, and then tardive dyskinesia (delayed abnormal rhythmic movements of mouth, tongue and facial muscles) dominated discussions of its risks. These motor signs were the fore-runners of the Parkinsonism and tardive dyskinesia that are hallmarks of chronic chlorpromazine use. Similar motor effects were soon reported for successor neuroleptic drugs and motor inhibition became a marker of these agents. Decades later, the "atypical neuroleptics" were developed and promoted for their lesser motor effects with disregard for their lesser clinical efficacy. The NIMH-sponsored large clinical trial known as CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) undertaken in the 1990s randomly assigned ambulatory out-patients either to the atypical neuroleptics olanzapine, quetiapine, risperidone, ziprasidone or to the typical neuroleptic perphenazine. The atypicals did not match the beneficial effects or costeffectiveness of perphenazine. 9 �The EEG profile of chlorpromazine showed dose-related changes of reduced beta fast frequencies, increased theta slow frequencies, and occasional bursts of slow waves and spike activity. These rhythms heralded the seizures that became an acknowledged risk of the drug’s use. We had begun with 50mg doses but rapidly increased single dosing to 200mg and daily dosing to 1800mg. We learned that 1200 mg daily was effective and well tolerated in 80% of our subjects. These experiences led us to undertake two random controlled trials, one compared chlorpromazine to insulin coma and another comparing the effects of chlorpromazine, imipramine, and placebo in patients with a broad range of behaviors. The Random Controlled Trial: A compelling motive for the comparison of chlorpromazine and insulin coma was the risks posed by the high doses of insulin. Seizures occurred in more than 10% of the sessions, and delayed spontaneous (“tardive”) seizures often occurred late in the day or night, requiring additional intravenous or gavage dosing with glucose. For patients whose psychosis was responding slowly, electrically induced seizures were added at the height of the comas to augment the changes in behavior. A prolonged coma was a much feared risk, the patient not becoming alert and oriented for many hours despite extensive dosing with intravenous and gavaged glucose. Many explanations were considered and many interventions tested, but we did not find an effective treatment or method of prevention. We depended on intensive nursing care, repeated dosing with glucose, and monitoring until recovery. Two deaths in prolonged coma occurred in the five years that I supervised ICT, a 2% mortality rate. Sixty patients referred for ICT were randomized to receive either 50 insulin coma treatments or oral chlorpromazine (0.3 to 2.0 Gm/day; median 0.8 Gm/day) with both treatments given for a minimum of three months. Chlorpromazine treatment was as effective as insulin coma but with greater ease of use, greater patient comfort, lesser risks, and lesser expense— clearly favoring chlorpromazine as a replacement for ICT. More than half of each sample improved sufficiently to return to their homes. 3 These findings led to the closing of the Hillside Hospital's insulin coma unit in 1958, followed swiftly by the closing of other units throughout the nation. Within a decade the treatment had disappeared from American hospitals. A few units continued to treat patients with ICT as exemplified by the report that the 1994 Nobelist John Nash had received ICT in 1961 at Trenton State Hospital. 4 The treatment also persisted for decades in Russia and China, and was brought to Israel by Russian emigres. My review in 2003 of what was known about insulin coma treatment, the lesser efficacy of ICT in treating psychosis and its 10 �increased efficacy with augmented electrical seizures led me to conclude that the spontaneous random seizures were the basis for ICT’s reported efficacy in relieving psychosis. ICT, to the extent it had therapeutic value, was best considered a less efficient and more riskful form of induced seizure therapy. 5 Optimizing ECT Procedures The EEG as Index of Seizure Efficacy Since seizures were the core process in both ECT and ICT how can one record and understand the brain events that were central to the treatments? The answer seemed to lie in electroencephalography, but such was not available at the hospital. In 1771 the Bolognese physician Luigi Galvani had demonstrated that an electric stimulus caused a living frog muscle to twitch and contract. He observed electric currents from living muscles by the movements of a magnetized “galvanometer” needle. His experiments connected the newly discovered phenomena of electricity to living tissues. Similar reports by Giovanni Aldini and Benjamin Franklin strengthened the conviction of electricity in living tissues. 6 A century later, in 1875, the physiologist Richard Caton recorded electric oscillations from the exposed brain of a living animal, securing the connection between brain functions and electricity. But these currents were too small to be recorded through the skull and could only be demonstrated in an exposed brain. Then, in 1929 Hans Berger, a Jewish hospital psychiatrist in Jena Germany adapted the device that was developed to record the electrical activity of the heart to record electric oscillations from electrodes on the intact human scalp. Rhythms varied with changes in vigilance, sleep, body physiology, and the effects of systemic drugs. In his third report Berger described changes in the EEG under the influence of cocaine, scopolamine, morphine, chloroform, and sleep. The electrical changes associated with insulin-induced hypoglycemia (as in insulin coma therapy) and the chemical and electrical induction of seizures were next charted, as these treatments were increasingly applied in the severe mentally ill. Hillside Hospital lacked an EEG laboratory. I sought training in recording and interpreting the EEG at the Mount Sinai Hospital in New York City supported by a fellowship of the National Foundation for Infantile Paralysis. 7 By the end of 1953 an EEG technician had been trained, a laboratory established, and developed a protocol for the study of the changes in EEG associated with ECT. An application to the National Institute of Mental Health funded a five-year study under Grant MH-927 "Altered Brain Function Following Electroshock" in the summer of 1954. The support established a team of researchers to study the treatments. For the next 11 �decade, the physicians, psychologists, and technical staff were centered in a Department of Experimental Psychiatry. 8 The EEG brain rhythms in alert normal adults are filled with 8-to-12 Hz (alpha) frequencies with amplitudes of 40 to 80 microvolts (µv). Patterns vary with age, during day and night, and are altered by drugs and disease. After head injury and intracranial bleedings, the rhythms slow with increasing amounts of theta (4.5 -7 Hz) and delta (2-4 Hz) frequencies and the amplitudes increase from 50 µv often to 150 and 200 µv. As brain pathology improves, normal EEG rhythms return. During my EEG education I was shown records with high voltage slow waves with “spikes” appearing in one-to-three second bursts with longer runs of lower voltage slow waves as evidence of an epileptic seizure. We found similar records on inter-treatment days during the course of ECT. The pre-treatment records of our psychiatric ill did not differ from those of healthy individuals, with older patients showing slower rhythms than did the younger. In the minutes and first hours immediately after a seizure, EEG voltages increase, frequencies slow, and burst patterns appear. In ensuing days, the changes after each treatment persist for longer periods. After 4 to 10 treatments, slow waves persist throughout the day, then for many days and in some patients for weeks thereafter. It was technically unfeasible to record the actual seizure as our instruments became "blocked" by the electrical stimulus. 9 But we could examine the “interseizure” record, the changes in the resting EEG record on days between treatments. Brain electrical rhythms slowed and amplitudes increased during the ECT course. After treatment ends, more rhythmic, regularized alpha frequencies return. The changes induced induced by electricity and by the chemicals Metrazol or flurothyl are not distinguishable, arguing that the EEG records during treatment are related to the seizure and not to the seizure-inducing agent. We concluded that progressive slowing of inter-seizure frequencies was necessary for beneficial behavior effects. The patients whose inter-treatment rhythms changed very little did not recover from their illness. 10 Although it was customary to describe the rhythms in non-quantitative descriptive terms, I sought more reliable indices, measuring the frequencies and amplitudes by height and width of each wave, using calipers and ruler, one wave after another, in 10-second epochs , up to 60 seconds for each sample, with an average of 600 waves measured at baseline and 350 to 450 waves at the end of a course of treatment. By comparing numbers of treatments and degree of slowing for each patient, slowing occurred earlier and to a greater degree in patients exhibiting symptom relief than in the patients whose behavior changed slowly or failed to improve. EEG frequency slowing and amplitude increases became markers 12 �of the brain changes that underlie behavioral improvement. The rate and amount of change varied with electrical dosing and the number and frequency of treatments. We concluded that EEG change was necessary for the clinical changes to take place and marked the physiological changes that are the basis for the treatment response. This lesson became the critical observation of the ECT process and became the core of my studies to optimize and understand the convulsive therapy process. That the changes in EEG rhythms with ECT were similar to those in epilepsy and after head trauma was often used to justify an anti-ECT prejudice voiced by the public, by patients, and by psychiatrists and psychologists encouraging beliefs that seizures “damaged the brain.” We thought otherwise, concluding that the EEG changes induced by the seizures were necessary markers for the clinical benefits -without persistent EEG slowing, recovery of illness did not occur. The patients referred to hospital for ECT are very ill, unable to function at home or at work, sad and unhappy, expressing thoughts of suicide, strange ideation, and occasionally with aggressive manic behaviors. 11 Almost all have been treated by a cascade of medicines, psychotherapies, vacations, diets, and much else before the patient was exposed to electroshock, widely conceived as hazardous and life threatening. The patients met today’s diagnostic criteria for major depression, bipolar disorder, and schizophrenia. The quickest resolutions of illness occurred in the severely depressed, suicidal, catatonic, manic, melancholic, and delirious patients. The least benefits, were in the withdrawn, apathetic, poorly motivated, thought-disordered patients who today meet the criteria in the standard diagnostic system for schizophrenia or bipolar disorder. 12 Modifying Seizures: Muscle Relaxants and Sedatives Electroshock treatments were “unmodified” -- without sedation or muscle paralysis, allowing the full grand mal seizure to develop in each treatment. For anxious patients, amobarbital was injected to sedate and relax. We also interrupted the longer seizures by injections of amobarbital. The body movements, EEG seizure patterns, and changes in physiology are similar for each treatment. Indeed, the “seizure” has the same form and is readily recognizable in all mammals. It is an inherent pattern that occurs both spontaneously and when stimulated by electricity, by chemicals, and by disease. What is the function of such a universal response? In natural environments a seizure puts the subject at undue risk of predators and one would expect that after generations the behavior would be extinguished by natural selection. But the biology persists. Does the seizure serve a useful purpose? What is it? 13 Fractures of teeth, vertebrae, and long bones were unfortunately common. Many forms of physical restraint and chemical inhibition were tested. Curare, extracted from South American plants, prevented both the tonic (increased muscular tone, stiffening of the body muscles) and the clonic movements (rhythmic 13 �movements of the stiffened musces) of the seizure. 14 But curare was unstable. In some patients curare effectively blocked the motor movements and in others, the effects were small and a full seizure occurred. A dose on one occasion might effectively modify the seizure, but in the next, the same dose would fail to relax the patient. On occasion, paralysis persisted after the seizure and it was necessary to ventilate oxygen through a mask until natural breathing returned. We discontinued curare use and depended on sheet restraints alone to prevent fractures. Spine x-rays were taken in 50 patients before unmodified seizures and repeated in the week after the last treatment. In seventeen patients a compression fracture of lumbar vertebrae 4 or 5 or both was recorded. Surprisingly, these fractures elicited little complaint from the affected patients. Such compression fractures were accepted as a cost of the treatments. In the spring of 1953 a new synthetic muscle relaxant suxamethonium chloride (succinylcholine) was introduced. Limb paralysis occurred within 30 to 60 seconds of intravenous injection, dissipating within a few minutes of its application, making it an ideal agent for ECT. In our first experience we had not pre-sedated the patient, succinylcholine was injected, and when muscular twitchings (fasciculations) and a weakened knee jerk were seen, the seizure was induced. Tonic arching and clonic movements were much weakened. Spontaneous breathing returned quickly and the patient was moved to the recovery room. We injected our second patient, induced a seizure, and then we heard cries of “I cannot breathe, I cannot breathe” coming from the recovery room. Oxygen was administered by mask only to have the same experience with the next patient. Thereafter, we induced amnesia in every patient with amobarbital or thiopental before the succinylcholine injection. As more physicians studied this method of muscle relaxation, “modified ECT” was broadly accepted -- sedation by barbiturate, oxygenation by mask, injection of succinylcholine, and seizure induced when motor fasciculations and diminished ankle or knee jerk were recognized. Although my initial experience was in a hospital setting, most treatments were administered in office settings, such as in my office in Great Neck, where I treated patients in the early evening hours assisted by a nurse. “Modified ECT” raised questions. What was the role of the preliminary sedative -- to induce sleep, reduce anxiety, or block memory of the procedure? After the 1960s and 1970s, as “anesthesia” became the province of organized anesthesiologists, psychiatrists administering a sedative and the muscle relaxant were no longer tolerated, effectively ending ECT in independent psychiatrists' office settings. New sedation agents were studied. Benzodiazepines raised seizure thresholds, reducing treatment efficacy and outcomes. Methohexital offered short duration of action, safety and efficacy. New anesthetic agents – propofol, etomidate, 14 �ketamine, isoflurane –were tested. Propofol raised seizure thresholds, and the enthusiasm among some practitioners for minimal energies to induce seizures led to ineffective treatments and poor outcomes. Etomidate became fashionable for a time but the sedation was slow in onset and injection sites often became inflamed. Intramuscular ketamine usefully sedated excited delirious patients. An intramuscular injection in a patient restrained in bed would quickly sedate so that the patient could be moved to the treatment room and succinylcholine safely administered. By the 1980s “modified ECT” had become the universal standard, but not universal practice. In some countries, as in India, the expense of the additional chemicals and the belief in the need for an anesthesiologist led either to the inhibition of treatments or continued use of “unmodified” treatments. 15 Are Subconvulsive Treatments Effective? Were the benefits of electroshock and insulin coma inherent in the changes in physiology associated with seizures and coma or responses in the patient’s panic and fear? What was the role of electricity and the seizure? To address these questions, we induced sleep using amobarbital, muscle weakness by succinylcholine, and controlled the dosage of electricity at levels that did not induce a grand mal seizure. These methods reliably elicited “subconvulsive” non-seizure “sham treatments.” Of 24 patients in whom seizures were induced, 17 responded clinically and were discharged from the hospital; of 27 patients treated with subconvulsive sham currents, only 4 responded. Nineteen of the non-responders went on to convulsive treatments and 16 became responders. The EEG recordings of the subconvulsive treatments failed to show characteristic slowing. We confirmed that subconvulsive treatments were clinically ineffective and supported our belief that the therapeutic benefit was inherent in the seizure and not in the passage of electricity alone. 16 These findings ran parallel to those of a well-designed study conducted by George Ulett in St. Louis that also confirmed the seizure as essential to the treatment’s benefit. The results of our study were published in my 1979 textbook Convulsive Therapy. That year the British psychologist Timothy Crow challenged the profession to prove the need for the seizure. His challenge elicited multiple UK government supported studies presented in an all-UK conference in September 1979 in Leicester, and in a published appraisal edited by Robert L. Palmer. No study supported efficacy of non-convulsive treatments, reconfirming the critical role of the induced seizure. 17 15 �Are Chemical-induced Seizures as Effective as Electrical? In 1959 flurothyl (Indoklon), a new seizure-inducing chemical agent was proposed as a replacement for electrical induction. Hexaflurodiethyl ether, a volatile congener of the inhalant anesthetic diethylether, is both anesthetic and seizure-inducing. After a few inhalations the subject loses consciousness; additional breaths elicit a full grand mal seizure, usually within a few minutes. Four research teams – Joyce and Iver Small at University of Indiana, Albert Kurland at the Maryland Psychiatric Center, Björn Laurell in Sweden, and I and my associates at Hillside Hospital compared the effects of flurothyl and electrically induced seizures. Seizures were readily induced, with similar motor, seizure and interseizure EEG patterns. Both were clinically effective. Flurothyl seizures were of longer duration. Laurell reported lesser retrograde amnesia with flurothyl. In our study, 15 patients received unmodified flurothyl seizures and 12 unmodified ECT. The clinical benefits, behavior patterns, fracture rates, and degrees of EEG slowing were the same. For lack of an identifiable advantage over electricity, the induction of seizures by flurothyl fell by the wayside. The drug’s high cost and persisting ethereal aroma in the treatment room were deterrents. The smell was unpleasant, objected to by both patients and staff members. Further, the ease with which a seizure was induced frightened the professional staff as the treatment room soon was suffused with an ethereal aroma. Installing an in-wall exhaust air conditioner reduced the smell and mitigated the fears, but could not eliminate them. No advantage for flurothyl seizures was seen and we abandoned the method.18 Decades later, the pre-occupation with memory loss led to widespread reduction in treatment efficacy because many practitioners shifted to unilateral electrode placement, ultra-brief currents, and minimal dosing. Increasing reports of treatment failures sent me to re-assess the experience with flurothyl as a potential non-electricity seizure induction method. In the first quarter of the 21st Century, when repeated hospital site procedures for renal dialysis and chemotherapies and radiation for cancers are widely accepted, anesthesia sessions using flurothyl could well achieve the therapeutic advantages of induced seizures without the fright associated with electricity and the words “electric shock.” The review showed that flurothyl-induced seizures were clinically effective, that the effects on cognition and memory were less, encouraging a reassessment of flurothyl seizures. 19 Alas, I failed to entice any clinician to undertake such reassessment. 16 �Is Isoflurane anesthesia therapy a replacement for ECT? In the 1980s, Gerhard Langer and his colleague Greta Koinig in Vienna induced repeated sessions of isoflurane anesthesia in depressed patients believing such anesthesia sessions could replace ECT-induced seizures. Isoflurane is an inhalant anesthetic that quickly induces stupor, inhibition of EEG rhythms, and a flat-line EEG. Their report that six sessions on alternate days relieved severe depressive illness and was an effective replacement for ECT prompted my visit to the clinic in Vienna in 1983. I observed the feasibility of inducing isoelectric (“flatline”) EEG periods with the anesthetic and decided to replicate this experience. With the collaboration of Stony Brook anesthesiologists, isoflurane anesthesia sessions were undertaken in six patients who had been readmitted with recurrences of severe depression after earlier courses of ECT. In 21 of 26 anesthesia sessions, an isoelectric “flat-line” EEG lasting between 5 and 12 minutes was recorded. We did not observe reductions in depression rating scale scores, nor persistent changes on memory tests, nor characteristic changes in the inter-session EEG. After these failures, the patients were treated with conventional ECT with clinical recovery in five of the six. Isoflurane EEG suppression was deemed not an effective alternative for the seizures of ECT. 20 Periodically, this technology prompts interest and is re-evaluated. The studies have been poorly controlled and the reports convey authors’ enthusiasm without evidence of persisting behavioral or physiologic effects. Role of Acetylcholine: Anticholinergic Drugs and EEG and Behavior In the 1950s little was known of the physiology of the slow rhythms in EEG after induced seizures other than that their presence was necessary for clinical benefit. As the significance of EEG slow-wave activity was recognized, the chemistry of seizures was studied. George Ulett and LaVerne Johnson in St. Louis reported that anticholinergic atropine and atropine-like drugs blocked both post-seizure EEG slowing and the anticipated behavioral recovery after ECT. Herman Denber reported that injections of the chemical diethazine, another anticholinergic agent, reduced EEG slow wave activity after ECT. We replicated the finding for diethazine and also found that the antiparkinson agent procyclidine and various experimental anticholinergic drugs known as the JB-series also reduced post-ECT slow wave activity. When anti-cholinergic drugs were introduced late in the course of ECT, when mood and thought disorders were relieved, the EEG reversal was accompanied by behavioral worsening – patients no longer expressed denial language and increasingly complained of the recurrence of their symptoms. A day later, when EEG slow-wave activity had again returned, symptom relief was again expressed. We concluded that EEG slowing is a consequence of increased brain cholinergic 17 �activity. Puzzling over the brain effects of repeated seizures led me to consider a cholinergic hypothesis for the recovery with ECT. Free acetylcholine and acetylcholinesterases were elevated in the cerebrospinal fluid (CSF) of epileptic patients. CSF acetylcholine levels increased during ECT. In cats subjected to graduated head trauma, the amount of free acetylcholine and cholinesterases in the CSF increased with the severity of the trauma. I imagined that induced seizures, like cerebral trauma and epileptic seizures, altered cerebral permeability, increased free acetylcholine and cholinesterase levels in the brain, slowed EEG frequencies and increased amplitudes and rhythmic bursts. I pictured these biochemical changes as the basis for the behavioral effects we were seeing with ECT. 21 Study interest in acetylcholine waned as interest in brain neurotransmitters shifted to epinephrine, and then to dopamine and serotonin, as pharmacologists, excited by their ability to measure these neurotransmitters in animal brains tracked the effects of each of the new psychoactive moieties, that were then enthusiastically welcomed by clinicians and the public. At this juncture, half a century later, I find little interest in acetylcholine in clinical psychiatry or epilepsy. Neuropsychological Tests and EEG Slowing Immediately after a seizure, the patient awakens in confusion, poorly oriented as to location, date, or month, and often unable to recall the names of the attendant personnel. Commonly, the recovery is complete within an hour. The duration and severity of a patient’s errors vary with the number and frequency of seizures, the sedative and electricity doses, but most important is patient age -elderly patients are confused longer. With recovery to mental health, orientation normalizes and patients return to home, school and work. We tested the responses on the Face-Hand Test and found normal responses in the weeks after the last treatment. With increasing numbers of treatments, denial test scores and the changes with amobarbital paralleled scores on EEG measures, as earlier research had suggested. Persistence in denial was more often scored in older patients, in the less well-educated, and in immigrants with English as their second language. Scores on the Rorschach test were loosely correlated with the treatment outcomes but the specificity and predictability of the Rorschach criteria was low. Social attitude was tested by the 10-item California F-Scale, a measure of prejudice and authoritarianism that became of considerable interest in the wake of the NaziFascist eras. The patients with high authoritarianism scores were more likely to show benefits from ECT. 22 18 �Book Two: After an ECT Research Hiatus, Renewed studies During a four-year sojourn at the Missouri Institute of Psychiatry an ECT facility was not open to me -- psychopharmacology and quantitative EEG were the focus of our studies. Soon after I returned to New York in 1966 to direct studies of opioid abuse at Metropolitan Hospital, I received a letter from Richard Abrams, an Army medical officer scheduled to join the college medical residency program the following July, asking if I would meet him at a December conference of the ARNMD in New York City. He had compared the clinical benefits and changes on memory of ECT using non-dominant unilateral or bilateral electrode placements at a military hospital. He had administered seizures three times or five times weekly for 20 treatments in 10 subjects and reported no difference in efficacy nor in cognitive effects between treatments of the two electrode placements. He wanted to continue such studies and asked for my support and collaboration. I was still interested in understanding the mechanism of electroshock and agreed to support his studies. New York Medical College’s Department of Psychiatry lacked an ECT treatment unit at any of its clinical sites. The department chairman, Alfred Freedman, referred me to Lothar Kalinowsky, a member of the teaching faculty, who was treating his ECT patients at Gracie Square Hospital (GSH), a private hospital facility on East 76th Street in Manhattan. Kalinowsky was an early student of ECT, having witnessed its first applications in Rome in 1938 when he was studying with Ugo Cerletti and Luigi Bini, the developers of electroconvulsive therapy. He had published a leading textbook on the somatic therapies in 1946. He agreed to be a consultant to our work, arranged for GSH Medical Board approval of the study and for the collaboration by the clinicians who treated their patients in the hospital. Abrams and I asked: What is the optimal placement of electrodes in inducing seizures? We randomized patients to seizures induced either with non-dominant unilateral or with bitemporal electrode placements, measuring clinical, cognitive, and EEG changes at weekly intervals. And, could the treatment course be shortened by applying multiple treatments in one sitting? Recognizing that most patients recovered from a melancholic depression after 6 to 10 seizures, Paul Blachly, an Oregon physician, had reported that multiple seizures in one session were as effective as the same number of seizures spaced over many days. The Differences Electrode Placement Makes, Again 23 We tested 76 patients with a mean age of 63.4 years, 43 treated with bilateral and 33 with unilateral placements. By diagnosis, 60 patients were endogenous depressed and 16 reactive (neurotic) depressed. At the time, unilateral placement was considered less efficient in generating seizures and indeed some patients in the sample required additional seizures during their treatment course. 19 �We found bilateral ECT to be clinically more effective than unilateral ECT, with better and earlier outcomes regardless of age, number of treatments, or coincident medications. The memory tests during the treatment course changed less in the unilateral treated patients than the bilateral, varying with the task selected. On auditory tasks, the patients receiving bilateral treatments showed greater decrements than those receiving unilateral treatments; on a visual task, however, performance was unimpaired by either treatment. 24 EEG frequency slowing was greater after bilateral placement than after unilateral. An asymmetry was also observed in EEG slowing, accentuated on the right side with right unilateral electrode placement, and on the left side in bitemporal-treated patients. Although we did not understand the significance of either the degree of slowing nor the sidedness, these findings confirmed that the degree of EEG slowing was related to clinical outcome. The lesser EEG changes and asymmetry of unilateral ECT were signs of lesser physiologic changes--and lesser benefit compared to bilateral ECT. 25 Can Multiple ECT Treatments Per Session (MMECT) Shorten the Treatment Course? In 38 patients we applied either 4 or 6 seizures within a single anesthesia session. Different placements – bitemporal, non-dominant unilateral, or anterior frontal -- were tested. Only one patient achieved clinical remission after one session through bilateral electrodes, though we thought the benefits were accelerated in several others. The degree of EEG slowing was not enhanced, however, and the asymmetries were the same as we found in our single treatments. Post-ictal sleep among the MMECT patients was prolonged with greater disorientation and clouding of consciousness especially among the older patients. Neither we nor the experienced clinicians whose patients we treated were convinced that multiple treatments in a single session were an effective modification. We confirmed Richard Abrams’ experience that unilateral electrode placement could elicit effective relief with lesser effects on cognition, but at a price of lesser efficacy. Seizures induced through unilateral electrode placement, even with the maximal energies of alternating higher energy currents, were less effective than those developed through bilateral placements. The physicians at GSH, experienced practitioners with extensive clinical practices, were not surprised by our results. Many, including Renato Almansi, David Impastato, Lothar Kalinowsky, and William Karliner, were emigres from Europe who previously had each tested different electrode placements, electric currents, and dosing schedules and had concluded, based on their clinical experience, that unilateral placements were inefficient, requiring more seizures for relief and entailing higher early relapse rates. 20 �ECT in Systemic Medical Illnesses. In 1972 I accepted an appointment at the Stony Brook Medical School to teach psychopharmacology and develop an ECT Service at University Hospital. As the responsible clinician in the choice of treatments in an academic general hospital I explored ECT in patients with systemic medical disorders and psychiatric symptoms. We successfully treated mentally retarded adolescents, pregnant women, patients with brain tumors, brain aneurysms, cardiac pacemakers, malignant catatonia, anemia, Parkinsonism, delirium, and pseudodementia. ECT in Adolescents. ECT for children and adolescents was broadly interdicted by child psychiatrists as a matter of faith. They believed that ECT permanently damaged the developing brain. They did not ask for ECT consultations nor would they consider prescribing psychoactive drugs until the 1990s. Gabrielle Carlson, the Stony Brook Director of Child Psychiatry, would not allow her residents, many of whom had been trained in ECT while on the adult service, to consider ECT in any of their patients. The adult service, however, admitted adolescent patients over age 13. We successfully relieved adolescent patients in delirious mania, suicidal depression, malignant catatonia, and psychosis induced by LSD and cannabis. Young patients tolerated the treatments easily and the relief of psychosis was rapid with almost all returning home and to school. Mentally retarded patients are not protected from disorders in mood or psychosis by their condition, but when they suffer such illnesses, ECT is interdicted by beliefs that inducing seizures would further damage their brains. As our experience with adolescents became known, MR patients were referred for treatment and we described positive outcomes with remarkable improvements in their quality of life. A 14-yr-old mentally retarded boy with persistent self-injurious behavior (SIB), unresponsive to social and medication treatments was referred for treatment. He was admitted wearing helmet, glove, and camisole restraints to keep him from injuring his head, monitored by full-time aides for continuing protection. With parental consent a trial of ECT was begun. Within two weeks the restraints were no longer needed and he was allowed the freedom of the hospital unit. Over the next half year, continuation ECT sustained him in his community residence without the recurrence of his self-injurious repetitive behaviors. Decades later, Dirk Dhossche, a graduate of the Stony Brook University residency training programs and a participant in the catatonia studies, and Lee Wachtel, Director of the Neurobehavioral Unit of the Kennedy Krieger Institute of Johns Hopkins University, would identify SIB as a form of catatonia in autism, relieved by ECT. 26 ECT in Pregnancy. Many clinicians feared ECT during pregnancy, anticipating damage to the fetus by the electric currents and by the mother’s seizure, inducing miscarriage. But as fetal malformations were increasingly 21 �associated with psychoactive drug use during the first two trimesters of pregnancy, ECT was increasingly ventured. We simultaneously monitored the maternal and the fetal heart rates during each treatment. As the seizure in the mother unfolded, we could hear the rapid increase in her heart rate from 70 bpm to the 110s while that of the fetus ran at its own steady rapid rate of 110 to 130 bpm. The fetal heart rate did not increase during the seizure, showing only a small transient increase during the post-seizure recovery. After more than a dozen such monitored seizures, we no longer requested fetal monitoring and routinely accepted pregnant psychotic patients for ECT. We learned how to treat patients in each pregnancy trimester and optimally position a large pregnancy for proper oxygenation and anesthesia. The benefits of ECT were not limited by pregnancy and is now an accepted treatment. Pseudodementia. Confused elderly patients with poor memory, poor orientation, and poor self-care are considered demented and commonly labeled to be suffering Alzheimer’s disease. In some patients, however, the behavior is not the result of a structural brain defect but the consequence of a melancholic depressive illness labelled "pseudodementia." Both the mood disorder and the dementia signs disappear with effective antidepressant treatments. All patients admitted to my psychiatric ward suffering “dementia” were carefully evaluated and many treated for melancholia. This lesson was brought home to me by a 58-yr-old depressed, often mute, staring, and posturing woman who had been diagnosed as suffering from Alzheimer’s disease at two prior hospital centers. For eight years she had been continuously cared for in her home by her husband and daughters. When Helen was admitted to University Hospital with acute pneumonia, she was confused, disoriented, and depressed. A trial of antidepressant medications offered temporary relief but a full course of ECT resolved her dementia. She returned home to care for herself and her family. She relapsed, however, and monthly continuation ECT sustained her for years. Each relapse was marked by mutism, staring and repetitive picking at pictures and wall signs. When these symptoms were recognized as signs of catatonia, treatment with lorazepam extended the periods of her relief and only occasionally was ECT required. She lived for another decade, caring for her home and family, and taking part in community affairs. 27 As we could not distinguish pseudodementia from a structural dementia by our examinations, we offered medications, especially the older tricyclic antidepressants, finding good relief in about a quarter of the trials. An 85-year-old man with a 2-year progression of dementia requiring continuous nursing care was admitted for evaluation. Among the test findings he exhibited a positive dexamethasone suppression test consistent with melancholic depression. ECT was offered and accepted. Within three weeks he became oriented and able to care for himself. Continuation treatment with imipramine sustained his benefit and on one clinic visit he appeared well-dressed, accompanied by a well-dressed mature woman, declaring that they were to be married that week. 22 �Sadly, in the ensuing years since I left active service the prejudice against ECT is so strong that my recommendation among consultations for senile dementia were frequently rejected. The risks of ECT and of tricyclic antidepressants are small compared to the potential gain to a more normal mature independent life. Delirium. Many psychiatric consultations in a general hospital are to evaluate delirium, the common confusional and disoriented syndrome associated with systemic diseases, trauma, anesthesia, and surgery. After successfully relieving patients in delirious mania with ECT, we successfully treated deliria in post-surgical patients, those with abnormal systemic hormonal and fluid balances, and in alcohol withdrawal. We often found signs of catatonia in delirious patients, justifying the recommendations for ECT or high doses of benzodiazepines. Systemic medical risks. Many authors ascribe undue risks for ECT in patients with systemic illnesses. Brain lesions, tumors, and vascular abnormalities are considered “absolute contraindications” for ECT on the fear that the seizure would increase cerebrospinal fluid (CSF) pressures leading to cerebellar herniation and death. But the CSF pressures do not rise during our modified treatments. We reported safe treatment in a patient with a growing meningioma and in another patient with a large arteriovenous malformation. 28 Treatment of mentally ill patients in atrial fibrillation found conversion to normal sinus rhythm to occur and led us to recommend ECT with anticoagulation treatment as safe. 29 Optimizing Treatments. Anesthetics. After the hiatus from the ECT studies at Hillside Hospital in the 1950s, we again evaluated ways to optimize our treatments. The sedation and amnesia associated with the anesthetics etomidate, propofol, and ketamine, which were similar to that of methohexital, sometimes proved valuable. We again found a special use for ketamine in delirious patients – an intramuscular injection sedated a very disturbed patient within a few minutes, allowing us to move the patient from the ward room to the treatment room, and successful treatments followed without need for additional anesthesia. The induced seizures were more robust and their durations longer with ketamine. Neither etomidate nor propofol offered better amnesia than methohexital. Propofol raised seizure thresholds and shortened the duration of seizures. In elderly patients its use elicited seizures of poor quality. The rise in threshold associated with propofol is useful, however, in treating adolescents since their seizures are often prolonged even at minimal electrical dosing. Seizure durations. We studied the varying durations of monitored seizures by EEG, heart rate, and motor movements. In such recordings EEG durations were generally greater than 40 seconds, and arbitrarily considered “prolonged” when 23 �greater than 180 seconds. We often used intravenous diazepam to end seizures that ran over 150 seconds. Measured durations of EEG were longer than that of the motor seizure and both were commonly longer than the duration of the heart rate increase. We augmented seizure duration by injections of theophylline and caffeine. Although both agents lengthened seizure durations, such use had no observable benefit in treatment outcome and we discarded their use. How best to select energy to induce an optimal seizure? Concern for the cognitive side effects led to popular use of ever lower energies, just sufficient to elicit a motor seizure, often measured as 10 to 30 seconds. Were these seizures “adequate” for clinical benefit? We evaluated our recordings and identified a pattern of a slow build-up of amplitudes, onset of slow wave bursts mixed with spike activity, sudden ending in an electrically silent period. Seizures less than 40 seconds did not show these characteristics. For a number of years, clinicians were confused about seizure duration and efficacy. Some considered a series of short seizures, with added durations greater than 25 seconds “adequate” but such short seizures were clearly ineffective. Adequate seizures are best defined when greater than 40 seconds in duration with the full elicited EEG pattern. ECT in schizophrenia. The role of ECT in treating schizophrenia is confusing. Early I used the guidelines for diagnosis that labeled patients who were persistently psychotic, with language and speech abnormalities, episodic excitement and aggressive behavior as meeting the Kraepelinian criteria for schizophrenia that were adopted in the official American Psychiatric Association DSM classifications. We had no test to identify or verify such diagnoses so the treated patients were highly varied in their syndromes. The report of the 1978 APA Task Force on ECT offered little guidance, citing promising reports from clinicians with wide experience and the failure of organized clinical trials. I was invited to write several reviews on the role of ECT in schizophrenia, each time offering ambivalent opinions in the report. 30 No consensus could be reached because the diagnosis of schizophrenia was itself ambiguous, not distinguishing among long-term, chronic hospitalized patients and short-term acutely ill in ambulatory settings. The types of schizophrenia identified as paranoid, disorganized, undefined, and residual (each best viewed as variations of “hebephrenia”) were unresponsive to ECT. The single form of schizophrenia that was responsive was the catatonic. But as described later, this form was erroneously identified as schizophrenia, and is best appreciated as a uniquely identifiable, verifiable and treatable disorder. The presence of mood disorder in conjunction with schizophrenia confuses the matter. A melancholic psychotic illness is difficult to distinguish from schizophrenia and the insecurity is commonly arbitrated with the label of “schizoaffective” illness. Except for neurosyphilis, some hormone and vitamin deficiencies, 24 �catatonia and melancholia, all other psychiatric diagnoses are “in the eye of the beholder” and are not test verifiable. By contrast, the diagnoses of systemic medical illnesses have come to depend more and more on verification tests. The “medical model of diagnosis” is rejected in psychiatry – indeed the DSM classifications, including the DSM-5 of 2013 specify that no tests are known and none are applicable and that the diagnoses are best made by the association of symptoms recorded in interviews, illness course, and family associations. In studies of catatonia and melancholia, my associates and I, however, have argued that the search for verification tests is essential to the development of a psychiatric science. 31 Clozapine and ECT. A patient’s slow responses to chlorpromazine or fluphenazine is often augmented by concurrent ECT. When clozapine was first tested for the relief of psychosis, it was associated with an acute blood dyscrasia and withdrawn from the formulary. At the behest of clinicians who believed they saw unique beneficial properties in its use, however, prescription of clozapine was reinstated, but limited to patients who had failed at least two prior medication trials and whose serum clozapine levels could be tested weekly. We did not see a particular clinical benefit for clozapine alone in our patients. When we augmented clozapine treatment with ECT, the augmentation was occasionally useful. Such combined treatments was encouraged , however, by the EEG of clozapine. With clinical doses the EEG pattern becomes filled with bursts of slow waves, and the risk of overt seizures at high dosages. Such physiologic effects justified a clinical trial. We treated psychotic patients with clozapine and then, when the results were poor, augmented the treatment with ECT. We thought the synergy of the two treatments might be clinically useful and considered a proper clinical trial. The faculty at Hillside Hospital had supported clozapine use in therapyresistant psychotic patients. Many patients, however, were poor clozapine responders and they constituted a large population in their clinic. After I resumed an affiliation with Hillside Hospital in 1997 for the CORE studies I raised the question of augmenting clozapine with ECT. I obtained financial support from NIMH for a random-assignment study of ECT in clozapine-treatment failures. Half the patients who had not responded to at least eight weeks of serum-level monitored clozapine treatment continued with ECT augmentation and half continued clozapine alone. A 40% reduction in PANSS positive symptom scores without change in negative symptoms was recorded in about half the patients. What was missing in this study was treatment by ECT alone after withdrawal of clozapine. Intensive statistical manipulation of the ratings found minimal statistical advantages. 32 25 �Brain concentrations of fluphenazine. Was the increase in response of patients whose neuroleptic treatment was augmented by ECT seizures due to elevated brain concentrations of the neuroleptic agent? Studies by Tom Bolwig of Copenhagen had reported an increase in permeability of the blood-brain barrier after induced seizures in rats and in humans. We measured the brain concentrations of fluphenazine in rats treated with electroconvulsive shock but were unable to record a difference. 33 The CORE Study of ECT in Depressed Inpatients. In 1992 the psychologist Harold Sackeim of Columbia University applied for NIMH support for a multi-site study of continuation medications – placebo, nortriptyline, and the combination nortriptyline and lithium -- after ECT (using unilateral electrode placements) among unipolar major depressed patients. The NIMH consultants reviewing the application asked why he did not consider continuation ECT instead of placebo, since high relapse rates with no continuation medication were well documented. He demurred insisting on the placebo treatment arm. The reviewers, however, were unwilling to support such a study of continuation medications alone. The chairman Jonathan O. Cole argued for support, however, agreed to by the members provided a parallel study could be developed comparing continuation ECT with continuation medication of combined lithium and nortriptyline. With Cole’s encouragement I enticed Charles Kellner (Medical University, Charleston SC), Teresa Rummans (Mayo Clinic, Rochester MN) and John Rush (University of Texas, Dallas TX) to collaborate in a multisite collaborative study with the criteria for selection of patients, outcome evaluations, and combined medications identical to the Columbia University Consortium study. The single distinction was the CORE use of bilateral electrode placements at a minimum of 1.5 times the measured seizure threshold while the Columbia group used unilateral electrode placements with dosing set at 1.5 to 2.5 times the measured seizure threshold in their treatments. Patients meeting the clinical criteria for unipolar depressed patients were to be identified by an interview with a trained social worker using questions from a standard behavior rating scale. Initially, patients labeled bipolar depressed were excluded from the study, although many were treated with the same protocol after rejection from the study. The outcomes of the two subtypes did not differ, so we designed a second study treating both unipolar and bipolar depressed patients randomly assigned to bitemporal, bifrontal, and right unilateral placements. Both CORE studies were funded in 1997 by NIMH. 34 In Columbia’s CUC study the six-month relapse rates were much as anticipated: 80% for placebo, 62% for nortriptyline alone, and 36% for the 26 �combined lithium and nortriptyline. In the CORE study, the relapse rate for lithiumnortriptyline was 39%. With Continuation-ECT 32% relapsed, 22% dropped out of the study, and 46% continued in 6-month remission. We were disappointed with these ECT results and realized that the C-ECT treatment schedule had been arbitrarily set, less effective than what clinicians reported as necessary in ambulatory treatment schedules. When patients relapsed and we were able to induce seizures on clinical criteria alone, almost all patients sustained their remission with ECT as needed, like the treatment of diabetes or heart failure. To sustain an ECT benefit we needed to be flexible and introduce treatments when symptoms recurred. This lesson had been learned by practitioners in the early decades of ECT practice; and summarized in the review by the 1996 ACT ECT Task Force. (We foolishly erred in the CORE study based on our desire to be comparable to the CUC study.) 35 Much was learned, however. Seizures induced with unilateral electrode placements (RUL) are inherently inefficient. The lesser immediate (and transient) memory-loss effects associated with a unilateral electrode are a poor justification for outcome inefficiencies and the increase in the number of seizures and anesthesia sessions. The benefits of bifrontal ECT are slightly inferior to bitemporal ECT but can be justified by their ease of application. ECT is as effective in patients with bipolar depression as in unipolar. The common belief that ECT is less effective in bipolar depressed patients is false, a consequence I believe of the pharmaceutical industry’s marketing drive to establish a place for inefficient “mood stabilizers” and anticonvulsants separate from the prescription of lithium and antidepressants in psychiatric disorders, and the unwillingness of research leaders to recognize ECT as effective and safe. ECT rapidly reduces suicide preoccupations in melancholic and delusional depressive illnesses. In the more severely ill, those with high ratings on suicide assessment (item 3) in the HAMD24 rating scale, the suicidal self assessments were reduced 60% with six treatments within two weeks, justifying ECT as the primary treatment in patients who require special protections for suicide risk. Delusions in depressed patients identify a population of ECT-responsive patients. In the 1970s, Alexander Glassman and his colleagues at Columbia University reported that delusional depression did not respond to blood-level, monitored imipramine treatment. They did respond to ECT, however. While the overall ECT remission rate for the major depressed in the CORE study was 84%, the rate among the psychotic depressed patients was much higher, at 95%. The common policy of first treating psychotic depressed patients with medications, especially the use of less effective serotonin targeted antidepressants, with or without atypical antipsychotic drugs, cannot be justified. Like the use of RUL treatments, the insistence that psychotic depressed patients be subjected to one or two medication trials before ECT is questionable in its efficacy and its ethics. 27 �The Persisting Stigma: Memory Loss and ECT The argument that memory loss is a critical risk in all induced seizure treatments persists, however, encouraged by the constant singing of a “memory loss” mantra by psychologists and by some in the laity. At this writing, more than half a century after the initial studies, the use of unilateral electrode placement persists despite compelling evidence of its lesser efficacy in the studies sponsored in the UK in the 1960s and the more extensive NIMH-supported studies by the Columbia University Consortium (CUC) and the 4-hospital Consortium for ECT (CORE) that clearly showed that seizures induced through unilateral electrodes were clinically less effective, lowered recovery rates by 40% and increased the mean number of treatment sessions from 7 to 10.5. 36 Physicians are applying unilateral electrode placements knowingly offering patients lesser effective treatments that increase risks of treatment failure and higher relapse rates. What is the impact of ECT on memory? Patients who come to this treatment are severely ill, often with long periods of poor self-care, poor sleep, weight loss, and preoccupation with the self, the body’s discomforts, and little attention to work or family. They are then advised that they will need anesthesia, and electricity will course through their heads. They are warned, verified by the consent that they (and often members of their family) are asked to read and sign that explicitly states that they may lose memory, become confused and disoriented. They are then given a chemical intravenously that puts them to sleep, electrodes are pasted on the head, and a grand mal seizure is induced. Every seizure disrupts the brain’s physiology and chemistry. Awakening is slow, with confusion and disorientation persisting for some minutes in all subjects, much longer in the elderly and brain compromised. Most patients since the 1960s have first been treated with brain toxins – every “psychoactive” pill, whether antidepressant, anxiolytic, or neuroleptic or whether the alcohols, marijuanas, opioids or sedatives that are publicly attractive -- induces persistent changes in the brain’s electrophysiology that is measurable by the EEG. Responses to questions in the first hours after a treatment are slow, deliberate, and confused. And, it is fashionable nowadays, and surely by the psychologists and nurses who test for memory effects, to fire questions, one after another before treatment and again as soon as the patient’s eyes are open. Where are you? What is my name? What is your name? Where do you live? How much is 23 times 11? What is today’s date? 28 �And on, and on. When tests are repeated after many hours, the answers are slow but now correct. But after a series of treatments the errors may persist for days, especially in the elderly and in the chronically ill who have been the most brain-altered by an extensive potpourri of medicines. When specific neuropsychological tests are presented before treatment and again a week, a month, and 6 months after the last treatment, the recovery of cognitive functions is progressive so that in time the recovered patient functions as well, often better than during the illness. In batteries of more than 20 tests, psychologists have generally found that the normal functions have returned with only personal memories still offering errors. Of course, psychologists have prominently carried the “memory loss, memory loss” mantra against ECT by attention to these singular test data, not relating their test measures to the clinical changes and benefits in the patients. I have repeated psychological testing in all my ECT studies, at Hillside (twice), New York Medical College, and Stony Brook. I am often surprised by the quick return of functions with recovery after the illness. In the elderly I am not surprised by the patients who, in the hours after a treatment, speak poorly, recognize a relative hesitantly, and soil themselves. For the many who recover, these deficits disappear, and they return to pre-illness activities. Patients and family members are satisfied; so much so, that they insist on ECT when the illness recurs. Slow recovery is common in the repair of any illness. Think of the pains and discomforts in the long rehabilitations after a fracture, after major surgery, after acute trauma. The recovery after electroshock is the same slow and repair quality of major surgery. Shouting “memory loss, memory loss” is the same as shouting “painful walking, painful walking” after hip surgery. What is to be made of the anti-ECT positions of psychologists, psychiatrists and psychotherapists? The slander that infected ECT from the immediate post World War II period persists and frightens practitioners so that they do not realize that by offering inadequate treatments they are encouraging ongoing negative attitudes. The enthusiasm of the ECT practitioners for non-seizure treatments and the scalp tickling of the “brain stimulation” movements (encouraged by payments by sponsoring industrial companies) thrives on the falsehood that these treatments “do not affect memory." My personal experience lead me to conclude that memory effects are transient and no more limiting than the pains and blood loss after surgery. The most realistic and best documented reviews of the cognitive data are to be found in Richard Abrams’ textbook. 37 29 �Book Three: Electroshock in the Public Eye Creation of Induced Seizures as Therapy Was the mark of Cain that prejudices the use of inducing seizures to relieve emotional illnesses deserved? The carnage of the First World War released inhuman attitudes and tolerance, even enthusiasm, for attacks on human bodies in the name of treating the severe psychiatric ill. Prolonged sleep for days on end was accompanied by pneumonia and death; comas and seizures induced by insulin led to prolonged coma and death; lobotomy, especially the ice-pick variety, was associated with seizures, hemiplegia, and death. Skills in neurosurgery encouraged open brain surgery and electrode placement and stimulation by deep brain stimulation, leaving many with permanent brain lesions. Although electroshock had none of these risks, it was lumped together since the practitioners of one were called upon for all. The first inductions of seizures by chemicals did not go well. Ladislas Meduna, at a state hospital in Budapest, induced seizures by injecting the irritant camphor-in-oil into patient muscles. Few injections resulted in a seizure, all were painful and irritated the tissues. He next tested the intravenous chemical pentylenetetrazol (Metrazol), which, although more efficient, failed often enough that patients became extremely anxious, frightened, and refused further treatment after experiencing panic induced by a partial seizure. Despite panic and pain, the occasional fracture, the immediate confusion, the relief occasioned by many of the first patients encouraged its continued use. In his review of his experience, Meduna reported half his patients improved sufficiently to leave the hospital. 38 In May 1938 two Roman physicians, Luigi Bini and Ugo Cerletti, devised a more assured and less frightening method using electricity that quickly replaced chemical inductions and has since become the principal method of inducing seizures worldwide. Although the inductions were still frightening to both patients and clinicians, they aroused little public concern. They were better accepted within medical practice, and less feared than insulin-induced comas, prolonged sleep, or leucotomy. The names “electroshock” and “shock therapy” added to public concerns but did not stop the practice. That the treatment relieved the suicidal depressed, the hopelessly psychotic, and the uncontrollable manic encouraged widespread use in the world’s sanitaria and physicians’ offices. This success occurred at the time when the leaders of psychiatry were enthusiastically following the flag of psychoanalysis, promising cures for the psychiatric ill after months and years of “talk therapy” catering to the walking wounded. Psychiatric leaders committed themselves to the psychology of the mind, separate from the functions of the body and the brain. Every report of relief of an emotional disorder by fits and the repeated highlight of another Freudian therapy had failed or required a new therapist stimulated defensive attacks by psychiatry’s leaders that electroshock did not help the patient 30 �“understand or resolve his conflicts.” The benefits of inducing seizures were considered transient and, furthermore, damaging to the brain and antithetic to psychoanalysis since seizures extinguished personal memories. ECT Immediately Rejected By the Profession Immediately after the end of World War II, American psychiatric leaders formed a select political society, the Group for the Advancement of Psychiatry, that issued its first broadside on “Shock Therapy” on September 15, 1947. The handbill complained that electroshock’s widespread use in office practices offered only temporary relief. The benefit was considered inferior to the psychoanalytic understanding of life’s experiences and the resolution of conflicts that were the basis for a patient’s distress. I had studied psychodynamic theory at New York’s William Alanson White Institute and had undertaken a personal analysis for five years. I saw no challenge to a “biological explanation” of a patient’s history and symptoms and the reality that “somatic” treatments relieved my patients. No matter how I presented my experiences of rapid relief induced by repeated seizures, I was met by disbelief. In the 1970s romanticizing Freud became fashionable for Hollywood and Broadway, accompanied by images of Frankenstein’s monster, the electrified man, as the frightening alternative. Public reports of an excessive use of ECT in children in Massachusetts in 1970 sharpened the attacks. State legislators frantically proposed laws to prohibit ECT. Milton Greenblatt, the director of the state’s mental health program, argued that legislative restrictions would interfere with accepted medical practice and negotiated the tabling of the proposed legislative bills until the actual experiences could be studied. He commissioned a survey of ECT in Massachusetts to be conducted by Fred H. Frankel, Professor of Psychiatry at Boston’s Beth Israel Hospital and an expert in hypnosis treatments. The 1973 review of practices in Massachusetts did find hospitals where ECT use was excessive, seizure inductions haphazard, and medical care facilities inadequate. Greenblatt issued medical guidelines to standardize ECT practice. His report and the regulations satisfied both legislature leaders and the practitioners, markedly improving clinical practice, becoming a national model for treatment facilities. The resolution encouraged a broader acceptance of the treatment and a reference source for establishing treatment facilities. First American Psychiatric Association ECT Task Force (1975) Early in my career in psychiatry, at annual meetings of the American Psychiatric Association (APA) I joined the Section on Brain Function & Behavior where ongoing arguments on how to optimize ECT were active. Discussions on ECT were also featured as clinicians assembled annually at the Electroshock Research Association, Society of Biological Psychiatry, and similar associations dedicated to lobotomy, insulin coma, and carbon dioxide therapy. When Milton Greenblatt 31 �deflected the drive of the Massachusetts legislature in 1970 to interdict the use of ECT, he organized the survey of ECT and also asked me to edit a special number of his journal Seminars in Psychiatry on the scientific status of ECT. 39 Legislative restrictions against the use of ECT and lobotomy with specific interdiction in persons under age 18 surfaced again in 1972, this time in California. In response, psychiatrists led by Dr. Gary Aden applied for court relief from legislative interference in accepted medical practice. The court agreed that the legislative restrictions of medical practice were unacceptable. The legislature responded by using the state’s power to monitor health and safety to limit the number and frequency of treatments, restrict guidelines for consent, require extensive reporting of treatments, and prohibit its use in persons under the age of 18. The regulations forced many patients in need of treatment to go out of state as California physicians abandoned the treatment. These regulations are still in effect in 2021 and severely limit ECT use, especially in adolescents. The same restrictions were adopted in Texas in 1993 and in other states to a lesser degree. Requests for professional support by California psychiatrists led the American Psychiatric Association to establish a Task Force on ECT in 1975, and appointed Fred Frankel of Boston as its chairman. I was an appointed member. The report published in May 1978 described whom to treat, how to assure safe procedures and effective treatments, and discussed concerns about cognition and memory and how to minimize these effects. A query about ECT practices had been sent to 20% of the Association’s membership. Responses were received from 75% of those canvassed. Was ECT an appropriate treatment for any of 11 different psychiatric diagnoses? The responses showed widespread confusion as to whom to treat. ECT was considered useful for patients with major depression (86%), less so for manic excitement (42%), and marginally for schizophrenia (25%). About 22% of the responding practitioners had used or recommended ECT in the prior 6 months. Featured in this confusion was the inadequacy of the official psychiatric classification schemes, their use providing poor descriptions and inadequate diagnoses and not assuring optimized treatment plans. The Task Force members were experienced in clinical care and most procedural questions were readily resolved. A thorny issue was endorsement of treatments using unilateral electrode placement. At a committee vote, I and another clinician member could not recommend the use of unilateral placement, arguing that its inefficacy necessarily led to increased numbers of seizures with attendant anesthesia risks, lengthened hospital stays, higher costs, and potential for increased morbidity. The reported lesser effect on cognition was transient, not justifying the inefficacy of the treatments and prolongation of illness. 32 �When the Task Force report was submitted to the APA Board of Trustees for publication under its imprimatur, the policy leaders insisted nevertheless that the unilateral form of treatment be endorsed (along with the bilateral), to support the practices and beliefs of some members. How best to assure consent? Patients referred for ECT are severely ill, depressed, psychotic, delirious, and suicidal, often mute and negativistic, raising questions as to their competency to understand the risks and benefits of proposed treatments and to consent freely. Can a patient so ill as to be referred for seizure therapy properly evaluate the risks of memory losses described by psychologists and in the public press? Medical practice treats patients by voluntary consent, the patient appearing at the physician’s office and choosing whether to follow the physician’s prescriptions. Can the same rules apply for electroshock? The Task Force members recommended a lengthy printed description of the procedure with detailed risks to be read by and to each patient, to be signed voluntarily, and properly witnessed. The form would name the treating personnel, and specify the maximum number of treatments under the consent. I was conflicted in this discussion. My father was a general medical practitioner; I had seen his interactions with patients and their families, and how they respected him and readily accepted his recommendations, including his insistence for an independent second opinion in complex diagnoses. I experienced the same deference when I took over his practice during his holidays and again when I opened a community office in Great Neck for consultations in neurology and psychiatry. In the Task Force discussions, I was one of two physicians who, at first, did not see the need for a written “contract”, but agreed before submission to the APA. ECT was viewed as a surgical procedure (since it uses anesthesia) with a potential for harm that must be specifically consented to by the patient. Patient autonomy would be respected by describing the anticipated benefits and risks before treatment and treating only those who voluntarily agreed. Further protection was to be achieved by a family member also reading the descriptions, discussing the procedures and risks, and witnessing the patient’s signature. Exceptions to voluntary consent were recommended for those with mental deficiency or dementia. These were considered to be the family and community responsibility. State-mandated procedures for judicial authorization for treatment on an incompetent patient’s behalf were supported by the task force. The recommendation of a signed, voluntary consent for treatment was the main benefit of the Task Force Report. The text was considered an “official” action of a national association and served as a guide for the opening of new ECT treatment centers throughout the nation in the post-1978 years. I was often invited to visit 33 �and organize new treatment units based on the Task Force Report. The recommended procedures were sufficiently conservative to be widely adopted. The Task Force report was distributed at the May 1978 APA annual meeting in Miami with each task force member presenting an aspect of the report to a large audience. I was the spokesperson for the technical recommendations. The report was generally accepted and praised. The concept of a written consent was argued but accepted. The note accepting treatments through unilateral placements, however, met strong protests from practitioners, notably New York’s Lothar Kalinowsky. Much of his criticism was directed at me as the spokesperson. The practitioners, themselves extremely well experienced with bilateral and unilateral electrode placements, argued that treatments through unilateral electrode placements were so inefficient as to put patients at risk of prolonged illness and suicide, poor outcomes, longer courses of treatments, and higher relapse rates. Out-Patient ECT: Association for Convulsive Therapy Commission Post-World War II, ECT patients had been increasingly treated as outpatients in doctor’s offices, both for their treatment courses and continuation treatments. But as ECT in the 1980s demanded collaboration of a qualified anesthesiologist, ECT became a hospital-based procedure. The prescription of a fixed number of treatments, usually 6 to 10, became commonplace. Such courses had been sufficient with the high energy, bilateral placement seizure inductions favored by the early office practitioners and those treating patients at Gracie Square Hospital. When patients showed signs of relapse, ambulatory continuation treatments were readily undertaken. During the 1970s, with repeated public and professional attacks on ECT, physicians often negotiated a fixed number of treatments for a course. The idea that the length and frequency of an ECT course could be prescribed in advance, even agreed to in the patient-signed consent, was widely accepted as recommended by the ECT Task Force of the American Psychiatric Association in its 1978 report. The treatment image became one of a specifically effective treatment, much like a prescribed antibiotic for an infection. But ECT treatment for depression or mania or even catatonia is more like that of insulin for diabetes: an acute fixed schedule is prescribed and is immediately effective but open-ended continuation dosing is necessary for sustained relief. When ECT was re-introduced in the 1980s, many clinicians thought that psychoactive medications would sustain ECT relief. After a course of ECT patients were prescribed psychoactive medications, often in unique combinations of polypharmacy, and while success was common, relapse became an increasing burden. In 1987, Thomas Aronson and colleagues from the Stony Brook out-patient treatment facility reported greater than 50% relapse rates within 6 months for my ECT-treated delusional depressed patients regardless of continued medications. I 34 �was chagrined and saw the need for continuation ECT. Our ECT Service treated patients three days a week, so we set aside one day (and later two) for out-patient treatments. We no longer asked patients to consent to a fixed number of treatments but asked their consent for continued observation and treatment “as needed” beginning as in-patients and continuing in our ECT out-patient clinic for six or more months. How best to prescribe and manage continuation treatments was widely discussed in the journal Convulsive Therapy and at meetings of the Association for Convulsive Therapy (ACT). That Association established a Task Force that surveyed usage, evaluated risks, and recommended guidelines, publishing their conclusions in 1996. I chaired the group and published a report that became a guide for continuation treatments. 40 The Stigma Persists: The Public Joins the Attack The popularity of psychotherapy and psychotropic drugs in the 1960s led to a sharp decline in ECT use. But as medication treatments increasingly failed and families asked what else could be done, ECT use resurfaced. The shadow of lobotomy and patient and psychologists' complaints of memory loss encouraged persistent attacks against ECT, and as these became more strident, my public support for the procedure brought me much public criticism. Burton Roueche’s exaggerated description of a government economist’s memory loss in the 1974 New Yorker article “All About Eve” brought Marilyn Rice to public attention. She instituted a malpractice suit against the psychiatrist who administered the treatments complaining that she had not been warned that her memory would be affected and that she would be unable to work. 41 She went on to develop and lead the public action group Committee for Truth in Psychiatry that launched further attacks on ECT. She frequently appeared at public forums to challenge ECT use, proclaiming her persisting loss of memories. (The Court supported the physician defendant.) After Marilyn Rice died in 1992 the Committee for Truth in Psychiatry was led by Linda Andre, who made the same claims after her treatment course following a suicide attempt by drug overdose. She was a vivacious, well-spoken, and attractively dressed woman who attended public meetings and paid particular attention to meetings in which I presented my work. She challenged speakers and attended the 1992 international ECT meeting in Graz, Austria to voice her opposition to the treatment. The international audience was surprised by her personal attacks. She attended my public lectures and protested my presentations at annual Continuing Medical Education psychiatry training sessions in various cities. On one occasion, when the floor was opened to questions, she attacked me as dishonest and paid to lie about the effects of ECT. She walked up to the podium offering me a tray containing a pig’s head surrounded by dollar bills. 35 �Church of Scientology and Malpractice Legal Suits In the 1960s, the national political and social movement of Scientology led by the futurist Ron Hubbard opportunistically attacked psychiatry with special attention to the prescription of psychotropic drugs in children and adolescents and the brain effects of ECT and lobotomy. The members and their children demonstrated with shouts and anti-ECT posters in the halls and at entrances to American Psychiatric Association meetings and other sessions at which ECT was discussed. On occasions when its members arranged for complaints to be aired on TV talk shows, I was asked to defend the treatment but refused to take part. The hosts delighted in challenging professionals on their incomes and on the damage that had been done to the patients who complained bitterly about memory losses. Yet, many patients spoke well, encouraged by the host whose mission was to support the “poor” patient and to castigate physicians for damaging patient’s brains. The Church of Scientology also encouraged and financed malpractice suits against practitioners, asserting that patients had lost memories of long periods of their lives, particularly the most personal family memories. I appeared as a witness for the defense on numerous occasions with Peter Breggin, John Friedberg, and Harold Sackeim as expert witnesses for the plaintiffs. The cases were weak and my defense of the practitioners was successful in every instance except that of Peggy Salters in South Carolina in 2005. She had been given ECT as an outpatient with 13 treatments in 19 days. The physician deemed the patient suicidal, but failed to offer her hospital protection. She complained that her memory was so damaged that she could no longer work. While I did not believe that the patient had suffered compensible damage, the physicians had not followed standard practice in protecting the suicidal patient nor in justifying almost daily treatments. I deem the judgment for the patient correct. Media Attacks: BBC-PBS Madness with Jonathan Miller. In 1990 I received a call from a London TV production company asking if I would help with the presentation of convulsive therapy in a planned 5-hour BBC/PBS documentary on the history of treatments of the mentally ill to be titled Museums of Madness. The producer, Jonathan Miller, had impressive qualifications as a Cambridge University graduate in neurology and the son of a psychiatrist. He had acted in the original cast of the successful Broadway play Beyond the Fringe (1960-64), directed performances in theatre and opera, and written and directed a popular 13-hour BBC production The Body in Question (1979). While playing on Broadway he attended Saturday morning Grand Rounds in Neurology at the Neurological Institute with H. Houston Merritt. 36 �I met with Miller and Grace Kitto of Brook Productions and agreed to their filming of my patients and the treatment procedures at University Hospital. I arranged that they return again three weeks after the first filming to record the patient’s progress and that I see the frames of my patients before they were aired. For filming on May 17, 1990 I selected patients with different diagnoses who were early in their course of treatment. SK, an 18-year old delusional psychotic man who had been in repeated treatments for more than two years; EF, a 60-year old psychotic depressed woman who was posturing, repetitive in speech, and unable to care for herself; ET, a melancholic depressed woman with a history of mania and excitement; and JF, an elderly man who had been depressed, lost much weight, and careless in his self-care. Appropriate consent for filming was obtained for each patient. The filming of interviews and treatments went smoothly. The team returned three weeks later for follow-up filming. Patient SK was better oriented, EF answered questions without repetitive speech or acts, ET smiled and was friendly and better oriented, while JF assured us that while he could not recall why he was being treated, he felt well and was ready to go home. Asked about memory, he thought that his memory was as good as it ever was. The treatments were not painful at all, he said, and surely less uncomfortable than seeing the dentist. On October 15, 1990 on my way back from meetings in Berlin, I visited the Brook Production Studios in London to review the print. The presentation of the patients and the treatment were very well done and I was pleased. My concept of neuroendocrine dysfunction as the basis for the disorders that are relieved by seizures was well presented. Many months later, when the series was aired in the U.S., Miller’s voice-over set a very different tone: ‘The administration of an electric shock through the skull is a comparatively crude assault on the brain. ‘. . . as machines were invented to whirl, swirl, shock, rock, and douche the patient back to sanity, the sick brain was treated to a series of traumatic assaults presumably in the hope that its distorted parts would be jolted into place. ‘. . . the treatments resulted in violent convulsions with serious bruising . . . fractures of limbs and spine . . . and other atrocious consequences. ‘. . . despite its understandably sinister reputation, ECT, Metrazole and insulin have much more in common with the whirling chairs and rotating cradles which they superseded, in that they were addressed to the brain as if it were a single undifferentiated organ.” 37 �Miller’s failure to find a positive thread in the histories presented by the patients left many viewers with a bad taste, and the series was not presented again. In a recent biography of Miller, the author Kate Bassett makes much of Miller’s conflicts with his father, a leading forensic psychiatrist, as the basis for his negative attitude to medicine. Whether this relationship contributed to his views of psychiatry or not, he was among many creative writers who saw psychotherapy and psychoanalysis favorably, indulged by themselves, friends and family members, seeing electroshock treatments as hazardous, ineffective, and not acceptable in their social class. An Active Defense: A Beautiful Mind: The Nobelist John Nash and Insulin Coma. A call from the biographer Sylvia Nasar in 2001 asking whether I had experience with insulin coma therapy made me aware of the life history of John Nash, the 1994 Nobelist in Economics. A brilliant mathematician, Nash had successfully completed his doctorate at Princeton University, publishing a thesis on game theory that was reputed to revolutionize economics. While teaching at MIT in May 1959 he became delusional, overactive, impulsive, and fearful, meeting criteria for delirious mania. He was treated in Boston’s McLean Hospital by psychotherapy and chlorpromazine. Aware that his statements led to his incarceration he hid his beliefs and was discharged to the community. He left his teaching position and returned to Princeton. The paranoid psychosis persisted and he fled to Europe and sought to give up his American citizenship. Returning to Princeton in 1971 floridly delusional, he was admitted to Trenton State Hospital. His Princeton colleagues implored the Medical Director that Nash was a potential Nobelist and warranted the most effective treatment. Insulin coma treatment, although discarded elsewhere, was still in use. It was the most heavily staffed service, and in response to his colleagues’ pleas, Nash was assigned for treatment in that unit. He responded by relief of his overt delusions but the director suggested the follow-up treatment be ECT. Nash’s wife and colleagues refused that “brain-damaging treatment” and he was continued on medication with chlorpromazine. Nash did not recover and did not return to productive work; he remained cared for by his wife and attended lectures at Princeton. Nasar’s biography A Beautiful Mind was to be the basis of a Hollywood film and she wanted advice on the actual experience of the treatments that Nash had been given. I described my experience at Hillside Hospital, noted that seizures occurred in more than 10% of the coma sessions. The film highlighted the seizure, and I was pleased by the portrayal of the illness and the treatment in the film. I reviewed my experience with insulin coma and concluded again that the central therapeutic events were the incidental seizures, not the coma or an effect of insulin, or any other aspect of the treatment. Like injections with camphor and 38 �Metrazol, insulin coma was best viewed as an inefficient form of induced seizure therapy. As the originator of ICT, Manfred Sakel insisted that the comas selectively destroyed sick brain cells leaving only healthy cells. He argued that the seizures were incidental, irrelevant side-effects. But experienced clinicians welcomed the seizures and often added ECT during coma sessions for the poorly responsive. I realized that the efficacy of insulin coma therapy lay in the occasional grand mal seizure, that ICT is best seen as an imperfect form of induced seizure therapy. 42 39 �Book Four: The Enigma: How Do Seizures Alter Behavior? Seizures are Inherent Reflexes Grand mal seizures are patterned reflexes seen in our species, indeed in all mammals. Seizures that occur spontaneously constitute the debilitating disease of epilepsy. Ladislas Meduna’s 1934 discovery that inducing seizures in the psychiatric ill relieved both abnormal thoughts and the peculiar and repetitive motor behaviors of schizophrenia was a remarkable and still unheralded discovery in the history of medicine. By 1938 electric currents had been shown to immediately induce a seizure with minimal pain and less risk than Meduna’s chemical methods, and the electrical induction of seizures -- electroshock -- quickly became a widely accepted treatment of the psychiatric ill. The induction of a bilateral grand mal brain seizure is the central therapeutic event. A patterned EEG of a minimum duration of 30-40 seconds is the principal marker of an adequate treatment. An increase in hypothalamic-pituitary hormones in the blood and cerebrospinal fluid is another marker. No characteristic of the induction stimulus itself, whether chemical or electrical, is essential for clinical benefits. Attempts to treat patients by subconvulsive electric or magnetic currents or by non-seizure inducing anesthesia (isoflurane) dosing have been unsuccessful in eliciting behavioral benefits. Although many patients report immediate changes in mood, motor activity, and thought, repeated seizures over many days or weeks are typically necessary for lasting clinical benefits. Attempts to sustain the clinical benefits by psychotropic drugs are occasionally successful, but for persistent benefits repeated seizures are best. How do seizures alter behaviors? We do not know. My thinking on this question has evolved over the years. Early in my career and with the hubris of the novice I combined physiological and psychological features in “a unified theory of the action of physiodynamic theories.” That construct was re-labeled the neurophysiologic-adaptive view a few years later. I argued that the changes in behavior, toward greater denial of illness, was facilitated by altered brain physiology. 43 My studies with anticholinergic compounds showed me that drugs that inhibit brain acetylcholine reversed the mood benefits of ECT. The elevated levels of brain acetylcholine associated with recovery in mood and thought seemed sufficient to justify what in 1962 I described as a cholinergic theory. I argued that seizures increased the brain levels of acetylcholine and cholinesterases, and that these changes altered neuroendocrine functions, mainly of the hypothalamic-pituitaryadrenal and hypothalamic-pituitary-thyroid axes. This hypothesis was consistent 40 �with the ongoing enthusiasm for changes in the brain transmitters that were thought the basis for the changes in behavior associated with psychotropic drugs. As chemist’s skills improved and concentrations of endocrine hormones in the blood could be measured, my interest focused on vegetative signs in psychiatric illnesses. Attention to the TSH hormone response to TRH and abnormal thyroid physiology was quickly followed by interest in adrenal hormones and the dexamethasone suppression test in depressive illness. Not only were thyroid and cortisol abnormalities markers in the psychiatric ill, the abnormalities normalized with effective treatments. I sought to confirm these reports in our patients treated with ECT at the Northport Veterans Administration hospital in Eastern Long Island. When Jan-Otto Ottosson also saw merit in a neuroendocrine image of ECT, we formulated a neuroendocrine theory that we published in 1980.44 After forty years, I believe this theory remains the most viable explanation for the efficacy of induced seizures in patients ill with melancholia. While this theory may not be applicable to the benefits in other psychiatric illnesses, it is a pointer that warrants greater study. The Theories The behavior changes induced in the psychiatric ill by the bizarre technology of repeatedly inducing grand mal seizures is puzzling and has encouraged a plethora of theories, some based on brain and body physiology and chemistry, and some on magical thinking. My ruminations and their origins have evolved with my experience. Neurophysiologic-adaptive theory. At Bellevue Hospital in the 1940s my teachers were much interested in anosognosia, the failure of awareness or the active denial of a deficit in motor functions (as in post-stroke) or denial of sensory loss (as in denial of blindness), as I described in Chapter 1. Special attention was paid to how humans perceived multiple stimulations as when two pinpricks or finger strokes were simultaneously applied to different body parts. Even in patients with brain functions compromised by trauma, age, infection or tumor, a single sensory stimulus may be readily perceived but the perception of two simultaneous stimuli varies with the subject’s alertness and vigilance. The errors are evidence of compromised brain functions, of the syndrome loosely described as the “organic mental syndrome.” After head injury, stroke, brain tumor, aging, infection or repeated seizures, only one stimulus is reported (extinction), or the second stimulus is perceived at another body site (displacement), or pointed into space before them (exosomesthesia). Under the influence of injected amobarbital, perception errors and the expression of denial language increase. These reports became the basis for the Face-Hand Test. During the course of electroshock, errors increased with numbers of treatments. The greater the degree of EEG change, the greater the perceptual errors. Among the scientists at Bellevue, Edwin Weinstein, Louis Linn, and Robert 41 �Kahn proposed “denial” as the mechanism for the relief afforded depressed patients by electroshock. They catalogued a “language of denial” making it possible to score the number of denial terms in an interview transcript. When amobarbital was injected at a fixed concentration and a specified rate, the number of expressed denial terms increased, especially in brain compromised patients. I studied the expression of denial during ECT by weekly amobarbital and EEG tests and recording patient responses. As EEG slow wave activity increased with more seizures, so did expressions of denial in those patients who showed the greatest relief of depressed mood., I adopted this explanation of the changes in behavior during ECT as an increase in denial. Depressed patients commonly complained of insomnia, anorexia, fatigue, weakness, and loss of interest in daily activities. After treatment, the complaints are relieved and when asked what is wrong, they deny their earlier complaints. Since the connection between denial and improvement had been proposed by my teachers, and as EEG and sedation tests verified their proposition, I adopted denial as an explanation. 45 I did not seek greater understanding of physiology until years later. Such an explanation was applicable in the patients with melancholic and psychotic depression, but was not relevant for the response of those in delirious states, catatonia, mania, or psychosis. These states are marked by disorientation and confusion, mutism and negatism, hyperactivity and disorders in thought that needed broader explanations than the simplistic denial of symptoms. Their responses required another explanation. Cholinergic theory. My interest in the effects of psychoactive drugs on the EEG led me to study the effect of drugs on the ECT process. A colleague, Herman Denber, interested me in studying the behavioral effects of diethazine, an experimental anticholinergic drug that blocked acetylcholine stimulation. The chemical was a new moiety created in industry with the hope that it might have clinically favorable psychoactive properties. He was unable to identify a clinical benefit, reporting that patients became more disorganized and irritable. I tested diethazine to our improving ECT patients, those with signs of denial and recovery from a depressive state and with high degrees of EEG slowing. The slow waves were blocked and the records became filled with low voltage fast rhythms. Patients became irritable, anxious, agitated and again depressed, a reversion to their pretreatment states. We inferred that the relief of depressed mood with ECT was related to increased levels of acetylcholine in the brain. George Ulett and his colleagues at Washington University had administered atropine, a potent anticholinergic drug, during the ECT treatment course and reported that it blocked EEG slow waves and elicited pre-treatment behaviors in the patients. Similar reversal of mood was also reported after injections of the experimental anticholinergic JB-329 (Ditran) and its congeners, supporting the connection between brain cholinergic levels and mood. 42 �Much interest was shown in acetylcholine in neuroscience research in the 1950s. Free acetylcholine and acetylcholinesterases were elevated in the cerebrospinal fluid (CSF) of epileptic patients. CSF acetylcholine levels increased during ECT. In cats subjected to graduated head trauma, the amount of free acetylcholine and cholinesterases in the CSF increased with the severity of the trauma. Again, hubris allowed me to picture the physiologic consequences of induced seizures as similar to those of head trauma. 46 I imagined that induced seizures, like cerebral trauma and epileptic seizures, altered cerebral permeability increasing free acetylcholine and cholinesterase levels in the brain, slow EEG frequencies and increase amplitudes and rhythmic bursts. I pictured these biochemical changes as the basis for the behavioral effects we were seeing with ECT. My focus on acetylcholine as the critical agent in treatment followed the happenstance finding that anticholinergic agents reversed the seizure-induced EEG and behavioral changes. But study interest in acetylcholine waned as interest in brain neurotransmitters shifted to epinephrine, and then to dopamine and serotonin, as pharmacologists, excited by their ability to measure these neurotransmitters in animal brains tracked the effects of each of the new psychoactive moieties, that were then enthusiastically welcomed by clinicians and the public. At this juncture, half a century later, I find little interest in acetylcholine in clinical psychiatry or epilepsy. The Neuroendocrine Hypothesis. When I was asked in 1977 to supervise an acute treatment unit and its ECT facility at the Veterans Administration hospital in Northport, much academic interest was being shown in brain peptide hormones in the psychiatric ill, particularly those of the thyroid, adrenal, and pituitary glands. The Nobel Prize for Medicine that year was awarded for the demonstration of peptide hormones in the brain and for the radioimmune assay that measured their presence. Hormone changes in our patients became measurable by thyroid and adrenal function tests. These glands are instrumental in maintaining the daily wakefulness cycle, the response to fear and stress, and monitoring sleep and other bodily functions. The TRH stimulation test, the release of TSH to an intravenous bolus of TRH, was blunted in a quarter of the severely depressed patients. After a course of ECT, we did not find the changes in TRH levels that we had hoped would help us decide whether the treatment course was successful. Cortisol derived from the adrenal gland was a useful marker. Serum cortisol levels were unusually elevated in institutionalized depressed patients, an observation in the 1970s that led an Australian psychiatric team under Brian Davies and Bernard Carroll to study cortisol functions in their patients. They developed the dexamethasone suppression test (DST) as a measure of adrenal function. Their reports are filled with extensive observations of hormone functions and psychiatric 43 �illness but the note that particularly stimulated my interest was their experience with ECT in melancholia. In five melancholic patients the cortisol measures were deemed abnormal (elevated and not suppressed by the steroid dexamethasone) before treatment. After ECT the clinical features of melancholia remitted and the cortisol measures normalized. Then two of the patients relapsed, again exhibiting signs of melancholia with abnormal cortisol functions. Second courses of ECT resolved the clinical illness, again normalizing the cortisol measures. Carroll described an additional seven patients in whom treatments had not resolved the depressive illness nor normalized the DST. The test, it seemed, was a marker of illness severity and of treatment response. At the Northport hospital a research fellow Yiannis Papakostas confirmed the relationship between severity of depression, abnormal DST, and the response to ECT that Carroll had described. The test was difficult to perform and the end-point criteria needed more careful study, but the changes in the neuroendocrine tests with improvement in melancholia led to more detailed studies of the response to ECT. Seizures, both in epileptic fits and in those induced in ECT, released the pituitary adrenocorticotrophic hormones (ACTH) and prolactin into the CSF and blood. By 1978 attention was directed to the association of the contributions to behavior of the products of the hypothalamus, pituitary and adrenal glands, (HPA axis) in melancholic depression and the response to ECT. At the 1978 New Orleans NIMH Conference on ECT, I described my experience with the DST, supporting Bernard Carroll’s experience. At the same conference Jan-Otto Ottosson independently supported the same endocrine findings. Melancholic psychotic patients have abnormalities in functions of the HPA endocrines, and these return to normal after recovery. I described a “neuroendocrine” hypothesis for ECT in Convulsive Therapy: Theory and Practice and cited what was known of the process: “A theory of convulsive therapy must account for the significance of the seizure but disregard the mode of induction, the direct actions of currents, and the distinctions caused by various electrode placements. It must consider the difference in response among patients with diverse psychopathologies and the time, measured in days, needed for a favorable outcome. Biochemical explanations must relate to changes in the brain rather than in the blood, urine or other tissues. Psychological, personality, and linguistic considerations may affect the behavioral response and should be considered, but these are probably not central to the antidepressant efficacy of induced convulsions.” And I described the hypothesis thus: 44 �“Hypothalamic dysfunction is a core process in endogenous depressive psychosis. Convulsive therapy alters hypothalamic activity both by direct stimulation of hypothalamic cells and by increasing the functional neurotransmitter activity in the brain, thereby releasing substances, probably peptide hormones, that alter the vegetative functions of the body and the endocrine glands. Specific substances are released that modify mood and the behaviors associated with mood disturbances. The biochemical events that precede and accompany the seizure are the trigger for increased neurohumoral activity. In ECT, the direct stimulation of electric currents augment but are not necessary for the effects on hypothalamic functions.” The mechanism was envisioned for patients with psychotic depression in whom the efficacy of ECT was well grounded, inducing remission in more than 90% of the cases. In the same chapter I discussed the evidence for ECT’s effect on mania, catatonia, and schizophrenia. While the treatments were successful in mania and catatonia, we lacked studies of endocrine changes to support a connection similar to that with melancholia. In schizophrenia the efficacy of ECT was insecure, being successful in acute illnesses and in catatonia, but ineffective in the more common chronic ill with the hebephrenic forms of the illness. In the 1980s I attempted a study of peptides in the cerebrospinal fluid during ECT. Of nine patients with psychotic depression referred for ECT with mean scores on the Hamilton Depression Rating Scale greater than 25, eight were nonsuppressors on the DST. I collected their lumbar CSF before ECT and then after treatments number 6, 10, 12 and 14. The samples were collected within one day after a treatment, and in five patients additional treatments were deemed necessary. The frozen samples were shipped to Charles Nemeroff and Garth Bissette at Duke University and to Huda Akil at the University of Michigan for analyses for the peptides of the corticotrophin-releasing factor, somatostatin, and beta-endorphin. The samples showed significant falls in levels of corticotrophin releasing factor and ß-endorphin but a non-significant rise in somatostatin. 47 The findings were not encouraging to the neuroendocrine hypothesis. While the hypothesis could be erroneous, our actual procedures did not meet the more optimal criteria that would be used today. We made arbitrary choices in our treatment mode. We used unilateral electrode placement with EEG monitoring of seizure duration, selected sampling in mid-course of treatment, with varying resolution of the illness and the DST, and were only able to test for a limited number of peptides. The study demonstrated the complexity of studies of the ECT mechanism. While I was interested in proceeding further, I lacked facilities for chemistry. Instead, I was in a position to pay more attention to the clinical questions of the ECT process that became the CORE studies undertaken between 1993 and 2005. 45 �Conferring in the Search for the Mechanism Believing that it must be possible to understand the relief of certain psychiatric illnesses by inducing seizures, I have participated and encouraged discussions of possible mechanisms throughout my working life. Surely the extensive experience that inducing seizures improves the behaviors and the lives of many severe mentally ill must be a challenge in present day biology. What follows is a chronological account of moments in this endeavor. 1972. The first encouragement came in convincing a committee at the NIMH to support a symposium on ECT mechanism. The committee asked two leading neurobiologists, Seymour Kety and James McGaugh, to join me in organizing a 1972 meeting in San Juan, Puerto Rico, titled Psychobiology of Convulsive Therapy. Attention was focused at the meeting on the neurophysiology of seizures, the role of changes in cognition, and the neurochemistry of catecholamines. 48 The panelists dedemed persistent changes in EEG recordings essential to the behavior changes in the therapy. In the absence of persistent EEG changes, only weak and transient behavior effects occurred. Changes in memory were not essential to the behavior benefits. The complaints of loss of recent memories were side-effects of the electricity, the anesthetics, and the seizure. The changes were not central to the effects of seizures on mood and thought. Much interest was shown in newly discovered brain neurotransmitters that “explained” the effects of psychoactive drugs on brain functions and behavior. Changes in the neurotransmitters were considered an explanation of the behavioral effects of repeated induced seizures as well. Seymour Kety cautioned, however, that “. . . there is no dearth of demonstrable biochemical changes which are associated with electroconvulsive shock. Indeed, the difficulty lies not in demonstrating such changes, but in differentiating between those which are more fundamental and those that are clearly secondary, and also in attempting to discern which of the changes may be related to the important antidepressive or amnestic effects and which are quite irrelevant to these.” In the 49 years since that meeting, the ECT literature has been filled with correlations of brain and systemic increases of many biochemical and behavior measures. But no study has offered a consistent association between neurotransmitter functions and changes in mood and thought, either for induced seizures or for any of the many psychoactive pills. 46 �1978. Continuing interest in ECT encouraged NIMH leaders to organize a larger conference in February 1978 in New Orleans on “Efficacy and Impact” with a larger panel of clinicians and scientists. In the six years since the San Juan Conference interests had broadened to the safety of regressive ECT (intensive daily treatments that were applied in chronic psychotic patients), the efficacy of different electrode placements, changes in electric currents from alternating to brief pulse currents, the clinical usefulness in patients with mania and schizophrenia, and the relation to endocrine measures. At this conference I became aware that Jan-Otto Ottosson had also been stimulated to examine the changes in neuroendocrine measures, and we joined in publishing the neuroendocrine hypothesis for the mechanism of induced seizures in Psychiatry Research in 1980. I was so impressed with the relation of neuroendocrine changes to behavior that in writing my 1979 textbook Convulsive Therapy: Theory and Practice, I credited the neuroendocrine explanation for ECT as the most viable. 1985. The hostility and controversies about ECT encouraged the NIMH to hold a public Consensus Conference in October 1985. Although the panelists included experienced practitioners, greater attention was paid to the critical opinions and biases of lay and professional critics. The discussions were raucous and were accompanied by shouting and hostility. The published reviews added little to either the clinical or the mechanism interests, reflecting the continuing rejection of and prejudice against the treatment in the public and the professions. 1986. Motivated by the circus of the Consensus Conference, Sidney Malitz and Harold Sackeim organized a conference at the New York Academy of Sciences in 1986. The presentations covered the broad issues of clinical efficacy varying with diagnosis, results of biochemical, neurophysiologic, neuroendocrinologic, and psychologic changes during the course of treatments, and mechanisms of action. Jan-Otto Ottosson detailed the essential characteristics of an effective seizure and treatment course; Bernard Lerer and Baruch Shapira looked at the impact of seizures on neurotransmitters; and Robert Post and his NIH colleagues discussed the anticonvulsant effects of seizures. They saw the anticonvulsant effects in mania in the therapeutic stream, endorsing anticonvulsant medicines to treat manic behaviors. Harold Sackeim and colleagues reported a rise in seizure thresholds during the course of ECT treatments, arguing that the benefits of induced seizures were in the anticonvulsant effects. Pierre Flor-Henry focused attention on the theoretic lateralized changes in the non-dominant hemisphere as the basis for the behavior change with seizures. These proposed mechanisms were no more exciting than the presentations a decade earlier in the San Juan conference, and they stimulated little further study. 1989. Still hoping that invited discussions might encourage study, and as Editor of the journal Convulsive Therapy, I asked Harold Sackeim to invite authors with an interest in the mechanism to write reviews for a special number of volume 5. An impediment to formulating a single hypothesis is the efficacy of induced seizures across the broad spectrum of psychiatric disorders. Surely, no single 47 �mechanism can explain the diverse effects in melancholia, mania, catatonia, delirium, and Parkinsonism. The same hurdles were described by Pesach Lichtenberg and Bernard Lerer and by Sukdeb Mukherjee in discussing the relief of mania. In a reprise of the debates on the merits of unilateral electrode placements, Richard Abrams challenged the reported advantage for treatments induced in the right hemisphere rather than the left, raising the importance of the details in any induced seizure study seeking to understand mechanism. Charles Nemeroff and I, in the midst of our collaborative studies of peptides in CSF, asked whether we anticipated higher or lower levels of peptides as the basis for melancholic depression and relief by ECT. We favored the image of lower levels of peptides active in maintaining normal mood and suggested that the seizures might release an active peptide that we named antidepressin. Our optimism in picturing an additional peptide was generated by the increasing number of substances that were being publicly characterized as altering mood, alertness, and cognition in the psychiatric ill. But, nothing has come of it, another nagging consequence of my not having developed skills in biochemistry. 1992. In editing a second edition of his textbook Abrams repeated the diversity argument that the efficacy of induced seizures over many illnesses made theorizing not particularly useful until a better understanding of psychiatric illness emerged. He saw our understanding as similar to that of the peoples in the 18th Century picturing burning as a process involving the imaginary substance phlogiston. He concluded that we await the intervention of a modern Anton Lavoisier, the French scientist who discovered oxygen, 20% of the air we breathe and the basis for burning substances by their combination. 1998. The continuing challenge of mechanism led Charles Kellner, the succeeding editor of Convulsive Therapy, to ask Bernard Lerer to invite opinions on what was learned about the neurobiology of seizures. Lerer again complained of the difficulty of seeking a single mechanism for a procedure with such a broad effect among many disorders. Reviews by John Mann and Ron Duman were no more useful. Nor was an explanation based on the anticonvulsant actions of seizures. Studies of the brain neurotrophic factor, neuropeptides, TRH and related peptides, and neuropeptide Y each fell to the criticism by Kety that the broad effects of seizures on many brain chemicals made it unlikely that changes in any single measure would be relevant to the mechanism. At best, any single measure would be a marker of the breadth of the changes induced in brain biology. 2014. The present editor of the Journal of ECT, Vaughn McCall organized another review of mechanisms. He asked Pascal Sienaert to organize the reports that were published in June 2014. Each survey considered the main measurable consequences of seizures – changes in the EEG and psychological tests, neurotransmitters, neuroendocrines, and immune and cardiovascular systems. I chose to remind readers that the central event was the seizure and not in any aspect of electricity, by noting the equivalent efficacy and consequences of flurothyl induced seizures to those induced electrically. 48 �Roger Haskett of the University of Pittsburgh discussed the neuroendocrine hypothesis. Haskett had studied cortisol in melancholia and ECT in collaboration with Bernard Carroll when both were at the University of Michigan in the 1980s. In retrospect, the discovery of the changes in human behavior by repeated inductions of seizures is a remarkable page in the history of medicine. As I read the invited articles on mechanism submitted to JECT in 2014, I do not see a better explanation than that of the impact of seizures on the hypothalamic-pituitaryadrenal and hypothalamic-pituitary-thyroid systems. 49 �Book Five: The Road to Catatonia During my days in medical school and residency training I assume I observed catatonic patients. Indeed I recall walking through hospital wards, dressed in the short white coat of the student, with two 500 mg vials of Amytal sodium in one pocket, a metal autoclave box containing a sterile syringe and needles, a tourniquet and bottled water in the other, to sedate the excited and the manic and to relax and obtain the cooperation of the negativistic and the mute. But during the decades of clinical practice as a research physician in New York and St. Louis hospitals, I cannot recall recognizing catatonia as a distinct syndrome. In my research positions, I had little front-line responsibility to examine and treat the acutely ill. It was during my visit to the Bakirköy Hospital in Istanbul in 1965 that I saw nude women, standing in rigid Christ-like postures in hospital windows and rows of posturing men as we went through the wards. Catatonia is a systemic disorder of acute onset with mutism, posturing, rigidity, and stupor, and at other times as intense excitement and delirium. Patients remained ill for months and years filling long-stay hospital wards. Now, we have the technical means and the skill to recognize and treat these patients successfully and rapidly. Turan Itil, my research colleague at the MIP in St Louis, and I were visiting the Istanbul Bakirköy hospital to supervise a study of a new neuroleptic, butaperazine. Our arrival was welcomed by a patient band, colorfully dressed in 19th Century Turkish pantaloons and multicolored shirts, beating drums and cymbals, and playing the baglama string instruments -- an image of a mental hospital before the psychopharmacology era. My enduring interest in catatonia was aroused in 1980, when I became responsible for supervising the care of acutely ill patients and teaching students on the in-patient unit at University Hospital at Stony Brook. My experience with a fully restrained delirious woman and the resolution of her illness excited my interest.. The Teaching Case On a morning in the Fall of 1987 I was teaching an expert class in ECT when a patient from the medical service was referred for evaluation. A class of five graduate physicians saw a restless, delirious and febrile 25-year-old woman in fourlimb restraints, nasogastric and urinary catheters and intravenous fluids running. When alert, she was negativistic, posturing, rhythmically thrashing, alternating mute and screaming. She was suffering the systemic disease of lupus erythematosus, an acute autoimmune disease, being treated with intravenous methylprednisone for the lupus and sedated with haloperidol and lorazepam. An EEG had shown seizure-like activity and phenytoin was prescribed to block spontaneous seizures. She was in an acute manic and catatonic delirium. 50 �Was she a candidate for ECT? The physicians, influenced by the severity of her systemic illness, the restraints, parenteral feeding, and manifest weight loss, thought not, that the treatment was likely to do her more harm. They demurred even after I described the rapid relief with ECT in three patients with the same psychiatric complications of lupus that had earlier been reported by Samuel Guze at Washington University. Contrary to the class opinion, the severity of her excited illness supported treatment with ECT since the treatment was remarkably safe even in the most systemically ill patients. With consent of her family and her physicians, a course of ECT was begun on hospital day 28. Within 10 days and 7 treatments the delirium was relieved, restraints were lifted and cooperation improved. But family and physician fears and prejudices against continuing ECT forced me to stop her treatment, a decision that I strongly objected. She regressed rapidly, again required restraints, and her family now pleaded for further treatment. A second ECT series from days 68 to 90 resolved her catatonic illness. By day 100 she was discharged with medical relief of lupus and without signs of catatonia or delirium, to remain well and report the care of her family at one-year examination. The severity and life-threatening nature of her illness, the rapid resolution with ECT, and my realization of her behaviors as “catatonia” intrigued me. Gregory Fricchione, then chief of Stony Brook’s Consultation and Liaison Service and very experienced with catatonia, having developed lorazepam treatment while studying at Boston’s Massachusetts General Hospital, had referred her for ECT after failed treatment with high doses of lorazepam. For the next few years we studied catatonia together. I became fascinated with the remarkable change from a delirious and moribund woman to a recovering mother with relief of a syndrome that I had hardly studied. I became interested in the story – how catatonia was discovered and described in Germany in 1874, how another German psychiatrist incorporated catatonia in his concept of schizophrenia that prevented much progress in its study. Catatonia as a Type of Schizophrenia In 1874 Karl Kahlbaum, the director of a private sanitarium in Görlitz, Germany, clustered peculiar motor behaviors of some of his patients into a single syndrome of “Die Katatonie.” In a rich text of 26 clinical vignettes, he clustered mutism, immobility, negativism, posturing, staring, grimacing, stereotypy, mannerisms, and several other motor signs as a single syndrome. The underlying illnesses that brought the patients for hospital care varied, with 12 patients severely depressed, nine suffering from seizure disorders, three with neurosyphilis, and two with tuberculosis. In a poignant final chapter of his book, Kahlbaum sadly notes that he could offer no useful treatment except to hope for spontaneous remission, which actually did occur in some cases. Death was all too common. 49 51 �By 1899 Emil Kraepelin, the German psychopathologist, teacher, and author of numerous textbooks, having recognized the same signs, published dramatic photographs of posturing and grimacing patients. He observed his chronic mentally ill patients for many years and characterized two principal syndromes. The patients with delusions, language difficulties, and hallucinations that began during adolescence and progressed to dementia were suffering from dementia praecox. Those with depressed moods alternating with mania suffered from manic-depressive illness. Catatonia was seen in both groups. In later editions of his textbooks, Kraepelin described catatonia as a marker of dementia praecox. This association of catatonia with dementia praecox was accepted by the Swiss psychiatrist Eugen Bleuler who renamed the illness as schizophrenia. His approach was based on the beliefs of psychoanalysis, seeing catatonic symptoms as accessory manifestations of Freudian complexes, thereby marginalizing their importance in the diagnosis of schizophrenia for generations of psychiatrists, sidestepping the analysis of psychiatric nosology and obscuring efforts to conceptualize catatonia. When official classifications of psychiatric disorders by the American Psychiatric Association emerged in the 1950s, schizophrenia, catatonic type was the singular recognition for catatonia. This characterization dominated the psychiatric classifications during all of the 20th Century. It was this association that I was taught. But Catatonia Is Not Schizophrenia Awareness that catatonia was not limited to patients with schizophrenia came slowly. By 1973, after examining the records of 2500 hospitalized patients with extended follow-up at the University of Iowa, James Morrison reported that 10% met criteria for catatonia at their index admissions. Re-examination of the records of those patients at a later date found 40% had, at some point, recovered completely after treatment with sedative hypnotics or ECT. Morrison argued that these recovered patients could not be examples of schizophrenia, a disorder for which treatments, at best, reduced the severity of symptoms but did not relieve the illness. A year later Richard Abrams and Michael Alan Taylor, two students from my classes at New York Medical College, identified 55 patients with one or more catatonia signs admitted to two wards at New York City’s Metropolitan Hospital over a 14-month observation period. Only four patients among these satisfied the research diagnostic criteria for schizophrenia, while more than two-thirds met the criteria for affective disorders, usually mania. They reported the salutary effects of treatments and a factor analysis of the data identified two factors, one associated with mania and good outcome with treatment. 52 �That same year, Alan Gelenberg in Boston described eight patients who became toxic and febrile with severe Parkinsonian motor signs after receiving high potency neuroleptic drugs. He cited the cases as instances of “the catatonic syndrome.” In 1980, Stanley Caroff in Philadelphia, after describing 60 reported cases of neurotoxic responses to neuroleptic drugs, labeled an acute onset lethal catatonia syndrome with fever, autonomic instability, altered consciousness, stupor, and the rigidity and posturing signs of catatonia as the “neuroleptic malignant syndrome” (NMS), a label that was widely adopted. He ascribed the syndrome to excessive dopamine blockade and prescribed dopamine agonists such as bromocriptine. In time we learned that these treatments were ineffective, and they were replaced by lorazepam and ECT, the effective catatonia treatments today. In Contrast to Schizophrenia, Catatonia is Treatable. In 1930 William Bleckwenn, an American physician in Wisconsin, reported that catatonia could be relieved by injections of 2.0 or more grams of amobarbital (Amytal). Mute, staring, stuporous and posturing patients responded to injections by speaking, answering questions, and self-feeding. These changes were reported and also shown in a black-and-white film that was instrumental in launching the practice I was taught. A second effective treatment of catatonia, inducing grand mal seizures, came de novo into the world on January 2, 1934 when Ladislas Meduna, a Hungarian neuropsychiatrist, injected camphor-in-oil into the buttocks of chronic psychiatric ill at the Lipótmezó sanitarium in Budapest. By happenstance, the majority of his patients exhibited the negativism, mutism, and motor abnormalities -- now considered signs of catatonia -- that were then considered signs of schizophrenia. His method of induction was inefficient, however, eliciting a seizure in only one third of the subjects. Behaviors changed little but the few that did improve sufficiently impressed him to continue. Later that year he used a better method of intravenous injections of pentylenetetrazol (Metrazol), which elicited fuller and more reliable seizures. The changes in behavior were so remarkable that he reported his cases in 1935 and again a year later at a meeting in Switzerland that canvassed experiences in new treatments of psychosis from 22 countries, setting the stage for worldwide interest in seizures as therapy. Three years later he published his experience with 110 patients, reporting relief in more than half, especially among those acutely ill with catatonia. A year after that, the Italian physicians Ugo Cerletti and Luigi Bini demonstrated the same relief-inducing seizures using electricity rather than chemical injections. These treatments were remarkably successful in relieving 53 �catatonia, so much so, that once clinicians caught on, it was possible for a neurologist in 1981 to ask decades later, “Where have all the catatonics gone?” Is NMS a Form of Catatonia? Recognition of the neuroleptic malignant syndrome came slowly into professional awareness. The occasional sudden death of a psychotic patient treated with chlorpromazine or other potent neuroleptic drugs raised little intellectual interest until the Caroff report appeared. After reading his description we at Stony Brook recognized three patients treated with neuroleptics who met his criteria for NMS. Repetitive motor movements, mutism, posturing, and negativism marked each story. We discontinued neuroleptic medications and, following Caroff’s guide, prescribed bromocriptine. One patient responded slowly, but two did not. ECT brought quick relief. Although my curiosity about catatonia was not aroused until we treated the woman in delirious mania described earlier, we did find other cases of NMS. 50 At the height of the summer of 1976, a 23-year old agitated and aggressive psychotic man under my care at the Central Islip Psychiatric Center was refusing food and fluids and required restraint and sedation. Intramuscular haloperidol was administered. The ward was incredibly hot, he became dehydrated, febrile, suffered a seizure, became stuporous, and died within 12 hours. Neither physical nor psychological post-mortem reviews suggested a compelling reason. In retrospect, his acute death was an unrecognized example of NMS, the toxic syndrome associated with haloperidol that was waiting to be discovered. Another example of NMS was the death of Libby Zion, an 18-year-old college student being treated for depressed mood with phenelzine. In the summer of 1984 she was admitted to New York Hospital febrile, agitated, and disoriented with abnormal motor movements. Meperidine was administered, her agitation worsened and parenteral haloperidol was added. Now in stupor, her temperature quickly rose to 107oF and she died. Her family sued the hospital for malpractice and in 1993 I was asked to review the records as an expert witness in the hospital’s defense. The many initial diagnoses did not consider NMS, but by the time of the legal case her experience was recognized as an example of neuroleptic-induced malignant catatonia. As NMS became increasingly recognized, various treatments were tested. By 1983 Gregory Fricchione described four cases in which high doses of lorazepam and withdrawal of the neuroleptic relieved the syndrome. Case reports of lethal catatonia secondary to neuroleptic use followed quickly, each affirming the connection and citing relief with cessation of neuroleptic use and treatment with benzodiazepines and ECT. The significant connection between malignant catatonia and prior experience of catatonia was made by Denise White of South Africa who described five patients in whom the catatonia signs preceded the administration of a neuroleptic. In a second report a year later catatonia was presented as a precursor 54 �to the malignant state, raising the question as to whether the neuroleptic malignant syndrome, malignant catatonia, and the non-malignant forms of catatonia were manifestations of the same psychopathology. The acceptance of NMS as a form of catatonia was slow, inhibited by the different treatments offered. Stanley Caroff and his colleagues believed that NMS resulted from the neuroleptic inhibition of dopamine activity and focused treatment with dopamine agonists bromocriptine and amantadine. Because the fever, muscle rigidity, and weakness simulated malignant hyperthermia, they augmented treatment with the muscle relaxant dantrolene. Despite poor responses and continuing deaths, many authors applied this prescription. An international debate ensued, carried on for more than two decades, whether NMS was best considered an abnormality of dopamine metabolism and treated with dopamine agonists or malignant catatonia and treated with benzodiazepines and ECT. The debate argued at meetings of psychiatric societies and in the literature with Stanley Caroff, Gregory Fricchione, Steven Mann, Patricia Rosebush, Theresa Rummans, Michael Taylor, Gabor Ungvari, Denise White, and myself as the protagonists. The debates strengthened my interest in catatonia, as I viewed NMS as a form of malignant catatonia. Essential to the different views was the failure to recognize the signs of catatonia. For many observers the essence of NMS was the fever, autonomic instability, and muscle rigidity, encouraging belief in an overlap with malignant hyperthermia. Interest in catatonia was minimal, blocked by the prevailing belief that catatonia was schizophrenia, despite the reality that few NMS patients met the criteria for the thought disorder, impaired speech, delusions, and hallucinations that characterized schizophrenia. Further, treatments of NMS-classified patients with barbiturates and benzodiazepines were considered to risk tolerance development and dependence, beliefs that were substantiated by the FDA’s restricted prescribing rules. Dosing was limited to a few milligrams of lorazepam, inadequate for the relief of catatonia. Few hospitals had ECT treatment units so clinicians could not prescribe this treatment--but all could prescribe dopamine agonists and dantrolene. Then, in 1990, Michael Taylor presented a detailed argument distinguishing catatonia from schizophrenia in a historical and clinical review of its 100-year history. He described both retarded and excited forms of catatonia and detailed effective treatments with barbiturates, benzodiazepines, and ECT. He connected the motor signs to the pathophysiology of the frontal lobes, presenting catatonia as an entity of many causes and many forms, thus challenging its consideration solely as a form of schizophrenia. 51 Simultaneously, the neurologist Daniel Rogers from the Burden Neurological Hospital in Bristol, England presented a similar challenge. Of the100 chronic schizophrenic ill he had examined, many exhibited catatonia and Parkinsonism. Their presentations, though, were similar to those that had occurred during the 1918 encephalitis epidemic, indicating that catatonia was not confined to 55 �schizophrenia. He described a systematic examination and a rating scale to identify catatonia, defining catatonia within neurology practice. 52 Both Taylor and Rogers questioned the Kraepelinian dictum that catatonia was a form of schizophrenia. Their doubts were consistent with my own that catatonia was not a marker of schizophrenia. That led me to argue for an independent status for catatonia in the illness classifications. The Drive to Official Definition. Was catatonia a singular identifiable disorder with common characteristics and homogeneous pathophysiology, or a galaxy of psychiatric aberrations with different pathologies? The 1980 DSM-III identified catatonia by the presence of at least one of the five signs of stupor, negativism, rigidity, excitement, or posturing. My Stony Brook colleagues culled the more detailed descriptions of catatonia signs by Kahlbaum, Kraepelin, Taylor, Rogers, Rosebush, and Lohr and Wisniewski to develop a 23-item list of identifiable signs scored on a 3-point scale and described a systematic examination that could be used to derive a diagnosis. Using that rating scale in 1994-95 we examined every patient admitted to our ward for catatonia signs. In potential catatonia cases, prescribed neuroleptics were quickly withdrawn, the effect of a single dose of intravenous lorazepam or diazepam was tested, and the patients treated with high doses of diazepam or lorazepam or with ECT. We next surveyed all patients admitted to the Psychiatric Service and the Psychiatric Emergency Room of University Hospital during a 6month period using our rating scale. Of 215 patients examined, 9% had two or more signs of catatonia. In the next year, of 470 patients examined we admitted 28 patients with four or more signs of catatonia to the in-patient service of University Hospital. Of these, 15 were affectively ill, 4 psychotic, 3 with NMS, and 6 with various systemic medical illnesses. A review of the University Hospital records for the 5-year period beginning in 1985 with discharge diagnoses of schizophrenia, catatonic type (DSM 295.2) identified 43 charts. Of these, seven patients were also charted or discharged as affective disorder, five as organic affective disorder, and seven as schizophrenia. Eleven had been treated with ECT, with full relief in eight, confirming again the remarkable efficacy of seizures to relieve catatonia. The Sedative Verification Test Could the relief of catatonia’s signs with intravenous lorazepam confirm the diagnosis? Since William Bleckwenn had rapidly resolved catatonia with injections of amobarbital, intravenous amobarbital had been widely used to gain speech for the mute, encourage feeding and toiletting in the negativistic, quiet the aggressive, 56 �and arouse the stuporous. In 1983 Gregory Fricchione recommended that amobarbital be replaced by lorazepam and that the reduction of catatonia signs be considered a verifying test for catatonia. As verification of catatonia in patients with 2 or more catatonia signs for 24 hours or longer, we adopted the criterion of a 50% reduction in the catatonia rating scale score, if it occurred within 10 minutes of the intravenous administrations of 1 to 2 mg lorazepam. The prescription of 3 mg/day of lorazepam, increased rapidly by 3 mg increments to 30 mg/day became our treatment protocol. Of 28 patients identified with catatonia signs, 23 recovered with lorazepam dosing alone, 5 did not. Of the four who consented to ECT, three recovered with 2 to 3 treatments, while one required 11 treatments. This experience was published in 1996 and the protocol became our standard diagnostic and treatment procedure; within a few years these methods were widely adopted and central to the recommendations of the textbook of catatonia that Taylor and I published in 2003. 53 The Many Faces of Catatonia. Beginning with our recognition of NMS, Michael Taylor and I soon accepted other syndromes such as delirious mania, toxic serotonin syndrome, pervasive refusal syndrome, NDMAR encephalitis, Self-Injurious Behaviors in adolescents, and several other labeled syndromes that exhibited multiple signs of catatonia that were relieved by known treatments. We thought that the syndromes must have a common pathophysiology since the signs were overlapping and the same treatments were effective. Delirious mania. Catatonia is recognized in a sedated form of stupor, mutism, posturing, and negativism. It also is recognized in an excited, manic state. Catatonia is more often recognized among manic patients than among those with depressive moods or psychosis. Among the patients admitted to our psychiatric facility so excited and overactive as to require physical restraint, we increasingly recognized the signs of catatonia. Some vacillated between aggressive screaming and posturing mutely, with peculiar repetitive movements. Others were febrile, hypertensive and tachycardic. Some were delirious, all were confused and poorly oriented. Many had been treated with haloperidol or other high potency neuroleptics precipitating the malignant febrile form of illness. Some had seized and anticonvulsants had been prescribed. Many patients required four-limb restraints or were maintained in a padded isolation room. We withheld neuroleptics, prescribed high doses of parenteral benzodiazepines, and were often able to minimize the excitement. But the severity of the fever often forced more immediate treatment with ECT. Daily ECT found relief of excitement, delirium, and fever had occurred by the third day in almost every case. 57 �Taking patients who are suffering a malignant systemic illness and subjecting them to the risks of anesthesia and induced seizures is counter-intuitive. But the fatality rate of febrile catatonia and the life-saving quality of daily ECT was demonstrated in 1952 by Otto Arnold and H. Stepan. They had treated 18 patients in their first clinic in 1947/48 with delayed treatments and 16 in their second 1949/50 with prompt treatments. Of the 18, 15 died and 3 survived; of the 16, 13 survived and 3 died, The lesson of daily or multiple seizures was learned, and I applied their experience on numerous occasions . The Stony Brook hospital unit consists of rooms around a circular core. From the entrance to the ward it is possible to see the doors to 3 to 5 rooms. I often came to the ward by 7 am, seeing a chair outside a room, with an aide watching the patient inside. These were the patients under 1:1 observation and care, often the most delirious and excited, or late adolescents with self-injurious behaviors. A 29year-old HIV infected man had become severely depressed, suicidal, and delirious, refusing his HIV medications. In the ER, he was injected with haloperidol, became agitated and febrile. On the ward he was in 4-limb restraints, 1:1 observation, and parenteral fluids. After increased dosing with lorazepam with little response, we induced his first seizure. That afternoon he was out of restraints, only to relapse slowly. His temperature elevated and treatments were repeated on each of the next two days, with complete relief, cooperation and full self-care. A 20-year-old college student was admitted in delirious excitement. After 4 daily ECT sessions he was discharged to continue out-patient ECT for a total of 10 treatments. He completed his college courses. A 25-year-old musician in delirious mania was relieved by 5 daily ECT sessions, fully recovered by a full course of 12 treatments. Four years later, he was re-admitted after returning from an overseas working trip during which he had become exhausted. Again, daily ECT relieved the syndrome and he remained well. In a review of the hospital records I found 9 additional patients with delirium, mania, and signs of catatonia who had responded well to ECT. These experiences encouraged additional treatment of non-manic delirious patients and led me to recommend that ECT was an effective treatment for delirium, regardless of cause. An interesting misconception developed in the 1980s as the label “bipolar disorder” was popularized as a diagnosis after its delineation in DSM-IV. Depressed patients with a single manic episode in their history were labeled as suffering from bipolar disorder, neglecting possible catatonic features. The treatments for bipolar disorder span the breadth of the pharmacy, applying atypical antipsychotics, mood stabilizers, lithium, anticonvulsants, anxiolytics, sedatives, and antidepressants in complex combinations with notoriously poor outcomes. As excited patients are forcefully restrained, treated with haloperidol and other potent neuroleptics, they rapidly develop seizures, fever, become mute, refuse fluids and food, become dehydrated and die, sometimes with fever and inanition or by improper tube 58 �feeding. Recognizing catatonia in severely manic and delirious patients and offering catatonia treatments is an unheralded aspect of the understanding of mania. But delirious mania is still not recognized in the revised nomenclature of DSM-5 published in 2013. In his critique What Psychiatry Left Out of DSM-5, the historian Edward Shorter identifies delirious mania as just one of many illnesses that are not recognized. 54 Michael Taylor makes the same observation in his personal history as researcher and clinician titled Hippocrates Cried. 55 Toxic serotonin syndrome. A 59-year-old married woman was admitted to University Hospital with a long history of treatment for mood disorder. Her most recent prescription had been the sedative trazodone at bedtime. She developed urinary incontinence and the serotonergic agent nortriptyline was prescribed. Within five hours after a single 25 mg dose, she became fearful, tremulous, sweating, tachycardic, hypertensive, incontinent of urine with explosive diarrhea. Four days later, she exhibited seizure-like movements of her extremities and lost consciousness. At the psychiatric emergency room she was mute, rigid, tremulous, tachycardic, sweating, and hypertensive. The examination was consistent with NMS and lorazepam [1mg q6h] was prescribed, relieving the motor and vegetative signs within two days. She remained depressed and retarded, however, and responded well to ECT with lorazepam as continuation treatment. She had not been exposed to neuroleptic agents as her husband, a high school biology teacher insisted, showing his daily record of her symptoms and all administered medications. Toxic serotonin syndrome (TSS) is an acute change in mental status with systemic signs following the addition or increase in dose of a known serotonergic agent to an established psychoactive medication regimen. No effective treatment is known other than withdrawal of the precipitating medications and supportive care. The overlap in signs of toxic serotonin syndrome with NMS, and the successful response to catatonia treatments, argues that toxic serotonin syndrome is best considered and treated as a form of malignant catatonia. Pervasive refusal syndrome. A syndrome described in the UK in 1991 meets our criteria for catatonia and represents another face of the syndrome. Four British girls between the ages of 9 and 14 suffered “a profound and pervasive refusal to eat, drink, walk, talk or care of themselves in any way over a period of several months.” They required nasogastric tube feeding and spent such prolonged periods in bed that they “occasionally requiring manipulations of the joints under general anesthetic to prevent contractures.” After extended hospital care and family and individual psychotherapies they eventually recovered. A report of an 8-year old girl who stopped eating and drinking after a viral infection and who was hospitalized for more than a year before being returned to her family in partial remission was brought to my attention by Donald Klein; did she meet our criteria for catatonia, he wondered. We agreed and asked the report’s authors whether not testing and treating for catatonia was unethical. The authors 59 �offered a complex rejoinder without explaining the failure to apply proper tests. A decade later I was consulted by the Irish child psychiatrist Fiona McNicholas about an 11-year old prepubertal girl who developed symptoms of asthma, abdominal pain, and insomnia. She refused to attend school or to eat or drink, became withdrawn and mute, and required nasogastric feeding and hospital care. After many months, a video of her behavior was sent to me. Mutism, negativism, and posturing confirmed catatonia. Lorazepam testing and treatment was recommended. The parents refused medication treatments but participated in family therapy. At first the girl took part but in time she refused. After 18 months of hospital care, as the date for her scheduled return home was imminent, she began to speak, eat and care for herself. Over the next six years she completed her schooling and went on to University. These cases are labeled “pervasive refusal syndrome.” Less than 30 additional cases are cited in the literature, with a 3:1 ratio of girls to boys. Each reported case required prolonged hospital care. Similar cases are labeled “elective” or “selective mutism.” The patients meet criteria for catatonia but it remains difficult for many physicians to consider catatonia except in the shadow of schizophrenia. The tragedy in each case is the availability of effective treatments and the clinicians’ refusal to offer a proper diagnosis and effective care. Recent descriptions of a “Resignation Syndrome” among Syrian refugees in Sweden and a “Nodding Syndrome” among children in the wars in Uganda find behaviors of withdrawal, mutism, loss of self-care, failure to feed that clearly mimic catatonia mutisms. Both these syndromes should be considered forms of catatonia. Such recognition would offer effective relief and bring these syndromes under the catatonia umbrella. Anti-N-Methyl-D-Aspartate Receptor Encephalitis. A 2008 case report in the New England Journal of Medicine describes a 26-year-old woman admitted for headache, behavioral changes, abnormal movements, and mutism of seven weeks’ duration. After extensive laboratory examinations a serum anti-NMDAR encephalitis test was reported positive, supporting the presence of an autoimmune disease. Throughout her illness she had been somnolent, mute, and negativistic, with repetitive movements of her arms and mouth, but these were not recognized nor treated as catatonia. An ovarian teratoma was found, surgically removed under anesthesia, and the encephalitis syndrome resolved within a day. Was the removal of the tumor or was the anesthesia the therapeutic agent? The rapidity of the resolution and her course favor the probability that catatonia was relieved by the anesthesia. Another report described a 16-year-old boy with protracted stupor, psychomotor retardation, mutism, posturing, stereotypical movement, refusal to eat and drink, and episodic agitation. A positive blood test supported an anti-NMDAR diagnosis. The presence of catatonia was not recognized and no consideration given 60 �to its treatments. Instead, haloperidol and other antipsychotic agents were prescribed worsening the symptoms. After seven months of nursing care the illness abated. The experience was trumpeted as a clinical lesson in the American Journal of Psychiatry despite the failure to recognize catatonia or to consider its treatment. The signs of catatonia were commonly described in a 2008 report of 100 cases of encephalitis with positive NMDAR serum tests, but neither catatonia nor its treatments were discussed. Case reports now dot the literature with most patients being female and with resolution after resection of ovarian teratomas when found. But the syndrome is also reported in males. Limbic encephalitis is an acute autoimmune neurological disorder first described in the 1960s as a ‘paraneoplastic condition’ – self-poisoning systemic changes induced by tumors. More than 80 different autoimmune disorders are described in the medical literature. The pathophysiology is poorly understood and the treatments are empiric and of limited efficacy. The diagnosis of anti-NMDAR encephalitis depends on a positive serum or cerebrospinal fluid antibody test. The recommended treatments are tumor resection when found and non-specific immunotherapy (corticosteroids, intravenous immunoglobulin or plasma exchange) or immunotherapy medications (cyclophosphamide or rituximab). These treatments have not been demonstrated to be effective and are associated with prolonged illness. My appreciation is that these patients have a systemic illness of acute onset, with a positive chemical test, with a high incidence of tumor, and frequently expressed as catatonia. These characteristics assure the syndrome's definition within the medical model. Treatments for catatonia, when applied, have successfully relieved the illness. A heightened enthusiasm for this diagnosis is reflected in an editorial in the British Journal of Psychiatry in April 2012 calling for laboratory tests for antiNMDAR encephalitis in “all individuals with a first presentation of psychosis, or people with psychosis and features of autonomic disturbance, movement disorder, disorientation, seizures, hyponatraemia or rapid deterioration . . . with the possibility of antibody-mediated encephalitis in mind.” The recommendation continues: “This assessment should include, as a minimum, a neurological and cognitive examination and early serum testing for antibodies against the NMDA receptor and voltage-gated potassium channel. All patients testing positive for these serum antibodies should be referred to neurological centres with expertise in managing these cases.” The enthusiasm for this diagnosis is also illustrated by the rapidly increasing case-report literature. The initial references to anti-NMDAR encephalitis cited in Medline are in 2007. By July 2014, the number had increased to 230 citations. and by February 2021 increased to 1588 with 83 with catatonia, and 19 with the catatonia treated with ECT. 61 �As with patients with pervasive refusal syndrome, recognizing catatonia in anti-NMDAR encephalitis offers effective treatment. It is reasonable to consider catatonia in the differential diagnosis and offer its tests and effective treatments but this is still too seldom done. Self-injurious behaviors in mental retardation and autism. Patients identified in the past as suffering from mental retardation are now often discussed as examples of autism or autism spectrum disorders. Many exhibit persistent repetitive movements, often screaming and hitting themselves. Such self-injurious behaviors cause much damage. Restraints, antipsychotic medications, and deconditioning procedures are poorly effective. Courses of ECT, however, markedly reduce the repetitive behaviors and many young patients have been returned to home and community. They do require continuation ECT, however. A benefit of the success of these treatments has encouraged broader acceptance of ECT among child and adolescent psychiatrists. Other repetitive behaviors in children and adolescents are recognized as obsessive compulsive disorder (OCD) and Gilles de la Tourette syndrome (GTS). These are commonplace among adolescents labeled as suffering autism or autism spectrum disorders. A 2014 report describes an 18-year-old man with a 8-year history of progressively severe GTS that responded rapidly to ECT. The scientific literature is speckled with incidental relief of GTS and OCD with ECT that encourages a more inclusive application of catatonia criteria to these syndromes with the application of catatonia treatments. The DSM Classification Debates: Where Should Catatonia be Classified? The initial classification of psychiatric disorders published by the American Psychiatric Association in 1952 was revised in 1968 and again in 1980. In each version catatonia was singularly recognized as schizophrenia, catatonic type (295.2), making catatonia signs markers of this broad class of psychosis and neglecting evidence of catatonia among other disorders. The catatonia-is-schizophrenia equation led physicians to prescribe neuroleptic drugs whenever catatonia signs were recognized. Such treatments were not only unhelpful, but they often precipitated a malignant neurotoxic state, worsening the illness, and causing death. Only when the clinician distinguished the signs of catatonia were the patients appropriately treated with barbiturates, benzodiazepines, and ECT. Taylor and I argued that it was necessary to divorce Kraepelin’s marriage of catatonia to schizophrenia and to recognize catatonia as a distinct, independent syndrome warranting a home of its own.56 The 1994 revision (DSM-IV) retained the five types of schizophrenia and added the independent class of “catatonia secondary to a general medical condition” (293.89). I was pleased that an independent syndrome was recognized and hoped that such a designation would increase its recognition and encourage the 62 �prescription of effective treatments. Indeed, over the next two decades, recognition of catatonia increased and reports of malignant catatonia declined. Another DSM revision was planned in 2008 with catatonia assigned for consideration in the Psychosis Work Group. By this time an extensive literature supporting catatonia as an independent entity had developed and a consortium of catatonia scholars that I led asked that the catatonia type of schizophrenia (295.2) be deleted and that catatonia be designated by a single code as a distinct, definable, and treatable syndrome. The publication of DSM-5 in May 2013 deleted the class of schizophrenia, catatonic type (295.2); continued the class of catatonia secondary to a systemic medical condition (293.89); offered a class of “unspecified catatonia” (781.89); and included a “catatonia specifier,” coded as xxx.x5, for ten principal disorders including depression, bipolar disorder, and schizophrenia types. (A specifier is a label added to a primary diagnosis to indicate a subtype of the primary diagnosis. It avoids a decision about which aspect of the behavior, the psychosis or the catatonia, is the verifiable diagnosis.) The divorce of catatonia from schizophrenia has led many psychiatrists to an earlier prescription of effective treatments, lowering rates of chronic illness and death. Many variants of catatonia with unique effective treatments are now recognized. Once considered rare, catatonia is now reported in about 10% of the populations admitted to psychiatric hospital units, assuring earlier recognition and more effective treatments. During these recent DSM deliberations the initial debates occurred between classical scholars represented by Gabor Ungvari and the catatonia scholars beginning with the work of Michael Taylor and Richard Abrams in 1970s. Ungvari supported the Kraepelin image of catatonia as the abnormal motor signs found among patients with chronic psychosis. He had treated hospitalized long-term Chinese ill in Hong Kong with lorazepam and saw little benefit, but he had not tested the benefits of ECT. Modern scholars, however, are recognizing catatonia in acute treatment hospitals, finding many cases that meet the Kahlbaum criteria for catatonia. When Kraepelin identified catatonia in his chronically ill patients, he assumed that he was describing the same syndrome. The experience of the DSM-I to DSM-III classifiers was with similar chronic hospitalized ill since their office practices of psychotherapy did not accept catatonic patients – those with mutism, negativism, and posturing, for example. By the time of DSM-IV’s publication in 1994, however, some scholars had identified the catatonia described by Kahlbaum. Their experiences led to the addition of the special class of “catatonia secondary to a medical condition.” The connection of the catatonia scholars to the Psychosis Work Group was through Stephan Heckers, the chairman of Psychiatry at Vanderbilt University. That he accepted our picture of catatonia as an independent treatable syndrome is seen in his retrospective review published at the beginning of 2015. After examining 339 hospital charts, two or more signs of catatonia were recorded in 300 patients with 63 �232 validated by positive relief with lorazepam treatment or ECT. The mean lorazepam dose was 6 mg/day with 84% responding. ECT was applied in 20% with 42 of 45 (93%) responding. Publication of a Catatonia Textbook and an ACTA Supplement Taylor and I decided to summarize our experience with catatonia and published Catatonia: A Clinician’s Guide to Diagnosis and Treatment, a 256-page text in 2003. At the same time we presented our experience in a review in the American Journal of Psychiatry. We are clinicians, not laboratory scientists. We identify illnesses, use verifying tests, and explore effective treatments. We recognize that inducing seizures is a most remarkable and unique discovery in medicine, one that has been unfairly stigmatized by the professions of psychiatry, neurology, and psychology, as well as by the public. The science is poorly taught in medical schools and psychiatric residencies, many of which have no facility for its use, thereby denying relief to many of the mentally ill who they serve. Since that publication we have explored catatonia further. A decade later it seemed timely to bring our knowledge up-to-date and I published a review as a supplement to the Acta Psychiatrica Scandinavica. It is a biography of the syndrome, how it was developed, its early exploration, the incorporation in schizophrenia, and its rediscovery as a definable distinct entity. The essay reviews the arguments about its classification, and the new forms that are recognized. It also discusses an interesting association with animal tonic immobility, a defense described in prey animals. Many catatonia signs – stupor, mutism, posturing, repetitive behaviors – are characterisic of animals when they find a predator in their neighborhood, and I suggest that catatonia is a relic of human biologic history. Subsequently, I have argued that catatonia is an atavism, a relic of the past when Homo sapiens was both predator and prey, with the defenses of flight, fight, and dissimulation that are retained today. How is catatonia best recognized and what is its place in the medical world? We soon came to see it as a behavior syndrome, severe and occasionally fatal but treatable, so much so that its resolution left no residual marks. Edward Shorter and I discussed these many aspects of the syndrome and in the fall of 2016 resolved to write its history. We organized our thoughts and decided that we could best assess the syndrome as an atavism, a relic of the primitive stages of animal development when fears encouraged defenses of freeze, flight, or fight. We formulated these thoughts in an essay asking "Does persisting fear sustain catatonia?" in the Acta Psychiatrica Scandinavica in 2017. 57 A proposal for a volume by Shorter and myself was accepted by the Oxford University Press, and in July 2, 2018 the first copies of A Madness of Fear: A History 64 �of Catatonia with the deep blue cover image of Caravaggio's Medusa were published. The text describes the 150 year story of a systemic medical syndrome, the successful application of the Hunterian model of the identification of a systemic illness. It joins neurosyphilis and melancholia as among the few behavior disorders that is identifiable, verifiable and successfully treatable. 65 �Book Six: Melancholia and the Medical Model of Diagnosis After publishing our text on Catatonia in 2003, MickeyTaylor and our wives Ellen and Martha met for a celebratory lunch in Chicago. "Well, what is next?" We agreed that Melancholia was a discussable syndrome -- multiple forms were widely recognized, each responsive to the tricyclic imipramine and to ECT, and a verification test in the dexamethasone suppression test had been described. Melancholia syndrome met our criteria for a medical diagnostic syndrome, parallel to our image of the catatonia syndrome, and we both had successfully treated melancholic patients. 58 Like catatonia, melancholia is not recognized as a clinical entity in any of the American Psychiatric Association Diagnostic and Statitical Manuals, although it is widely described in the clinical literature. Melancholia is accepted as a descriptor or modifier for DSM diagnoses, not as a distinct identifiable entity, not accorded a specific code. As a consequence its study is not well defined, not recognized in the citation indices, and is poorly studied; it is buried in the Major Depressive Disorder and Bipolar Disorder categories. The parallel with the catatonia story is uncanny. 59 During my Hillside Hospital experience, the treatment of severely depressed patients, suicidal, anorexic, insomniac, mute and stuporous, with ECT was remarkably effective. Often, inducing seizures daily resulted in complete relief in 24 days, with suicide risk, appetite, insomnia and withdrawal fully relieved. In our RCT study of chlorpromazine and imipramine, we identified a population of psychotic depressed patients that responded to both agents. 60 In my days in Missouri, we often identified melancholic patients but their diagnosis and treatment was of no particular interest. In our studies of ECT at Gracie Square, the clinicians recommended psychotic depressed, postpartum and partum depressed for treatment without our particular attention to their identification. The Dexamethasone Suppression Test: By the 1960s, chemists had reported serum cortisol measures to be elevated in melancholic patients. By 1972, the Australians Davies, Carroll and Mobray reported that a straighforward test, the Dexamethasone Suppression Test (DST) was a marker of severe psychotic depressive illness. Diurnal serum cortisol levels were elevated, and administration of the steroid dexamethasone failed to suppress the elevated levels. One report by Bernhard Carroll intrigued me. Five severely ill melancholic patients with abnormal DST responded clinically to courses of ECT; their DST normalized. Two relapsed, again with abnormal DST tests; re-treatment with ECT resulted in clinical improvement, again with normalization of the DST. 61 Was the DST a marker of melancholia and predictor of the response to ECT? 66 �I had been asked to supervise a psychiatric unit at the Long Island Northport VA in 1972. I organized clinical trials of a potential psdychotropic drug flutroline, which we found clinically ineffective. In 1968, the Fellow supervising treatments Yiannis Papakostas, accepted the tasks of developing the chemical tests for cortisol and TSH testing patients before and during the course of ECT.62 Of 20 unipolar melancholic patients, 16 exhibited abnormal DST. Of the 14 treated with ECT, all test normalized with recovery. These findings stimulated interest in cortisol as a test of a specific form of depressive illness. Over the next few years, numerous reports associating the DST and depressive disorders, some finding a close association with severe depression and psychosis, others finding poor relations. The APA TAsk Force on Laboratory tests concluded that the test was not useful in identifying major depressive illness. 63 As I and Bernard Carroll noted, a laboratory test with high specificity for melancholic depression was applied to a broad class of "major depressive illness" that included neurotic and characterological depressions, those unhappy with their social status and lives. The patients with positive DST tests were the severely ill, often suicidal, unresponsive to psychological therapies, but responsive to the more effective antidepressant tricyclic medications and ECT. Never the less, the DST was rejected as a test of a specific form of depressive illness; each variation of the DSM (-III, IV, 5) discarded all laboratory tests for the diagnosis of any of its hundreds of described conditions. Earlier I described my development of the CORE collaborative studies of depressed patients treated with bitemporal ECT with continuation treatments either lithium and nortriptyline or ECT. The study was an excellent opportunity to test the DST and severe depressive illness, but the NIMH committee and managers reviewing the study budget, rejected funding for the DST, justified by the APA Task Force report. Never the less, we examined the rating scales of our depressed patients for evidence of the loss of pleasure in all, or almost all, activities or lack of reactivity to usually pleasant stimuli at baseline. Of 489 patients in the CORE study, 311 (63.6%) met criteria for melancholic features. The overall remission rate was 68.1%, with higher rates (78.7%) for those who did not meet the melancholia specifier criteria and 62.1% of (or more) of six cited vegetative signs of melancholia. The specifier is added on the basis those with melancholia specifier (42). We concluded that the approximation of "melancholia" in our patients was a poor substitute for the DST.64 After our meeting in Chicago, a flurry of letters, interim reports, literature searches, led to our publication in the Spring 2006 by Cambridge University Press of our melancholia textbook. 65 We described the century-old experience, defined the syndrome by psychopathology and laboratory tests, treatments by medication and ECT, and argued for its recognition as a distinct entity in psychiatric classifications. The book was well presented but was priced very high, the advertising minimal, and the distribution disappointing. 67 �Increasing interest in melancholia led to an international conference in Copenhagen of authors who had studied melancholia, also in 2006.66 By the conference end, melancholia was defined as an identifiable mental illness, the DST was agreed as a defining test, and ECT as a definitive treatment. The argument for a unique identity among behavior illnesses was again made. Discussions with members of the DSM-5 panel for depressive illnesses were strongly made, but again ignored in DSM-5 in 2013. Disappointed with our failure to convince clinicians about the unique qualities of melancholia, both Taylor, in his book Hippocrates Cried 67, and I, joining with Edward Shorter, described the story in Endocrine Psychiatr that we published in 2010.68 At this editing in March 2021, melancholia iremains buried among the diverse illnesses coded as major depression and bipolar depression. Like catatonia, the illness needs efforts to identify its biology, to bring it out of its burial, much as was successfully done for catatonia. 68 �Book Seven: Studies in Electroencephalography (EEG) EEG Introduced to Hillside Hospital 1953 Electrical rhythms from the intact human scalp were first described in 1929 by Hans Berger, a German psychiatrist. Within two years, in his third report, he described the changes associated with morphine, scopolamine, and other psychoactive drugs. Spontaneous seizures and the rhythms of the inter-seizure EEG in epilepsy were next described. Would EEG recordings distinguish effective from ineffective treatments in the induced seizures of ECT? Could the EEG identify a successful course of treatment? Were the seizures induced by pentylenetetrazol the same as those induced by electricity or by insulin? While I had seen electroencephalograms of patients as a medical student and a resident at Bellevue Hospital, I had no technical experience with the procedure. Reports of recordings during epileptic seizures induced by Metrazol, the chemical used by Meduna to induce seizures in schizophrenic patients, had dotted the literature since 1938 followed by similar descriptions for insulin coma and for ECT. During each procedure EEG frequencies slowed, amplitudes increased, and sharp, spike-like waves appeared. Missed and partial seizures induced little or no change in the EEG. Greater slowing of frequencies and increases in the duration and amplitudes of slow waves and spike activity marked more intense seizures. The altered rhythms persisted for weeks and, in a few patients, for months after the treatment course ended. I sought training in recording and interpreting the EEG. As my residency at Hillside was to be completed in December 1952, I applied for a fellowship at the Mount Sinai Hospital in New York City beginning January 1953. (By this time, too, after five and half years of postgraduate medical training I opened a private-practice community office in neurology and psychiatry, which I did in the summer of 1953 in Great Neck, Long Island. ) With Hans Strauss and Mortimer Ostow I learned how to apply scalp electrodes, maintain the EEG recorders, and interpret the records. The Medical Director Joseph S.A. Miller, established an EEG Service with a Grass electroencephalograph purchased with a $5,000 grant from the Dazian Foundation obtained by Dr. Israel Strauss, the Founder of the Hospital. By the end of 1953 I had appointed and trained an EEG technician and developed a protocol for the study of the changes in EEG associated with ECT. An application to NIMH funded a five-year study under Grant MH-927 "Altered Brain Function Following Electroshock" in the summer of 1954. Hans Berger had recorded rhythmic frequencies of 4 to 16 Hz. The more common 8-12 Hz waves were labeled alpha waves, the faster (>13 Hz) as beta, and the slower labeled as theta (4.0-7.5 Hz) and delta (<4.0 Hz) waves. 69 �At first the changes were measured from baseline crossing to baseline crossing by a ruler to estimate mean frequencies. The peak amplitudes were measured for each wave using calipers. In our first study of the changes after induced seizures, the technician Hannah Mosquera and I measured the height and width of each wave in 10-second epochs for 60 to 120 seconds in artifact-free samples for each weekly recording. We scored the records as low, medium and high degree changes. As the recordings were done weekly, we had six to eight records for each subject. Progressive slowing of frequencies and increased amplitudes marked treatment courses. In later records, bursts of slow waves with sharp spike activity were seen. The best clinical recoveries occurred in patients with high degrees of slowing and amplitude increases and we concluded that the EEG changes were necessary for the recovery of the patients. EEG recording became the center of my research interest, studying changes during the hospital course of patients treated with ECT and ICT. We were unable to record the actual seizure as our instruments were "blocked" by the electrical stimulus. But we could examine the interseizure record. Treatments were given on Mondays, Wednesdays, and Fridays with EEG recordings done on a regular schedule for each patient on Tuesdays or Thursdays. These records showed varying degrees of progressive slowing with increasing numbers of treatments. The grand mal seizure was the central feature for changes in behavior and the beneficial behavior effects. With increasing numbers of seizures the EEG rhythms slowed and the amplitudes increased. The patients whose inter-treatment rhythms changed very little did not recover from their illness. Those with greater degrees of slowing had the better clinical evaluations. The development of slow rhythms and higher amplitudes were markers associated with recovery. Necessary, but not sufficient. Some patients with these rhythms did not show beneficial behavior changes. At the time, we were treating a wide range of illnesses. Many would meet criteria for major depression, bipolar disorder, and schizophrenia in modern classifications. The schizophrenic patients, except those with the catatonic form of the illness, showed the least benefit with treatment. The specificity of seizure effects depended on psychopathology. Diagnosis became a critical process by which patients with high likelihood of benefit could be selected for treatment. For the next four decades I reported on the EEG effects of ECT and ICT; then the changes accompanying many new psychoactive drugs introduced after 1954. I developed methods to quantify EEG changes using digital computer methods; classified psychoactive drugs by their EEG characteristics; and developed and defended the contentious concept of the "Association of EEG and behavior with psychoactive drugs in man." 69 70 �EEG in Psychopharmacology By 1954, the first clinical tests of chlorpromazine found it to be very effective in reducing aggression, excitement, and paranoid thoughts. The EEG profile of chlorpromazine differed from amobarbital and ECT. Imipramine (Tofranil, IMI), our next new agent, was also distinguishable from chlorpromazine. Were these differences related to their differing behavior effects? And how were the changes related to behavior changes? While the changes in EEG during ECT were easily seen and readily measured by ruler and calipers, the changes accompanying the chemical agents were more subtle, the changes much smaller. We looked for a more sensitive quantitative measuring instrument and EEG quantification became an interest. The Grey Walter Frequency Analyzer. During World War II the English physiologist Grey Walter at the Burden Neurological Institute developed an electronic frequency analyzer to measure the degree of EEG slowing to assess the severity of head trauma. A single channel record, electronically filtered to minimize movement artefacts, was sent through a bank of 24 electronic filters, each tuned to respond to individual energies from 3 Hz to 33 Hz. The premise of its military medical use was that increases in slow-waves were signs of brain dysfunction following trauma. In 1957, George Ulett at Washington University described his use of a Grey Walter device to measure the effects of atropine and scopolamine on the postseizure EEG. He quantified the changes in brain electrical energy as mm pen deflections within each frequency band and reported that both anticholinergic chemicals reduced the percentage time and the magnitude of high amplitude EEG slow waves induced by seizures. I visited Ulett in St Louis and was impressed that the device did measure the drug-induced EEG changes. I received funding from NIMH and Ulett built a device for my studies at Hillside. We obtained the instrument in the autumn of 1959 and used it in various studies, most prominently in the CPZ-IMI-PLO random assignment study. While CPZ enhanced the amplitudes and slowed the frequencies, imipramine increased the percent time of fast frequencies, distinguishing the brain effects of each agent. EEG Analysis by Digital Computer. In 1960, at the dedication of the Brain Research Institute at UCLA, scientists from the Massachusetts Institute of Technology presented the analysis of a short EEG segment using digital computer programs. Ten seconds of analog electrical activity were digitized and then measured by two statistical programs labeled power spectral density and period analysis. 71 �The Walter analyzer was inherently unstable and sensitive to room temperature. It required daily calibration. I was impressed that digital computer analyses would be within the future for the analysis of psychoactive drug effects. Central to my move to St. Louis was my request for funding to explore digital computer analysis methods for medication studies. In early 1963 I approached the computer center at Washington University to establish a laboratory for EEG analysis at the Missouri Institute of Psychiatry. Donald M. Shapiro, a doctoral candidate in digital computer processing, agreed to develop the computer programs. In the autumn of 1964 an IBM 1710 digital computer system with a central processor based on the IBM 1620 was installed at the MIP. Over the next few years Shapiro developed signal processing programs to record EEG on digital tape, filter electrical noise, digitize the analog measurements, file the numeric values in the computer memory, and keypunch the data on Hollerith cards for statistical analysis. After examining different analysis programs, we concluded that the baseline cross and power spectral analysis gave us the best measures of medication effects. Some years later, we compared the relative merits of these analysis methods, concluding that the methods offered useful analogous measurements. IBM-1800 Analysis System: In 1966 I moved to New York Medical College to study opioids and their antagonists, hashish, and marijuana, and to renew my studies of ECT. Donald Shapiro joined me, and in 1967, with NIMH funding we leased an IBM-1800 computer system that he programmed to quantify taperecorded EEG records. The programs for both power spectral density (Fourier) and period baseline cross analyses were developed and applied. This system was complex and while more stable than the Grey Walter frequency analyzer, also required constant maintenance. Yet, we were enabled to quantify the EEG changes, identify drug-related patterns, predict their clinical uses, suggest effective dosage ranges, and relate the EEG changes to behavior. We also measured the time course of single dose effects and related them to drug and metabolite plasma levels. Following the introduction of chlorpromazine, then its congeners, and then different agents related to imipramine, came a flood of putative psychoactive drugs from industry laboratories. Psychopharmacologists were busy testing their effects on physiology and behavior in animal species. How to find new chemical entities with defined behavioral effects in man became researchable and fundable questions. Testing drugs in mice and rats identified animal toxicity. Phase-1 human toxicity trials in volunteers guided clinical use and safety. But what measures could be markers for antipsychotic, antidepressant, or anxiolytic potential? While a broad science of animal pharmacology catalogued the physiologic and behavioral effects of known psychoactive agents, did such studies predict the effects of new agents in man and in patients with different behaviors? 72 �Pharmacologists developed simple motor tests in animals responding to known chemicals, and then brought to human trial those agents that matched the pre-clinical response profiles of known drugs. Scientists at each pharmaceutical company tested their chemicals in rabbits, mice, rats, cats, guinea pigs, and occasionally in monkeys and chimpanzees. But their predictions did poorly when tested in the clinic. Although proposed agents matched known active agents in the pre-clinical animal trials, many failed in the clinic. Human trials became necessary to identify the association between the tests in animals and in man. Clinicians in the NIMH supported ECDEU program studied different physiology measures as markers for the effects in patients. In the Hillside CPZ-IMI-PLO trial, we had distinguished the EEG, physiologic, psychologic and behavioral effects of the active agents, seeing each as profiles of the classes of antipsychotic and antidepressant agents. We tested amobarbital and amphetamine, then the new compounds megimide and fenfluramine. The novel anticholinergic diethazine very rapidly desynchronized the slow waves developed during ECT. Study of this compound and other experimental anticholinegic drugs led to our hypothesis of a cholinergic basis for the clinical effects of induced seizures. Soon, the flood of psychoactive agents that were being prescribed in diverse patterns to our hospitalized psychiatric patients elicited complex baseline EEG patterns. The effects of each agent persisted for days and weeks, absorbed in body tissues and slowly leached out and metabolized in time. Each exposure altered the brain patterns in complex, difficult to define, ways. We could no longer find “a clean head” in which to measure a new agent’s EEG effect. We sought to test agents in prisoners, and came into conflict with changing concepts of ethics in human research. Prisoners were not “free agents” and, although we were careful to assure that their participation had only a monetary award and no change in their civil penalty, we were discouraged from such use. In New York we studied new drugs in healthy male volunteers, paying for their hourly participation, and found such trials useful to identify the central effects of new entities. The digital computer system offered quantitative measures of frequency and amplitude changes with each agent. We developed EEG criteria for antipsychotic, antidepressant, stimulant, and sedative drugs using the effects of chlorpromazine, imipramine, amobarbital, and amphetamine as guides. We also identified patterns for hallucinogens (LSD, mescaline), deliriants (atropine, scopolamine, diethazine), opioids (heroin, methadone, levomethadyl), their antagonists (naloxone, cyclazocine), marijuana, hashish and Δ-9-tetrahydrocannabinol, and a miscellany of agents with reported behavioral effects including phenytoin, aspirin, diphenhydramine, and novel peptides. Numerous world laboratories studied the EEG effects of psychoactive agents and with the leadership of the German scientists an International Pharmaco-EEG Society (IPEG) was formed and met every two years. The behavioral and 73 �physiologic effects were defined in patient and volunteer trials. Many consulted with industry pharmacologists and offered identifications of clinical activity that was inconsistent with the predictions of drug effects in animal studies. While the human studies were more reliable and predictive of the clinical activity of the compounds, these were expensive, time consuming, and difficult to fund and carry out. The association of EEG and human behavior was discussed at the 1966 meeting of the CINP, in a symposium on "Anticholinergic Drugs and Brain Functions in Animals and Man." The dissociation between predictions of behavior effects in animals and man was not resolved. 70 As new entities were created in industry laboratories increased emphasis on the absence of side effects resulted in compounds sent to the clinic with decreasing efficacy. These were identified as selective serotonin and norepinephrine reuptake inhibitors and the atypical antipsychotics. At clinical dosing and in volunteer trials, the impact on EEG were hardly measurable. We were unable to identify patterns the we had established for different behavioraltering agents. Our methodology was criticized as failed, and discarded. But over the past three decades, the benefits of these new agents were increasingly not distinguishable from placebo comparators. Not understanding the role of brain change measurable by EEG in man has resulted in a worldwide flood of ineffective medications. Psychopharmacology Lessons Learned by Pharmaco-EEG Over the three decades of activity, we profiled agents that were clinically active and some marketed, measured the relative potency and dosage ranges of sedative and stimulant drugs to guide clinical use, examined the psychoactive properties of agents in the search for a new useful chemical core, and agents that showed little promise that were abandoned. In some instances the EEG profile was instrumental in predicting effective clinical uses and dosage ranges and targeting marketing applications. Doxepin (Sinequan). Based on its chemistry and its effects in animal tests Pfizer pharmacologists recommended this tetracyclic compound for clinical trials as an anxiolytic. After a year in clinical trials with a lack of an observable benefit in anxious patients, investigators met at the company’s offices in Groton, CT to review the experience. A pall hung over the discussions until three investigators, Turan Itil, Herman Denber and I offered understanding from our EEG studies. We had failed to find the patterns of anxiolytic drugs, but did see changes similar to those of the antidepressant imipramine. We recommended doxepin be tested in depressed patients. Guided by our findings, doxepin was was quickly reported effective in depressed patients. It was successfully marketed as an antidepressant. Mianserin (Tolvon, GB-94) was developed by the Dutch company Organon and recommended for a use in treating migraine. The research director, Theodor (Jack) Vossenaar, sent the compound for EEG assessment to Turan Itil in St. Louis 74 �who reported its EEG profile to be most similar to that of amitriptyline. Because the pharmacologists considered the finding inconsistent with their experience as a serotonin and histamine antagonist, Vossenaar asked me to replicate the EEG study. I quickly confirmed Itil’s finding and the subsequent clinical testing and marketing in Europe and Asia as an antidepressant was medically and economically successful. I became invested in the EEG-mianserin story and presented the findings in many venues. Mirtazapine, 6-azamianserin. chemically related to mianserin, is a racemic mixture. In preclinical chemical and animal studies, the dextro-enantiomer was reported to be active and the laevo-enantiomer inactive. We examined the EEG profiles of both enantiomers and found no difference between them in the magnitude of the EEG changes with a pattern most similar to that of mianserin. Clinical trials for each enantiomer found both to be clinically effective although neither differed from placebo at the tested doses. The racemic mixture was successfully marketed as the antidepressant Remeron in the1990’s. Flutroline. Pharmacologic studies in dogs reported that a single 1-mg dose of flutroline inhibited the vomiting induced by apomorphine for as long as one week. Extrapolated to man, pharmacologists enthused that flutroline would be an ideal antipsychotic, requiring a single oral dose each week, pictured as the “Saturday night pill.” In our clinical trials in actively psychotic patients we failed to elicit an antipsychotic effect, even at multiple and higher dosing schedules than initially recommended. EEG measures in our volunteers also failed to show a measurable change. The preclinical prediction of small doses being effective for days or weeks was untenable and studies of the drug ended. Aspirin, Anticonvulsants, Antihistamines. We looked at commonly marketed agents with reputed behavioral effects seeking potential alternative clinical uses in their EEG profiles. Acetylsalicylic acid (Aspirin) was reported to be soporific at its common dosing of two tablets each at .0325 Gm. We tested single doses of 0.65, 1.95 and 3.6 Gm in healthy adult men. The two higher doses elicited quantitative EEG, symptom effects, and cognitive functions characteristic of soporifics. Doses of 0.65 Gm were similar in direction and pattern but failed tests of significance. We sought to measure the basis for reports of changes in mood with the anticonvulsant phenytoin, finding the EEG patterns to mimic those of antidepressant drugs. The dosages for clinical benefit were high, so high as to risk toxicity. In an enthusiasm for peptides following the identification of euphoriant effects of beta-endorphin, we examined the effects of the peptides ACTH4-10 and desTyr-gamma-endorphin. We could not elicit systematic EEG changes at the dosages and the parenteral routes that we were advised to use based on pre-clinical trials. 75 �The sedative effects of antihistaminic agents were well documented. Diphenhydramine and terfenadine elicited soporific, not antidepressant or anxiolytic patterns, and were not tested further. Opioids and Cannabis. The same principles of EEG study of new agents were applied to opioids and their antagonists, and hashish, marijuana and THC-∆-9. We defined the EEG and behavior profiles of the compounds and measured the speed with which the antagonists blocked the effects of heroin and levomethadyl. In studies of marijuana and hashish the behavior and EEG effects were consistent with THC-∆-9 content. The Association/Dissociation EEG and Behavior Controversy. Industry searches for new agents with potential for human benefit are commonly based on similarities in chemical structure and observations in animal trials. Early in our EEG studies, beginning with chlorpromazine and imipramine, our descriptions of the effects in patients and normal volunteers differed from the reports of EEG studies in animals. At meetings of EEG and biological psychiatry societies, both Turan Itil and I were often criticized for reporting effects on behaviors and EEG that differed from those reported in the animal trials that had preceded our human studies. Changes in the resting alert EEG in patients and healthy volunteers had elicited drug specific changes in frequency and amplitudes that we related to their clinical effects. During the course of ECT, EEG frequencies slowed and amplitudes increased. During the ECT course some agents increased and others inhibited slowing, some increased fast frequencies, and some altered amplitudes. The post-ECT EEG became a sensitive index of brain function that varied in response to the chemistry of the tested medication. These studies had been done at Hillside Hospital in the 1950s. Diethazine had been a new agent with well-defined anticholinergic properties that we administered to our patients during an ECT course. In postseizure recordings with slowed EEG frequencies and increased amplitudes, intravenous diethazine sharply and quickly reduced amplitudes and increased the mean frequencies. The patients became agitated, depressed, and reported their preECT symptoms. We inferred that seizures liberated free acetylcholine in brain and CSF and increased concentration of brain cholinesterases. These observations led me to suggest a cholinergic explanation of the ECT mechanism. Replications of the same effect with Ditran and experimental anticholinergic drugs of the JB series assured us of this pharmacology. When we measured the EEG effects of imipramine in our patients, in volunteers and in ECT patients, we found the same changes as we had seen with the anticholinergic agents. We inferred that imipramine blocked free brain acetylcholine, a finding that was inconsistent with its inferred pharmacology. 76 �At a Montreal conference in 1969, my suggestion of imipramine’s anticholinergic activity was criticized since such effects had not been observed in animals. The pharmacologists insisted that imipramine lacked such effects. In time the anticholinergic effects of imipramine were increasingly recognized. The anticholinergic properties were even flouted as riskful by marketeers seeking to replace imipramine with newer agents. The next year, at the World Congress of Psychiatry also in Montreal, nine investigators from Europe and the United States, described their experiences with new psychoactive agents on the EEG and behavior. EEG changes characterized the qualities of psychoactive drugs – the defined changes predicted the behavior effects, and their absence identified clinically ineffective agents or ineffective dosing. Itil, I, and an increasing number of electroencephalographers studied druginduced changes in human volunteers. As we described drug-related patterns that were clinically confirmed, greater interest in human screening of new clinical entities developed world-wide. The study program that began at Hillside Hospital, flourished at my laboratories in St Louis and New York. Many industrial pharmacologic laboratories established animal testing centers using implanted electrodes in diverse animal species. When pharmacologists assayed the EEG effects of putative and established agents in rats, mice, rabbits, cats and dogs, results differed from parallel findings in human studies. The principal argument was made by Abraham Wikler who tested morphine, atropine, n-allylnormorphine and mescaline in dogs in slings. The animal EEG recordings showed sleep patterns; yet, their legs and eyes were moving rapidly. He concluded that there was a dissociation between the induced behaviors and the EEG effects. His inference was supported by pharmacologists studying other animal species. At an international conference of the CINP in Washington DC in 1968, the issue of pharmacologic “association” or “dissociation” was debated and resolved by acknowledgement that the systemic and brain pharmacology of animals are not identical to that of man. Indeed, an agent showing similar effects in an animal species and in man is a happenstance that cannot be predicted in advance. Preclinical studies in mice, rats, cats and dogs studies do not reliably predict drug effects in humans. We had our own experience with the differences between the behavioral effects of drugs in animals and in man in St. Louis in the mid-1960s. Sam Gershon had trained in Australia and studied lithium in the treatment of mania. On the advice of Jonathan O. Cole, I invited him to join the MIP staff as pharmacologist. He brought an interest in the actions of acetylcholine, studying the anticholinergic drug Ditran and the cholinomimetic agent tetrahydroaminoacridine (THA). He developed animal testing facilities and appointed a team of collaborating pharmacologists and technicians. 77 �His animal of interest was the beagle dog. One occasion, when Gershon was away from the Institute, the administrator asked me to approve the purchase of six setter dogs as replacements for unavailable beagles from the animal breeder. The price for the setters would be the same. Not knowing of any difference between the species, thinking “a dog is a dog,” I approved the purchase. A few weeks later, Gershon complained that his anticholinergic drug experiments with setters failed to elicit the behaviors that were readily elicited in beagles. That the pharmacologic sensitivities varied among dog types as well as among animal species supported my argument that human trials were essential to understanding psychoactive drug effects. The Pharmaco-EEG Paradigm Whether the EEG and behavior of psychoactive drugs are “associated” and predictable in man as we maintained or were “dissociated” as pharmacologists asserted, clarified the pharmaco-EEG paradigm in clinical studies. Today’s search for new psychoactive agents is rooted in the happenstance that chlorpromazine was a powerful sedative agent especially in paranoid, aggressive, hostile, and manic patients. Similarly, the antidepressant relief accorded by imipramine encouraged its trials in melancholic psychotic patients. These experiences invigorated a massive industrial investment, mainly in animal studies, with lesser expenditures in the clinics. Much energy is being spent to find the effects of the agents on the brain’s neurohumoral and neuroendocrine chemistry. Psychoactive substances alter behavior to the extent that they change brain chemistry. The pharmaco-EEG paradigm offers quantitative measures of these chemical changes that relate to their behavior effects. We are able to predict the behaviors of psychosis, depression, or anxiety, elicit a delirium or reduce a manic episode, from the EEG changes. Failure to alter the EEG means that the agent has little effect on behavior, that it is behaviorally inert, and best marketed as a placebo. Human studies are expensive and the science of pharmaco-EEG failed its promise and is no longer supported either in research laboratories or in individual patient care in clinics. Sadly, the same questions are now being asked in human studies using the present-day fashionable brain imaging methods with emphasis on concepts of connectivity and the size of brain nuclei. It is difficult to see such measures that are momentary images and not continuous as having more promise than that of pharmaco-EEG, which readily permits continuing assessments over time. Sadly, pharmaco-EEG in managing individual patients and in predicting the effects of chemical agents and physical treatments is a discarded science. 71 78 �Book Eight: A Medical Experimentalist is Created Medical School Experiences 1942-1945 My letter of admission to New York University College of Medicine arrived on December 6, 1941, the day before the Japanese attack on Pearl Harbor and the entry of the nation into war. That Sunday I was accompanying my father on a house call, listening to radio news, when the attack was announced. My parents had actively encouraged the emigration of friends and classmates from Vienna, acting as surety for their transitions to America. They had avidly followed the news of the war in Europe and were particularly agitated by the Nazi murders of Jews. I began a three-year intensive medical school training program at New York City’s Bellevue Hospital in June 1942. We were sent to Fort Dix in New Jersey for a week’s military orientation and returned to classes as soldiers dressed as Privates First Class in the U.S. Army. The war had called many experienced faculty members to military duty offering students unusual opportunities for hands-on medical experiences and responsibility for medical and surgical procedures far beyond our knowledge and experience. I vaguely remember the anatomy and chemistry lessons of the first year. The cadaver was an elderly, skinny woman. My teammates were Felix Wroblewski, who later did medical research at the Rockefeller Institute and Luther Cloud, an officer in an insurance firm. Neuroanatomy was taught by Wendell Krieg, who asked each student to make paper mache crossection models of the human brain. These models were supplemented by brain slices preserved in formaldehyde in crocks that allowed us to map the brain’s nuclei. Neurosyphilis and Cerebrospinal Fluid: Clinical teaching began in the second year and in an assignment to the syphilis clinics I was taught by Bernhard Dattner, a 1938 émigré from Vienna. He had studied under Julius Wagner-Jauregg, the 1927 Nobel Prize winner in Medicine for his report that malaria-induced fevers relieved one third of patients of active neurosyphilis. While at Vienna's Allgemeines Krankenhaus, the number of white cells and levels of protein in the cerebrospinal fluid (CSF) were highest in the actively ill, making CSF examination indices of the severity of the illness and guides to treatment. Withdrawal of cerebrospinal fluid by lumbar punctures between Lumbar- 3 and Lumbar-4 vertebrae are often followed by headache. To reduce this incidence Dattner obtained the CSF from the 4th ventricle by an occipital puncture to the cisterna magna. For the next month I monitored the progress of the patients by CSF measures obtained by ventricular taps. I assumed that it was a customary procedure, despite the risk of penetrating ("pithing") the brain stem. The procedure is now considered too riskful to be considered even by experienced neurologists. 79 �Neurosyphilis is a late development in the life course of syphilitic disease, appearing years after the original infection. The symptoms develop slowly, making difficult an accurate diagnosis with its devastating consequences in personal life and the risks of the toxic treatments of mercury and arsenic. A principal sign of the disease is pupillary irregularity and failure to narrow with a light stimulus (the Argyll-Robertson pupil). When mental and neurologic symptoms appear, this sign is present in less than 60% of known ill. Dattner argued that white cell counts and the concentration of protein in the CSF offered better and more reliable criteria of the severity and activity of the disease. The presence of cells, elevated protein and positive colloidal gold reaction tests were the guide to fever treatments. The CSF changes normalized in the patients who responded to the fever therapies. While syphilitic patients were treated with arsenical preparations, the more actively ill were also subjected to malarial or “sweat box” fevers. Patients remained seated for hours in a box heated by lightbulbs with only their heads exposed. The treatments were severely debilitating and assuring hydration and monitoring body temperatures was one of my responsibilities. Follow-up studies did show improvements in serological and CSF tests and some relief in psychiatric symptoms. I was astonished by what patients were willing to suffer on the promise of cure. During my schooling in 1943, Bellevue Hospital’s R-S buildings were filled with more than 200 patients with syphilitic disorders. Six years later in 1949 when I returned as a resident in neurology, 2/3 the beds no longer served these disorders, the remarkable impact of penicillin therapy. In later years, when I applied novel treatments for psychiatric ill, I sought similar test guides to treatment outcomes – as in the Face-Hand Test, the amobarbital denial test, and the high levels of slow wave and spike activity in the interseizure EEG as measures of progress in ECT. Later I was fascinated by the dexamethasone suppression tests in melancholia and the lorazepam response test in catatonia. Personally Experiencing Psychoactive Drug Effects. Student training in pharmacology included individual experiences with medications administered to and by fellow students – morphine, scopolamine, atropine, vasodilators, nitrous oxide, amobarbital, and amphetamine are those that I recall. Doses were pharmacologically active and our observations were recorded. Blood samples were taken and nasogastric tubes passed. The hilarity induced by nitrous oxide inhalation and the pleasant feelings associated with barbiturates made some of us look forward to these classes. For others, the unpleasant experiences with scopolamine and morphine drove them from the laboratory. 72 Osteomyelitis. Among children, infections of fractured bones required intensive care. Débridement (surgically removing dead and infected tissues) was followed by repeated flushing with warm saline and dressings to keep the wounds clean to encourage healing. Plaster casts restrained the movement of limbs. In my 80 �junior year during the rotation in pediatric surgery I debrided children’s wounds. An ongoing research study applied live maggots to the open wound to clear the pus and dead tissues. I cleansed bone fragments and tissue debris, washed wounds with sterile saline solutions, created a plaster protective shell to immobilize the limb, and applied live maggots for days at a time. Maggots digested pus and wound debris, allowing surgical repair of the skin and bone. This usage disappeared with the introduction of antibiotics but references now appear from time to time citing maggot therapy in resistant infections. Barbiturates. During a rotation on the active psychiatric service at Bellevue Psychiatric Hospital in my senior year I was taught to use amobarbital (Amytal Sodium) to control agitated and aggressive behaviors. It also relieved catatonic refusal of food, mutism, and posturing. I do not recall the use in stuporous catatonic patients, a use that became a central interest four decades later. InterneshipTraining 1945-6 My first Random Controlled Trial; Penicillin in Empyema My medical internship continued the same ‘hands-on’ experiences. During a rotation on the pulmonary medicine service, patients with pleural cavity infections (empyema) filled the beds. Every other day I introduced a large 18-guage trocar between the ribs into the pleural space, removed pus, and washed out the pleural space with warm saline. An ongoing experiment washed the pleural space with either sulfadiazine or an experimental substance “x” with patients randomly assigned by the odd or even final number of their chart record. Supplies of “x” were locked in a safe in the hospital director’s office. Withdrawn samples were carefully recorded according to the patient's chart number. Within a few weeks the superiority of substance “x” became apparent, even to a neophyte physician – thick pleural fluid thinned rapidly from yellow putrescent pus to pink serous to clear fluid; fever curves flattened, pain and apathy disappeared, and appetite and activity improved, all within 10 days of administration. A young febrile Hispanic woman with empyema was admitted with her nursing infant. The random medication assignment was for sulfadiazine Assuring myself of the ethics of the switch for a nursing mother, I administered “compound x” and did so daily. When the empyema rapidly cleared, the Attending physician Dr. Eli Rubin was puzzled. Checking the records he noted the switch and in anger, marched me to the Medical Director’s office and ordered my suspension from the internship. I had broken two rules, direct orders of an Attending physician and the research protocol. Cooler heads prevailed a few days later and I was re-instated but the lesson of adherence to research assignment was learned. (Compound “x” was penicillin.) 81 �Work schedules were exhausting, with 48 hours on call frequent, with learning from an Attending physicians who supervised each patient’s care was payment for the exhausting hours. The neurologist Nathan Savitsky visited his patients at 7:30 each morning, inviting any interne to join. He was a dynamic and knowledgeable teacher, citing the literature much as Google or Wikipedia provide today. I joined him often and soon I was called to attend the autopsies of patients we had examined together. The logic of the symptoms and course of illness and the demonstrated neuropathology was impressive. Residency Training: 1948-1952 New Science of Percutaneous Carotid Angiography As the new hire at Montefiore Hospital’s residency in July 1948, I was first assigned to the neurosurgery rotation. As a student assistant during brain surgery with Dr. Leo Davidoff, the hours standing as a masked assistant in one place without voice or movement were enervating, and I escaped to the clinic as quickly as I could. The technology of percutaneous carotid angiography had just been perfected and the neurosurgical residents taught me how to insert the needle into the carotid artery by touch, rapidly inject radio-opaque dye, and call for three x-ray images at 2second intervals. I became skilled in identifying the signs of meningioma, glioblastoma, subdural hematoma, arterial aneurysm, and arterial blockage. In pneumoencephalography air is injected into the cerebrospinal canal and ventricles through a needle puncture between lumbar vertebrae 4 and 5. The air fills the ventricles outlining the spaces showing any abnormal images. I became skilled in obtaining cerebrospinal fluid and used the technique in later studies. The films showed tumors, bleedings, and encephalopathies, directing neurosurgical intervention when appropriate. 73 Montefiore Hospital was a museum of chronic neurological disorders under study for decades. The film library included examples of classic syndromes of abnormal motor movements and seizures that I viewed to properly label peculiar repetitive movements. I have no recollection of experience with psychiatric patients. In July 1949 I continued training at Bellevue Hospital, first as resident in neurology and then in psychiatry. Percutaneous carotid angiography had not been introduced to the hospital so I brought this new technique to the Neurology Service. After obtaining permission from Prof E. D. Friedman to develop such tests, a fellow resident Joseph Stein and I built a film holder for multiple images and collaborated with radiologists to organize a service. The first films of a subdural hematoma showed the blood vessels, displaced by a dark mass, clearly outlining the lesion and its effects, encouraging surgical relief. Over the next year, we did 102 procedures, 82 �reporting a high diagnostic success rate and a 5% morbidity rate. Studies of the CSF showed no persistent abnormalities as a result of these tests. After one such procedure, a young man lay in bed, alert, relaxed, staring into space. Asked what he was seeing and pointing to objects in the room, he pleasantly confabulated responses of imaginary objects. He had developed an acute syndrome of visual neglect and denial of blindness known as the Anton Syndrome. After a few days of nursing care his condition resolved. My teachers interpreted the phenomenon as an interaction between the physical changes induced by the injection and the psychological “defense mechanism of denial” based on psychoanalytic philosophy. It was a lesson in applied psychodynamic philosophy to psychopathology. Other clinical experiences were as intriguing. The popular folk singer Lead Belly -- Huddie Ledbetter -- was admitted with advanced amyotrophic lateral sclerosis. No effective treatment was known but my teachers thought the disease resulted from neurotoxicity caused by the passage of toxins through the bloodbrain-barrier to progressively destroy neurons. Animal studies had shown that the transmission of proteins through the barrier could be inhibited by infusions of large molecule dyes such a trypan red. Lacking any effective treatment, daily infusions of 1% trypan red in saline were administered. Lead Belly was a very black man and after a week of perfusions, his sclera, palms, and soles of his feet became brilliant red. He died in December 1949. Double Simultaneous Stimulation: The Face-Hand Test Two teachers, Morris B. Bender and Edwin A. Weinstein encouraged my interest in clinical research during my neurology residency at Bellevue Hospital. While in the Naval medical service Bender, a clinician trained with the neurologists Israel Wechsler and Israel Strauss at Mt Sinai Hospital, became interested in the phenomenon of visual extinction on double simultaneous stimulation in a sailor with a parieto-occipital shrapnel wound. The interaction of simultaneous administered stimuli delineated sensory lesions better than single stimulation. Following professorial tradition he called me and my colleague Martin A. Green to his office, handing each a stack of 3x5 inch blank white cards, telling us to survey the responses of patients to simultaneous tactile stimulations of the face and hands – first in our patients on the Neurology wards, and then on the Psychiatry wards. When we had a hundred such records he asked that we find 100 normal children, then he sent us to Letchworth Village in Thiells, Rockland County to examine an equal number of mental retardates. Applying pin pricks or finger touches simultaneously to both cheeks or hands were correctly perceived by normal adults. But in patients with diverse brain dysfunction and diminished vigilance, as after head trauma, structural brain damage with bleeding, tumor, or stroke, one stimulus was reported and the other was not, even though the sensation of each single stimulus was readily perceived (extinction). 83 �At times the patients mislocated one of the stimuli on their body (displacement) and occasionally insisting that the stimulus was applied to space in front of them (exosomesthesia). These phenomena were not explicable by classical neuroanatomy. The phenomena had been conspicuous in soldiers with severe head injuries and we reported the same phenomena in patients with abnormal brain syndromes, publishing reports on the Face-Hand Test (FHT) as a measure of gross brain dysfunction, the organic mental syndrome. Similar test abnormalities were demonstrated in normal children under the age of 6, and in patients with mental retardation with low mental age scores on Stanford Binet tests. The positive FHT was a rapid estimate of mental age, normalizing at age 6. Impaired brain functions in the elderly were demonstrated in those with impaired orientation and memory. Intravenous injections of amobarbital increased omissions and displacements. Sensory errors increased during the course of electroshock therapy (when slow waves in the EEG became prominent after 3 to 9 seizures) when brain functions were altered. In later experiments carefully measured sensory stimuli demonstrated extinction as sensitive to the stimulus strength as well as the state of vigilance. For a time the FHT was widely recommended as a “soft neurological sign” of brain abnormality but seems no longer to be so used. 84 �Book Nine: Personal Biography I was born in Vienna on January 16, 1923, the same year that my father Julius Fink graduated from the University of Vienna Medical School. He had special training in the new science of radiology and took an externship in medicine and radiology at the Bergen County Hospital in New Jersey. My mother Broniaslawa Lowenthal (Bronia, Bronka) had been a medical student at the University of Vienna. She was much courted and married Julius on March 12, 1922, in her third year of training. I was born within a year. My mother cared for me in Vienna while my father worked in New Jersey. My mother and I sailed from Bremen on the SS George Washington on October 17, 1924 arriving in New York on October 24, shepherded under the watchful eye of her younger brother Adolf Lowenthal, who had been sent by the family from New York. A Greek scholar Lazaros Triarhou published a report on the faculty and students at the Wagner-Jauregg clinic in Vienna when W-J received the Nobel Prize in 1927. A class picture shows the faculty and cites 6 women graduates who went on to careers in neurology and psychiatry. He portrays two graduates, Alexandra Adler and Edith Klemperer, who were consultants during my residency days at Bellevue and my work at Hillside. Thinking of their education, I realized that they were students in Vienna in early 1920s, likely classmates of my mother Bronia, who left her education because of pregnancy. She tried to return to medicine in 1950, was not accepted, and graduated the Columbia University School of Social Work in 1953. In the picture, Josef Gerstmann, Bernhard Dattner, and Paul Schilder appear, scholars who taught at Bellevue New York University during my schooling. Dattner was particularly instrumental in developing my interest in tests and diagnosis. In our family setting, I always “knew” that I would become a physician. Admission to medical school in the U.S. was limited by the publicly acknowledged quotas for Jews, and to successfully gain admission one needed to be “in the top of the class.” My elementary and high school classes were at PS 77 and James Monroe High School in the Bronx, a few streets from my father’s office at 1201 Elder Avenue. My high school teachers, sympathetic to my goal and recognizing the problems in college and medical school admission, encouraged me to be a leader of the Arista Club, to publish articles in the German-language magazine Plaudermäulchen, and to be the Manager of the football team, gaining my athletic “M” at graduation. I graduated from high school in January 1939 at age 16 and enrolled at the New York University College campus at University Heights of the Bronx for its Feb/Sep program. In 1942, at age 19, I began medical school at NYU School of Medicine. The demands of WW II collapsed our training period to 3 years, and I graduated on June 12, 1945 at age 22, the youngest member of my class. 85 �My medical experience began in my father’s office, developing x-ray films, clinical tests of blood and urine, and answering the telephone when he was out of his office. He was a general medical practitioner in a free-standing office equipped for clinical laboratory tests of blood and urine, x-ray, fluoroscopy, and electrocardiography. He trudged to house-calls at all hours of day or night, in all weathers. He was a model for my brother and me, both selecting medical careers. My schooling emphasized an experimental, “hands-on” approach beginning in college where teachers answered questions by suggesting experiments. When I entered my junior college class, I volunteered for the project to count the numbers of mitoses in the neural ependymal layer of the 48-72 hour developing chick, to answer the question how the diurnal light-dark cycle impacted the growth rate. Other students had measured the mitoses in the 24 to 48 hour and 72 to 96 hour cycles. (As I recall, the light cycle did not affect the rates of mitoses.) During medical schooling I lived at home in the Bronx, about an hour’s subway trip. Although school began at 0900, the Army rules insisted that we be present for roll call each morning at 0730. Such was not easy during the winter and I soon was reprimanded for lateness and ordered to guard duty as punishment. Students had some holiday time and on June 6, 1944 – D-Day - I and fellow classmates were camping on Big Burnt Island in Lake George to hear the shouts and waving paddles announcing the invasion as classmates canoed back from Lake George Village. I came of age in America during the war years of the 1940s and 1950s, and for seven decades I have been a treating clinician and researcher, caring for neurologic and psychiatric ill. For many decades, the mentally ill had been warehoused in large sanitaria far from city centers, at least until the seizure therapies, electroshock and insulin coma, were introduced in the 1930s slowing the growth of mental hospital populations from the peak in 1955 at 560,000 patient beds to 170,000 in 2014 in the United States. The efficacy and the mystery of these treatments, inducing grand mal seizures, became my lifelong challenge. The treatment methods, however, were highly controversial in the public and within the profession. For my interest I was often berated and have thought that a less hostile life might have been preferred. The 1950s and 1960s brought new psychoactive medicines that changed brain chemistry and physiology, with resultant improvements in behavior, encouraging a massive deinstitutionalization, pushing tens of thousands of the severe psychiatric ill to leave U.S. hospitals and live at home, or on the streets, in jails, in flophouses, or in and out of community hospitals. Identifying the benefits and developing treatment protocols for these new medicines became a professional challenge. As the effects of the new agents were measurable in the electrical 86 �readings of the scalp recorded electroencephalogram (EEG) patterns, and the digital computer revolution offered means to quantify these effects, the new science of pharmaco-EEG occupied 35 years of my research life. My interest in the effects of psychoactive medications on the human brain included active studies of the opioids and cannabis that were interdicted by governments as addicting and life-threatening. In my later years I actively led an effort to rescue the disorder of catatonia from its entombment within the poorly understood concept of schizophrenia and show it as an independent, identifiable, verifiable, and fully treatable syndrome. Bringing it out of its closet encouraged worldwide recognition and improved diagnosis and effective care. Catatonia is unique among the behavior disorders in having two effective treatments and a useful verification test, which makes each recognition of the syndrome life-saving. The arc of my professional career runs from a childhood in the Bronx, medical school in New York City, a decade organizing Hillside Hospital’s research facilities, a brief stint to establish a Psychiatric Research Institute in Missouri, back to New York for a continuing academic career in different hospitals, then spending 35 years teaching psychiatry at the State University of Stony Brook. After meeting requirements for professional certification in neurology, psychiatry, and psychoanalysis, I spent my years as an experimentalist researcher and teacher. Family Affairs. I married Martha Pearl Gross, a graduate of Barnard College on September 11, 1949. We had met when I returned from a trip as the ship's surgeon on the Grace Line's Santa Monica in March 1948. Martha was dockside awaiting her parents who had been passengers on the cruise to Barranquilla and Cartagena. Her father was ill with amyotrophic lateral sclerosis, and as the ship's surgeon I was called for his care. After I called on her parents at their home in Great Neck, we dated and married after her graduation in June. I continued my training at Bellevue and in May 1951 our son Jonathan was born. We had an apartment at 404 East 54 Street in NYC. When I continued my training at Hillside, we moved to Martha's parents' home in Great Neck, about 10 minutes from Hillside. Our son, Jonathan was born on May 2, 1951, our daughter Rachel September 29, 1956, and our daughter Linda June 3, 1958.. In early 1953 we bought a home in Russell Gardens at 11 Wensley Drive. Dalliance with Psychoanalysis: School and Personal Analysis My interest in psychoanalysis developed during my classes in Texas in 1946. The enthusiasm for Freudian psychodynamic theory and practice rapidly infected American psychiatric teaching and practice. Beliefs that Freudian images explained the behaviors of the psychiatric ill and also offered effective treatment, personal understanding, and clinical relief flashed through clinical psychology, psychiatry, and popular culture in the theatre, film, and education. As a military 87 �veteran, I was entitled to educational training supported by the GI Bill and like many peers, I decided to attend an analytic training program. The New York Psychoanalytic Institute and Columbia University programs required full-time attendance and clinic care of psychiatric patients but the William Alanson White Institute organized its classes during evenings and week-ends. I enrolled for their psychoanalytic course for physicians not for any faith in their beliefs but to continue my neurology training. I began a personal analysis with a WAW graduate Dr. Joseph Miller, meeting for one hour three times a week for the next five years. The WAW did not see merit in the “Freudian couch” approach so the discussion was face-to-face. A psychological assessment by Dr. Ralph Crowley directed the early discussions. School classes were small with Clara Thompson, Ralph Crowley, Frieda FrommReichman, and Janet and David Rioch among my teachers. David Rioch offered elective classes in neurophysiology and brain function that were held on Saturdays in Washington, D.C. We read the writings of Sigmund Freud, Karen Horney, Erich Fromm, and Harry Stack Sullivan, emphasizing the social aspects of interpersonal interactions rather than the classical studies of the unconscious and psychological defenses. I completed the school’s requirements for a Certificate for Physicians in 1953. During my residency at Hillside, my supervisor was Sidney Tarachow, a teaching psychoanalyst from the Columbia University School of Psychoanalysis. He enquired whether the presence of one or two parents during childhood influenced the expression of a psychoneurosis. Did the absence of one parent by death, separation or divorce early in childhood encourage the expression of an obsessivecompulsive neurosis while the childhood presence of two parents was associated with a hysterical neurosis? It was a testable question. I examined the hospital records for those diagnosed with a psychoneurosis, abstracted the family history and evaluated the patient's main symptoms. We identified patients with dominating obsessive or hysterical symptoms and found 50 records with sufficient data for study. We did not find a difference in family histories to support the hypothesis. 74 Another study also failed to support the psychodynamic suggestion that homosexuality was a root of paranoia. I was assigned the care of a 26-year-old Jewish married man with severe panic episodes. The faculty diagnosis varied between a neurosis with homosexual panic and paranoid schizophrenia. Supporting the diagnosis of schizophrenia were his fantasies of aggression and the paranoid imagery on his Rorschach Test responses. I presented his story to an audience of psychoanalytic teachers. The discussion was robust in interpretations but inconclusive as to diagnosis and treatment options. The proceedings were published. Re-reading this report after 60 years showed the many changes in our diagnostic styles, the rejection of homosexuality as a disease, the present tolerance of American society of homosexuality as a life-style, and the awareness that our later experience with medications would offer patients effective treatment with imipramine. 88 �Neither the teachings of Freudian scholars at Hillside Hospital nor the social psychological principles of the Sullivanian scholars at the William Alanson White Institute impressed me as useful therapies. Nor did I have the patience to indulge hour after hour, month after month, listening to a patient’s anxieties, social difficulties, moods and fantasies. In time, my interests shifted and by 1958 I decided to close my private office and devote my life to a medical research career. Military career and travels as ship’s surgeon My active military service as medical officer began in April 1946. After two weeks of field training I was assigned to a regimental field station in Camp Campbell, Kentucky, managing morning sick-call and incidental accidents and injuries. That winter I received orders to attend the Army School of Military Neuropsychiatry at Fort Sam Houston in Texas for a 4-month intensive program in neurological and psychiatric examinations, management of traumatic injuries and combat stress reactions, psychodynamic principles, and lectures on ECT, insulin coma, and lobotomy. Many instructors were imbued with the fervor of psychoanalysis, promising cures for the most severe mental disorders. We were enthralled and so enthused that many of us sought psychoanalytic training when we returned to civilian life. After completing basic military training I was assigned to Kentucky’s Fort Knox Station Hospital as Chief of Psychiatry. Three wards of 30 patients each included a range of severely ill psychotic patients, some undergoing insulin coma and some ECT. The nurses and technicians were competent and experienced, more so than I, and my responsibilities of supervision were light. The nearest medical school was in Louisville, about an hour away. I attended weekly Grand Rounds in Neurology with Ephraim Roseman and took a course in the Rorschach test procedures with Arthur Benton. The war against Japan ended with the atomic bomb in August 1945, saving the lives of many thousands of American soldiers as well as of many Japanese. By 1946 President Truman, faced with the costs of a very large active military service, ordered the summary discharge of thousands of soldiers on duty. As a member of an Officer's Board to decide on the qualifications for soldiers desiring to remain in the post-war career Army and as the panel psychiatrist I used interpretations of the Rorschach Test in the recommendation for discharge or retention. My comments had little influence on the Boards’ decisions, as only the longest serving and meritawarded soldiers were recommended for retention. At the end of November 1947 my service was suddenly ended after 20 months active duty. I had enrolled for residency training in neuropsychiatry at the Montefiore Hospital with H. Houston Merritt for July 1948. The tantalizing question became whether to advance my medical training experience to January or to spend the six89 �month gift of freedom elsewhere. After the continuing years of schooling and military service the glamour and challenge of a position as ship’s surgeon led me to Grace Line’s Hudson River Pier 57. A position was open on the S.S. Santa Maria, a C-2 freighter with 52 passengers, leaving five days later to the west coast of South America, with stops at ports in Columbia, Peru, and Chile. The duties of the ship’s surgeon were "sick call" sessions twice a day, writing health status reports of passengers and crew on entry to ports, examination of food storage areas and freezers for vermin, and accompanying port health inspectors as they surveyed the ship in each port. It was possible to visit port cities during one to two days of loading and unloading cargo. I visited the local mental hospital in Lima where Honorio Delgado, a leader in psychoanalysis, cared for the severe mentally ill. He encouraged patient art. Although the hospital was more like a prison with stone palettes, iron rings in the walls to attach restraints, patient drawings and paintings adorned the walls of the wards. These paintings were fore-runners of the enthusiasms for “Outsider Art” in the 1970s. After two 5-week voyages to Valparaiso, I signed on the Santa Monica for a 3week cruise to Cartajena and Barranquilla on the north coast of Colombia. My final trip was on the American Export Lines Marine Perch, a large C-4 passenger ship that served as troop carrier during the war and as refugee ship after the war. We traveled to Palermo (Sicily), Naples (Italy), and Valleta (Malta). The ship had a large medical complement and the work was easy. In Naples, I hired a taxi for a 28-hour trip to tour Rome visiting the Roman ruins during the night. When we landed in Malta, I visited the port and soon I had a following of young boys and girls, pointing to my white uniform and especially my white shoes. When I enquired as the cause of the hilarity at a silver shop managed by a Jewish owner he pointed to the almost universal black clothes of women and men, honoring the dead. “I must be rich, very rich, to wear white shoes.” Peregrinations In 1962, I was invited to direct a new research institute, the Missouri Institute of Psychiatry on the grounds of the St. Louis State Hospital, with an academic affiliation as Research Professor at Washington University School of Medicine. We found a home in the Lake Forest suburb, and our children were soon registered in the community schools. When our youngest child, Linda was schooled daily, Martha enrolled at Washington University for an M.A. in Education, which led to her lifelong elementary school teaching career. We adjusted to a new community even though warnings of religious intolerance appeared early. When we were looking for a home, I asked George Ulett, 90 �the head of the State mental health services who invited me, where he lived. “In Ladue,” continuing with the advice, “You would not be happy there.” I did not catch the warning but we soon experienced the strong smells of anti-semitism and nativism that pervaded the St. Louis communities, the state, and even the hospital government during our stay. My appointment to the MIP was announced as “Austrian Heads Institute.” Two years later the Missouri State legislature failed to renew the biennium funding for the Institute, and I and the other scientists fled. I found a position at the New York Medical College to lead the opioid detoxification center at New York City’s Metropolitan Hospital beginning in July 1966. Martha and I found a home in Great Neck and enrolled our children in community schools. Martha began teaching students at the elementary school in Port Washington and then in Great Neck schools. I set up my computer center to analyze EEG at the Psychiatry Department offices on East 102nd Street, developed an ECT study at Gracie Square Hospital, and obtained a Federal contract to study the systemic effects of hashish in users in Athens, Greece. I had exceptional students in Richard Abrams, Michael Taylor, and Robert Levine and was fortunate in the collaboration of Rhea Dornbush, Jan Volavka, Jiri Roubicek, and Donald Shapiro. In July 1969 Herman Denber, the director of psychiatric research at Manhattan State Hospital, invited me to join him on a single-engine Cessna 172 flight that he piloted over the Hudson Valley and the New York harbor. It was a day of brilliant sunshine and I decided to learn to pilot a small plane. A flying school was still active at LaGuardia Airport and I began my flying lessons on July 4, 1969. I soloed Nov 13, 1969. For the next few years I leased airplanes at Long Island’s Republic and Westchester airports. I piloted Jonathan’s move to Colby College in Maine and flew to professional meetings. A transcontinental trip in May 1970 from Westchester Airport, through Tulsa, then the next day on the southern route to San Diego and San Francisco with Herman Denber to attend the APA meetings. Interested in leasing a summer home in the Adirondacks in May 1972 Martha and our daughters flew to Lake Placid. My last flights as pilot were in June 1973. In 1972 a new medical school was established 40 miles East of Great Neck at Stony Brook, Long Island. Chairman of Psychiatry Stanley Yolles invited me to join his faculty to lead research in psychopharmacology and ECT. I gladly accepted to avoid the hassles of travel to New York City and the social and political hostilities of the addiction community and the city leaders. For the first few years I taught students and residents at the Central Islip Psychiatric Center and the Veteran’s Hospital in Northport. With the opening of University Hospital in 1980 I organized my teaching, EEG, and ECT studies at that facility. Martha and I bought a home in Nissequogue on the Stony Brook harbor in 1980. By that time our children had each graduated with doctoral degrees in the 91 �sciences and had begun their academic careers. Jonathan’s degree from Stanford University led to a post-doc in volcanology and an academic career at Arizona State University in Tempe. Rachel graduated in marine biology from Cornell and Duke Universities and then taught at Mt Holyoke College in Massachusetts. Linda received her undergraduate degree from Amherst College, among the first women after the college became co-ed, and her doctorate in entomology at University of Florida in Gainesville. She began a teaching career at Sweet Briar College in Virginia. Each married at our Nissequogue home and soon the family grew with four grandchildren. My research work was well supported by NIMH and private foundations and I led a consortium to study continuation treatments after successful ECT in depressed patients. (The CORE studies.) For various administrative reasons I was unable to carry out my portion of the NIMH funded collaborative study at Stony Brook and I moved the project to Hillside Hospital, a return for me after 35 years. For the next decade I supervised this study, developed others, and continued teaching. In 2005, at the age of 82, I left the study group at Hillside and retired to my home to pursue writing. Since 1999 I have wrtitten articles and books with Michael Taylor, Jan-Otto Ottosson, Edward Shorter, and multiple colleagues on convulsive therapy, catatonia, ethics, and melancholia. I also continued to lecture and attend national and international meetings until 2019. Martha died suddenly on March 31, 2016. I remained at my Long Island home spending my time writing. By 2018, I established a second home in South Hadley, Massachusetts with my daughter Rachel. In June 2019 I sold my Long Island home and moved to Rachel's home in South Hadley, Massachusetts. 92 �Books Authored by Max Fink Electroencephalography in Human Psychopharmacology. EEG Journal, Supplement 23, 1964. NY: Elsevier. Convulsive Therapy: Theory and Practice. NY Raven Press, 1979. ELECTROSHOCK: Restoring the Mind. Oxford U Press, New York, 157 pp., 1999. Electroshock: Healing Mental Illness. NY: Oxford U Press. 2002. Ehics in Electroconvulsive Therapy. NY: Routledge. 2004. (Ottosson J-O, Fink M.) Catatonia: A Clinician's Guide to Diagnosis and Treatment. Cambridge UK: Cambridge U Press, 2003 (Fink M, Taylor MA.) Rediscovering Catatonia: The Biography of a Treatable Syndrome. Acta psychiatr Scand. 127: Supplement 441;1-50, 2013. The Madness of Fear: A History of Catatonia. NY: Oxford University Press, 2018. (Shorter E, Fink M.) Melancholia:The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. Cambridge UK: Cambridge University Press, 2006. (Taylor MA, Fink M,) Endocrine Psychiatry: Solving the Riddle of Melancholia. NY: Oxford U Press. (Shorter E, Fink M.), 2010. Edited Books: Fink M. (Ed.) Convulsive Therapy. Seminars in Psychiatry. Grune & Stratton, 1972. Fink M, Kety S, McGaugh J, Williams T. (Eds): Psychobiology of Convulsive Therapy. Washington, DC, V.H. Winston and Sons 1974. Bradley P, Fink M. (Eds): Anticholinergic Drugs and Brain Functions in Animals and Man, P. Bradley and M. Fink (eds.), Progress in Brain Research, Vol. 28, Elsevier, 1968. Dornbush RL, Freedman AM, Fink M., Chronic Cannabis Use.. Annals N.Y. Academy of Sciences, 282: 430 pp., 1976. Stefanis C, Dornbush RL, Fink M. Hashish: A Study of Long-Term Use (eds.). New York, Raven Press, 181 pp, 1977. 93 �1 2 3 4 5 6 7 8 Archives: When the historians Edward Shorter and David Healy visited my home in 2006 to examine my files and books for their history of the shock therapies, they were impressed by the extent of the files and asked what I planned to do with them.1 They encouraged their being publicly archived. The Stony Brook University Library archivist Kristen Nyitray examined and agreed to archive the collection. These files are established as the Max Fink Archives in the Special Collections at the Main Library of Stony Brook University. I also deposited my library; these books are indexed in the University files and in WorldCat. Contact: Kristen J. Nyitray, Head, Special Collections and University Archives, University Archivist, Associate Librarian, Stony Brook University. < kristen.nyitray@stonybrook.edu> t: 631.632.7119 / f: 631.632.1829 Rachlin HL, Goldman GS, Gurvitz M, Lurie A, Rachlin L. Follow-up study of 317 patients discharged from Hillside Hospital in 1950. J Hillside Hosp 1956; 5:17-40. Fink M Shaw R, Gross G, Coleman FS. Comparative study of chlorpromazine and insulin coma in the therapy of psychosis. J. Amer. Med. Ass., 1958; 166: 18461850 Sylvia Nasar's biography A Beautiful Mind was filmed; I was the consultant to the producers in the making of the film. Discussed in Book Three. Fink M. A Beautiful Mind and insulin coma: social constraints on psychiatric diagnosis and treatment. Harvard Review of Psychiatry 11: 284-290, 2003. Fink M, Bolwig T. Electrotherapy of melancholia: The pioneering contributions of Benjamin Franklin and Giovanni Aldini. J ECT 2009; 25:15-18. Beginning January 1953 with Hans Strauss and Mortimer Ostow I learned how to apply scalp electrodes, maintain the EEG recorders, and interpret the records. The Medical Director Joseph S. A. Miller, purchased a Grass electroencephalograph with a $5,000 grant from the Dazian Foundation obtained by Dr. Israel Strauss, the Founder of the Hospital. In the 10 years of its existence, Ira Belmont, Martin A. Green, John C. Kramer, Max Pollack, Eric Karp, Donald F. Klein, Abraham Kaplan, Arthur Willner, Karl Andermann, Joseph Jaffe, Hyman Korin, George Krauthamer, Nathaniel Siegel, Henry J. Lefkowits, Harold Esecover, and Barre Alan, collaborated in the studies. Arnold G. Blumberg of the Medical Department was an active collaborator.. 94 �9 By 1977 in USA, Paul Blachly created an ECT stimulating device using brief pulse stimuli that recorded the EEG of the seizure. His device, labeled MECTA, has been widely adopted. The technology became world standard. 10 11 12 13 14 15 16 17 18 Fink M, Kahn RL, Green M. Experimental studies of the electroshock process. Dis. Nerv. Syst., 19: 113-118, 1958. In the last two decades, ECT has been denigrated as a "neurostimulation." Since neurostimulation devices are applied in neurotic depressed and character disordered subjects, increased outpatient usage has changed the character of modern treatment to encompass low energy, short seizure, RUL placement treatments that fail to influence severely ill, but act mainly as placebo psychotherapiess similar to the weakened SSRI, SNRI antidepressants and atypical neuroleptics that dominate outpatient care since the 1990s. Fink M, Taylor MA, Shorter E, Vaidya NA. The failure of the schizophrenia concept and the argument for its replacement by hebephrenia: applying the medical model for disease recognition. Acta Psychiatr Scand 2010; 122: 173-183. The question is the basis for the neuroendocrine hypothesis of ECT, that the seizure pattern is based on systematic changes sensed by pathology in the organism that can be redressed, much as a sneeze or a cough clears physical passages. Bennett, A.E. The introduction of curare into clinical medicine.Present and potential usefulness. Am Sci 46; 34:434-431. While on a lecture tour in 5 cities in India in 1991, the first question at each site was my attitude to the use of unmodified ECT, inducing seizures without sedation and motor relaxation. When I expressed my experience, recalling the benefits of my first experiences at Hillside in 1952, I opined "unmodified ECT is better than no ECT." The audience applauded. The argument persisted for many years as the cost of the agents and the fee of the anesthesiologist surpassed the reimbursements for the ECT procedure. When the anti-psychiatry cries of psychologists became strident again in 2020s, with claims that ECT had not been properly tested in an RCT with sham ECT. The sham-ECT study data was republished in 2001 in JECT. Palmer RL. Electroconvulsive Therapy: An Appraisal. NY: Oxford U Press, 1981 Fink M, Kahn RL, Karp E, Pollack MA, Green MA, Alan B, Lefkowitz HJ. Inhalantinduced convulsions. Arch. Gen. Psychiat., 4: 259-266,1961. 95 �19 20 21 22 23 24 25 26 27 28 29 Cooper K, Fink M. The chemical induction of seizures in psychiatric therapy: Were flurothyl (Indoklon) and pentylenetetrazol (Metrazol) abandoned prematurely? J Clinical Psychopharmacology. 2014; 34(5):602-7. Fink M, Greenberg LB, Gage J, Vikun S. Isoflurane anesthesia therapy: A replacement for ECT in depressive disorders? Convulsive Ther 1987; 3: 269277. Fink M. Cholinergic aspects of convulsive therapy. J. Nerv. Ment. Dis., 1966; 142: 475-484. The results are widely published by Robert Kahn, Max Pollack, and Ira Belmont. The results are summarized in Convulsive Therapy: Theory and Practice, NY: Raven Press, 1979. We received four-year funding from NIMH for the project. After we introduced the study to the GSH practitioners, many agreed to cooperate and to let us treat their patients according to our protocols. They endorsed their patients’ cooperation for EEG and psychological tests. Aside from Richard Abrams and myself, our study collaborators were Jan Volavka, Jiri Roubicek, Rhea Dornbush, and Stanley Feldstein from the Biological Psychiatry Research division of the New York Medical College. This is my second study reporting the greater efficacy of seizures induced by bilateral electrode placements. The CORE study replicated again. Fink M, Abrams R, Volavka J, Roubicek J, Dornbush R. Lateralized EEG changes after unilateral and bilateral electroconvulsive therapy. Dis. Nerv. Syst., 31 (11) Suppl.: 28-33, 1970. Wachtel LE, Dhossche DM. Self-injury in autism as an alternative sign of catatonia: implications for convulsive therapy. Med Hypotheses 2010; 75(1):111-4. Bright-Long L, Fink M. Reversible dementia and affective disorder: The Rip van Winkle Syndrome. Convulsive Ther 1993; 9: 209-16. Greenberg LB, Mofson R, Fink M. Prospective electroconvulsive therapy in delusional depressed patient with a frontal meningioma. Br J Psychiatry 1988; 153: 105-107. Petrides G, Fink M. Atrial fibrillation, anticoagulation, and electroconvulsive therapy. Convulsive Ther. 1996; 12: 91-98 96 �30 31 32 33 34 35 36 Fink M. Is EST a useful therapy of schizophrenia? In J.P. Brady and H.K.H. Brodie (eds.): Controversy in Psychiatry. Philadelphia, W.B. Saunders Co., 183-193, 1978. Fink M. EST and other somatic therapies of schizophrenia. In L. Bellak (ed.): Disorders of the Schizophrenic Syndrome. Basic Books, New York, 353-363, 1979. Fink M., Sackeim HA. Convulsive therapy for schizophrenia? Schizophrenia Bull. 1996; 221: 27-39 Fink M, Taylor M.A. The medical evidence-based model to identify psychiatric syndromes: Return to a classical paradigm. Acta Psychiatr Scand 2008; 87: 81-84 . I did not believe that ECT augmentation of clozapine in clozapine non-responders was effective. When George Petrides, with the encouragement of John Kane to publish a "positive" report, I withdrew my association. Augmentation by ECT of fluphenazine and chlorpromazine treatment in psychosis are better documented. Greenberg LB, Zervas I, Suckow RF, Cooper T, Jandorf L, Fink M. Rat brain concentration of fluphenazine during a course of electroconvulsive shock. Convulsive Ther 1990; 6: 273-9. I moved the study site to Hillside Hospital with George Petrides as Principal Investigator. Fink M. What was learned: Studies by the Consortium for Research in ECT (CORE) 1997-2011. Acta Psychiatrica Scand. 129: 417-426, 2014. Fink M, Taylor MA. Electroconvulsive therapy: Evidence and challenges. JAMA 2007; 298: 330-332 . R. Electroconvulsive Therapy. Edition IV. NY: Oxford University Press, 2002. 37Abrams 38 39 40 Meduna L: Die Konvulsionstherapie der Schizophrenie. Halle Germany, Karl Marhold, 1937. Fink M. (Ed.): Convulsive Therapy (ed.). Seminars in Psychiatry 4: 1. Grune & Stratton, Inc., New York, 70 pp. Fink M, Abrams R, Bailine S, Jaffe R. Ambulatory electroconvulsive therapy. Ta force report of the association for convulsive therapy. Convulsive Ther. 1996; 12: 42-55. 97 �41 42 43 44 45 46 47 Fink M. Complaints of loss of personal memory after electroconvulsive therapy: Evidence of a somatoform disorder. Psychosomatics 2007; 48:290=293. Fink M. A Beautiful Mind and insulin coma: social constraints on psychiatric diagnosis and treatment. Harvard Review of Psychiatry 2003; 11: 284-290. Fink M. A unified theory of the action of physiodynamic therapies. J. Hillside Hosp.,1957; 6: 197-206. Fink M, Ottosson J-O. A theory of convulsive therapy in endogenous depression: Significance of hypothalamic functions. Psychiatry Research 2: 49-61, 1980. Fink M. The mode of action of convulsive therapy: the neurophysiologic-adaptive view. J. Neuropsychiat., 3: 231-233.1962. Fink M. Cholinergic aspects of convulsive therapy. J. Nerv. Ment. Dis., 1966; 142: 475-484. Nemeroff C, Bissette G, Akil H, Fink M. Neuropeptide concentrations in the cerebrospinal fluid of depressed patients treated with electroconvulsive therapy. Corticotrophinreleasing factor, beta endorphin and somatostatin. Br J Psychiatry 1991; 158: 59-63. 48 49 50 51 52 53 Fink M, Kety S, McGaugh J, Williams T. (Eds): Psychobiology of Convulsive Therapy. Washington, DC, V.H. Winston and Sons Kahlbaum KL. Die Katatonie oder das Spannungsirresein: eine klinische Form psychischer Krankheit. Berlin: Verlag August Hirshwald, 1874. Greenberg LB, Gujavarty K. The neuroleptic malignant syndrome: Review and report of three cases. Comprehens Psychiatry 1985; 26:63–70. Taylor MA. Catatonia: A review of a behavioral neurologic syndrome. Neuropsychiatry, Neuropsychology Behavioral Neurology. 1990; 3(1):48-72. Rogers D. Motor disorder in psychiatry. Chichester UK: John Wiley & Sons, 1992. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia: I: rating scale and standardized examination. Acta psychiatr. Scand 1996; 93 (2): 129-36. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia: II. Treatment with lorazepam and electroconvulsive therapy . Acta Psychiatr. Scand 1996; 93 ( 2):137-43. 54 Shorter E. What Psychiatry Left Out of DSM-5. NY: Taylor & Francis, 2015. 98 �55 56 57 58 59 60 61 62 63 64 65 Taylor MA. Hippocrates Cried: The Decline of American Psychiatry. NY: Oxford U Press, 2013. Taylor M, Fink M. Fink Catatonia in psychiatric classification: A home of its own. Am J Psychiatry 2003; 160: 1233-1241. Fink M, Shorter E. Does persisting fear sustain catatonia? Acta Psychiatr Scand 2017; Nov; 136(5):441-444. Our experience together had been at New York Medical College during his residency training and when he and his colleague Richard Abrams joined the Stony Brook University faculty. Clinicians versed in ECT see the rapid response of catatonia and melancholia, in their varied forms, to repeated induced seizures. The DSM commissioners, all five teams from 1952 to 2013, lacked members with experience in ECT. Many were known opinion leaders and paid consultants to industry, with ambulatory office practices and little experience with the severely ill, so had no experience with the many forms of catatonia and melancholia. Further, in the decades from 1980 to 2013, they were paid well as industry consultants to support the new agents, the SSRI, SNRI, and atypical neuroleptics, and reject the tricyclic antidepressants (imipramine, amitriptyline) and the typical neuroleptics (chlorpromazine, fluphenazine) as toxic. Fink M, Klein DF, Kramer J. Clinical efficacy of Chlorpromazine-Procyclidine combination, Imipramine and placebo in depressive disorders. Psychopharmacolgia (Berl.), 7: 27- 36. Davies BJ, Carroll BJ, Mowbray RM: Depressive Illness: Some Research Studies. Springfield, IL: C. C Thomas, 1972. Papakostas Y, Fink M, Lee J, Irwin P, Johnson L. Neuroendocrine measures in psychiatric patients: Course and Outcome with ECT. Psychiatry Res 1981;4: 55-64. Glassman A. APA Task Force on Laboratory Tests in Psychiatry: The Dexamethasone Suppression Test in Psychiatry. Am J Psychiatry 1987;144:1253-1262 Fink M, Rush J, Knapp R, et al. DSM melancholic features are unreliable predictors of ECT response: A CORE Publication. JECT 2007; 23(3): 139-146. Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. NY: Cambridge University Press, 2006. 99 �66 67 68 69 70 71 72 73 74 Bolwig T, Shorter E. Melancholia: Beyond DSM, Beyond Neurotransmitters. Acta Psychiatrica Scandinavica Supplement 433; 115:1-183, 2007. Participants included, in addition to the Editors, Gordon Parker, Michael Taylor, William Coryell, Athanasios Koukopoulos, Donald Klein, Bernard Carroll, Jules Angst, Walter Brown, Max Fink. Taylor M. Hippocrates Cried. The Decline of American Psychiatry. NY: Oxford University Press, 2013. Shorter E, Fink M. Endocrine Psychiatry: Solving the Riddle of Melancholia. NY: Oxford University Press, 2010. Bradley P, Fink M. (Eds): Anticholinergic Drugs and Brain Functions in Animals and Man. Progress in Brain Research, Vol. 28, Elsevier, 1968. Fink M. EEG classification of psychoactive compounds in man: review and theory of behavioral associations. Psychopharmacology: A Review of Progress, 19571967: D. Efron, J. Cole, J. Levine and J.B. Wittenborn (eds.): U.S. Govt. Printing Office, Washington, DC, pp. 497-507. Fink M. Remembering: the forgotten neuroscience of pharmaco-EEG. Acta Psychiatr Scand 2010; 121: 161-73. In my schooling, self-administration of trial medication was accepted as part of my educational experience. By 1980s, a change had occurred among students. When teaching psychopharmacology I offered self-exposures to various psychoactive medications,many of which I had experienced. The students refused, and I was admonished by the Dean that such teaching was not acceptable. As the death of President Kennedy was announced over the hospital radio, I was in the r-ray suite, inserting a needle in a patient's spinal canal for a PEG. Dr. Tarachow presented these findings at a meeting of the American Psychoanalytic Association in New York in 1953. I was denied admission to the meeting as I had not graduated from an accredited psychoanalytic institute. 100 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biographical Files Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource 70 Years an Experimentalist in Neurology and Psychiatry Subject The topic of the resource <a title="Autobiography" href="http://id.loc.gov/authorities/subjects/sh85010050" target="_blank" rel="noreferrer noopener">Autobiography</a>, <a title="Psychiatry" href="http://id.loc.gov/authorities/subjects/sh85108381" target="_blank" rel="noreferrer noopener">Psychiatry</a>, <a title="Neurosciences" href="http://id.loc.gov/authorities/subjects/sh91006099" target="_blank" rel="noreferrer noopener">Neurosciences</a>, <a title="Neurology" href="http://id.loc.gov/authorities/subjects/sh85091139" target="_blank" rel="noreferrer noopener">Neurology</a> Description An account of the resource Unpublished autobiographical account written by Dr. Max Fink, M.D. Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank" rel="noreferrer noopener">Fink, Max, 1923-</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Date A point or period of time associated with an event in the lifecycle of the resource 2021-04-18 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank" rel="noreferrer noopener">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Relation A related resource The Max Fink Collection Type The nature or genre of the resource text Identifier An unambiguous reference to the resource within a given context mfp_experimentalist_20210418 Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/511f4f0361d13255b6a58a7278a6c995.pdf aa5fa93900e4b745f3e573a0963c15cc PDF Text Text May 17, 2017 A Boy from the Bronx: A Recollection Max Fink, M.D. Arline Alda’s “Just Kids from the Bronx” enticed me to recollect the first 20 years of my life.1 The personal stories of her friends and those of her husband Alan Alda of childhoods spent in Bronx apartment houses and public schools described the rich lives of European immigrants first to the city and their spread to the outer borough of the Bronx with their farms and parks and unimproved acres. Her 19-year old brother Adolph came from New York to shepherd us across the Atlantic on the SS George Washington. We joined my mother’s families the Gottliebs and the Lowenthals in a cluster of apartment houses on Fifth Avenue just north of Central Park. The park, bicycle paths, lake and boat pond were our playgrounds. After my father received the New York State license to practice medicine, my parents travelled along the newly developed Pelham Bay Park elevated train line, along the southeast corridor of the Bronx, stopping at one exit after another, walking the streets near each station, seeking an apartment suitable for a doctor’s office. A five story apartment building at 1201 Elder Avenue just 50 yards from the elevated train station offered a six room ground floor apartment. The corner store was a pharmacy and soda fountain and a luncheonette with newspapers and magazines on the other side. 2 The dual track train stood on steel columns along Westchester Avenue, over trolley car tracks that offered a busy and noisy transportation hub. Multi-story brick houses with honey locust trees filled the avenue. PS 77 elementary school3 was two streets to the North and East on 172 Street and Ward Avenue, with the James Monroe High School just one street to the North. My parents joined the reformed synagogue on �Elder Avenue and 172 Street.4 This enclave became a vibrant Jewish community that sustained my father’s practice. Other practitioners settled in the neighboring streets and the need for hospital facilities led community physicians to establish the two-story Hunts Point Hospital and then a few years later a much larger Bronx Hospital, both offering facilities for practitioners to treat their patients.5 My mother’s brother Max Lowenthal established his office and home on Washington Avenue, a few streets from the Bronx Hospital. His home was on a large lot offering a playground for our family visits. His oldest son Charles was a Scoutmaster and both my brother and I were active Boy Scouts. In time my parents rented an apartment (#3) in the same building as our home. Melvin and Ruth Muroff, lifelong friends lived in Apartment #2. (Apartment #4 was the office of our dentist Dr. Heyman.) In 1928, my father’s mother Dvora Grunwerg migrated and was established in Apartment #5. She occupied the first two rooms leaving the large living room with windows facing the elevated railroad as a play area for my brother Sidney and myself. We adapted to the screeching brakes of train halts and noises of the doors and motors every few minutes, day and night. The living room was our playground, with Lionel electric trains on the floor, chemical experiments, chess and marble games on tables. My grandmother adhered to orthodox Jewish practices and tolerated our noises and arguments. My father’s office windows faced the street. Although Elder Avenue was lightly travelled, my friends and I were admonished to keep the noise levels low. My father parked his car in front of the building entrance, a notice that he was in his office. His open “office hours” �were 12 to 1 and 6 to 8 each day. My brother and I were expected to join him for dinner each day at 5:30. The office telephone was monitored at all times so early in my life I learned to answer the ring with ”Dr. Fink’s office” and record the messages. When my father went to a movie house or a play or opera in the city, he sought an aisle seat after notifying the usher that he was available for calls. I had a mutt dog called Pal. He developed seizures, often vomited, and more often whimpered and cried for long periods. My father had various medications in his office and I soon learned that the pink capsule (secobarbital, Seconal) would quiet Pal nicely. One night, when my parents were at a movie house, Pal was very upset. I fed him two capsules and went back to reading and listening to radio music. Not hearing from Pal, I found him under the dining room table, unconscious and not responding. Panicked, I called my father and blurted that he should come home quickly for an emergency. After a hurried drive through the broad streets of Southern Boulevard, over the trolley tracks, he rushed in and when I showed him the “dead” dog, he listened and examined and opined that the dog would soon recover. My chagrin was an early lesson in the need for examination before ringing a panic button. During the financial depression of the 1930s a barter system was in place. I was often sent to the grocer, butcher and fish shops, pharmacy and laundry, bringing home packages after my mother had called. I rarely needed cash money except to use the train or trolley systems. By 1936 the developing Spanish Civil War and the anti-Jewish restrictions in Germany became daily family concerns as my parents sought to bring Jewish relatives and school classmates to America. To obtain a visa the immigrants needed evidence that they would not �become wards of the government. My parents established bank accounts in the names of each of the relatives with a joint owner, often using me as the citizen.6 PS 77 and the James Monroe High School were well regulated. Boys wore white shirts and dark shorts or knickerbocker pants (knickers) clustered just below the knee; girls wore white midi-blouses and dark skirts. While the halls were noisy between classes, hall “monitors” maintained order. Being a “monitor” was an “honor” and despite my small size, I was an active hall monitor. Desks bound to the floor filled classrooms. I was short and usually sat up front and did not realize until I took eye tests for a driver’s license at age 16 that I was near-sighted. My first pair of glasses were a revelation. I surely was a “nerd” and in the practice of the time I skipped grades four times, graduating from elementary school at age 12. I qualified for the prestigious Manhattan high schools, but my parents refused permission saying that the James Monroe High School was just four streets away and required no travel. The school had four program “tracks” and I was soon established as college bound on the academic track. I studied German to meet the language requirement and became an editor of the monthly Plaudermäulchen (“chatterbox”) and wrote each issue’s crossword puzzle. I was favored by Ms. Sweet, teacher of English literature and head of the Arista, the honorary academic society. Tall and lean, always well dressed, she was an enthusiastic reader of murder mysteries, sharing them with students. When she learned that I wanted to go to medical school, she sent me to the coach of the football team, Mr. Wiedman who offered me a position as a “team manager.” I kept records of the games, team equipment, medical supplies, and monitored travel arrangements for off-site games. At the end of the game season I arranged a team dinner, �once at a New York City retaurant on Times Square. At the school graduation I was awarded an athletic letter M, a note in my college application that may have supported my college admission as a “well rounded student.” I graduated high school in January 1939 at age 16 and enrolled in New York University’s College at its Bronx campus for its Feb-Sep program.7 I lived at home and used the trolley line to come to school. By the second year I established myself as a library assistant in the Gould Memorial Library and a research fellow in the biology programs under Carl Sandstrom and Horace W. Stunkard.8 I soon found niches in the Library and Biology Buildings in which I could leave a cot and some clothes and I often remained on campus for days on end. As an editor of the Heights Daily News, the college’s 4 to 8 page newspaper, I spent a night each week at the printshop in Fort Lee, New Jersey, editing page proofs and setting type for headlines. I wrote stories of campus events and visiting lectures. The aroma of print ink settled in my clothes and led me to work from time to time in the art book multi-color print shop of Martin Jahoda. Martin was émigré relative of my father’s medical school classmate Julius Halpern who fled Vienna with his wife Frieda and daughter Eva on March 12, 1938 (the day that Hitler was welcomed into Vienna). The family lived nearby on Elder Avenue as he studied for the New York State medical licensing examinations. I coached him in English and as a gift he gave me a Leica camera that was compact and easily fit my trouser’s pocket. I used it throughout my medical school career. My parents moved their home to Pelham Manor at 528 Manor Ridge Road before WW II. I did not live at that home. My parents had supported the Elder Avenue Synagogue and they led the organization of the Pelham Jewish Center in their village. It took many years of effort to overcome the community’s restrictive covenants against Jews and blacks, the prevailing Nimby �attitude of Westchester County communities at the time. The Center and Synagogue opened on the Esplanade in 1953. My brother Sidney was born in 1927. He followed the same trajectory in the same public schools that I attended. He graduated Columbia College in 1948 and Columbia’s College of Physicians and Surgeons for his medical degree in 1952. His residency training in medicine at Montefiore Hospital was followed by years of research as a Damon Runyon Fellow. He specialized in gastroenterology and by 1959 he left the Bronx for a career in community practice.9 I recall our Victrola, a large mahogany box that played 10- and 12-inch vinyl records. My parents and then I collected records, mostly symphonic and operatic. My parents had been well versed in opera during their education in Vienna. Radio music dominated our living room as we avidly followed the news, hours of symphonic and operatic music, and the stories of Manchu the Magician, the Lone Ranger and Jack Armstrong, the All-American Boy and other “soap operas” for boys. What else do I recall of my experience in the Bronx? During childhood, cars and trucks were few, much if not most traffic was horse-drawn wagons, leaving manure on the streets. White-clothed Sanitation sweepers kept the streets clean; but we were accustomed to playing ball in littered streets. The Bronx River flowed three streets west of Elder Avenue. “The mud flats” of its banks, the Morrisania Farms with milk cows and chickens just to the north. The Bronx Zoological and Botanical Parks a quarter mile north, well within walking distances, were our playgrounds. We played stickball, practiced skills with marbles (immies, steelies, aggies), tossed and collected Goudey Indian and World War I Air Ace Cards, and built carts using 4-wheel �roller skates. On week-end afternoons we took the train to New York City to visit the Museum of Natural History with its dioramas and Saturday afternoon films like Nanook of the North and the conquest of the North and South Poles by Admiral Peary and Roald Amundsen. I learned to swim at the Castle Hill pools and ride horses at Pelham Bay Park. Speaking of Indian cards, in 1990 my daughter Linda was teaching at Middlebury College. She and Martha went on a shopping trip leaving me to wander US Route 7 alone. A bookshop showcase contained Goudey Indian Cards of 1936 vintage. Nostalgia led me to buy three for $5. For the next decade I bought, bartered, and exchanged cards at ephemera shows until I had a full set of 216 cards in good to excellent condition. These have been a prize collection in my library and are now at the Oregon Museum of Science and Industry in Portland. I received my letter of admission to New York University Medical School on December 6, 1941 the day before the Japanese attack on Pearl Harbor. That summer I began my studies at Bellevue Hospital and was inducted into the Army Specialized Training Program (ASTP) for my medical school years. Because Bellevue faculty made up one of the Hospitals sent overseas, we were taught by a very junior faculty. I participated in many research protocols and was encouraged to undertake procedures as obtaining blood and spinal fluid, set fractures, deliver babies, and do minor surgery. On graduation in June 1945 I started an internship at Morrisania City Hospital in the Bronx. In April 1946 I went on active military duty, was trained in neuropsychiatry at the army School of Military Neuropsychiatry in San Antonio and served 20 months stateside. At age 24, I was suddenly discharged in November 1947 with the end of the war and troop demobilization. Having been in school continuously since childhood I elected to spend the next six months as a ship’s Surgeon on the Grace and American Export Lines. On a Grace Line cruise to South �America I met Bertie and Harry Gross of Great Neck, and met their daughter Martha when we returned at the end of the cruise to Pier 57 in NYC. We began our courtship and Martha and I married in September 11, 1949 after her graduation from Barnard College in June.10 Throughout medical school days I lived at Elder Avenue, often taking the subway to the school. My internship at Morrisania City Hospital from July 1945 to June 1946 and my residencies at Montefiore and Bellevue Hospitals kept me within the borough. On January 2, 1952 I joined the staff of Hillside Hospital on the eastern edge of Queens. I had already established a base at Martha’s parents home in Great Neck in 1949 and thereafter my connection to the Bronx was limited to visits to my father’s Elder Avenue office until his death in 1965 at age 67. My mother Bronia was my father’s assistant when he opened his office. After my brother and I spent our days in school my mother took part in community services, especially during the war years. She organized a storefront child care center on Elder Avenue, nurtured it to become an affiliate of the Federation of Jewish Philanthropies. She developed centers at Clason Point and then at Bronx River Housing. During the war years she was chairwoman of the local rationing board. She was a well known community leader. Bronia’s medical education was interrupted by my birth during her fourth year at the University of Vienna. After the war, when Sidney and I were well along in our schooling she sought to enroll in a New York City medical school to continue her medical education, but was refused admission. With her experience as a community leader, she turned to training in social work, graduating from the Columbia University School of Social Work in 1956. Thereafter she worked at the Lenox Hill Hospital until retired by age at 65 (1967); then at the Brandywine Nursing Home where she worked for an additional 12 years, �My uncle Max Lowenthal had three children. His daughter Irma was very close to my mother and after her children were grown, she too was active in Bronx projects. She married a physician Henry Fleck. She was born in Poland in 1919, emigrated in 1921, and died in 2004 at age 84. Her obituary describes her extensive efforts in enhancing Bronx culture.11 Our families were educated and nurtured in the Bronx. It was a happy environment with little to anticipate the riots and burnings and the white flight of the 1970s.12 During the years of the economic depression, a barter economy and volunteer community efforts encouraged child care and welfare for the poor. It was a nurturing community. 1 Alda, Arline. Just Kids from the Bronx. New York: Henry Holt & Co., 2015. 2 The luncheonette was managed by the Muroffs who were lived next door neighbors. Their son Melvin, 2 years older than I, became a lifelong close friend. A graduate of the Menninger Foundation Institute in Topeka, he later practiced clinical psychology in Scarsdale, New York. He and his wife Blanche were loyal friends and supporters of my research as members of the Board of the International Association for Psychiatric Research. 3 4 Now redesignated Public Schools 195 and 196, at the junction of Ward Avenue and 172 Street. My brother and I obtained our Jewish education and celebrated our Bar Mitzvahs at this center. 5 By 2015 neither hospital, nor the Morrisania City Hospital were still to be found. 6 My parents became citizens in 1928, and I was designated as a citizen at the same time. 7 For students who completed high school admission in February an intensive summer program allowed students to join the sophomore class in September. 8 My research problem was to study the impact of light and darkness on the mitosis diurnal cycle in the ependymal layer of the 48 to 72 hour chick. Others had studied th 24 to 48 and 72 to 96 hour cycles. We found no changes in mitosis rates. 9 After a period of research at Montefiore Sidney began a clinical practice in Paterson, New Jersey with a group headed by Irving Selikoff, an eminent researcher in pulmonary diseases,. He moved to an academi position in Chicago, then at the Veterans Hospital in Providence. He married Eleonor Engelman, a student at Barnard College. They had 3 children Michael (now in Chicago working for more than 25 years as an analyst at United Air Lines); Deena on the faculty in Mathematics and Computer Science at New York University’s Courant Institute; and Bert, a publicist for Rogers & Hammerstein Music studios. While in Providence Ellie died; Sidney joined the US Air Force as medical officer, where he met and married nurse Nesta Hignett, moved to the Veterans Hospital in Hampton VA. After her death he retired to Hampton community. �10 Martha died suddenly on March 31, 2016. Her ashes are under a Japanese Cherry tree on our lawn in Nissequogue. We had been happily married for 67 years. We have 3 children born between 1951 and 1958. Jonathan is Professor and VP for Research at Portland State University; Rachel is Professor of Biology at Mount Holyoke College, and Linda is Professor of Ecology at Sweet Briar College. Jon married Nina DeLange in Phoenix and they have a daughter Laurel and a son Andrew. Laurel graduated Arizona State University and obtained the Master’s degree at the University in Brisbane, Australia. Andrew is completing his sophomore year at University of British Columbia in Vancouver, Canada. Rachel married Tom Dennis, a Professor of Astronomy/Physics and has Rose Dennis who graduated Mt Holyoke College on May 15, 2016 and Hieu Dennis who is completing his 2 nd year at Union College. Linda married the Monarch Butterfly scientist Lincoln Brower who taught her during her career at Amherst College. They do not have children. 11 http://www.nytimes.com/2004/02/26/nyregion/irma-fleck-84-who-battled-decay-in-the-bronx-is-dead.html?_r=0; http://timesmachine.nytimes.com/timesmachine/1971/01/12/83198899.html?pageNumber=26; http://www.nytimes.com/1986/09/17/opinion/l-a-way-for-hay-fever-victims-to-fight-back-763486.html; http://www.nytimes.com/1989/06/07/opinion/l-violence-of-old-men-vs-the-idealism-of-youth-what-tocquevillesaid-279689.html 12 Mahler J. Ladies and Gentlemen, the Bronx Is Burning: 1977, Baseball, Politics, and the Battle for the Soul of a City. NY: Farrar, Straus, Giroux,2006. Appendix 2: The Forgotten Merits of Diagnostic Tests � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biographical Files Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Boy from the Bronx: A Recollection Subject The topic of the resource <a title="Memoir" href="http://id.loc.gov/authorities/subjects/sh85010050" target="_blank">Memoir</a> Description An account of the resource A short, unpublished autobiography written by Dr. Max Fink, M.D. Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Date A point or period of time associated with an event in the lifecycle of the resource 2017-05-17 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Relation A related resource The Max Fink Collection Type The nature or genre of the resource text Identifier An unambiguous reference to the resource within a given context mfp_aboyfromthebronx_20170517_dis Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/dd6aa613ad864b41d42710aa943de4df.pdf e331912b9bfc1f22ac2706d3f155e8a5 PDF Text Text 5 ,ﬁ, . 1 Confinia Neurologica 9/ NEURQPHYSWLUEY [ABQRMURY HILLSIDE HOSPITAL GLEN OAKS' N' Y- Borderland of Neurology -— Grenzgebiete der Neurologie Les conﬁns de la Neurologie Edidit: E. A. SPIEGEL Basel S. KARG ER Separatum Vol. 12, Fasc. 4 (1952) : 3 . New York Printed in Switzerland From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellevue Hospital, New York City A Clinical Evaluation of Carotid Angiography by MAX FINK and JOSEPH M. STEIN ._.I I ‘ f .3 I Since carotid angiography has become a routine procedure in the management of intracranial conditions, an evaluation of its use is necessary. Both the indications and hazards of the procedure must be considered in recommending it for diagnostic purposes. It seemed valuable, therefore, to review the angiograms done on the neurological service of a general hospital. During the past 20 months, 117 percutaneous diodrast angiograms were completed by members of the resident house staff. The majority were done di- rectly by the authors. A variety of neurological conditions including suspected brain tumors, vascular anomalies, subdural hematomas, vascular diseases and diffuse degenerative diseases were selected by the attending staff as suitable candidates for angiography. In each case, a percutaneous carotid angiogram was performed according to the usual descriptions (1). Either local inﬁltration by novocaine or general anesthesia by pentothal or surital was used. A CournandGrino needle was inserted into the carotid artery at the level of the thyroid cartilage. In most instances the common carotid artery was cannulated; in a few instances the internal carotid alone. Ten to twelve cc. of 35 % diodrast solution were used in each injection. A simple manual multiple cassette holder was used. This permitted three consecutive lateral ﬁlms and a single anteroposterior (A—P) view. In each case the A—P and lateral ﬁlms were immediately developed, and, if indicated, the injection was repeated. If no pathology was noted on these ﬁlms, the procedure was repeated on the other side whenever advisable. Bilateral procedures were carried out in 26 subjects. �182 Max Fink and Joseph M. Stein Results Diagnoses of various conditions were made prior to angiography. Of these, “brain tumor suspects” made up the largest group; suspected vascular anomalies and subdural hematoma were the next largest groups (see Table I). The interpretation of the ﬁlms was based on descriptions by Moniz (2 a), Lima (2b), and Green and Arana (l b) . Brain Tumor Suspects Of 55 patients in whom intracranial masses were suspected, angiographic diagnoses of brain tumor were made in thirty. Of these, 25 were conﬁrmed by subsequent surgery or air studies. Conﬁrmation was not obtained in three patients because further studies were contraindicated by patient’s age or family’s refusal to give permission. In two cases the angiograms were interpreted incorrectly and these cases are described. Case I: D.H. a 48 year old woman was admitted to Bellevue Psychiatric Hospital because of headaches and progressive confusion. The examination revealed early papilledema, left central facial palsy, skull tenderness on the right and memory deﬁcits. An electroencephalogram showed a right cerebral focus. Bilateral carotid angiography under general anesthesia revealed deﬁnite elevation (displacement) of the parietal branches of the right middle cerebral artery. Subsequent to this procedure the spinal ﬂuid syndrome was noted to be positive for active syphilis. Anti-luetic treatment was instituted and the patient improved rapidly. Five weeks later, the right carotid angiogram was repeated. These ﬁlms showed the parietal vessels to have a normal conﬁguration. Case II: 0. 0., a 64 year old male was admitted because of recent onset of grand mal seizures and left-sided weakness. Examination revealed a mild left hemiparesis, most marked in the lower extremity. There was a positive Babinski response and increased reﬂexes. The cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under local anesthesia was performed and demonstrated good ﬁlling of the anterior and middle cerebral arteries. There was straightening and depression of the pericallosal artery on the lateral views; and increased vascularity near the termination of the anterior cerebral artery on the A—P ﬁlm. These changes were interpreted as evidence of a parasagittal tumor mass displacing blood vessels. A pneumoencephalogram was done and this did not demonstrate the mass. The patient improved without treatment and was discharged. He was readmitted a few weeks later with evidence of an acute brain stem syndrome. In View of the course of the illness and multiplicity of lesions, it was believed that the patient’s symptoms were due to degenerative changes, and not a neoplasm. No further studies were undertaken. In this group of suspected brain tumors 22 angiograms did not show any pathology. Eleven of these were conﬁrmed by air studies or autopsy. In two patients, however, satisfactory angiograms failed to demonstrate lesions later demonstrated by other studies. �A Clinical Evaluation of Carotid Angiography 183 III: F. M., a 57 year old man was admitted to the hospital because of left hemiparesis, bladder and bowel incontinence, and grand mal seizures of 4 weeks duration. On examination, there were severe personality changes, and a spastic left hemiparesis with pathological reﬂexes. Cerebrospinal ﬂuid syndrome was normal. A right carotid angiogram under pentothal anesthesia was done. Two sets of lateral ﬁlms and one A—P view were taken. The ﬁlms showed no evidence of cerebral tumor. One week later a ventriculogram demonstrated a large right fronto-temporal mass. The presence of a malignant glioma was conﬁrmed by surgery. Case IV: J. S., a 49 year old man developed left sided seizures and aphasia during hospital treatment for furunculosis. On neurological examination there was evidence of a lesion in the right hemisphere. On skull x-ray the pineal shadow was shifted to the left. An arteriogram on the right side under general anesthesia was done and no pathology demonstrated. A pneumoencephalogram, however, revealed a deformity of the right frontal born. The patient expired one month after angiography and at postmortem, multiple cerebral abscesses were demonstrated bilaterally. Case Other erroneous angiographic diagnoses were made in patients who proved to have vascular thromboses. In two patients with signs of a brain tumor, the angiograms revealed an avascular area in the parieto-temporal region with displacement of middle cerebral vessels. Surgical exploration revealed edematous necrotic brain tissue, without evidence of tumor. Each case came to autopsy, and TABLE I ANGIO GRAPHIC DIAGNOSES Group No. of Patients Intracranial Mass Vascular Anomaly and Aneurysms Suhdural Hematoma Occlusive Vascular Disease Other (f) 55 _ Pos. 30 Pos. Neg. Not Diagnosis Diagnosis Incorrect Neg. Diagnostic (3) Conﬁrmed Conﬁrmed Diagnosis 22 3 25 1 2 21 17 9 9 (d) ll 11 7 13 2 4 10 8 — — l ll 4 (b) 1 (c) 9 6 (e) 7 — 1 —— 5 —— —— Notes: (a) Technically unsatisfactory ﬁlms. (b) Two cases conﬁrmed by surgery but 7 other patients'with anomalies demonstrated on arteriograms were not subjected to further studies. (c) The 11 patients with negative arteriograms were not subjected to further study. ((1) Includes seven diagnoses of subdural hematoma, one of intracerebral hematoma and one of brain tumor. (e) F ailurc of the anterior or middle cerebral, or internal carotid artery to ﬁll on at least two consecutive injections, while the remainder of the circulation ﬁlled well. (f) Includes three “follow-up” angiograms, seven patients with diﬁuse degenerative disease and three patients with lesions of the skull. �184 Max Fink and Joseph M. Stein in both, thrombosis of a branch of the middle cerebral artery was found. The angiograms could not be differentiated from those seen in cases of tumors in the same region. Vascular Anomalies: Twenty-one patients suspected of intracranial vascular anomalies or aneurysms were subjected to angiography. The angiograms were bilateral in only three of these, and unilateral in the other nine. One set of ﬁlms were not satisfactory and were not repeated. Seventeen of these patients had manifested spontaneous subarachnoid hemorrhages. In nine cases an anomaly was clearly outlined on the arteriogram. Five of these were aneurysms at the base, and four, vascular malformations of the hemisphere. No anomaly was demonstrated in eleven cases. Conﬁrmation of ﬁndings by other methods of study was most difﬁcult to obtain in this group. In the nine cases where the anomaly was demonstrated, further conﬁrmation was achieved in two cases. In one, an angiomatous malformation was amputated at operation. In the other, an aneurysm of the anterior communicating artery was dissected at post mortem. Air encephalograms were normal in two patients, despite the angiographic evidence of a large angioma of the cerebrum. The speciﬁcity of angiography in the diagnosis of vascular malformations is demonstrated by such cases. Of the eleven patients with negative angiographic ﬁndings, two were subjected to air studies. These ﬁlms were normal. The other nine patients were discharged without further study. Subdural Hematoma: The diagnosis of subdural hematoma was made angiographically in seven of seventeen patients suspected of traumatic intracranial hematomas. The characteristic separation of the vascular patterns from the internal table of the skull as seen on the A—P projection was the basis for these diagnoses. In each of these cases the diagnosis was conﬁrmed by trephination. Furthermore, in the eight patients in whom a diagnostic vascular pattern was not seen, diagnosis of no blood in the subdural space was made. These diagnoses were all conﬁrmed by pneumoencephalography. In two patients angiography demonstrated an intracerebral mass, rather than a subdural process. In one case, this diagnosis made it possible for the surgeon to approach the lesion by a well localized and deﬁnitive procedure. The diagnosis was conﬁrmed in the second at autopsy. Vascular Disease: Angiographic studies were done in 11 patients in whom occlusive vascular disease was believed to be the basis �A Clinical Evaluation of Carotid Angiography 185 for their neurological ﬁndings. Failure of a portion of the vascular distribution to ﬁll on two consecutive injections was observed in seven of these cases, and normal vascular patterns were seen in the other four. In the ﬁrst group incomplete ﬁlling of the middle cerebral artery was seen in four cases; of the anterior cerebral artery in one case; and of the internal carotid artery in two cases. The vessels which appeared involved on the ﬁlms were in each instance the same vessels as indicated by the patient’s clinical syndrome. In four of these patients pneumoencephalography demonstrated areas of atrophy in the involved region of the brain. In one case, post mortem studies conﬁrmed the angiographic ﬁndings. No conﬁrmation was obtained in the other six cases. Miscellaneous Group: Of the 13 angiograms in the group, seven were done in patients with diffuse cerebral disease of a degenerative type. These ﬁlms were not characteristic but in each case air studies demonstrated an enlarged ventricular system without shift or deformity. In three patients with lesions of the skull angiography failed to demonstrate any cerebral involvement. Pneumoencephalograms were done in only two of these patients and were normal. Complications: In an evaluation of the indications for a diagnostic procedure the incidence and severity of complications must be considered. In this series of 117 angiographic studies, 36 patients suffered a total of 43 complications. There were ﬁve cases with severe and permanent complications. In all other instances the complications were mild and transient. Of the transient complications, 22 hematomas of the neck were recorded. This was recorded only when the hematoma was large. In one case, in a child, the hematoma was large enough to cause tracheal shift and respiratory difﬁculties. It was necessary to intubate the patient and maintain the airway during the evening of the procedure. Transient hemiparesis or transient increase in an existing hemiparesis was seen in 7 cases, and a grand mal seizure was observed in 2 patients. In each instance the phenomena disappeared within 48 hours. In 4 cases urticaria, chills and vomiting followed angiography, and seemed to represent an allergic response to the diodrast. In one patient, in whom a vascular anomaly was demonstrated, fresh blood was manifest in the spinal ﬂuid the morning after the procedure. Of the severe complications, death occurred within 24 hours of angiography in two patients (cases V, VI). In three other patients �186 Max Fink and Joseph M. Stein severe complications were directly related to angiography. In a young child an osteomyelitis of the transverse process of the ﬁfth cervical vertebra resulted after a difﬁcult cannulization (case VII). A permanent mixed aphasia (case VIII) and an intensiﬁcation of a pre-existing hemiparesis (case IX) were also observed. Case V: G. B. male, 62. Craniotomy, three months before arteriography, had demonstrated a right middle fossa spongioblastoma polare which was spreading along the sphenoid ridge and had crossed the midline. The patient completed a course of x-ray therapy and was alert and ambulant. A vertebral angiogram was suggested to evaluate the intracranial mass. The patient was sedated with demerol, scopolomine and luminal. Three injections of 11 cc. each of 35% diodrast, were made. The record states that: “while attempt was made to enter right common carotid, patient became cyanotic, respirations shallow, and pulsations of the artery, which were strong, became weak.” The patient expired within 20 hours after developing hematemesis, melena, and two grand mal seizures. No autopsy was obtained. Case VI: R. W., a 40 year old male, was admitted because of sudden onset of headache and stiff neck. The spinal ﬂuid was grossly bloody and the diagnosis of a spontaneous subarachnoid hemorrhage made. Patient developed pneumonia and ran a septic course. This responded to antibiotic therapy and patient seemed well one month after admission when he developed a second episode of subarachnoid bleeding. One week later, while patient was comatose, a right carotid angiogram was done. The ﬁlms were not diagnostic and patient expired within 18 hours of the procedure. An aneurysm of the anterior communicating artery with hemorrhage extending into the lateral ventricles was seen at post mortem. Case VII: N. B., a 5 year old girl, was admitted because of petit mal seizures for two months. Examination demonstrated left homonymous hemianopsia and an electroencephalographic focus of abnormal activity on the right parieto-occipital region. A right percutaneous carotid angiogram was done under general anesthesia, with difﬁculty, and a normal vascular pattern demonstrated. Patient had a large hematoma of the neck with tracheal shift, necessitating intubation that night. Patient recovered rapidly, but complained of pains in the neck and kept the head ﬁxed with chin turned to the left. Repeated x-ray examinations eventually disclosed an area of rariﬁcation in the transverse process of the ﬁfth cervical vertebra. This responded to immobilization and chemotherapy. When seen six months later, the child had recovered completely. Case VIII: M. C., a 30 year old male, was admitted to the neurological service because of left sided headaches of a few years duration and three episodes of loss of consciousness during the previous six months. On examination there was diminution in perception of tactile stimuli in the right hand. This defect was exaggerated by double simultaneous stimulation. Electroencephalography demonstrated a persistent focus in the left parietal region. The pneumoencephalogram was normal. A left percutaneous carotid angiogram was done. Four injections of diodrast were made. After the last injection a complete hemiplegia, hemisensory syndrome and hemianopsia was observed on the right. The patient was totally aphasic but responsive. During the ensuing weeks the weakness and sensory changes cleared, so that when seen one year after the episode, only minimal sensory changes in the �A Clinical Evaluation of Carotid Angiography 187 right upper extremity were observable. The aphasia, however, after some initial resolution, persisted. The patient expressed himself with difﬁculty and made many errors, could not carry out complicated commands, and made errors in imitating mouth and hand movements. The angiographic ﬁlms were interpreted as within normal limits except that the vessels of the middle cerebral group were few in number and widely separated. Case IX: E. B., a 64 year old man, was admitted because of headache and “nervousness” of some months duration; and repeated episodes of loss of consciousness without convulsive movements for one month. On examination there were mental changes, hyperreﬂexia and a positive Babinski on the left, but no manifest weakness or sensory changes. A right percutaneous angiogram was done with local anesthesia using four injections of diodrast. Immediately after the last injection the patient lapsed into a torpid state, his eye movements became dissociated, and the left upper and lower extremities were ﬂaccid. During the ensuing days, the torper diminished until the patient could respond verbally to command, but the hemiplegia became spastic. It persisted until the patient was transferred to another hospital one month later. The angiograms were interpreted as normal. A pneumoencephalogram revealed bilaterally dilated ventricles Without shift or distortion. A number of factors such as sensitivity to the contrast medium the amount of drug and rapidity of injection (3b), and existing hypertension (3 c), have been suggested as causes for complications. In the present series, these factors are not outstanding in the patients who developed complications when these are compared to the uncomplicated cases. Either conjunctival or intradermal diodrast sensitivity tests were carried out in every subject. In one case, the onset of wheezing, sweating, and palpitation after the intradermal test caused us to cancel the studies. In all other subjects, including the patients with complications, the sensitivity tests were negative. This was notably true in the four patients who developed “allergic-like” reactions of urticaria, chills, and vomiting, following the angiography, but who failed to react to the test dose. There is no apparent relation in the data between complications (excluding hematoma of the neck) and the number of injections of diodrast (see Table 2). (3 a), TABLE II No. of Injections No. of patients with complications No. of patients without complications * 1 1 3 more than 2 0 9 3 6 4 5 6 6 2 1 6 0 27 22 13 8 3 Total" 16 85 Excluding 16 uncomplicated cases in whom total dosage was not recorded. Similar analyses of the factors of anesthesia and the number of carotid punctures at one session (unilateral or bilateral angio- �188 Max Fink and Joseph M. Stein graphy), reveal no signiﬁcant correlation between these factors, taken singly, and the incidence of complications. Arterial hypertension was not a contraindication in the selection of patients for angiography. Ten hypertensives (all with diastolic pressures of 100 mm. Hg. or more, and systolic pressures of more than 160 mm. Hg.) were subjected to angiography, and in none of these were there any complications. Of the patients with severe or transient complications (other than hematoma of the neck) none had hypertension. Discussion Recent reviews have emphasized the diagnostic reliability of carotid angiography in vascular anomalies (4), suspected brain tumors (lb, 5), traumatic cerebral states (6), and occlusive vascular diseases (7). Our observations conﬁrm the recommendations of the authors in the ﬁrst three groups. Prior to angiography’, the diagnosis of vascular anomaly could not be conﬁrmed except by surgical exposure or autopsy. Since air studies are not reliable in demonstrating vascular anomalies or is choice of in establishing the procedure angiography aneurysms, such diagnoses. In 43 % of the patients in this series in whom such a lesion was suspected, the anomaly 'was satisfactorily demonstrated by angiography. In an unpublished series of similar cases studied by one of us (Fink) at Monteﬁore Hospital, ﬁve aneurysms were demonstrated in 14: suspects. Similar results are recorded by other authors (4), and numerous recommendations have been made to increase these results. Routine vertebral injection, combined with bilateral carotid punctures, will demonstrate anomalies in the posterior portion of the Circle of Willis (14). Oblique A—P views at 45 degrees have been recommended to demonstrate small aneurysms of the carotid (4 (1). With these modiﬁcations in the procedure, it is to be expected that the incidence of positive identiﬁcation of anomalies will increase. The role of angiography in the management of spontaneous subarachnoid hemorrhage is not clear. Recent reviews emphasize the importance of demonstrating the lesion where surgical intervention is indicated (4b, e). The effect of angiography during the acute phase of bleeding has not been clariﬁed. Many authors have recommended angiography only after the bleeding has ceased. Others, such as Wechsler and Cross (7 b), suggest early use of angiography during active bleeding. This principle of waiting until bleeding ceased was adhered to in the cases in this series, and no statement of the effect of angiography on bleeding can be made. �A Clinical Evaluation of Carotid Angiography I89 Angiography is the diagnostic procedure of choice when a supratentorial brain tumor is suspected. It is recommended for lesions located in the anterior two-thirds of the cerebrum. Occipital lobe, posterior fossa and some midbrain tumors are not consistently demonstrable by this technique. Angiography is recommended in subjects with papilledema, since this procedure, unlike air studies, does not make immediate surgical intervention necessary (5, 7). Furthermore, numerous reports emphasize the differences in the patterns made by gliomas, meningiomas, intracerebral hematomas and vascular tumors (1, 2, 3c, 5). Such clues are helpful to the surgeon in planning the operative procedure. In a few of our cases, multiple foci of a metastatic tumor were demonstrable on the ﬁlms, clarifying the management of the case. Such discriminations are usually not possible by other diagnostic techniques. The diagnostic reliability of angiography in cases of brain tumor is high. In this series, 25 of 29 conﬁrmed brain tumors were outlined by angiography. In a series of 96 brain tumor suspects, 39 of 42 veriﬁed neoplasms were demonstrated (5 a). In the series from Monteﬁore Hospital angiography revealed the neoplasm in 45 of 52 conﬁrmed cases. Similar satisfactory correlations are seen in the negative angiograms of these three series. This diagnostic reliability of 88 % compares favorably with encephalography. The value of air studies in brain tumor diagnoses has been frequently reported. In one such study by Grant (8), ventriculography demonstrated the lesion in 130 of 150 cases—an incidence of 87%; while pneumoencephalography in 69 cases, revealed the tumor in 81%. Further indications for angiography are in cases of traumatic intracranial hemorrhage. Numerous reviews emphasize the displacement of the anterior cerebral artery and separation of the ﬁne vessels from the calvarium on the A——P ﬁlm as diagnostic of subdural hematoma (6). Furthermore, angiography differentiates intracerebral and subdural lesions, altering the surgical approach (6 a). This was clearly demonstrated in two of our patients in whom subdural hematoma was suspected, but in whom the angiogram demonstrated an intracerebral mass. In cases of cerebral vascular accident angiography appears less helpful. Failure of a vessel to ﬁll may be due to a variety of reasons including slowing of the circulation, vascular spasm, and anomalies of the system. These factors have been emphasized (7b). Angiography, however, is not contraindicated in vascular disease. It provides a useful means in differentiating a thrombosis from an intracerebral clot, or from a tumor, in cases where the diagnosis is unclear. �190 Max Fink and Joseph M. Stein While the indications for angiography are many, they cannot be evaluated without a discussion of the risks involved. The complications of the procedure are of three types: (a) transient local phenomena; (b) transient cerebral vascular phenomena; (e) permanent severe deﬁcits. In the ﬁrst group of transient phenomena are burning pains in the head during injection, hematoma of the neck, and allergic reactions. Hematoma of the neck is a potentially dangerous complication (see our Case VII) but in a recent review no sequellae were observed (9). Allergic reactions are infrequent and usually mild. It was noted in this series that the routine intracutaneous or conjunctival testing for sensitivity was not found satisfactory in predicting these complications. Transient hemiparesis, aphasia, seizures and elevated blood this In (10). have been following angiography reported pressure series these complications were observed in nine cases—an incidence of 8%. A similar incidence was observed in the Monteﬁore Hospital series. That these phenomena are probably due to temporary vascular insufﬁciency (spasm?) is evidenced by the clinical pattern of neurological ﬁndings and their duration. Of seven patients with hemiparesis, the deﬁcits had disappeared within three hours in three patients, while in three others it was gone in 24 hours. In one of the subjects angiography was repeated in the other side six days later, without complication. In the seventh patient, arteriography had demonstrated an aneurysm of the internal carotid artery on the left and the common carotid artery was ligated on that side. One month later, angiography was repeated on the right side and following the ﬁrst injection of diodrast, the patient developed a right hemiplegia. This disappeared during the ensuing 72 hours. Vascular syndromes of the anterior and middle cerebral arteries have been observed. In one patient a lower limb monoplegia developed after two injections of diodrast. A third injection on the same side was done within 15 minutes of the appearance of the defect. The arterial views obtained showed good ﬁlling of all branches. The monoplegia disappeared within 12 hours. These complications were not observed in patients with hypertension. Deterioration of a patient’s condition or death following angiography has been reported in a number of instances. Bull (5d) summarizes the mortality rate of the procedure as 3 per 1000, which he states compares favorably to ventriculography. More recently, Dunsmore, Scoville and Whitcomb (10b) report three fatalities in 147 cases, and Olsson (11) reports three cases of “deterioration of patient’s condition” in a series of 360 angiograms. �A Clinical Evaluation of Carotid Angiography . 191 There were two fatalities in our present series, and one patient had a severe aggravation of a pre-existing hemiparesis. Each of these patients, like those of Dunsmore, Scoville and Whitcomb and Olsson, were severely ill before the procedure. In contrast to this are the large series of Curtis (5b), Wickbom (1 c), Torkﬂdsen (Sc), Lindgren (la), and Green and Arana (1b) wherein no deaths were related to the procedure. It is possible that with widespread use of angiography, subjects with more advanced cerebral lesions are selected for these studies and the risks thereby increased. A number of reports by Olsson and associates (3b, 11, 12) emphasize the summation of the toxic effects of large doses of diodrast given over a short period of time. They indicated the nature of the toxicity as an increased permeability of the blood vessels and a change in hemodynamics. Furthermore, the relation between concentration of diodrast and toxicity was demonstrated by Cross (13) when he introduced diodrast for angiography. His observation that seizures follow the use of 50% and 70% diodrast has been conﬁrmed by numerous investigators. Despite the use of 35% diodrast and low total dosages of diodrast, in this series, complications ensued. There was no signiﬁcant relation between dosage and complications. Other factors must be operative and some hint has been given in the observation on circulation time (41') and the effect of other injurious agents summating with diodrast (3). Conclusion Angiography is preeminent in the management of cases of intracranial disease suspected of vascular anomalies, supratentorial tumors, and traumatic hematomas. It is a satisfactory non-surgical method of demonstrating a vascular anomaly, malformation or aneurysm. In the diagnosis of supratentorial masses it will outline 90% satisfactorily. In addition to establishing the presence of a tumor, arteriography is superior to other diagnostic technics in yielding evidence as to the type of mass and its locus. In cases with papﬂledema, surgery is not made immediately mandatory by the procedure. It is not a satisfactory method in demonstrating obscure and diffuse lesions of the ventricular system, or tumors of the posterior fossa or occipital lobe. In cases of traumatic intracranial lesions, angiography is a satisfactory method in outlining subdural hematomas, and differentiating such lesions from intracerebral hematoma or tumor. �192 Angiography is Max Fink and Joseph M. Stein thromboses cerebrovascular in not clearly helpful and hemorrhages. would and not transient, the for most part, Complications are, are The complications in cases. most the limit procedure seem to bilatnumber or anesthesia, not directly related to hypertension, factors a Other play diodrast. of erality of injections, or amount is necessary. further and role study more important Summary reviewed were carotid angiograms A series of 117 percutaneous in involved angiography. risks and for indications the to evaluate studied including supraconditions were intracranial of A variety and hematoma traumatic anomalies, vascular tentorial tumors, of intraevidence with disease. patients Fifty-ﬁve cerebrovascular cranial tumors were subjected to angiography, and a positive in conﬁrmed were These diagnoses diagnosis was made in thirty. ﬁlms misinterpreted. the were subjects In two only of the cases. 83% in in conﬁrmed 50%; were the diagnoses Of the negative ﬁlms, demonlater lesion show fail a to did the angiograms only two cases intracranial with suspected 21 Of patients strable by air studies. of In two outlined angiography. by vascular anomalies, nine were air manifest on not revealed anomaly an these, the angiograms traumatic of suspected of seventeen patients studies. In a group in made seven was diagnosis positive intracranial hematoma, a in cases, eight ﬁndings the well negative as as These diagnoses cases. all conwere in two demonstrated cases, intracerebral tumors and lesions cerebrovascular of In studies. cases ﬁrmed by subsequent complications Transient value. of diagnostic not angiography was consisted and of the one-third patients, in of angiography were seen In urticaria. and seizures, of hematoma of the neck, hemiparesis, These and severe permanent. ﬁve patients (4 %) complications were discussed. factors the and described cases are cerebral of angiorisks limited the conclude that authors The of the in usefulness management its from detract do not graphy intracranial vascular malformations, suspected supratentorial tumors and traumatic lesions. Zusammenfassung 117 durch perkutane Injektion in die Arteria carotis gewonnene und Indikationen der Gesichtspunkte Angiogramme werden vom Gefﬁﬁanomalien, Tumoren, Gefahren besprochen. Supratentoriale der GehirngefﬁBe und Erkrankungen Haematome traumatische �A Clinical Evaluation of Carotid Angiography 193 werden besprochen. 55 Patienten mit Zeichen von intrakraniellen Tumoren wurden mit Angiographie studiert; in 30 wurde eine positive Diagnose gestellt. In 83% der Falle wurde die Diagnose bestatigt. In 2 Fallen wurden die Filme falsch gedeutet. In 50% der negativen Filme wurden die Diagnosen bestatigt. Nur in 2 Fallen vermochte das Angiogramm nicht eine durch Luftfiillung demonstrierbare Lasion zu zeigen. In einer Gruppe von 21 Patienten mit vermuteten intrakraniellen GefaBanomalien wurde in 9 Fallen die GefaBstﬁrung demonstriert. In 2 dieser Falle zeigte Angiographie die Anomalie, wahrend Luftfiillung ein negatives Resultat ergab. In einer Gruppe von 17 Patienten mit Verdacht auf traumatisches intrakranielles Haematom wurde eine positive Diagnose in 7 Fallen gestellt. Diese Diagnosen, wie auch die negativen Befunde in 8 Fallen, und intracerebrale Tumoren, die in 2 Fallen demonstriert wurden, konnten durch weitere Studien bestatigt werden. In Fallen von Gehirnlasionen, die durch GeféiBprozesse bedingt waren, hatte Angiographie keinen diagnostischen Wert. In 1/3 der Falle kam es zu voriibergehenden Komplikationen (Haematoma des Halses, Halbseitenlahmung, Kréimpfe, Urticaria). Bei 5 Patienten (4%) waren die Komplikationen schwer und dauernd. Diese Falle und ihre Besonderheiten werden besprochen. Die Autoren gelangen zu der SchluBfolgerung, daB die begrenzten Risiken der cerebralen Angiographie von der Anwendung dieses wertvollen Verfahrens in F ﬁllen von GefaBanomalien, supratentoriellen Tumoren und traumatischen Lasionen nicht abhalten sollen. Résumé Les auteurs passent en revue une série de 117 angiographies carotidiennes percutanées, dans le but d’évaluer les indications et les risques qu’elles comportent. La série d’aﬁ'ections intracraniennes étudiée comprend des tumeurs supratentoriales, des anomalies vasculaires, des hématomes traumatiques et des affections vasculaires du cerveau. Cinquante-cinq patients présentant une symptomatologie de tumeur intracranienne furent soumis a l’angiographie et un diagnostic positif put étre fait dans trente cas. Ces diagnostics se conﬁrmérent dans 83% des cas. Chez deux patients seulement, les radiographies furent mal interprétées. Parmi les angiographies négatives, 1e diagnostic clinique fut conﬁrmé dans 50% des cas; dans deux cas seulement les angiogrammes ne montrérent pas de lésion qui, plus tard, put étre mise en évidence par injections d’air. Parmi 21 patients suspects d’anomalie vasculaire �194 Max Fink and Joseph M. Stein intracram'enne, 9 purent étre révélés par l’angiographie. Dans deux cas, les angiogrammes révélérent une anomalie que les ventriculogrammes n’avaient pas rendu manifeste. Dans un groupe de 17 patients suspects d’hématome traumatique intracranien, un diagnostic positif fut conﬁrmé dans 7 cas. Ces diagnostics, de meme que les résultats négatifs de 8 autres cas, et les tumeurs intracérébrales démontrées dans 2 cas, furent tous c0nﬁrmés par des études ultérieures. Dans les cas de lésions cérébrales d’origine vasculaire, l’angiographie est restée sans valeur diagnostique. Des compli— cations passagéres de l’angiographie furent observées dans un tiers des cas et consistérent en hématomes de la région du cou, hémipareses, crampes, et urticaire. Chez 5 malades (4%), des complications durables et plus graves apparurent. Ces cas sont étudiés en détail et les facteurs on cause discutés. Les auteurs concluent que les risques limités de l’angiographie cérébrale ne sauraient faire renoncer a une méthode aussi utile pour le diagnostic des malformations vasculaires intracraniennes, des tumeurs supratentoriales et des lésions traumatiques. REFERENCE S 1. a) Lindgren, E.: Br. J. Radiol. 20, 326, 1947. — b) Green, J. B., and Arana, R.: Am. J. Roent. and Rad. Ther. 59, 617, 1948. — c) Wickbom, 1.: Acta Radio]. Suppl. 72, 1, 1948. — 2. a) Moniz, E.: “L’Angiographie Cérébrale”, Masson & Cie, Paris, 1934. — b) Lima A.: “Cerebral Angiography”. Oxford Univ. Press, London, 1950. 3. a) Olsson, 0.: Acta Radiol. 35, 65, 1951. b) Broman, T., Forssman, B., and Olsson, 0.: Acta Radiol. 34, 135, 1950. — c) Torkildsen, A.: Acta Psych. and Neur. Suppl. 55, 1, 1949. — 4. a) Lowman, R. M., and Duﬁ, S. D.: Amer. J. Roent. and Rad. Ther. 53, 341, 1945. — h) Poppen, J. L.: Radio]. 53, 347, 1949. — c) Wickbom, I.: Acta Radiol. 34, 387, 1950. — d) Lo'fstedt, S.: Acta Radiol. 34, 339, 1950. e) Wechsler, I. 5., Gross, S. W., and Cohen, I.: J. Neur. Neurosurg. and Psych. 14, 25, 1951. — f) Raney, R., Raney, A. A., and Sanchez-Perez, J. M.: J. Neurosurg. 6, 222, 1949. — 5. a) Culbreth, G. E, Walker, A. E., and Curry, R. W.: J. Neurosurg. 7, 127, 1950. — b) Curtis, J. B.: Brit. J. Surg. 38, 295, 1951. — 0) List, C. F.: Radio]. 55, 327, 1950. ~ d) Bull, J. W. D.: Postgrad. Med. Jour. 26, 157, 1950. — e) Fabritius, H. F., Frovig, A. G., and Kristiansen, K.: Arch. Neurol. and Psychiat. 61, 352, 1949. — 6. a) Wickbom, I.: Acta Radiol. 32, 249, 1949. — b) Kristiansen, K.: Surgery 24, 755, 1948. — c) Webster, J. E., Dawson, R., and Gurdjian, E. S.: J. Neurosurg. 8, 368, 1951. ~ d) Raney, R. B., and Haney, A. A.: Calif. Med. 73, 342, 1950. — 7. a) Govons, S. R., and Grant, F. C.: Arch. Neurol. and Psychiat. 55, 600, 1946. — b) Wechsler, I. S., and Gross, S. W.: J. A. M. A. 136, 517, 1948. — c) Lusignan, F. W., and Gross, G. 0.: Calif. Med. 73, 240, 1950. — d) Alorris, A. A., and Fulcher 0. H.: Surg. Clin. North Amer. 30, 1783, 1950. — 8. Grant, F. C.: Arch. Neurol. and Psychiat. 27, 1310, 1932. — 9. Berdal, P., and Emblem, L.: Acta Psych. and Neurol. 26, 1, 1951. — 10. a) Chusid, J. G., Robinson, F., and MargulesLavergne, M. P.: J. Neurosurg. 6, 466, 1949. b) Dunsmore, B., Scoville, W. B., —— -— —— �A Clinical Evaluation of Carotid Angiography 195 and Whitcomb, B.: J. Neurosurg. 8, 110, 1951. — 11. Olsson, 0.: J. Neural. Neurosurg. and Psychiat. 12, 312, 1949. — 12. Broman, T., and Olsson, 0.: Acta Radiol. 30, 326, 1948. — 13. Cross, S. W.: Arch. Neurol. and Psychiat. 46, 704, 1941. — 14. Sugar, 0., Holden, L. B., and Powell, C. B.: Amer. J. Roent. and Rad. Ther. 61, 166, 1949. �[ha / A M777, APP/f5; (#4)/7.rz. omen tummu W mm “KW W II: link, 3.». ma asap}: :1. Stein, IL». .7"*'*‘ , 9W .m § "v.1 "t; , ‘ waiver-1w canon of Indiana and the lam-01931.11 8min if the aura mun-u. hollow Rental, lav mark 633:. - .V T?!“ 1* ' = ' �line. antacid aaczozruphw tn mum of 1:1th an: bocgnn a ruuttun proaoﬁuro'xn cautions. In ovulation at 18.. no in nun-um. lath 15h. inﬂation and mm at cm proa«dun mt be amid-M in humans it for «lacunae aux-pom. It «and valuable, thereto”, to an.” tn «non-m am on tho Wei-clan um.“ or u acuml human . Min; m put to math, :17 panama“: Mount animu- nn can» put“ him-n or the minim hm amt. m mama were «at directly by tho “than . 5 variety of “urological amnion: including 11min Mon, moan: alt-mun, ”Maul hunts-nu, vascular dunno: Ion “law by tho dam“ and arm. “twang um: u with» «Midﬁe- ror WWW. In «ch mu, 9020qu met“ mien-u was performed «cording to the W1 «Manama (1) .' mum.- 10011 infiltration by normal” A 01f 3mm manhunt. by mutant}, or «mm m and. Gem-Grin» mu. m inﬁrm into the mend artery at tho 101010: 1'.» thyroid M11130. In no“ mum» the «non «3th WM" 0.. carotid artery 13th “an. .‘ m mm; in a In butane“ tho into!!!) M 1:0 mm: u. ref 35! “can“ inﬂation. A solution were and in «on «1:91. mm). “18133110 auntie Miner m and. that amounts." luau). 11m tad a um. mun. m: 130th yuurior (5-21 view. m In «on me the Au! and lateral £11m mantel: «#010904. lad, 1: indium. the injection In mutant. 1: no It: noted on than mm, the other 11¢. than» manna. pathology the vacuum at Bilateral mum on panam- urn �2. «aid but in 36 gnaw». .. mm amtlm‘ mu nu prior mum. Wu at the», ”bum W mu“ am 1m.“ my. :0 of " up the muted moun- manna lad «mu but... an an mt “m “wanna” or the film's!" («0 m1: m: mod tn «mimic» t7 In“ (a). amt»),- md ﬁrm I Am: 1m.» 1-). (1b). ‘ ‘ ' m amount). mm «spotted,at ammo nun-u «WWMMthMy. than. nu «ma «haunt sum or as: .m». continuum m not attained in turn ”that: boom mm than m quM B: gaunt“ m or “all”: W M cm ”mm“. In on» the mom I»! 1&th described. than» of 55 pun-nu in were by 25 - two tumour m m» m an A; 3.3». a #8 na- a:s.“ W m «Ilium to 1011mm humane mam been“ mm m manna" amt-n. m ail-inﬂux mallard «1-11 mum-u, 10ft mm rum pa”. mm Wu 0:: the ”at and nun «11:18:. m An rim 3mm}. “on Ilium-n1 mm magma under new“ mamas mound donut. olmtim (”apnea-ant} or the mum Who. of tho right W). Mm. museum in this ﬂaunt/annulus”: the a. .-. w. uphill mm Indra” m not“ to be We posits." for “’61" until” . Annama- mm: m taunted ' 11pm“ with. nw inks later, the right and the mum: mum mum as meat“. �“ > luv In want-um“ m ﬁr NHI II , mkamm WWW (Minimum: mutant—imam m» H CW u (CHI-um m ‘ . .‘ WWW‘rude-buﬂm �3. it... (11:: Innuud tho par1ota1 vantols ta have n nomlll cen— figuration. 6.3. II: 0.0., a yin: 91¢.la10 an: Idlitted buotule at roeunt onset at grina.unl aniline. .nﬂ lortantdcd untknoia, lxnuhntion rO'Dnlid a I114 10th bullpIrCItl, taut unwind in the 6% lénbr caﬁrunity. lhnru in: a punitive llbiulki response and incr¢:sod rutlaxtn.Moorutvuop1n31 fluid OIRQrUID III nounu1. A right curatld nn¢1o¢run undar local unauthonia III pur~ rarlnd and dIInnIttltod 390d 21111n¢ at tin Interior and l1ddlo oorobrn1 uttering. that. Ill straightening and dcprognian at tho pertain“). mar: am- the an... on up mm; um; and manned yum-mt: “mum. at cm manor mm: at»; on the 1.1- an. changes wort intorprutod Ian- 41-piuozn; blood vetucln. ll avtdlnoo at a pnruaagsitnl tumor ‘ pnnunninaophnlocrul,ula done and thin did not dclnnntruec thy IIII. It. patiant anarovud withaut troutncnt and lit dinohnrsod. In It: rtlanattod a to! lick! 1:10: with avid-not or an aunt. talin Ital syndronn. In '10! a: tin ¢uuruo a! uni 111ncll and.nultxplxoity of 1051.33, at in: bolicvod that the pntiaut'n uyggtanl A 1 ' taro duo to doccatrntiio ahnaccs, and net a unoplaun. lo turthgr Itudiou var. andnrtaknn. In this group or lunpcatod brain tumors 22 ausiogruln 414 not than any pathnlo;7. ilovcn at that. 10:. canrialnd by I1! studio: or tntapsy. In tun pationts, houovcr, untilrtotery angiogra-s failed to dalunltrutc lesions lttcr other Itudicl. mum to m danmmstrntod by an. m; n... .1 57:»:- em m m hospitdl koala-c of lift Inilplroutu, bladaor and and mud no.1 gum: or 1; inks aux-«zen. 6:: bcuul incontinence, man. than �#. never. poroonnlity ohoncoo, and o opootlo loft honiporoo1o with pathological roam: . embrupinll nun snare-o was nor»). . were right oorottd onciogron.undor pontothnl onoothnoin on: dono. outs of lotorll £11.. and on. to? via! Into taken. in: films A two thouod no ovidonoo or lorehrol tumor. can rock Into: a vantrtoulogrln dolonotrotod a large right con“ trontooto-porol IISI. Ibo protons. of a malignant slioln ill tin-0d by ournory. : Goo. IV; 3.3.é°:bzzkzoor old man developed loft stood toizuroo Iphlliu during/$rottlont for turunonlooil. on anurolucicll ennuinltion chore woo ovidonoo at n lotion in tho risho honiophoro. en Ikull x—ro: tho piuill outdo! In: shirtod to tho 102%. An ortorioaru on on right nu scum). mom-1a m and done ond no pathology dononotratod. ma A pnounoonoophnlosrln, houovor, revollod a dofornity of the right frontal horn. in: patient uzpirod on: lonth otter oust-graph: and ot pout. norm, mum} emu-u 0”qu mm anon-mm autumn. 9th.: erroneous onaiocrlphio d1oanoIOI our. and. in patient. who provod #0 have vooonlor throubosoo. In tlo potionto with Iisnl the oncxosru-o rovoolod on oraoaulnr are: in tho poricto-tonporol vision with dioplooonont o: Iiaolo oorohrll voooolo. Surgical exploration rovoolod odouotono necrotic brain tilooo, without ovidonoo of tolor. loch oooe oono to antopoy and in both or I brain only». man:- or . branch or. on. man «mm mm m rm. o:m angiogruno onulo not be dittoronttotod from thou. noon in on... tnnoro 1n the Inn: raglan. Vaoogggg.tnoup11oog ﬂuonty~ono patient: Iuopootod or intro» ' ornniol vaooulor Inouolioo or Quintin-o not. oubjootod to lnslo~ stools. 1h» Insaosrunl wort billtdrtl in only throo or thooo. and ��7. mt N contact“. um“. m nu In this aorta of 117 WWMB 36 ”tum- “from a to“: at is «unusual. and peanut «mutation. In an mm can with the «mutation and at in Of the a»: mo «Quantum. 22 m «W mm m an mum. man: mm. mm MmmuMuHthmm-uw. ammo. in am. mutumnmwummmmm' manta: mun It as mm to tntubtn m yum: mmmmmmmmmumpmmm; mun mom mm: man a «um mummuwmu. mnmmnmmomm a nun“. :3 Wk mm. m within . an ou- pm mm #8 W. talcum-Wont... cummmuurmmwowhy. all no.“ to rcpt-aunt an mung mpm h m atom-Mt. Inmautmh umummmmmmmrua Hummutumnmauammmm W.a: m mm causation. loath um um Mr. in in ”man (mu 7. n). In tum ash-r W or 1“ mm. Inamcuul‘uumum otmmvmupmuat th:mn mm mm mm m s difficult W31“ (mo m). W: m spa-nu (em um m mmmuu-n a: Mum mm“ («m I!) m an. «W. mum: sum emanation we «may “um 80 an A m mm. panamamumnmmmmmmmmmuu a Wow. than. 11mm Mm m twink“ I mm mm. tau ”Omnimtm ma. all... 63. elm was... an muons am and Mt. A completed a 13W and as most“ to «3.1qu war» a: may mm mam was ��10. at 1a.; or np1nud¢c on. mth. aunne1ausntgt u1thout convulu1vo unvunnne: for «nan-11:11:,» and a pou1t1vt lub1nlk1 on than mm mm tbs 10:1.ths no I sensory «Itasca am», Winn lua1tcut weaknass a: ‘ 1 31331 percutancona In31u3zun was inns u1th 10011 tainthna1n nn1n3 {our 1njoot1ons of diodralt. >xllad1a$oly Ittcr tho last 1nJ¢¢t1an thy pat1ont lapsed 1319 a 102911 3:11., M1: cyuruovanantt 3101.0 d1llo¢18ttd, and tan loft layer and In!!! tatul1t1o§ I09. N mum nonpanﬂ anon. am the tmu Mum mm m Vtrhully to «allnnd. but tum han1pl¢31t booinpit10at 00114 tplnt1c. It porn1ltad ant11 tn. put1on1 its trunnruraod to ancillt anap1¥I1 can nanth 11102. tn31usrnll I110 tatcrprttod an annual. A pnaulalnoaphnlo~ 3run.rovualtd b1latcrnlxy 61.301 vuntr1c10u u1thout nh1tt er 1%. .d1lvort1an.1 walker (31) the at stator: that’s: Ions111v1ty tn the eonsrust Indtwn, amt a; m me many at 1111009103 (33), and mum tar «aupl1ant1onl In in. prusuat 19:10., till. {natori It. nut ant-taun1n3 1n tn. pat1enta uh. 107110301 «unpliont1aa- when tunic tr. 01.31301 10 tin hwptrtonn1un (38), havu bola a133Ot$ed as OIIIOI _ unoonpl1enta1’onacs. l1thsr eonsaapt1v11 at 1ntaadnrlal aiadrnst gonn1t1v1ty tent: turn cnrr1od out 13,0?!93 luhaoot. In out cute, in: cane: at «humus, means, an: myzuum mu- the m: am» an to ouncol tan I9I11II. 3111th mm 1B1: In 111 1mm: 1n51ud1n3 an. athgr turnouts, amuuum, m Im1t1uty to». m mun. Ill notably true 1n tbs {tar pat1outs who dtvu1opod “n11.331c~ rsaot1ons of urtiolr1t, oh111n,“ van1t1n3, tolleu1a3 tho In31osraphy. but who £11101 to rule: to tbs tent 4916. Shaw. 1: an apparent rolae1an 1n tho ant: bntanon «anp11out1ons 11km” �13.. (luntudias hunttuun If In. it. acct) and tin ms it 13:00t10an 1 2 3 mania: or 1n1¢otzunn t 5 6 Iﬂﬂ"th‘ﬂ‘6 lo. .1 patiouta 11th cu-pzioctiaun'l e 6 6 I 1; lo. at pt... without «uncanny 3 9 1m :38 ' it Ebﬁazﬁ ' o 16 '3 as *Ixnluata; 16 Inna-plsnusad «Isa: 13.1huu tutu: data.» uua ngt rocordnd. o: m t’utoru or nae-than and m' author I: carotid punstaraa at on. Ion-1:: (unilaturtl or bilaterll Iagiacrlph!) rtvttl as significant entrolltton botluon thtao riotorl. 3mm mm» t3. inolaunno at calvlaltxaau. Arm-1n max-«mun m in a eonmuuan in m. poxootxon or patzants tar Ingtosrlphy. ihn.hw)hrtoanzvoa (:11 with diastnlia prisaurio at zoa-n. It. or'nnvi. and urtialto ar0§turtu at more than lﬁaun. In.) It». subjueted to nasitgrOphy, and in nan. at Shut. the. that. lay tonplioaticna. .0: thn paticnta with Icvorc up titan singly. and -- ‘tsnnszont oclplzsaﬁiaan («chit than hGIRQﬂlﬂ ot‘tho unak) aunt and V hrpdrﬂlnlzan. unseat mortal: hart alphlatlid tan diagnottta rtlzuhalat: it alrutid lasincruah: 1n vascular nan-alto: (k), auapoetod brutu talnru (lb. 5), tram-I310 aurchmt1~utdbn (6). tan ooaluntvu vascular axsaaaon (7). our ebucrvataons coatirn.thn rocounnadatzana at tho ham 1:. um run m m.in. _ diagnnst- a: van¢u1nr nan-n17 could nut he ountlmuld Cincpt iv insulin} Impaiurt at luttpuy. Itnte sir trudiyi are nut vuiiuilo 1n dlnanntrntins vautnlur annualaos a!”IEIIrIIIITMInﬂtﬂcrlrhr“tﬁmiﬁlﬁpiiﬂtiuri"ttwin%00w%nwiiitblllhins Iran? to ausiouruphw. �13. sign ailsnnsts. Xn-haﬁ at th@“p&t10nﬁs in this surint-An shun.nnth , n luntan was unspoctea, tho yam-p1: was natzutaggarilr“dauauntmatad um «am: or miagrap‘hy; man ‘mnu‘blishad w am» um“ lbnte£tta0lnbsp£bai, five anenrwnnn wore dn-waatritoa-an la anapoota. ﬁtnilar ”caulk: are rooardea by tthar ﬁlth!!! {¥), can anagrams mmemuona have. hem nae ta inn-cue than Wis. Routine mtehml injectim, scanned with bilateral 6:th panama. will «laminate maladies 1n the posterior portion at the 611-010 at ‘ﬂillin (1!). Oblique A.P views tt #5 403:... have been ruoanuoadnd to damonltratc until aneurysms er tn. aaratid (#d). with thtne noditicatiana 1n~the prooed&re, 1t 13 to—bq§gxpeoted that the incidence at positive 1d¢ntﬂiut1m at will the rule of angiogrnphy 1n the management or apontansaua am” mm. Iuharaahnoid hannrrhnes 13 not alear. Recent review: emphlstxo in. 1n»9rt&a¢e of alnnnltrtting tha Xenian nhmrs turaiaal intervaattun 1! indiettnd (ﬁt. a.) !hc affect of Iaszonxlphw 03:13: twat. it. 53:10 a: blending his act beta a1nr::1¢d. lung nuthnra tutu roan-acalid :a;1¢lxnphy only :ttor tho blending has 09:306. 0th.». such an (m. mm «:1: m u mama-v man m nun mm. m. mun um... um um mu m tn in 5::o0t in mum: and adhorul at 4 or the cases thin 3095's, and no ntutqnnnt of tho Inciozraphw an binoding can be undo. Aagiogrnyh: in tho diagnoctio panoodnro o: «halt. visa a Quaratoatawiil human tumor :1 auspoetod. it 1: rcounnandnd tar Ionian: lecaﬁol in :3. Iatortcr tlu~thsrds a: tht_¢¢rolvun. ana$p1tt1 1th.. posterior toast and nuns unabrszu innnru a». uni conntttnntly Mutable by this Hath pip111@dama, team”. 11mm“! in lawn” WW ant unltki ztntc than venucdnro, lit ntuditc. anon ��1‘. In snot: or cnrcbgll vuucniqr;acutdant,Inciﬂlllvi¥~tnrﬂﬁrl,1003 helpful. .rlilurv 0:,a rental to £111 any Do an: t. u.vurtety t: mamas 310m»:ntm1umut1m. .mmm min. in! ”mm at m sum. mm mum mm boon ”but!“ (75). 1;- aot ,imwmwludzu Mimi!» mum man. It proud” \- mam. mu 1i: arm-gamut” o. twain tron m tntrusarnhmtl 010%, or f!!! a tunes, in OIIOI Ihnre tho I1tsnonll-as mucus W. unelcwr. ' ﬂhile the indications tar angiography are many, that cannot be evaluated uithuut ; aincuauian at thy risk: involved. ‘iha emm911a1~ ,tiuau or the praceanre are a: turccthpoat.(n) trunnient latul phcnunanlg (b) trannient cerebral vascular phenlnnnlg (o) pcmlanant 2mm «£1411». , xn the vburaias Dﬂlnl 1n the :1“:ng at trmniont mama m m It‘d during 1nJooeton, hauttuul in.tho noak, and ullorzie venetiann.. numatann.1n the acek in a potentially dangcraus samplicntien (see aur.Caso VII) but in a ragent review no Inqucllas varc,aha§rve¢=(9). »Allor¢10 notation: «we larreqaant and usually llld. .1: in: nat¢¢ in thin action that ﬁns manila. intvaautlanouu or csngunntivua talking tar sensitivity It: not fauna untitraotorw $n prudiottus ﬁnale-clnpliotticnl. lblnninat,hun1paanszs. aphlltl. :eiunros nna citritod blaod pruuunre haw: hath reported fallouina unstogrtphv (16). In that series than. qunmlieationn n!!! OttarVQdfin nine canal »~ an incidenae of 35. {A similar tantdanao uni-nhucrvud In tho lbntcrluao Ibnpaell 30:103. lint.th030 Philll'n!.!rﬁ pribttly in: to tunporary vaaaulnr innutriuionﬂr (I’lﬂlﬂ) 1: I71lnnn¢d by the cliniunl pattorn at nourolngzctl findings and thair‘dnrutzun.. at asv¢u 3:310:90 with �it. M101” 15. m an tin-00 unwanted 01ml: than. 0m:- it no so” in an laws. In m panama, mu m of the amsun autograph: m "mm in a. 0M um 01: an um, 01MB «manna. In tho 0mm: mum, Woo-0m banana-«10, and tm mammmuumamummuamnmm left me the 0min 1mm that m m»: later, in» first 0m may m 0100. an mm m mind”that run an tho 0100 and mum M01090! 0 right M4- 13:00:10! 0: 01941-0“. tho MWMmth-Wﬂm. Vacant OW M 0mm mm.» 9103“. of that mun-101- hue been observed. 02:0: m 13300151”: in: do» within 15 010010 plant 0 1000: am manna 007010904 0:? “can”. third Quintin 0: m "I! 0140 In an. A mm 0: tin 09m“ 3: m «rent. an. m mumnmnwsmnmgumma. within Wu. omnuum m0 not unwind: 61mm m. 19 in ”#103150 01th W103. 6menoun-1mm.» a: 0 ”um '0 condition or men nun-1a; wemyhymummmmammumm. mud) , them-.1319“: ormpmuamxm. mam Mm :um «mare; “may to «unanimity. um many. and mu.» (1») mart «no 1080110100 mm.and80011110 0: “data-imam u: clown (11) than 1n mu mm. anus, 1." ”that“ ”mum” in a «£100 a! 36° won-000. no" mo in «hung: in an:- pmmt 005-100. an: m patient and 0 «m. nunvation 0f than at 0. pvt-mung Mum. 111 b01020 W10. 80071110 and tin pmodm‘e. in contrast 00 this In! 0! than 90810330, 111:. mum at 910003. 1:090 0010:“: m the 10:30 has.“ of M1: (53); , �(5e), Won (14), m um he), muten w deaths ﬂare related ta precadure.‘ (1b) thawein no 16. and mm It 13 tum passablc adrlannd that with vidnupread use a: angzoeraphr, Iubﬁeatu titl.naro cerebrul lesions tru selccted far these stud1eu and tha rink: ﬁharlhv 1n¢rcanod. A what 9: mm: by 01:36:: am manta: (BB. 11, 12) alphantxs tho-launntxon at tho taxis atteatn o: 31:30 limit a: diodmalt given ovar a abort 99:10! a: ﬁans. '1hor tailgatic in. nature at the toxicity Is an inoréégea permanbility at tho blood 1.33:1! and u chanxe 1n hennaynlaieh. Furthlxﬂﬂliy aha rolatian between canoentrt~ ma taunt; m, mean-am I» am: (13) when no am or introauegd dladraxt far Instagruphy. a1: abtathtiun that seizures £0116! thc use at 595 and 70% éiearaut has been ovatimnné by unmitiul amt invautizatarb. auspite thc use at 351 diodrast and law total Gasman: er diodraat, in this series, eumplications ensued. share I81 no nisni~ tioaat rnlntiaa between.dosasc 1nd canaliettionn. ethar raetars ' not he ”mum and same elrculntian tint (#t) and mung ma «team: V ' H 31.3 ‘71... i mummy mt. has been given in the “amnion an tau affect of other 1nJurious ﬂaunts (a). eri 8h. moment a: em: or man. cranial aiaenaa :uupoeted or raueular animalios. an;znt¢atar1t1 talcum. and traumatic hu-Itunns. IS 1: n natintcetory non*lurzie¢1 ntthad at dtnunutrntina I Visuallr annuals; nnltoznation or ‘nourrnn. 1. 1:: in: dilsnoail of Iupratuntorill.llnlts it will takiinc 9Q! tttinruntarlly. In,udﬂ1t1¢u to catnblzlhinz thn pzoqanao at a kunnr. :rtorauarapny 1! unparacr ta 0th.: asnannstto tookaios 1n yialazna calling. I: to it. typo ot’lnul lad 1t. local. In Cl!!! with In �17. a not and. Wkly “at”: by tn mm ohacuro 13 mined-II». It alt a Inttlthstaww'litind'13.!UIlaatulﬂmaa or ﬂu. and mm. mum of tho nah-unlu- min, or mimic: fun w ”0199.15”. I»... 1. a in «us of tantrum mam, m Mm» «turns»: arm "ﬂunk: mm proucdnri. m: mm mm. a intricarutrll hilatlll tiastlt-Ilah MW m emu mum «now am» mu. at taunt. 10.113» tram 1: 1. eon-punts” mg. “I? tho mt pm, Wink. and would not in no“ mu. he savanna.» m no. tn was ﬂu not "mm u human-1m math-nu, min or tutor: uncanny d: tunings. a sum: of «mu. r010, and "My 1. mum. pm a mu W mm m W «mud Woman part-mt Mm m rm an: m mm "an“ mm: mm”no: a: A 117 hum. mam o: ta risk: of Ingiography. no author. «mum: that the 1mm taliﬁttionl and mt: ot at the mum” do «mu m autumn: an the meant or mean: alumna”, mum mmtarial brain Wm ms! was not 13th 1.1;- 10am. ' u ,____ __ _#».47.L_...;M._.z _,_..._.,___L__, .__u “A, . �RUIIARY eeriee a: 117 pereuteneoue oerotid ensiosreee were revieeed to eveiuete the indidetione for end rieke involved in engiosrephy. Petieute with e veriety or intredreniei conditione were etudied including eupretentoriel tenure, veeeuier endeoliee. A treaeetio heeetaee end eerebroveeduler dieeeee. titty-rive petiente with evidence at intreoreniel tenure were eueJeeted to engiogrephy, end e poeitive diesnoeie eee eede in thirty. fheee diesnoeee were auntie-ed in 83$ or the eeeee. ’ In duly tee eabjedte were the tiiee eieinterpreted. or the aegetive tilee. the diegnoeee were dentineed in 50!; in only tee men an the ensiosreee teii to aim e leeion um- deeenetrehie b7 eir etudiee. or 21 petiente eith euepeeted intreereniel veeduler endedliee, nine were outlined by ensiosrephy. In tee of theee, the engiosreee reveeled en end-e11 not eeniteet on eir etudiee. In e group at eeveuteen petiente euepeeted o: treneetie intreoreniei heeeteee, e poeitive diesnoeie wee eede in seven eeeee. Theee diesnoeee ee well ee the necetive findinse in eight ceeee, end intreeerehrei theere deeonetreted in ten ceeee, eere e11 contimeed by euheeeuent etudiee. In oeeee at cerebroveeduier leeione ensiogrephy wee not at diecnoetio veiue. Treneient ddeplieetione of engiogrephy were eeen in one—third of the petieute, end edueieted or heeetaee or the neck, heeipereeie. eeieuree, end erticerie. In five petiente (I!) eoepiicetiene eere eevere end peeeenent. Sheee oeeee ere deeerihed end the restore diecueeed. Ehe ‘Vl eethere deecrihe the ueetulneee or engiosrephy in �“Hermann“ been»: intact-mill condition: . they canal“. that tho united risk: of cerebral miomphy 69 not data“ from it: ”0mm”. in the summon: a: mammal vacant alternations. unopened «panama-1.1 man and human hum. the variety or ��mm rams. LG. and mummy, L: mum...» my... warms,anion-mph: ma cox-chm than”. mu.lgu_gnl.mz¢hiat. omml Q}, 359“"368: ‘9’11: 39”intmmiu (1) new. I. : mummy in polt~trmtio 2w¢2583 “tam; 19‘9. 910‘ ES. 4““ WWI. m at in the (1») lumbar, 19W. intmmid 3.: 9mm}. maximum? 755468, W001: (o) 5. 6. WI! New ' . _ mm. 3!; 3.8.: m dammit er mum. B. m 3.!" mm, by intact-unis! tutu-mic humane axiom”. J. Imam- . (6) Q5, 363~376o N17. 1951- LB. and um. ‘.l.8 Eh. contribution at «roam 1950. mm. angina-mm in “tannin. «mam. : m $2-3m, catcher, of (3) mm. 3.3. and mm. 1.6.: Wriemphic visualisation 600-618, 251. lesions. mh.!m1.ggzehiu. ammuni19‘6“3.; (b) mm. 1.3. and mm, mm carom}. Marion-why in191.8. nub-mountain Mum. g.i.l.i.. 1.36: 517-581, M... (a) mzm. 1.1:. am mm. 6.6.: mum-min autograph: in the tmmnt at «1'0an maul” accident: . can: .M. , m (4) 7. ,_ V (a) LA. and mm, 9.3.: carotid minmtw; It: ".1130 sum. in pun-.11 t 121th conditim. M£11mgorth “or. , 8. m, the mmmolwruzohint. 31; : thrionlmaphy m mmmmw. mu- um. be. 1.31m: . localization had tram: or 111%”:er 1310-13“. June, 1932. m, P. and Pmuunum «mud miouaphy: m, "farm” ine“ iota blob. laurel” I»: complications in th- and pun-ms. ‘10 . 11. b with special 11: been to the larynx. 16;; 1-6, Juan-r1. 1951. 1. sad mum-amen, 1.2.: umimt 3.6., trauma,with. cyan. union-why. Lima“. unbnl 32-191. in unpainted 19‘9466 “ll, number. g; of (b) mm, 3.. 36mm. VJ. and unseen, 3.: cmuaum 1951. 110418, angina-why. g4, mum. , g; ham, India a: tar emtmt 0. cerebral unplug £01m» won, 312-316, lov.,19't9. a: dim» type. 1 .lmu Joni-elm. "paint. E; (u) a » to a aid 01,8861. 0.: 103.3ch of «mm: bland vouch 336~3#8, Indian or the “adult group. mm We}... 32; lava-tho, 1m. pines in aux-01min]. 13. @038, am. u 8mm}. ”tomography: It: 704-711., Oct... 12 . 1*. mm, contra-t ‘1'. ‘ «lanolin. Arch.lm¢1.ﬂgguat.. 53!. 6.. mm , run. and 3.3.: Vertebral 'W tokﬂﬂnt. ‘ rm. 166.5182, "bm’lg‘g. ‘ u‘doMc; £12. 19“. Wm. 83131 o � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A clinical evaluation of carotid angiography. Confin Neurol. 1952; 12(4): 181-95. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-5-007 Date A point or period of time associated with an event in the lifecycle of the resource 1952 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Stein, Joseph M. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and publication. Confinia Neurologica. From the Department of Neurology and Psychiatry, New York University College of Medicine and the Neurological Service of the Third Division, Bellvue Hospital, New York City. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Basel; New York: Confinia Neurologica Contributor An entity responsible for making contributions to the resource Spiegel, E. A. Published http://exhibits.library.stonybrook.edu/mfp/files/original/7e92065b94f7b6d5425d61aa477e6ec4.pdf e45a9c50dfd09b37a641b179b46ee31a PDF Text Text ABSENCE OF A PARENT AS A SPECIFIC FACTOR DETERMINING CHOICE OF NEUROSIS Preliminary Study SIDNEY TARACHOW, MD.1 and MAXIMILIAN FINK, MD.2 New York, N. 'Y. Psychoanalytic experience has made important contributions to the problem of the differential etiology of various neuroses, psychoses, and character disturbances. This has been accomplished chieﬂy by the identiﬁcation of the decisive areas of conﬂict in the patient. Among the factors involved are the nature of the instincts in the conﬂict, the time of the decisive conﬂict, the intensity of the frustrations or traumata, the availability of substitute gratiﬁcations, and the characteristics of the historical situation (Fenichel, 1). It is difﬁcult to evaluate the speciﬁcity of any one of these factors in the choice of a particular neurosis. Recent investigations tend to show that while a particular neurosis may apparently be an expression of conﬂict at a certain level of development, nevertheless experiences at some earlier or previous level may produce tendencies which provoke, potentiate or distort conﬂicts of a subsequent period of development. With increasing psychoanalytic knowledge, the task of isolating concrete factors inﬂuencing speciﬁc choice of neurosis becomes ever more difﬁcult. It becomes even more difﬁcult if one attempts to assess the intangible factor of ego strength of an individual in his struggle to control and express his various instincts or his attempts to fashion defenses or character traits. Nevertheless, it 1Attending Psychiatrist, Hillside Hospital, Glen Oaks, N. 2 Fellow in Psychiatry, Hillside Hospital, Glen Oaks, N. Y. 67 Y. �68 TARACHOW—FINK should be possible to ﬁnd a way of approaching mental operations in a systematic way which would lead in the direction of solving the problem of speciﬁcity of choice of neurosis. In seeking a systematic way to solve this problem, it occurred to us that perhaps certain elements in the external historical situation might lend themselves more easily to the preliminary steps of such a search. If a certain external historical situation were isolated and studied, perhaps it could be correlated with certain invariable psychic consequences. Freud (2) made such an observation when he noted that men who have weak or absent fathers tend to develop homosexual trends. The external historical factor we selected was the presence or absence of both parents during the important developmental years of the child. We decided to investigate the relation of this external factor to the success or failure of the resolution of ambivalent feelings, the ability to fuse the instincts of love and hate. For reasons to be noted we selected hysteria and obsessive-compulsive neurosis as the clinical expressions of the success or failure of the fusion. We then set up the following hypothetical basis for this study and made a tentative prediction of the data to be discovered. A child brought up by both parents will solve the problem of resolu— tion of ambivalent feelings more satisfactorily than a child who has lost one parent for any signiﬁcant period of time. A child facing only one parent does not have both his love and his hatred equally and freely available to be directed to the parent. If he loves the single parent the hate will tend to be repressed, and vice versa. A child with both parents, on the other hand, has two objects against whom both sides of the ambivalence can be directed in turn. He can hate one and love the other, or the opposite. Two objects give the child much more liberty than one. This freedom would not hinder resolution of ambivalence, but rather facilitate it. He would have all his feelings relatively more available to him in comparison to the child with one parent. When the time arrives for the necessary fusion of feelings for more mature relationships the child who had had both parents is in a better position. Both sides of the ambivalence having been available, the fusion is more complete and normal. The other child, having relatively only one side of the ambivalence available, never succeeds �CHOICE OF NEUROSIS 69 in fusing his ambivalent feelings and remains with a burden of one-sidedly more repressed and defused instinctual feeling. According to our hypothesis the child who had two parents and had succeeded in fusing his feelings would tend to develop hysteria, if he developed a neurosis. The other child would tend to develop obsessive compulsive neurosis. This follows from the familiar psychoanalytic formulations of defused ambivalence in the compulsive neurosis and the fused genital level of feeling in hysteria. This hypothesis was tested by consulting the case material from Hillside Hospital. We searched for clearly deﬁned cases of each category and studied the incidence of absence, death or loss of one parent for any reason whatever. Only clear-cut cases were used. All mixed and intermediate syndromes were eliminated, as were phobias and anxiety states. Sixty-one records have so far been found suitable: of these, twenty-seven were patients with conversion hysteria and thirty-four with compulsive-obsessive neurosis. Separation from a parent was deﬁned as the absence of a parent for periods exceeding one year before the child’s ﬁfteenth year of age. Note was made of the time of the separation, the reason, the duration, and the age of onset of the neurotic symptoms. Of the twenty-seven patients with conversion hysteria, three (11%) were subjected to periods of separation. In each the separation occurred between the ages of ﬁve and nine; in two by death and in one by emigration. In the latter the period of separation was of six years’ duration. Of the thirty-four patients with obsessive-compulsive neurosis, ﬁfteen (44%) suffered extended periods of separation. Nine occurred between the ages of ﬁve and nine, four before the age of ﬁve, and one each at thirteen and ﬁfteen. Separation was caused by death in nine subjects, hospitalization in three, and emigration in three. In the latter the separation lasted from one to three years, during the child’s age of three to seven years. In four subjects there were double separations. In one subject there was hospitalization of a parent for a year, return home as an invalid for two years and then death. In three other subjects there was death of one parent and illness of the other at another time in the child’s life. In all instances the parental loss occurred before the clinical onset of neurotic symptoms. �70 TARACHOW—FINK These data point in the same direction as the hypothesis suggested, namely, that loss of a parent tends to increase the difﬁculties of solving the problem of ambivalence.3 So many other factors enter into the situation that we would limit ourselves to the conclusion that these ﬁndings warrant further study of the suggested correlation. Other studies of parental deprivation have taken a somewhat different direction. Oltman et al. (5) studied the difference in rate of parental deprivation, comparing various psychoses with neuroses. They found that the incidence of loss of a parent did not vary in schizophrenia and manic-depressive psychosis from their control group, while psychoneuroses were higher. Their control group was State Hospital personnel, with 32 per cent deprivation. Psychoses showed 34 per cent and the neurotic subjects 49 per cent. The psychoneurotic group was not diagnostically further differentiated. Madow and Hardy (4), in a study of clinic population in the Army, found parental deprivation by death in 36 per cent of the neurotics. They used as a control, life insurance statistical tables which indicated an 11 to 15 per cent incidence of parent loss before the age of sixteen. A third study (3) of a student health clinic population in a State University indicated that 31 loss of neurotic the cent through subjects reported parent per death, while only 131/2 per cent of the controls (normal students) did. None of these workers were searching for the factors we are, and there is no breakdown into the various neurotic categories. These observations cannot be used comparatively with our speciﬁc point in mind. In general the data from the literature indicate that the incidence of parent loss is greater in neurotic subjects than in psychotic and control groups, although the various control groups show a lack of uniformity. Our own subjects taken as a group (this excludes many mixed neuroses, phobics and anxiety states) show an average incidence of parent loss of 30 per cent. The incidence in the obsessional neurotic is higher than in the cited controls, while in hysteria it coincides with the lower percentages of the controls. Apart from the subtleties of the psychodynamic processes which this study overlooks there are also gross difﬁculties in evaluating 3Chi square was calculated as 6.32 which is signiﬁcant at the .01-.02 level. The chi square was corrected for continuity by Yates’ method. �CHOICE OF NEUROSIS 71 the statistics. First of all, the sampling is small. This will be remedied as the study continues. No other study differentiated among the neuroses, and diagnostic criteria probably vary from one institution to another. This study can be reﬁned and develoPed in a number of directions. The dynamics with reference to the separation could be explored. The presence or absence of parental surrogates should be looked into. Other factors of separation such as deafness or blindness or parent’s going out to work must all be considered. SUMMARY A hypothesis was formulated stating that unresolved ambivalence (instinct defusion) may be related to the absence of one parent during the critical formative years. It was tentatively predicted that obsessive-compulsive neurosis (illustrative of instinct defusion) would therefore show a high rate of parental deprivation and that hysteria (illustrative of instinct fusion) would show a low rate. The actual data were: thirty-four cases of obsessive-compulsive neurosis showed 44 per cent of parental loss: twenty-seven cases of hysteria showed 11 per cent parental loss. We consider this at least a provocative difference. Even though many intrapsychic factors enter into the problem of unresolved ambivalence, these data warrant further study along these and related lines. REFERENCES (l) Fenichel, 0.: The Psychoanalytic Theory of Neurosis. New York: W. W. Norton 8: Co., 1945. :2(2) Freud, S.: Three Contributions to the Theory of Sex. In The Basic Writings of Sigmund Freud. New York: Modern Library, 1938. (3) Ingham, H. V.: A Statistical Study of Family Relationships in Psychoneurosis. Am. J. Psychiat., 106:91-98, 1949. (4) Madow, L. and Hardy, S. E.: Incidence and Analysis of the Broken Family in the Background of Neurosis. Am. J. 0rthopsychiat., 17:521-528. 1947. (5) Oltman, J. E., McGarry, J. J., and Friedman, 8.: Parental Deprivation and the “Broken Home” in Dementia Praecox and Other Mental Disorders, Am. J. Psychiat., 1082685-694, 1952. �Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 1953 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A statistical study of a psychoanalytic hypothesis: absence of a parent as a specific factor determining choice of neurosis. Journal of the Hillside Hospital, 2: 67-71, 1953. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-11-015 Date A point or period of time associated with an event in the lifecycle of the resource 1953 Creator An entity primarily responsible for making the resource Tarachow, Sidney; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from JOURNAL OF THE HILLSIDE HOSPITAL Volume II, Number 2 April, 1953 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/11575e68e7e18c8231219284212ca0ba.pdf 8597351b5fddeee289bccffd6b5c1c4f PDF Text Text 9Q J. Hillside Heapital, 1957 6: 197-206, A UNIFIED THEORY OF THE ACTION OF PHYSIODYNAMICTHERAPIES1 MAX FINK, MD.2 The proper role of the physiodynamic therapies (convulsive, insulin coma and lobotomy) in psychiatry remains poorly deﬁned. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neuropllysiologic-adaptive view of electroconvulsive therapy has been presented (41, 32, 38, I). This view ascribes the therapeutic process in electroshock to a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. The type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, an awareness of a similar mode of action in insulin coma (31) and lobotomy (40) has developed. During the past four years we have studied the relation between alteration in various indices of brain function and the behavioral response of psychiatric patients to therapy. The neurophysiologicadaptive view of electroshock has been supported and ampliﬁed (11, 12, 13, 19, 21); evidence for a similar view of insulin coma has been presented (22); and recently the concept has been extended to the newer “tranquilizers" (9). These studies provide the basis for a generalization concerning the efﬁcacy of these therapies. It is our purpose in this report to examine the experimental evidence to determine whether or not the mode of action of each of these thera— 1From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N. Y. Read at the. 2nd International Congress of Psychiatry, Zurich, September 6, 1957. Aided by Grant M-927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service; and the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 2 Director, Department of Experimental Psychiatry, Hillside Hospital. 197 12-» �198 MAX FINK pies may result from their ability to induce sustained alteration in cerebral function; and the corollary question, whether measurable alteration in cerebral function is a necessary condition for the efﬁ— cacy of these therapies, or a “complication" or "untoward effect." The indices of brain function used in these studies have varied. These include memory scales (2G), visual (20) and tactile (10) perceptual tasks, and changes in language patterns of orientation both clinically (19) and after intravenous amobarbital (21). In electroencephalographic studies of this problem, changes in the delta index, both in routine records (ll, 12) and after activation by intravenous thiopentone (32, 33), and in the beta index (16) have been applied Successfully. For this review, two indices will be stressed: changes in the delta index of the unactivated EEG, and clinical neurologic signs. These indices have been selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities. OBSERVATIONS (a) Electroshock 4.1 "1M The following notes summarize our experimental studies of the role of 'changes in EEG delta activity in the response of subjects to electroshock (11, 13). In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. Grand mal treatments were administered three times a week, for twelve to twenty treatments. The EEG records were quantitatively analyzed for the amount of induced delta activity, and classiﬁed into categories of “high,” “moderate” and “low” degrees of delta activity. At the end of treatment, the patients were independently rated for their shortterm clinical response into the categories of “much improved," “moderately improved” and “unimproved." In the initial series of patients, a signiﬁcant relationship between the early induction of high degrees of delta activity, and clinical ratings of “much improved” was observed. Eighty per cent of the records in the much improved group were high degree delta by the fourth to sixth treatment; and the percentage was sustained at 90 per cent in the third’ and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the ﬁrst three weeks, and only 20 per cent of the records in the fourth week were so classiﬁed. In a subsequent predictive study, the EEG records during the a wan-pow �THEORY OF PHYSIODYNAMIC THERAPIES 199 second and third weeks of treatment were analyzed. Of the patients who had high degree delta records on both occasions, 67 per cent were rated as much improved, while of the patients without such records, 70 per cent were in the unimproved and moderately improved categories. Roth (82, 33), studying the EEG delta activity evoked by intravenous thiopentone after electroshock, has related both the stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. He concluded that patients not attaining a speciﬁed delta activity level "have not acquired an adequate physiological basis for recovery,” and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of delta activity that vary from low to high, subconvulsive therapy rarely alters EEG patterns or induces low degrees of delta activity (13). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demonstrated a signiﬁcantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (13) recently completed here, twenty-seven patients received a course of subconvulsive therapy. Electroencephalograms, taken at weekly intervals, demonstrated minimal changes—none of the records were scored as middle or high delta activity. Of the twenty-seven patients, no change in behavior was noted in twenty-three, and of these, nineteen were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed signiﬁcant changes in behavior, while of the ﬁve who did not show the delta response, only two showed a behavioral change. Tranquilizing Drugs When the newer drug therapies are studied from the viewpoint of their electroencephalographic and clinical neurologic effects, a meaningful classiﬁcation emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efﬁcacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly deﬁnable electroencephalographic patterns. Based on observations made in chronic admin(b) �MAX FIN K 200 istration of drugs in adult psychiatric patients, the EEG changes may be classiﬁed according to predominant changes in the frequency spectrum. There are three broad types: Increased slow wave activity with hypersynchrony (“bursts")—“delta shift" II._ Desynchronization with voltage and frequency irregularity and irregular theta activity—“desynchronization” III. Increased high voltage fast activity—“beta shift.” Of the group of drugs inducing a delta shift, the phenothiazine derivatives chlorpromazine, promazine, and perphenazine are clear examples. Each drug induces seizures in nonepileptics or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). Each drug induces clinical parkinsonian neurologic patterns when given in adequate dosage. In our laboratories, we have induced parkinsonism in all patients receiving chlorpromazine (l4) and have observed seizures in 10 per cent of a group of psychotic patients without previous ltistnl'y of seizures. Induced delta activity, including burst activity, \ms nlm-ned in more than half the patients in this series. Rrxrxpiue also ernkes delta activity when given in large doses (3- \t liitth tlnugt‘ levels. it exaggerates seizures in epileptics and "I'lihrs wzmtes in animals (35). .-\t the usual clinical dosages, howr.:-:, ”supine imluu's desynrhronization of frequencies with a t; w-lrtxh‘ mitease in theta activity (28), without seizure induction in: mm definite motor rigidities. In a series of patients treated here ("T'H. parkiuwuism was induced in all patients. EEG Changes were limited to desynchronization only, without delta burst activity. The primary response of two other drugs, mepazine and benacty. . Ime. is the induction of EEG desynchronization. Mepazine, a phen()t‘ttLt/mt‘ derivative. induces desynchronization with small amounts; it n\n\ \ \ l‘h'lt'h .‘n‘H\'n\ has nx‘u t\\\‘ll 'li‘it‘l‘ﬁk‘n. nor have .-' m: Immd reports either of seizures or parkinsonism in the clinical literature. Benactyzine, a potent anticholinergic compound, induces a blocking of alpha, ﬂattening of the record and occasional theta activity (5, 17). Neither seizures nor parkinsonism have been described for this agent. Meprobamate is the clearest example of the group of drugs inducing a beta shift in the EEG (3). This agent further differs from the phenothiazines and reserpine in not producing parkinsonism and not only are clinical seizures not induced, but deﬁnite antiepileptic activity has been described (30). Habituation is readily 1. x a w �THEORY OF PHYSIODYNAMIC THERAPIES f 201 achieved, and withdrawal phenomena of agitation and seizures have been observed (42). In these actions, meprobamate is more like barbiturates than like the other new tranquilizers. If we determine the clinical efficacy of these agents, we note a parallel between the induced EEG effects and their potency in altering behavior. The drugs that most readily induce a delta shift in EEG frequencies—the phenothiazine compounds—are those with the greatest clinical efﬁcacy in the therapy of psychoses. The compounds with lesser activity in this direction are less efﬁcacious clinically. i f ,1 ,i / I/ ! Insulin Coma Therapy The effects of insulin coma therapy on the nervous system are well documented. During each coma, EEG delta activity is induced, which usually persists for minutes to a few hours after gavage. Not infrequently, in approximately one third of patients receiving deep coma therapy in this hospital, seizures, aphasia or prolonged coma results. After such events, EEG changes of delta activity persist for days, and in cases of prolonged coma, for weeks and months (43). The relation between prolonged coma, altered brain function and behavioral response has been discussed at length. Revitch (31) reported eight cases of prolonged coma and concluded that improvement may be attributed to the induction of organic brain damage, similar to lobotomy. Yaeger, Simon, Margolis and Burch (43), describing twelve cases of prolonged insulin coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (34), emphasizing EEG data, and Kwalwasser and Caplan (27) presented individual cases to support the same conclusion. We reported a similar relationship between prolonged coma and behavioral response in a case study (22). A 34-year-old schizophrenic patient with paranoid ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. He became lucid, loquacious and denied his illness. His former paranoid-withdrawal type pattern was replaced by a friendly cooperative attitude. These changes were accompanied by delta changes in the EEG, as well as language changes after amobarbital indicative of altered brain function. The neurologic symptoms resolved, but the behavioral changes persisted so that he was discharged two months later as “much improved." , l 5, ' ‘ (c) m..- aunts..- 5 ’j 2 “ \lU, 5‘ r ' - �202 MAX FINK (d) Lobotomy to study lobotomy While we have not had the opportunity of of view of this summary, the reports the point from EEG patients a similar relationship. numerous observers clearly documentin all subjects postoperatively of changes of delta activity are present Walter et al. (40) in a study (6) and persist for varying periods. EEG persistence of abnormal 150 patients, found an 80 per cent be? relation noted a also authors activity after three years. These of postextent and and the degree tween clinical improvement operative slow wave activity. “complication," being variPostoperative seizures are a frequent (25). in up to 20 per cent of subjects ously reported as occurring of brain extent the between Furthermore, there is a relationship Circumscribed surgical tissue cut and the therapeutic outcome. improvement rate lower than lesions, regardless of locus, have an are frequently inadequate unilateral lobectomy; and these latter bilateral procedure (36). and are “improved” upon by a and i there havi Thﬁ tior the pa 5V 1,,“ F .'r' l s. l ‘_ DISCUSSION are essayed from the When the various physiodynamic therapies mode in brain function, a common point of view of an alteration which therapies represent devices of action becomes apparent. These function, with resultant change induce appreciable changes in brain and lobotomy induce measurable in behavior. Convulsive therapy directly; insulin coma primarily diffuse changes in brain function the phenothiazine and reserpine when complications ensue; and when given in adequate dosage. groups of tranquilizers function affect behavior is How persistent changes in cerebral“reversed" or “obliterated." is not not clear. Psychotic behavior the central nervous system milieu, in Rather, with an alteration of behavior including perception, there is an alteration in all aspects attitude. The speciﬁc adaptive mood, affect, memory, judgment and each subject and is dependent on numerous response is variable for Premorbid personality (18), historical and environmental factors. and the duration of environmental situation and expectations (13), have recently been discussed as the alteration in brain function (12) under these conditions. determinants of the behavioral response evaluated by the psychiaThe induced changes in behavior are the degree of “improvement." trist, administrator or family as to based the upon such factors as These ratings are value judgments, tolerance behavioral response, the environmental type of induced . JUN-laws �THEORY OF PHYSIODYNAMIC THERAPIES "Omy 0f ‘S E15G VC‘Iy } 'Of l EC ‘1 ’6 _ W . - . f . .-‘ i / / . ‘ y . “ (a 203 and the observer's expectations. In this context, the physiodynamic therapies do not induce “improvement"——-rather they induce behavioral change which is secondarily evaluated as improvement. The alteration of cerebral function is therefore not a “complication" or an "untoward effect" but the desired goal of these forms of therapy. Of the many “organic" therapies introduced during the past thirty years, none apparently has been a speciﬁc agent for the therapy of psychoses (in the sense that penicillin is speciﬁc for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efﬁcacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not speciﬁc for a type of psychosis. The early enthusiasm that reserpine or chlorpromazine was speciﬁc for schizophrenia, or hypotheses that ascribe signiﬁcance to an antagonism between these drugs and “psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a speciﬁcity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine-insulin coma control‘study (l4). EEG analysis of these therapies permits a more explicit deﬁnition of the induced alteration in brain function. Changes in cerebral function reﬂected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as “bursts" or “hypersynchrony” provide the change in milieu that is more effective in altering behavior. The signiﬁcance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the tranquilizers. That a delta shift has some speciﬁcity is seen in the analyses of the drug effects. Those drugs that induce the delta shift—the phenothiazines and reserpine—have been consistently reported as effective modiﬁers of psychotic behavior. Changes in brain function reﬂected by EEG desynchronization only, or a shift in frequency spectrum to the faster range, have a limited efﬁcacy in altering psychotic behavior.3 The signiﬁcance of a delta shift is further seen in the limited efﬁcacy of subconvulsive electroshock when compared to convulsive electroshock in the management of psychoses. Another aspect of the alteration in brain function which may be deﬁned is the change in seizure threshold. With the delta shift in 3 These observations suggest the application of EEG screening of new chemotherapeutic compounds for therapeutic efﬁcacy according to their ability to induce delta burst activity with a minimum of side effects. �MAX FINK 204 the EEG, an increase in clinical seizures would be anticipated. This is indeed true. Seizures have been described following electroshock (4, 24); they are prominent after lobotomy (40) and a common “complication” during and occasionally following insulin coma therapy (23). With the tranquilizers, the parallel of clinical efficacy and seizure induction is most striking. Phenothiazine compounds induce seizures commonly; reserpine rarely; benactyzine not at all; and meprobamate is a potent anticonvulsant! The lowering of seizure threshold parallels the extent of the EEG delta shift induced by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism—both potent indices of an alteration in cerebral function. The neurologic basis for the delta shift and increase in seizure’ frequency is unclear. Whether this represents a persistent change in function of some speciﬁc brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a delta shift, with or without hypersynchrony, it appears more likely that the EEG changes reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of speciﬁc cellular masses. SUMMARY 1. The neurophysiologic and clinical neurologic aspects of con- vulsive therapy, “tranquilizers,” insulin coma and lobotomy, are reviewed. 2. The efﬁcacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the EEG spectrum and an increase in incidence of seizures are two indices. 3. Alteration in cerebral function is an essential prerequisite of behavioral change with each of these therapies. Such alteration is neither a “complication,” nor an “untoward effect," but is the sine qua non of the mode of action of these therapies. 4. No evidence has been educed in these studies that the physiodynamic therapies are speciﬁc agents for the relief of psychoses; nor do they affect a speciﬁc segment of the nervous system; nor do they induce speciﬁc behavioral'changes. 5. The therapeutic process of convulsive therapy, insulin coma, lobotomy and tranquilizers may be ascribed to the induction of a persistent alteration in cerebral function which provides the milieu for a change in adaptation of the subject to his environment. r.—-r,y.,.",,,, �THEORY OF PHYSIODYNAMIC THERAPIES 205 REFERENCES (1) (2 V i l l : Aird, R. B.: Strait, L. A.: Pace, J. “7.; Hernolf, M. K. 8: Bowditch, S. C.: Neurophysiologic Effects of Electrically Induced Convulsions. A.M.A. Arch. Neural. (9 Psychiat., 75:371-378, 1956. Arellano, A. P. 8.- ]eri, R.: The Ellcct of Reserpine on the Scalp and Basal Electrocncephalogram. EEG. Clin. Neurophysiol., 8:150 (abst.), 1956. Berger, F. M.: The Chemistry and Mode of Action of Tranquilizing Drugs. Ann. N. Y. Acad. Sci., 67:685-699, 1957. Blumenthal, I. j.: Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy. ]. New. & Ment. Dis., 122:581-588, 1955. Coady, A. 8.: jewesbury, E. C. 0.: A Clinical Trial of Benactyzine Hydro. chloride (“Suavital”) as a Physical Relaxant. Brit. Med. 1., Mar. 3, pp. 485- 487, 1956. Colin, R.: EEG Study of Prelrontal Lobotomy. Arch. Neurol. 65' Psychiat.,_ 532351-357, 1945. (7) Dcnber, H. C. B.: Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia. Second Int. Congress of Psychiatry, Zurich, 1957. (8) Fabisch, “7.: Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients. J. Neurol., Neurosurg., (‘5' Psychiat., 20:185-190, 1957. (9) Fink, M.: Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior. Presented Second Int. Congress of Psychiatry, Zurich, 1957. (10) Fink, M.; Green, M. A. 8: Bender, M. B.: The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome. Neurology, 2:46-58, 1952. (11) Fink, M. 8: Kahn, R. L.: Quantitative Studies of Slow Wave Activity Following Electroshock. EEG Clin. Neuraphysial., 8:158 (abst.), 1956. (12)' Fink, M. Sc Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies. AM.A. Arch. Neurol. (‘5Psychiat., 78:516-525. 1957. (13) Fink, M.; Kahn, R. L. 8: Green, M. A.: Experimental Studies of the Electroshock Process. 1. New. (9- Ment. Dis. (in press). (14) Fink, M.; Shaw, R.: Gross, G. 8.- Coleman, F. 8.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis. ]. Am. Med. Assoc. (in press). (15) Hankoif, L. D.; Kaye, E.; Engelhardt, D. M. 8.: Freedman, N.: Convulsions (5) (16) 1946. (17) Jacobson, E.: Suavitil, et Nyt Stat Med Speciﬁk Virkning pa Centralnervesystemet. Ugeskrift for Laeger, 117:1147-1151, 1955. (13) Kahn, R. L. 8: Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy. Conf. Neural. (in press). 8: (19) Kahn, R. L. Fink, M.: Changes in Languages During Electroshock Therapy. In: Psychopathology of Communication. New York: Grune 8c Stratton, (in press), 1957. (20) Kahn, R. L. 8c Fink, M.: Perception of Embedded Figures After Induced Altered Brain Function. Am. Psychal., 12:36] (abst.), 1957. (21) Kahn, R. L.; Fink, M. 8: Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock. A.M.A. Arch. Neural. 6' Psychiat., 76:23-29, 1956. (22) Kahn, R. L.; Graubert, D. 8: Fink, M.: Delusional Reduplication of Parts of the Body After Insulin Coma Therapy. This Journal, 4:134-148, 1955. ~ ,,L...-.u.. . . Complicating Ataractic Therapy, Their Incidence and Theoretical Implications. N. Y. State J. Med., 57:2967-2972, 1957. Hoagland, H.; Malamud, W.; Kaufman, I. C. 8c Pincus, 0.: Changes in Electroencephalogram and in Excretion of l7-Ketosteroids Accompanying Electro-shock Therapy of Agitated Depression. Psychosom. Med., 8:246-251, �MAX FINK 206 and Other Hoch, P.: Shock Treatment, Psychosurgery 8c Stratton, 1952. Grune York: New Somatic Treatments in Psychiatry. This States Following Electroshock Therapy. (24) Karliner, W.: Epileptic Journal, 5:258-263, 1956. in Prefrontal Loof Seizures, with EEG Findings, (25) Klotz, M.: Incidence 1955. 74:144-148. 65' Psychiat, and botomy. A.M.A. Arch.8.- Neurol. Kwalwasser, 8.: Relation of Changes in Memory 1956. 16:88-96, (25) Korin, H.; Fink, M. Neurol., Electroshock. Conf. Learning to Improvement in A Case of Prolonged Insulin Coma: Treat8.- Caplan, M.: (27) Kwalwasser, S. 1952. ment. This Journal, 1:145-155, Drugs on EEG. EEG Clin. “Tranquilizing” of Effect T.: W. (23) Liberson, Neurophysiol., 8:523, 1956. Fits in LeuN.: The Occurrence of Epileptic (29) Liddell, D. W. 8: Retterstol, Neurol., Neuro]. Therapy. Chlorpromazine cotomized Patients Receiving 20:105-107, 1957. Disorders. surg, &» Psychiat., Miltown, Its Use in Convulsive and Related A.: M. (30) Perlstein, 1956. 161:1040, J. Am. Med. Assoc., ImproveOrganic Brain Damage and Clinical 28:79-92, 1954. (31) Revitch, E.: Observations on Quart., Coma. Psychiat. ment Following Protracted Insulin Produced by the EEG Under Barbiturate Anesthesia (32) Roth, M.: Changes in for the Theory of Signiﬁcance Their and Treatment Electro-Convulsive 3:261-280, 1951. ECT Action. EEG Clin. Neurophysiol., and Pentothal K.; Shaw, J. 8: Green, ].: Prognosis W. D. M.: Kay, Roth, Treatment. (33) Electra-Convulsive in Induced Electroencephalographic Changes 1957. 9:225-238, EEG. Clin. Neurophysiol., and Clinical P. W.: Serial Electroencephalographic Neural. & (34) Shagass, C. 8: Rowsell, Arch. A.M.A. Coma. Insulin Studies in a Case of Prolonged Psychiat., 72:705-711, 1954. Interaction of A.: Mechanisms Involved in the (35) Sigg, E. B. 8: Schneider, J. Neurophysiol., 9: Clin. EEG. Reserpine. and Various Central Stimulants 419-426, 1957. M.: Unilateral and L. 11.; Adams, J. E. 8: Bowman, K. (35) Simon, A.; Margolis, A.M.A. Arch. Neurol. 6' Evaluation. Controlled A Bilateral Lobotomy: Psychiat., 66:494-503. 1951. Use to Activate Electroencephalographic (37) Stewart, L. F.: Chlorpromazine: 9:427-440, 1957. Neurophysiol., Clin. EEG Seizure Patterns. of Convulsive and SubEvaluation C.: 8c G. Gleser, K. (38) Ulett, G. A.; Smith, Am. J. Psychiat., Control Group. a convulsive Shock Therapies Utilizing (23) Kalinowsky, L. B. 8: . . 112:795-802, 1956. of A. G.; Fink, M. 8: Miller, J. S. A.: Evaluation (39) Wachspress, M.: Blumberg, Journal, 5:67-77, This of Anxiety. Relief for Reserpine Therapy High-Dose 1956. C. L.; Margolis, L. H. 8: Simon, A.: The EEG Changes 111:590(4°) Walter, R. D.; Yaeger, and Bilateral Frontal Lobotomy. Am. J. Psychiat., in Unilateral 594, 1955. and Physiologi8c Kahn, R. L.: Denial of Illness: Symbolic (41) Weinstein, E. A. 1955. cal Aspects. Springﬁeld, Ill.: C. C. Thomas. Communication. (42) Wilder, A.: Personal L. H. 8: Burch, N. R.: Electroencephalo(43) Yaeger, C. L.; Simon, A.; Margolis, Ment. Dis., 118: Coma. ]. New. 6' graphic Studies in Posthypoglycemic 435-441, 1953. . 39W" _ . w . if �A Unified Theory of the Action of Physiodynamic Therapies Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Respital, Glen Oaks, Read at the 2nd International Congress of Psychiatry, Zurich, September 6, N.Y. 1957. of the National Institute of Mental Health, National Institutes of Health, U.S. Public acalth Service; and the Board of Directors' Research Fund of the Society of the Hillside Bbspital. Aided by 10-7-57 grant M-927 �Iv: unified A The 10/5/57 Theory of the Action of Physiodynamic Therapies proper role of the physiodynamic therapies (electroshock, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their mode of action. In the past six years increasing evidence for a neurophysiologic-adaptive view of electro- (hl, 32, 38, 1). This view ascribes the there“ shock therapy has been presented peutic process in electroshock to a persistent alteration in cerebral function which provides the milieu environment. The for a change in adaptation of the subject to his type of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, of action in insulin coma (31) and lobotomy During the past four years we (MO) of psychiatric patients to therapy. The a similar view of insulin relation between and the behavioral response neurophysiologic-adaptive view of electroshock has been supported and amplified (9, 10, for mode has developed. have studied the alteration in various indices of brain function similar an awareness of a coma has been ll, 20, 21); evidence presented (19); and recently the concept has been extended to the newer "tranquillizers" (12). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the experimental evidence whether or not the mode of action of each of these therapies may to determine result their ability to induce sustained alteration in cerebral function; from and the coroln lary question, whether measurable alteration in cerebral function is a necessary �- - 2 condition for the efficacy of these therapies, or a "complication" or "untoward effect." The include indices of brain function used in these studies have varied. memory scales (26), visual (22) and tactile changes in language patterns of orientation both intravenous ambbarbital (20). changes in the clinically (21) and after In electroencephalographic studies of this problem, by intravenous thiopentone (32, 33), and successfully. For this review, have been (13) perceptual tasks, and delta index, both in routine records (9, delta index of the unactivated These and after activation in the beta index (16) have been applied two indices EEG, 10) and will be stressed: changes in the clinical neurologic signs. These indices selected because of their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities . �OBSERVATIONS: (a) Electroshock: The role of changes in following notes summarize our experimental studies of the EEG delta activity in the response of subjects to electro- In these studies, electroencephalograms were obtained before shock (9, 11). treatment, and at weekly intervals electroshock referrals. week, for after a treatment in consecutive Grand mal treatments were administered treatments. 12-20 on a day The EEG three times a records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of "high", "moderate" and "low" degrees of delta patients were independently the categories of In the At the end of treatment, the activity. rated for their short term clinical response into "much improved”, "moderately improved" and "unimproved". initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of "much improved" was observed. Eighty percent of the records in the much improved group were high degree delta by the h-6 treatment; and the percentage was sus- tained at 90% In contrast, none of the unimproved in the third and fourth weeks. patients developed high degree delta records in the 20% third weeks of treatment were analyzed. delta records on both occasions, 67% were patients without such records, categories. 70% and only classified. of the records in the fourth week were so In a subsequent predictive study, the and first three weeks, EEG Of records during the second the patients rated as who had high degree much improved, while of the were in the unimproved and moderately improved �*“1 h Both (32, 33) studying the EEG - delta activity thiopentone after electroshock has related both the evoked by intravenous stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. activity level, He ...... " concluded that patients not attaining a specified delta have not acquired an adequate physiological basis for recovery," and recommended measurement of delta activity levels after thiopentone clinical as a guide to the management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of vary from low to high, subconvulsive therapy rarely alters duces low degrees of delta delta activity that EEG patterns or in- activity (11). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Gleser (38) demon- strated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (11) recently completed here, twenty-seven patients received a course of subconvulsive therapy. weekly Electroencephalograms, taken at intervals, demonstrated minimal changes as middle or high delta activity. Of - none of the records were scored the 27 patients, no change in behavior was noted in 23, and of these, 19 were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranquillizing Drugs: When the newer drug therapies are studied from the viewpoint of �-5their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electro— encephalographic patterns. Based on observations made of drugs in adult psychiatric patients, the EEG in chronic administration changes may be according to predominant changes in the frequency spectrum. classified There are three broad types: I. Increased slow wave activity with hypersynchrony ("bursts") - "delta shift" II. Desynchronization with voltage and frequency irregularity and III. Of irregular theta activity - "desynchronization" shift." Increased high voltage fast activity - "beta the group of drugs inducing a delta derivatives chlorpromazine, promazine, Each drug induces shift, the phenothiazine and perphenazine are clear examples. seizures in non-epileptics or exaggerates seizures in epileptic patients (7, 8, neurologic patterns 15, 29, 37). when given Each drug induces in adequate dosage. clinical parkinsonian In our laboratories, have induced parkinsonism in all patients receiving chlorpromazine have observed seizures in 10% (1%) and of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, observed in more than we half the patients in this series. was �-5Reserpine also evokes delta At high dosage levels, it activity when given in large doses (2). exaggerates seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in patients. EEG all changes were limited to desynchronization only, without delta burst activity. The primary the induction of EEG response of two other drugs, mepazine and benactyzine, is desynchronization. Mepazine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity has not been described, nor or parkinsonism in the have we found activity (7). Delta reports either of seizures clinical literature. Benactyzine, a potent anticholin- ergic compound, induces a blocking of alpha, flattening of the record and 17). Neither seizures nor parkinsonism have occasional theta activity (5, been described for this agent. Meprobamate beta shift in the and EEG is the clearest example of the group of drugs inducing a (3). This agent further differs reserpine in not producing parkinsonism from the phenothiazines and not only are clinical seizures not induced, hut definite anti-epileptic activity has been described (30). Habituation is readily achieved, and withdrawal phenomena of agitation and seizures have been observed (h2). barbiturates than like the other If we determine the In these actions, meprobamate new is more like tranquillizers. clinical efficacy of these agents, we note a parallel �-7between the induced drugs EEG effects and their potency in altering behavior. that most readily induce a delta shift in thiazine compounds - are those with the therapy of psychoses. The compounds EEG frequencies - the The pheno— greatest clinical efficacy in the with lesser activity in this direction are less efficacious clinically. (c) Insulin Coma The well documented. Therapy: effects of insulin During each coma, persists for minutes to a few hours EEG coma delta activity is induced, after gavage. imately one third of patients receiving deep seizures, aphasia or prolonged coma therapy on the nervous system are coma which usually infrequently, in Not approx— therapy in this hospital, results. After such events, of delta activity persist for days, and in cases of prolonged changes EEG coma, for weeks and months (h3). relation between prolonged The coma, altered brain function ioral response has been discussed at length. Revitch of prolonged coma and concluded tion of organic brain damage, that (31) reported improvement may be insulin eight cases attributed to the similar to lobotomy. Yaeger, Burch (#3), describing twelve cases of prolonged and behaVo induc— Simon, Margolis and coma, noted a correlation between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (3h), emphasizing and Kwalwasser and Caplan (27) presented EEG individual cases to support the data, same conclusion. We reported a similar relationship between prolonged response in a case study (19). A 3h coma and behavioral year old schizophrenic patient with paranoid �-8ideation developed a left hemiplegia during insulin coma therapy. With the onset spatial of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and inattention, there was a marked change in speech and behavior. loquacious and denied his illness. was by He ludic, became His former paranoid—withdrawal type pattern replaced by a friendly cooperative attitude. These changes were accompanied delta changes in the as well as language changes EEG, dicative of altered brain function. The neurologic after amobarbital symptoms in— resolved, but the behavioral changes persisted so that he was discharged two months later as "much improved." (d) Lobotomy: While we have not had the opportunity from the point of view of document a this summary, similar relationship. all subjects postoperatively (#0) in a study of 150 after three years. EEG (6) and to study patients lobotomy the reports of numerous observers clearly changes of delta activity are present in persist for varying periods. Walter et al., patients, found an 80% persistence of abnormal These authors also noted a EEG relation between clinical ment and the degree and extent of postoperative slow wave activity improve— activity. Postoperative seizures are a frequent "complication," being variously reported as occurring up to relationship between the 20% of subjects (25). Furthermore, there extent of brain tissue cut and the is therapeutic Circumscribed surgical lesions, regardless of locus, have an improvement lower than unilateral lobectomy; are "improved" upon by a and these a outcome. rate latter are frequently inadequate bilateral procedure (36). and �DISCUSSION: When view of an These the various physiodynamic therapies are assayed from the point of alteration in brain function, a therapies represent devices of action becomes apparent. common mode which induce appreciable changes in brain function, with resultant change in behavior. Electroshock and lobotomy induce measurable diffuse changes in brain function when directly; insulin coma primarily complications ensue; and the phenothiazine and reserpine groups of quillizers when given How tran— in adequate dosage. persistent changes in cerebral function affect behavior is not clear. Psychotic dehavior is not "reversed" or "obliterated". Rather, with an alteration in the central nervous system milieu, there is all aspects of behavior including perception, and attitude. is dependent The affect, alteration in memory, Judgment specific adaptive response is variable for each subject on numerous historical and environmental sonality (18), environmental situation of the mood, an alteration in brain function factors. and expectations (10) have (ll), and Pre-morbid perand the duration recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the administrator or family as to the degree of "improvement." psychiatrist, These ratings are value judgments, based upon such factors as the type of induced behavioral response, the environmental tolerance and the observer's expectations. In this context, the physiodynamic therapies do not induce "improvement" - rather they induce behavioral change which is secondarily evaluated as improvement. alteration of cerebral function is therefore not a "complication" or The an "untoward �-10.. effect" but the desired goal of these forms of therapy. therapies introduced during the past thirty years, Of the many "organic" none apparently, has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. In this context, the various physiodynamic therapies are not specific for a type of psychosis. was The early enthusiasm that reserpine or chlorpromazine specific for schizophrenia, or hypotheses that ascribe significane to an antagonism between these drugs and "psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a specificity of insulin coma for schizophrenia is also untenable, and support for this view is presented in a recent chlorpromazine— insulin coma EEG control study (1h). analysis of these therapies permits a the induced alteration in brain function. by a shift in the spectrum of EEG Changes more explicit definition of in cerebral function reflected frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as "bursts" or "hypersynchrony" provide the change in milieu behavior. The that is more effective in altering significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the That a delta drug effects. reserpine tranquillizers. shift has Those drugs - have been some specificity is seen in the analyses of the that induce the delta shift - the phenothiazines and consistently reported as effective modifiers of psychotic �- 11 - of psychotic behavior. Changes in brain function reflected by EEG desynchroniza- tion only, or a shift in frequency spectrum to the faster range, have a limited efficacy in altering psychotic behavior. * The significance of a delta shift is further seen in the limited efficacy of subconvulsive electroshock when com- pared to convulsive electroshock in the management of psychoses. Another aspect of the is the change alteration in brain function in seizure threshold. delta shift in the With the in clinical seizures would be anticipated. which may be defined This been described following electroshock (h, 2h), EEG, an increase is indeed true. Seizures have are prominent after lobotomy (ho) and a common ”complication" during and occasionally following insulin coma therapy (23). With the tranquillizers, the parallel of clinical efficacy and seizure induction is most striking. commonly; reserpine rarely; benactyzine not at all; anticonvulsant! EEG Phenothiazine compounds induce seizures The lowering of delta shift induced and meprobamate is a potent seizure threshold parallels the extent of the by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism - both potent indices of an alteration in cerebral function. The quency some neurologic basis for the delta shift and increase in seizure is unclear. Whether fre— this represents a persistent change in function of specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a screening of new chemo— therapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. * These observations suggest the application of EEG �- 12 - delta shift, with or without hypersynchrony, EEG changes it appears more likely that the reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. �- 13 SUMMARY: 1. shock, The neurophysiologic and clinical neurologic aspects of electro- "tranquillizers, insulin H 2. The coma and lobotomy, efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent of which a delta shift in the seizures are 3. two EEG change in cerebral function, spectrum and an increase in incidence of indices. Alteration in cerebral function is behavioral change with each of these therapies. a "complication," nor an "untoward mode of are reviewed. an essential prerequisite of Such alteration is neither effect," but is the sine 92a action of these therapies. h. No evidence has been educed in these studies that the physiodynamic therapies are specific agents for the relief of psychoses; nor specific non of the segment of the nervous system; nor do they induce do they affect a specific behavioral changes. 5. and The therapeutic process of electroshock, insulin tranquillizers may be in cerebral function coma, lobotomy ascribed to the induction of a persistent alteration which provides the milieu the subject to his environment. for a change in adaptation of �L.A., Pace, J.W., Hernoff, M.K. and Bowditch, S.C. (1956): Neurophysiologic Effects of Electrically Induced Convulsions, A.M.A. Arch. Neurol. & Psychiat. 15: 371-378. Aird, R.B., Strait, Jeri, R. (1956): The Effect of Reserpine on the and Basal Electroencephalogram, EEG. Clin. Neurophysiol. Scalp Arellano, A.P. and g: 150 (abet). Berger, F.M. (1957): The Chemistry and Mode of Action of Tranquillizing Drugs, Ann. N.Y. Acad. Sci. é]: 685-699. I.J. Spontaneous Seizures and Related Electroencephalographic Findings Following Shock Therapy, J. Nerv. Ment. Dis. 122: 581~588. Blumenthal, (1955): Coady, A. and Jewesbury, E.C.O. (1956): A Clinical Trial of Benactyzine Hydrochloride ("Suavital") as a Physical Relaxant, Brit. Med. Journ. Mar. 3, pp. ABS-#87. Cohn, R. (l9h5): & EEG Psychiat. Study of Prefrontal Lobotomy, Arch. Neurol. 5;: 351—357. Denber, H.C.B. (1957): Discussion, Symposium on the Psychopharmacologic Approach to Schizophrenia, Second Int'l Congress of Psychiatry, Zurich. Fabisch, Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients, J. Neurol. Neurosurg;_& Psychiat. 29: W. (1957): 185—190. 10. Fink, M. Fink, M. Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol. §: 158 (abst). and Kahn, R.L. (1956): Delta Activity to Quantitative Serial Psychiat. (in press). and Kahn, R.L. (1957): Relation of Behavioral Response in Electroshock: Studies, ll. . A.M.A. Arch. Neurol. & EEG Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the Electroshock Process, J. Nerv. Ment. Dis. (in press). Fink, M. (1957): Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior, Presented 2nd Int. Congress of Psychiatry, Zurich. �- 15 REFERENCES 13. Fink, M., Green, M.A. and Bender, M.B. (1952). The Face-Hand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology' 2: h6—58. 14. Fink, M., Shaw, R., Gross, G. and Coleman, F.S.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. (in press). 15. Hankoff, L.D., Kaye, E., Engelhardt, D.M. and Freedman, N. (1957): Convulsions Complicating Ataractic Therapy, Their Incidence and Theoretical Implications, N.Y. State J. Med. 51: 2967-2972. l6. Hoagland, H., Malamnd, w., Kaufman, 1.0. and Pincus, G. (l9h6): Changes in Electroencephalogram and in Excretion of 17 Ketosteroids Accompanying Electro-shock Therapy of Agitated — Depression, Psychom. Med. Q: 2h6~251. 17. Jacobson, E. (1955): Suavitil, et Nyt Stof Med Specifik Virkning pa Centralnervesystemet, Ugeskrift for Laeger, 117: 1147—1151. 18. Khhn, R.L. and 19. Kahn, R.L., Graubert, D. and Fink, 20. Kahn, R.L., Fink, Fink, M.: Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press). (1955): of Parts of the Body After Insulin Hospital. '3: 13h-1h8. Coma Delusional Reduplication Therapy, J. Hillside and Weinstein, E.A. (1956): Relation of Amobarbital Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. M. Test to Psychiat. & 21. M. 1g: 23-29. (1957): Changes in Languages During Electroshock Therapy, in Psychopathology of Communication, Grune & Stratton, Kahn, R.L. and Fink, M. (in press). (1957): Perception of Embedded Figures After Induced Altered Brain Function, Am. Psychol. 12: 361 (abst.). 22. Kahn, R.L. and Fink, 23. Kalinowsky, L.B. and Koch, P. (1952): Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry, New York: Grune & 2h. Karliner, M. Stratton. W. (1956): J. Hillside Epileptic States Following Electroshock Therapy, HOSp. 2: 258—263. �- 16 REFERENCES 25. Klotz, Incidence of Seizures, with (1955): M. Prefrontal Findings, in Psychiat. 1E: EEG Lobotomy, A.M.A. Arch. Neurol & Ink—1&8. 26. and Kwalwasser, S. (1956): Relation of Changes in Memory and Learning to Improvement in Electroshock, Korin, H., Fink, M. Conf. Neurol. 16: 88-96. 27. Kwalwasser, S. and Caplan, M. (1952): A Case of Prolonged Insulin Coma: Treatment, J. Hillside Hosp. 1: Ins-155. 28. Liberson, W. EEG T. (1956): Effect of "Tranquillizing" Clin. Neurophysiol. Drugs on EEG, 8: 523. (1957): The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy, J. Neurol., Neurosurg., & Psychiat. 29: 105-107. 29. Liddell, 30. Perlstein, D.w. and Retterstol, M.A. (1956): Disorders, J. Revitch, E. (l95h): Clinical N. Miltown, Its Use in Convulsive and Related Assoc. 161: thO. Am. med. Observations on Organic Improvement Following Psychiat. Quart. 28: 79-92. Brain Protracted Damage and Insulin Coma, (1951): Changes in the EEG Under Barbiturate Anesthesia Produced by Electro Convulsive Treatment and Their Significance for the Theory of ECT Action, EEG Clin. Neurophysiol. g: 261-280. 32. Roth, 33- Roth, M., Kay, D.W.K., Shaw, J. and Green, J. (1957): Prognosis and Pentothal Induced Electroencephalographic Changes in ElectroConvulsive Treatment, EEG. Clin. Neurophysiol. 2: 225-238. 3h. Shagass, C. and Rowsell, P.W. (195k): Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma, A.M.A. Arch. Neurol. & Psychiat. 12: 705—711. 35- Sigg, E.B. and Schneider, J.A. (1957): Mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine, EEG. Clin. Neurophysiol. 2: h19-h26. 36. Simon, A., Margolis, L.H., Adams, J.E. and Bowman, K.M. (1951): Unilateral and Bilateral Ldbotomy: A Controlled Evaluation. M. A.M.A. Arch. Neurol. & Psychiat. gg; ugh—503. �- 17 REFERENCES Chlorpromazine: Use to Activate Electroencephalographic Seizure Patterns, EEG Clin. Neurophysiol. 2: #27-hh0. 37- Stewart, L.F. (1957): 38. Ulett, G.A., Smith, K. Convulsive and Control Group, 6.0. (1956): Evaluation of Subconvulsive Shock Therapies Utilizing a and Glesser, Am. J. Psychiat. 112: 795-802. Wachspress, M., Blumberg, A.G., Fink, M. and Miller, J.S.A. (L956): Evaluation of High—Dose Reserpine Therapy for Relief of Anxiety, J. Hillside Hosg. 2: 67-77. #0. Walter, R.D., Yaeger, C.L., Margolis, L.H. and Simon, A. (1955): The EEG Changes in Unilateral and Bilateral Frontal Lobotomy, 111: 590-59h. Am. J. Psychiat. hi. Symbolic Weinstein, E.A. and Kahn, R.L. (1955): Denial of Illness: Thomas. C.C. and Physiological Aspects. Springfield, 111.: he. Wikler, A.: Personal Communication. (1953): Yaeger, C.L., Simon, A., ﬁargolis, L.H. and Burch, N.R.: Electroencephalographic Studies in Posthypoglycemic Coma, J. Nerv. & Ment. Dis. 118: h35—hhl. �A Unified Theory of the Action of Physiodynamic Therapies Max Fink, M.D. From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Read at the 2nd International Congress of Psychiatry, Zurich, September 6, N.Y. 1957. Institute of Mental Health, National Institutes of Health, U.S. Public Health Service; and the Board of Directors' Research Fund of the Society of the Hillside Hospital. Aided by grant M-927 of the National 10-7-57 �Iv: A The 10/5/57 Unified Theory of the Action of Physiodynamic Therapies proper role of the physiodynamic therapies (electroshock, insulin coma and lobotomy) in psychiatry remains poorly defined. In part, this results from the lack of an adequate formulation of their of action. In the past mode six years increasing evidence for a neurophysiologic-adaptive shock therapy has been presented (hl, 32, 38, 1). view of electro- This view ascribes the thera- peutic precess in electroshock to a persistent alteration in cerebral function which provides the milieu environment. The type for a change in adaptation of the subject to his of adaptation evoked is dependent upon the personality of the subject, the environmental situation, and the duration of the induced alteration in cerebral function. Concurrently, of action in insulin mode coma (31) and lobotomy (ho) has developed. During the past four years we have studied the alteration in various indices of brain function of psychiatric patients to therapy. The view of insulin relation between and the behavioral response neurophysiologic-adaptive view of electrhshock has been supported and amplified (9, 10, for a similar similar an awareness of a coma has been ll, 20, 21); evidence presented (19); and recently the concept has been extended to the newer "tranquillizers" (12). These studies provide the basis for a generalization concerning the efficacy of these therapies. It is our purpose in this report to examine the exPerimental evidence whether or not the mode of action of each of these therapies may to determine result their ability to induce sustained alteration in cerebral function; from and the corol- lary question, whether measurable alteration in cerebral function is a necessary �-2condition for the efficacy of these therapies, or a "complication" or "untoward effect." The include indices of brain function used in these studies have varied. These memory scales (26), visual (22) and tactile changes in language patterns of orientation both (13) perceptual tasks, and clinically (21) changes in the delta index, both in routine records (9, 10) and by intravenous thiopentone (32, 33), and successfully. For this review, have been selected because of after In electroencephalographic studies of this problem, intravenous amobarbital (20). delta index of the unactivated and in the beta index (16) have been applied two indices EEG, and after activation will be stressed: changes in the clinical neurologic signs. These indices their successful application in the analysis of the electroshock process, and because data is available for each of the therapeutic modalities . �OBSERVATIONS: (a) Electroshock: The role of changes in ll). shock (9, following notes summarize our experimental studies of the EEG delta activity in the response of subjects to electro- In these studies, electroencephalograms were obtained before treatment, and at weekly intervals on a day after a treatment in consecutive electroshock referrals. week, Grand mal treatments were administered for 12-20 treatments. The EEG three times a records were quantitatively analyzed for the amount of induced delta activity, and classified into categories of "high", "moderate" and "low" degrees of delta patients were independently the categories of In the activity. At the end of treatment, the rated for their short term clinical reaponse into "much improved", "moderately improved" and "unimproved”. initial series of patients, a significant relationship between the early induction of high degrees of delta activity, and clinical ratings of Eighty percent of the records in the "much improved" was observed. much improved group were high degree delta by the h-6 treatment; and the percentage was sus- tained at 90% in the third and fourth weeks. In contrast, none of the unimproved patients developed high degree delta records in the 20% three weeks, and only of the records in the fourth week were so classified. In a subsequent predictive study, the and first third weeks of treatment delta records were analyzed. on both occasions, 67% were patients without such records, categories. 70% EEG records during the second 0f the patients rated as who had much improved, high degree while of the were in the unimproved and moderately improved �Roth (32, 33) studying the EEG h . delta activity thiopentone after electroshock has related both the evoked by intravenous stability and the rate of remission of patients with endogenous depressions to the peak value of the induced slow activity. activity level, " He ...... concluded that patients not attaining a specified delta have not acquired an adequate physiological basis for recovery," and recommended measurement of delta activity levels after thiopentone as a guide to the clinical management of patients. Further information is obtained from convulsive-subconvulsive control studies. While convulsive electroshock induces degrees of vary from low to high, subconvulsive therapy rarely alters duces low degrees of delta delta activity that EEG patterns or in- activity (11). In their comparative study of different convulsive and subconvulsive techniques, Ulett, Smith and Glaser (38) demon- strated a significantly greater recovery rate for the convulsive than the subconvulsive group. In a similar study (11) recently completed here, twenty-seven patients received a course of subconvulsive therapy. weekly Electroencephalograms, taken at intervals, demonstrated minimal changes ~ none of the records were scored as middle or high delta activity. 0f the 27 patients, no change in behavior was noted in 23, and of these, 19 were referred for a second course of treatment. Grand mal electroshock induced a high degree of delta activity in fourteen. All patients in this group showed significant changes in behavior, while of the five who did not show the delta response, only two showed a behavioral change. (b) Tranguillizing Drugs: When the newer drug therapies are studied from the viewpoint of �-5. their electroencephalographic and clinical neurologic effects, a meaningful classification emerges. Furthermore, a relationship between the degree and type of induced change in cerebral function and therapeutic efficacy may be noted. The ability of these agents to induce such signs of central nervous system dysfunction as motor rigidity, depression, excitement and seizures are well known. Less well documented, however, are the clearly definable electroencephalographic patterns. Based on observations made of drugs in adult psychiatric patients, the EEG in chronic administration changes may be according to predominant changes in the frequency spectrum. classified There are three broad types: I. Increased slow wave activity with hypersynchrony ("bursts") - "delta shift" II. Desynchronization with voltage and frequency and III. irregular theta activity — "desynchronization" shift." Increased high voltage fast activity - "beta Of the group of drugs inducing a derivatives chlorpromazine, promazine, Each drug induces irregularity delta shift, the phenothiazine and perphenazine are clear examples. seizures in non—epileptice or exaggerates seizures in epileptic patients (7, 8, 15, 29, 37). neurologic patterns when given have induced parkinsonism in have observed seizures in 10% Each drug induces in adequate dosage. clinical parkinsonian In our laboratories, all patients receiving chlorpromazine (1k) and of a group of psychotic patients without previous history of seizures. Induced delta activity, including burst activity, observed in more than we half the patients in this series. was �- 6 - Reserpine also evokes delta activity At high dosage levels, it exaggerates when given in large doses (2). seizures in epileptics and induces seizures in animals (35). At the usual clinical dosages, however, reserpine induces desynchronization of frequencies with a moderate increase in theta activity (28), without seizure induction but with definite motor rigidities. In a series of patients treated here (39), parkinsonism was induced in patients. EEG changes were limited to desynchronization only, without all delta burst activity. The primary the induction of EEG response of two other drugs, mepazine and benactyzine, is desynchronization. Mepnzine, a phenothiazine derivative, induces desynchronization with small amounts of theta activity has not been described, nor or parkinsonism in the have we found activity (7). Delta reports either of seizures clinical literature. Benactyzine, a potent anticholin— ergic compound, induces a blocking of alpha, flattening of the record and 1?). Neither seizures nor parkinsonism have occasional theta activity (5, been described for this agent. Meprobamate beta and shift in the EEG is the clearest example of the group of drugs inducing a (3). This agent further differs from the phenothiazines reserpine in not producing parkinsonism and not only are clinical seizures not induced, but definite anti—epileptic activity has been described (30). Habituation is readily achieved, seizures have been observed (ha). barbiturates than like the other If we determine the and withdrawal phenomena of agitation In these actions, meprobamate new is and more like tranquillizers. clinical efficacy of these agents, we note a parallel �- 7 between the induced drugs that thiazine most EEG effects their potency in altering behavior. and readily induce a delta shift in frequencies - the pheno- the greatest clinical efficacy in the compounds - are those with therapy of psychoses. EEG The The compounds with lesser activity in this direction are less efficacious clinically. (c) Insulin Coma The well documented. Therapy: effects of insulin During each coma, persists for minutes to a EEG coma delta activity is induced, after gavage. few hours imately one third of patients receiving deep seizures, aphasia or prolonged coma therapy on the nervous system are coma which usually infrequently, in approx- Not therapy in this hospital, results. After such events, changes EEG of delta activity persist for days, and in cases of prolonged coma, for weeks and months (h3). relation between prolonged The coma, altered brain function ioral response has been discussed at length. Revitch of prolonged coma and concluded tion of organic brain damage, that (31) reported improvement may be insulin eight cases attributed to the induc- similar to lobotomy. Yaeger, Burch (h3), describing twelve cases of prolonged and behav- Simon, Margolis and correlation coma, noted a between length of coma, degree of organic confusion, remission of mental symptoms and degree of EEG abnormality. Shagass and Rowsell (3h), emphasizing and Kwalwasser and Caplan (27) presented EEG individual cases to support the data, same conclusion. we reported a similar relationship between prolonged response in a case study (19). A 3h coma and behavioral year old schizophrenic patient with paranoid �- 8 - ideation developed a left hemiplegia during insulin coma therapy. With the onset of neurologic signs of hemiparesis, hemianopsia, hemisensory syndrome and spatial inattention, there was a marked change in speech and behavior. loquacious and denied his illness. was by became He ludic, His former paranoidowithdrawal type pattern replaced by a friendly cooperative attitude. These changes were accompanied delta changes in the as well as language changes EEG, dicative of altered brain function. The behavioral changes persisted so that he neurologic was after amobarbital in- symptoms resolved, but the discharged two months later as "much improved." (d) Lobotomy: While we have not had the opportunity from the point of view of document a this summary, similar relationship. all subjects postoperatively (to) in a study of after three years. 150 EEG to study lobotomy patients the reports of numerous observers clearly changes of delta activity are present in persist for varying periods. Walter et al., patients, found an 80% persistence of abnormal EEG activity (6) and These authors ment and the degree and also noted a relation between clinical improve- extent of postoperative slow wave activity. Postoperative seizures are a frequent "complication," being variously reported as occurring up to 20% of subjects (25). Furthermore, there is a relationship between the extent of brain tissue cut and the therapeutic Circumscribed surgical lesions, regardless of locus, have an improvement lower than unilateral lobectomy; are "improved" upon by a and these outcome. rate latter are frequently inadequate bilateral procedure (36). and �DISCUSSION: When view of an the various physiodynamic therapies are essayed from the point of alteration in brain function, a therapies represent devices These of action becomes apparent. common mode brain which induce appreciable changes in function, with resultant change in behavior. Electroshock and lobotomy induce measurable diffuse changes in brain function when when given How clear. is primarily tran— in adequate dosage. persistent changes in cerebral function affect behavior is not Psychotic dehavior is not "reversed" or "obliterated". Rather, with alteration in the central nervous system milieu, there is all aspects of behavior including perception, and coma complications ensue; and the phenothiazine and reserpine groups of quillizers an directly; insulin attitude. The mood, affect, an alteration in memory, Judgment specific adaptive response is variable for each subject dependent on numerous historical and environmental sonality (18), environmental situation factors. and Pre-morbid per- and expectations (11), and the duration of the alteration in brain fUnction (10) have recently been discussed as determinants of the behavioral response under these conditions. The induced changes in behavior are evaluated by the psychiatrist, administrator or family as to the degree of "improvement." These ratings are value judgments, based upon such factors as the type of induced behavioral response, the environmental tolerance and the observer's expectations. context, the physiodynamic therapies induce behavioral change which do not induce "improvement" - is secondarily evaluated as In this rather they improvement. alteration of cerebral function is therefore not a "complication" or The an "untoward �- lo - effect" but the desired goal of these forms of therapy. therapies introduced during the past thirty years, Of the many "organic" none apparently, has been a specific agent for the therapy of psychoses (in the sense that penicillin is specific for neurosyphilis and nicotinic acid for pellagra dementia), but rather devices with greater or lesser degrees of applicability and efficacy in altering behavior by altering the cerebral milieu. this context, the various physiodynamic therapies are not specific In for a type of psychosis. was The early enthusiasm that reserpine or chlorpromazine Specific for schizOphrenia, or hypotheses that ascribe significane to an antagonism between these drugs and "psychosis" or "schizophrenia" are not tenable. Similar enthusiasm claiming a specificity of insulin also untenable, insulin coma EEG and support control study for this view coma for schizophrenia is is presented in a recent chlorpromazine- (1’4). analysis of these therapies permits a more explicit definition of the induced alteration in brain function. Changes in cerebral function reflected by a shift in the spectrum of EEG frequencies toward the slower range, with a concomitant increase in voltage and a periodicity described as "bursts" or "hypersynchrony" provide the change in milieu behavior. The that is more effective in altering significance of the delta shift has been clearly demonstrated in electroshock therapy; and can be inferred from the available data in lobotomy, insulin coma, and the That a delta drug effects. tranquillizers. shift has Those drugs some Specificity is seen in the analyses of the that induce the delta shift - the phenothiazines and reserpine - have been consistently reported as effective modifiers of psychotic �-11... of psychotic behavior. Changes in brain function reflected by tion only, or a shift in frequency Spectrum efficacy in altering psychotic behavior. is further to the faster range, have a limited * The significance of a delta shift seen in the limited efficacy of subconvulsive electroshock when Another aspect of the alteration in brain function in seizure threshold. change With the which may be defined delta shift in the in clinical seizures would be anticipated. This is indeed true. been described following electroshock (h, 2%), are prominent (to) and a common comp ‘ pared to convulsive electroshock in the management of psychoses. is the desynchroniza— EEG EEG, an increase Seizures have after lobotomy "complication" during and occasionally following insulin coma therapy (23). With the tranquillizers, the parallel of clinical efficacy and seizure induction is most striking. reserpine rarely; benactyzine not at all; commonly; anticonvulsant! EEG Phenothiazine compounds induce seizures The lowering delta shift induced and meprobamate is a potent of seizure threshold parallels the extent of the by these compounds. Similar analyses can be made for the potentiation of sedative action and induction of parkinsonism - both potent indices of an The quency some alteration in cerebral function. neurologic basis for the delta shift and increase in seizure fre- is unclear. Whether this represents a persistent change in function of specific brain stem nuclear system, as the centrencephalic, thalamic or hypothalamic, is conjectural. From the wide range of agents that can induce a * These observations suggest the application of EEG screening of new chemo~ therapeutic compounds for therapeutic efficacy according to their ability to induce delta burst activity with a minimum of side effects. �- 13 SUMMARY: 1. shock, The neurophysiologic and clinical neurologic aspects of electro- "tranquillizers," insulin 2. The coma and lobotomy, are reviewed. efficacy of each therapy in the treatment of psychoses is related to the ability to induce a persistent change in cerebral function, of which a delta shift in the seizures are indices. 3. two EEG spectrum and an increase in incidence of Alteration in cerebral function is behavioral change with each of these therapies. a "complication," nor an "untoward mode an essential prerequisite of Such alteration is neither effect," but is the gigs 333 299 of the of action of these therapies. M. No evidence has been educed in these studies that the physiodynamic therapies are Specific agents for the relief of psychoses; nor specific do they affect a segment of the nervous system; nor do they induce Specific behavioral changes. 5. and The therapeutic process of electroshock, insulin tranquillizers may be in cerebral function coma, lobotomy ascribed to the induction of a persistent alteration which provides the milieu the subject to his environment. for a change in adaptation of �- 1a - REFERENCBS Pace, J.w., Esrnoff, M.K. and Bowditch, 8.0. (1956): Neurophysiologic Effects of Electrically Induced Convulsions, A.M.A. Arch. Neurol. & Psychiat. 12: 371-378. Aird, R.B., Strait, L.A., Jeri, Arellano, A.P. and R. (1956): The Effect of Reserpine on the EEG. Clin. Neurophysiol. Scalp and Basal Electroencephalogram, §: (abet). 150 The Chemistry and Mode of Action of Drugs, Ann. N.Y. Acad. Sci. é]: 685—699. F.M. (1957): Berger, lizing I.J. Tranquil- Spontaneous Seizures and Related Electroo Following Shock Therapy, J. Nerv. Findings encephalographic Ment. Dis. 122: 581-588. Blumenthal, (1955): Coady, A. and Jewesbury, E.C.O. (1956): A Clinical Trial of Benactyzine Hydrochloride ("Suavital") as a Physical Relaxant, Brit. Med. Journ. Mar. 3, pp. h85-h87. Cohn, R. (l9h5): Study of Prefrontal Lobotomy, Arch. Neurol. ﬁg; 351-357. EEG Psychiat. & Discussion, Symposium on the PsychOpharmacologic Approach to Schizophrenia, Second Int'l Congress of Psychiatry, Zurich. Denber, H.C.B. (1957): Fabisch, Effect of Chlorpromazine on the Electroencephalogram of Epileptic Patients, J. Neurol. Neurosurg. & Psychiat. g9: w. (1957): 185-190. Fink, M. and Kahn, R.L. (1956): Quantitative Studies of Slow Wave Activity Following Electroshock, EEG Clin. Neurophysiol. g: 10. Fink, M. 158 and Kahn, R.L. (1957): Relation of EEG Delta Activity to Behavioral Response in Electroshock: ‘Quantitative Serial Studies, 11. (abet). A.M.A. Arch. Neurol. & Psychiat. (in press). Fink, M., Kahn, R.L. and Green, M.A.: Experimental Studies of the Electroshock Process, J. Nerv. Ment. Dis. (in press). Fink, M. (1957): Therapy of Schizophrenia: Role of Alteration of Brain Function in Behavior, Presented 2nd Int. Congress of Psychiatry, Zurich. �- 15 REFERENCES 13. Fink, M., Green, MlA. and Bender, M.B. (1952): The Faceoﬁand Test as a Diagnostic Sign of Organic Mental Syndrome, Neurology .§= ”6‘58. 1h. Fink, M., Shaw, R., Gross, G. and Coleman, F.S.: Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Psychosis, J. Amer. Med. Assoc. (in press). 15. Hankoff, L.D., Kaye, E., Engelhardt, D.M. and Freedman, N. (1957): Convulsions Complicating Ataractic Therapy, Their Incidence and Theoretical Implications, N.Y. State J. Med. 21: 2967—2972. 16. Hoagland, H., Malamud, W., Kaufman, I.C. and Pincus, G. (l9h6): Changes in Electroencephalogram and in Excretion of 17 Ketosteroids Accompanying Electra-shock Therapy of Agitated Depression, Psychom. Med, g: 2h6~251. 17. Jacobson, E. (1955): Suavitil, et Nyt Stof Med Specifik Virkning pa Centralnervesystemet, Ugeskrift for Laeger, 117: llh7-1151. 18. Kahn, R.L. and Fink, M.: 19. Kahn, R.L., Graubert, D. and Fink, 20. Kahn, R.L., Fink, Personality Factors in Behavioral Response to Electroshock Therapy, Conf. Neurol. (in press). (1955): of Parts of the Body.After Insulin Hospital. ‘3: 13h-1h8. Coma Delusional Reduplication Therapy, J. Hillside and Weinstein, E.A. (i956): Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. & 21. M. M. Psychiat. {1§: 23~29. Changes in Languages During Electroshock Therapy, in Psychopathology;of Communication, Grune & Stratton, Kahn, R.L. and Fink, M. (1957): (in press). M. (1957): Perception of Embedded Figures After Brain Altered Induced Function, Am. Psychol. lg: 361 (abst.). 22. Kahn, R.L. and Fink, 23. Kalinowsky, L.B. and Koch, P. (1952): Shock Treatment, Psychosurgery and Other Somatic Treatments in Psychiatry, New York: Grune & 2h. Karliner, Stratton. W. (1956): J. Hillside Epileptic States Following Electroshock Therapy, Hosp. g: 258-263. �- 16 - REFERENCES Incidence of Seizures, with (1955): 25. Klotz, 26. Korin, H., Fink, M. Prefrontal lhh-lh8. Findings, in Psychiat. 13: EEG Lobotomy, A.M.A. Arch. Neurol & and Kwalwasser, S. (1956): Relation of Changes Memory and Learning to Improvement in Electroshock, in M. Conf. Neural. 1Q: 88-96. 27. Knalwasser, S. and Caplan, M. (1952): A Case of Prolonged Insulin Coma: Treatment, J. Hillsidewﬂosp. 1: 1&5-155. 28. Liberson, W. EEG T. (1956): Effect of "Tranquillizing" Clin. Neurophysiol. §: 523. (1957): The Occurrence of Epileptic Fits in Leucotomized Patients Receiving Chlorpromazine Therapy, J. Neurol., Neurosurg., & Psychiat. 29: 105-107. Betterstol, 29. Liddell, 30. Perlstein, 31. Revitch, E. (l95h): D.W. and N. Miltown, Its Use in Convulsive and Related Am. Med. Assoc. 161: thO. M.A. (1956): Disorders, J. Clinical Observations on Organic Brain Improvement Following Pszghiat. Quart. g§z 79—92. Roth, M. Drugs on EEG, Protracted Damage and Insulin Coma, (1951): Changes in the EEG Under Barbiturate Anesthesia Produced by Electra Convulsive Treatment and Their Significance for the Theory of ECT Action, EEG Clin. Neurophysiol. g: 261-280. 33- Roth, M., Kay, D.W.K., Shaw, J. and Green, J. (1957): Prognosis and Pentethal Induced Electroencephalographic Changes in ElectroConvulsive Treatment, EEG. Clin. Neurophysiol. ‘2: 225-238. 3h. Shagass, C. and Rowsell, PM. (195M: Serial Electroencephalographic and Clinical Studies in a Case of Prolonged Insulin Coma, A.M.A. Arch. Neurol. & Psychiat. lg: 705~711. 35- Sigg, E.B. and Schneider, J.A. (1957): mechanisms Involved in the Interaction of Various Central Stimulants and Reserpine, EEG. Clin. Neurophysiol. ‘2: h19-h26. 36. Simon, A., Margolis, L.H., Adams, J.E. and Bowman, K.M. (1951): Unilateral and Bilateral Lobotomy: A Controlled Evaluation. �- 17 - REFERENCES Chlorpromaiine: Use to Activate Electro~ encephalographic Seizure Patterns, EEG Clin. Neurophysiol. 2: h27-hh0. 37- Stewart, L.F. (1957): 38. Ulett, G.A., Smith, 39- Wachspress, M., Blumberg, A.G., Fink, #0. Walter, R.D., Yeager, C.L., Margolis, L.H. and Simon, A. (1955): The EEG Changes in Unilateral and Bilateral Frontal Lobotomy, 111: 590-59h. Am. J. Psychiat. kl. Weinstein, E.A. and Kenn, R.L. (1955): Denial of Illness: Symbolic and Physiological Aspects. Springfield, 111.: C.C. Thomas. #2. Wikler, A.: R3. Yaeger, C.L., Simon, A., Margolis, L.H. and Burch, N.R.: (1953): Electroencephalographic Studies in Posthypoglycemic Coma, J. Nerv. & Ment. Dis. 118: h35~hhl. Glesser, 6.0. (1956): Evaluation of Convulsive and Subconvulsive Shock Therapies Utilizing a Control Group, Am. J. Psychiat. 112: 795-802. K. and Miller, J.S.A. (L956): Reserpine Therapy for Relief of M. and Evaluation of High-Dose Anxiety, J. Hillside Hosp. E: 67~77. Personal Communication. �- 12 _ delta shift, with or without hypersynchrony, EEG changes it appears more likely that the reflect an alteration in the diffuse biochemical activity of the nervous system rather than in a focal activity of specific cellular masses. �gﬁéW W ¢ mA/LWWW“??? ﬂﬂmw ”ﬂ 0 WA; .Wbﬂ' WV WW/W» Wﬁwé W erﬂc/ééé/‘nggg WW Wan/Raw ,5, wage; 4* ”Jaw“ £5149 MM 55¢?” 44%“ €40» MW + mama 5-an we 9 MA 401: é’U—k , é1w%(b Wdyk 7" «anlwn/em r 6 MW Www MAM/:2 WAMWMmM ”acacia/77¢“ M 0.4.2. 407973 WWMMWM MWMA Wﬂ’wwvéob (law w W MfM 3k- (WALK-MW —~ c w mQa—éﬂaec. "1426 7'":wa ﬂow szC 2’ , VM’bgek-«tk’ ﬂ/Lf/wa «6% Egg kw Mgr , LWwaCA/I wwaﬂ/VL/e .Z 9744M /,’_5._ J 1(HMWA‘QWW CWc/QW'OA‘: /\ ("‘1‘ fyék" W W “FM W (aw/WWW wa» W/MW W»! 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' ”i'QUq \ qi‘ﬁ-«x;.¢'\§§\r "ix ‘3 ,, 3 F—J-n , r) ,, ., -- M A v = ‘\ - | J) J} \3_ } 9531‘wNAQDQ s;- "(f‘ LJ) ' l . 3 r k1\ J _ ‘53 x 1- 2' 743. \3: - 4344;- 3‘*‘ AV‘JJQ.» ’ ‘2‘J&\ I a “432.35 «3513:; )vaia r"3-1-3 51,5r ‘ *7 \ , ._3 ~ \ , . 3 (\x ,‘ .3-.M—vx;“* f T . . 3 \I-J‘IJL‘J ‘ ,3 3.3\J -\_)\r§ 3 Q [11-43) " j J—‘~f'\' {t ’3‘ .3. 3 3, u r “331,-. ‘ is m N3 a . v �QFURTHER OBSERVATIONS MADE SINCE THE ARTICLE "Electro-cncephalo- graphic Evidence of Bersonality Changes by Ataraxic Drugs in Mentally Disturbed Patients." WAS WRITTEN. l) A number of mistakes due to faulty or non-standardized technique in the assessment of alpha a) Duration of the recording: It was found that some activity for the first stability patients had were made. little alpha five to ten minutes of the who recording deve10ped a more stable alpha activity, later it is on. therefore suggested that samples of alpha activity should be taken at least ten minutes after the beginning of the E.E.G. recording. b) Period of the day: Slight differences of habitual alpha activity were observed in one and the same patient according to the time of the day when the E.E.G. recording was taken. applies also to the period of the last meal. It is therefore suggested that the E.E.G. tracings The same should be taken at the same time of the day and at the same intervals after the last mealhad been taken. c) Waiting of the patient before the E.E.G. recording. It observed that if patients had to wait for long periods in the waiting room before his E.E.G. recordwas ings were taken the alpha activity was poorer than on d) Noises. The effect of any noises, particularly of any talk, during the E.E.G. recording changed thexalpha E.E.G. pattern imedia-telyss It seems therefore that the total absence of any noise is necessary to produce a valid E.E.G. recording for the assessment of alpha 0) A stability. Special alpha run, allowing the simultaneous trac-' ing of temporal and parietal occipital alpha was found to be useful. �2) The alpha stabilizing effect of Largactil and Serpasil. a) Single administration: intravenous and intramuscular administration of a single large dose of Largactil (100 mg.) or Serpasil (5 mg.) often had little or no effect on the 1. The alpha stability. ii. The period of administration of the 3 days to 2 same drugs, over a weeks, did produce an alpha stabilization. b) Age groups: effect of these two drugs, in sufficient quantities, was observed in all children whose habitual alpha activity was poor. ii. In adults there were some exceptions to the rule, particularly elderly people suffering from depression. 0) Quantitl: The effect of alpha stabilization, even after a long period of administration, was sometimes only observed when large quantities of the drugs were given. It is therefore suggested that in case of a negative E.E.G. effect the test should be repeated after in1. The creasing the dosage of the drug. d) Temporal Alpha: It is observed that in sons cases the alpha stabilization occurred equally in the temporal and parietal occipital regions. Most often however, the alpha stabilization was more marked in the temporal regions, infrequently the alpha stabilization occurred in the temporal regions only. and not e) An experiment was conducted on 30 schizophrenic pmients, 10 patients received Serpasil 3 grs. daily, 10 patients received a new drug to be tested and 10 patients received a placebo. E.E.G. tracings were taken before the 'administration of the drugs and on one occasion after the course of drugs was started. Psychological tests were made to assess the clinical improvement. �It that the patients who had received Serpasil showed a statistically significant improvement of their alpha-stability. The ten patients who had received the new drug that was to be tested showed a significant diminution was found of alpha-stability in the temporal regions. The patients who received the placebo showed a random distribution of improvement or deterioration of their temporal alpha rhythm. The correlation between improvement of alpha-stability int.- the temporal region and clinical improvement was about +0.45 only, in all 30 cases, whether this was due to the effect of drugs or not. The Doctor who was conducting the experiment, the statistician of the Mental Hygiene Department and our own observations in our E.E.G. Department showed that many relevant factors during the psychological testing (in which unfortunately "socialis- ation“ was not a part) suggesting improvement were not controle' led. f) It is that alpha-stability may be correlated with relaxation and alpha-blocking with tension, though this is certainly not the full story, probably a reasonable hypothesis to assume only an approximation. About 80% of true melancholics, who are certainly not relaxed, have an exceptionally high alpha index. Ostow's suggestion thatwalpha activity generally respons to a preparation for constructive thinking and the disappearance of the alpha activity when the constructive process was put into action, probably, is nearer to the truth. The more correct hypothesis would seem to be that relaxed patients generally ruminate less than tense subjects. 3) Further references bearing on the subject of alpha stabilization: a) "By hypnotic suggestion to relax, Ford and Yeager reported the induction of "good" alpha patterns in several patients with anxiety states, whose previous E.E.G.'s showed little or no alpha-rhythm.' Relaxation suggestions were not followed by EE.G. changes in subjects whose E.E.G.'s rhythm." naturally showed "good" �- 4 _ Ford, W.L. and Yeager, C.L. "changes in the electroencephalogram in subjects under hypnosis. "Dis.nerv. systo 1948, 9, 190—192. H a) There are several references in the literature to the fact that short courses of electro-shock-treatment tend to increase the E.E.G. alpha activity. 4) W: quoting a reference of Ellingson a mistake occurred in my article which should be corrected. When Should read - preposition by Saul and Davis that passive indiv— iduals tend to have regular persistent alpha rhythms of high index has been often cited in the literature and “The appears to have been accepted as fact. Sisson and E11ingson reviewed the evidence upon which that preposition was based and found it unconvincing.” uni?“ �/ g , §n\3\ L. @ 6 W Q wwwwwsméo WﬁpﬂoA Ni Nf \\ WWUWMNW . w glwﬁg ENK :xWng W . (GMWECQMV wmim 3% 13mm v Eé . IVSNEPSNxMPIQXB \m\§§£§§w\% ‘ gmxmigg §§\ W I \KQ‘PVGV \um m EQ® “Sag V � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A unified theory of the action of physiodynamic therapies. J Hillside Hosp., 6: 197-206. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-23-028 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource 5 items. 1: Xerox copy. 2: Two presentation copies. 3: Handwritten manuscript.4: Draft copy. 5: Chart. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/4d1964245452e951a0fc4a640e62c9dc.pdf 68280c1aa72a42e9812ae2fd531e09b0 PDF Text Text 50 ALTERATION OF BRAIN FUNCTION IN THERAPY MAX FINK following summary of observations made at a 200-bed voluntary, nonproﬁt, open-ward psychiatric hospital during the past three years is presented as the basis for discussion. The major interest of our Research Service is an investigation of the mode of action of various somatic therapies, especially electroshock and drugs. The disciplines represented in the research unit are clinical and psycho« dynamic psychiatry, neuropsychology, and experimental and clinical psychology. The following data summarize various studies that have previously been reported only in part: (I) High-dose reserpine for relief of anxiety: double-blind placebo study. (2) Chlorpromazine-insulin coma study. (3) Electroencephalographic effects of various drugs. (4) Electroshock process: concurrent psychiatric, psychologic, and neurophysiologic observations. HE OBSERVATIONS Reserpine In a placebo-controlled, double-blind study of oral and intramuscular reserpine, consecutive patients referred for drug therapy were rated for degree of manifest anxiety.1 The patients with high degrees of anxiety received randomized three-week periods iof reserpine therapy, divided into the following daily dosage periods: 10 mg. of reserpine (5 mg. oral, 5 mg. intramuscular), 5 mg. of reserpine (oral or intramuscular), or Reprinted from Psychopharmacology Frontiers. Proceedings of the Psychopharmacology Symposium of the Second International Congress of Psychiatry held in Zurich, Sw1tzerland on September 2-4, 1957. Published and copyrighted 1959 by Little, Brown and Company, Boston 6, Massachusetts, USA. �326 PSYCHQPHARMACOLOGY FRONTIERS placebo. Drugs were administered daily. None of the observing therapists knew which sequence was being followed or the dosages administered. Relief of anxiety symptoms related to drug dosage was seen in 20 per cent of the group. In 80 per cent no relief was noted, and of these, onethird exhibited severe depressive reactions which eventually responded to electroshock therapy. The high doses of reserpine administered resulted in signiﬁcant clinical manifestations in every patient. The be~ havioral changes induced were directly related to the degree of concomitant physiologic disturbance. It was the conclusion of this study that high-dosage reserpine therapy has limited usefulness in the relief of anxiety symptoms. The dangers of induced depressions were clearly manifest, and the uncomfortable nature of the side effects of drug administration has resulted in a limited application of this drug in this environment. Chlorpromazine-insulin coma During a ﬁfteen-month period, all patients referred by the supervising psychiatrists at this hospital for insulin coma therapy were divided by random sampling into an experimental group and a control group.2 The control group received classical insulin coma treatment, following the basic technique of Sakel. All patients received ﬁfty comas, each of a duration of one hour or longer, at the physiologic level of Babinski reﬂex or absent lid reﬂex or deeper. The experimental group received chlorpromazine therapy in rapidly increasing dosages until toxicity had been induced. When toxic signs of rigidity, drooling, ﬁxed facies, seizures, dermatitis, or marked weakness appeared, the dosage was gradually reduced until a maintenance level was obtained. Patients were sustained on this regime for a period of three to four months. In both groups, behavioral observations were made by investigators none of whom was the for referred treatment, resulting were Sixty patients therapist. patient’s in two groups of 30 each. The maintenance dosage of chlorpromazine was 300 to 2000 mg. daily. Initial dosages ranged from 1400 to 3600 mg. daily. Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic, and less violent. One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves, became sloppy, and failed to dress. Affective changes during chlorpromazine were varied. Four patients became increasingly agitated, tense, and tremulous, and either refused to continue on the drug regime or were induced to do so only with �MODE or ACTION 327 difﬁculty. Such an affective .storm appeared early in the therapy and persisted. .. In 4 other cases, depressive symptoms were signiﬁcantly relieved, with an increase in affective lability and responsivity. In 2 patients, depressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with eventual alleviation. In most patients mood changes were small. Ideation was altered during the period of chlorpromazine therapy in 12 of the patients. Eight patients had a loss or a signiﬁcant diminution of psychotic ideation. In 5, the hallucinatory and referential experiences were no longer reported even on inquiry, and in 3 others, delusional ideation was less prominent. In 1 patient, however, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regime. The clinical effects of insulin coma therapy have been exhaustively reported, and the ﬁndings in this series are comparable to those previously published. With regard to the evaluation of improvement, all 60 patients of this study have been discharged from the hospital. Table I lists patients according to the four-fold classiﬁcation in use in the hospital at the discharge conference. TABLE I DISCHARGE RATINGS Chlorpromazine Insulin Coma Recovered Much improved Improved Unimproved 2 4 0 5 l7 l5 7 10 Inherent in the design of this study were high doses of chlorpromazine, pushed until symptoms of toxicity appeared. In this context, therefore, all patients developed signiﬁcant drug effects. In all, rigidity of extremities appeared, frequently accompanied by a decrease in facial expression, drooling, and festination. Untoward complications are listed in Table II. Electroencephalograms were obtained in 20 of the chlorpromazine patients. On adequate doses, concomitant with a change in clinical behavior a moderate amount of low-voltage 4 to 7 cps delta and theta activity was observed. This activity was exaggerated by hyperventilation. In the 3 patients in whom seizures were induced, the delta activity was not signiﬁcantly different from the remainder of the group. There was a �328 PSYCHOPHARMACOLOGY FRONTIERS suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. TABLE II COMPLICATIONS Chlorpromazine Agitation and panic Dermatitis, severe Seizures Refusal of further therapy Hypotension Secondary reaction, frequent Prolonged coma (more than 6 hours) Insulin resistance Regression of behavior 4 3 3 2 Insulin Coma 3 5 2 2 — — Dab—409ml 2 It was the conclusion of this study that neither Chlorpromazine in high doses nor insulin coma is a speciﬁc treatment for schizophrenia. It was noted that these treatments were devices to temporarily alter behavior that had been socially unacceptable. Since Chlorpromazine was safer, easier to administer, and more controllable in its effect and had fewer side effects, it was recommended that it replace insulin coma. Role of electroencephalographic changes in behavioral change As noted in the following section, a direct relation between changes in electroencephalographic delta and behavioral changes in electroshock had been observed in these laboratories. For this reason, a survey of the role of various newer drug agents was undertaken to determine the potential relationship between behavioral change and electroencephalographic effects. Chlorpromazine and promazine are effective agents for the induction of changes in motor patterns of behavior. Concomitant electroencephalographic effects are the induction of delta activity, a desynchronization of the record, and a decrease in the amount of fast activity. Both drugs also induce seizure activity spontaneously in patients who have not had seizures prior to the administration of the drugs, and in whom pre-treatment electroencephalograms have not demonstrated dysrhythmic activity. Reserpine, while inducing a deﬁnite parkinsonian syndrome, does not generally induce seizures. At therapeutic levels, the changes in the electroencephalogram are limited to an increase in fast activity. We have not observed delta activity in any patient receiving reserpine. In patients receiving meprobamate, also, delta activity has not been observed. Records consistently demonstrate high-voltage beta activity, similar to barbiturate. Clinically, meprobamate has some effect in �MODE OF ACTION 329 reducing seizure activity. When dosages are suddenly reduced, we have observed spontaneous seizures in 2 subjects. This observation is similar to that noted in animals.3 Electroshock evalution studies In the course of an extensive evaluation of the electroshock process, a direct relationship has been observed between the degree of induced delta activity and the degree of behavioral change.4 We observed that serial records taken during the course of electroshock therapy and measured for quantitative changes in delta activity could serve as a guide to the therapeutic outcome. Of 11 patients who were clinically rated much improved, 10 had high-degree delta records in the third and fourth weeks of treatment, whereas of 7 unimproved patients only 1 had such a record. In a subsequent series,5 these observations were extended in a predictive study. It was suggested by these initial observations that the much improved patients were those in whom high-degree delta activity had been induced early in the course of treatment and sustained. Records taken during the second and third weeks of treatment were assessed. The results in 54 consecutive patients are noted in Table 111. Of the patients who developed high-degree delta activity during the second and third weeks of treatment, 67 per cent were rated much improved, whereas only 30 per cent of the patients without such activity were so rated. TABLE III PATIENTS WITH HIGH DELTA ACTIVITY IN EEG DURING SECOND AND THIRD WEEKS OF TREATMENT EEG Delta Both high (18) One high (16) None high (20) Much Improved 12 (67%) 4 (25%) 6 (30%) Clinical Rating Unimproved Moderately Improved 4 (22%) 8 7 (50%) (35%) ' 2 (11%) 4 (25%) 7 (35%) Delta activity in the electroencephalogram reﬂects the state of brain function, and is a guide to alterations in that state. To verify the relationship between delta activity and behavioral change, concomitant amobarbital tests for altered brain function6 were done in this series of patients. It was observed that the amobarbital test results were parallel to the electroencephalographic effects.7 Of patients in the initial series who had been rated as much improved, all had positive amobarbital test reactions after the seventh to ninth weeks of treatment and sustained this response. Of the unimproved patients, however, 15 per cent had �PSYCHOPHARMACOLOGY FRONTIERS 330 positive amobarbital responses in the third week and 28 per cent in the fourth week, but these responses were not sustained. A comparison of both electroencephalographic observations and the amobarbital test data, as related to the eventual clinical ratings, is seen in Table IV.5 TABLE IV ’ EEG AND AMOBARBITAL TEST RESULTS DURING SECOND AND THIRD WEEKS OF TREATMENT Much Improved Moderately Improved Unimproved Both positive amobarbital and high EEG delta activity Either positive amobarbital or high EEG delta activity Neither positive amobarbital nor high EEG delta activity Totals It 25 10 3 8 12 5 0 3 11 33 25 19 apparent that the cluster of positive amobarbital tests, high EEG delta activity, and the much improved clinical ratings is a signiﬁcant one; equally signiﬁcant is the cluster of negative amobarbital tests, low to moderate EEG delta activity, and a clinical rating of “unimproved.” In the clinical observations in the electroshock study varied behavioral responses were observed. These included the absence of noticeable symptoms with the return of pre-morbid behavior; hypomania, euphoria, and denial; paranoid states with ideas of reference and delusional formation; confusional states with varying degrees of memory disturbance; increased somatic complaints and preoccupations; states of increased panic, excitement, and agitation; and varying degrees of withdrawal and seclusiveness. Similar psychopathologic reactions were observed in schizophrenic patients undergoing either chlorpromazine or insulin coma treatments, or patients with severe manifest anxiety undergoing reserpine therapy. In the electroshock group, the degree of behavioral change was directly related to the degree of alteration in neurophysiologic indices. This direct relationship between neurophysiologic change and behavior was even more clearly manifested in a group of patients treated with subconvulsive therapy. In another control study, 27 subjects received subconvulsive therapy instead of grand mal therapy. The electroencephalo— grams demonstrated either no delta activity or a minimal amount of such activity during the course of treatment. In no patient were moderate or high-degree delta activity records observed. In the amobarbital tests, only 3 patients had positive reactions during treatment, and'in each instance this. occurred only once. Of the 27 subjects no change in sympis �MODE OF ACTION 331' toms or behavior was noted in 23. Nineteen were later referred for a second course of treatment. Of these, grand mal electroshock induced changes in brain function reﬂected by high-degree delta activity and /or repeated positive amobarbital tests in 14. All 14 showed signiﬁcant changes in behavior, whereas of the 5 patients in whom physiologic indices showed only minor changes, only 2 showed a deﬁnite behavioral change. It is important to note that there was no direct relationship between the physiologic changes and a speciﬁc type of behavioral change. There was, however, a direct relationship between the degree of induced physiologic change in brain function and the degree of behavioral change. In a further attempt to determine the relationship between the type of behavioral change and other variables, we have carried out studies on the role of personality in the behavorial response.8 The initial study of the role of personality was devoted to a study of the relation between the characterologic disposition of patients to show denial mechanisms and the clinical results. The relatives of 47 patients were interviewed and denial personality scores were assessed, following a structured interview. Denial scores range from 0 to 25, with a median of 11. The scores were then divided into two groups: scores from 11 to 25 were classed as high denial and those from 0 to 10 as low denial. Of patients with high denial personality scores, 58 per cent were in the much improved group and only 1 patient was in the unimproved group. The ratings of improvement for the patients with low denial personality scores were random, about one-third appearing in each rating category. These studies support the present neurophysiologic adaptive hypothesis of the mode of action of electroshock therapy. This hypothesis notes that alteration in brain function is the central effect of electroshock therapy and is a prerequisite to behavioral change. It also notes that under the conditions of the induced change in brain function, altered patterns of adaptation are expressed. The type of adaptation varies, apparently dependent upon the personality organization. CONCLUSIONS Largely on the basis of these observations, as well as of reports of numerous other observers, the following conclusions regarding the role of physiodynamic therapies in schizophrenia are suggested: (1) None of the present therapeutic regimes, including insulin coma therapy, electroshock therapy, and the newer drug therapies including chlorpromazine, reserpine, meprobamate, and promazine, are speciﬁc for schizophrenic illnesses. No evidence has been educed that any of these therapies have altered the basic schizophrenic process. �332 PSYCHOPHARMACOLOGY FRONTIERS (2) Behavorial change in electroshock has been shown to be depend- ent on an alteration in brain function, as evidenced by serial changes in delta activity in the electroencephalogram. Under these conditions, the pattern of behavioral alteration varies markedly, depending on the degree of induced cerebral dysfunction, the personality of the subject, and the environmental situation. (3) The newer drug therapies have effects on brain function in direct proportion "to their ability to alter behavior as determined by clinical observation. The parallel between electroencephalographic change and behavioral change leads to the proposition that the mode of action of newer drug therapies may be similar to that of electroshock therapy; viz., by altering brain function in a nonspeciﬁc manner, behavioral changes are induced.9 To the extent that the behavioral alteration is of a kind that is rated as improved by the environment, the drugs are considered satisfactory therapeutic agents. In this regard, it is important to note that improvement ratings are but a special case of behavioral change, dependent on the type of adaptation elicited, the expectation of the therapist, administrator, and family, and the tolerance of the milieu. REFERENCES l. Wachspress, M., Blumberg, A. G., Fink, M., and Miller, J. S. A. Evaluation of high-dose reserpine therapy for relief of anxiety. 1. Hillside Hosp, 5: 67, 1956. Fink, M., Shaw, R., Gross, G. C., and Coleman, F. S. Comparative study of chlorpromazine and insulin coma in therapy of psychosis. ]. A. M. A. In press. 3. Wikler, A. Personal communication. 4. Fink, M., and Kahn, R. L. Relation of EEG delta activity to behavioral redr Arch. A. A. Neural. M. studies. serial electroshock: in quantitative sponse Psychiat., 78: 516, 1957. 5. Fink, M., Kahn, R. L., and Green, M. A. Experimental studies of the electroshock process. Dis. Nerv. System, 19: 113, 1958. 6. Weinstein, E. A., Kahn, R. L., Sugarman, L. A., and Linn, L. Diagnostic use of amobarbital sodium (“Amytal Sodium”) in organic brain disease. Am. ]. Psychiat., 112: 889, 1953. 7. Kahn, R. L., Fink, M., and Weinstein, E. A. Relation of amobarbital test to clinical improvement in electroshock. A. M. A. Arch. Neurol. 69' Psychiat., 76: 2. 23, 1956. Kahn, R. L., and Fink, M. Personality factors in behavioral response to electroshock therapy. Conﬁnia neural. In press. 9. Fink, M. A uniﬁed theory of the action of physiodynamic therapies. J. Hillside 8. Hosp, 6: 197, 1957. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Alteration of brain function in therapy. In NS Kline (ed.), Psychopharmacology Frontiers. Little, Brown & Co., Boston, 1959: 325-332. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-33b-011 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from Psychopharmacology Frontiers. Proceedings of the Psychopharmacology Symposium of the Second International Congress of Psychiatry held in Zurich, Sw1tzerland on September 2-4, 1957. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Boston: Little, Brown and Company Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/00442514cc7c4740e6535ae86cb27a98.mp4 ca0462dd7c4eebcdd294288b69b8223c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Biographical Files Moving Image A series of visual representations imparting an impression of motion when shown in succession. Examples include animations, movies, television programs, videos, zoetropes, or visual output from a simulation. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Interview with Max Fink, MD: World-Leading Expert on Electroconvulsive Therapy Subject The topic of the resource Neuropsychiatry (MeSH) Suicide (MeSH) Electroconvulsive Therapy (MeSH) Psychoanalysis (MeSH) Catatonia (MeSH) Description An account of the resource <span>Max Fink, MD, Professor of Psychiatry and Neurology Emeritus, Stony Brook University, was interviewed by Lorraine Botti on March 18, 2018. The location was Special Collections in the Melville Library at Stony Brook University, where his archive is housed. In the interview, Dr. Fink discusses: the circumstances which brought him to Stony Brook University in 1972 including his appointment by Dr. Stanley Yolles; his administration of electroconvulsive therapy (ECT) services; the Second World War and Sigmund Freud; psychoanalysis vs. ECT then and now, and its effect on suicide; and catatonia verification and treatment.</span><span> </span> Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548">Fink, Max, 1923-</a> Publisher An entity responsible for making the resource available Stony Brook Medicine Date A point or period of time associated with an event in the lifecycle of the resource 2018-03 Contributor An entity responsible for making contributions to the resource Interviewer: Lorraine Botti Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> <a title="https://rightsstatements.org/page/InC-EDU/1.0/?language=en" href="https://rightsstatements.org/page/InC-EDU/1.0/?language=en">https://rightsstatements.org/page/InC-EDU/1.0/?language=en</a> Stony Brook University owns the rights to this video. Max Fink, MD owns the Intellectual Property Rights. Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource video/mp4 Type The nature or genre of the resource MovingImage Identifier An unambiguous reference to the resource within a given context mfp_MaxFink_videos_20190301 Source A related resource from which the described resource is derived Stony Brook Medicine's YouTube Channel published this video in 2019: <a title="https://www.youtube.com/watch?v=_dxp3N12uAY" href="https://www.youtube.com/watch?v=_dxp3N12uAY">https://www.youtube.com/watch?v=_dxp3N12uAY</a> Biographical http://exhibits.library.stonybrook.edu/mfp/files/original/ebad71bc432e0d061b6d76102561eb88.jpg d26ec53ef5fc55ebe3fcacc96a4b2ac2 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. 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Title A name given to the resource Anna Lowenthal Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-001 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Maternal grandmother of Max Fink Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/12764b529d79f1eb96174bc90f2534b6.pdf ca3411637648ce13d529a98dea9e5b2f PDF Text Text Behavioral Patterns in Convulsive Therapy MAX FINK. MD. AND ROBERT L. KAHN. Ph.D. GLEN OAKS. L. |.. N. Y. �Reprinted flow the Archives of General Psychiatry July 1961, Vol 5, [71). 30— 36 Copyright 1961,]1y Agzeiican Zl/[edical Association Individual differences in the behavioral response to convulsive therapy are marked. In psychiatric practice, patients with similar psychopathologic syndromes, and of similar sex and age, show a variety of clinical responses: Some improve and sustain such change; some improve, only to relapse quickly; and some fail to improve. These differences have been related to the degree and duration of induced neurophysiological change?“6 premorbid patterns of personal— ity,""11'15 sociopsychological characteristics,13' 15 and psychotherapeutic approaches.1 While these studies have emphasized ratings of improvement, the derivative nature of this evaluation and its dependence on staff attitudes, expectations, and family tolerance have been stressed.2""5'8 The manifest behavioral patterns provide the basis for the evaluations of clinical response. It is the purpose of this report to describe behavioral patterns in patients undergoing convulsive therapy and to relate these to problems of the evaluation of improvement and to an understanding of the convulsive therapy process. Behavioral Patterns in Convulsive Therapy Of consecutive patients referred for electroshock therapy during 1956-1957, seventy-three patients were subjects of the analyses described here. The patients were selected for treatment by the resident therapist and the supervising psychiatrist -——the investigators playing no role in their selection. These observations were made during a lllll|llllll|Illllllllllllllllllllllll|lllllllllllllllllllllllllllll|lllllllllllllllllllllllllllllllllllllllllllIlllllllllllllllllllllllll|lllllllllllilllllllllllllllllllllllllllllllllllllllllll MAX FINK, MD. AND ROBERT L. KAHN, Ph.D. GLEN OAKS, L.I., N.Y. convulsive-subconvulsive electroshock study in which subjects referred for therapy were randomly assigned to courses of subconvulsive or con— vulsive treatments. Electroshock was administered 3 times weekly under thiopental sodium (Pentothal) premedica— tion, using either a Reiter unidirectional or a Medcraft alternating current instrument. Grand mal or subconvulsive treatments were administered by altering the strength of current. Neither Submitted for publication Jan.6, 1961. From the Department of Experimental Psy— chiatry, Hillside Hospital. Present Address: Division of Psychiatry, Monteﬁore Hospital, Bronx, N. Y. (Dr. Kahn). Read in part, at the New York Divisional Meet— ing, American Psychiatric Association, November, 1957. Aided by Grant M- 927 of the National Institute of Mental Health, National Institutes of Health, U. S. Public Health Service 52 �CONVULSIVE THERAPY 31 ﬂecting the patient’s adaptation 2 to 4 weeks fol~ lowing the last treatment. patient, therapist, nor evaluating physicians was aware which course of therapy each patient received until after the evaluation period. Changes in brain function were measured at weekly intervals by tests of language patterns both clinically and after amobarbital and by the degree of slow-wave activity in electroencephalograms. The intercorrelation of these indices and their relation to behavioral changes have been reported previously?” The manifest symptom patterns of the referred patients were variable and included suicidal preoccupation, retardation, disturbances of mood and affect, excitement, agitation, panic and tension, delusions, ideas of reference, negativism, withdrawal, and somatic complaints. The clinical diagnoses were depressive psychoses of manic-depressive, involutional and reactive varieties, and schizophrenic psychoses of paranoid, mixed, catatonic, and pseudoneurotic types. Clinical behavior was assessed in weekly psychi— atric interviews, structured perceptual task situa— tions,“'15 and by conferences with the patient’s therapist. In these observations, the evaluation of improvement along the continuum of “recoveredunimproved” appeared inadequate and was supplemented by a rating of the degree of behavioral change. The degree of change in clinical and ward behavior was rated on a 4-point scale of “marked,” “moderate,” “minimal,” or “no change. H These evaluations were not value judgments as to the quality of the change, but rather quantitative es— timates of differences in behavioral patterns under similar conditions of observation. The assigned rating was based on changes observed during the treatment period and for 2 weeks post treatment. Evaluations of improvement response were made on the 4—point scale of “recovered,” “much im— proved,” “improved,” and “unimproved or worse.” These evaluations were value judgments, based upon the behavior of the patient, the therapist’s expectations, the tolerance by therapist and patient of those aspects of behavior often called “side— elfects of the treatment,” and the therapist’s judg— ment as to the family’s attitudes to the patient’s behavior. These evaluations were short—term, re- Observations A. Behavioral Change and Improvement. A comparison of the behavioral ratings and the improvement evaluations is presented in Table 1. That ratings of recovered and much improved were associated with high or moderate degrees of behavioral change is an expected observation. Similarly, that patients with minimal or no change in behavior were evaluated as unimproved or improved, is also expected. The signiﬁcant relationship, however, lies in the patients showing high and moderate degrees of behavioral change and still rated as showing a poor clinical response. Of the 30 patients observed with high degrees of behavioral change, 17 were evaluated as recovered and much improved, and 13 as improved or un— improved. B. Modes of Adaptation—Analyses of the behavioral patterns of the subjects during and following treatment permitted the description of various modes of adaptation. For illustrative purposes we have described 4 behavioral patterns under the titles of euphoric—hypomanic, somatization, paranoidvuithdrawal, and panic modes. Euphoric-Hypomanic Mode: These subj ects appeared pleasant, affable, and friendly. They dressed neatly, spoke quietly, and participated in ward activities with increased interest. Occasionally they dressed gaudily and smiled and giggled excessively. Pretreatment symptoms were not manifest, and premorbid attitudes and behavior were again prominent. 0f Evaluations of Behavioral Change and Clinical Improvement (Convulsive and Subconvulsive Therapies) TABLE l.——C0mparison Improvement Rating Ichavioral Change High degree change Moderate degree change Minimal degree change No change F ink—K ahn Recovered (30) (17) (10) (16) Much Improved 9 6 0 0 8 3 0 L? 53 Improved Unimproved and Worse 8 6 2 5 5 1 15 5 �32 - In their psychotherapeutic interviews they described their illness in a detached manner, emphasizing “it” (illness) as having “dis— appeared.” They denied having been ill and facetiously suggested they were at the hos— pital for a rest, or that the institution was not a hospital, but a resort or a school. Symptoms were described in the past tense, and the quality of having been a different person during the illness was reiterated. Speech was marked by denial, displacement, evasion, qualiﬁcation, and cliches.“ The third person mode was frequently used, as in such statements “the doctor says I am ill” or “my wife should have come here.” Gross changes in memory were either not apparent, or were described for the treat— ment period only. The patients expected and accepted these deﬁcits, and neither connection with treatment nor apprehension was expressed. They looked forward to home visits and made realistic discharge plans. While conﬂicts with family members were described, these were minimized and expressed mainly in the past tense. Referential questions were answered in a referential manner and with— out an arousal of affect. For the more hypo— manic subjects, questions about home planning were responded to nonreferentially, with marked use of inappropriate clichés. When pressed with referential inquiries, they quickly exhibited anxiety and discom— fort, minimized their feelings, and changed the focus of the session. Such adaptations were sustained throughout the discharge planning period. The more hypomanic features were rarely sustained and within a few weeks were replaced by a more stable euphoric or somatization type of adaptation. Somatization Mode: In these subjects, in— cessant complaints about bodily symptoms and loss of memory, demands for reassur— ance and relief, and preoccupation with feel— ings of unreality and confusion dominated behavior. They remained unkempt and their rooms were untidy. When such an adapta— tion appeared early in therapy, further treatment was refused. ARCHIVES OF GENERAL PSYCHIATRY Speech was principally in the present tense and in the ﬁrst person, with few third person references and a minimal use of clichés, denial, or qualiﬁcations. In psycho— therapy sessions, they were demanding and hostile, reporting their problems in terms similar to those used prior to therapy. They complained that the treatment caused addi— tional and more incapacitating difﬁculties. To referential questions, answers were gen— eraly correct, but associated with complaints of memory impairment. They described their family relations in pretreatment terms, with an occasional “I don’t remember” in response to experiential inquiries. Discharge planning was difﬁcult, since they insisted that their new symptoms prevented any home adaptation. On the ward, their hostile demands for attention and relief of symptoms increased with treatment. Participation in group ac— tivities increased, however, for those sub— jects who had previously been withdrawn and seclusive. Memory complaints were preeminent. Pa— tients demanded reassurance that their memory would return and repeatedly asked if treatment would be harmful. They de— scribed feelings of derealization and con— fusion. Events, bodily feelings, and relations to friends and relatives seemed strange, fuzzy, unclear, and out of focus. While they complained chieﬂy of memory impairment, they also complained of back pain, headache, tingling of ﬁngers and toes, nausea and weakness, and ascribed these to the treatment. At the end of treatment, the symptoms for which hospitalization had occurred were no longer present, and although complaints were many, their relation to the treatment and their transience was so universally ac— cepted by both the staff and the patients, that the results were evaluated as beneﬁcial. This adaptive mode was sustained into the postdischarge period. Paranoid and Withdrawal Mode: Another pattern was the appearance of paranoid ideation, suspiciousness, hostility, ideas of reference, and delusions. These patients Vol. 5, July, 1961 �CONVULSIVE THERAPY failed to care for themselves and remained unkempt in their dress. Their rooms, in which they remained much of the day, were untidy. Speech was sparse and not spontane— ous. When questioned about their illness, they were hostile and demanded to know why they were questioned. They refused to answer inquiries or categorically denied or agreed to all speciﬁc questions. Experi— ential questions were answered referentially. When inquiry was insistent, they denied illness and minimized the symptoms which had resulted in their admission. They refused or avoided sessions with their therapist and insisted convulsive ther— apy be ended because it was harming them. When treatments were continued, they demanded release from the hospital, or pre— cipitated discharge by elopement, suicide attempts, or aggressive and destructive out— bursts. They were unable to discuss their relations with family or friends and focused on demands for either release or relief from somatic symptoms. Hostility was overt and engendered a fearfulness in the staff. On the ward, when coaxed out of seclusion, they were loud, aggressive, and demanding. They were suspicious of attempts at friendliness and expressed thoughts that others wished to harm them or talked about them. While insisting on discharge, no realistic discharge planning was achieved. Their View of the environment was grossly distorted and self—centered, preventing adequate care. In testing, they were uncooperative, and voiced angry suggestions of being experi— mented upon or abused. Complaints of memory impairment were infrequent and occasionally denied even when clinically manifest. On such occasions, they were en— raged at the implied deﬁcit. Panic Mode: These patients became increasingly anxious, agitated, restless, sleep— less, and anorexic. In their dress, they were neat and cared for themselves. Speech pat— terns were unchanged and continued with emphasis on ﬁrst person and present tense modes. Symptoms were distressing and prominently voiced. When asked about pre— treatment symptoms, these were expressed . Fink—Kuhn 33 in the same terms as those used earlier, with the complaint that treatment had made everything worse. Patients feared treatment and hid on treatment days, or pleaded with the staff to forego further applications. They threatened elopement and if this failed, submitted administrative requests for discharge. On the ward, they continued their pretreatment patterns of minimal participation. On treatment days, they were withdrawn, sullen, and negativistic, and cooperation was poor. They demanded to see their therapists and on such occasions insisted that treatment be discontinued. They were unable to discuss family situations or their attitudes to others, being preoccupied with their feelings of fear. In discussing their home, they insisted on immediate discharge, while stating they were severely frightened, anxious, depressed, and unwell. Ideation was unchanged with fearfulness as the principal affect. Fears of damage to the brain or mind was expressed, accompanied by the awareness that memory impairment may be a Sign of such damage. Complaints of memory impairment were infrequent and when present, were ex— pressed as a speciﬁc reason for discontinuation of treatment. Patients were uncooperative and fearful of testing and participated only if encour— aged that such tests may be helpful in the therapist’s decision about further treatment. Occasionally, when treatment was discon~ tinued, a more stable adaptation of relief, acquiescence, and denial appeared. C. Adaptive Mode and Improvement Ratings—Thus, for the various adaptive behavioral patterns, a range of short—term evaluations was observed. Those subjects who developed and sustained the euphoric— hypomanic modes were generally rated as recovered or much improved. Patients with somatization and panic modes were oc— casionally rated as improved, although unimproved ratings were frequent. The paranoid—withdrawal mode was evaluated as unimproved or worse, as were patients exhibiting the panic modes. The relation be— �34 ARCHIVES OF GENERAL PSYCHIATRY TABLE 2.—Adapti7/e Mode and Improvement Improvement Rating Modes Euphoric-Hypomanic Somatlzatlon Paranoid-Withdrawal Panic No adaptive change‘ ‘ Includes subconvulsive (36) (10) 7) ( 7) (13) ( Recovered Much Improved 11 14 0 0 0 0 l 10 5 0 0 0 2 2 l Improved Unimproved, Worse l 4 5 5 12 treated subjects Without second course of ECT. tween adaptive modes and ratings improvement is summarized in Table 2. of Studies relating physiological or psychological aspects of convulsive therapy to clinical outcome have reported inconsistent results}6 Thus, it has been reported that depressed patients respond favorably to convulsive therapy while schizophrenic or neu— rotic subjects do not; while other observers indicate that neurotic depressive patients re— spond badly, and that some schizophrenic subjects do have favorable outcomes. Vari— ous measures have been suggested as predic— tors of improvement, only to fail on more extensive testing. In such instances, the differences in results and discrepancies in convulsion can be related to the utilization of a variety of global estimates of improve— ment as the criterion of behavioral change, without adequate speciﬁcation of the standards used in the evaluation. Such standards differ widely, depending on institutional populations and staff attitudinal factors. Varying attitudes toward “side-effects,” the use of global rating scales, and varying psychosocial attitudes affecting goals of treatment have each served to make results from different laboratories incom— patible. Thus, in our evaluations of con— vulsive therapy, the development of changes in memory, recall, and orientation have been considered as temporary manifestations of therapy and disregarded in the clinical eval— uations.3'19 Patients developing the euphoric or hypomanic modes, despite concomitant memory loss, have been rated as much im— proved. In a comparable study by Johnson et al.,10 the Lorr global ratings of behavioral change were utilized. In this type of evaluation the changes in memory and orientation are in— Comment These observations emphasize the variety of behavioral adaptations that occur during convulsive therapy and relate short—term evaluations of improvement to the type of behavioral change. Earlier observers of con— vulsive therapy have described a range of behavioral patterns, ascribing the changes to ego adaptive responses, to the trauma of the treatment, organic brain changes, or psychologic signiﬁcance of the treatment.7' 9'21 These observations that subjects with similar psychopathologic syndromes receiv— ing similar treatment may exhibit discordant behavioral adaptations and be variously rated as recovered or unimproved, are of signiﬁcance for an understanding of the convulsive therapy process. In earlier studies, the conclusion was reached that persistent alterations in brain function were a necessary condition for behavioral change in convulsive ther:«ipy.2""6 With changes in brain function, all aspects of behavior undergo modiﬁcation. Percep— tion, mood, affect, judgment, attitude, mem— ory and recall are altered, and with these, the subject’s adaptation in the environment. Not all behavioral changes are viewed as improvement, however. Improvement ap— pears to be a special type of behavioral response, being the subjective estimate by an observer that the patient is “better.” It is based, not only on the patient’s behavior, but also on such nonspeciﬁc aspects as the observer’s expectations, and tolerances, and those of the family and environment. 56 Vol. 5, lily, 1961 �CONVULSIVE THERAPY cluded as negative scores in the improvement scoring, so that a high number of subjects were reported as “unimproved or worse.” Besides population differences, this single factor is sufﬁciently potent to alter the rela— tionships between the 2 studies and justiﬁes the discrepant observations. The use of global estimates of behavioral change in evaluating therapy has other signiﬁcant deﬁciencies. Psychiatric therapies are rarely focused, or effective in modifying a single symptom. The induced changes affect a spectrum of behaviors, with varying rates of change for different aspects. Global estimates tend to lose differences in individual elements within the medial designations necessary to deﬁne the whole response. In such situations changes in behavior which may be prominent, though not pervasive nor enduring, may dominate the evaluation as to overshadow other, potentially more signif— icant changes. Thus, alterations in memory and recall, or increased somatization or in— creasing withdrawal may dominate unim— proved evaluations; while explicit verbal denial, clichés, and euphoria may lead to recovered or much improved designations. The use of improvement ratings may be empirically justiﬁed as an early approxima— tion in studies of a new therapeutic meas— ure, but further analyses of the behavioral ‘ observations are required for understanding and adequately applying the treatment. The typologies described in this report are one approach—one that has been helpful in our understanding of the convulsive therapy process and one that is now being tested in studies of psychopharmacologic agents. In addition to the differences in improve— ment evaluations occasioned by attitudes to “side—effects” and the use of global ratings, there are differences due to the attitudes of therapists toward various sociocultural pop— ulations. The adaptation of explicit verbal denial in a lower class patient in a community institution is welcomed by therapists and family, but the same adaptation in an upper class professional in a psychothera— peutic hospital is considered poor or psy— chotic. The display of rationalization. Fin k—K01m 35 minimization and displacement, even when accompanied by a return to premorbid work levels, is considered marked improvement in one setting, but is viewed as a lack of improvement in another if goals of insight had been set by the therapist. Interference with memory and recall may be disregarded by therapists for one sociocultural group, but arouse empathic solicitude for patients of another social class. Such factors affect not only institutional attitudes, but within an institution, therapists of different thera— peutic orientations may have differing atti— tudes towards evaluations and therapies. The many recent sociocultural studies of thera— pists, and their attitudes towards selection of therapies, are indicative of these attitudinal differences.13'17-18'20'22 It is our impression, therefore, that im— provement ratings are no longer useful devices in evaluating psychiatric therapies. For the symptomatic therapies extant today, which are seemingly not directed toward the alteration of an etiologic factor, typologic descriptions have a greater applicability and empiric justiﬁcation. Typologies based on concepts of diagnosis, target symptoms, or on dynamic—structural formulations have attempted to structure the pretreatment clusters in which therapies may be effective. Treatment and post—treatment symptom improvement scales have been used with utility. These are limited approximations, however, and there is a need for a broader approach to both the pretreatment and the treatment behavior, and a phenotypic, adaptive be— havioral typology, using multivariate tech— niques of data analysis, seems worthy of assessment. Summary An analysis of the variety of behavioral adaptations of 73 voluntary psychiatric pa— tients undergoing convulsive therapy resulted in the description of 4 major patterns. These are described as euphoric-hypomanic, somatization, paranoid—withdrawal, and pan— ic modes. The relation of these modes to clinical ratings of improvement is described. The �36 ARCHIVES OF GENERAL PSYCHIATRY derivative and generally nonoperational nature of improvement ratings is empha— sized. The difﬁculties in a communicative deﬁnition of this variable is seen as a major factor in the discrepant studies of indices predictive of improvement in convulsive therapy and in understanding the processes of somatic therapies in psychiatry. Therapy (With and W'ithout Atropine), Arch. Gen. Psychiat. 2:324-336, 1960. 11. Kahn, R. L., and Fink, M.: Changes in Language During Electroshock Therapy, in Psychopathology of Communication, edited by P. Hoch and J. Zubin, New York, Grune & Stratton, Inc., 1958, pp. 126-139. 12. Kahn, R. L.; Fink, M., and Weinstein, E. A.: Relation of Amobarbital Test to Clinical Improvement in Electroshock, A.M.A. Arch. Neurol. Psychiat. 76 :23-29, 1956. 13. Kahn, R. L.; Pollack, M., and Fink, M.: Sociopsychologic Aspects of Psychiatric Treatment in A Voluntary Mental Hospital: Duration of Hospitalization, Discharge Ratings, and Diagnosis, A.M.A. Arch. Gen. Psychiat. 1:565-574, Max Fink, M.D., Department of Experimental Psychiatry, Hillside Hospital, 75—59 263rd St., Glen Oaks, L.I., N.Y. REFERENCES H Esecover, H.; Jaﬁe, J., and Kahn, R. L.: Psychotherapeutic Techniques with Electroshock Patients, J. Hillside Hosp. 7:17-25, 1958. 2. Fink, M.: A Uniﬁed Theory of the Action of Physiodynamic Therapies, J. Hillside Hosp. 6: 1. 1959. 14. Kahn, R. L.; Pollack, M., and Fink, M.: F igure-Ground Discrimination After Induced Altered Brain Function, A.M.A. Arch. Neurol. 2:547-551, 1960. 15. Kahn, R. L.; Pollack, M., and Fink, M.: Social Attitude (California F Scale) and Convulsive Therapy, J. Nerv. Ment. Dis. 130:187—192, 197-206, 1957. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electro— shock: Quantitative Serial Studies, A.M.A. Arch. Neurol. Psychiat. 78:516-525, 1957. 4. Fink, M.; Kahn, R. L., and Green, M.: Experimental Studies of the Electroshock Process, Dis. Nerv. Syst. 19:113~118, 1958. 5. Fink, M.; Kahn, R. L., and Pollack, M.: Psychological Factors Aﬂ'ecting Individual Differences in Behavioral Response to Convulsive Therapy, J. Nerv. Ment. Dis. 128 :243-248, 1959. 6. Fink, M.; Kahn, R. L.; Karp, E.; Pollack, M.; Green, M.; Alan, B., and Lef‘kowits, H. J.: Signiﬁcance of Inhalant Induced Convulsions for the Theory of the Convulsive Therapy Process, Arch. Gen. Psychiat. 4:259-266, 1961. 7. Frosch, J., and Impastat, D.: The Effects of Shock Treatment on the Ego, Psychoanal. Quart. 3. 1960. 16. Kalinowsky, L., and Hoch, P.: Shock Treatments, Psychosurgery and other Somatic Treatments in Psychiatry, New York, Grune & Stratton, Inc., 1952. 17. Kaplan, A. 1., and Lefkowits, H. J.: Inﬂu— ence of Staff Attitudes and Environmental Factors on Treatment Selection, J. Hillside Hosp. 1961, to be published. 18. Klerman, G. L.; Sharaf, M.; Holzman, M., and Levinson, D. J.: Sociopsychological Charac- teristics of Resident Psychiatrists and their Use of Drug Therapy, Amer. J. Psychiat. 117:111-117, 1960. Korin, H.; Fink, M., and Kwalwasser, 5.: Relation of Changes in Memory and Learning to Improvement in Electroshock, Conﬁn. Neurol. 16: 19.. 88-96, 1956. 20. McIver, J. and Redlich, F. C.: 17:226-239, 1948. 8. Frosch, J.; Impastato, D.; Ottenheimer, L., and Wortis, S. B.: Some Reactions Seen After Electric Shock Treatment, Amer. J. Psychiat. 102 Patterns of Psychiatric Practice, Amer. J. Psychiat. 115:692- 311—315, 1945. 697, 1959. 21. Millet, J. A. Glueck, B. C.: Psychopathologic Reactions and Electric-Shock Therapy, New York J. Med. 42:1553-1557, 1942. 10. Johnson, L. C.; Ulett, G. A.; Johnson, M.; Smith, K., and Sines, J. 0.: Electroconvulsive Psychosom. Med. 6:226-237, 1944. 22. Pasamanick, B.; Dinitz, S., and Lefton, M.: Psychiatric Orientation and Its Relation to Diag— nosis and Treatment in a Mental Hospital, Amer. J. Psychiat. 116:127-132, 1959. : P., and Morse, E.: On Certain Psychological Aspects of Electroshock Therapy, 9. 58 Printed and Published in the United States of America ��Putt-ran at Bohgvioral chant. and Inprorcnnnt 1n canvullivo rhcrapy In: Pink, x.n. and nobcrt L. Kuhn, Ph.D.* from the Dapartncnt or Expnrinontnl Psychiatry, ulna oakn, L.I., n.x. Hillside noupitsl, gratt K~927 of tho lattcnal Initituta a: nontal noulth, lutional Institutua a: Hatlth, United Status Puhlie Hualth survzoo. Reta in part, gt th.".!. 91'1319311 looting, American Payehintric Aidod by Association Northbor, 1951. : Btvﬂiomit o: Psych-try. Mutation 30-91%“. *Pruont Bronx, 1.1. VII: 1/61 “an" �Individuol ﬂittoroncoo in tho bohoviorol roopouoo to oonvoloivo thoropy oro oorkod. In poyohiotric proctico, potionto with oanslor poyohopotholoxtc oyudroaoo, one or oililor varioty or olinieol rosponooo: oooo toprovo old ouotoin ouch chongo; oooo 1-provo, only to rolopoo quickly; ond oooo toil to taprovo. rhooo dittorooeoo hovo boon rolotod to tho dogroo ond duration or indoood nourophyoiolociool ehongo (3,6) prooorbtd pottorno or poroonoltty (5,11,15), ooulopoyeholoctool chorootoriotioo (13,15) and porehothoropontto opprooehoo (1). Vh11o thooo otudioo hovo onphooiood voting: 0: taprovooont, tho dorivotivo unturo or thin ovoluotion ond 1t: dopondonco on otort ottttudoo, oxpoctotiono ond tooily toloronco oox ond ago, ohow o has boon strooood (2,h,5,8). rho oonttoot bohoviorol pottorno provido tho boots tor tho ovo$uot1ono of clinical rooponoo. It 1o tho purpooo o: thto roport to doocriborbohovtorol pottorno 1n pottonto nndoraoinz oonvolsivo thoropy, ond to roloto tho-o to problooo of tho ovolootioo of taprovooont and to on ondorotondinx o2 tho coo- vuloivo thoronyIProcooo. �gethod: or consecutive pe$$en$e reterred for electreehoek therepy 63:13; 1956—57. teveatybthree pettente were subjecte e: the eaelyeee eeeeribed here. the patients were selected tor treeto sent by the reeident therepiet end the aupervteiuc peyohietrteﬁ - the inveetzceterp playing no role in their selection. These convulsive—euhcenvulaSve electroc 3 during were III. obeervettene eheok study a; whieh subject. referred tar enereyy were rendenly unsigned to entrees e: cuboenvuletve er convulsive treetnente. Electroeheek wee edginietered three tines weekly under pentethel preunedieetiea, using either e letter unidirectional er e xederett alternating entrent inattenent. arena eel or enbeenvnleive treetnente were eduin1utered by titering the etrongth of current. leither patient, therapist not eveluetinx phyeiaiene tee evere which entree e1 therapy each pétient received until titer the evaluation period. weeiiy intervals cheese: in urea: tunetion were neeeered at by test: of leagues. petterne both 011336.11: eta etter eneberbitel, and by the degree e: 310: were activity in electroencephelegrene. 2he interoerreletien e: theee indieee 3 �.3cooplointl. rho alinicol dioxnoooo woro doproootvo of nonio—doproooivo, involutioaol ond rooetivo and ooaotic poyuhoooo voriotioo; one oohioophrontc poyehoooo or poronoid, aixod, oototonto and pooudonourotie typoo. clinical bohovior woo oooooood in vookly poyuhiotric intorviovo, otrootorod porooptuol took oituotiono (1h,15) and with contorouooo tho potiont'o thoropiot. II thooo ohoorvo~ by tiono, tho ovolootion of :Iprovouont along tho continual of 'rooovorod-untnprovod' oppooroa inoaoquoto, and woo topplonontod by o roting of tho dogroo of bohoviorol ohongo. rho dogroo of chonzo 1n olinieol tad word hohovior woo totod on o four point ocolo or 'norkod', “nodoroto', 'nininol' or'ho chango'. Thooo ovoluotiono woro not voluo Judznonto no to tho quality of tho ohonxo, but rothor, quontitotivo ootinotoo o: ditforouooo in hohoriorol pottorno undo: oinilor condition: at otoorvotion. rho oooigood voting woo hoood on ohongoo oboorvod during tho trootnont poriod and for too vooko poot~ trootaont. lvolootiono or ingrovonont roopoaoo woro undo on tho four point ocolo or 'rocovorod', 'nuoh taprovod', ﬁtnprovod', and “nailprovod or onroo'. rhooo ovolootaono ooro voluo Judgnouto, hoood upon tho bohovior of tho patient, tho thoroptot'o oxpoctotiono, tho toloronoo by thoropiot and potiont of thooo oopoeto of bohovior otton oollod *oido-orroeto of tho trootnont’, and tho thoropiot'o Judgnont on to tho tonily'o ottitudoo to the potioat'o hohovtor. fhooo ovolnotiono ooro abort-torn, rotlocting tho potiont'o odoptotion two to tour wool“ following the lost troutnOHto �gbaorvationo: (a) Donatioral chango and Ingrovonont coaparioon at tho bahavioral ratingo and tho iaprovoaont ovaluationo 1o proooatod in tabla I. that ratings at rocovorod and nuch iaptovod woro aaaociatod with high or moderate dogrooa at bohavioral change it an oxpoctod obaorvation. similarly, that patioato with ainiaal or no chango in behavior taro avalaotod ao uni-proved or iaprovod, io aloe oxpootod. tho aixaitioant rolatianahip, hovovor, lioa in tho patianta ohooing high and oodorato dogrooo or bohavioral ohoazo and atill ratod ao ohaoiaz a poor oliniaal roopoaao. at tho thirty patioato obaorvad with high dogrooa or hohaviaral ohango, aovontoon voro ovaluatod aa raeavorod and much iaprovod, and thirtoon ao inprovod or aainprovod. l .. --.. . ZLBLI (b) undo: at Adaptation I -“ﬂ--. o: the bohavioral pattorna at tho oobaocto daring and tailoring traataont poraittod tho description or variauo today of adaptation. For illoatrativo purpoooa vo havo doaoribod tour bohoriorol pattorna undo: tho titloa a: oaghorie-hzgoaanio, oaaatiaation. garanoid-withdraoa; and Analyooo Rania nodoo. Bughorio-lzzoaanie Roda: Thooo oubjocta appoarod plaaaant, atrablo and friaudly. they are-sod neatly, opako quiotly, and participated in word activitioo with ineroaaod �Zlﬂﬁﬁ I atnpgrtann 0t Evaluationl Qt nohavttrnl change and clinical Inpruvcnont (c0uvu1317c and subconvnlutru 1h0r&pico) ﬁtting XIErOVOIORt locovorod » _ Itch Inprdvod ﬁninpruvod and Ingrovod 39:30 Bahaviorll Ghangc nigh dogroo change (39) ﬁ lodorato (17) 8 9 8 5 3 6 6 2 Juana (‘10) o a 5 S (16) o 0 1 15 I. change ' ' I' �. ~5-. interest. 'oeeeeieeelly they dreeeed aeadily, end exiled end giggled excessively. Pre-treeteent eyepteee were net eenifeet end preeerbid ettitudee end hehevier were egeie prenieeet. In their peyohetherepeetie interviews they deecrihed their illueee in e deteched leaner, eepheeieieg ”it“ (illneee) ee they denied having-been ill end feeetieeely eeggeeted they were et the heepitel fer e reet; er thet the inetitutiee wee net e heepitel, but e reeert er e eeheel. Syeyteee were deeeribed in the pert teeee, end the geelity of keying been e different pereen during the illeeee hevins “dieeppeered’. reitereted. Speeeh wee eerked by deeiel,.diepleeeeeet, ereeiee, quelitieetiee end eliehee (11). the third pereen wee ' eede wee frequently need, ee in eeeh eteteeeete the doctor eeye 1 en 111' er *ey wife eheeld here eeee here.II Greee ehenzee in neeery were either not eppereat, or were deeeribed fer the treeteeet period only. the petieete expected end eeeepted theee defieite, end neither eeeeectiee with treeteeet her eppreheneien were expreeeed. they looked forward te here wieite end eede reelietie dieeherge pleee. While conflicts with feeily eenbere were deeeribed, theee were eieieieed end expreeeed neiely in the peet tenee. heferentiel qeeetieee were eeewered in e referential nearer end without en ereeeel of effect. for the mere hypeeeeie eebaeete, queetiene eheet here planning were reepended te nearefereetielly, with marked nee of inepprepriete eliehee. When preeeed with referentiel inquiries, they quickly exhibited �.5anxiety and dieeeatort, aiuiaieed their feelings and changed the teeua.e£ the eeeeien. Seek adaptatiene were euetained throughout the discharge planning period. The mere hypeaaaie features were rarely suetained, and within a for weeks were replaced by a mere etable euphoric er aenatizatien types of adaptation. ,8enatizetien Hades In theee_enbdeete, incessant eeaplainte about bodily eyaptene and lees e: eatery, deaands fer reaeeurenee and relief; and preoccupation with feelings of nnreality and eeeteeion doainated behavior. Ehey retained unkempt and their When each an adaptatien appeared early in were untidy. reels therapy, further treatment wee refused. speech nae printiptlly in the present teaee and in the first pereen, eith fee third peraen references and a ainiaai use at clichea, denial er qualifications. In peyohetherapy eeeeiene, they vere-deaandies and hostile, repertihg their prehieae in terae eiailar to these need prier to therapy. !hey eeaplained that the treatment eaaeed additieeel and mere incapacitating difficulties. re referential queatiens, answers were generally correct, but associated with eenplainte of aeaery inpairaent. they deeeribed their taaily relations in yreotreatneet terns, with en oecaaional '1 den't reaenber' in reepenee to experiential inquiriee. Discharge planning eaa dittiealt, as they insisted that their new eynptene prevented any home adaptation. their heetile demands for attentien and relief at eyupteas increased with treetaent. Participation in creep activities inereaaed, however, tar these eabaeete who had an the ward, �-7. previeaely been withdrawn and eeoleeive. Heaory eeaplainte were pre-eaiuent. ratioate deaanded reaaaaranee that their aeaery would return, and repeatedly asked if treatment would he hararul. they deeoribod feelinge of derealiaation and confusion. Erenta, bodily feelinge and relatiena to friends and relativee eeeaed etrange, teeny, unclear, and out of :oeue. While they oonplained ehietly e: book of alao ceaplained pain, headache, they iarairnent, aeaory tingling o: tinsera and teee, aaaaea and roakaoee, and aeorihed there to the troetaent. which end symptom: the for the at treatment, heepitalit iaatioa had occurred were no longer present, and although and to the treatment were relation their their aany, eoaploiate transieaoe eae eo univoreally aeeepted by both the start and the patients, that the rooalte rare evaluated or beneficial. !hie adaptive node wee eeetained into the peat-dieoharge period. Paranoid and Withdrawal lode: Another pattern tea the appearance or paranoid ideation, euepicieuaneea, hostility, ideae of reference and deleaiene. These patients failed to care for theaaolvee, and roaained unkeapt in their dress. Their reeaq.in which they reaained each or the day, were untidy. Speech eaa eparee and not epontaneeaa. when questioned about their illneae, they were hostile and demanded to know why they were queetiened. they retaeed to anewer inquiriee er categorieally denied or agreed to all epecixio queetiene. Experiential caeetiena were anewerod roterantially. When inquiry was ioeietoat, they doeidd illneea and ainiaieed tho ayaptena which �~8- resulted 3: their ednieeien. they retueed er eveided eeeeieee with their therepiet, end ineieted eenvuledve therepy he ended beeeeee iteee herningy then. When treeteente rere continued, they demanded releeee free the_hoepite1, or precipiteted dieeherge by elepeneut, euietde ettelpte er eczreeeive end deetreetdve outberete. They were uneble to diecuee their reletiens with relily or triende, and teeeeed either en deaende fer releeee or relief tree resette eynptoee. Ieettlity wee overt, end engendered e teertelneee 1n the etett. an the nerd, rhea eeexed out of see» Ineien, they were lend, eggreeetve end deeend1ng. They were eeepieieee e: etteepte at friendlteeee, end expreeeed theeghte thet other: edehed to here the: or talked ebeﬁt then. while ineieting en dteeherge, no reelietie dieeherge pleating wee eehseved. their View er the envirtneent wee creeely distorted end eelreeeutered, preventing'edeqnete care. In testing, they were uneeeperetive, end rained angry eeggeetiene a! being experirented ugen or ebueed. Complaints at nenery impairment were intrequent, and occeeienelly denied when even clinicelly meniteet. on such occasione, they were eareged et the inplied deficit. Peale Bede: Theee'pettﬂate beeene increeeingly enzione, eglteted, reetleee, eleepleee end enorexie. In their dreee, they were neet end eered ror themselves. Speech patterns hed were unehegged end eontinued with eepheeie on tiret pereon and preeent tenee nodes. .synpteme were dietreee1ng end prentuentiy voiced. When asked about preetreetment eynptore, �.9. theee were expreeaed in the aaae terae ae theee need earlier, with the eaaplaint that treataent had aade everything weree. Patienta reared treat-eat and hid an treataent daye, er pleaded with the etatt to forage farther applications. they threatened elepeaent and it thie tailed, enhaitted administrative reqaeata fer discharge. an the ward, they continued their preatreataent patterns at participatien. 0n treataent daye, they were withdrawn, aalien and negativietie, and cooperation wae peer. they deaanded te aee their therapiete and on each eceeeiene ineieted that treataant be discontinued. they were unable to diecnee {anily eitaatiene er their attitudee to ethere, being preo eeeayied with their feeling: at tear. In dieeaeaieg their minimal heaa, they inaiated en iaaediate dieeharge, while atating they were aewerely trightened, anxieaa, depreeeed and unwell. ’Ideatien was unchanged with tearfulneae ae the principal . affect. reare te the brain er aied wae expreeeed, aeeeapaaied by the awareaeee that aeaory iapairaeet may be a sign at each damage. ceaplainta at aeaery inpairaent were in~ ex daaage frequent and when present, were expressed ae a apeeitie reason (or dieeeatinaatiea of treatment. Patiente were uncooperative and fearful at testing, and participated only it encouraged that such decision about further tests may be helpful treataent. occasion. in the therapist's ally, when treatment wae diacentinued, a more stable adaptation of relier, aeqaieeeenee and denial appeared. �' (3) 29:9" tivo H96. and rovunoat n;¢1 3 Thus, fo:_th¢ var1oua_gdaptivq bohnvitrnl ptttornl, a runs; or ihort term evaluations were obsorvad. thus: subjects aha devolaped and sustained the euphoric-hyponanie nodou were generally ratoﬁ us rocaverod or nueh inpravod. Patients uith ponatizatian gnd panic modes were ocgusiantlly rated as improved, nithgugh uninprevod ratings were frequent. The paranoid-with. ﬁgural node was evaluated as unimprGVad or worse, as were model. The relation batucon the panic pn§;ontl czhibiting adaptive node and ratings or improvonent are Ialnnrilod in ' d‘ fable 1!. 1133! II -‘C- “CC- �tivo.ﬂndc 3nd Ada rovonoat Ingrovcnont Rating Rtoovered 3.4.. anh Improved Inprovcd ﬁninpravod, Horn. Euphoricvﬂyponanic (36) 11 1h 10 1 Selatinttion tiranotdniithdrauul (10) o 1 5 h ( 7) 0 o 2 5 Psntc ( 7) o o 2 5 ndaptivo ohtngoi (13) 0 0 1 12 I. alnoludas snbcenvulsivo trcntod unbaoctu without cocond course 01 not, �Bieeoeeien: fheee ebeervatiene eaphaeiee the variety of behavioral adaptatiene that-occur daring eonvaleive therapy, and relate abort tern evaluatieee or iapreveaeot to the type of behavioral change. larlier obeervere at oooveleive therapy have deeoribed a range of behavioral patterns, aeoribing the ehaogee to age adaptive reepenaee,to the traaaa of the treataent, organio brain changes, or peyehologio oigoifioanoe of the treataeot (7,8,9,21). These ebeervatione that subjects with eiailar peyohopethelegio eyndreaee receiving aiailar treatment aay exhibit dieoordaot behavioral adaptatiene, and be varioaely rated aa recovered or aaiaproved, ie o! eigoirieanoe for an onderetahding e: the eonvnlaive therapy prooeee. In earlier studies, the ooholoaioo val reached that pereietené alteratioea in brain tanotioo were a neoeeeary eonditieo to; behavioral change in oonvaloive therapy (2,h,6). With changes it brain tuaotioo, all aepeote of behavior undergo modification. Perception, need, affect, Jadgaent, attitude, aeaery and recall are altered, and with theee, the eabaeot'e adaptation in the environment. let all behavioral ebaegee are viewed aa iapreveaeot, however. Improvement appeare to be a special type oi behavioral reepooee, being the eobjeotive eetiaate by an obeorver that the patient ie 'hotter’. It ie baled, not only on the patieot'e behavior, but also on each oeo-apeoitie aepeeta aa the obeerver'a expeotatione, and toleraooee, and these at the taaily and eovirenaent. Studies relating physiological or peyehologioal aepeote �-12or oonvnloivo therapy to clinical inreported that deproeeed ontoone have reported been hae Thne, (16). it ooneietont roanlte eohiaowhile oonvnleivo therapy to patients reopond favorably oheorvore other while do not; oabjoota nonrotio phrenio or and badly, reepond patiente dopreeeive neurotic that indioate ontooaoe. do favorable have enhaeota that ooae aohiaophronio of inprovoaa predictora been enggeeted have Various noaanroe each inetanoea, In extensive tootinx. on aoro to lent, only tail can eonolneion in and diaoropanoioo in results the dittorenooe or oetiaatoe of global of a variety be related to the utilization vithoot behavioral change, of the criterion ilproveaent an evaluation. the need in etandarde of the adequate epooitioation Snoh etandarde differ videly, depending on institutional atatt attitadinal taotore. Varying attitudeand eoaloe of rating global the nae toaard 'aide-otteota', popelatione and o: treataent goale afteoting attitndee varying peyohoeooial have baoh eorved to lake reenlte tron different laboratorioe oonvnloivo therapy, o: ovalaationa in our fhne, inooapatiblo. and orientation recall in ohangee neaozy o: devolepaont the , and of therapy aanitoetatione have been considered ae teaperary dieregardod in the olinioal ovalaatione (3,19). Patients oonoonitant doepito aodea, hypeaanio the euphoric or developing anon been on ieproved. have rated neaory loee, In a ooaparable etndy by John-on gngg, (lo), the Lorr global of In type thie utilized.“ were change rating! of behavioral inolndod and orientation are in ohanxee the neaory evaluation �-13- negative oeoroa in the inprovenent nearing, no that a high nnaher or enhaooto were reported an 'aninproved or nerao.‘ Booidoe population ditterenoee, thia einglo factor in eattioiently potent to alter the relationehipe between the two etadios, and Justitieo the diooropant eboervationa. the nae or global eetinatea or behavioral change in evaluating therapy hae other significant detieieneiee. Psychiatric therapiea are rarely toenaed, or effective in modifying a single eyaptea. the induced ohanxoo affect a opeetrna oi hehaviera, with varying ratoa of change for ditterent aepoote. Global aetinateo tend to loae differenooe in individual ole-onto within the nedial deoignatione neeoeaany to define the whole reeponee. In oneh oitnationa ohangee in hehavier which nay he preninont, though not pervaaive nor enduring nay doninate the evaluation an to overehadoe other, potentially nore aignitioant ehanzee. than, alterationo in aenory and recall, or increaeed eonatination or inereaaing tithdrawal nay daninato nninproved evaluations; while explicit verbal denial, olieheo and euphoria nay lead to recovered or each iaproved designations. the nae o: inprevenent ratings nay he enpirioelly Jaatiried an an early approxiaation in studies of a new thorapeutio aoaonre, but inrthor analyoea o: the behavioral eboorva~ tiona are required for anderatanding and adequately applying the treatnent. rho typologiea deooribod in this report are one approaeh - one that hoe heon helptal in our nnderatanding or the oonvaloive therapy prooeea, and one that in non being teatod in etadiee o: payohepharaaeoloxie agento. on �ulhIn sddltlen to the differences in leprevesent evelestlens eeessieeed by attitudes to 'elde-effeets' end the use ef glebel due to the ettitedes ef thereplsts differences there ere retinls, tersrd rsrlees seeleesltsrsl peeeletiens. The edeptetien of explicit verbsl denial in s lever clues pstient in e eennenlty lestitntlee is welcomed by therspiste and really, but the seas sdsptstleu in en upper elese professional in e peyehethsrspeetle The displsy ef or psychotic. is hospital considered peer when and even nintnisstlen displscenent, retlensllsstien, eeeenpenied by s return to preeerbid work levels, is eensidered nsrked leprevenent in ens setting, but is viewed as e leek ef inpreveneet is enether if ceels of insight hsd been set by the thersplet. Interference with memory end reeell say he disregsrded by therspists fer ene seeieeeltnrel group, but sreese espethle eeliettede fer petlente ef endkher seeiel eless. Seek feetere effect not enly institutienel,%tt1tedee, but riteln en 1nst1ts~ tion, therapists of different therepeutie erlestétlees sey here evglestieae nsny thersples. towards sad the differing ettltedee recent seeiecnlterel studies ef therspists, end their sttitedes tevsrds eelsetion ef thersples, sre indiestive of these sttitndinsl differences (13,17,18,2o.22). It is our impression, therefore, thet inprevenent rstlngs are no longer useful devices in evslusting psyrhietrie therepies. For the eynptometie therapies extent today, which ere seemingly net direeted tewerd the slteretien ef en etiologic fecter, typelegte deecriptiens have s greeter spplleebility sud enpirie �-15. Justification. typologies haaad on concepts at diaxaaaia, targat aynpaaaa or on dyaaaio-atractaral formulations harattaaptad to atructara tho pra-traataaat clusters in witch thoraptaa nay be attaativa. fraatnant and paat—troatnant ayaytan impravaaant acalaa have haan used with utility. Thaao ara linitad approxinatiaaa, howavar, and thara 1a a naad far a broader approach to bath tho pra-traataant and traatnant bahaviara, and a phanotypio, adaptiva bahaviaral typolacy, aaing aaltivariata taohniqnaa at data analysis, aoana worthy a: aaaaaaaant. �w in enelyeie_er the veriety e1 beheviorelvudeptetiene or 73 velnntery peychietric petiente undergoing convulsive therepy reeulted in the description er tear nejor patterne. These are deecribed ee eupheric-hypenenic, eenetizetien, paranoid-withdrawal end penie nedee. the reletien er the-e nedee te clinical retinge e: ieprevenelt ie deecribed. the derivative end generally neu-eperetienel unture e: ieyrevenent retinge in enpheeieed. the difficulties in e cennunieetive detinitien e: thie veriehle ie eeen ee_e nejer teeter in the dieerepent etudiee et indieee predictive e: inprevenelt in cenveleive therapy, end in underetendinc the preeeeeee e: ee-etic therepiee in peywhietry. �-17- W' 1. Ieeeever, 1., latte, J. and Iain, R.L.: Peyehetherepeetie rechaiqaee with lieetreeheek Patiente. J. lilieide .3332..1; 17~2§, 1958. link, 1.: i ﬁaified theory of the ietiea e: Phyeiedyuanie rherapiee. J. lilleide legg. é; 197-206, 1957. BIG and of Delta Activity te telatien 1.5.: lake, link, I. lehavierel leepenee in lleetreeheek: Quantitative serial Stadiee. A.!.i. ireh. laurel. & Pezdhiat. 19: 516-525, 1257. n.: prerinental Studiee or «a. lleetreeheek Preeeee. Die. lerv. slat. 11: 113-119, and 3.1. Pellaek, a.a Payehelegieal rector. take, 3., tier, rant,§a.. lane, 1.1. and Green, 1958. Affecting Individual Differences in Behavioral Reapenee to canvaleive Therapy. J.l,!.B. 13g. 2k3-2h8, 1959. 6. Fiat, u., Kenn, 3.5., tarp, 3., Pollack, 1., Green, H., Alan, B. and Lei‘kewite, LL: Significance of Inhalant Induced neural-ion: tor the Theory er the convulsive Therapy Preeeee. L.H.i. Arch. Gen. Pezehiat. (in press). Preach, J. and Iepaetate, 9.: the Effects of shock Treataent on the 3:0. Pezgheenal. Quart. l1: 226-239, 19h8. Ireeeh, 6., Inpaeteto, 9., attenheiner, L. and Wartie, 8.3.: Some Reactions Seen After Electric Sheet Treatment. Amer. J. Pezghiat. 1021 311-315, 19h5. �.13- 3.0.: reyehepethelegie Reactiene end Bleetrie-Sheek Therapy.‘ 1.1: State J. led. g3. 1553-1557. 19h2. 10. Jehneen, L.c., Ulett, G.L., Jehneen, H., Snith, I. end Sines, 3.6.: Electreoeavuleive therapy (with end 9. alueek, Hithaut Atropine). Arch. Gen. Pazghie . g; 32h-336, 1966. 11. Kenn, 1.1. end Pink, l.c change: in Language Bering Elactroahock therapy. re ehe‘ethelo er colnunioetien, Ed. Roch, P. and Zubin, 3., Stuns e Stratten 126-139, 1958. 12. R.L., link, x. end Weinetetn, B.A.i Reletien of tnoberbitel rest to Clinical Inprevenent in Electroehock. Arch. neural. e rezehiet. lg: 23-29,'1956. 13. Kuhn, R.L., Pollack, H. end flag, 3.: Seeiepeyeheloxie Aspect; a: Peyehiatric Ireetnent in A Velentery Mental Hospital: Duretien or Hoepitelixetiea, Discharge hating: end Biegaeeie. 1.x.1. Arch. Gen. Pezehiet. ;} Kehn, 565-57h, 1959. 1k. Iehn, R.L., rolleck, H. end rink, H.a Figure-around Discriminetien After Induced Altered Brein Functien. A.H.L. Arch. lea-oi. g: 5&7-551, 1966. 15. Kuhn, R.L., Pollack, I. end tint, H.c Sociel Attitude (alliternie W ? Scale) end Convulaive Therepy. gig: 187~192, 1960. J.I.H.D. 16. lelileweky, L. and Heck, 2.: Shack trout-eats, Peychoeurgery end eﬁher Betetie Ireetnente 1n Peyehintry. Grtne end ___________._________________________.____ strn‘t.n. 3.1. , 1952e �lethed: 9t eeneecetire petiente referred fer eleetreeheek therepy during 1956-57, eeveety-three petiente were eebjeete of the ehelyeee deeerihed here. the pettente were selected fer treetnent by the reetdeut therepiet end the eupervieies peyehietriet the inveettsetere pleying he rele in their eeleetten. theee eheervetieee were nede during e eeeveletve-eeheeevuletve eleetreeheek etedy in which euhaeete referred for therepy were rendeely eeeirned to eeereee e1 eeheenveletre er eenreletve treeteente. Bleetreeheek eee edeiaietered three tinee weekly under pentethel pre-nedteetien, eeing either e letter unidireetienel or e heeerett elternetieg eerrent instreeeet. Greed eel or enheenvuleive treeteente were edninietered by eltering the etreexth a: current. [either petieht, therepiet her evelueting phyeieiene tee ewere which eeeree e: therepy eeeh pitieet received until etter the ewelnetiee period. eheugee in hreie tenetiee were neeeered et weekly intervele by teete e: leexeece petteree heth alerteelly end etter eeeberhttel, end by the degree e: elew eewe eetivity in electroencephelexrene. the intereerreletien e: theee indieee end their reletien te heherterel eheagee here been reperted prewieeely (3,1g). the senateet eyeptee petteree e: the referred pttiente were reriehle, end included euteidel preeeeepetien, reterdetieu, dieterheneee e: need end erreet, exeiteneat, egitetien, penie end teneaen, deleeiene, ideee et reference, hegettrien, rithdrewel 1 � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Behavioral patterns in convulsive therapy. Arch Gen Psychiat. 1961 Jul; 5:30-6. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-53-019 Date A point or period of time associated with an event in the lifecycle of the resource 1961 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprint and [preprint]. Reprinted from the Archives of General Psychiatry July 1961, Vol 5, pp. 30—36. Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/98f5a5a06c57d2e2f02f1dbcc6c9195d.jpg 6777b73026075a1d135fcdc9d1219af9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bronia Lowenthal Fink and Max Fink, 1923 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-005 Date A point or period of time associated with an event in the lifecycle of the resource 1923 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/ce1a927f03a0885334cebe3e532e87fc.jpg a787b4faf4f9a825a0c61436412f1491 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bronia Lowenthal Fink in medical school anatomy class, Vienna, 1922 Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-002 Date A point or period of time associated with an event in the lifecycle of the resource 1922 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/c9bcff7ab808daf91947155abc826b10.jpg bb5f4ea36367e11b5dd3430512e88499 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bronia Lowenthal Fink in Vienna, undated Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-003 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/4ba5e96b945ff650600fd8eebc62b978.jpg 9e63d62436644f7352adb6c407f61300 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Photographs Still Image A static visual representation. Examples include paintings, drawings, graphic designs, plans and maps. Recommended best practice is to assign the type Text to images of textual materials. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Bronia Lowenthal Fink in Vienna, undated Type The nature or genre of the resource Image Identifier An unambiguous reference to the resource within a given context mfp-04-01-001-0-004 Subject The topic of the resource <a title="Photographs" href="http://id.loc.gov/authorities/subjects/sh85101195" target="_blank">Photographs</a> Relation A related resource The Max Fink Collection Description An account of the resource Mother of Max Fink Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Format The file format, physical medium, or dimensions of the resource jpeg Photographs http://exhibits.library.stonybrook.edu/mfp/files/original/7bd07b6cfa28408a13dfb7a2b134ee43.pdf 7a8e9dcb7ef041dbb63226e8de460992 PDF Text Text �Reprinted from Psychopathology of Communication Grime & Strstton. Inc., 1958 Printed in. (1.5.4. 9 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY By ROBERT L. KAHN, PH.D., I AND MAX FINK, M.D.* Weinstein and his associates have described patterns of symbolic adaptation in patients with cerebral dysfunction.l The main emphasis in their work has been placed on altered language patterns. Their observations have shown the similarity and relationship between various kinds of behavior which were previously regarded as disparate phenomena. Instead of being isolated defects due to focal brain lesions, these phenomena can be understood as uniﬁed aspects of an altered pattern of adaptation under the conditions of a diffuse disturbance in brain function. Some of the factors which determine the particular type of adaptation shown include the premorbid personality and the nature of the environmental stresses. This emphasis on language has been shown to be a useful method of study. For example, the presence of certain characteristic changes in language under the influence of amobarbital sodium, such as disorienta— tion for time and place, denial of illness, and reduplication, has been standardized as a diagnostic test of brain disease in neurological patients?! 3 This technique has application in the study of other conditions of altered brain function, as in the somatic therapies. The electroshock population is of interest for two reasons. It is possible in these patients, as it is not in those with neurological diseases, to manipulate experimentally the stimulus causing changes in brain function. Secondly, the mode of action and the psychological changes associated with electroshock treatment remain poorly understood. In a previous study we have shown that a favorable clinical response to electroshock treatment is related to early and persistent manifestations of language changes with amobarbiN RECENT YEARS * Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, New York. Prepared with assistance from the National Institute of Mental Health, Public Health Service and the Dazian Foundation for Medical Research. 126 �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 127 tal sodium characteristic of altered brain function} This ﬁnding was considered to support the hypothesis advanced by Weinstein and Kahnl’ 5 that the mechanism of therapeutic action of electrically induced convulsions lay in the creation of a condition of altered brain function in which the patient might express his problems in a new symbolic fashion, particularly in the form of denial. The present investigation is a further attempt to test this hypothesis by studying changes in language that occur with treatment. The following questions speciﬁcally were studied: 1. Are there characteristic identiﬁable changes in language which develop in the course of electroshock treatment? 2. Are these changes related to the clinical response? 3. Are these changes related to the degree of alteration of brain function? 4. Does the administration of amobarbital sodium prior to treatment produce any changes in language which have prognostic value for the eventual clinical response to treatment, the development of altered brain function, and the development of language changes during treatment? METHOD Population: Sixty-ﬁve consecutive referrals for electroshock treatment at the Hillside Hospital were studied. The Reiter electrostimulator was used on 49 patients, while 16 were treated with the Medcraft. There were 20 men in the series and 45 women and ages ranged from 21 to 68. Each patient was tested prior to treatment and retested during the second week of treatment after having received 4-6 convulsions, and during the third week after having received 7-9 convulsions. On each of these occasions the patient was ﬁrst tested clinically and then after amobarbital sodium had been administered at the rate of .05 grams per minute until nystagmus, slurred speech, drowsiness, and errors in counting backward were noted.2 The test consisted of a standardized series of questions concerning orientation and awareness of illness. This study is based, however, on the response to only three of the questions used: (1) What is your main trouble? (2) Why did you come to this place? (3) If you could have one wish, what would you wish for? All responses were recorded verbatim. Observations were also made on such nonverbal aspects as smiling, laughing, gestures, and other bodily movements. �128 PSYCHOPATHOLOGY or COMMUNICATION RESULTS Patterns of Language Change Noted Clinically During Treatment In evaluating the changes in language, the original responses to the three questions given clinically prior to treatment were used as the baseline. The evaluation of what constituted a change was based on explicit objective changes in grammar rather than on subjective or interpretative changes as to affect, mood, feeling, pitch, voice quality, etc. In this manner the following types of language change were noted clinically during the course of treatment: (1) alteration in the syntactical use of person, (2) evasion, (3) verbal denial, (4) qualiﬁcation, (5) change in tense, (6) displacement, (7) stereotyped expressions and cliches, and (8) smiling and laughing. Alteration in the syntactical use of person. Instead of using the ﬁrst person singular as in the pretreatment period, 28 patients used the second or third person and, occasionally, the ﬁrst person plural. To the question concerning main trouble such responses were given as, “It’s what they call a depression,” “They told me I was emotionally and mentally sick,” “We’re having a lot of trouble with my mother-in-law,” “My cousin brought me; she said I was nervous,” “What’s your main trouble, or don’t you know?” and “My Mrs. is sick and I would appreciate it if they would let her in here as soon as possible.” The reason for coming to the hospital was variously given as, “My wife brought me,” “My father told me to come here,” or “My doctor said this was a good hospital.” The wish was given as “Perfect health for my family,” “My children, my husband, and all my good friends should be healthy and happy,” and “There should be peace in the world.” Evasion. Evasion in answering the question about their illness was shown by 27 patients. This commonly took the form of answering this question with another, as, “What do you mean by my main trouble?,” “What do you expect me to say?,” “Well, what it it?,” and “What did I say last time?” Other language patterns considered evasive included such responses as, “I don’t know how to tell you,” “I don’t get what you mean,” “Let me think,” “It’s hard to say,” and “I just don’t know how to express it.’ One patient asked the examiner to give her a hint. Verbal denial. Explicit verbal denial of illness was shown by 23 patients. They either said they had no main trouble, were well or else, after giving evasive ‘I don’t know” responses, denied their illness and symptoms when speciﬁcally questioned about them. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 129 Qualiﬁcation. Qualiﬁcation of a response in the direction of less commitment was shown by 19 patients. This language pattern was characterized by the use of such words as “guess,” “kind of,” “sort of,” “think,” “apparently,” “probably,” “possibly,” “might be,” “seem,” “assumed,” 9, and “perhaps. Thus such responses were given as, “I guess I have been jittery,” “I seem to be very much depressed,” “Probably that I’m nervous,” “I suffer from anxieties, apparently,” “Possibly worry about the future,” “I have sort of gotten frightened,” “Mentally upset, I assume,” and “I think I’m a little insecure.” Change in tense. In 18 patients there was a change in tense in describing their illness. In most cases the patient used the past tense: “I was depressed when I came here” or “I had been nervous.” In other cases the patient answered the question about his main trouble by putting it in the future tense as a wish. Displacement. In 20 cases there was a displacement of the complaint to something other than originally given prior to treatment. This was invariably less serious than the original complaint. Sometimes the displacement was in the form of a somatic complaint, as saying the main trouble was “diarrhea,” “headaches,” “pain in the feet,” “I slammed the ﬁnger in the door,” and “I’ve got an itch.” In other cases the displacement was to some concrete aspect of the hospital situation, as “My main trouble is getting these treatments,” or “I’m upset because I was transferred to another ward.” Stereotyped expressions and cliches. The use of stereotyped expressions and cliches was shown by 11 patients. They gave such responses as “It seems to me under the proper circumstances I’d be all right,” “ [My trouble is] monetary problems with people that are honorary and sincere,” “That’s the root of the whole thing,” “The only thing certain is death and taxes,” “Learn my lesson and be a good boy,” “To be a person of pep and reliability,” and “I just want to stop being a lazy lout.” One woman responded to a question of her one wish with, “I think I should consult my husband before I make a wish because he’s a lawyer and the father of my children.” Smiling and laughing. In 20 cases the patient was noted to smile or laugh either immediately preceding or following his response to the question concerning his illness. Language Changes Shown with Amobarbital Sodium During Treatment The language patterns after amobarbital sodium during the second �130 PSYCHOPATHOLOGY OF COMMUNICATION and third weeks of treatment were similar to those noted clinically. With the drug, however, the changes appeared earlier in the course of treatment. A given language pattern might be noted in the second week of treatment with the drug, but would not occur clinically until the third week. In addition, the reactions to the drug took more extreme forms, which are described as (l) cryptic responses, and (2) withdrawal reactions. Cryptic responses. These were shown by 23 patients. Responses were classed as cryptic when they had no obvious relevance to the test question or when their meaning was obscure, representing a very personalized expression. Thus one patient, when asked his main trouble, said, “Nightmare of the afternoon of the evening of the nightmare.” Others do the know the didn’t “I such problems—couldn’t as responses gave problems,” “Getting my husband to write down what he does,” or “What could I say—you don’t get the crossword.” Withdrawal reactions. Some pattern of withdrawal was noted in 33 patients. This behavior was characterized by incomplete sentences, incoherent mumbling, neologisms, perseveration, the use of a foreign language by bilingual patients, and delay or failure to respond to the questions. These patients would characteristically lie with their eyes open, would smile or turn their heads when the examiner spoke, and would speak clearly and promptly and in English when asked questions not pertaining to their illness. Other Changes in Language Other changes in language were noted both clinically and with amobarbital sodium in response to the other questions of the test battery but not as a part of this study. There was frequent misnaming of the examiner or reference to him as “Mister.” With the drug those patients who had a “positive reaction,” i.e., one characteristic of altered brain function, showed the characteristic patterns of disorientation for place and time and confabulation described in previous communications. (2) Relation of Language Changes to Clinical Response The evaluation of clinical response to treatment was made independently of this study. The patients were rated by the supervising psychiatrist in charge of the treatments, by the patient’s own therapist and supervising psychiatrist, and by the medical director. On the basis of these ratings the patients were classiﬁed into three groups: 28 patients were �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 13]. considered much improved, no longer showing the symptoms which had brought them into the hospital; 22 patients were rated as moderately improved, showing some symptomatic relief but still showing disturbing features; and 15 were regarded as unimproved, having shown only equivocal or transient changes at best. The ratings were short term evaluations, being made within two months after completion of treatment. For quantitative purposes the language changes shown during both the second and third weeks of treatment have been grouped together as though the patients had been tested only once. If a particular pattern was shown during both periods, the item was scored only once. Altogether, 89 per cent of the patients showed at least one of these patterns of language change clinically during treatment. Such changes were found in all of the much improved patients but in only 73 per cent of the unimproved group. It was apparent that there was a relation between the degree of clinical improvement and the number of changes in language patterns. When the data are analyzed for the patients who showed three or more language pattern changes, there is a signiﬁcant difference between the groups (table 1). While 68 per cent of the much improved patients showed three or more language changes, only 20 per cent of the unimproved patients showed this degree of language change. Using Chi-square, the over-all difference is signiﬁcant at better than the 1 per cent level of conﬁdence. TABLE 1.—Relation of Language Changes Shown Clinically to Response to Treatment Three or more * patterns Fewer than three Change No. Much improved Moderately improved Unimproved 28 19 22 7 32 15 68 15 3 20 12 80 65 29 45 per cent 36 55 per cent Total *X’ = 11.26; P < 68 per cent patterns 9 * 32 per cent .01 When each language pattern is analyzed individually (as shown in fig. 1) it becomes apparent that not all patterns discriminated equally �132 PSYCHOPATHOLOGY OF COMMUNICATION between the groups. In all but one case, a greater percentage of the much improved group was most likely to show denial, use of the second or third person, evasion, and displacement of complaint. The only lanmuch the between found diﬁerence which little was on pattern guage improved and unimproved patients was the incidence of smiling and laughing. Analysis of the changes shown by the diﬁerent groups under amytal is shown for the cryptic and withdrawal reactions only in ﬁgure 1. While the crytic responses did not vary much with the different groups, the showing of a withdrawal reaction differentiated the three groups signiﬁcantlyﬁ‘ occurring in 71 per cent of the much improved, 45 per cent of the moderately improved, and only 20 per cent of the unimproved patients. Relation of Language Changes to Electroencephalographic Response In a previous communication a method of quantitatively evaluating electroencephalographic records was described.6 Criteoria were established for rating records as showing relatively high, middle or low degree of slowing according to ﬁve criteria: average per cent time delta waves (waves of six or fewer cycles per second), the highest per cent time delta waves at any one lead, the lowest frequency in the record, the highest amplitude of delta waves, and the longest duration of a burst of delta waves. In the present study, an electroencephalogram was obtained prior to treatment and in the second and third weeks of treatment. Each record was evaluated according to the dichotomy of showing a relatively high degree of delta activity or not, using these criteria. In table 2 the relationship is shown between electroencephalographic slowing and changes in language. Those patients with the highest degree of cerebral dysfunction, having high degree delta in both the second and third weeks of treatment, show a greater number of language changes both clinically and with amobarbital sodium. Using the withdrawal reaction as an index of the drug effect, however, the difference just fails to be statistically signiﬁcant. Pretreatment Language Patterns The language patterns described in this study were considered as changes only when they occurred after the original pretreatment clinical test which was used as a baseline. Seven patients, however, showed some " X2 = 10.72, signiﬁcant at better than the 1 per cent level of conﬁdence. �133 CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY TABLE 2.—Relation of Language Change to High Degree Delta on the Electroencephalogram During the Second and Third Weeks of Treatment Withdrawal reactions with amobarhital sodium T Change No. Three or more changes clinically Both weeks high Delta Activity One week high Delta Activity No high Delta Activity 25 16 16 8 50 9 56 24 6 25 8 33 = 7.62; P < TX” = 4.87; P < * X2 * 64 per cent 15 60 per cent .05 .10 M form of these language patterns in the initial clinical test. The manifestation of these same patterns by these patients at any other time was accordingly not scored as a change. When given amobarhital sodium prior to treatment, however, 30 patients (or 46 per cent of the total) showed some language change comparable to that noted during treatment. Table 3 shows the relation between such changes at this time and the eventual clinical response. These changes were found in 68 per cent of the much improved patients, in 36 per cent of the moderately improved, and in 20 per cent of the unimproved groups. TABLE 3.—-—Relation of Pretreatment Language Changes with Amobarbital Sodium to Eventual Clinical Response Change No. Much improved Moderately improved Unimproved 28 19 22 8 36 15 3 20 “ X2 = 10.30; P < .01 Change with amobarhital sodium 68 per cent * �134 PSYCHOPATHOLOGY OF COMMUNICATION In table 4 it is demonstrated that the pretreatment change with the drug was also prognostic of the eventual physiological response to treatment as measured by the degree of electroencephalographic slowing. The over-all distribution just falls short of statistical signiﬁcance, although when those who showed high delta activity in both periods are compared with all the other cases as a group, the difference is signiﬁcant at the 5 per cent level of conﬁdence. of Pretreatment Changes with Amobarbital Sodium to High Degree EEG Delta Activity During the Second and Third Weeks of Treatment TABLE 4.———Relation Both weeks high Delta Activity One week high Delta Activity No high Delta Activity "‘X2 = 5.27; Change with amobarbital sodium No. Change P < * 64 per cent 25 16 16 6 38 24 8 33 .10 Finally, the initial response to amobarhital sodium was also prognostic of the degree of language change shown clinically and to the manifestation of withdrawal reactions with the drug during treatment (table 5). Between Pretreatment Language Response to Amobarbital Sodium and Clinical Changes and Withdrawal During Treatment TABLE 5.——Relati0n No. Pretreatment Three or more clinical lan* guage patterns barbital sodium = 4.26; P < 'l'X2 = 6.88; P < "‘X2 .05 .01 tions to amobarbital sodium '1‘ 30 18 60 per cent 21 70 per cent 35 11 31 12 34 response to amobarhital sodium N0 pretreatment response to amo- Withdrawal reac- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 135 DISCUSSION The relationship of the language changes to the development of altered brain function and to the clinical response is consistent with our original hypothesis concerning the mode of action of electroshock treatment. In 6 studies4’ we have shown that the clinical outcome is related previous to the presence and degree of alteration in cerebral function. Using the “amytal test”2 and the EEG as indices, it has been found that those patients with the earliest and most persistent manifestations of cerebral dysfunction were most likely to have a favorable response. Such physiological changes create the milieu which facilitates behavioral change. The present study, analyzing language patterns, clariﬁes the nature of the behavioral changes that occur with treatment. The language shown originally (prior to treatment) may be summarized in the statement, “I have this particular illness.” The subject of this sentence answers the question “who,” the predicate refers to “what,” and the verb describes the relationship, including the temporal and intensity aspects. During treatment the subject of the sentence may be modiﬁed by changes in the use of person, so that the sentence might read, “You [or he, she, or they] have this particular illness.” Changes in the predicate are shown by such patterns as displacement or evasion. In displacement the sentence might read, “I have some other kind of illness,” while, with evasion, it would be, “I have something, but I don’t know what.” Changes in the verb are shown by denial, qualiﬁcation, or alteration of tense. In denial the statement would be, “I don’t have this particular illness;” a qualiﬁed sentence would read, “I might have this particular illnessg” while with alteration of tense the sentence would be, “I had this particular illness.” Some language patterns modify the sentence as a whole. If the patient smiles, or if he introduces his statement by saying, “The doctors tell me that . . . ,” any part or all of the sentence may be modiﬁed. In other reactions, particularly those noted under amytal, the patient avoids giving any meaningful statement at all. In the withdrawal reaction he says nothing or omits part of the sentence. In the use of cliches or cryptic expressions no speciﬁc referential meaning can be drawn from the language. It is evident from this analysis that the language changes are not random or bizarre, but form a patterned reorganization of communica- �136 PSYCHOPATHOLOGY OF COMMUNICATION tion characterized by an alteration in the patient’s attitudes to his problems and his illness. The patient either says he is not now and never has been ill, displaces his illness temporally, spatially, or personally, is less committed to his awareness of his illness by the use of qualiﬁcations, or avoids the whole problem by evasion and noncommunication. These patterns are comparable to those noted previously by Weinstein and Kahn:l in patients with cerebral disorders, and referred to by these authors as the “language of denial.” Similar language changes have also been described following other somatic therapies. Frank“ 8 reports that lobotomized patients avoid talking about the operation, and he states that “the facility and glibness with which they say ‘well I had an operation for my nerves, I guess’ contain the quality of unconscious denial.” Legault,9 working intensively with post-lobotomy patients, found persistent attitudes of denial. One patient, when asked why she came to see the doctor, said it was her relatives’ idea. Many gave qualiﬁed responses, saying they “supposed” they had had an operation. Others doubted that the operation was on the brain, or used an evasive, stereotyped expression as “some nerve in there,” or displaced the procedure as in, “Oh, yes, I went to the hospital and got two black eyes.” When asked about the symtoms that led up to the operation, patients gave such response as, “It seems to have gone.” In studying patients who showed clinical improvement following prolonged coma reactions in insulin coma therapy, we have noted similar changes in language. In a case report10 we noted the appearance of reduplicative phenomena, evasion, verbal denial, displacement, increased use of stereotyped expressions and cliches, cryptic responses, and much smiling and laughing, at a time when clinical improvement was most marked. Since these language changes occur most frequently in patients who are clinically evaluated as improved, may not the language patterns themselves be the critical cues that give a favorable clinical impression? There is traditionally much difﬁculty in rating patients after treatment. Such evaluations are highly variable because of the lack of suitable objective criteria. While there are other objective cues which can be used, such as the amount of sedation required or the quantity of food eaten, the appearance of these language patterns may constitute an operational basis for clinical evaluation in the psychiatric interview. Not all patients, however, who showed at least three of the language changes were regarded as much improved, and not all of the much im- �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 137 proved patients showed this degree of change. There may be other aspects of language and communication not covered by this study which are signiﬁcant. Another explanation is that the use of these language patterns may vary in time or in different situations. On the basis of our previous observations of the “Amytal test” and the electroencephalogram in electroshock patients, we should predict that unimproved patients would show these language changes only transiently, while improved patients would show them persistently. Future work should also be directed toward comparison of language patterns shown when the patient is speaking to a physician with those used when he is with his family or friends. The degree to which members of the patient’s family are made more comfortable by the changed language, and even their inclination to use similar language, may explain the variability in the duration of 11 and Both Kahnl' Weinstein and improvement following treatment. Legault9 have indicated a relationship between the patterns of communication of the patient and those of his family. Finally, our results demonstrate the prognostic usefulness of amobarbital sodium administered prior to treatment. The prognostic value of the drug in the somatic therapies has been noted previously by Hoch12 and others,““14 who felt that patients who became more normal in speech, ideation, and behavior under the inﬂuence of barbiturates were most likely to improve with treatment. In the present study the manifestation of a change in language with the drug was related not only to the development of altered brain function and to the clinical outcome, but to the eventual manifestation of these language patterns clinically. On this basis, an operational deﬁnition of the goal of electroshock therapy might be described as enduring clinical manifestation of those language patterns which occur initially only with amobarbital sodium. SUMMARY AND CONCLUSIONS consecutive patients referred for electroshock treatment were studied prior to and during the second and third weeks of treatment. Each patient was tested at these times both clinically and with amobarbital sodium with a standard series of questions concerning attitude toward illness. 2. The results showed that characteristic changes in language occurred both clinically and with amobarbital sodium during treatment. These changes were signiﬁcantly related to the clinical response to treatment 1. Sixty-ﬁve �138 PSYCHOPATHOLOGY OF COMMUNICATION M and to the degree of alteration of brain function as measured by the electroencephalogram. 3. The presence of these language patterns with amobarbital sodium prior to treatment was related to the eventual clinical response, the development of altered brain function, and the development of language changes clinically during treatment. 70 a 6050 40 'lo 30 FIG. 1. CLINICAL WITH AMOBARBITAL r-——| I uucu Imovso- Ei Ionmovw Cl ‘ummovso Relation of each language pattern to response to treatment. 4. It is felt that these language changes constitute an operational basis for the evaluation of the clinical response. 5. The results support the hypothesis that the therapeutic mechanism of electroshock treatment is the development of different patterns of symbolic adaptation to the patient’s problems and illness under the conditions of altered brain function. REFERENCES 1. WEINSTEIN, E. A., AND KAHN, R. 2. L.: Denial of Illness: Symbolic and Physiological Aspects. Springﬁeld, III., Charles C. Thomas, 1955. SUGARMAN, L. A., AND LINN, L.: Diagnostic use of amobarhital sodium (“Amytal Sodium”) in organic brain disease. Am. J. Psychiat. —, —, 112: 889-894, 1953. 3. —-~, , AND MALITZ, 5.: Serial administration of the “Amytal test” for brain disease: its diagnostic and prognostic value. Arch. Neurol. & Psychiat. 71 : 217-226, 1954. �CHANGES IN LANGUAGE DURING ELECTROSHOCK THERAPY 139 Relation between altered brain function and denial in electroshock therapy. Arch. Neurol. & Psychiat. KAHN, R. L., FINK, M., AND WEINSTEIN, E. A.: 76: 23-29, 1956. WEINSTEIN, E. A., LINN, L., AND KAHN, R. L.: Psychosis during electroshock therapy: its relation to the theory of shock therapy. Am. J. Psychiat. 109: 22-26, 1952. FINK, M., AND KAHN, R. L.: Quantitative studies of slow wave activity following electroshock, Electroencephalog. Clin. Neurophysiol. 8: 158, 1956. FRANK, J .: Clinical survey and results of 200 cases of prefrontal leucotomy. J. Ment. Sci. 92: 497-508, 1946. —: Some aspects of lobotomy (prefrontal leucotomy) under psychoanalytic scrutiny. Psychiatry 13: 35-42, 1950. LEGAULT, 0.: Denial as a complex process in post lobotomy. Psychiatry 17: 153-161, 1954. 10. KAHN, R. L., GRAUBERT, D., ll. FINK, M.: Delusional reduplication of parts of the body after insulin coma therapy. J. Hillside Hosp. 4: 134-137, 1955. WEINSTEIN, E. A., AND KAHN, R. L.: Personality factors in denial of illness. AND Arch. Neurol. & Psychiat. 69: 355-367, 1953. 12. HOCH, P. H.: The present status of narcodiagnosis and therapy. J. Nerv. Ment. Dis. 103: 248-259, 1946. 13. HARRIS, M. M., Honwn‘z, W. A., AND MILCH, E. A.: Regarding Sodium Amytal as a prognostic aid in insulin and metrozol shock therapy of mental patients (dementia praecox). Am. J. Psychiat. 96: 327, 1939. 14. GOTTLIEB, J. 5., AND HOPE, J. M.: Prognostic value of intravenous administration of Sodium Amytal in cases of schizophrenia. Arch. Neurol. & Psychiat. 46: 86-100, 1941. ��r i , ‘ 4‘ __ W g 1" ' 3 m' 13 1956 ‘ L g 0 cm In meme: mama wrmsnocx mm! Robert L. mm, mm. (1) m m; 3.9. (2) x a 3 E m the Roman Service, Rama 303mm, f 610:: om, In Ion-k Research Assistant (Psychology). (1) (2) Inmmumrtufﬂmumrdn : um,upon,bymtmavrmmhmmmmeumwmmum l hum). Instant-a We quiz . .____.,_T f 3 32 I m M“ 7 , , , ‘ of Heath, Public Health Service, and tin mm mum :m' W/we‘bé , . 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Album ﬁrst pom singular is wing and 12mm. , in tho pmtmttmt Warmingtha patient. used the second or third pom and occasionally the ﬁrst. person plural. to me question anoaming min trouble such reopen.” ward given us ”It's what they call a depress- 10a.”- 17823.64, 28 Whaytoldmlmmﬁomuyandmmliuck,‘ We'mhavingalatef trouble with w mﬂme-lm,“ my cousinbrnght no; she said I was mus,“ mam troublo, er mm mm,“ and my lira. it sick and I tram tppmciato it bar in how u soon a pas-ibis.” thq mum team for coming to the heapiul m anomaly given a W wife hm: no," "W "What‘s 11‘ tamortaldm to m hora! oriwdeow mid mama mumm.‘ will: an: grim as “Part-rat ' The 3.0% mu: for w M13," W alumna.- my Tho husband and anwgoodfm uhauldbelnnlﬂvandhappy' mﬁmmaummmm m Md.“ �“”1 ‘ ~5i I LAW Men Wiring m. m M 2. w 1:: 21 patients. rm- with a question, as ”What. do. mm; m Wm momma the queetioh about their tea: the tom of you new by m main trouble?,' “that do you «poet mo; won, what 1:: m,“ and "What «he 1 may last than?“ Gum-1W patterns considered and" included such responses as ”I don't know how to tell you,“ ”I don’t get what you mean," "Let ale think,“ um hard to any,“ ad “I no to m Just don‘t hint. how to expanse 11:." One patient asked the «minor to give her a W. mutwmmammummwzspu an,” Wm W. 1mm. they either math-y had no um «am or an axing evasive “I don't mow” reapeneeo, denied specifically questioned about. him. ' eomltmont the use their illness and a... arm- mention a: a meme in the dimtion a: 1»- m ohm by 19 patients. a: were. as ”31103:," ably, " "possibly,“ ”man. be,“ were given no '1 gun: I have ”pmbably that I'm This lulguago pattern was characterised by ”kind of, “an,“ been ' , “sort at " ”think " “apparentlyﬂ "prob- “assumed," and “perhape." That such Jittery,” “I seen to he very ream mammaed,“ mom,” “I suffer from emotion, apparently,“ ”Poenbly early about the fume," ”I have sort or! gotten momma,“ upset, I and ”I think I'a a little inseam..." W. ”W ‘ Inlapntiente therewaeaohangein um,” mum» in; their 1111:)“. In most cane the patient used the past tense, as "I wan depressed when I one here” or 'I had been mm.” In other canoe the patient answered the question about his main trmzble by ' 131%(2mg. In 20 cases mung it in the future there no a diamamnt tense as 3 Huh. of the Wt ‘ W to something other than originally given prior to treatment. This was mummy lest Bonan- than the original comm. Sometimes the dilplacamnt was in the tom of a emetic complaint, as laying the main trouble was ”diarrhea," “headaches,“ �WWWWMI—Fr‘ .6. ' ”pm in the tests," “I slams the rings;- in the door,“ stair case: the displacemnt as ‘33: main form»! m to some mores. aspect or the: itch.” In hospital situation, trauma in getting those treatments," or “I'm upset because I to another 7.} and "I‘vs got. an was trans- wand.” Suﬁsm mania and 011mg. Tho use of stereotyped sxpmssim andsliohumaambyupltisntl. Thsygan-uehnnponauunltmtam undo:- the proper circumstance: Igd be alright," with pupils than. are honorary and sinners,“ “The only '1‘0 be thing «mm is “(my tmblo in) monetary "Tut’- the root of the (bath and taxes,“ "Loam my pmblou whole thing,“ lesson and be a good boy,” person a! pep Ind nhtbility,” and “I just want to stop being a hly lent.“ Muhammlpmbdto‘aqusstimothsrmwishuth, 'Imnkllhmaoonsultw a. W. husband borers 8. laugh I make a wish became ho'a a lawn: and the {nth-r or InﬁOcaauthopatimtmmtodtoamoor 01m manuly wounding or following his coming xv childish." suspense to the question can- nu 111m". to. language ”zoom um:- ambarbitsl mom during to. mono and tom: units of treatment. were 11min:- to those noted clmenlly. with the drug, haunt, the changes 5mm earlier in the sour» or treatment. A given Imguags pattern might be noted in the second was]: at insistent with tho drug, but. would not occur annually until the third mt. In Audition, the motions to the drug took more extreme forms, which are ascribed cryptic responses and withdrawal remnants. 1. W. u patients. 3031mm” wars class-sdas cmtiswhmthsyhndmobﬁm relevance to the testqueetion ormthsir 31118 was shown by 23 m obscure, 1'31)an a very momma-d «pr-union. Thu: ms patient, MWMsMntmnble, ma'mghmoftmuumomofmmmgattm naming night-am.” Others gave such msponsoa an to. problem," ”gutting no husband to you duo‘s get. the naturism." '1 MN. know the pmblsm - cm‘t do ma dm mo he does,“ or ﬁrm oouu I uy .. �M_W~«W.“hm... ,Wﬁr—yyw'V‘amn"WW—wzmw. wm-u.www‘wex"w\’murvxl'ww’byum—lam. 7, am....-.. We. .: . ~ . , V . ... 7 or Wham-x“... .3». > my- a. ~u..r-_..L-r.-‘~w ﬂaw. ,‘m,r__ wry", “Tee ‘11ng reaction. 8m pattern or withdrawal was noted in 33 patients. 2. m: behavior we: ohenoteriled by ineomlete egim, pomemtdon, the use or failure to eve-pond of e totem Manage by bilingual patients, and delay to the questions. meet; patiente would cheruoterietioelly lie m1. with their eyes open, would or turn their heed clearly end promptly and in would speak eentencee, incoherent mumbling, mela- when the miner epoke, and Well when asked motions not pertaining to their illness. comm sodium My endwith ambarbitel oom- changes in hnguege were newborn in neponee to the other qua-time of the tut battery but not part of thie more use frequent dimming of the manner, or uteri-mg to hm :- .‘Eﬂater.’ with the drug these Intimate who had e “punitive reaction,“ my one characteristic characteristic patterns of acclimation for place and time and contebuhtion deeorlbed in preview! communion! (2) . of altered man Motion, showed the the evaluation of clinioel memo to treatment we mede independently of thie may. The Intimate were mted by the supervising peyohietnet in charge of the teammate, the patient‘ﬂ om therapist end eupenieing peydxiatﬂat, anaby the director. 0:: the beeie of these ratings the petiente were unsealed “eel into three gmpa: W turned, 28 pmenu um widened much which brought then aiming em into the hoepitel; eynptometio 22 improved, no longer showing the petiente were rated as moderately relief, but still ehowing dimming restore" 15 were ragweed ee mmproved, having elbow: on]: equivocal or trmeient and We at beet. me rating: were abort term evaluations, being ude within two loathe after coupletim of them. �PERCENTAGE SHOWING EACH LANGUAGE PATTERN ACCORDING TO RESPONSE TO TREATMENT 70 60 CLINICAL I—————————-‘ WITH AMOBARBITAL l———_I I MUCH IMPROVED El UNIMPROVED I400. IMPROVED �*8. For quantitative purposes the language change: diam during both the mead third week: of tmtaent have been grouped together“ as though the patient: had been tested only once. If e particular pattern we chm during both periods, the the: me scored only wee. ntegether, 895 of the petiente enabled at least one at and then patterns of We manually dining treatment. Such changes were fomdinullthemch mpmvoepauembntinonly7motuuunmpmdm. It as nmt. and the amber [the patients a: chengee who showed mungmgo patterns. three or more leaguege language change. em a.“ is analysed for Wed petm enlyZOSottbeunimpmedpaﬂenu ienteehmdthmotmnlmgugechangee, this degree of When We- petum changes, there is a signiﬁ- I). ‘gieent differ-wee between the groups (Table shaved clinieel apparent that. there me e relation between the degru of 681 of the much Bung cm! the menu dietdbuﬁdnie lim- mMatbetmtnmth-uwaercmnm. Relatian of. W m 1mm (28) WW MW (22) W (15) 1‘0“!- (65) Chang" W Shawn 3. Wally to Ream“ to Treatment. lie. lo. 5 1 19 685 9 32: 7 )2! 15 681 3 201 12 895 29 ' W 36 551 :2 - 11.25 1! <m Hheneachlengmge pettemiemelyeedmdivimm,um1nﬂ¢m1, itbecaneeeppemtthetnotenpe‘btem wcmmequmymmw. Inﬁlbntoaeem,emmmtmeftmmmmdpeumuwmmn ’ �Y «my v m. n.“ .-‘ nmxw “gamma. — yawn , v mama-gm m w“... n- ,.—., »1—0” —W -.~.- - V , , n «Fur run...“ .- - . 17,1,» - . , men-1mm, mottheeecmdormmpeum, Wanda-Newt o! ambush; The aﬂy 1111311130 petum on While}: little airtime was found between mmmmmmmdmmamemdmmmum. .Anuymatmmemwmwrmmmup-meumm termerypueandwithdmel mam anlyinrigun 1. mmaypuc reepeneee did mtnrymeh with the afferent groups, the withdml, moving of e mum differentiated the three gmupe eigﬁfimm: occurring in 711 of the mach Whﬂdthemdenﬂhhpmndmdmmzﬁottbmnpmdpauwu. x. : mu.“ Mum of In a e to ., vs; mea new M of qumtitaﬁvm Mam electro- Mama pm ducribed (6). emeMgraphic ' a resend: records an m inning relatively high, middle ,a; criteria 62‘ ~ were established low degree for rating of abnonnliia according to five agitating avenge percent. time delta. wee (waves at :11 cycles per mood or lees), the highest percent time delta. mm at my one low. the lowest tremmney lathe moord,thehigheetamplitudeofdelteme, burst. of delta me. mummumote In the present study, an electroencephelogm wee obtained priortotmmntandm the ”Windmirdmk a: treatment. Each ”comm «alum mending to the dichom at showing eliw er m, using the-e axe-Lurk. In Table ality V and changes the relation-hip 2 in animation, Wag show a 1mm. am reletively h1g1 demo at ebnon'e- mm mm abetroonaeplulognphtc linem. Tho: patients with the in Why of high mate; mm: 18 I. greatest degree at cerebral both the «can! I2 a 10.72, thinner:- at mmt, hmge change- both clinicallyxand with Waite]. and“... the mama. mum at! mime-u: at the drug effect. ' m, was the 3m. ran- to be statistically signiﬁcant. I» end. Wimt 1% better than the ' 11 level or comm. �ﬂ‘rﬁwwwme—wmm. . ‘ermmmﬁmvﬁmimmw' TABLE Relation of Language Ghana. ’60 High 3 WW (25) OnMunimzé) ‘ lo 315: Ahnamauw (2h) mm withdrawal Motion! with W191}. Seem: i lo. 1 15 as a 50% 6 255 - 15 601 _ 9 5“ ‘ B 335 . Yoa P < 0°, :2 12 Language when they ._._.r,._r. Eloctmmmalom Dunne , m1: < ‘ Both Weeks 31g: 2h: , of Treatment clinical]: lo. may “at on the or Kan changes m._.—r.m~. 2. 83m and Third ﬂecks the , P pat-Mm «termed in that: stuck wan manned afar tho original ’ has? .19 < midsmd a: change: mmmm clinical test which an and u a. baseline. Bum patients, 11mm, .Ihmd can form of than 1mm puttem in the initial 91.1mm test. me minimum or thus same pattern! bythaeepnuenuatmomrtimmmonnnmnatuconduachmgo. mm gum Wits). actual prior to tmtmt, War, 30 patients", at Wot‘ﬂwmu,mmdmhngmgammnbhmmntnommtmh neat. In‘hbh3thonhumbomahmgamhchmguat mamumhm m'mmmeumm mm». Manfmdméﬁﬁdmmw pmdpmmnu, thwzyséiutlmnoammynwdwamozmmmd W. . ‘ , par" .— .V �w :u—v-r—wwxv—mww: Relatim of W W3 Pn-tmmt Language Ghangon autumnal Mun with mm and clinical Mona cm. with Ambarbital mu 1 Ho. Knob Impravod (28) Hodomtely MIMI: W 68$ 19 (28) 8 36% 3 W 30 It“ (15) Tom (65) l :3 - 10.30 P< In Tab}. was I; .01 it 1. “inﬁltrated that the pm-vtmtmnt change with the also prognostic of tho eventual drug Widow anionic to tmtment as mound ouctmcaphalogmmc abnomanw. Tho mun distribution 3m; tall: chart at statistical lawman, although than who my: almonby m. magic. 01' m mlityinboﬂpeuoda an conpnrodwiﬂzall’ehsothor crence is significant at th- 51 1m]. 91‘ canﬂdonoo. Relation of ma mnuam, thaw:- Pwtmmt Languag- Ghanges with manual. Sodium and High Basra Em Abnomliw Drug the Second and Third Weeks of Tmman‘b Both Wuks High One week mmty (25) M Announnw (16) Chung: With Amobarbital Sodium Ho. 1 16 6&1 6 . 38$ ’ la High Abnormality (2h) 8 335 - 5.27 P<olO 1a �many, the initial degru a! Ianguagl clung. I‘hm cunicamand "actions with the drug during twat-ant (km: S). tho m hcpom to 5 . human at Pro-tantalum sodium.an pregnant?“ at to tho Mutation otirithdmnl response to ambarbital Language . NW mm mm: 5041mm . 1': 011mm Chang“ and Withdrawal Remuom 3 Clinical PatternLeague. 03' Hora lo. Pmtmmm Respom to max-mm Sodium (30) In l’ru—treatment Response to Mammal Soditm (35) 18 , 11 :2 aims 9‘00; Withdrawal Reaction! ﬁo Amour-Mu]. Sodium 1 30. i 601 21 705 311 12 3M - 6.38 P<ll°1 x2 _ �'Iwwa‘v-rI—Ku,WM wc-v— ~33- w".— «my. qzwrr * Discussim the relationship or the language changes to the development of sltsred brain function and to the clinicsl reepcnee is cmistent with our original vaethesie cenceming the nude have shown ct action or electmehock treatment. In previous stmnee that the clinical outcome is related to the (hﬁé) we presence and degree of alter- ”mm test" (2) and the we as indicse, it has been fomd that those patients with the earliest and most persistent Mutations were met likely to have a favorable response. Such physioof cerebral aticn in cerebral function. Using the mm logical changes create the milieu which facilitates behavioral change. present study, analysing language petteme, clezii’ies the nature a: the beheviorel changes that occur with treatment. the language chem criginelly, mic:- tc. treatment, my be amused in the The statement, "I have this particular illness.” The subject or this sentence answers the questicn 'Who,’the predicate refers to What,‘ and the verb describes the relationship, including the femoral and intensity aspects. During treatment the sub- dectoi’thesentencemybenoﬂtiedbycmngesinthemotpereon, eothntthe sentence night read "You (or he, she or they) have this particular illness." Changes in the predicate are shown by such. ﬁettem as displacement or evasion. In displncs- nent the eentencc night tied “I have ecu other kind of illness," em... with evasion, whet.” Change: in the verb are it would be, "I have something, but I don't m qualification or alteration of tones. In denial the statement would be, “I don‘t have this particular illnessg' a. qualified sentence would read, “I light have this particular illneseg“ while with alteration or tense the sentence would be, "I as this particular illness,” ﬂown by deniel, Sons language psttems- modify the sentence as a whole. " If the patient mice, or 1: n. introduces his etstewent by saying. "no doctors tell me theta...“ any, pert or all of the sentence my be emailed. Other reactions, particularly those noted under mytcl amid giving any meaningful statemt at ell. In the withdrawal reaction w”... �W, wwcww—mw '-—-—'- ..r.-_m..—w., ”ﬁr .,,,,.:.._._‘,._.. r_.‘-“‘1KvW“ﬁW——r—W‘w‘wwﬂwmwwi'w ,_,. WWW .Vw—ya-awwmwnmr an... Wpemsaysnoﬂﬁngormiupertottlnsen’om. Intheuseotoliohesot cryptic expxessions no specific referential meshing can be dram free the language. or numemm-WumtwmoW-mmom bot rose mourned him, mrzaniutim a of omioeuon Motorised by so alteration in the petient's attitudes to his problems and his illness. The patient either says he is not now and never has ill, displaces his illness temporslly, or parsmslly, in less committed to his or his illness by the use of quelifioeums, or avoids the whole problem by evasion and These pettems en oonpereble to these noted previously by Weinstein end Kahn (1) in patients with cerebral disorders, and who Memo to than as the "m3. w spam use of detain." Sinus: lsngusge mm” Manon. changes have also been described following other emetic therapies. Frank (7,8) reported that lebotonised ptiente avoid talking sheet the operation, end he states that " the teoility and glibness with which they say Well 1 had so operation for nerves, I guess' contain the quality a! moon-:' scion!» q denial." Benoit (9), working mummy with postnlobotouy patients, some ‘ persistent attitudes a: denial. the patient. when asked why she ems to see the doot-or, said it was her, relatives' idea. new game qulii'ied responses, saying they owned the operation was on the brain, or used an evasive, stereotyped «passion as "sou nerve in there,” or aispleoed the procedure es in “oh, yes, I went to the hospital and got one black eyes.“ when asked “suppose“ they had an operation. Others ' about the symptoms that led up to the eperstioo suoh responses were given as ”it seems to have gone." In stucbring patients who showed clinical improvemt following prelooged om reactions in insulin eons thin-em, we have noted sinilsr changes in lengoege. In a ease report (.10) we noted the sppeerenoe of nduplicetive phenomena, evasion, verbal dermal, displacement, incmsed use or stereotype expressions and cliches, eryptio responses and moh mung and laughing at pmemt was most marked. s. time than clinical ile- �wmmmemMMp‘mmm mmmamuwmmmmpmmmum mmmum nugtammmmmr ‘mmumm mmwuumpmmmm MWmm mmammammwmwmm ultimatum awn'mmamhMMuMdemwmm utyotrmdummwdmmpmmwmututamw mmmrormmumummm um. mapm,m,mmummumwmu unwumwwmmammwpﬂmm mommd'm mummommdhwudmmmm . mmwmsmméhmummt. Wruﬂmﬂmumtﬂnm amewma-wmmmwmmnmm. fathom deﬂumﬂmdtﬂ‘WM’udm-Wm an,uwmmtmmpmmmmg mmwtm.mwpmmmmmupem may, WMWMMWMWWRWM n- wtbpmsnumammmmmuummmorm. mumwtbpmvammyummnmmbnbymmm, mammmmmwmmm,mmmnmmhmwdm duration of tone-mg and ! 1 Wt hmt(9)mmmamumummpmmammam mutant; nmmmrumv Both Hon-ma Km (1, n) and ' ' m.mmquWWde-ob iummmummg mpwmamwmmmm ‘ ’ mmmmmupmmwmm)uomm.mmmz mtmmmmmumgw,mmnmwmurwm i �”mm “mm“..m—wwaww—lw""" , A m. wl’vr-w—w-‘mx'r- :46nnuanco at barbiturates were most likely to 1W0 with treamnt. In the pumt at. chum mmguagowieh‘mdmgm nut-daetenlyto an Mom's a! alum bmn sanction and to the clinics]. but to the av. mmwamum 5mm mutation of then 1mm puttom' clinically. mm. this built, an aparauaml definition at the god of electroshock therapy night be «scribed an enduring On mm museums: of than mm natural which only occur initially with no. humui main. ' �v." 77—79». mm? - , WW. W'm“wu}—r¢ MN '-v" r 0.: navy—w ' , _ , 4 “aw—Ia W.wmv3ww,wmx-. WW,'—-‘W ~01” my iyg‘w 'w-w Hunwyw—m...“ 4.7.» may 1. , GWI saw-an ammunw mums rotomd for!" platteﬂmck What an tmtasnt. Mmﬁent’ ammwwmmmmmmu clinicallymdwith m umummww suburbia). BOMﬂthiltﬂndu, am: at Mom mooning unwa- mm 1111mm. 2. mo result: :1th that. ahamoteriatia chug“ an language We both 01mm and after gum-mm ”dim during mums. mm ohmgu we. sign“- and 1canﬂy ”hudtothe chainsaw-panes to tmtmntmdtaﬂmdegreoufalund mum at maund by thc alwmlogm. 3. Tho presume at then 1mm mam with ambit-him ”(than pain:to tmtmt was directly mum to th- mntml clinical aspen-e, tho Malay-sent bruit: ' otaltendbrainfmcﬁm. undthadmlomntutlanguagcchmgu clinicallydnring treatment. that than language éhangu What. an opomtim bun m- m mluntim of the clinical 5. the mum: ‘n'mport an hypoﬂmia that tho thanpeutio or oloctroshoak Mama“. in the develomt of walnut putt-m at symbolic adapt. 1;. It. in $311: mm. mum to the pntiont'u problem and 111m” talcum. am. _ War the conditions a: slum brain .w-wm. __..,‘ ’n’rr' 2-}— �1o “sustain, E. A. and Kuhn, R. L. AW, Springticld, 2. , 1111mm, 8mm, , . W cum: of L. A. and Man, ("mm Sodium") 39am. I maul! Evacuated. mm, 1955. L. : Dwain Us. at Ambaxbitul 6. argma Brain 1n Symbolic and maul, Ann-1m J. meant... $183943?!» 1953.. ”J 3. _____, and mm, Psychintg, E: Serial Administration at the for ”Am/ta]. Test." “mm, MILL. Arch. 217.226, 1951;. 1!. and Yul-match, E. A. s h. mm, R. 1... Pink, cation and x It: Diagnostic and Prognostic Vila, Brain 131mm: a: 3. mm in Ebotroﬂxock Therapy, 361.31% Between Alum: Bran rm- L114. Arch. ”enrol. G: ' Pageant... in press. 5. Renown, E. It: am: 1., L. and Kuhn, B. Linn.» Kantian be the of Timmy La Psychosis During Electmhock Shock Ehex'npy, Am. J. Paychiatu ' 14. and mm, 3. Lu Quantitative Studies mammm. m. cm 7. Frank, J. I clinical Survey J. ﬂuent. 301., 8. 23! 1;th, 0.: Dani-.1 161. 1994. 10. ram, R. Body at 1956. , 7 (Putnam mom) Under Psychoanalytic u a comma m” in Post know, yummy, u: 1531 1mm 0m 11.: morally. a. 11. Hem-tan, E. A. and Kuhn, R. In: Arch. Activity Founding 354:3. 1950. I... Gmubert, n. and Fink, Am:- - mm o: 200 Cm: or Putnam Macaw, of lobotomy Scrutiny, Psychiatry. 9. (mm). Heumphysiol. g: 158 and Slow wave ”7-508. 13%. Some Aspects I 01‘ mt ' 22-26, 1952. 6. Pink, Burk» mm. a: Pawn»... éi‘ Delusional Redupliaation of Parts at th- mum. Wm, Personality Eastern b; ”Iv-1&7. 1955. 1:: Denial of ’ 355-367, 1953. Inna”, �"ﬂ..- v.w-m,.__wWR—v~.....,1,..e..r.»-w.q.w,__ v7 Koch, P. 313., n. : no Prognostic n W “F" _~—,w .— Mm vunw H.‘ r u-vn ~..»u-,Ww—~wwwwnw~. WVWVWW ,wuwyﬂ—w ”Maw—v.4. 1911.6: Roma, 3. A. and men, n. 4.: lid in Insulin and Home]. Shock mgammg ‘I‘hompy (was Pmeox), m. a. Paychitt" 2g: 327. 3.939. 11;. ‘swa ant. Status as Memo-1- and Thoupy, J. Harv. Mont, m8 W59; 13. Harris, :4. a... , scum was. as a of Inantal Patients Mm», a. s. and Hop-,4. u. ! Pragmatic van; ,0! 1:11.va amusmum at Mm W]. in ease: of Schisommin, Arch. 3mm}... & Wt.f 5g: 86400. ' 191.1. ' um" , l u, ,, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes in language during electroshock therapy. In P.H. Hoch and J. Zubin (eds.), Psychopathology of Communication. Grune and Stratton, New York, 1958: 126-139. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-27-002 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource Kahn, Robert L.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [preprint] and reprint. Reprint from Psychopathology of Communication Grime & Stratton. Inc., 1958 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0a04fd8af8c99e319cfc9e14d05f3ffd.pdf d38bf0d44fbbfe5439d4cca003bd77b2 PDF Text Text CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D., MAX FINK, MD. Reprinted from Tm: JOURNAL or AND ROBERT L. KAHN, PHJ). NERVOUS AND MENTAL DISEASE 130, No. 3, March 1960 Volume Printed in U.S.A. �Reprinted from THE JOURNAL OF NERVOUS AND MENTAL DISEASE Volume 130, No. 3, March 1960 Printed in U.S.A. CHANGES IN VERBAL TRANSACTIONS WITH INDUCED ALTERED BRAIN FUNCTION JOSEPH JAFFE, M.D.,1 MAX FINK, MD. Repeated interviews with patients under— going convulsive therapy reveal progressive changes in the interpersonal relationship, which are referable to verbal and non-verbal transactions. While non-verbal aspects of communication are difﬁcult to quantify, techniques are available for the measure— ment of verbal behavior. Using such lin— guistic methods, we have observed systematic alterations in language patterns during convulsive therapy, which were related to independent evaluations of behavioral change and to improvement. The description of these language patterns has provided a useful quantitative method for understand— ing interpersonal changes which occur during therapy. In a syntactic—content analysis of recorded interviews during convulsive therapy (6), such changes as denial (negation), qualiﬁcation (subjunctive and .adverbial modiﬁers), displacement (person and tense), and cryptic and clichéd remarks were scored. An increased incidence of these changes in the patients’ speech was related both to the degree of induced altered brain function and to the evaluation of therapeutic response. It has been clinically observed that when the language of the patient is affected by neurologic dysfunction, modiﬁcation of the interviewer’s speech patterns occur. In the syntactic-content analyses, in which a structured interview was used, the examiner’s participation was restricted to statements in the questionnaire. This two-person inter— 1Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. This study was aided by grants 56-151, Foundations’ Fund for Research in Psychiatry, and M-927 of the National Institute of Mental Health, U. S. Public Health Service. The technical assistance of Mrs. Jean Kolodny and Mrs. Ann Horowitz is gratefully acknowledged. 235 AND ROBERT L. KAHN, PHD. view group (or dyad) therefore assumed special characteristics. Interactive effects were minimized. The constraint of the questionnaire interrupted the reciprocal modiﬁcation of the examiner’s speech. In such a dyad, scoring of the patient’s responses alone constituted an adequate description of changes in the verbal transactions of the two-person communication system. Judgements as to mental status are usually arrived at in less structured conversa— tions between doctor and patient. It was suggested that measurable changes in language patterns would occur even in con~ ventional clinical interviews, and furthermore that such changes would be related to those observed in structured interviews. The methods of dyadic analysis were developed (3—5) to permit a quantitative description of verbal transactions in unstructured interviews (diagnostic, psycho— therapeutic). In this analysis, the speech of doctor and patient is considered as one continuous behavior, and the measurements are performed on consecutive units, irrespective of speaker. The verbal ﬂow of the interview is thus considered as a single out— put, irrespective of speaker. The justiﬁcation for this maneuver rests ultimately on the correlation of dyadic speech patterns with those obtained by other methods, and is an aim of the present study. These scoring measures of unstructured interviews have been applied to weekly interviews with patients undergoing convul— sive therapy. It is the purpose of this report to 1) determine the pattern of change in dyadic language measures with convulsive therapy; 2) study the relation of these measures to the degree of induced altered cerebral function; and 3) relate the dyadic scores to syntactic language measures ob- �236 JAFFE, FINK AND KAHN tained concurrently in structured inter- repetitive the interaction. For these studies, both the mean and standard deviation of views. the TTR distribution of each interview sam— SUBJECTS AND METHOD ple was obtained. For the syntactic speech analyses the paTwenty-seven consecutive referrals for convulsive therapy in a voluntary mental tient was seen by another examiner during hospital were studied. On a random basis, the same intervals. This interview consisted ten patients were assigned to a control group of a standardized questionnaire composed and the remaining seventeen constituted the of speciﬁc items concerning the major comexperimental group. Both groups were com— plaint, reasons for coming to the hospital, parable for age and education; the convul- and temporal and spatial orientation (9). sive group had a mean age of 47 and 11.7 The verbatim responses were analyzed for mean years of education, while the mean the presence of syntactic language changes age of the subconvulsive group was 47.8, previously described as occurring with inwith a mean of 10.5 years of education. The duced cerebral dysfunction (6). Prior to, and at weekly intervals during investigators had no part in the treatment process, and did not know which cases treatment, an electroencephalogram was reserved as controls until data collection was corded in each patient. These records were measured for the per cent time of induced completed. The experimental (convulsive) group was slow wave activity (1). In the dyadic TTR analyses, experimengiven grand mal electro-convulsive therapy three times weekly, under pentothal pre- tal (convulsive) and control (subconvulmedication for a minimum of 12 treatments. sive) groups were compared. In relating The control subjects were treated in identi— dyadic TTR changes to induced slow wave cal fashion except that they received sub- activity and to syntactic language analyses, convulsive electrostimulation while under the mode of treatment was disregarded, all pentothal premedication. patients being considered as a single group. All patients were interviewed prior to RESULTS treatment, and in the week of the 12th 1. Dyadic TTR: A consistent change was treatment. An unstructured clinical diagnostic interview technique was used centered observed in the TTR patterns of the experiabout the patient’s symptoms and life prob- mental group. Scores for consecutive 25 lems. The patient was encouraged to talk word units of interaction in 500 word samfreely, with occasional guiding interventions ples were plotted before and during the by the interviewer. Long silences resulted treatment course (end of the fourth week). in increased interviewer activity. All inter- Figure 1 shows a graph of the TTR patviews were tape—recorded. terns for one patient. Next to each graph is For the formal dyadic analyses (3, 5), the frequency distribution of the 20 consecu— the ﬁrst 500 words of each interview were tive scores shown. The change in the distranscribed in temporal sequence without tribution for this case was a decrease in the regard to the speaker. This sample of dyadic mean and an increase in the standard deviaspeech was divided into consecutive 25 word tion of the dyadic TTR. This pattern of units. The type-token ratio (TTR) was cal- change was characteristic of the expericulated for each unit. The type—token ratio mental group. is the number of different words (types) Table 1 shows changes in the group mean divided by the total number of words (to- T TR score during treatment. Although there kens). Thus, the lower the TTR the more was a decrease in both groups, the change �237 LANGUAGE CHANGES WITH BRAIN DYSFUNCTION was signiﬁcant (p < .01) only in the convulsive group and not in the control (sub— convulsive) group. Table 2 shows the changes in standard deviation of the group TTR scores during treatment. There was a signiﬁcant increase in standard deviation (p < .01) in the convulsive group. In the control (subcon— vulsivc) group the standard deviation was decreased during treatment. The change, however, did not reach statistical signiﬁ— cance. 2. Relation of Dyadic TTR to EEG changes: The changes in dyadic TTR scores were related to changes in brain function as reﬂected in measurements of the amount of slow wave activity on the electroencephalogram. For this purpose, the per cent time delta activity in the EEG record obtained in the same week as the interview was used. While almost all members of the experimental group developed prominent amounts of EEG delta activity during treatment, none of the control group demonstrated such changes. Using the method of rank order correlation, the change in standard, deviation of the dyadic TTR correlated +65 with the per cent time of delta activity TABLE 1 Change in Mean TTR with Electroshock Subconvulsive Convulsive .92 j .xv-rp/w. p. l— .76 . /. - - with Electroshoclc Subconvulsive Convulsive ,5 3 83 ° .5660 ,0 .92 El e4 ...76 .68 .60 . .68 D—URING TREATMENT / f .76 T” text). .92 Lo 55 5“ 83 m Ea /\T I .56/6068 .76 TTR FIG. 1. .84 ﬂ—I 6 0 10 17 During Difference treatment treatment 8.6 8.1 76 9.2 —0.5 +1.6* *Signiﬁcant at 0.01 level, using Wilcoxon’s method of paired replicates. TABLE 3 Relation of Syntactic and Dyadic TTR Language ZWeasnres Dyadic Analysis: Syntactic Analysis N Change in Mean Fewer than two changes Two or more changes Change in Standard Dev1at10n 15 —0.8 —0.1 12 —3.0** +1.4* < .01). The greater increase in variability in the language measure was thus associated With the greater degrees of altered brain function. Changes in the mean T TR, however, were not signiﬁcantly related to the changes in brain function (r = +19). 3. Relation of Dyadic TTR to Syntactic Language Changes: A comparison of dyadic TTR scores with syntactic aspects of the patient’s speech obtained in independent structured interviews was made. The patients were divided into those who showed two or more syntactic language changes, and those who showed fewer than two such changes, regardless of the type of treatment (Table 3). For the patients showing (19 0 N Group Pre— Signiﬁcant at 0.02 level. ** Signiﬁcant at 0.01 level. 0’) . —0.8 —2.4* TABLE 2 Change in Standard Deviation of TTR 25 WORD UNITS) E2 80.3 79.2 * ————“‘7 /' 17 81.1 81.6 Signiﬁcant at 0.02 level, using Wilcoxon’s method of paired replicates. PRE-TREATMENT 1.0 10 treaItirient tiggfﬁiltegnt Difference * DYADIC TTR PATTERN (CONSECUTIVE N Group .84 .92 LIO Plot of TTR patterns for one patient (see �238 JAFFE, FINK AND KAHN two or more syntactic changes, both dyadic indices showed a signiﬁcant change during treatment. There were no signiﬁcant altera— tions in TTR indices for the group showing fewer than two syntactic changes. DISCUSSION These observations indicate a signiﬁcant difference in dyadic transactions in the experimental (convulsive) and control (subconvulsive) groups—a difference which is referable to a consistent change in the subjects receiving convulsive therapy. The ﬁnd: ings are consistent with those reported by Weinstein and Kahn (9) in their studies of patients with altered brain function. They observed increased use of the second and third person, non-aphasic misnaming, cli— chés, stereotyped expressions, condensations and neologisms. These language patterns were termed the “language of denial” and were regarded as symbolic adaptations. Kahn and Fink (6) noted similar language changes in patients with brain function al— tered by convulsive therapy. The present observations indicate that verbal transactions during altered brain function are not only more stereotyped qualitatively, as in the use of clichés, but are also more stereotyped quantitatively as in the increased repetition of words. Thus, analyses of the more formal aspects of speech parallel analyses of content. Alteration in brain function was also related to changes in the dyadic indices. The low, but signiﬁcant correlation between the dyadic scores and EEG delta activity suggests that the two-person communication system as a whole may reﬂect neurophysio— logical alteration in one of its participants. The low correlation is consistent with previous observations that the dyadic TTR pattern is sensitive to factors other than al— tered brain function (5). Other studies of the dyadic TTR and syntactic language measures during drug administration (2) are consistent with the present ﬁndings. Administration of agents which produce EEG hypersynchrony similar to that of convulsive therapy was associated with changes in both language measures in the direction of increased stereotypy and repetitiveness. Agents which produced EEG desynchronization, however, were associated with decreased repetitiveness and a decreased number of syntactic alterations. These observations, though limited to acute drug interviews, indicate that similar changes in language patterns can be antici— pated in subjects following the chronic administration of psychotropic compounds. We anticipate that alteration in patterns of lan— guage may provide cues for the evaluation of behavioral change in drug therapies as well as in convulsive therapy. It is of signiﬁcance that changes in dyadic speech are measurable when the neurophysiological status of only one of the participants is altered. This observation is consistent with concepts of verbal behavior as a two-person phenomenon, inseparable from its interpersonal context (7, 8, 10). The method and ﬁndings also demonstrate that neurophysiologic effects can be investigated in unstructured interviews and that the results may be related directly to those obtained under more structured experimental conditions. Thus, the measurement of formal aspects of language in clinical interviews may be viewed as another tool of neurophysiologic investigation. CONCLUSION Formal language measures in unstruc— tured clinical interviews were undertaken in the course of a study of convulsive and subconvulsive therapies in a hospitalized psychiatric population. Dyadic TTR (Type—Token-Ratio) measures showed a signiﬁcant decrease in the mean and an increase in the standard deviation in the subjects receiving convulsive therapy, but no differences in those receiv— ing subconvulsive therapy. The degree of change in dyadic indices was related both to the degree of induced delta activity on �LANGUAGE CHANGES WITH BRAIN DYSFUNCTION the electroencephalogram, and to changes in syntactic language patterns obtained in independent structured interviews. Theoretic implications for the understanding of language changes during altered brain function were discussed. 1. REFERENCES FINK, M. AND KAHN, R. L. Relation of EEG delta activity to behavioral response in electroshock. AMA. Arch. Neurol. & Psychiat., 78: 516—525, 1957. J. AND KAI-IN, R. L. Drug induced changes in interview patterns: Linguistic and neurophysiologic indices. In The Dynamics of Psychiatric Drug Therapy, SarwerFoner, G., ed. C. C Thomas, Springﬁeld, Ill. 2. FINK, M., JAFFE, 3. In press. JAFFE, J. An objective study of communication in psychiatric interviews. J. Hillside Hosp., 6: 207—215,1957. 239 J. Dyadic analysis of two psychoanalytic interviews. Presented in Symposium on Psycholinguistic Analysis of the Psychiatric Interview, Divisional Meeting of A.P.A., New York City, November 28, 1959. JAFFE, J. Language of the dyad. Psychiatry, 21: 4. JAFFE, . 249—258, 1958. . . KAHN, R. L. AND FINK, M. Changes in language during electroshock. In Psychopathology of Communication, Hoch, P. and Zubin, J ., eds., Grune & Stratton, New York, 1958. SAPIR, E. Language: An Introduction to the Study of Speech. Harcourt-Brace, New York, 1949. .SKINNER, B. F. Verbal Behavior. Appleton— Century-Crofts, New York, 1957. . WEINSTEIN, E. A. AND KAHN, R. L. Denial of 10. Illness: Symbolic and Physiological Aspects. C. C Thomas, Springﬁeld, Ill., 1955. ZIPF, G. K. Human Behavior and the Principle of Least Eﬁort. Addison-Wesley, Cambridge, Mass, 1949. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Changes in verbal transactions with induced altered brain function. J Nerv Ment Dis. 1960 Mar; 130:235-9. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-003-44-010 Date A point or period of time associated with an event in the lifecycle of the resource 1960 Creator An entity primarily responsible for making the resource Jaffe, Joseph; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Kahn, Robert L. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource Reprinted from The JOURNAL of NERVOUS AND MENTAL DISEASE Volume 130, No. 3, March 1960 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/4829a346731c642d4b009d69ede20ef4.pdf f52f80e5b4fabf3b53f885310a3d6354 PDF Text Text Clinical and electroencephalographic effects of Megimide in patients Without cerebral disease Martin A. Green, M.D., and Max Fink, M.D. the introduction of Megimide (beta, beta methylethylglutarimide) as an antagonist for barbiturate intoxication in 1955, considerable interest has been stimulated in its clinical applicability. Initial reports noted its efﬁcacy in barbiturate poisoning,1—4 but subsequent studies failed to substantiate this applicationf)"8 In this laboratory, barbiturates are frequently administered under the standardized conditions of the “amobarbital test.”9 It was thus possible to assess the efficacy of Megimide in altering the behavioral response of human subjects to physiologic equivalent amounts of barbiturate. In addition to its suggested antagonism to barbiturate, Megimide induces both paroxys— mal discharges in the electroencephalogram and clinical grand mal seizures.10—14 The present report concerns our experience with both the behavioral and electroencephalographic effects of Megimide. FOLLOWIXG AIATERIAL AND METHODS Thirty-four hospitalized voluntary psychiatric patients with psychoneurosis, depression, or schizophrenia, ranging in age from 27 to 64 years, were studied. Megimide in a concentration of 5 mg. per cc. was administered intravenously at the rate of 0.5 mg. per kg. per minute, until deﬁnite changes were observed in the electroencephalogram and often beyond this point. The amount of Megimide varied from 45 mg. to 250 mg. In 15 subjects Megimide was administered without prior amobarbital. In 19 patients it was given following the administration of in— travenous amobarbital which was injected at 0.5 mg. per kg. every 40 seconds, in amounts necessary to induce nystagmus, slurred speech, and marked drowsiness or sleep. All experiments were undertaken in the elec- troencephalographic laboratory. An electroencephalogram was made prior to the injections and was run continuously during the administration of both drugs. The electrode placement consisted of frontal, motor—parietal, occipital, anterior temporal, posterior temporal, vertex, and earlobe'. Both scalp—to-earlobe and scalp-to-scalp combinations were used. RESULTS The electroencephalogram in all subjects prior to the administration of the drugs was “normal,” that is, symmetric and non-dysrhythmic. Electroencephalographic Response In the amount and rate of injection of Megimide employed, electroencephalographic changes occurred in every patient. The type of response and the amount of drug necessary to induce such a response were highly variable. The electroencephalographic changes included irregular low- and moderate-voltage slow ac— tivity, bursts of slow activity (usually of high voltage), single spike discharges, and spikewave forms (ﬁgure 1 A, B, and C). These ef— fects were diffuse and symmetric, with greatest prominence in the temporal leads. The sequence of these responses was inconstant. Irregular, low-voltage slow activity was the most frequent initial change in the record. In other instances, bursts of highvoltage slow activity or spike activity appeared initially. As the injection continued, the amplitude and per cent time delta activity inFrom the department of experimental psychiatry, Hillside Hospital, Glen Oaks, Long Island, New York. Read at the meeting of the Eastern Association of Electroencephalographers, New York, December 1956. Aided by Grant M 927, National Institute of Mental Health, National Institutes of Health, US. Public Health Service. Reprinted from NEUROLOGY, Minneapolis, September 1958, Vol. 8, N0. 9 Copyright 1958, by Lancet Publications, Inc. �EFFECTS OF MEGIMIDE "NV‘VV Mvw LP-RP *V‘JlWMAA/‘fr'rwm“MWHWIMS‘WWVWWMmeLMMA. L0‘ R 0 (memwwmewwWWW» WM WﬂM‘j(Ml/\rlY/‘Vr'j‘ﬂuj'wwMWWWWWWJWMW VWLWMW WWW/wWWJMWW *WWWWWWW AT R P T I‘ 5A , ”v w. a WW1 '«M “-34x4“ MW‘WMMWW I ‘A ‘M’m‘rv‘v‘rﬁ‘w Jam.M’w’M—‘ﬁ' draw; R “ij MW ® .I 50 35cc MEGIMIDE (5 cc/ MIN) mv lSEC, LP-RP @ 30 cc MEGIMIDE (Soc/MIN.) ' SEC' creased. Bursts of high—voltage slow activity were seen eventually in almost all patients. Spike discharges, however, were less frequent, even with relatively large doses of Megimide. For example, the tracings in one subject after receiving 220 mg. of Megimide and in another after receiving 250 mg. showed irregular diffuse slow activity without spike activity. Seizures Because of the nature of the population and the goals of our study, we specifically avoided administering Megimide in rates and amounts that would produce clinical grand mal seizures. Despite these precautions, a grand mal seizure was inadvertently induced in one patient. A 33 year old woman was given 200 mg. of Megimide at the rate of 50 mg. per minute. Up to 150 mg. there was only a decrease in the voltage of the alpha activity. After 200 mg. there was a sudden long run of diffuse, rhythmic 4 to 5% cycles per second high voltage activity, with intermixed spike activity which was immediately followed by the seizure. The electroencephalogram during injection and prior to the seizure showed minimal changes, and the seizure was not anticipated 35M: MEGIMIDE (Sac/MIN.) SE“ F IG. 1. Different types of electroencephalographic response to Megimide. A, delta activity, irregularly and in bursts, B, single spike activity, C, spike-wave activity Subjective Response The subjective reaction to Megimide was minimal, even when the induced changes in the electroencephalogram were severe. A few subjects complained of nausea, “dizziness,” “shakiness,” or a peculiar sensation in the abdomen. It was possible, however, to continue the injection without further increase in the symptoms. Two subjects became apprehensive, and in one of these the injection had to be discontinued. Myoclonic jerks occurred frequently. They were usually mild and conﬁned to one extremity. Less frequently they were bilateral and more severe. The relationship between these movements and spike activity was inconstant. The myoclonic jerks usually preceded the appearance of spike activity, althOugh the reverse occurred occasionally. The simultaneous appearance of spike activity with myoclonic jerks was infrequent. The effect of Megimide was short-lived. There were no instances of seizures or other abnormal responses later in the day following its administration. However, since intravenous amobarbital followed in all patients, this may have prevented such occurrences. The clinical and electroencephalographic responses to intravenous amobarbital following Megimide appeared similar to those seen in subjects in whom amobarbital is administered without prior medication. The slow-wave or spike activity induced by Megimide disappeared and the usual patterns associated with barbiturates developed (ﬁgure 2). However, �NE UROLOGY 684 the well-modulated high per cent time beta activity usually noted after barbiturate administered was less prominent. M egz’mide Following Amobarbital One group of subjects received intravenous amobarbital prior to Megimide until drowsiness, slurred speech, and nystagmus were induced. The electroencephalogram showed the patterns commonly associated with barbiturates, that is, an increase in voltage and per cent time fast activity and a decrease in amount and voltage of alpha activity. The most prominent clinical change was the awakening of the subject. Within the few minutes necessary for the injection, the patient became more responsive, slurred speech disappeared, and drowsiness, both on subjective and objective evaluation, was minimal or absent. Nystagmus became inconstant, unsustained, or disappeared completely. Gait, including heel-totoe walking, was steady. However, the awakening effect was not uniform for all aspects of behavior altered by barbiturate. For ex— ample, if the subject became euphoric and more talkative with barbiturate, such behavior may have persisted in a milder form, even after the drowsiness of amobarbital was abolished by Megimide. These clinical changes were accompanied by alterations in the electroencephalogram (figure 3). Patterns of drowsy activity disappeared. Alpha activity increased both in amount and voltage. Fast activity induced by amobarbital usually persisted unchanged or was reduced only sightly. In some instances it increased in amount and voltage. The prior administration of amobarbital did not prevent the appearance of paroxysmal discharges. WW W LP-RP W WJMWW LO'RO LF-RF -om A mmwwwwwwvwvv WWW/”WWW AT-PT @RESTING RECORD W wa~VMMMWh~WMphﬁwnw~ L AT-F R MMKWWWMMVWVJ @ UL ‘vr—WW‘W wabwuvmh1-vun~pa~h4qu WWW» 50!”?— 1 azsrmc RECORD 252 (28 mg. AIOBARBIYAL rug/40 SEC.) 40 c: IEGEIIDE (5 cc / III.) FIG. 2. Effect of amobarbital following administration of Megimide ﬁWWA/VWW 38cm MEGIMIDEHScc/MIN.) r. W WWW WWWWHW WWW WWW WVNMWMWWM o LO . R0 F: MNVWVWVWVW—M’NW’ Megimide is similar to pentalenetetrazol (Metrazol) in that it induces delta activity, spike and spike-wave activity in the electro— encephalogram, and clinical grand mal seizures. Such changes occur in nonepileptic subjects without brain disease, and considerable individual variability in the threshold for these changes exists. These discharges are nonspecific and cannot be used as evidence of the presence of a seizure disorder. The possibility of using Megimide in activating the electroencephalogram has received study.10—1‘-’ Several investigators have noted a more gradual onset of the electroencephalographic and clinical changes with Megimide than with Metrazol. For this reason, the opinion is expressed that Megimide may be more facile in reproducing both clinical and electro— encephalographic seizures in patients with seizure disorders. It should be emphasized, however, that in the one patient in the present study in whom a grand mal seizure occurred, the seizure began suddenly and was not anticipated either from the electroencephalogram or previous clinical responses. Megimide is effective in counteracting the clinical effects of small doses of intravenous amobarbital. This property has been previously demonstrated in animals3 and is being utilized LF-RF k WN-WINW‘MWMNWVM DISCUSSION 0%va6Wwaw'wwrwwqp'v LM-RM {-0 Bursts of high-voltage slow activity, spike activity, or spike-wave activity often appeared, usually during or after awakening. Such activity was not a necessary accompaniment of the awakening response, however, since other subjects in whom clinical drowsiness disappeared did not show such discharges. 500 mg.AMOBARBlTAL (50 mq./40 SEC.) Effect of Megimide following administration of amobarbital FIG. 3. SEC. �EFFECTS OF MEGIMIDE in anesthesiology to shorten the recovery period from barbiturate anesthesia postoperatively.15 It is questionable whether this action is speciﬁc for barbiturates or whether it also applies to states of altered consciousness due to other agents as well.16 CONCLUSIONS Thirty-four psychiatric patients without cerebral disease were given Megimide (beta, beta-methylethylglutarimide) before and after the administration of intravenous amobarbital. 2. Megimide produces irregular delta activ~ ity, bursts of delta activity, and spike and spike-wave activity in the electroencephalo1. 685 gram. Such effects are similar to those produced by pentalenetetrazol (Metrazol). 3. Considerable individual variability exists in the amount of drug necessary to produce these changes. 4. A grand mal seizure was inadvertently induced in one patient. The electroencephalogram during the injection and prior to the seizure showed minimal changes and the seizure was not anticipated. 5. Megimide counteracts the clinical and some of the electroencephalographic effects of small doses of intravenous amobarbital. Megimide supplied through the courtesy of A. las Ltd., Slough, Bucks, England. & I. Nicho- REFERENCES A., SHAW, F. H., CASS, N. M., and \Van, H. M.:M. A new treatment of barbiturate intoxication. Brit. J. 1:1238, 1955. 1. SCHULMAN, to . 3. 4. 5. 6. 1. 8. 9. F. H.: Further experiences with Megimide—a barbiturate antagonist. M. J. Australia 2:889, 1955. SHAW, F. H., SIMON, S. E., CAss, N., and SCHULMAN, .-\.: Barbiturate antagonism. Nature 174:402, 1954. HARRIS, T. A. 13.: A barbiturate antagonist. Lancet 1:268, 1955. L()U\V, A., and SONNE, L. M.: Megimide in the treatment of barbituric acid poisoning. Lancet 2:961, 1956. PEDERSEN, ].: Amusing effect of Megimide and Ami— phenazole in allypropymal poisoning. Lancet 2:965, 1956. PLUM, F., and SWANSON, A. G.: Barbiturate poisoning treated by physiological methods. J.A.M.A. 163:827, 1957. CERSHON, S., and SHAW, F. H.: Effects of Bemegridc on barbiturate overdosage in humans. Brit. M. J. 2: 1509, 1957. \VEINSTEIN, E. A., KAHN, R. L., SUGARMAN, L. A., and LINN, L.: The diagnostic use of amobarbital sodium (“Amytal sodium”) in brain disease. Am. J. Psychiat. 109:889, 1953. SHAW, 10. COURJON, 1., and BONNET, H.: Comparative effects of Metrazol and Megimide in activation of epileptic pa- tients. EEG 11. 12. 13. 14. 15. Clin. Neurophysiol. 8:710, 1956. DROSSOPOULO, G., GASTAUT, H., VERDEAUX, G. and J., and SCHULLER, E.: Comparison of EEG “activation” by pentamethylenetetrazol (Metrazol) and Bemegride (Megimide). EEG & Clin. Neurophysiol. 8:710, 1956. Room, E. A., RUTLEDGE, L. T., and CALHOUN, H. D.: Megimide and Metrazol (A comparison of their convulsant action in man and in the cat). EEG & Clin. Neurophysiol. 10:208, 1958. SOD‘TRBERG, U.: Eﬂect of Bemegride (Megimide) on cerebral blood flow and electrical activity of brain. Arch. Neurol. & Psychiat. 792239, 1958. PEACOCK, J. M.: An electroencephalographic examina— tion of the effects of Megimide and Daptazole in bar— biturate narcosis. EEG 8: Clin. Neurophysiol. 8:289, 1956. VVYKE, B. D., and FRAYVVORTH, E.: Use of Bemegride in terminating barbiturate anesthesia. Lancet 2:1025, & 1.957. 16. BOTTINGER, L. E., ENGSTEDT, L., and STRANDBERG, 0.: Is Bemegride a speciﬁc barbiturate antagonist? Lancet 1:932, 1957. �6mm and m We“: at Was in Patients WW?» 66”me Mum W m A. 11.3. ‘W-AMWI < I . the m Gala, Wt30!.of mm mm. mm swam. Glen 1mm... matting at the Max “manhunt: or m at thoMubor Elsemmm. 1956. Nam Yam-k, " Aiéadhy Grant Wham 3/58 65f I! 92?, Katina}. M‘W‘lﬁi at mm Kalil), 0.3. ﬁbula Knuth 3031“. mm. 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Magma: as net 6.1119195.qu of men. dawn of tutu-amp“ maba'rhim. etfeete, �� Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical and electroencephalographic effects of megimide in patients without cerebral disease. Neurology. 1958 Sep; 8(9):682-5. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-001-22b-027 Date A point or period of time associated with an event in the lifecycle of the resource 1957 Creator An entity primarily responsible for making the resource Green, Martin A.; <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint] and reprint. Reprint from NEUROLOGY, Minneapolis, September 1958, Vol.8, N0.9 Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Published http://exhibits.library.stonybrook.edu/mfp/files/original/0cb0657cbbdab38351d56e14b15f8cbf.pdf 7766c5312815a1dcb5171a3528e92d6e PDF Text Text Reprinted from The Journal of the American Medical Association April 12, 1958, Vol. 166 Copyright 1958, by American Medical Association COMPARATIVE STUDY OF CI] LORPROMAZINE AND INSULIN COMA IN THERAPY OF PSYCHOSIS Max Fink, M.D., Robert Shaw, M.D., George E. Gross, M.D. and Frederick S. Coleman, M.D., Glen Oaks, N. Y. With the advent of “newer” drugs for the treatment of psychiatric illnesses and the concomitant awareness that the effectiveness of insulin coma therapy was limited, a control drug therapy—insulin coma study was undertaken. Preliminary trials with various medicaments available in 1954 demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports had noted its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. The study was designed to assess the therapeutic efﬁcacy and indications for intensive chlorproma: zine therapy, compared to classic insulin coma therapy, an in open-ward, voluntarily hospitalized psychiatric population. Subjects and Method All patients referred for insulin coma therapy during the period Sept. 1, 1955, to Dec. 31, 1956, were observed. Supervising psychiatrists made the recommendation for insulin coma therapy independent of the research group. Their criteria for referral were those implicitly held by the hospital administration and were not altered for this study, Randomly selected patients were placed on chlorpromazine therapy instead of insulin coma therapy. This selection was made by the psychiatrist in charge of the insulin therapy unit without prior notice of the referring therapist or the supervising psychiatrist. Sixty patients were referred for insulin coma therapy during the study period, and half of these received chlorpromazine. Insulin Coma.—The standard technique of Sakel for insulin coma was used. All patients received 50 comas, each of a duration of at least one hour, at the physiological level of Babinski reﬂex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous administration of glucose. Treatments were given ﬁve times weekly for a period of three to four months. Chlorpromazine.—To establish an equivalent group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased until well-deﬁned physiological effects were observed. These included rigidity, drooling and ﬁxed facies, seizures, or severe dermatitis. In most instances this was achieved below 1,400 mg. daily, although dosages were increased to 3,600 mg. in one patient. In each instance, the drug dosage was slowly reduced until From the Department of Experimental Psychiatry, Hillside Hospital. The effectiveness of chlorpromazine was compared with that of insulin coma in 60 patients referred for insulin coma therapy. One- half the group, selected on a random basis, received chlorpromazine by mouth for at least three months in doses adjusted so as to fall just short of toxicity in the individual patient,- this dosage varied from 300 mg. to 2,000 mg. daily, with a median of 800 mg. The insulin coma was induced by a standard technique 50 times in each patient. Although many minor differences were noted in comparing the effects of these two methods of treatment, the ultimate results at the time of discharge were essentially the same for the two groups of patients. Neither treatment affected the basic schizophrenic process, but chlorpromazine had the advantage of being safer, easier to administer, and better suited to long-term management. a maintenance dose, just under that producing toxicity, was obtained. This varied from 300 mg. to 2,000 mg. daily with a median of 800 mg. To determine the comparability of the subjects in the random sampling procedures used in this study, the groups were compared as to their psychi— atric diagnoses and ages. Table 1 shows a comparison of the groups as to diagnoses and demonstrates an equal distribution of subjects in each category. In the analysis of the age distribution, the median age for patients subjected to insulin coma was 24 years, with a range of 17 to 38; the median age for patients receiving chlorpromazine was 28, with a range of 19 to 42. Here, too, the distribution shows no signiﬁcant difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals. After completion of the treatment period, reports of the patients’ behavior were obtained from the therapist and supervising psychiatrist. The “improvement” rating was determined by the medical director at the patient’s discharge conference and was based on the fourfold scale of recovered, much improved, improved, and unimproved. Neither the authors nor the supervisor of the insulin therapy unit participated in these evaluations. �THERAPY OF PSYCHOSIS—FINK ET AL. Vol. 166, No. 15 Observations Clinical Observations—The following clinical effects were noted in patients who received chlorpromazine and in those subjected to insulin coma therapy. Chlorpromazine: Chlorpromazine induced motor retardation in all subjects. Overactive, destructive behavior rapidly disappeared, and patients became more tractable, less negativistic, and less violent. The nurses’ and therapists’ records noted patients as “less easily excited and frightened,” “cooperating TABLE l.—P.s-ychiatric Psychoneuxosis ....................... Schizophrenia, paranoid ..... Schizophrenia, catatonic ............ Schizophrenia, mixed ................. Schizophrenia, hebephrenic .......... Manic-depressive psychosis ........... Diagnoses Insulin Coma Chlorpromazine 1 2 10 7 10 7 8 3 1 6 2 3 better in ward activities,” and “less restless and less panic-ridden.” One-third of the patients were more sociable and less seclusive and were noted to care for themselves in a more presentable fashion. In instances where severe motor symptoms supervened, however, the patients were less able to care for themselves; they became sloppy and failed to dress themselves. Such periods were usually short and could be signiﬁcantly modiﬁed either by a reduction in drug dosage or by anti-Parkinsonism drugs. Affective changes during chlorpromazine treatment were varied. Four patients became increasingly agitated, tense, and tremulous and either refused to continue on the drug regimen or were induced to do so only with difﬁculty. Such an affective “storm” appeared early in the treatment and persisted. In four other patients, depressive symptoms were relieved with an increase in affective lability and responsivity. Depressive ideation increased, associated with complaints of insomnia and anorexia in two patients. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of chlorpromazine therapy in 12 patients. Eight had a loss or a signiﬁcant diminution of their psychotic ideation. In ﬁve, hallucinatory and referential experiences were no longer reported even on inquiry, and, in three others, delusional ideas were less prominent. In one patient, phobias were relieved and the patient could once again participate in ward activities. In another, hypochondriasis was sufﬁciently modiﬁed to permit a more meaningful relationship between therapist and patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration and resulted in discontinuation of the drug regimen. 1847 Insulin Coma: The clinical observations in this group were similar to those reported by others.‘ Alteration in behavior was prominent in all patients once repeated comas were induced. Overactive, hostile behavior rapidly diminished and was replaced by alternating periods of somnolence, irritability, and withdrawal. In most patients, nausea, abdominal distress, belching, sweating, and lassi— tude were common sequelae each afternoon and assumed prominence in the recorded reports. These symptoms often interfered with the patients’ ability to care for themselves, and they became unkempt in their dress. Changes in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, dis— appearing in these on direct inquiry. Suicidal and outWardly directed destructive thoughts were modiﬁed in three patients, only to recur in each at the end of the treatment period. Mood changes were small. Increasing agitation, tension, and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms was noted early in the treatment and was sustained. In the usual practice of the treatment unit, con— current electroconvulsive therapy was instituted when behavioral control by insulin coma alone was limited. In six patients, such combined treatment was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well deﬁned alteration in behavior, but this was unsustained. None of these patients was rated as improved on discharge. Discharge Evaluation—All patients were dis— charged from the hospital within four months of the end of treatment. Table 2 lists the hospital discharge evaluations for patients treated with chlorpromazine and insulin coma. Ratings in Patients Treated with Chlorpromazine and Insulin Coma TABLE 2.-—Discharge Treatment ........................ ........................ Recovered, no. Much improved, no. .................. Improved, no. Iinimproved, no. ..................... Chlorpromazine Insulin Comaﬁ 2 0 4 17 5 15 7 10 Included in the group of patients treated with chlorpromazine who were rated as unimproved were four who received inadequate course of therapy (less than one month) because of complications of the therapy. Of the 10 patients treated with insulin coma who were rated as unimproved, four had inadequate courses of therapy, two because of complications (seizures and prolonged coma), one be— cause she became more disturbed, and one because of administrative transfer to another facility. �‘ THERAPY OF PSYCHOSIS—FINK ET AL. 1848 It apparent that there is no difference in the clinical evaluation at the time of discharge between the group receiving insulin coma and that receiving chlorpromazine. To determine whether this sample was biased because of its small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported.2 In table 3, the discharge ratings for both is TABLE 3.-—Discharge Ratings Compared for 1950 and 1956 ............................. ....................... Improved, % ......... .................... Unimproved, % ........................... Recovered, % Much improved, % _ Present Group (30 Subjects) 1950 Group (48 Subjects) 0 14 17 19 42 50 33 ‘25 years are compared. The percentage improvement rates for each category are not signiﬁcantly different. Toxicity and Complications—Patients receiving chlorpromazine and those subjected to insulin coma therapy were compared as to toxic reactions and complications, with the following effects noted. Chlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to a level producing symptoms of toxicity. In this context, all patients developed signiﬁcant drug effects. Rigidity of extremities, accompanied by a decrease in facial expression, drooling, and festination, was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Most patients became drowsy, retarded, and less active in ward activities. In four patients increased tension, agitation, restlessness, and excitement supervened, leading to a discontinuation of the drug regimen in two. Seizures occurred spontaneously in three patients. Pretreatment electroencephalograms had manifested no dysrhythmia, and no history of seizures had been elicited. In each, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema to mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine hydrochloride therapy was substituted for chlorpromazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from that noted in patients receiving chlorpromazine. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than 0.5% of subjects treated. In the preliminary studies at Hillside Hospital, 3 patients of a group of 20 developed transient clinical jaundice. J.A.M.A., April 12, 1958 Electroencephalograms were obtained in 20 of the patients who received chlorpromazine. With increasing doses, the modulation of the record became more irregular in each. A moderate amount of low-voltage 4-7 cps delta and theta activity was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow-wave activity and the drug dosage. Insulin Coma: The complications of insulin coma therapy in this series were not unusual. Insulin resistance was noted only once and was eventually overcome by the method of alternating dosages. Prolonged reactions occurred in three patients. In each, neurological examination and electroencepha— lography demonstrated signs of persistent central nervous system dysfunction for at least 10 days. Aphasia, hemiparesis, and paresthesias were frequent in ﬁve patients and transient in eight others. Seizures occurred in ﬁve patients and were recurrent in three. Frequent secondary reactions, nausea, vomiting, abdominal distress, sweating, pallor, lassitude, and generalized weakness occurred in all patients with varying frequencies. The complications of both forms of treatment are listed in table 4. Certain effects, such as dermatitis and hypotension, secondary reactions, and prolonged coma are individual for each therapy, and seizures, agitation, and refusal of therapy were noted with both regimens. The frequencies of these are not signiﬁcantly different. Effects on Psychotherapeutic Relationship—Pa— tients were referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. TABLE 4.-C0mplicati0ns of Treatment with Chlorpromazine and Insulin Coma Treatment _______./\—————5 Agitation and panic .................. Dermatitis, severe ..................... ............................... Refusal of further therapy .......... Hypotension .......................... Secondary reaction, frequent ........ Prolonged coma (>6 hr.) ............ Insulin resistance ..................... Seizures Chlorpronmzine Insulin Coma 4 3 3 3 2 5 2 2 6 3 . . . 1 Chlorpromazine: During the period of effective drug action, 15 of the patients treated with chlorpromazine were described by the therapist in response to an inquiry as “more accessible,” “speaking more freely,” and “more amenable to psychotherapy.” The behavioral changes could be classiﬁed in two groups: subjects in whom tension and preoccupation with somatic symptoms became much less, and those in whom hallucinatory or delusional preoccupations ended. Such changes in �I Vol. 166, No, 15 THERAPY OF PSYCHOSIS—FINK ET AL. in— described as an we1e frequuitly '.*‘-1;welationship stww‘arease in “contact In 13 subjects, psychotherapy either was still‘not feasible” or had become less feasible because of increasing uncontrolled tension, anxiety, or preoccupation with the side-effects of wthe drug regimen. Insulin Coma: Similar observations were made in the patients treated with insulin. Of the 30 patients, 7 were noted to be less tense and less anxious during therapeutic sessions. The theiapists noted that the patient “verbalized more freelv” and was more aware of his environment.” Four patients were speciﬁcally treated with a “modiﬁed anaclitic” approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional tactics. In the remaining patients (19), while supportive, educational, and environmental manipulating techniques were applied, the therapists were no more successful than prior to insulin therapy. In 11 patients, the physiological effects of the treatments (secondary reactions, sweating, nausea, vomiting, and weight gain) were reported as interfering with psychotherapeutic attempts. Comment Clinical Considerations—In these patients, nei— ther chlorpromazine in high therapeutic doses nor insulin coma speciﬁcally modiﬁed the psychotic had of 88% these Since a diagpatients process. nosis of schizophrenic illnesses, we concluded that neither treatment has a speciﬁcity in altering the schizophrenic process. When given in adequate dosage, however, both treatments are potent methods for the alteration of behavior. In the discharge evaluations, the treatments are similar. In only 20% of the patients were induced behavioral patterns persistent, with the rating “much improved” or “recovered.” For the others, the induced behavioral changes were transient or minimal. Since these therapies fail to induce a recovery from the psychotic process, consideration should be given to their ameliorative, palliative, and supportive aspects. Symptomatic relief was frequent but generally limited to the treatment period. Patients were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is little advantage in either therapy. Both methods were said to enhance relationship therapy, although the therapists’ evaluations favored chlorpromazine therapy. Excluding those who deveIOped increased agitation, patients were more comfortable, more alert, and physically better able to discuss their feelings and experiences while on chlorpromazine treatment. It is clear that“interpretive” psychotherapy is not enhanced, rather, 1849 supportive, educative, reorienting, and directive types of therapy are. When there is a modiﬁcation of agitated, hallucinatory, depressed, manic, or aggressive behavior, both the therapist and the patient are more comfortable and better able to discuss the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assume decisive signiﬁcance. To maintain such therapy after discharge and continue thereby the relationship established in the hospital setting may be an important element in sustaining the behavioral changes induced by hospitalization. Other Studies.—While many reports of the treatment of psychosis by chlorpromazine have appeared, we are aware of only one similar comparative study. Boardman, Lomas, and Markowe,3 after a review of the problem, reported a study of 100 patients randomly divided into two groups of 50 and treated with either insulin coma or chlorpromazine. The chlorpromazine dosage was lower than that used in the present series (average 300 mg), but the drug period (three months) was the same. Their observations are directly comparable to this study. They reported no difference either in discharge evaluations or in symptom assessments for either treatment group. The patients treated with chlorpromazine, however, remained in the hospital an average of 6.2 weeks less than the subjects treated with insulin. This was a signiﬁcant difference between the groups. They concluded, “There is inconclusive evidence that chlorpromazine has advantages over insulin in the treatment of schizophrenia [but] insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the ﬁrst treatment of choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been conﬁrmed by an adequate follow-up study.” Boardman and his co-workers emphasize the problem of evaluating the therapeutic efficacy of insulin coma. They note a number of reports that raise doubts as to the efficacy of insulin coma therapy in schizophrenia. Bourne,4 in an extensive review of the merits of insulin therapy in schizophrenia, concluded, “There is no proof of any speciﬁc therapeutic effect, and the long term prognosis is in no way influenced.” The recent observations of insulin treatment of 5 schizophrenia by Ackner, Harris, and Oldham are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbiturate coma in the same ward and under similar conditions. Evaluations of results were made by psychiatrists without knowl- �1850 THERAPY OF PSYCHOSIS—FINK ET AL. edge of which treatment the patients received. The authors noted a similar outcome, whether the loss of consciousness was induced by a barbitufate or by insulin, and concluded that insulin was not a speciﬁc therapeutic agent in the outcome. In the follow-up studies done in this hospital,2 the therapeutic results of insulin coma therapy were disappointing. Patients referred for insulin coma had the longest period of hospitalization (6.5 months, as against 6.04 with'psychotherapy and 4.95 with electroshock), the poorest discharge‘ rating (33% recovered and much improved as against 63% with psychotherapy and 67% with electro— shock), and, within four years, a 50% rehospitalization rate (compared to 33% with psychotherapy and 29% with electroshock). While these observa— tions reflect the idea that the more severely ill patients are referred for insulin coma, they also support the belief that insulin coma is not a specific treatment for the patients referred. From these reports we would conclude that, despite considerable study and the passage of many years, insulin coma therapy has not been shown to induce persistent behavioral changes more frequently than other nonspecific, less dangerous, and less expensive therapies. To the list of alternate therapies of limited value in the management of psychosis we may now add Chlorpromazine, not— ing, however, its advantage of lesser risk and ease of administration. Dosage of Chlorpromazine.—F0r the purpose of assuring an adequate level of Chlorpromazine dosage for evaluation, the amount of medicament given was increased in all subjects to t0xic levels. This level was too high for its behavioral effects, as evidenced by the reduction in all responsive cases to maintenance levels of 300 to 2,000 mg. It is our impression that Chlorpromazine affects the function of the central nervous system (as evidenced by changes in modulation and per cent time delta in the electroencephalogram and the systemic phenomena of rigidity and lassitude) and results in a nonspeciﬁc alteration in behavior.6A Such behavioral change is varied and is dependent on a variety of factors, of which the personality organization and the expectancy of the milieu are signiﬁcant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness, and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances where an affective “storm” supervenes, continuation of therapy at ].A.M.A., April 12, 1958 higher levels, with concomitant administration of trihexyphenidyl hydrochloride (Artane) and benztropine (Cogentin) methanesulfonate should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology and to the present concept of the mode of action of electroshock therapy.6 Summary In a.study of patients referred for insulin coma therapy in an open-ward, voluntary psychiatric hospital, patients received randomly either insulin coma therapy or intensive Chlorpromazine therapy. Chlorpromazine was found to be as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications, or effects on the psychotherapeutic relationship for either therapy. In comparison to insulin coma, Chlorpromazine is safer, easier to administer, and lends itself to long—term management. Patients receiving chlorpromazine therapy are more comfortable than those receiving insulin coma. No evidence has been educed that either therapy has altered the basic schizophrenic process, nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. 75—59 263rd St. (Dr. Fink). This study was supported by the Board of Directors" search Fund of the Society of the Hillside Hospital. Re— The chlorpromazine used in this study was supplied as Thorazine by Smith, Kline & French Laboratories, Philadelphia. The promazine hydrochloride used in this study was supplied as Sparine by Wyeth, lnc., Philadelphia. References and Hoch, P. H.: Shock Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry, ed. 2, New York, Grune and Stratton, lnc., 1952. 2. Rachlin, H. L., and others: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. 5:17-40 (Jan) 1956. 3. Boardman, R. H.; Lomas, J.; and Markowe, M.: Insulin and Chlorpromazine in Schizophrenia: Comparative Study in Previously Untreated Cases, Lancet 2:487—494 (Sept. 8) 1. Kalinowsky, L. B., 1956. 4. Bourne, H.: Insulin Myth, Lancet 2:964—968 (Nov. 7) 1953. 5. Ackner, B.; Harris, A.; and Oldham, A. J.: Insulin Treatment of Schizophrenia: Controlled Study, Lancet 2: 607-611 (March 23) 1957. 6. Fink, M., and Kahn, R. L.: Relation of EEG Delta Activity to Behavioral Response in Electroshock: Quantitative Serial Studies, A. M. A. Arch. Neurol. 81 Psychiat. 78:516— 525 (Nov.) 1957. 6A. Fink, M.: Uniﬁed Theory of Action of Physiodynamic Therapies, J. Hillside Hosp. 6:197-206 (Oct.) 1957. �Printed in U. S. A. �Cjéz,,4./rv./¢ COMPARATIVE STUDY OF CHIDRPROMAZINE AND INSULIN COIvIA IN THE THERAPY 0}”? PSYCHOSIS *- Max ColemanAM.D. Fink M.D., Robert Shaw M.D., George E. Gross M.D., and Frederick S. * From the Department of Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. Supported by the Board of Directors' Research Fund of the Society of the Hillside Hospital. 7-22-57: IV �Comparative Study of Chlorpromazine and Insulin Coma in the Therapy of Peychosis for the treatment of psychiatric illnesses, and the concomitant awareness that the effectiveness of insulin With the advent of "newer" drugs limited, a control drug therapy-insulin coma study was undertaken. Preliminary trials with various medications available in l95h demonstrated chlorpromazine to be potent and relatively safe. Concurrent reports coma therapy had noted was its value in schizophrenic illnesses, and it was therefore selected as the experimental agent. study was designed to assess the therapeutic efficacy and indications for intensive chlorpromazine therapy compared to classical insulin coma therapy in an openaward, voluntary hospitalized psychiatric population. The Subjects and Method All patients referred for insulin coma therapy during the period September 1, 1955 to December 31, 1956 were observed. Supervising psychiatrists made the recommendation for insulin group. Their criteria for referral coma therapy independent of the research were those implicitly held by the beepital administration, and were not altered for this study. Randomly selected patients were placed on chlorpromazine therapy instead of insulin psychiatrist in charge of the insulin therapy unit, without prior notice of the referring therapist or the super- coma. This selection was made by the vising psychiatrist. Sixty patients were referred for insulin during the study period, and half received chlorpromazine. coma therapy �.2... a) Insulin Coma: The patients received standard technique of Sakel was used. All 50 comes, each of a duration of at least one hour at the physiologic level of Babinski reflex, absent lid reflex, or deeper. Recovery was induced by gavage and occasionally by intravenous glucose. Treatments were given five times weekly, b) Chlorpromazine: was given team and To for a period of B-h months. establish an equivalent group, chlorpromaziner for at least three months. Dosages were determined by the research were rapidly increased until well defined physiologic effects were observed. These included rigidity, drooling and fixed facies, seizures or severe dermatitis. In most instances this was achieved below lhOO mgm daily patient. In each instance, slowly reduced until a maintenance dose, just under although dosages were increased to 3600 the drug dosage toxicity, was was obtained. a median of 800 mgm in This varied from 300 one mgm to 2000 mgm daily with mgm. To determine the comparability of the subjects resulting from the in this study, the groups were compared as to their psychiatric diagnoses and ages. Table I compares both groups as to diagnoses, and demonstrates an equal distribution of subjects in random sampling procedures used each category. ‘M% c: such-on .m & Chlorpromazine supplied as "Thorazine" through courtesy of Smith, Kline 3 French, Inc. �.3TABLE I PSYCHIATRIC DIAGNOSES Insulin Psychoneuresis Coma Chlorpromazine 1 2 10 10 Schizophrenia, Catatonic 7 7 Schizophrenia, Mixed 8 6 Schizophrenia, Hebephrenic 3 2 HaniooDepressive Psychosis l 3 Schizophrenia, Paranoid In the analysis of the age distribution, the patients was 21; for the insulin with a range of 17 to 38 ; while the chlorpromazine patients had a median age of 28 and a range of 19-122. shows no median age Here, too, the distribution significant. difference. For both treatment groups, behavioral observations were made by the research staff at weekly intervals . Following completion of the treatment period, reports of the patients' behavior were obtained from the therapist and supervising psychiatrist. Medical Director The "improvement" at the patient's Discharge four~fold scale of recovered, rating was determ‘ned by the Conference and was based on the much improved, improved and unimproved. None of the authors, nor the supervisor of the insulin therapy unit, participated in these evaluations. �Observatigns 1. Clinical Observations all subjects. Overactive, destructive behavior rapidly disappeared, patients in ghlgrpromazine: Chlorpromazine induced motor retardation a) became more tractable, less negativistic and less violent. and The therapists' records note patients as "less easily excited and frightened," "cooperates better in ward activities," and "less restless and less panic ridden." One-third of the patients were more sociable and less nurses' and seclusive, and were noted fashion. In instances patients were to dress. modified to care for themselves in a more presentable where severe motor symptoms supervened, however, the less able to care for themselves; Such periods were usually short, became sloppy and significantly and could be either by a reduction in drug dosage or by anti-Parkinson drugs. Affective changes during chlorpromazine were varied. became failed increasingly agitated, tense continue on and tremulous and patients either refused to the drug regimen or were induced only with difficulty. affective "storm" appeared early in the treatment other patients, depressive affective lability and symptoms were medication was persisted. In four relieved, with an increase in patients. The continued, however, with an eventual alleviation. In most mood changes were Ideation and Such an reaponsivity. Depressive ideation increased, assoc- iated with complaints of insomnia patients, Fbur was and anorexia, in two small. dramatically altered during the period of chlorpromazine therapy in twelve patients. Eight had a loss or a significant diminution of their psychotic ideation. In five, hallucinatory and referential experiences �.5. inquiry were no longer reported even on once in three others, delusional patient, phobias were relieved and the again participate in ward activities. In another, ideas were less prominent. In patient could and One hypochondriasis was sufficiently modified to permit a more meaningful relatedness of therapist became more prominent. and patient. In one patient, paranoid ideation This was associated with increasing anxiety and panic during drug administration, and resulted in discontinuation of the drug regimen. b) Insulin similar to those reported prominent in all patients clinical observations in this group'were others (1). Alteration in behavior was The Coma: by once repeated comes were induced. hostile behavior rapidly diminished, of somnolence, irritability and and was replaced by Overactive, alternating periods withdrawal. In most patients, nausea, distress, belching, sweating and lassitude were common sequellae each afternoon, and assumed prominence in the recorded reports. These abdominal symptoms often interfered with the patient's ability to care for themselves, and ﬂiey became unkempt in their dress. in ideation appeared slowly during the course of therapy. In eight patients, paranoid and delusional thoughts became less prominent, disappearing in these on direct inquiry. Suicidal and outwardly directed destructive thoughts were modified in three patients, only to recur in each Changes at the end of the treatment Mood period. changes were small. Increasing agitation, tension and panic were reported in three patients, leading in two to a refusal of further therapy. In one depressed patient, relief of depressive symptoms were noted early in �-6the treatment, and was sustained. In the usual practice of the treatment unit, concurrent electroconvulsive therapy was instituted when behavioral control by insulin limited. In six patients, such combined treatment was coma alone was instituted primarily because of a continuation of overactive or delusional ideation. There was, in four instances, a well defined alteration in behavior, but this sustained. None was un- of these patients was rated as improved on discharge. 2. Discharge Evaluation All patients were discharged from the hospital within four months of the end of treatment. Table for both the chlorpromazine and II lists the hospital discharge evaluations insulin coma TABLE treated patients. I}; DISCHARGE RATINGS Chlorpromazine Insulin 1. Recovered 2 O 2. much Improved h 5 3. Improved 17 15 h. Uhimproved 7 10 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate course of therapy (less than one month) because of complications of the therapy. four Of the ten unimproved insulin had inadequate courses of therapy (seizures, prolonged - coma patients, two because of complications coma), one because she became more fourth by administrative transfer to another facility. disturbed, and the �-7. It is apparent that there is no difference in the clinical evaluation at the time of discharge between the insulin coma treated groups. To determine whether this sample and the chlorpromazine its was biased because of small number, we compared these discharge ratings with a similar group treated in this hospital in 1950 and previously reported (2). In Table III, the discharge ratings for both years are compared. TABLE Present Group 1950 Group (30 subjects) (h8 subjects) 0 1h% 17% 19% Improved 50% h2% Ikrhmproved 33% 25% Recovered Much The III Improved percent improvement rates for each category are not significantly different. 3. Toxicitx and Complications a) ghlorpromazine: Inherent in the design of this study were high doses of chlorpromazine, pushed to symptoms of toxicity. In this context, all patients developed significant drug effects. Rigidity of extremities, accom— in facial eXpression, drooling and festination was frequently observed. In three instances, rigidity appeared as drug dosage was reduced. Host patients became drowsy, retarded, and less active in ward panied by a decrease activities. In four patients increased tension, agitation, restlessness and excitement supervened, leading in two. to a discontinuation of the drug regimen �-8Seizures occurred spontaneously in three patients. Pre-treatment electroencephalograms had manifested no dysrhythmia and no history of elicited. In seizures did not develop at the seizures each, the drug medication was reduced, and had been lower dosages. Dermatitis was a frequent complication. All patients developed a transient erythema ato mild solar radiation. Severe intractable skin reactions occurred in three patients, with resultant discontinuation of drug therapy in two. In dze third, promazine* therapy was substituted for chlorpromazine, with a was relief of the dermatitis. The indistinguishable in this patient behavioral effects of the promazine from that noted for the chlorpromazine group. In this group, no patient developed clinical jaundice. This complication has been variously reported as occurring in less than %% of subjects treated **. Electroencephalograms were obtained in twenty of the chlorpromazine patients. With increasing doses, the modulation of the record irregular in each. activity A became more moderate amount of low voltage h-7 cps delta and theta was induced, and this activity was exaggerated by hyperventilation. There was a suggestive relationship between the degree of the induced slow wave activity b) series were and the drug dosage; Insulin Coma: The complications of insulin not unusual. Insulin resistance eventually overcome by the method of coma therapy in this was noted only once, and was alternating dosages. Prolonged reactions * Supplied as "Sparine" through courtesy of Uyeth & Co. as In the preliminary studies at Hillside Hospital, three patients of a group of twenty developed transient clinical jaundice. �-9occurred in three patients. In each, neurologic examination and electroencephalography demonstrated signs of persistent central nervous system dysfunction for paresthesias at least ten days. Transient aphasia, hemiparesis, were frequent transient in eight others. were recurrent in three. Frequent in five patients, Seizures occurred in five patients, and and secondary reactions, nausea, vomiting, abdominal lassitude and and generalized weakness occurred distress, sweating, pallor, in all patients in varying frequencies. The complications of both forms of treatment are listed in Table IV. Certain effects, as dermatitis and hypotension, secondary reactions and prolonged coma are individual for each therapy, and seizures, agitation and refusal of therapy were noted in both regimens. The frequencies of these are not significantly different. TABLE IV COMPLICATIONS Chlorpromazine Insulin Agitation and Panic h 3 Dermatitis, severe 3 - Seizures 3 5 Refusal of further therapy 2 2 Hypotension 2 — Secondary reaction, frequent - 5 Prolonged Coma ( + Insulin Resistance 6 hours) 3 l Coma �.10.- h. Effects on the Psychotherapeutic Relationship In.this setting, patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effective drug action, treated patients were described by the fifteen of the chlorpromazine— therapist in re6ponse to an inquiry as "more accessible," "Spoke more freely" and were "more amenable to psychotherapy." subjects in The behavioral changes could be classified into two groups: whom tension and preoccupation with somatic symptoms became much hallucinatory or delusional preoccupations ended. Such changes in relationship'were frequently described as an increase in "contact." In thirteen subjects, psychotherapy was either still "not feasible" less, and those in whom less feasible because of increasing, uncontrolled tension, anxiety or preoccupation with the side effects of the drug regimen. Similar observations were made in the insulin treated patients. Of the thirty patients, seven were noted to be less tense and less anxious during or had become therapeutic sessions. more freely" The therapists noted that the patient "verbalized and "was mere aware of his environment." Four patients were specifically treated with a "modified anaclitic" approach. In each instance, this relationship was unsustained during treatment and the therapists resorted to more conventional ive, educational therapists tactics. In the remaining patients (19), while support- and environmental manipulating techniques were were no more successful than applied, the prior to insulin therapy. In eleven patients, the physiologic effects of the treatments (secondary reactions, sweating, nausea, vomiting and'weight gain) were reported as interfering with psychotherapeutic attempts. �-11Discussion 1. Clinical Considerations In these patients neither chlorpromazine in high therapeutic doses nor insulin specifically modified the psychotic process. Since 88% of these patients were diagnosed as suffering from schizophrenic illnesses, we concluded thatiieither treatment has a specificity in altering the schizocoma phrenic process. shen given in adequate dosage, however, both treatments are potent methods for u1e alteration of behavior. the treatments are similar. ioral patterns persistent In only and others, the induced behavioral Since these therapies 20% rated as of the patients were induced behav- much improved or recovered. For the transient or minimal. Chang 5 were fail to In the discharge evaluations, induce a recovery from the psychotic process, then consideration should be given to their ameliorative, palliative and supportive aSpects. Symptomatic to the treatment period. Patients relief was frequent, but generally limited were made uncomfortable by both therapies, however, and the complications and toxic effects have already been noted. In assessing the role of concomitant psychotherapy, there is advantage of either therapy. Both methods were said to enhance little relationship therapy although the therapists' evaluations favored chlorpromazine therapy. Excluding those who developed increased agitation, patients were more comfortable, more alert and physically better able to discuss their feelings and experiences while on chlorpromazine, than on insulin coma. It is clear that "interpretive" psychotherapy is not enhanced, but rather supportive, educative, re-orienting and directive types of therapy. When there is a modification of agitated, hallucinatory, depressed, manic or aggressive behavior, than both the therapist and the patient arernore comfortable and able to discuss �-12the reality aspects of the life situation. Therefore, in this context, the ease of administration and the possibility of continued maintenance of chlorpromazine in an outpatient setting assumes decisive significance. To maintain such therapy after discharge continue thereby the relationship established in the hospital setting an important element in sustaining the behavioral changes induced by and may be hospital- ization. 2. Other Studies While many appeared, we reports of the treatment of psychosis by chlorpromazine have are aware of only one similar comparative study. Boardman, Lomas and Harkowe one hundred (3), after a review of the problem, report their study of patients randomly divided into two groups of SO and treated either insulin coma or chlcrpromazine. The chlorpromazine dosage was lower than that in this series (average 300 mgm) but the drug period (3 months) was the by Their observations are directly comparable to same. no difference in the discharge evaluations, nor in this study. They reported assessments for symptom either treatment group. The chlorprcmazine treated patients, box-raver, remained in the hoslaital less than the insulin treated subjects. This was a significant difference between the groups. They concluded that: "There is inconclusive evidence that chlorpromazine has advantages over insulin in the an average of 6.2 weeks treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness on the nurses. Chlorpromazine is the phrenia, but this conClusion and has is for the patients first and greater strain treatment of choice in schizo- based on the immediate results of treatment not yet been confirmed by an adequate follow-up study." �«n13- his co-workers emphasize the problem of evaluating the Boardman and therapeutic efficacy of insulin coma. They note a number of raise doubts as to the efficacy of insulin coma reports that therapy in schizophrenia. (h), in an extensive review of the merits of insulin therapy in Boume is no proof of any Specific therapeutic the long term prognosis is in no way influenced." schizophrenia concluded that "there effect, he and recent observations of insulin treatment of schizophrenia by Harris and Oldham ( S) Aclmer, are relevant. In a carefully controlled study, young schizophrenic patients were randomly treated either by insulin or by barbit- urate coma results in the same ward and under were made by patients received. similar conditions. Phraluations of psychiatrists without The knowledge of which medication the authors noted a similar outcome whether the loss of consciousness was induced by a barbiturate or by insulin, and concluded that insulin was not a specific therapeutic agent in the outcome. In the fol] oar-up studies in this hospital (2), the therapeutic results for insulin coma therapy were disappointing. In that report, patients ferred for insulin coma had re— the longest period of hospitalization (6.50 months for electroshock), poorest discharge rating (3325 recovered. and much improved, 1?. 63:5 for psychotherapy and 67% for electroshock), and within four years, a 5015 re-hospitalization rate (compared to 33% for psychotheram and 29% for electroshock). while these observations reflect 1g 6.0).: for psychotherapy and 14.95 the observation that the more severely coma, it also ill patients are referred. for insulin supports the belief that insulin coma is not a specific treatment for the patients referred. From these reports and the passage of many we would conclude years, insulin that, deepite considerable study coma therapy has not been shown to �.mpersistent behavioral changes more frequently than other non~specific, less dangerous and less expensive therapies. To the list of alternate induce therapies of limited value in the chlorpromazine, noting, however, management of psychosis we may now add its advantage of lesser risk and ease of adninis tration . 3. Dosage of Chlorpromazine for For the purpose of assuring an adequate level of chlorpromazine evaluation, the medication This level was too high duction in was increased in all subjects to toxic levels. fox-its behavioral effects, as evidenced by the re- all responsive cases to maintenance levels of 300 to 2000 mgm. our impression that chlorpromazine affects the function of the central nervous system (as evidenced by changes in.modulation and percent time delta in the electroencephalogram and systemic phenomena of rigidity It is results in a non-Specific alteration in behavior. Such behavioral change is varied and is dependent upon a.variety of factors, of which the personality organization and the expectancy of the milieu are sigand lassitude) and nificant. In this context, the induction of a state of altered cerebral function is a necessary prerequisite to behavioral change. The only assurance of achieving a therapeutic level, therefore, is the appearance of toxicity, and a lowering of dosage from that level to a maintenance dose. The effects of rigidity, drowsiness and lassitude, therefore, are necessary concomitants of the therapy and should be induced in all patients in whom a therapeutic effect is desired. In instances uhere an affective "storm" supervenes, continuation of the drug at higher levels, with concomitant artane and cogentin, should be considered. Such an attitude in therapy is comparable to the application of digitalis in cardiology, and to the present concept of the action of electroshock therapy (6). mode of �.15Conclusions 1. In a study of patients referred for insulin open ward, voluntary insulin coma psychiatric hospital, patients coma therapy in an randomly received either therapy or intensive chlorpromazine therapy. 2. Chlorpromazine was as effective in modifying psychotic behavior as insulin coma therapy. There was no difference in the improvement rating on discharge, incidence of complications or effects on the psychoﬂaerapeutic relationship for either therapy. 3. In comparison to insulin administer, and lends itself to coma, dilorpromazine long term management. is safer, easier to Patients receiving chlorprcmazine therapy arernore comfortable than those receiving insulin coma. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity of either form of therapy for schizophrenic illnesses. b. No evidence has been educed �REFERENCES l. Kalinousky, L.B. and Hoch, P.H.: Shock Treatments, Psychosurgery, and. other Somatic Treatments in Psychiatry, Grune and Stratton, 13.15. 3 1952. Rachlin, H.L., Goldman, (3.5., Gurvitz, $1., Lurie, A. and Rachlin, L.: Follow-up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside Hosp. §_: 174.0, 195 6. 3. Insulin and Chlorpromazine Comparative Study in Previously Untreated Cases, Lancet, Sept. 8, 1956, pp. 1:87—1:91. Boardman, R.H., Lamas, J. in Schizophrenia - and liarkma‘e, M.: A Boume, H.: The Insulin Myth, Lancet, Nov. 7, 1953, pp. 961;~968. Ackner, B. , Harris, A. and Oldham, A.J.: Insulin Treatment of Schizophrenia - A Controller} Study, Lancet, March 23, 1957, pp. 607-6110 Fink, 1-1. and Kahn, R.L.: Relation of ETTG Delta Response in Electroshock: Quantitative Arch. Neurol. and Psychiat. (in Activity to Behavioral Serial Studies, AJ'LA. press). �January 31, 1957 Subject: Drs. From: To: - Insulin Control Chlorpromazine Max Study: Interim Report Fink, Robert Shaw, George Gross and Fred Coleman Dr. Joseph S. A. Miller, Dr. Simon Kwalwasser and the Research Committee of Medical Board Following insulin During is a summary of the observations in the control chlorpromazine- study, instituted September 1, 1955 and completed January 1, 1957. coma this period, 59 patients were referred for insulin coma Half therapy. of the group was placed, by random sampling, on chlorpromazine * therapy in- stead of insulin coma. Four patients received both insulin and chlorpromazine therapy. of the patients of therapy of less than who received chlorpromazine, seven received courses one month. patients, three had an of the 29 insulin inadequate course of therapy. I. During the period l95h—1955, preliminary PROHLEH: azime resulted in the awareness and safe. In view of the unusually poor trials of that the drug showing of was the insulin chlorpromp both potent coma populat- ion in the 1950 Fbllowaup Study (1), and the appearance of numerous articles in the psychiatric literature recommending chlorpromazine as a therapy schizophrenia, a comparative study of chlorpromazine taken. The a) - insulin for coma was under- following questions were postulated: What b) What is the clinical effect of adequate doses of chlorpromazine? is its therapeutic efficacy'when compared to insulin coma therapy? 0) ‘Ehat are the indications (and contraindications) for the use of chlorpromazine and/or insulin coma? * Chlorpromazine supplied as "Thorazine" through the courtesy of Smith, Kline and French 00., Philadelphia. Rachlin, H,L., Goldman, G.S., Gurvitz, M., Lurie, A., and Rachlin, L.: Follow—up Study of 317 Patients Discharged from Hillside Hospital in 1950, J. Hillside HOSp., _5_: 17-ho, 1956. (1) �«2. II. All patients referred for insulin SUBJECTS: coma therapy during the period September 1, 1955 and December 31, 1956 were observed. Supervising psychiatrists made the recommendation independent of the research group. Their by the hospital administration, patients made by coma therapy criteria were those implicitly held and were not were placed on chlorpromazine for insulin altered for this study. Selected therapy. selection The was random and the supervising psychiatrist of the physical therapy unit, without prior notice of the referring therapist. III. a.) Insulin nga; EETEQQ: standard technic of Sakel was used. The All patients received 50 comes, each of a duration of one hour or longer at the physiologic level flex or deeper. Recovery ous glucose. of Babinski reflex or absent was induced by gavage and lid re- occasionally by intraven- Treatments were given five times weekly, for a period of 3-h months. b.) Chlorpromazin : To establish a complementary therapeutic group, chlorpromazine was given for at least three months. Dosages were determined by the research team and were rapidly increased clear-cut physiologic effects ifest rigidity, drooling, ere dermatitis. were observed. These included and fixed clinically mans facies; or toxicity, as seizures or sev- In each instance, the drug dosage was slowly reduced a maintenance dose, until just under toxicity, was obtained. until This was maintained for the duration of the observation period. Laboratory blood counts, tests were carried out at irregular intervals liver function tests, glucose tolerance tests and included and electroenceph- alogramS. In both experimental groups, behavioral observations were made at'weekLy intervals. Following completion of the treatment period, reports of the ther- �4-3- apist and supervising psychiatrist were obtained. The rating of "improvement" Conwas that established by the Medical Director at the patient's Discharge ference. IV: RESULTS: Chlorpromazine A. l. until signs creased rapidly of was achieved in daily dosages to 3600 in mgm. 2000 mgm. one patient. of chlorpromazine was in- The dosage QEEEEE.22.22EQEEEEEEEEEEF rigidity appeared. In most instances this below lhOO mgm. although dosages were increased The maintenance dose varied from 300 mgm. to daily. 2. Clinical effects of chlorpromazine: motor retardation in all subjects. Chlorpromazine induced a Overactive, destructive behavior rapidly disappeared, and the patients were more tractable, less negativistic and less violent. The nurses' and therapists' records relate that patients are "less easily excited and frightened," "cooperates better in "less restless and less panic-ridden." ward activities," and One-third of the patients were more sociable and less seclusive, and were noted to care for themselves in a more presentable fashion. In the instances where severe parkinsonism supervened, however, the patients were less able to care for themselves; became sloppy and failed to dress. by Such periods were short or could be significantly modified anti-parkinson drugsn Affective changes during chlorpromazine were varied. In four instances, the patients became increasingly agitated, tense, tremnlous and either refused to continue on the drug regimen or were induced only with difficulty. Such an persisted. In four other instances, depressive symptoms were significantly relieved, with an increase in affective lability and responsivity. In two patients, deaffective "storm" appeared early in the therapy and �.u. pressive ideation increased and was associated with complaints of insomnia. The medication was continued, however, with an eventual alleviation. In most patients, mood changes were small. Ideation was dramatically altered during the period of-chlorpromazine therapy in twelve of the patients. Eight patients had a loss or a significant diminution of psychotic ideation. In five, the hallucinatory and referential xperiences were no longer reported even on inquiry; and in three others, delusional ideation was less prominent. In one patient, phobias were relieved to a degree that the patient could participate in ward activities. In another, hypochondriasis was sufficiently modified to permit of a more meaningful latedness of therapist and re— patient. In one patient, paranoid ideation became more prominent. This was associated with increasing anxiety and panic during drug administration, with resultant discontinuation of the drug regimen. 3. Effects en the psychotherapeutic relationship; Patients are referred for insulin coma therapy after a period of verbal relationship therapy. Such referral implies a failure of interpersonal communication. During the period of effectiwadrug activity, ten of the patients were described by the therapist in reSponse to an enquiry as "more accessible," "spoke more freely" and were "more amenable to psychotherapy." The responses could be classified into two groups: the subjects whose tension and pre— occupation with somatic symptoms became much less and those in whom halluc- inatory or delusional preoccupations ended. In each instance, the therapist described the change in relationship as an increase in "contact". In twelve subjects, psychotherapy was either still "not feasible" or "less so because of increasing, uncontrolled tension." �-5. In no instance did the problem of drug addiction or drug dependence play a role, nor was there an appreciation that drug therapy altered the therapeutic relationship adversely. h. §g§igg§ twenty four have left the hospital. thirty patients in this series, or the 93 "improvement": Table I lists the number of patients evaluated by the Discharge Conference, according to the four-fold classification in use in the hospital. For comparison, the discharge ratings of the insulin coma therapy patients, following the TABLE same criteria, have been included. I DISCHARGE RATINGS Chlogpromazine Insulin l. Recovered 1 O 2. Much Improved 3 1 3. Improved 15 10 h. Unimproved S 8 Coma Included in the unimproved group of chlorpromazine patients are four who received inadequate courses of therapy (less than one month) because of complications of the therapy. or the eight unimproved insulin coma patients, four had inadequate courses of therapy - two because of complications (seiz- ures, prolonged coma), one because she was a severe the fourth by administrative transfer to the V. A. 5. Toxicity g£_chlorpromazine: management problem; and Inherent in the design of were the high doses of chlorpromazine, pushed to symptoms of this study toxicity. In this context, all patients developed significant drug effects. In all, rigidity of extremities appeared; frequently accompanied by a decrease in facial expression, drooling and festination. In a number of patients the pafkinsona. �~6— ian features appeared as the drug dosage was reduced. symptoms were became drowsy, relieved when retarded, the drug and was discontinued. less active in ward In.each patient the Almost all patients activities. In four pat- ients, increased tension, agitation, restlessness and excitement supervened, to a degree that led to a discontinuation of the drug regimen. Seizures occurred in three patients. Ineaach, the drug medication was reduced, and seizures did not develop at the lower dosages. Dermatitis was a frequent complication. Severe, intractable skin reaction occurred in three patients, with resultant discontinuation of drug therapy in two. In the third, promazine * therapy was substituted for chloru promazine, with a relief of the dermatitis. The behavioral effect of the promazine was indistinguishable in this patient from the chlorpromazine group. All patients developed a skin photosensitivity so that on exposure to sun, transient erythema developed. Refusal of further medication because of drug effects occurred in two patients. Both developed severe tension and agitation. In two other instances, agitation resulted in the therapist insisting upon a change in treatment regimen. Table II lists the complications of both treatments. Certain effects are individual to the type of therapy, as dermatitis for chlorpromazine; and prolonged coma, severe secondary reactions and nausea and vomiting in insulin coma. 0there, as seizures, fainting spells, and increased are seen in both. *- Surplied as "Sparine" by the courtesy of Hyeth and Co. states of agitation �'77“ II TABLE COMPLICATIONS Insulin _Chlorpromazine Coma “ Agitation h and Panic 2 - Dermatitis, severe 3 Seizures 3 3 Refusal of further therapy 2 2 Hypotension 2 - Secondary reaction, frequent - 5 - 3 ~ 1 Prolonged Coma (+ 6 hours) Insulin Resistance In this chlorpromazine series, no patients developed clinical jaundice. This complication has been variously reported as occurring in less than %% of the subjects treated.* Liver function and blood element studies were done in this group of patients. Changes were small, and at the recommendation of the medical consultant, the studies were discontinued. Electroencephalograms were obtained patients. and On in fifteen of the chlorpromazine adequate doses, a moderate amount of low voltage theta activity was induced. This activity h—7 cps.delta was exaggerated by hypervent- ilation. There was a suggestive relationship between the degree of the induced slow wave activity and the drug dosage. 6. Adjuvants tg_Chlorpromazine: With the development of rigidity, festination, and drooling, patients received cogentin or artane medication. Both drugs relieved the symptoms, and in a few instances, to a significant * In the initial studies at Hillside twenty developed Hospital, three patients of a group of transient clinical jaundice. �-8degree. Concomitant with the relief of the rigidity a feeling of euphoria and wellabeing was occasionally noted. In one of the patients who developed effect. therapy, anti- an affective "storm" the administration of artane had a salutary In patients who developed seizures during insulin coma convulsant medication (dilantin, phenobarbital) has been routinely employed. Such agents were on lowered not used with chlorpromazine as the seizures did not recur dosages. Insulin B. Coma Theragz clinical effects, complications, the treatment results of insulin ccma therapy have been exhaustively reported. In this series, twenty-nine patients began insulin coma therapy. Of these, nineteen have completed their period of hOSpitalization and ten are either completing their treatment perThe iod or are awaiting discharge. The over-all ratings of "improvement" are listed in Table I. When comp pared with the Hillside HOSpital Follow-up Study of 1955, the percent improve— ment in each category is not significantly different, although the trend is less optimistically than the 1950 group. In Table III the percentages are listed for each evaluation category of this to rate the present series somewhat group compared to the 1950 populatidn. TABLE INSULIN III COMA THERAPY Present Group E 1. Recovered 0% 2. Much h% 19% 3. Improved 52% h2% h. Unimproved hh% 25% Such a Improved difference in trend, if sustained, 1h% may reflect a variety of factors, including changes in criteria of "improvement;" prior administration �.9... tranquillizing agents exerting a selectivity on the population admitted to the hOSpital; and changes in staff criteria for referral for in» of the newer Sulin coma therapy. complication rate in this insulin group is comparable to published studies. No unusual complications, and no deaths were observed. The role of psychotherapy in patients undergoing insulin coma therapy The is complex. In this group, four patients were treated with a "modified anaclitic" approach and an effort at establishing a working psychotherapeutic relationship was made. In the remaining patients, no unusual efforts at psychotherapy were made, with the consensus that a supportive, educative, enviru onmental-manipulative, reassuring type of therapy was achieved, to varying degrees. Therapists reported (in 7 instances) that patients were less tense less anxious during sessions while in coma therapy. In eight patients the physiologic effects of the treatment (secondary reactions, sweating, nausea, vomiting, weight gain) interfered with relationship therapy to a significant and degree. C. Therapeutic Results in Relation to Final Diagnosis Table IV lists the final diagnostic categories for the patients in each group. All diagnoses were represented in each series with an equivalent distribution. TABLE IV EBYCHIATRIC DIAGNOSES Insulin Coma Chlorpromazine Psychoneurosis l 2 Schizophrenia, Paranoid 0\ we U1 O\ U1 \n \» to +4 DD Schizophrenia, Catatonic Schizophrenia, Mixed Schizophrenia, Hebephrenic Manic Depressive Psychosis �~10— No diagnostic group had a significantly better treatment response than any other with either form of therapy. V. DISCUSSION: A. Comparison of Chlorpromazine and Insulin Coma Therapies: Neither chlorpromazine in high therapeutic doses, nor insulin are Specific treatments for schizophrenia. The discharge evaluations both treatments are not significantly different. There is, coma, for however, a def- inite tendency for more patients in the chlorpromazine group to be rated in the better classifications than in the insulin coma group. The trend assumes significance when both the type of sampling and the qualitative aspects of the treatments are taken into account. the The random sampling is exemplified by resultant matching of diagnoses. Since these treatments have not resulted in a recovery from the psychotic process, then their ameliorative, palliative and supportive aSpects must be considered. The insulin coma patients are usually uncomfortable throughout their treatment period. Nausea, vomiting, secondary reactions, are Prolonged coma common. loss of is a and drowsiness realistic threat; as well as the threat to life. The chlorprcmazine patients also suffered considerable disagreeable side effects. Parkinsonism, drowsiness, and skin reactions are significant, must be considered as concomitant management problems. and Seizures and jaundice are the most severe reactions, and to date, have not been permanent. It is possible to modify the significance of these side effects to a considerable extent by anti-parkinson and anti-convulsant medication. There is no question, furthermore, as to the ease with which chlorprom- azine can be administered, in contrast to insulin coma. A significant element in the use of these agents in the therapy of schiz- �.11... ophrenia is concomitant psychotherapy. Such relationship therapy by both It was therapies. apparent in the therapist's evaluations, however, that the chlorpromazine regimen was apy. Patients, excluding those comfortable, alert iences while on and was enhanced more conducive to concomitant verbal who developed ther- increased agitation, were more physically able to discuss their feelings and exper- chlorpromazine, than insulin coma. In another respect, the ease of administration of chlorpromazine advantage. Patients who respond to drug therapy can is of be maintained on such therapy for as long as needed, even on an outpatient basis, while the "course" of insulin coma is limited. Are these treatments equivalent? Can one be substituted for the other? While these questions cannot be answered by the data the negative can be denied. groups are not The in a positive assertidn, results of these treatments in equivalent different with regard to the discharge evaluation. The changes in behavior noted and the symptoms alleviated are not significantly different. In this series, three patients had adequate courses of both regimens. Two have been discharged"improved," and the third is still in the hospital. There has been no significant differences in their reSponse to either form of therapy. Comparison With Other Studies: B. While many studies of chlorpromazine in schizophrenia have appeared, only one report of a controlled study is available. gt_al_ (2) after an excellent review of the problem, report their results in one hundred patients, coma randomly divided into two groups of SO and Boardman, treated either by insulin or chlorpromazine. Their chlorpromazine dosage was lower than in this series (average 300 mgm) but the drug period ( 3 months ) was the same. Their observations are directly comparable to this series. They noted that the over(2) et a1: Insulin and Chlorpremazine in Schizophrenia — Study of Previously Untreated Cases, Lancet g5 h87-h9l, Comparative (September) 1956. Boardman, R.H. A �all clinical results were slightly more favorable in the chlorpromazine group than in the insulin group judging both by interview status and by a rating scale of difference was not of high statistical signif- The symptom change. state, however, that the chlorpromazine patients remained in the hospital an average of 6.2 weeks less; and that this difference was statistically significant. They concluded that: "There is inconclusive evidence icance. They did that chlorpromazine has advantages over insulin in the treatment of schizophrenia," but "that insulin has disadvantages in the form of greater danger and more unpleasantness for the patients and greater strain on the nurses. Chlorpromazine is the first treatment of -choice in schizophrenia, but this conclusion is based on the immediate results of treatment and has not yet been confirmed by an adequate follow-up study." In Boardman‘s review, due cognizance therapeutic efficacy of insulin come. He is given to the problem of the notes the number of'dissident re- ports that raise doubts as to the role of insulin In this regard, for insulin it is therapy in schizophrenia. important to note the results of the Hillside Follow-up in which patients referred for coma, coma such therapy had the period of hOSpitalization, poorest discharge ratings, and a ization rate (compared to 33% for psychotherapy and 29% 50% longest rehosPital- for the electroshock therapy groups). Two other control studies of chlorpromazine in psychoses are relevant to this report. "blind" study ment at Feldman gjgggp (5) Topeka reporting the observations in a controlled, State HOSpital noted a significant degree of improve- for chlorpromazine. They<eoncluded that "thorazine was found to be useful in converting acutely disturbed psychotics into tractable, accessible patients who could (S) Feldman, P.E. then participate more actively in the hOSpital rehabili- et al: A Controlled, Blind Study of Effects of Thorazine Clinic, a9; 25-h7, 1956. on Psychotic Behavior, Bull. Men. �.13... tatidn program." Tenenblatt and Spagno (6), describing the St. Elizabeth's Hospital eXperience, in another control study, noted significant behavioral effects in psychotic illnesses other than involutional psychoses. Effect of Study D. An on Staff: inherent factor in a control study of any therapeutic modality is the effect that the knowledge of random selection of patients or the use of placebos has on the therapist in his choice of therapy. sulin coma referrals were to be given Knowledge that in- either chlorpromazine or insulin coma created a feeling of insecurity and impotence in the therapist. Their control of the therapeutic situation was in a decrease in the drug effects, and number of felt as severely constricted. This resulted referrals, an exaggeration of the physiologic in the patients expressing doubts as to the therapeutic efficacy of the drug despite significant changes in ward behavior. On numer- therapists called to enquire which therapy their patient, referral for ICT had not yet been made, would get. Prior prejudice ous occasions, ‘whose suitability of either therapy resulted in the therapist's expressing disappointment at the modality used. In two instances, such preabout the judices led to early discontinuation of chlorpromazine therapy, when the pat~ ient experienced eanLy signs of drug effects. E. Dosage of Chlorpromazine: For the purposes of assuring an adequate level of chlorpromazine for evaluation, the medication was "pushed" in level in was too high all all subjects to toxicity. This for its behavioral effects, as evidenced responsive cases to maintenance levels of by the reductidn hOO-lOOO mgm. The effects of parkinsonism, drowsiness and lassitude are prdbably necessary concomitants (6) Tenenblatt, 3.8. and Spagno, A.: A Controlled Study of Chlorpromazine Therapy in Chronic Psychotic Patients, Quart. Rev. Peych. & Neurol., �1":114- of the therapy; and should be induced effect is desired. In instances where in all patients in an whom a therapeutic affective "storm" supervenes, con- inuation of the drug at higher levels, with concomitant artane or cogentin, should be considered. VI. CONCLUSIONS: In a control study of patients referred for insulin coma therapy, chlorprcmazine therapy was found to be as effective in modifying psychotic behavior patterns as insulin charge ratings to be coma therapy. is There better for the chlorpromazine a tendency for the group than dis- for the insulin coma group. In comparison to insulin coma to administer, more controllable in therapy, chlorpromazine is safer, easier its effects, and has fewer side effects. that either therapy has altered the basic schizophrenic process; nor is there any evidence that there is greater specificity for either form of therapy for schizophrenic illnesses. No evidence has been educed �February 3, 1958. that at a bucuti 1.. t :1 1251 : or EEG Dona Maturity to Bohuioml Quaint-Adv. 801-111 Studiu, “Hg, . kaponn in metro-hock: a: Arch. chhnt. 18; 516-525. 1957. Fink, H. and Kuhn, my a.L.s 3818321511 . Mime ﬂux-spin, Units.“ Theory of the Action of 1957. 197-306. g. Hillside 3032. 9: ILL: Significance of Individual Variability in ma human to moctmlhock, g. Bullio- Raga. Q: 229-21“), 1957. link, 91.: A 3. m, h. Join, 5. Kuhn, 3.1.. and $. him, 8.1... J. «In An abacus.” Study of Went-.1031 £111.16. Hog. 9,: 207.215, 1957. link, In blink, PchhiaMc Interview, Figural Artur Induced mm (1957). g: Perception of m5. Puma)... mum, Altered Bruin 1n 361 H. and Pink, 15.: Social Salaam of Factorl 1n 216-228, 1957. 7. 3. and Pink, Ha Role or Stimulus Intensity 1n Pomcpuan tom, ' Simultaneous Gunman: Electrical Stimuli, 1. munch Hog). 9" 2181.250; 195?. at ‘ mama“ 8. Karin, 8. (With Tameka, 8. and Friedman, 8.): Pomeptim Stw o: Ambit-lanai, mg, hard, I: inching.. 1Q: 1&7-176, 19 7. 9. Punter. in; H. (with Geldfarb, Lgﬂé. knack, H. LE. 322‘ E a g Md it): gaunt. ﬂ! (with‘marb, m): Test in Schilophrcnic 0111mm, 6354-6132, 1957. htum of Orientation in Childm in 303.1de Instant. for 8mm Bonnier Daemon, her. J. Mama . 213538-552, 195?. n. (with Battarnby, v.3. and Radar, 14.3.): Tnchia’wteopic hunk, “minimum of Contour 1n ﬂuent: with Brain mange, J, Cog. algal. gm 61° ﬂ. 3’ 220.227, 1957. Pollack, K. (with Battersw, $1.3. and War, 11.3.): Visual Deficit After Brain Damage in Man as Hammad with Rupidlyakpoud chromatic Stimn, mr. BIS-“2.9;. £2} 7’ 1‘68, 19570 0 13. Pollack, u. (with 00161111), in): cum-a1 ma Ehviromntal Factors attracting Complex Exception in the Institutionaliud Aged, ,1. Gomntolu l2“: ’1, “374‘38’ 19570 �Wf— ,. . , , . ~v-wwwavw—wmvwwnw—wu—va . «m <-~w—-~ uv-v—r rvs—«wv ﬂv‘w—I-‘V n V'Wuzwr- may, mm "—31-— "Wu Flbmuy 3, 1958. Imagination! in Pro”: 1. 3., Mfo, J. humor, with mantra-hook 2. Pink, 3. Pink, IL, Shut, R... Grass, 0. and Colo-Inn, F.3d and Kuhn, Yuma“, J, 3.1.: chhomompenuc Techniques Hang. (in press). was 8.. [$11, 3.1.. tad anon, 14.1.: ﬂuctuahook Prone-l, m, luv. “perinatal M. mama). J. r ‘mo (in Phi.)i and Insulin Cm in the Studio: of the (in press). Omani» Study of Therapy of Psychosis, * h. Pink, 5. ma, LL. 11.: 2E8 Laura}. Gnu Gun. In macaw. a u m- Indu a! the Sedation Munch}, in press). W. and Pink, 24.: humanity Factors (in nutmnhock Therapy, in Buhuioral mu). name to .- v- w. 1r, ,mrnv .7 w K, - �Luvzuv-amwnvww «7,. w—nwrruwm...»~.\,..—... W. WA R .. ran n-«cmvrrme—u»:‘v' February m. »u r’er’I-‘vs 3 , 1958 . many: in m Rayon-buy. Inﬂow“ York, Pom-my 1957. 1. Fink, IL: Individual 2. ﬁnk, Mu cut-m 3. Pink, 3., Kuhn, 8.1:. 1nd km :1; the Sociow no scanty, In 1n Enluation of Clinical Bolivian}. physiologie Alp-ct... Presented at LBJ... at Motropoutan Band Change: Neuro- ma tabla, Chicugo, by 1957. Exporiunm Gm, LL: of Biological Pm“. Juno 1957. Studio: of the msctmahock Psychiatry, Atlantic City, H. and Kuhn, R.L.I mum of amt-wean: Role of Alteration in Brain Function in Bah-dot. Pnsented at. Int. Congas: of Pnychntry, Zurich, Sept. 1957. h. ﬁnk, S. I!” xﬁn, 3.14. ”d “an, 3.! “ICC“ Qt 01:!qu “tend 3w m’Function on Pomaption. Pruemad at the 17 Int. Congrats of Psycholog, Ema-1c, August 1957. ' 6. Fink, II. and him, 3.1“: Random Pattoml in Induced Stat» of Aland Road at w. New Ion Divisional Hating, A.P.A. 1m. 1957. Brain 7. Pink, Mu 8. on m ma sumnwm tar hoary of Le Enact. or M,Pmaou of Conwlaivo Thu-um. Read It. Mom “Inﬂation of manna mum. of m quancy Shirt for Plychintz-y. Simian“SOQCW‘ HoY: 30'. 1957- ”Mum EEG 13101313511). anecphalographm, Nov 9. 10. Road at. M30, 4.: 1621:, Doc. 1957. Bahamian). chug” Plyohomum in Evaluation of Clinical Round Tabla, Chicago, Hay 1957. lingnhuc “pom. Fromm at A.P.A., in hymn-Le Interview. NationA.P.A.. Nov. 1957. MIC, J.: Lu Obj-«tin Study of had at um How Iork Divisions). Mating, in Buhuioral Euponu to metre-hock Thonpy. haunted at meta-omen}: Research “mention, [11:21, 3.1.. and Pink, 11.: Pomonality Factor! Chicago, Ram, New 1957. LL. and link, Aland Brain Mu Pompticn or Function. Road We! Figures Arte:-InInduood Ierk, August 1957. at Ann. Plyehol. Luau” Karin, H. (with runabout, S. and Friedman, 84): Pomption Expouunu in a Study of Allah-Amen. End at Suction on lourolog I: Plychintry of Ed. of Kodiak)! and LY. Roux-01. Socioty, NJ. Jm. 1957. low �__. _.__ .7...._—M wvwwﬁwww «V . ., m«m1.1m: 1. _ (5....»“1 .._ _ w. ....,._-,_..,..._.. «1...; .I.-....._.L,,.r..». w“ynw-WMW r‘m-vnr—Vwﬂtnﬂw’all ' 7 I-vrn" “rm” ‘ nun—mm.—.,.m~ I2 (Iith Italahau; s. and lhindnan, 3.): th- Relation a: Ambasulnneo Mansion and Monty 1n Wan-antic mum... and at Amt. Mabel. Ame. Sept. 1957. (New Kerk). 15. Karin, B. (with Tarmac»: and Mama, 8.): Stun” in “bitumen. 1h. lbrin, H. to Pnlantad boron Sahildar Sociew, M York, 00%. 1957. 16. Pamak, H. (with Galena), W. and Dam, 14.): Pain mucus in Schumann 02:11am. Haunted at Mr. Orthapaychntrio mac. Chicago, Marah 1957. 17. ‘ M.‘(v1th Integer, H.P.)I.Oan1mtor'and Bantam Put-m 1n o: lamina, Sahisophnnia Wldran. P's-mug! at Mr. knack, Am 18. Pollack, H. (with Butterﬂy, v.3. and Bond-r, 11.8.): ﬁgure-mane! Pamphlet: Tumor. But! *Enmm Payahol. uses... In York in Plunges with 13111 0“.an 19 7o it Pollack, K. (with Batu-thy, H. 3. and Bondar, 3.3.): Datum in Visual Phraoption in Brain mm:- Patten“. Flaunt-d baton Int. Congrats or ngcha1., aux: 1957. (Brunloll). .20. anuok, K. (with Battarnby, v.3. and Bondar, 14.3.): Visual M1611: After with Rapidly-kpand Chmtia 9mg. a Mutant! Assoc" Nu Int-k, Sept. 1957. Pmud at Ann. PaychoI. Brain 1:: Man Stimuli. Pollack, H. (with Goldhrb, A.): Cultural and Environ-um Factor: Aged. Presented “hating (De-plan: Pox-caption in tin Institutiamliud at the “analogical Society, Cleveland, 00%. 1957. 22. Pollack, 11.: Brain Dung... Pmanud It. Nil mm Inhalation and Childhood Sauomania. Hating, MPJ. new. 1957. York Divisions). � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Published Works Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc. 1958 Apr 12;166(15):1846-50. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-31-008 Date A point or period of time associated with an event in the lifecycle of the resource 1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a>; Shaw, Robert; Gross, George E.; Coleman, Frederick S. Subject The topic of the resource Published Works -- Articles and Reviews Relation A related resource The Max Fink Collection Description An account of the resource [Preprint and reprint]. Reprint from The Journal of the American Medical Association April 12, 1958, Vol. 166. Observation letter. 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Fr‘e—L WW’ Am); Maﬂuﬂ/EW/ �INDEX TO ADVERTISERS _ PAGE AAAS ........................................................ 5, 394, 396, Inside Back Cover American Tobacco Company _____________________________________________________ Back Cover Columbia University Press _____________________________________________________________________ 6 Ford Instrument Company ______________________________________________________________________ 391 International Equipment Company _____________________________________________________ 398 Johnson Research Corporation..--__________--_.____-________________-_.-____; ______________ 5 Macmillan Company _________________________________________________________________________________ 8 Measurements Corporation _____________________________________________________________________ 6 Microcard Foundation _____________________________________________________________________________ 392 Oxford University Press, Inc ________________________________________________________________ 391 Rinehart & Company, Inc ________________________________________________________________________ 394 Ronald Press Company ___________________________________________________________________________ 2 Schwarz Laboratories, Inc ______________________________________________________________________ 4 Ivan Sorvall, Inc ______________________________________________________________________________________ 7 Taconic Farms, Inc __________________________________________________________________________________ 394 University of California Press _______________________________________________________________ 393 University of Chicago Press ___________________________________________________________________ 3 D. Van Nostrand Company, Inc _____________________________________________________________ 395 John Wiley & Sons, Inc .......................................................................... 397 399 ��£32 » . x : ‘ . . . , V ( - 4 ‘ V ‘ ‘ ' . , \ . , - '1' ”:5. .9. ,2; «E a‘ ,7;- 7- \77 ‘- . _ mtg if} m: 34ifv; 5:32;: ;. ‘ , er?” is VF» ‘ﬂh‘flaz: ”r: 91‘;._;.;..,.::_:.»’~~:_V ;‘;,».+~:-.éé ,5». ifp. ,, ..~- .393, - ,_-_».;,-,-« r .- - ' - 2 . . �DEW? 17; 1956 Gamept of Gamma]. Localisaﬁm to Hana Action Effects 1) Certain functionnascribod to CNS are "localiaable", as motor power, motor aphasia; while others, an memory. Judgment, Mm, insight, m1- culation, figure-ground, m nmlocaliuble. The first. greup am aortical (mom pariphemi than antral); damage is generally permanent; will lenient! have maimed exam; and EEG is usually not pathological. lam-vloodiubla lesions are generally deep or basal; mowezy at m:ctim is possible; null lesions have no effect (1w. at mass wtian 1am in The effects are pmﬁnmt. 2) m results in a nonuloealiuble lesion .. with diffuse Mfmcﬁwa is the teahnic gxgalleneo to study such mass whim lesiom‘ applieabla) and It 3) EEG a; Psychological tests ’of ”OW” am positive to the dogma that they measure mass action affect»: ram” than focal - exaept it focal interferes with pexfbmnoe as in lesions meating 75.31011, actor power and mum speech» 1;) Concept of Active vs sum Lesions! In studies of head insulin, lobotom and post. apex-nun me! of an or more mths duration, the atudiaa reflsct 100311111313 (cortical) Meats mainly: for the deeper activities am no lager active“ Any defects in hm» cticm am expresaima of speciﬁc certioal laculinbla W» mtmst, studiee of brain tumors, immediate post-tnmtie statues, post-v 19mm, and EM (early) are stud-m or active dysfunction - a. cambinntim of the focal and the diffuse defeats. m degmo of: dysmnction depends on the ma In offset, plus the localised defect. �J.A.M.A., Dec. 13, 1958 PNEUMOTHORAX—MAURER ET AL. 2014 ination revealed adherence of the fundus and nodules throughout the adnexa. A diagnosis of pelvic endometriosis was made, and on Aug. 18, 1955, total hysterectomy with bilateral salpingo-oophorectomy was performed. The patient’s postoperative recovery was again uneventful. In the four and one-half years after the thoracotomy, the patient has had no recurrent chest symptoms or pneumothorax. Comment Aberrant endometrial islands have been reported in many locations, including the ovaries, uterine ligaments, rectovaginal septum, sigmoid colon, urihernia umbilicus, bladder, laparotomy scars, nary sacs, appendix, vagina, vulva, cervix, lymph glands, and small intestine, and in bizarre locations, such as the upper and lower extremities, lungs, and pleura.l Sampson’s2 original theory of transtubal regurgitation of menstrual blood and endometrial particles, published in his original paper in 1921, could certainly explain the method of implantation of endometrial growths on the pelvic and intraabdominal viscera, as well as on the inferior aspects of either leaf of the diaphragm. The lymphatic and hematogenous dissemination theory of Halban would be necessary to explain distant endometrial implants in the thigh, lung, and pleura.1a Distant spread without passing through the pulmonary capillaries could occur only by way of the vertebral veins or “lung shunts” which have apparently been demonstrated between the pulmonary arteries and veins bypassing the lung capillaries. In view of the concomitant ﬁnding of pelvic endometriosis and the involvement of all layers of the right leaf of the diaphragm, with perforation and supradiaphragmatic seeding demonstrated by thoracotomy, in the present case report, it would seem logical to conclude that the endometrial involvement of the diaphragm must of necessity have occurred as the result of transtubal regurgitation and transperitoneal dissemination. Exact explanation of the method of development of the pneumothorax on the right side is more difficult. However, the clinical observation that all episodes of pneumothorax occurred only during the time of menstruation, and the inability to demonstrate any source of lung leak or primary disorder in the lung which could explain any possible leakage of air into the pleural cavity, would suggest that the recurrent pneumothoraces in the case reported here were the result of erosion and perforation of the right diaphragmatic leaf by endometrial implant and the fa]of the from the of air by uterus way passage lopian tubes into the peritoneal cavity and then by way of the opening in the diaphragm into the pleural cavity, with consequent pneumothorax. Although we are unable to ﬁnd any reports of spontaneous pneumoperitoneum occurring during the menstrual cycle, the practical possibility of this is suggested by the free anatomic communication between the cavity of the uterus with the peritoneal space by way of the fallopian tubes. Practical application of this knowledge is regularly used in the so-called Rubin test for patency of the tubes. During this procedure, carbon dioxide is passed into the uterus and then by way of the tubes into the peritoneal cavity. During the test, patients may experience shoulder pain and present roentgenographic evidence of pneumoperitoneum. Summary Chronic recurring pneumothoraces resulting from erosion of the diaphragm by endometrial implants during periods of menstruation occurred in a young woman. This was surgically corrected by excision of the involved portion of the diaphragm. The un— anticipated ﬁndings encountered at operation in this patient present an additional indication for exploratory thoracotomy in all cases of unexplained, constantly recurring, spontaneous pneumothorax. 827 Union Central Bldg. (Dr. Maurer). References 1. (a) Novak, E., and Novak, E. R.: Textbook of Gyne- cology, ed. 5, Baltimore, Williams & Wilkins Co., 1956, p. 546. (b) Nunn, L. L.: Endometrioma of Thigh, Northwest Med. 48:474—475 (July) 1949. (c) Hartz, P. H.: Occurrence of Decidua-Like Tissue in Lung: Report of Case, Am. J. Clin. Path. 26:48-51 (Jan.) 1956. (d) Hobbs, J. E., and Bortnick, A. H.: Endometriosis of Lungs: Experimental and Clinical Study, Am. J. Obst. & Gynec. 4:832-843 (Nov.) 1940. (e) Nicholson, H.: Endometriosis of Pleura, Thorax 6:75-81 (March) 1951. 2. Sampson, J. A.: Perforating Hemorrhagic (Chocolate) Cysts of Ovary, Arch. Surg. 3:245—323 (Sept) 1921. FUNCTION OF THE BRAIN.-—Any biological view of the function of the brain leads us to an unavoidable conclusion: consciousness is not unique to man, to the primates, or to the mammals: it goes back to the roots of vertebrate history and has been progressively elaborated in content, coloring and complexity roughly in proportion to the evolution of the neuromuscular system. It cannot even be argued that consciousness is a unique vertebrate invention—the crab, the octopus, the butterﬂy, the ant, all possess sensory devices imparting to them the awareness of their world; all demonstrably engage in integrated time-binding, self-serving action, and it must be presumed that all participate in some proportional measures in conscious awareness of themselves and their environment—H. W. Smith, The Philosophic Limitations of Physiology, Perspectives in Physiology, Washington, D. 0, American THE Physiological Society, 1954. �2013 Vol. 168, No. 15 TO DUE PNEUMOTHORAX SPONTANEOUS RECURRING CHRONIC ENDOMETRIOSIS OF THE DIAPHRAGM Elmer R. Maurer, M.D., James A. Schaal, MD. and F. L. Mendez Jr., M.D., Cincinnati Chronic recurring spontaneous pneumothorax is results which disorder usually common relatively a from rupture of subpleural blebs. Endometriosis of the diaphragm, on the other hand, is an exceedingly has be determined, lesion as and, nearly can as rare never been reported in association with, or as a cause of, unilateral recurring pneumothorax. The following case report is presented because of the extreme rarity of the lesion involved and the unusual association of pneumothorax with the menstrual cycle. It is the ﬁrst recorded instance of successful surgical treatment of chronic recurring pneumothorax by excision of a defect in the diaphragm that has resulted from endometriosis. communicated This diameter. in 2 cm. was an aperture freely with the peritoneal cavity. The area of disease in the diaphragm, along with the defect, was widely and completely excised. The consequent diaphragmatic opening was 0. size of cotton, sutures mattress with interrupted repaired Examination of the specimen showed that the disease had involved the complete thickness of the diaphragm. Final inspection of the superior surface of the diaphragm revealed which 1 in diameter, nodule, cm. purplish-red a solitary obviously represented a supradiaphragmatic endometrial implant. This also was completely excised. Following reexpansion of the lung and the placement of an intrapleural catheter for water seal drainage, the chest wall was closed of endometriosis diagnosis was The postoperative in layers. the right leaf of the diaphragm resulting in perforation and Report of a Case A 35-year-old woman was ﬁrst seen in consultation on March 13, 1953, because of pain and dyspnea resulting from a spontaneous pneumothorax on the right side. The patient had had two previous spontaneous pneumothoraces 1952. Nov. 14, occurred ﬁrst on the having the right, on Findings on the general physical examination were negative except for distant breath sounds over the upper right part of the chest and hyperresonance of the percussion note due revealed chest of the Roentgenograms pneumothorax. to a a very minimal pneumothorax (15%) over the extreme apex and the base of the right lung. No emphysematous blebs were apparent in any portion of either lung. Because of the small quantity of air in the chest and the absence of serious thoratube thoracentesis or of air the by removal symptoms, costomy was not thOught to be indicated. The patient was discharged from the hospital for follow-up care by her attending physician. She was again seen in consultation on March 20, 1954, approximately one year after the original examination, because of 12 new episodes of recurrent pneumothorax on the right side. All pneumothoraces were associated with pain and mild dyspnea and had been veriﬁed ﬁrst the chest. For of the examination by roentgenographic 15 all that information the volunteered the patient time, episodes of spontaneous pneumothorax had come during the period of menstruation. The important clinical signiﬁ— time. the at appreciated not observation this of was cance Because of the chronicity of the lesion, open thoracotomy with possible talc poudrage and excision of any blebs that examinaroentgenographic been on have apparent not may tion was recommended. Right thoracotomy on March 31, 1954, revealed a persistent moderate pneumothorax on the right side. Careful examination of all lobes of the right lung revealed no evidence of blebs. Testing of the lung with positive pressure, while saline solution was dripped over the surface, disclosed no points of air-leak. The lung parenchyma grossly presented a normal appearance and consistency. The most re— markable ﬁnding involved the right diaphragm. Near the point of emergence of the inferior vena cava and extending radially and laterally in the central portion of the right leaf of the diaphragm was a circumscribed, oval-shaped area of attenuation which measured 4 by 3 cm. in diameter. Numersurface. this modulations on apparent were purplish-red ous In the central portion of the diseased area in the diaphragm Photomicrograph of excised lesion, showing, endometrial stroma and glands extending through ﬁbromuscular structure of diaphragm. implant of endometrial nodules on the intrathoracic surface of the diaphragm. Microscopic examination of the surgical specimen showed extensive involvement of the ﬁbromuscular stroma of the diaphragm by nests of endometrial stroma and glands (see ﬁgure). The single nodule on the supradiaphragmatic surface was composed of endometrial tissue. The postoperative course of the patient was entirely uneventful, and she was discharged from the hospital on her ninth postoperative day, being afebrile and ambulant, and with her right lung completely expanded. Because of pain in the pelvis and dysmenorrhea, the patient was seen by a gynecologic consultant. Bimanual exam- � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Research Files and Unpublished Works Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Consciousness studies (notes), 1956-1958 Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-03-01-002-5-005 Date A point or period of time associated with an event in the lifecycle of the resource 1956-1958 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource <a href="http://id.loc.gov/authorities/subjects/sh85113021">Research Files</a> and Unpublished Works -- Hillside Hospital, Glen Oaks, NY, 1953-1965 Relation A related resource The Max Fink Collection Description An account of the resource Research papers, files, and related correspondence: notes: consciousness studies Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Research http://exhibits.library.stonybrook.edu/mfp/files/original/8e849ba9f746fe3f3d7dfa06949260e6.pdf 8553122d50c6bdf930a7c52ea7d5cac8 PDF Text Text October 11, 1970 Dear Dick, The 8-10 p.m. slot is fine. As for the additional slot for “less formal interactions", I would hesitate to commit myself—— after all, the daytime was meant for skiing, and I suspect that the after 11 p.m. time will be the best for daytime interactions. My best regards. Sincerely yours, Max Fink, M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Dick Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-9-549 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/81898a2c1d75a251835acbe57f4dcb70.pdf 7edfd4f876a99040cf58c1a40608da87 PDF Text Text .. .. ., < u .4- . , . Fvw“ ~nmw-m~W¢—v ~ w “urn" ._.v.« V. .. Jammy 3, 1967 Assistant to the Director Natimal Library of Medicine 8600 Rockville Pike Bethesda, Maryland 2001“ Dear Sir: Imuldbemtefulfwowiuofthepﬂotissues wblished BibLLagMphy 05 Mailed of the v-w by NIH and A- Ream, recently as described in a meant issue of Science. V ~ y <-. Thank you for yum cooperatim. Sincerely yams, ,rcpwwug—mwr w .7. yup-4.»; 4 ~ " Max W’ *"WWHWJ‘ W'II'W'WE' “7-“? —: 'rrma ' Fink, PM). Professor of Paycmatry Wzkp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: National Library of Medicine Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-2-032 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9743cf0335a8ee917a0c128f570efa6e.pdf 02ba2e104afe4bf814c932bc9dff0196 PDF Text Text ”A . "hm :z'wrru,....-r. December 22, 1969 4r Dear A1, -. 'WF’VM;'\ ‘Y’Mi‘ com v-vanhgrgwmmw Don Klein of Hillside has asked if he could have urine samples from our chronic marijuana subjects since his chemist is trying to develop tests for objection and Arthur sees no problem. Any THC. reason not to cooperate? . Max Fink, M.D. I saw no � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Alan Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-023-6-539 Date A point or period of time associated with an event in the lifecycle of the resource 1969 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/a3dc847273160ad8b270845b8916c028.pdf 079fabe5de7be7a0fbc41af87da20d78 PDF Text Text June 13, 1971 Dear Andy, I have reviewed your arranged the following: and ' applications and have Your appointment as Assistant Professor, effective at an annual salary of $28,000 minimum (although November 1, 1971 if my letter budgets are approved, Your appointment it will be $30,000). to the an appropriate research and the exact amount of work will itself out in the V.A. at staff position, the exact title is unclear, salary from them next few eeks. is unclearn~ but that By discussions with the V.A. authorities in washington, we have a committment for a drug abuse treatment center for July, 1972; and possibly for July, 1971. Alternatively, if I wish it, they will entertain an application for a drug aabnse demonstration project effective almost immediately. In either of these cases, the research budget is likely to be very large, in the order of $300,000 to 400,000, making your program the most heavily supported one in the Division. The petitions you have requested are signed and will be processed through the medical college. Copies will be sent to you as they are signed and approved. The V.A. cannot make you a full staff memeber until assured them that you have a license to practice medicine. I it was your intention to take your examinations promptly and indicated that you should be licensed by the end of 1972. Keep well, and I look forward to your joining Sincerely yours, Max Fink, M.D. us in New York. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Andy Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-5-316 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/060e4c7659794de8e7dfc482026a9bf9.pdf 236b21b75ed43b8102a712d371530ff9 PDF Text Text Septemebre 10, 1971 Dear Andy, I spent 6-days in Europe, exhausted, returned to find your some maneuvers for you. two in Washington, and letters, First, as to your questions. and to the Department of Psychiatry, somewhat and immediately tried Your appointment to the V.A. should,like all appointments at the medical school, be independent of me or any other person—all appointments are for an indefinite term, and while tenure is granted only after five years service, there are no discharges of staff members except with an extensive warning. to the visa, I called Washington and after As many calls, reached the best office. I indicated that your appointment to the VA was in the national interest since you are coming to develop a drug addiction treatment program focussed on the returning Viet—Nam file a veteran. Under these conditions, special will allow "Temporary 'H" petition"-~ it is and if possible to approved, it you to come to the states, and wait here for the permanent number to be assigned. At that time, you will have to visit the immigration offices (possibly in Washington) for certain formalities. With this information, I am prepared to file this petition on your behalf, and will do so as soon as it is received. The State Board problem is more thorny. Dr. Volavka has struggled with the Board, and I would defer your questions to him. As he is in Athens for a.few weeks, I will hold up this inquiry until he returns, and ask hint to answer you. I do not know about bathelo quarters at either location, but will defer this inquiry also until some data is established and then can ask specifically. In Washington this week, the principal question was the ways to expedite the development of a narcotic antagonist of long duration and to improve on the available drugs. Funds are available, and should your enthusiasm not flag, I am confident that we can build as strong a program as your energies will allow. best I am up to my eyeballs in work; and on top of it all, am planning to return to Europe on September 21 for two or three weeks. Our projects in Athens are doing very well; and the work will be expanded to Jamaica this winter. I look forward to your joingng the group-- I now have four fine co-workers in clinical programs, and three experimentalists-- my best group ever. Our best to Betty. As ever, � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Andy Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-7-477 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/0727284819b2858d2510301e3ad14ab8.pdf 8987d792402effc7910e39cd1e9edc60 PDF Text Text October 31, 1970 Dear Arnie, Please pay the Hotel Hilton (attention Mr. Paul Steiner) final charge for the 1970 meeting. Letter enclosed. $137.42 as the Please send a list of members, as of the latest date, to Dr. Charles Shagass for the membership committee; to Jon Cole, for the Nominating Committee; and to the AMA (address attached). If you have an urge to invest some of the cash of the Association, I can arrange to obtain Treasury Billaa for 91 or 182 dollar lots. It seems that you will have no until late February, and if you wish to buy 91 day bills, call me. There is no reason to touch the savings accounts; and the securities are probably in as good a shape as one could find. It is not prudent to invest in straight securities (the amount being small) and other funds will do no better. I would suggest, however, that additional funds be used to invest inn other securities, and that dependence on one fund is unwise. In March, after the returns for the meeting and membership are in, we can discuss the possibility of selling some of the Lehman stbck (they pay their major days in multi—thousand major eXpenses dividend in the spring) and investing in another fund. Peace. Sincerely yours, Max Fink, M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Arnie Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-9-509 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/223f4f9a5a648952b6cc353ed59f1f1a.pdf a899abf4f1fed72c9731ad34e2a287a2 PDF Text Text March 12, 1970 Dear Bob, It last wrote. The studies are still exciting papular interest, with many reprint has bean sumo weeks since you requests continuing to coma in. There are also kooky some of which I have sent on to Mickey. letters, I am enclosing Carl Ffoiffer's lotto: to you-» he aunt it to the Biological Psychiatry, but it is meant for both of you. As he in an oxpotioncod investigator with an extensive exporieoco in schizophrenia, I enjoyoé his report ané on sure you will also. you Surely, this work should be continued, and I hope that will plan to continue as soon as this chore in over. Will you be able to come to San Pranoioco ? If so, the Biological Psychiatry meetings are May 8~10 at the San Francisco Hilton. I hope that you will be able to join us for dinnod sumo evening. . . Stanley has some of your work dooen- I asked in response to Mickey a request, but it is unclear what has to be done next. I suggested you or Mickey write directly to him. ané I am sure he will answer. _ There is much that is going on here~- tho College is increasing the paoo of its discussions of the move to Westcheoter; our affiliation with Kirby Hospital (1/3 Manhattan 3toto) has progressed to the joint appointmont of the new director (a former student of mtno, Mort Woohoproao); and our contract for studies in Athens has boon approved. Stay out of miaohiof. Sincerely yours,' � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Bob Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-3-118 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/76e7e5df188e8460f0b41cba5ed44e30.pdf 61d3c398095bc2a3804b430d7458ba4e PDF Text Text November 29, 1970 Dear Bob, It and I am has been some time since we have heard from Texas, writing to bring you up~to~date with the programs here, and to ask if your plans for 1971 are sufficiently clear to be discussed. I have just written to Mickey, and have offered him a position in the Division. wuw wmypwwr. » 1";"0‘merélwmw‘ During the past month we have negotiated an agreement with Albany that permits us to assume responsibility for Kirby Hospital-- training and research- and the necessary clinical programs. We plan to start with the MMHC units (5 & 6): we will name the unit directors, send residents from the MMHC pool, and be responsible for teaching and treatment. The director will be Kesselbrenner, who will be part of the NYMC faculty. We asked to have the funds through the College but this was refused, and we will appoint to their budgets. All appointments will be joint, and for the two units the appointments will be to the Division of Biological Psychiatry. 1,2,3 or We do not know whether we will divide the 4 units into number depending on the staff we can recruit and the type of research programs we wish to start. ECT and penicillamine 4 sections, the are already projected; Would you studies are in the planning stage. like to join this Division this summer ? new drug If so, I will be pleased to work out the details. (There are so many other projects in the works, that the choice is a good one, now that we have some funds Keep again). well, and write soon. Sincerely yours, Max Fink, M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Bob Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-9-461 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b92b35510b4c8f46f08b2934c1d3b341.pdf b28d1aba672e496dcf2c15bcf9537fcf PDF Text Text ,. ww- . WWW-”1|.“r:-.--_-n;.T-.-- _~,_3 . ' "WWW > , ~ , , » ‘w-w “WWWIWWWIM gym—saw» .mw.~w-»wv-at”- 1,... .M V ,W "wt. ‘,__,_, “f, V” ., .. ,. . .7— , June 28, 1970 >‘nm’mvvmwv'qlmev-wun Dear Dick, -—m’n-w—Mn~w.mqr‘u «4 r With reference to the for membership: ACNP request regarding nominations I would like to nominate two of my associates, whose work is well known to me, and who will be able to make significant contributions to the College: 1.:“unwm Jovan Simeon, M.D.- Assistant Professor at the New York Medical College. He has been working with me since 1966, and is now a project leader, working in adolescent and child psychopharmacology. Ali Keskiner, M.D.— Associate Professor, University of Missouri, St. Louis. I have known his work since he joined the Missouri Institute of Psychiatry in 1965. He is an independent investigator in schizophrenia, with particular interest in rehabilitation - .. wrwnr. as it is enhanced by psychoactive drugs. In addition, there are three young men at this College independently and should be candidates in the are next few years: who now working Richard Abrams, M.D. Arthur Zaks, M.D. Richard Resnick, M.D. Dr. Keskiner have already seconded the nomination of year; and will recommend Dr. Simeon next year, if I believe that I this this is permissible. Good luck ! Sincerely yours, Fink, M.D. Professor of Psychiatry Max I � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Dick Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-6-264 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/0e51ebce72dc850f20ba2f35970d831a.pdf 3b95d2c77f2d989bf4e75d1535962923 PDF Text Text usxonannux March 24, 1972 Mrs. Ebert T0: — EH34: Dr. Max Fink SUBJECT: Painting As per our memo Maintonance of March 15. requesting painting of room 42A and Lab 42A; please add to 5;, to b. painted in the this request, same color (very room 42 and Agboratogz light blue). Charge 39-270-0. ‘. . 'l.\.u .— ,-V.‘.\4 ‘ MiaLh—h‘ ‘ I *Wkﬂgiﬁw � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Ebert Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-026-1-039 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ea73f42e992e2e446a008c280768dc1e.pdf b01028d12113503e84e2482807c5d882 PDF Text Text w- March 14, 1985 Dear Gerry, Thank you for your note about answering public inquiries. accordingly. it I will act Please accept this copy of Feynman's book, with my compliments. Ifound that l have sent a few out to some friends. so delightful, also enclose a newsletter sent me by Arnold Mandell. For the past 20 years, Arnold Mandell has sought the Rosetta Stone to psychiatry in mathematical models of brain function. i have always found him obscure and confused, and he has always presented himself as a California guru. His messages have left me unimpressed. But he has been named to every prestigious award, including a MacArthur brilliant scholar, so I have had to temper my reactions with the admonitionJhat my lack of appreciation is probably a fault of mine. After all, he could not total all the awards committees, or could he? As a founding fellow of the American College of Neuropsychopharmacology —- a self proclaimed select group of neuroscientists -- i receive his broadsides periodically. A Perhaps these equations have meaning for you. My best regards. Sincerely yours, ‘- � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Gerry Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-030-6-181 Date A point or period of time associated with an event in the lifecycle of the resource 1985 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/777fd7e74714a6cd44c432c0b52f66fd.pdf 39ea4c2ccd741d42120f687efe89d506 PDF Text Text January 25, l985 Dear Harold, It was kind of you to ask about old psychiatric books. following: I am looking for the Meduna, Ladislaus von. Die Konvulsionstherapie der Schizophrenie. Carl Marhold Verlagsbuchhandlung, Halle a. 5., 1937, 121 pp. Wagner-Jauregg, Julius. Fieber- und Infektionstherapie. Ausgewahlte Beitrage 1887—1935. Verlag ﬂlr Medizin, Weidmann 6: Co., Wien, Leipzig, Bern. 1936, 299 pp. Wagner-Jauregg, Julius. Lebenserinnerungen. Herausgegeben und erganzt von L. Schbnbauer und M. Jantsch. Springer-Verlag, Wien, 1950, 187 pp. Sakel, M. Neue Behandlungsmethode der Schizophrenic. Perles, \Vien, 1935. These books are out-of-print and are among the bed-rock documents of the somatic therapies era. ECT is having a resurgence of interest. 1 am told that one article on ECT appeared in a Boston newspaper science section on January 114 and another is scheduled to appear either this week or next. There will also be an article in the local papers, reflecting the recent meetings in New York. All seems well here. We did miss you during the New Year's celebrations Alice and at Marty's. it was fun, and the weather was reasonable. My best regards and my thanks for your kind efforts. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Harold Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-030-6-190 Date A point or period of time associated with an event in the lifecycle of the resource 1985 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/784f4cdd9d166cfef6bbaa68b8850cf1.pdf c93b5e9b8d28078c000a6cd8437dac48 PDF Text Text March 7, 1970 near Irene, Thank you for the inquiry about a coufaronce on phenothiazines. As you know, my primary interest is in the I have neurophysiology of compounds, and not their chemistry, so not had much of direct interest to contributa.to anrliar conferences. be hald, preferably in ﬁeverthelaaa, I think such a confarencu should where much of the England 1971 (late), in Europe, preferably in work seems to be progressing rapidly. An is generally experioncad in many confarenccs, a amall mnetjng of £O—60 participants and an additional 30~50 observers 333mg to he the most useful. The theme of the meeting shoulﬁ deciée on the participants, and suraly the lander: of tha last nesting may ha the best to assess the relevant interesting tapicn. My best regards. Sincerely years, Max Fink, M.D. Professor af Psychiatry mf/ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Irene Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-3-139 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/cf1a8c78ddd2aeb15ccefafbdb61144e.pdf 0b9f5807585a76b604bbcc9d025e2886 PDF Text Text March 7, 1970 ﬂoat Irena, far the inquiry about a confatence on phanathiazinas. you knaw. my primary interest is in the naurophysiology of compounds, and not their chemistry, so I have not had munh of direct intereat to contributa.to warliar conferences. Thank you As Heverthaless, I think such a eonferencc should be held, preferably in 1971 (late), in Europa. preferably in England whit: much of tha work seams to be prngzeoaing rapidly. As is generally expariencad iuv many confurences. a small wanting o£ aowse participants and an additional 30~50 observers anew; :0 he the moat nacful. of the m&ettng shauld decide on the participants, 9f the last wanting may ha the best to lmadara the suraly the ralavant internating topics. assaaa and The them: My best regards. Sincernly yours, Max Pink, M.D. Professor of Psychiatry mil � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Irene Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-3-141 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/1230f9c4f00d73be1d469b9abdd26496.pdf 8e349e2582d217a5d7b01049fe29f056 PDF Text Text January 12, 1997 Dear Jack, It was good to hear from you again; I also received a card from Sophie and her family on holiday. All is well here. Martha has just returned from a short visit to our two grandchildren in Phoenix. The are growing well and the reports were glowing. My son, as a Department chairman, is in that phase of his life that he is dealing with ‘movers and shakers’ -- deans, university presidents, and corporate executives. He likes the power. At the same time, he is at a pinnacle of his research career, with much research money and many students, and has to decide which effort -- the academic or the political -- to follow. Martha reminds me that I was in the same phase when I was in Missouri as the head of an institute. I am glad I chose the research. On the topic of research, a few years ago I urged some leaders in ECT to organize a study comparing the efﬁcacy of continuation ECT to that of continuation medications [lithium and a tricyclic]. After three years of bargaining, the Government has awarded grants to four hospitals in a collaborative effort. Unfortunately, the federal funds are inadequate to do the study properly. In the past, universities were willing to support the research effort, seeing such work as part of their academic responsibility. No longer. The issue now is wholly -— how much money do you bring in as a clinician; how much are we paying you; and if we cannot make a proﬁt, maybe it is time to go. So, I am in the process of returning the money to NIMH. The process has become ugly. The Dean has asked whether I am willing to retire now. After all, he says, he can hire two psychiatrists for my salary. When I noted that I have been accorded all sorts of honors as a teacher and as a leader in research, he smiled and said that the school had paid me for such efforts in the past, but for me to ‘get with it’ -- the times have changed. Martha and I have begun the necessary dialogue to retire later this year, after I have completed my present assignments. These end in June and after some months of terminal leave, I should be free. My book ELECTROSHOCK is coming along nicely. I have written a for the laity. I have a good publisher [Oxford University Press]. All the main description chapters are written; I am busy with the end-notes and appendices. While it will not lead many to this useful treatment, it will serve to answer some questions. �As with my university, a similar immediate return seems to have affected old your company. Earlier in the year, when mirtazepine [ORG 3770] was about to be marketed, I reached the research director at Organon USA and suggested that we undertake a clinical trial of mirtazepine in delusional depressed patients, with an eye to deﬁning its efﬁcacy in hospitalized patients. I noted that the ﬁling data in the US. [which he had sent me] was limited to out—patients. In return, he said that they were not at all interested in testing mirtazepine in in—patients. [I do miss the days when it was possible to talk directly to Organon’s leaders] I replied that I ran a clinic of depressed patients and I offered to examine mirtazepine in either our depressed patients after a course of ECT [was it as effective as a tricyclic in continuation treatrnent?] or in those who were not so ill, and for whom we could deﬁne the clinical efﬁcacy at the same time as its effects on adrenal functions. Again, he wrote to say that they were not interested. Too bad. The competition for attention in modern psychopharmacology is based wholly on hiring ‘names’ to give ‘talks’ about new drugs and to ‘testify’ as to their effects. Most of my peers are already on the do g-leash for other compounds [of which there are about eight]. I fear that mirtazepine will have no better fate than mianserin in this country. Martha continues her supervision of student teachers; our daughter Rachel in Massachusetts has adopted a lovely, bright, and intelligent Chinese girl whom we love. And Linda has convinced her husband to take a position in Virginia -- they are building their home on almost 200 acres of mountain-top nearby to her college. I continue to give courses in ECT and lecture on my new-found interest, the syndrome of catatonia. Martha and I are off to Melbourne in late February. That will be our ﬁrst trip to Australia. So, we move on from one phase to another. When I step down, it should be possible to travel more freely. We will see. Meanwhile, Martha joins me in thanking you for your kind note, and we wish you and your family continuing health in 1997. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Jack Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-8-170 Date A point or period of time associated with an event in the lifecycle of the resource 1997 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/133c186e3a73d0d2b267ddc84c5490f9.pdf 904675e3482cb6fb7ff512bd96250432 PDF Text Text July 17, 1992 DearJana, Thank you for the articles on bibliographic software. do wish that could transfer from Scimate, but it works well enough. just took a course in EMBASE and found, to my chagrin, that there are many more articles in ECT in journals not indexed by MEDLINE than had thought. Unfortunately, EMBASE is quite expensive, both in search time and in downloading citations. But had to begin and downloaded citations for 1991-92 that did not have in MEDLINE. I I I I I i am often asked why Convulsive Therapy is not indexed in MEDLlNE, and can only answer that the MEDLINE review board makes its decisions in its own way (like NlH Committees?). But Convulsive Therapy is indexed in many other indices, and all can do is to urge readers to seek citation lists outside I I MEDLINE. incidentally, the last citation list contains a review of ECT in Czechoslovakia. Their therapist are also male chauvinist pigs, shocking women more often than men! But they seem to either have a different appreciation of the efficacy of ECT in schizophrenia than we do [or their diagnostic criteria are different]. assume the difference is probably the latter reason. I Let’s get together soon. My best to Vojta. Max � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Jana Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-033-2-043 Date A point or period of time associated with an event in the lifecycle of the resource 1992 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/9f47b8e762737d3ed3f036204124221a.pdf 6ef40d1089cc75e661fa788fc497457a PDF Text Text .Wr w v“' -m"wrv-Awn—untn‘-’IAI—u4uw‘r' November 18, 1977 » . - ' Dear John, “rthm1L"v<~l".—" nu luv-w— x " fur-n "Pam to viiit Jamaica is excellent. The only with Michael Beaubrun, whom I visited in 1970 or 1971. While he agve the EEG part of his study to Korein and Karacen. contact I had we Your idea was have remained friends, and I from you. He is the (or which the reports was) the emerged. trust that he will respond to a letter director or the Bellevue Hospital from w u . 'u- rww'mmz'nrwu1—‘clrIvmv'mwm. you will let If you me know can see your way to return via and we can reason the problem New York, together. I hope I'm busy these days wrestling with ECT again. I have a number of questions which I think could be answered by yet another study, and I am planning a VA collaborative study. Otherwise, the programs here are purring along rather quietly. my best regards. “mmywmwﬁtvmnn Sincerely yours, Max Fink, M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, John Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-028-6-263 Date A point or period of time associated with an event in the lifecycle of the resource 1977 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/acc13cf6c1d03f8918a800edb56058ec.pdf 7e479a7bb9f11a187b360acf657f0dd5 PDF Text Text September 8, 1970 Dear Josh, Enclosed is a proposed subcontract for the Athens study. I have taken the model suggested by Mr. Graduall, and added the modifications that I believe would cover our specific problems, expenditures for personnel and volunteers in Greece. I have also decided to append a full copy of the general provisions, some of which apply Specifically and the others should provide some evidence of NIH intent for anyone interested in reading them. I would anoreciate your calling me at my office if the changes are minor; and if major, I would appreciate yourrmaking the appropraite amendments and I will send a messenger to pick up the corrected text. Many thanks. Sincerely yours, Max Fink, M.D.V � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Josh Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-8-424 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/be7da813b3c51cb2a1133e3f99a9b34a.pdf f8e22f2399cfdfed6dc046eeac7042e4 PDF Text Text September 12. 1966 ﬂie- Hurray Active Translation Bureau. Inc. 1472 Broeawly Entrance 147 W. 42nd 8t.. ﬁnite 306 new Ybrk. new York Deer ﬂies Murray: I would be grateful if you would translate these doculente in e fedhion satisfactory to the Department of Education in Albany. Before translating the Yugoelevian document- call office and provide II with en eetinnte o: the coat. I would be grateful if you would complete this 6 you ny hetore October 5. as they will he needed on Octdber 7. Thank you for your cooperation. Sincerely youre. Hex rink. H.D. Proteeeor of Peydhiatry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Murray Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-7-405 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/8fe0d6a7600d7152ed944a83c614c947.pdf 3881a53af10ea0ce774a338ba31702ea PDF Text Text '— v“ w m-rvr-w-v January 14, 1921Dear Peter, you Thank you for your two letters. I hope that you have overcome illness-- it is a shame to miss the early classes, but I will make these up. your know that The notes on the Clyde Mood scale were very helpful. I had already compared the output to the placebo schles and was sure that the CMS was helpful. Your suggestion of comparing the last five minutes of EEG to the CMS is a very good one, and I will try to keep it in mind as the data analyses proceed. I have asked that you be reimbursed for your travel, and due course. .this should arrive in Your notes about the start of the placebo paper are good; but I am confused by the request for a return of the general summary you left with me. The summary I read, I believe I returned. I have made a folder on placebo/EEG/Irwin, and is not there; nor is does Bruce have it. Are you sure I did not return my it at home; nor copy to you ? If not, descibe it again, please. (I'm embarrassed, because in the past I could always turn to kathy and she would save me from an embarrassing memory 0. it Feb 1, and We Glasser has just appointed a research assistant to begin I believe he will Spend much time on the problems as outlined. shall see something by mid-March. Keep working and keep well. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: ?, Peter Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-026-1-124 Date A point or period of time associated with an event in the lifecycle of the resource 1972 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/a1471f903d87facc80f9e5c203b41dbe.pdf 4eda7a67aa203adec79242d493bff35b PDF Text Text 19 Mirth 1974 mm- H '1 mm- pray: sqmgeup Charltn sangaau. 3.9. -Prnnidnnt Annriann Paychapathologtcal Anaactatian Rantarn Panamylvanin Psychiattie Inatttuco Pbiladulphtn, Paunlylvunia .3. Dog: Charlie: ragarwwvz'yww. Tb w! 19129 Enclosed ch: heat at is a eopy a! the nouinationl for APPA cumndttccs. roanllncttoa. cvnryona nominated sccaptad. my 1;»; 4 $2: 'tw-mx m I an 136.06 dnlijhtnd that Ed Saahcv will be eh. Chairman of the next Frost-a Conﬂict... Enclosed is a lcttur for you and Ed for your connldnration for thu progrun. My ‘mﬂ‘ﬂ'm. best rsgnrds. Sinunraly yours, huh-W5- an, m ﬂnk' HOD. ‘ mien 1" "‘3‘" £9215 rs, u 2 MW». - _ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: (article) Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-027-6-506 Date A point or period of time associated with an event in the lifecycle of the resource 1974 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/eaddf94a9bb8c0794d6463b54308a496.pdf ce4021873459f00ace10f55417bc31c9 PDF Text Text February 28, 1966 Division 3, 1986 Praaaadims Amriam Paycialagical Association 1206 Samumth Street, Washingm, D.C. 20036 - NM. W: Wadmdmftaapiaaafﬂanpart‘mScalpmd mammsmwaamwmmm AW casting of tha Stimlatim" for yaw midaratim far the Mariam Psychological Association. malsomlosad. 1966 ‘ma capias of an abstract ‘mcfigmsdmatratMsmaftracbsat-vatmm butamnatavailablatoday. Iwillsubdt being thanwithinﬁamxttandays. Mywmrynwhfarymmidamtim. Stately yours . Max m. 24.1). Professor of Psychiatry Hszp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: 1966 Proceedings Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-2-131 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/fa8a36f127e31deaa6f92d1a9e0d260e.pdf c6bbecc73a9ac5a4a932ab02c7cf8054 PDF Text Text March 7, 1958 Division 3. 1966 Mandingo American Psychologiool Association 1200 Sevontoonth ﬁtroet, N.w. Washinatm, D. C. 20036 Gentleman : copies of tho report Way 1 3mm four draft to $1113.11th Roma Averaged Evoked Responseconsideration Electrical Stimlatim" for your (2&1th1966 "Tho Scalp for the "‘161’5“ ”WW/"'W'w‘ vv-~.,.nA,-.. or .‘ “,2”. No.61,” mating of the Mariam Poydwlogiool Associatim. Page 1 had one manqcialetod, and-I om angina of a mlmemt. Monodalaoemfm annotoforigimla mddunoaotsofyeomoopion. Figumlintobeineortod mmamornma. Figures 2, 3, mpegelt. .vam‘wﬂvvqﬂ'ng figures. melanin; ofum Thank you . mod n complemont W13 1, 3. and 5 for yaw consideration. . Sincerely yours, Max mm 14?sz Fink, H.D. Professor of Payalﬁntry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: 1966 Proceedings Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-3-173 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/4c98bfbfab6b328b72de61a07a4e9031.pdf 14d3fc239741924e6c3adf1ae6a0b562 PDF Text Text May ' » 17, 1967 Officer 365th General Hospital 100 N. Forest Road Buffalo, New York 1&221 Dear Sir: IamwritinginsupportofthemquestofDr.ArthurZaks forassigunentintheNewYorkareadtminghissunmertmining PW. Dr. Zakshasbeenanactiveparticipmtinthestudyof cyclazocine which is a new agent in the treatment of narcotic addicts. This study is a special research project of the Department funded by the National Institute of Mental Health and the New York State Narcotic Addiction Authority. He has been centrally involved in evaluating the untoward effects Of this canpomd. The studies are prOgressing actively and will continue for the remainder of this year. helpful if Dr. Zaks could continue his observation of these patients. He has already deferred some of his vacation time in order to continue the study program. It We would be most grateful if it were possible for him to military time in the New York City area. would be most spend his Sincerely yours , Fm, m Professor of Psychiatry MOD. Mszp cc: Dr. Zaks ‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: 365th General Hospital Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-5-278 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/39601a9eb4e94cabc8498d28a29c0f04.pdf a870ac3ca8ec7a7443cbe99528066dbb PDF Text Text 4 J! I‘m (2 Dr. Harold Aaron The Hedical New y ’y r560 Q' ‘6, . only 11, 1969 Letter York City Dear Dr. Aaron, interest. clear. I have read the summary, Methoqualone and REM, with report seems direct and well written, and is very The As I am not in the habit am unable to contribute of regularly recording aleevaEG records, I to the content of the report, nor to assess its fairness or accuracy. for your interest, and for your offer of a trial May I suggest that the address of record is not the New York University College of Medicine, but the New York Medical College: Thank you subscription to medical Letter. Max Fink, M.D. Professor of Psychiatry York Medical College East 102 Street New 5 New York City 10029 Sincerely yours, Max mf/ Fink, M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Aaron, Harold Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-023-4-414 Date A point or period of time associated with an event in the lifecycle of the resource 1969 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/bc5bbc4948d4f288c42c6f8b9a884bf1.pdf 63761bd445a54de1f849b149c2c9f2d2 PDF Text Text 731:038 (00h) January 31. 1973 Abbott Lebels unlimited 78 Mill Road Freeport, L.I., New York 11520 Deer Mrs. Verin, request your printing 1,000 labels, following the specifications of January 12: We .002 matte Permanent ﬂumbera silver ~ Foil- Dark red in sequence beginning: Text: lettering 1000 International Associetion for Psychiatric Research P.0. Box 269 Great Neck, New York Proof requested. Bid price: ‘126.36 (Tex exempt: HIS l38hhh) Thank you. Sincerely yours, Mex Fink, M.D. Executive Director � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abbott Labels Unlimited Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-026-7-542 Date A point or period of time associated with an event in the lifecycle of the resource 1972 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/5cebcf51ea4af977c7321bb849ba0673.pdf c6fd29d75217a1d1829cff329a2b4e86 PDF Text Text Wm...” -w.:m.~. November 13 , 196M Professor Sanshi Abe of Hokkaido University School of Medicine Dean Sappmo. Japan Dear Professor Abe: Dr. Kazuo Saito of the Departurmt of Public Health at Hokkaido University Sdrool of Medicine has applied for an appointment at this research and training center as a research fellow in neurophysiology. He has suggested that we write to you for additional informatim. _ We would be grateful for any consents you to nakemﬂrdjng Dr. Saito's experience, his ability to relate to his co—workers, and any talents that he may have exhibited muting his experience with you. As you may guess, we are particularly interested in his ability to relate to members of our staff, so that his language ability is an inportant determinate. Insofaras the program in reseamh at this center are dedicated to evaluating the changes in brain physiology associated with variws changes in the matzent process of the severe mentally ill, much of Dr. Saito's work will be in clinical and experimental electroencephalography. Any cements that you may wish to make regarding his ability in this type of work may wish would be appreciated. ‘ Thank you very much " for yew cooperatim. Sincerely yours , Max ' Fink, Director M.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abe, Sanshi Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-7-770 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/f8af9de213e2fda0c9ba288bfced3b50.pdf 0e6a733f2195c6b7315461dcf18c1173 PDF Text Text Irv-w" _.... . urnv'vlwmnrﬁ‘v'vm rmt‘ arm—a e n’ } June 15, 1970 H. Abelson Science Editor, 1515 Massachusetts Ave., Washington, D.C. 00005 Dr. Philip N.W. Dear Dr. Abelson: ”Death from Heroin,” in the June 12 issue of Science, highlighted an important medical and sociological problem. The conclugion that two methods of treatment, methadone and emotional support, seemed promising, omitted what may be another exciting and potentially significant advance in opiate Your editorial, dependence hiatOry - that of the use of Opiate antagonists. Coincidentally, the same crisis in heroin deaths spurred antagonist data. early May to call a meeting to review the New York Academy The meeting was hastily convened June 4, at the of Medicine, co-sponsored by the National Institute of mental ﬂealth. We regret we did not know of your interest in this issue, for we would have gladly invited an observer. us in . have prepared a summary of the meeting for your considera— tion for publication in Science. The list of participants includes the American scientists actively involved in clinical trials, as well as pharmacologiata and chemists with interests in opiate attended antagonists. Industrial and governmental representatives with an and hopefully, returned to their laboratories and offices appreciation of this approach to opiate dependence. We Publication of this meeting summary in Science may serve to inform others, unable to attend, of this progress, and may stimulate additional research endeavors. Sincerely yours, WWWT.M Max Fink, M.D. Professor of Psychiatry 1 .v-‘mw Hszp 811C . NW“. , � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abelson, Philip H. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-6-281 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/45d3e61100f3a05117c81aee70cb987b.pdf 6ce4f63f8ed6c68675c0ca4bc79b2059 PDF Text Text March 9, 1965 L” Abm animosity of Illinois 912 South Wood Straat Dr. mileage, Illinois Dear Loo: Encloaad lo a lottar addroaaad to you at this office. I: to an invitation from tho warship Conant“ for you to apply for unbornhlp. I plauad to propoaa you for township. if you worn lutaraacad. aubjact to one llnitatlon. Would you plan and no a alogla page abut-ant of tho report which you am planning to ptoaont to tho soolaty on Saturday morning. Hay l? I know that you an in tho middla of moving. but 1: would ha roost helpful it I could how an outline of your presentation ao that I can with each of tho othar participants. would ha mica“ ' Boot Fink. 2M). Professor of Payohiatry Max Minn Enclosure tagarda. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-2-121 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/dbeea7bd10280fb9514f452b7ada0015.pdf c6ecc9337be47cee88f83e4b921f049d PDF Text Text April 3, Dr. Leo 1965 ; AbOOd Dimctor cf Research thiwmity of Illinois 911 South Hood Smut 011mm), Illinois Who: Imoncloaingadmfteopyofthomportbym. Gamhmformsmimmmy l, 1955.. » Sincerely yours, Max MF:jm Encl. Fink, H.113. meessw of Psychiatry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-2-179 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/50b9ea51bb28689068b3a61f005dc2ac.pdf 16a0115efa1150bf10949d5b9bef2804 PDF Text Text April 19, 1965 Dr. Leo Abood of Research NW miwmity of Illinois 911 Scum Wood WW, Strut 1mg ' be: Enclosedisadmrtofmmpovtbynr. Rimmmite Dear {3:st Biological Psychiauy Meeting. on Satmday, May 1, Sincerely, Fink, M.D. Professor of Psychiatry Max Khjm ﬁnal. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-2-204 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/c694e4a5855562499d6a088daf57cbfc.pdf 6a435fe551c53e7851eb3d98afdac45b PDF Text Text April 2", 1965 Dr. 130 Abood mentor of Ram Illinois Univumity of 911 MIllinoisStreet Chicago. Wood Dear Dr. Abood: Wedhachaftofmmpombyw.mumfor the penal "Antidzolhwrgic Hallucinogem" for Saturday May 1. itavanotyetamngadforaplaee forlmcmonm and apmciateymmmetingm at the ofthemmingmsiminﬂxemys‘dteatﬁmm York Hilton Hotel, after the martian by Dr. 91003. Saturday but wwld Sincerely yours , PM, “0 D. m Professor of Paymim'y Wzkp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-2-220 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/6d4cb8a2679c190d9f9adce2609bd4be.pdf 100ab27b04e7b55905ac79bb9b2a65a3 PDF Text Text May 7, 1955 Dr. boAbood center for-81mm mimityofkoamm Rodnstor, NowYork Durham Iwanttotaksﬁdaoppmmitytoﬁmkyoumagajn mmtatim. an Smmy, Professor Sdunitt dcdieatcdaportimofhistalktomcalstudiessimﬂarto for your my fin. ymmdmdumfmtomwoﬂcatmm. Ehclosedisalstterwhichlmmivedmer.manpsm. Ilodcforwardtomceivingﬁwmctedﬂgmaandthe ﬁxaloopyofywz‘pqaer. Sincerely yours, ﬂax Fink, H. D. Professor of Psychiatry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-3-234 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/7e2eb89bf201b3e968b7e3f953b25771.pdf ede72aa02bec830771187bd4c54a2fb7 PDF Text Text Hatch 9, 1965 Dr. Leo Ahead Univutlity of Illinois 912 south Wood Street Chicago. Illinois Deer Leo: Incloaed ia a letter eddroeaad to you at thia office. It ia an invitation from the warship Committee for you to apply for Hilberahip. I would be pleased to propose you for membership. if you were interested. eubjoct to one liuitation. Would you please send no a eiugle page abecraot of the report vhioh you are planning to preeent to the Society on Saturday morning. May 1? I know the: you are in the middle of moving. but it would he not: helpful if I could have an outline of your preeentation so the: I can communicate with each of the other participants. neat regards, Pink. H.D. Professor of Psychiatry HA: HF:3I Bnmloanro � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-3-241 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/91ac0ca3f2c5d8e237ce5ac136fa06ee.pdf bc2499ad8245f20aa63edd41d9452ba2 PDF Text Text November 12 , 1985 lac Abocd center for Brain Reseandm (hivereity of Rochester Fodmster, New York Dr. Deer MO: in for the forthcoming Prom Omnittee 1966 has asked Dr. The C.I.N.P. Washington on March meeting “~81, Philip Bradley md myself to ammge e sywosium on the general topic of neuropharmacology. Wehavedecimdtoamgeesympositmmﬂw subject of: MWOLINERGIC WW8 . Anticholinergic hallucinogens have received cmsidereble study and the data relates to the problems of central nervous systh daclinergic mdmmism in the therapeutic effects of various somatic treatments , and to the special problem of the dissocia— tion of ms and behavior. Recomizing your experience with these canpounds and yaw interest in these pmblm we would like to invite you to participate in this syupcsitm. 1. If you are able to accept this invitatim. would you please send me a proposed title for your presentetim, and a short paragraph describing the toms and type of data you wish to present? Upon willoake Dr. Bmdley and I madman, emmdedpmgmhalmcing the tin for receipt of these up he C.I.N.P. Oomittee has agreed that this symposium will have at least one session of simltanews tmslaticn, so that reports may be presented in the language of your choice. presentations and discussions. 2. The C.I.N.P. has not stated a general publication policy propose to publish these reports and discussions as a and we his cum expenses separate volume. from 3. mtieipates that each participant will pay in attending this testing. For those attending The C.I.N.P. hope. a charter flight my be organised by Dr. milip Bradley. �I». Abood War 12, 1965 ~2~ In the amt that travel fmds are nemaazy, please indicate. the mount muestod to swplenmt your available fmds md we will tumult these mqmsts to the Program and Emmtive Camittees for their decision. a. The Committee has asked that are beingmda by: we indicate arrangements Miss Margaret K. Taylor c/o C.I.N.P. Secretariat 3836—16131 Street, Washingtm, If you am planning to her dimctly? Dr. Bmdlayandl symposium. NM. D. C. 20010 to attend this muting. would you ‘ write lookforwardtohavingyoujoinminthis Sincerely yours , Pink, M. D. Professor of Psychiatry Max � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-7-590 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/883ee12fadd54d6faca3650cce3f350a.pdf 6ab2322224819be72b376e7d9d2fc52f PDF Text Text n‘u'ﬂwﬂ'AVm'v‘wt‘w»: mm»... “.7. , . ‘ m‘wnwmwmpvrvn.Iv'rwv-uurz‘ mw WU<V 'm-‘IK $7.".n-1<vx-wm vmv ~Wm ‘3.“"& ul" Novenber 20, 196“ Lac 6. Ahead, Ph.D. University of Sdml of Illinois Medicine 912 South Wood Street, Chicago, 12, 111121018 Durban: Wmverywohformpﬂngmminvimim smegma: at the Society of to participate in the 1965. May, in Biological Psychiatry I am enclosing a copy of the call fer scientfﬂc papers and a lettar that Sam has written to Dr. white. I mpmpoeingﬁmtyouwilltalkabwt "Bio- chemical Cmmpts of Anticholimrgic Psydwtmﬁmtios". This proposal will 1m sent to the camdttae prom AssoonmI fordiowaimatitsmtingmmrard. mymwoaptedmmmndaﬁm. I'will mmﬂm‘ writctoyouanditmymmbemmssarytosuhﬁtasm abstract. My best regards. Sinoemly Max Fink, NJ). wreath mles encloams yam, m,1-v‘:-~ A I‘m—w- mnvh � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-7-781 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ba8e12ae5e33dea1d2cdb3bb7709fc6d.pdf 723ead6a4edbd11ffe67e85f61731a08 PDF Text Text January 13, 1965 Illinois Street Illinois University of 912 South Wood Chicago, Burma Itgivesmmatplmmtotellyouthatﬁwmw OmittoooftheSociatyotBinlogicalPsyohktryhasmpmdthe for mtatim at the 1965 panel. "Antishch Sociatyming. mmmmmdtimof.tlmmsimMrnt,as yet,bem.achedulod. Mmﬁngsmltmplammﬁidayaftm mm,Apul130ﬂ1,mdmylstmd2nd. Imuldauggesttmtym MW" 7 Mummﬂmmlinmmrkforammm. 'Inadditimtoﬁmpmﬁcipmtsﬂmdymmyou, mmcwimsuggeamdﬁutmincludommrkofhr. Hemdhiaassociateshavasub- ‘WillimP. ﬁlm.1nﬁ15.apanl. ﬁttedmabamct,aoopyofuhidaisuwloaed,wmmﬂtw his is maimwanmdwiﬂum fifﬁxmport. Gandttm’a “madam, the Tommdinmmpmgrm.1wwldlﬁcetohmm mdatitle, (a singlepa'gemmbgplmty) W‘ofyumm soﬂutlomcimnmmtoeachofﬂmpu‘ticipmm. Ialmady mamofmmmmmdwmnrgicpsymﬁw In additim to this, affectingmmmivitymdbodytmm. Imuldappmaiatemyatlnrmpﬂntawhidxmnypmvidaﬂmbasisfor www.mﬂutlmuldmpnaammmdsmdﬂmmtoeam ofﬁuoﬁxerparticipmts. «gems. Ianlodcingforwaxdtomintemsﬁngmeﬁng. Mybent . _ Shoemly yams, Max Pink, PM). Prof. of maximal � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-1-039 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/c19de1973177a42ca4b47859f431f6a4.pdf d4a0733e9201ea82418cf64f31b4f105 PDF Text Text April 6 , 1965 Dr. Inc 3. Ahead murmur of Research thiwmity of Illinois 91] South Wood Strut (111535800 Illinois Dumbo: I an writing to ball yau that the symposiun m Antidnliw-gie Hallucinogen at the Socioty of Biological Paydxiatry has been for fatally afternoon, My 1, at 2:30, at the New Yuk Hilton Hotel. m Way ' With the tin inwlwd, I an asking each of the participants to meat their material in 15-40 mums, rims alluring 5 to lo ﬂames of discussim for each pm. rmmmstmnatamﬁsmsim, Imamlosingabstmcts ofﬂumpomofﬂuoﬁwrparticipmtsandasmaslhavethdr pmuillwxdyauaopies. Inwdcrtofm ﬁndismssims, Iwill take itupmnysclf- toopenmediswssimofywrmport,butwouldliketoaskyou teaponﬂmdiswaimofmu Gemhm‘s report. I menclminga pmlimhmydruftofhispapermlhnmmmiwditfmnhimand wouldliknywtomaditmdbepmpmdtoopmthedimaim. HandymjoinmasmygmatforlmdmatﬂnﬂmYorkHﬂtm Hotclltmmmﬂayl? 'Ihhwmldprwide-anopportmityforus tombottormqmintadandmyp‘mvidcforamatimhﬂng aftermm. harm. Iwinmdymmdemuastothelmdwmma Immtﬂutyourmvingiawmingalmgsmothly. Hybest mm. Simly yams, Pink, H. b. m Wessex! of mm � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-2-168 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/de60374970c829a42cf300e0262d00d7.pdf c6724851124160949ec973f7642ae10d PDF Text Text my 26, 1955 1):. L00 6. Ahead 00am for 8min March Unimity a! Water Water, New?“ Mimi IhawooneatodanﬂnmpwtsofoursmosimianYm wwwstﬂmittndthnmtom.mmistodny. yourpaperimltodcﬂnlibertyofhavmgmylibmvimmmo yamcitatiminﬁustyhofﬁuhodt. Aoopyofﬁntmiaod listismlmod. will, mythanks formparricimtim. Whom Shmmlyyum, Fink, ”a D. m meesaar of Psydxiatxy � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-3-294 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b4177899d32fcf7167779429a7d2bd80.pdf 3b2bc800a120e8edade804284a4b2d8e PDF Text Text “ mm;.\ q-w. W ‘..1— ”wax”, -_.. October 26 , 1966 Dr. Leo G. Abood, Professor The University of Rochester River Canpus Station Rochester, New York 114627 Dear Leo, thanks for your letter of October 17. While I would be pleased to recommend Bernie, I am in the difficult position of his never having worked directly with me, so that I am acquainted with his professional competence secondarily. Many As you know, Sam recon-ended his initial work an independent his appointment and supervised in St. louis. After role. Sam left, Perhaps we can get together in Puerto Rico. regards. Bernie assuned My best Sincerely yours , Fink, M.D. Professor of Psychiatry Max mka � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-7-460 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/94e90e205f672366f252b20188ef0f9b.pdf 4606e94d779bb6046090f99ec62e4e81 PDF Text Text November 10, 1972 Leo G. Abood, Ph.D. University of Rocyhster Rochester, New York 14627 Dear Leo, In a recent discussion of the role of cholinergic agents a report written by you in 1961 was brought to my attention: Distribution of Piperidine in the Brain and its Possible Significance in Behavior, NATURE 191: 201-202, 1961. on the CNS, Have you done any subsequent work particularly in other spetiee as to where I may Many ? If so, I find the reports. thanks, and my with piperidine, would appreciate some direction best wishes. Sincerely yours, :2 Max 4 f 1/ Fink, M.D. Professor of Psychiatry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abood, Leo G. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-026-5-382 Date A point or period of time associated with an event in the lifecycle of the resource 1972 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/6ea3e9265f96ab01bca9050a09bc4912.pdf d86ba0c85435d7a348ca8e35e2abacc3 PDF Text Text July 10, 1955 Dr. Gerald Abraham Moehav Tel ﬂaerut Mood Iarael Dear Dr. Abraham: my apologiea for not replying to your letter more promptly; however, I have been away. The residency training program in psychiatry at the Hiaaouri Institute of Psychiatry ia a three-year. fully accredited program. Candidatea may come to thia program tron overaeaa on an exchange student visa. It is also possible to come to this eountry on a permanent immigrant viaa and participate in this program. Please accept Enclosed is 65 acadeeie an outline of the.¢oureeo available during the 1964year. The staff of the Institute providea moat of the didactic courses. and the program is affiliated with the University of Missouri School of Medicine., The olinioal work is undertaken both within the facilities of the Institute. end thoae of the institutions of the Division of Mental Diseases, including the St. Louie State Hospital. . Stipenda are available for candidates on a three-year program varying from $6. 900 to $8. 900 per atone. In addition, there ia a tire-year career program in which candidates obtain their clini— cal experience, aatiafaetory for the American Boards of Psychiatry and Neurology, in inatitutiona of the Division of Mental Diseases, as well as their academic training et the Inatitute. While candidates are encouraged to begin their program in July, we have. on occasion. admitted candidates in January. I! this oppor— tunity intereata you, I would be pleased to receive a copy of your curriculum vitae. and a small photograph. As I plan to be in Israel from August 6 to 14, I would like to meet with you. I will he in Tel Aviv most of that time. but expect to make side trips to Haifa and Joruaalem. If you will indicate which site ie the beet for you, I shall be glad to arrange to meet you at one of the three cities.- Sincerely yours, MI/jb Me: Pink. - Director- M. D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abraham, Gerald Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-5-516 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/09322f5cd20db28d0ee534ff161515f4.pdf 4d4e064f0ec5c6583794bef9ff793142 PDF Text Text September 21. 1964 Dr. Gereld Ahrehen heehev Ream Tet-Head - 7 legal but Dr. Abraham After lame: yen in Israel, eohhiem my tour throng: Europe and bed en «alien: return; I teem! your iile fairly complete end 1: the 11m: meeting of the Resume; committee, your appointment was considered. I In pie-ma he tell you the: your epplieetiee for 1 career residency he: been ”peeved. eﬂ'eetive January 1. 1965. or July 1, 1965. depending upon the dehe at your swivel. Creation. 1' (in my in which mdidetee we: miéemy is five your training program. during the first, second end filth yen-e in training 1: the Minoan Institute of l’eyehiehry end the Sh; We ﬂute hospital. The third end {earth yem m experienhe years end Maiden“ ere «abject he ueigemt by the Dim»: e! the simian at henh11 Dieeeeee in inetitetioee of the The 1, ease numb In semi-11, appointments in Inetihutim in St. Louie. or terminate!“ a hmity en hour quarter am from St. Louie. Divider: within the Shehe ef ere nude and one- initial stipend is $10,006 per 3711: with en mud incense of $1. 250. Venetian, 11m tine. alignment. end other deteile ere eebjeet to the teleet the Divieien e! Hentel Dieeeeee. The mining program begins on the first of January or the first of July only. I would be pleased to hen you join the shelf he em 11 yea wieh he «range it end during the initial few mthe of your appointmeet. I would like to hm you week within the inehihuhe proper in one of While the reeideecy' , our eeeeereh presume. I look fewerd to you joining W!” eta“. Sincerely were . rink, Direhter Hex c oC.‘ﬁbre ‘ _ Inf/ls 11 SICttCn Bro Rege , Mina 11.13. . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abraham, Gerald Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-6-639 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b54c365c05051abc530a42974a7ff40b.pdf 8488e7ad82ccbcbefe6aa99a953f957a PDF Text Text Jammy 5 , Dr. Gerald Abmlm c/o S.S. Israel 1965 - Passenger Haifa, Israel Dear Dr. Abraham We lodcforwardtohavingywjoinus inSt. Innis. memwillbenoproblemaboutyothagemimﬂnhospital will and hold for your arrival. In addition we will accept provide mandarin-ls for your use on yam mival in St. Louis. In the event that those are satisfactory, it is possible to use the Wims formextendodperiod. discuss this with the Chaiman of the: mu Ivan Sletten. W Youwillbe able to Canni‘t‘tee, . I donotthinkyouhavetobeoonoemdaboutymmlate start. I am sure that you will with satisfaction . . mush the training program ~ Wl'xenymaniveinNmYomhwouldyouplease call secretary, Mrs. Anita Watzig, collect at 3111 MIssim s-suus so that she cm make me specific armaments regarding your arrival in St. Iouis. my Sincerely yams, m, Director HEX mfzdk cc: Dr. Gerald Abram c/o S. 3. Israel ' Zim Lines New York City. New - Passenger York MOD. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abraham, Gerald Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-1-024 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/3cf57eb11e644a3b64f2689167749667.pdf 056b78f416dc736443bbb01670a367dd PDF Text Text /j 4v / August 17, 1977 Dear Mark, I have not had much experience with drugs that inhibit libido outside the ones described in the third page of the report. I, too, have had patients with schizophrenia treated with antipsychotic drugs who complained that they were less interested in going home than we thought they should be. A discussion showed that impotence was a factor. In my I have had more experience with sexual stimulating drugs. work with opiates (also sexual downers and heroin was regularly associated with impotence), I used the narcotic antagonists cyclazocine We found that patients on cyclazocine showed increased libido, aggressiveness to nurses, and even priapism. We were not sure at first whether it was a direct result of cyclazocine or the blocihde of the negative effects of heroin. In an experiment in depressed patients, cyclazocine also stimulated libido, but here, also, we could not be sure it was a direct resuly of cyclazocine or a result of the relief of depression. When we tried the effects of nalozdne, the findings were never clear. These data were reported by Alfred Freedman about 1972—73. and naloxone. studies of chronic hashish users in Athens, of #7 long-term insisted that hashish use improved libido, performance, and potency. We checked with the wives, and in social worker interviews, 2/3 favored intercourse with their husbands on hashish Again, we could not be sure it was a direct effect of hashish or the absence of the users, In my more than 2/3 irritability these men showed during withdrawal from hashish. The data : Hashihh— Studies of Long—Term Use, edited R. Dornbush and M. Fink, Raven Press, New York, 1977. can be found in the volume by C. Stefanie, I trust these comments are helpful. Sincerely yours, Max Fink, H.D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abramowicz, Mark Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-028-6-288 Date A point or period of time associated with an event in the lifecycle of the resource 1977 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/0904b814105961b72aa910c6689fd9e1.pdf aa3189dfc0abf09184062fe5a4b0f7c1 PDF Text Text a «a: j-ryup .. "s-‘ww --7 January 28, i9 88 ‘ Mark Abramowicz, M.D. The Medical Letter New Rochelle, NY Dear Dr. Abramowicz, i am disappointed with present methods of psychoactive drug evaluation. The debacles in assessment which are cited in the article on fluoxetine are matched by the over-investment in the use of benzodiazepines as antidepressants. The present methods of contract assessment in out-patients, with inadequate monitoring of the case material or the 'blindness' of the assessors; the inflation of rating scale data to suggest that individuals can be working with Hamilton Depression Scores above 22; the very high fees paid assessor groups (up to $2500/patient); the failure to consider the likelihood that practitioners do know when the patients begin a new medication and therefore know when to inflate and deflate scores; and the lack of placebo controls all serve to make modern assessments of efficacy of antidepressant and anti-anxiety agents highly suspicious. - While I have not worked with this compound, 1 would still caution readers more strongly -- " Until effective in-patient trials of fluoxetine against placebo and active antidepressants are published in indeprendent review journals, the responsible physician will use these compounds only in patients properly cautioned that the results are tenuous and that the treatment must be seen as experimental." Thank you for sending me the Medical Letter. The reports remain invaluable. mw’W'V-l" Sincerely yours, w ' no Max Fink, M.D. Professor of Psychiatry wmv-mmn-W'IWW'dW-IW "I“lwu'ﬂ‘x-u'fwhz 'r-""WF'WIW M1?! """mel n any-M P.S. Much has changed in the treatment of severely depressed patients with electroconculsive therapy. Perhaps it is time for the readers of the The Medical Letter to read about the efficacy and safety of this treatment. J � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abramowicz, Mark Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-031-3-071 Date A point or period of time associated with an event in the lifecycle of the resource 1988 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/72649af14b3f78875cdc255d25f56b6e.pdf c9149a907fb56447d89128f50063f2a1 PDF Text Text October 26, 1966 Dr. Richard Abram 1014 Children Shepherd Air Force Base, Texas 73611 Dear Dr. Abrams: Dr. Madman has sent me your lettw of October 11+. Iwwldbepleasedtohaveywvisitdnmingyoxmnext trip East. If you will call my secretary or write, I would be pleased to set up a definite appointment. Sincerely yours , Fink, M.D. Professor of Psychiatry Max MF:kp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-7-461 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/6ec7c9a068ac138f30330e714ef1abc4.pdf 20dd6dac71bf3edaaec12133709cf2c3 PDF Text Text Novmnber 9 , 1966 Dr. Richard Abrams 10“ Childress Sheppard AFB, Texas 76311 DearDr. Abrams: aftermon of Friday, December 2, would be the best for I will be attending the meetings of the ARNMD at Roosevelt and these may be of interest to you as Hotel the The afternoon session interests me least and I would well. be pleased to meet with you at 2:30pm at the registration desk. Ifyouwill inquire formeat that time, Iwillbe inthe The me. immediate neighborhood. my I If there is office am. any problem about finding me, please 369-7900 Ext. 2“? and my The Hotel Roosevelt is secretary will on Madison Avenue and “Sth I look forward to meeting with call know where Street. you. Sincerely yours , n E avg—my,” Fink, M.D. Professor of Psychiatry Max .4.——.,-n4.uwu‘ vI-r‘m < mfkp' ' � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-8-489 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/d7989414a0ba2775ebbd038f8d41169a.pdf eaa18300b342ade8484374b7f7f058c5 PDF Text Text Decenber 19, 1966 I». Rickard Abrams 1M Childrese Sl'xepparﬁ AFB, Texas 76311 ' DearDr. Abram: I havemad'yoxm letter of December 6 with great interest andfindthepmpoeed studyereaeombleandim-tantcne. I wouldliketodoevezythinglcmtoeeteblishit. wt The most critical determimtion at fimt. will be the wave activity produced by milateml ECT. Surely, if unilateral BCT produces a different warrant of slow wave activity thanbilateralEC‘I‘andtheclinioelomditionsamthe same, then the original hypotheses will have to be reviewed, as you suggest. of slow I do not think there is any diffimlty with regard to may of the essential elemnta for the study accept a. biodmist. At the presenttimellommmeinthemtropolitanNeWYor-kmewho is interested in xmdertakirg the oinlinestmse or acetylcholine measures hitIthinkwecanlookforthat. Ihevewrittmenotetotheduirmnofthemmntand toDr.Hemld1<aplanvdnieinc1m‘geofereeidencytr-aining progran, requesting a review of your fwtlnaning two year residency period so that adjuements may be made to provide an opportxmity tomﬂmmﬂzie'sunycmmmtlywithyowtmining. Assam asltuveanmr,lwillsemitmtoyou. Year. Mybestwiehes foreheppymlidayseasonandfortheblew Sincerely yours, Mex Pink, M.D. Hofesaw of Psychiatry HFﬂcp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-8-546 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/debce3c4fbebdecffbc1d40b6ae1101b.pdf f202b59831bc2b9688504414e3515e26 PDF Text Text "1v - January 16 , 1967 1., .rcau—nrrm- Dr. Richard Abrams ‘53)! u»; —_ - —v ‘4 101+ Childress Sheppard AFB, Texas 76311 - rr- DearDr. Abrams: .w«.-.~':a,.«—~r.- «SJEIFTV-‘K’JF" . "’x-<'n'9 wjgvne—z-v 1- was -‘:-‘ 47w“: ' " 1'15! 1. '5"- .11; A mm w w 21 mix; .Ef Since writing you on January 9, I have read the article at all. in the Arne/aim Jamal, 05 9191mm. This by Martin is a clearer exposition of the experiences BCT ment With unilateral interrelation of the nemery change data, improvescores and the allusion to EEG data are very clear. and the If these observations are confirmed, then the study you suggested should be augnented by a detailed examination of a variety of aspects of menbry function. Once a study is to select patients and to treat them in two different ways , it would be a most useful theoretical addition to examine the possibility that the memory changes both in quantitatife and qualitative aspects may be related to the degree of altered brain function as measured by the techniques umiertaken you suggested. Sincerely yours , Fink, M.D.. Professor of Psychiatry Max Mfzkp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-2-052 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/0ab066cfc865113100a3adcb91b47482.pdf 6200a4f2c9829abd6a5f3636a3fd275d PDF Text Text January 9, 1967 Dr. Richard Abrams 10” Childress Sheppard AFB, Texas 78311 Dear Dr. Abrams: I have discussed your request with Dr. Preednan and Dr. Kaplan have reviewed the experiences you have already had in relation to the study progran in the Department. I am pleased and z-a' z. : ﬁﬂﬁww-vﬂ! we thattheChaimanhasbeenabletoaffirmthatastudypmgzun should be latter portion of your training. months the initial assignments will undertaken during the «rum-1,2- . :9 _ Deming the first few be made in those areas in which you lack specific experience as narcotic addictiOn, the mental hygiene clinic and child psychiatry. As soon as these are accomplished in a satisfactory fashion, we believe that the study program you have outlined may be undertaken. critical part of the study is in the development of EEG patterns with unilateral ECI‘. I have read the Zamora article and am mimpressed. I have requested the Martin article but have not yet seen it. Surely, your om experience becomes very critical and I wwld suggest that you outline the observations which you yourself have made regarding the EEG differences with unilateral and bilateral ECT. Especially, if The different _ you have samples of the records in subjects treated with unilateral clinically and comparing these with other ECI' showing improvement subjects of approximately the bilateral BCT. same age stoning improvement with In reading your protocol of December 6 , the introduction so is the hypothesis, Imam, of the four alternate ezqalanations, the fourth is unclear. The first is straightforward and three are quite good. "‘5"? ,HCTAFWF-thwhm"! 'I'hemethodisrelevmtandImuldonlyaddthattheEEG delta activity is to be recorded following ECI' at a specific time, hours. Your suggestion of the determinatims of CSF acetylcloline and chinesterase is a good one, but this may be the most difficult part of the study to acoanplish. probably aways-1y,» mm: ~1sz _ , ‘ V W ’2"?! 9 -.- times» Few: was: NWT): 2n �-2- Dr. Abram ~ January 9, 1967 _ At our last meetiru you suggested that you would like to collect the literature relevant to this problem. The citations which I have listed at the end of my. few reports are those that appeared to me to be most relevant. Surely, by checking these one can obtain the citations to many other articles which, perhaps should be in your library. If you wish, I would suggest thata the next opportunity for you to be inNew York that you visit with me and we can go over my collection making such notes as may be necessary to provide you with the basis for a literature review. I have not carried out a systematic survey of ECI‘ literature since 1959 and perhaps an alternate solution would be to check through the major indices for literature and ask for the articles which may have appeared in journals not ordinarily available in the major I am delighted that this study program. Good we New York libraries. will have an opportunity to undertake luck in your present programs. Sincerely yours , Pink, M.D“v’ Professor of Psychiatry Max ME‘:kp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-2-077 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/f96e4506c9897f23ed755b89cbca059d.pdf 9f019b1462976812ab60e5b3b71e781f PDF Text Text February 21, 1967 Dr. Richard Abrams 10“ Childress Sheppard AFB, Texas 76311 Dear Dr. Abram: abstract should interest you. I have not article, but think that it is important that The enclosed yet seen the you do so. Sincerely yours , Fink, M.D. Professor of Psychiatry Max Mfzkp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-3-146 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/3d8ec5f3f872e10b43d59eafbf9f6e9c.pdf 4513b77a615775e1d571ad26222182ee PDF Text Text February 9, 1967 Dr. Richard Abrams 10% Childress Sheppard AFB, Texas 76311 Dear Dr. Abrams: I have read your letter and your report with interest. I found the review of focal seizures quite good and you confirm the need for a definitive EEG, behavioral and study. The my data demonstrates clinical equivalents for unilateral and bilateral BUT, the more important a definitive study becomes not only for the practical aspects but the theoretical as well. For this reason, I regret very much that the EEG material was not collected. However, you indicate that you may be able to collect EEG records in the remaining subjects. If this is so, for comparability it would be very helpful to have records collected 2M to 30 hours after a seizure so that comparisons can be made with my earlier studies. more the In reading the paper, which appears to be mislabeled, I am impressed with the equivalents of the mennry tasks. However, why were the clinical results not included? Surely, since these patients were receiving treatment the records must show whether symptom relief occurred, or whether there were changes in global aspects of behavior, or whether there were some other secondary effects, Perhaps you wish to wait until you have completed the additional thirty subjects. But if you believe that this data is sufficient for the menory results, it should be as sufficient for the behavioral data. Incidentally, I think the title should more properly be related to the detailed analysis of memory changes than as a general statement of the daily administration of unilateral BCI‘. In your letter you indicate hat you have collected the data at each five treatment intervals. It would be helpful to exandne these as carefully as the results after memory twenty treatxents because give an idea as to whether it will two differ. the rate of change between the groups may ' �-2- Dr. Abrams he February 9, 1967 Your question regarding Dr. Abood is either interested or has the is good, but I doubt that facilities to undertake these clinical and our experimental However, cnoe the aspectsaredefinedIoancallsaneofthepeopleinNewYorklﬂce deteminations. Dr. Abood. literature review sounds good and I will make available to New York. As to the statistician who my files can perform the tests you require, if you will lay out the numbers on sheets identifying the variables, I can try to get the work The done in when you come New York. I have recently re-read the BOP studies of Dr. Paul Blachly of the University of Oregon. He describes the administration of multiple treatment in one day with EEG control and argues that with proper ventilation the memory changes are minimal and the clinical improvement enhanced. He has a single report which appears in Compaehmiue PAchy, Volume 7, g: 100-107, April, 1966. As part of your reading I suggest you become acquainted with this article. He too has theoretical suggestions which warrant testing. Keep up the good work. Sincerely yours , Fink, M.D. Professor of Psychiatry Max Mszp , � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-3-170 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/5eff8389eaca7578af7ec888ab18b3b0.pdf bbf7339ffa86b6b38b588bc64b344595 PDF Text Text April 3, 1957 Dr. Richard Abrams 101+ Childress Shepherd AFB, Texas Dear Dr. Abrams: Enclosed are the you requested. original data and the calwlations which The technique applied has beenthe Mann—Whitney U Test, which is a mn~parametric test of significance in two groups. The test is designed for such small populations as you present. The test was applied for the differences between the unilateral and bilateral populations before and after treatment and for the differences resulting from treatmnt. The same was done for the Beckomberga Rating Scale. There are no differences in the two populations before treatment, after treatment, or in the differences resulting from treatment. But if one looks at the differences induced by each treatment, there is significant effect for the change in the Hamilton Depression Score with unilateral. ‘ECT and with bilateral BCT, indicating that in your population the changes induced by treatment were (as expected) I am significant. visiting Dr. Blachly on April 10 and will obtain a first-hand impression of Tie methods and problems. This should be useful when we begin our program I will be at the APA meetings in Detroit and if you are planning to come, we should arrange to get together. I will be staying at the Hotel Pontchartrain. ‘ Sincerely yours , Fink, M.D. Professor of Psychiatry Max MP:kp � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-4-221 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/981625881b6c65eb4a11879091c881ee.pdf 42bba3bdd1b1f0d9ec37575289be3539 PDF Text Text May 15 , 1967 Dr. Richard Abrams 10a Childmss Shepherd APB. Texas DearDr. Abrams: sorry for the delay in answering your letter of but preparations for the APA occupied most of my April time. I have read your paper with interest and have taken the liberty of marking it with the questions that occurred to me as I read the text. I think it is sufficiently clear, however, it should be submitted for publication. I am 1'4, You are correct that the changes induced in unilateral and bilateral ECI‘ were significant in their changes in the Hamilton Rating Scale. The data for the Bedmberga Scale were too scant to be useful. I have had the opportunity to visit Dr. Blachly and that his technique , which pennits three to six treatto be given in one morning, is probably a useful method to be tried. He suggests that the differences between his observations and those of others is related to the degree of oxygenation. IhavealreadyspokentoDr. Kalinowskyand perhaps we will be able to mdertake such a study, following his line of investigation, if we can obtain the services of found ments an experienced anesthetist. Such ‘ a study is of special interest may since the its-patient services are undertaking a special study of the rapid treatment of all admissions to the service. They are particularly interested in any device that may shorten the treatment period and such a mthod as fits well Dr. Blachly suggests It would be quite helpful earlypartofJuly, as can plan the study more My with our present needs. if you could Ithirﬂchillbe definitively. visit during the inNewYorkmdm best regards. Sincerely yours , ., 3.. WIT/;: Fink, M.D. Professor of Psychiatry his-.111W‘Wl Max .7- r, p" W;—.qu..\h rw‘rW-Wn MF:)q> � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-021-5-280 Date A point or period of time associated with an event in the lifecycle of the resource 1967 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/82982e7cc22c9a4c028f9c7a02ff4521.pdf a0e9d71fb471b610d66f6b512686d59b PDF Text Text February 19, 1971 Dr. Richard Abrams York Medical College York, New York New New Dear Dick, seminars in Psychiatry, a new quarterly publication edited by Milton Greenblatt and Ernest Hertmann, has suggested that the first issue of 1972 (February) be devoted to Recent Progress in Convulsive Therapy. I an pleasedyyou have accepted the invitation to contribute the report on "Clinical Results: ECT". The notes in the outline are suggestions, and you are free to expand on the topic as you wish. is usually typescript pages. The volume 200~300 120«160 typeset pages, equivalent to Your report should range from 25 to 30 double spaced pages (including To meet the publishers by the and of June? citations). deadline, can ' you make a draft available It is a policy of the Seminars to re~issue reports of general interest in hard cover. If we are successful (and I anticipate the volume to have widespread interest), the volume should then be cited both as a periodical and as a book, assuring a wide distribution. I hope you can join us. Sincerely yours, Fink, M.D. Professor of Psychiatry Max MF:kt . Mvw 5)."— � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-2-108 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/8c6782262c7195bd60b46ecd423aebf7.pdf 06dab7701229c24eef9b3118a20afeae PDF Text Text ,.w__~,_——m___—mw.____ Wmmm—W w-wmmmmmm r-vrrrw November 8, l97l TO: Richard Abrams, Rhea Dornbush Jan Volevke The various reporfs for +he ECT issue of lhe Seminars in Paychiatry are in The hands of the publisher, and we should receive galleys wlfhin 6 weeks. The issue is due to appear in February. publisher has indicafed Thai he will give each of you a subscriplion, in grafifude for your cooperafion. The enclosing a copy of The idenfificaflon sheaf, as submifled. if incorrecf, please advise. l am l van? #0 express my personal thanks for your splendid I know the? l would nof have undertaken and enfhusiasm. cooperation I no? had This efforl, if fell lhaf you would do as well as you did. i The confribufion to ECT undersfandlng fhaf make hope fhe issue does is so sorely needed. My Thanks. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-8-514 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/2eab39ce85312a1a0224f300c7e04402.pdf 79c3e6f2420dd087ea0314156b8ac22e PDF Text Text 73828-628 April 19. 1973 Mr. & Mr:. Henry retool, 7 What 8lst Stroot, New York City, E.Y. Dear Hurt: and Hoary, An I thumbod through my’nail the other day, 1nd sonnnod o host of Journals and Junk. I saw the uncle-ed covor, and without looking at tho credits immodlotcly I it do not was can of your friends;, knew think the roproduotlon does his work Justice. but I must admit that this kind of op—ort in interesting. Perhaps «won more so is the fact that I can recollect of no other modern pointing reproduced on the cover of thin Journal for usny. many months. They usually use a olaasiaol. representational type art. of Martha must have told you that vo are Joining you in Iuyporting a second house. w» have found a cottage overlooking the voter in strong’s Nook (Betauket). is tvolvo minutes from.my office at the Univorolty. A: MLrthu says, it in possible to stood in the middle of the living room with a dust cloth, turn 360°. ond have completed the cleaning. Th1: I trust the family are wall. my boat regards. Sincerely youro. Mn: Fink. M.D. Professor of Psychiatry MP/id Eno. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-027-1-084 Date A point or period of time associated with an event in the lifecycle of the resource 1973 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ce4e9f016aaa851cad5a69323cd997e7.pdf 2f4dc1322c679734db5e1fcefad71605 PDF Text Text 7383-627 Amril 19th, 1973 Dr. Jchn R. ﬂushes, Canaultina Editor, EEG aWTn-K‘Wﬂw>' qurnnl, Book Ravicva, Northwestern university, 303 3. Chicago Ava., Chictgo, Illinois 63611. 4_.‘rl'vl~'l A; w. . ,rv ,r-w v —« v'wp‘I-ﬂlnmsmr =-—u:—.v.v, W 30m. I have received the voluna “International Review of Reurubiology". and look tbrvurd to reviewing 1t fur the EEG Jburnul. I have a tow chore: to do over the noxt few vuckn, but should got to it during late Mhy, and helluva I can must your July daadline. Thai-v.11" thy err-"a v-wo- thank: for thinking of no. my 4‘5' den: best regards, Sincerely yours. woman-UV»: Fink. M.D. Professor of Psychiatry Mb: “/""‘.‘.‘ gnmlr .5 up. warm} A «2— v.:W’u-'>¥"‘:--I..,-r~rr.~ ,m ; "mm-m, v-vrwru lwmmw Mr/id � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-027-1-086 Date A point or period of time associated with an event in the lifecycle of the resource 1973 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/1e0c2aa1507bdbd941bd67a0f6571193.pdf 87f9a95e42405a39fb8b72e8bff39c21 PDF Text Text 7388-6h6 April 27. 1973 Mr. John R. Coxsolino. Harootio Investigator, Suffolk County Health Dept., Eonpitol Affairs Division, Route #113, Rivorloizh Avo., Bimb.“ , Ho 1 a Door Kr. Coozolino, I rogrot that I nova had to cull you. The enclosed letter from tho BHDD invottigntor indicates that BHDD is unwilling to provide the necessary registration until the State rogiutrotion hos been completed. Thank you for your cooperation. anooroly yours, Pink, M.D. Professor of Payohiztry Mu: Mir/1.1 Eno. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-027-2-156 Date A point or period of time associated with an event in the lifecycle of the resource 1973 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/71db784ff64396a242544fe0745c5b85.pdf ffe8c855fce752d246fbe251c7b2e5f4 PDF Text Text _ ..wr.wm'—__,ww .. w. ”- \,w.,-.u—.M.r—. “mm—mam. w.,...,..,_..w, November 18, 1985 Richard Abrams, M.D. Department of Psychiatry Chicago Medical School 3333 Green Bay Road North Chicago, IL 60064 Dear Dick, have received the enclosed invitation, at the suggestion of Arnold Friedhoff. Before proceeding with the intent of cooperating, I need your advice as to how such a presentation would impinge on our present agreement. It is my impression that it is not a conflict. I My best regards. Sincerely yours, Max Fink, M.D. Professor of Psychiatry . � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abrams, Richard Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-030-6-145 Date A point or period of time associated with an event in the lifecycle of the resource 1984 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/56425d8f1dab2e33d0d18ad7d04041ef.pdf eb0688e9e518e435dd2ebf52fb7f0f89 PDF Text Text November 28, 1989 Prof. Oded Abramsky Chief Scientist Israel Ministry of Health Jerusalem Dear Prof. Abramsky, I write this letter to encourage the application of Dr. Seth Kindler for support as a research scientist at Ezrath Nashim and the Hebrew University. I have known Dr. Kindler through his publications and his presentations at international psychiatric meetings. I have known his mentor, Prof. Lerer for more than a decade, and have been an enthusiastic supporter of their important research in electroconvulsive therapy and the receptor mechanisms in depression. Despite his youth, Dr. Kindler has an impressive record. He graduated the Hebrew Medical School in 1982, and in seven years, completed his formal psychiatric training, published important research findings, and developed laboratory and clinical skills. He seeks to combine these in studies of the neuroendocrine aspects of depressive disorders. I am particularly impressed with the importance of these studies for our understanding of the mechanism of action of ECT, a most useful treatment. Prof. Lerer has already contributed much to this knowledge. In 1980, Prof. Ottosson of Goteborg and I proposed a neuroendocrine theory of the mode of action of ECT. Much work has been done in the United States, Greece, the UK, and Israel on this theory. It remains Viable and I believe that Dr. Kindler’s research into serotonergic mechanisms is important in our progress. Few laboratories in the world are as well equipped and as interested in research in the affective disorders as those at Ezrath Nashim which I visited a few years ago. Under the leadership first of Prof. Belmaker and now Prof. Lerer, the studies have made important contributions to our knowledge. Any encouragement that can be given Prof. Lerer, as in the support of Dr. Kindler, should pay handsome dividends in research and in the position of Israeli research in world psychiatry. I congratulate the Ministry of Health on having such a promising opportunity to support important research. Sincerely yours, Max Fink, MD. Professor of Psychiatry Editor, CONVULSIVE THERAPY � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abramsky, Oded Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-031-7-165 Date A point or period of time associated with an event in the lifecycle of the resource 1989 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/46c44252aa0071cb20bc1283a4f040e3.pdf ab4bba3f7a4b2dc440f1902e2d93c82a PDF Text Text January 25, l97l Dr. Wllllam Abruzzl, M.D. Sfudenf Personnel Dlvlslon Sfudenf Healfh Cenfer Stale Unlverslly College New Palfz, New York l256| Dear Dr. Abruzzl: As you know, There Is no sallsfacfory +herapy of oplafe dependence, and prevenflon and educaflon remaln lhe prlnclpal roufes lo success. Methadone subsflfuflon ls useful and legal, provldlng a pollllcally saflsfacfory solullon. In +he research Iaboraforles, a process of decondlflonlng wlfh +he ald of narcoflc anfagonlsfs, as naloxone and cyclazoclne, ls under sfudy, buf The procedures are no? yef avallable for general cllnlcal frlal. I suggesf you wrlfe Dr. Dole af Rockefeller has complefed a responsible revlew and recommends Unlverslfy. In repealed doses (every 4 hours); and naloxoee (IV, nalorphlne I when If becomes avallable (Naloxone, Endo Labs, mg/4 hours) Garden L.I., N.Y.). For heroln He 0.0., ley, If you are pIannlng Io vlslf fhe clfy, you may wlsh To vlsl+ our unIf and speak To my assoclales who are +rea+lng our narcollc addlcfs In a varlefy of ways. Slncerely yours, Max FInk, M.D. Professor of Psychlafry MF:k+ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abruzzi, William Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-1-033 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/a1f8bb764547d7a059e3223ec792038c.pdf ec48fa13c5d93492e21d810d1938d54b PDF Text Text ., -1 r7'zVI'.'Vrr"‘-VmVm'r'r’wvvrwwwlwunv‘ -. December 6, 1977 wv-vvm ’—.-V<7nr'm 1: r .., mum. w runway. "Wllrwu-V‘H. ..‘,.. ray :1 1-». V Wm. Abruzzi, M.D. Fox Farm, Loon Lake Road Malone, New York Dear Dr. Abruzzi, c.v. exemplifies a rich experience. As to your questions, is difficult to know how to answer the first. For decades, various it authors have suggested that cannabis is associated with psychosis. Two theories have been stated—- that cannabis is a psychotogen, and that it Your '1iberates' psychotic tendencies that already exist. The issue is not whether cannabis is a psychotogen, for that issue is spurious. Since there is good evidence that cannabis inhalation alters brain function, it is clear that with such alteration there must be changes in behavior and there is no reason why such changes could not be manifest as psychotic symptoms. After all, the definition of psychosis is in the eye of the beholder, not in the symptoms themselves. , If you have some additional data, then why not follow established custom and present the findings and the controls ? it became clear At the New York Academy of Sciences meeting, under and Costa controlled Rica, the observers in Greece, Jamaica that conditions, could not confirm the development of psychosis in long-term users. But reporteds from India (Chopra) and Egypt (Souief) did say that psychosis was common. There is a need for someone from the U.S., with the same support that the other fOreign studies obtained, to go to India and Egypt and confirm their observations. Perhaps, a mission through your association at studies and would not do another. Good luck in your summary NYU. I you could undertake such have done my bit in such of the recent studies. Sincerely yours, Fink, M.D. Professor of Psychiatry Max � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Abruzzi, William Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-028-6-258 Date A point or period of time associated with an event in the lifecycle of the resource 1977 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/2ce92702c8a1b37fcf3cc62ce845732c.pdf 97ea0be673e80d38f79ed3dd46a8b4b2 PDF Text Text March 2, 1966 Rad-mic Press Inc. 111 Fifth Avenue New York, New York 10003 mum: Tm qmitatiw analysis of changes in 010mm signals mmmmmmtmmmmummoragm applications, 33033 to mater mm. Of tinlavaawcific: inseam of special interest . mach anaempiulommy uffort has into the gone am mixed of evoked potentials and many excellent reports have been written. me electronic: wands of been by a popular mview anly'sis km by two Soviet amim ma distributed in translation by the Duper-tuna": of . may Wm mm mm the of clam-ages in frequmcy. MW aspect ismeaning from mthwia, drugs, sleep, etc. pattern and mum Tim laboratories have Miopad various applicatiom of digitnlmﬂwdsforﬂmpumoms. Warmvammimdmyw qmstn for our program and have men aged to swim this infomtim in a mammal mm]... We believe that “chum is modforsmhamrmiaalcbcmnttobemadammmmlly available and are sending it to you for yaw midwation for publicatim. If this interests you, we would be pleased to diam mlifimtiom and mdiﬁaatiom that may be meeasary to provide a man: m wally applicabla Want. you for your miﬂemtim. ‘ Sixmly yours , Hm: Fink, 3.0. Professor of mm � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Academic Press Inc. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-020-3-152 Date A point or period of time associated with an event in the lifecycle of the resource 1966 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/8bd8cf3bcff48adafa4b1cece02a5b8d.pdf 243ab3a6c4385e36ce9db3f3d31442f8 PDF Text Text w- ‘ --:--—m~ July 20, 1965 0mm]. Mounting Office ; Retinal Imtitute of Mental Health muted States Public Health Service Bethesda, Marylmd - 2001i; Gentlmn: RE: m MGR-01 ﬂ-l 8388—01 an herewith returning Treasury C136: No. 77,828,213“, dated July 1“, 1985 made out to the Paymmtrlc Research tandem, in the mum: of $12,000. This cheek represents He amhadvmminﬂuebovemmt, mmqmstedmﬂarmm, 1965. when this was not received by June 22, we Human requested payment of $26,166 for the coupletim of both grunt m—aaaa MGR. paid. mt maloaeddndtmpnmtamowrpaynmxtmdishmby mtunnd for deposit in the and This ($26,166) was U. S. Maury. Sincerely yours, Mex Pink, Mauve 14.1). Director The � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Accounting Office Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-5-426 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b1096f8420c4fd2013936d41eb461015.pdf b1fa2191ed8fc222247a997bf9ce0a8a PDF Text Text r... erw wwwn. _ M, July ’23, 1965 Centre; Accomting Office Retinal Institute of rental Health United States Public: Health Service Bethesda. Maryland 2001‘! I . RE: Gmtlemzme Psydxietric Ree-arch Femdmim of kiwi-8338431 ’ Kim M mkteddlﬁuexpmimmmietmininggrmtmim terminatedJm 30, 196“. This meme ferﬁnsmof 832,000.00 for and $8u0.00 nests treinim stipends at 29. direct cementum were Wed The sunrise; for irdirect $31,999. 92 for pretender“). seamen for indirect costs and an item of $993.29, (WI) forﬁnﬂueerecipiente. Imefweetmthmmnmm mien represents payments for social «entity benefits appointedeulyl,wewexemquimdmpey0ASI md again in 1965. 111195“ Immitimetthietimteimuireifmypmdtm Muwmfmimmbemimdform 'emndumehmmympnmmmpmtewhidx m bedckeeping enqumditm cm 111-8338 wmld he imimifiemt, He amid be for yew mietmoe. Sincerely yam, Hex Pint, PM). Emcetiw Director on: ’ We Dr. Vm mum � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Accounting Office Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-019-5-445 Date A point or period of time associated with an event in the lifecycle of the resource 1965 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/736ee055bbee495b1d8b8f3e54851480.pdf f454c4b911a7bd1aac8b456cf57e44f7 PDF Text Text July 1, 196‘ , Laonard 3. Annex. Ph.D., M.D. Madlcal Bepartaau: Sande: Phaxuacautlcala Haaovat. ﬂaw Jaraay Baa: Dr. Achor: On behalf of tha Psychiatric Raaaarch Foundation, I «lab to :aka thla oppottunity to thank you and Sande: Fharuacautlcala to: your favorable canaldaratlan of out :aquaat for grant-1n-ald for our tasaarch and training proazaha. The funds will ba uaad in tho acudy prograna of EEG and human payehapharuacology, unda: tha dlraetlon of Dr. Turan 1:11 and myself. rha aupply of L89 recanely requested atrivad aafaly. thanks again for you: kind canaldaratlon. Many Slncoraly youra. Max Fink. H.D. Exacuclvu Director MP/jh ﬁne. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Achor, Leonard B. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-5-492 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/ce83d3966738b502ad162e4b0abdbc67.pdf 213cd99d5897d18505f267c2d45561c4 PDF Text Text July 23, 19M. . Leonard B. Aehot. Ph. 9.. M.D. Medical Depsrtneet Sande: Phszaseeetlcels Hanover, New Jerney Deer Dr. Asher: During the pest week. we hsve ctystelleed our research pregrem in.the enelysls of the EEG end behevlorel changes with thiorlde~ sine and chlerdlsespoxlde. When I celled Dr. Renae, he was kind enough to send as samples of Kelleril (100 mg.) and corresponding p18“b°l e These have been compared with the capsule: sent to us by Hoffman- Lsknths, end theysere indistinguishable. In ressseeslng our protocol, we hsve concluded the: a greater degree of flexibility weuld be tntrbdueed into the progrsm 1f the chlorideelne capsules were nude in 50 as. strength. Can this be secoupllehed? If so, we estimate that for the full study we will need 16,000 espsules of 50 as. strength, In eddltiau, we will need a total at 16,000 cepsulss at placebe, end would request Sande: Phsrns~_ deutlcsls to supply us with belt thst amount. Would you consider, therefore, this letter as e reqnsst fer supplies of thiarldezlns, 50 n3. espsules. 1n the smount quoted shove, and placebo? We will need these supplies over s full year. and 1f the full accent is not svellebls 1n the immediate futute, we would like to reeeive s supply_eu££1¢1ent to begin the study within the next few weeks. Then! yen for your cooperation. Sincerely yours, Mu Fink. ,Dlrector Ms De HF/jb ‘P.3. The espsulse of placebo were lebeled ﬁwOGISS, and the capsules 0! Hillsril.ss H-00267 (100 mu. thlorideziue hydrochloride). ‘ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Achor, Leonard B. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-5-545 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/e0591b78b11160f3657efb9a297da426.pdf 78d8f8c196e3561773b4e7fb06782998 PDF Text Text iarch 29, 1989 John M. Ackerman, M.D. 2417 Castillo Street Santa Barbara, California 93105 .v— - " i am acquainted with publications describing electro—acupuncture ECT (EACT) by Dr. Xue and his coworkers in Beijing, and another by Drs. He and Zhuosan (in a separate report from Xian). Both reports appeared in CONVULSIVE THERAPY in 1985. They suggested an equivalence in efficacy between EACT and conventional ECT but greater safety for EACT. in the absence of a random -._w;,.v~——..—.—-— W. V, ., < ”w...”— —w-mw—r—--- -. "nu-v!" Dear Dr. Ackerman, ' assignnient study with independent assessments of outcome and cognition, we remain in the dark as to the importance of these reports. ‘ The second report, "An investigation of Transient Absence of Brain Wave During Convulsion of EACT and ECT" seems to be an abstract. The citation is not given. From the abstract, it is not clear when in the course of the seizure, the TAB W occurred. In 1966, Blachly and Gowing described the end-point of EEGmonitored seizures as 'precise' or 'imprecise‘. Recent studies of the end point find that more than 2/3 of seizures end in a period of iso-electric activity, a flat EEG which may be what is described by Dr. Xue as TABW. The period of isoelectric activity in ECT varies but may be prolonged for more than a few minutes in unusual cases. Usually the duration is under 30 seconds. We are now investigating whether a precise end-point is a favorable prognostic sign (and am imprecise endpoint, an unfavorable one). If i am considering the same phenomenon (TABW = isoelectric activity), then Dr. Xue's observation that 4.1% of cases with EACT had TABW while 31.496 of ECT cases had TABW, would suggest that ECT was the more favorable (effective) treatment. But such speculation needs to be examined with Dr. Xue or another practitioner of EACT. At one time, Dr. Xue correSponded with me and I invited him to visit Stony Brook where l was prepared to let him demonstrate his technique in our unit. He was unable to accept, so i do not have any direct experience with EACT. ww. 'Wumv ‘vw'qm'wwwimmm A ”m— Like other modifications of ECT, the burden of proof of claims of efficacy or safety lies with the protagonist. I do not know how many Cases would be required to define a difference between EACT and ECT, or if there is a difference. i suppose one could estimate the number of cases needed after observing EACT practice in a few model cases. in assessing differences between unilateral and bilateral electrode placements, for example, it required a few hundred cases to demonstrate a difference. �Dr. John Ackerman EACT vs ECT - Page 2 If Dr. Johnson is enthusiastic to try EACT, an open clinical trial in characteristic depressed (and delusional) cases would be of some interest. If he could verify the claims that seizures were induced with remarkably low currents; that needle electrodes were safe and effective; and that the number of treatments needed were either equal or fewer than ECT, it might justify others trying EACT. During Dr. Xue's visit, did he demonstrate EACT? if yes, I would be pleased to talk to an American observer who may have participated in such a demonstration. ' " Thank you for bringing Dr. Xue's arguments to my attention. if there is more that needs discussion, you can call me most mornings at my office (5164M 2929). Sincerely yours, Max Fink, MAD. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Ackerman, John M. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-031-6-148 Date A point or period of time associated with an event in the lifecycle of the resource 1988 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/afc7018cf8906a140d1660c4fe4f19f0.pdf 11df0ad7e126ea056f19f37658592cef PDF Text Text November 1n, 1979 Sigurd Aokermen, M.D. Montefiore Hospital Bronx, New York 10MB? Dear Sig, Enclosed are the two reprints concerning our studies of lactate in anxiety. The letter was a way to indicate that we-had replicated the findings of Pitts and McClure. We did not go further as the proposals, sent to NIMH, were not accepted. (Since then, the reviewers have undertaken very similar studies.) sample. The EEG report summarizes our few records in the . I hope these are of interest. discussing your work. My It was a pleasure regards. Sincerely yours, "ﬁfe-w Fink, M.D. Professor of Psychiatry Mex first � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Ackerman, Sigurd Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-029-8-285 Date A point or period of time associated with an event in the lifecycle of the resource 1979 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/e04d76f81eaa35366b648badcb67dfbd.pdf 9627849223def2a2ed630f481b1029b3 PDF Text Text -WV .{1 ,_ -v ....,...A.,,‘, Mardh 22, 1971 Acts Psych. Scandinavica Munksgaard Frags Boulevard 47 2300 Copenhagen 3. , Denmark Gentlemen: We like to purchase copies of: Supplement 213, by Laurell on Flurothyl Supplement 215, by D'Elia on Unilateral would Are these available, and at what cost? Thank you. Sincerely yours, Fink, M.D. Executive Director Max MF:kt ECT. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Acta Psychiatrica Scandinavica Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-3-197 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/58c99adfbf159473ded28b1fe080d4f9.pdf 888988d6120c41d5c955a5ee1f3e79d5 PDF Text Text T “WVNW wmw.mwy“m “m v- v—v- March 22, 1971 Acta Paych. Scandinavica Hunkagaard Praga Boulavard 47 2300 Copanhaaau 8., Denmark Gantleman: Wa would lika to purchase copiea of: Supplamant 213, by Laurell an Flurothyl Supplamant 215. by D'Elia on Unilateral ECT. Ara thaaa availabla, and at what coat? Thank you. Sincerely youra, Pink, M.D. Executive Director Max MF:kt � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Acta Psychiatrica Scandinavica Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-3-201 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/78db499f4231183ae614d0164395494f.pdf f9a9837eed64df6c87578af2dc677cc5 PDF Text Text March 5, 1971 Miss Carolyn Adams c/o 782 Hemlock Rd. Union, New Jersey 07083 Dear Miss Adams: the central effects of substances clinical practice of neurology (neuropsychiatry). we are investigating we are not in the While of abuse, letter is detailed about your search for help, but fails to mention, help for what. Perhaps you should see your family physician or a member of the staff at either the New Jersey School of Medicine in Newark (try Dr. Louria) or at Rutgers Medical School, and allow them to recommend the consultants you may require. Your If you wish to detail the history of the symptoms that trouble you, I will ask one oﬁ our research staff to review the material and perhaps we may make a more specific recommendation. Sincerely yours, Fink, M.D. Professor of Psychiatry Max MF:kt � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Adams, Carolyn Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-3-238 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/b6b7873b4c4f9b8873b5859080aa19d8.pdf 1d822164eafe85eeb2d792761ccc1e3f PDF Text Text ._... w~wmvnnv “Hr-1""- WWW— 1 March 5, 1971 Miss Carolyn Adams c/o 782 Hemlock Rd. Union, New Jersey 07083 Dear Miss Adams: investigating the central effects of substances are not in the clinical practice of neurology (neuropsychiatry). Your letter is detailed about your search for help, but fails to mention, help for what. Perhaps you should see your family physician or a member of the staff at either the New Jersey School of Medicine in Newark (try Dr. Louria) or at Rutgers Medical School, and allow them to recommend the consultants you may require. While we are of abuse, If you, I perhaps we you wish to will ask one we may make detail the history of the symptoms that trouble oi our research staff to review the material and a more specific recommendation. Sincerely yours, Fink, 24.1). Professor of Psychiatry Max MF:kt � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Adams, Carolyn Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-025-3-246 Date A point or period of time associated with an event in the lifecycle of the resource 1971 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/1bcd0f3c59e852a66567805599c3d0f6.pdf 88b6e15c5269b19b074664fadda3c3cb PDF Text Text "wwvn‘ .uwun-grp". June 2, 1970 Dr. Henry Adams university of Georgia Athens, Georgia Dear D . Adams, my associates and I have read your recent report, ”Electroconvulsive Shock, Brain Acetyloholinesteraee Activity and Memory" with considerable interest. we would like to become acquainted with any subaequent studies from your laboratory. are aware, Ulett and his co-workers were unable to even with higher dosages of'atropine (oft Johnoon et al., Arch gen Psychiat., 2:324—336, 1960). In reviewing their experiences, and our own with various anticholinergic drugs, we became concerned that studies (particularly in man) that dependeddbn the anticholinergic effects in the central nervous system were often unsuccessful because the peripheral effects of'atropine exceed the central effects, especially at low dosages. While the same is less true for scopolamine, this compound also has extensive peripheral effects. we tested a variety of active anticholinergic drugs and reported that benactyzine, Ditran and diethazine seemed to elicit a higher degree of central activity in proportion to their peripheral effects.(cj2 EEG clin. As you replicate their findings, Neurophysiol. , 12.- 359—369, 1960) . time ago, I reviewed the available data on central and anticholinergic cholinergic activity and the convulsive therapy and am I taking the liberty of’enclosing a reprint that may process, Some be of interest. Again, our congratulations on a nice piece cf’work. Sincerely yours, m Fink, M. D. Professor of’Psychiatry mf/ � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Adams, Henry Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-6-305 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/a7c2396a70602e219a71a9924a1cbbec.pdf 41a23429d75aa4ed21ee63360a45d886 PDF Text Text ,7, W. w ~ v.7 pr...- ——m - an ) v n.“ ~v..~w~-w.ﬂu are—v. .... ., ..:..v.. .. I .7 ,_ e , .. M. .77. September 15, 1977 John B. Adams, H.D. College of Medicine University of Florida Gainesville, Florida Re: Ali Kestiner, M.D. Dear Dr. Adams, It is a pleasure to write the following regarding my association with Dr. Ali Keskiner. I first met him when he came to Missouri and joined the staff of the Missouri Institute of Psychiatry, about 1963, at a time when I was Director of the Institute. He accepted a position of clinical responsibility in managing one of the Institute's 25 bed units, and undertook clinical research in that population. In the course of became interested in the aftercare of psychiatric patients and he became the principal investigator in a long-term community treatment project. At the time I left the Institute, in 1966, he was a leader of a clinical team and a responsible researcher. I thought highly of his work, and invited him to come with me to New York. his work, he His principal studies were in the clinical effects of new in treating the mentally ill. At the time, our interest was in the application of fluphenazine enanthste, and it was Dr. Keskiner's contribution to demonstrate the efficacy of this compound for the maintenance of the long term mentally ill in the community. He showed the contribution that the drug could make when combined with social casework and adequate aftercare management. His work was honored by compounds a number of awards. effectively pleasant, all my association, I fcund him friendly, and firm. He broad His knowledge is clinical responsible. relaxed, relates well to staff and patients and his unit was often used as a demonstration unit for visiting dignitaries. In his research protocols, he was innovative and particularly sensitive to the personal needs of the patients. He is a sensitive clinician and a well ‘brgenised teacher. On a number of occasions he lectured to the residents and his lectures In and were well received. faculty, I and am pleased to believe he recommend him for an appointment do a commendable job. will to the teahhing Sincerely yours, . Max Fink, M.D. Professor of Psychiatry � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Adams, John E. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-028-6-280 Date A point or period of time associated with an event in the lifecycle of the resource 1977 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/6d27bc5f1b5639a8b7c4b2a9ff0a3872.pdf bd9f234be4c7e59b21d378ee4184c543 PDF Text Text rAngust 21, 1964 Paul L. Adams, M.D. Assistant Protector of Psychiatry Road. Child Psychiatry Division Department of Psychiatry College of Modicino Univcrsity of Florida Gaincsvillo. Florida Dear Dr. Adams: Dr. Habib Nathan has applied for a position in the clinical roaocrch programs at this reaccrch and training center, and has suggested that we may write to you for a recommendation. at this institute are devoted to clinical psy~ chiatric research, primarily of a nouropharmacologicai and nourophysiological variety. The grogrsms are designed also The programs as tho basis for tho training of residents in psychiatry. would be grateful for any information you can give as regarding tho ability of Dr. Nathan to participate in clinical psychiatric research programs; his parsonality as related to his patients and codworkcrs; and his facility with the English language. we Thank you very much for your cooperation. Sincerely yours. Fiﬁk. m Director mljb M. D. � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Adams, Paul L. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-018-5-585 Date A point or period of time associated with an event in the lifecycle of the resource 1964 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence http://exhibits.library.stonybrook.edu/mfp/files/original/56d026c9235f0342d432d53ca4e8840d.pdf 6bed9e674bdf0dc603b79a75da157c93 PDF Text Text .... v vw "nav'uwl: m'JKIL-‘r -:"'n;'!.‘—K\ urn-n u n. v-ww:""~ "'0’..’ll"~ ~r-wrmn~m hwy-‘4 w. at; Wu.- ..~...-- ._. . v m .7 ,. r, v,‘,-.— _.. “re—v7“ “'Kif’ . Kan—".7 '11 .w. , , wVlrr‘ \m- w... Vg....N: , . . M 2 -.~ September 30, 1970 Addiction Research Foundation 344 Bloor Street West Toronto 4, Canada ,..._., . .Jymwuwu. Wham. rm ﬁn- Gentlemen: I have received "An Interim Guide to the Cannabis (Marihuana) Literature” by Oriana Josseau Kalant and I have read it with great interest. I wish to commend the author for a clear and unbiased review of a difficult subject. For those articles which I already knew, I found the technical statements clear and usefhl. Many thanks for sending me a cepy. Sincerely yours, WT: Fink, M.D. Professor of Psychiatry Max Mszt � Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence Text A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text. Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Correspondence to: Addiction Research Foundation Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-05-00-024-8-389 Date A point or period of time associated with an event in the lifecycle of the resource 1970 Creator An entity primarily responsible for making the resource <a title="Fink, Max, 1923-" href="http://id.loc.gov/authorities/names/n79039548" target="_blank">Fink, Max, 1923-</a> Subject The topic of the resource Correspondence -- Correspondence Relation A related resource The Max Fink Collection Description An account of the resource Rights Information about rights held in and over the resource <a title="IN COPYRIGHT - EDUCATIONAL USE PERMITTED" href="http://rightsstatements.org/vocab/InC-EDU/1.0/" target="_blank">IN COPYRIGHT - EDUCATIONAL USE PERMITTED</a> Source A related resource from which the described resource is derived Special Collections and University Archives, University Libraries. Stony Brook University Libraries (State University of New York). Language A language of the resource en-US Format The file format, physical medium, or dimensions of the resource application/pdf Publisher An entity responsible for making the resource available Contributor An entity responsible for making contributions to the resource Correspondence