http://exhibits.library.stonybrook.edu/mfp/files/original/73f23282cc67af28739fea856ee770e8.pdf e300a093a9da17b1283d89c0561639fc PDF Text Text Reprinted from ”Electroencephalography and Clinical NeurOphysiology Iournal" Vol. 10, No. 1, February 1958. LATERAL GAZE NYSTAGMUS AS AN INDEX OF THE SEDATION THRESHOLD 1 MAx FINK, M.D. With the technical assistance of HANNAH MOSQUERA Department 0] Experimental Psychiatry, Hillside Hospital, Glen Oaks, N.Y. (Received for publication: October 17, 1957) On reading the report of Thorpe and Barker (1957) in the recent issue of the Archives, we were moved to assess our own experiences with the sedation threshold, and to report a clinical guide to the “inflection point” that we have found useful. Following the initial description of the technique by Shagass (1954), we modified our tests which included the administration of the amobarbital test for brain dysfunction (Weinstein et al. 1953) to obtain a measurement of the sedation threshold as well. Our technique was identical to that of Shagass, with the addition of the measurement of nystagmus on lateral gaze which the latter test required. The change in beta amplitude in the EEG was measured visually in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to identify the onset of slurred speech with consistency. Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction of sleep. As we were also obtaining a record of the induction of nystagmus on lateral gaze, we became aware that this index was reliably agreed upon by the two observers, and a correlation with the sedation threshold was sought. We, therefore, omitted the instructions regarding counting and substituted the following instructions. Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged tion period. The administration of barbiturates con— tinued until nystagmus was observed, and then an additional 2 cc. were given. RESULTS To date, we have 91 measurements. The following table notes the difference between the number of milli- grams of amobarbital per kilogram body weight for the EEG measure (the sedation threshold) and for the onset of nystagmus. Differences greater than one unit did not occur in this series. The two measurements are seen to be reliably related by a unit of 0.5 or less in more than 90 per cent of the observations. M TABLE I Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg. amobarbital/kg. body weight) No. Tests (91) 1 47 12 +0.5 +1.0 27 4 Test-Retest Reliability: During these studies we have also had the opportunity to repeat the sedation threshold measurement three to five times in the same patient at weekly intervals. These measurements were done in randomly selected patients receiving subconvulsive doses of elec- TABLE II Absolute Range of ST. Values Range 0 0.5 1.0 1.5 2.0 No. Subjects (16) 0 2 6 2 4 fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. Such observation was repeated after each injection of 1 cc. of amobarbital solution, between the 25th and 40th sec. of the injecSupported by the Board of Directors’ Research Fund of the Society of the Hillside Hospital. 1 2 tric current under barbiturate premedication as part of a study of convulsive-subconvulsive electroshock. The behavioral changes in this group were small 14 of the 16 were referred for grand mal electroshock within 4 weeks after the subconvulsive treatment -—— period. The range of sedation threshold measurements under these conditions is noted in table II. [162] �LATERAL GAZE NYSTAGMUS OF THE SEDATION THRESHOLD Being unable to ascribe greater validity to one reading than to any other, we determined the mean sedation threshold for each subject, and the range of variability about the mean. In table III we have listed the subjects in each range of variability about the individual mean value. Thus, the intra-patient inter-test variability for this test in this series is considerable. The test reliability of nystagmus as an index of the electroencephalographic change is well within the retest variability of the test in these subjects. 163 lographique mesuré chez ces malades et dont la validité a été démontrée. Il est recommandé d’utiliser cette méthode en remplacement de celle qui est basée sur l’apparence de troubles dysarthriques. ZUSAMMENFASSUNG Das Auftreten von Nystagmus mit lateralem Blick ist ein klinisches Mass fiir die Sedationsschwelle, welche gut mit dem gemessenen EEG-Index iibereinstimmt und dessen Verlasslichkeit nachgewiesen werden konnte. Gebrauch dieser Methode wird daher TABLE III Range of ST. Values from the Mean Range No. Subjects (16) 0.1—— 0.6—— 0 0.5 1.0 0 6 4 CONCLUSION The appearance of nystagmus on lateral gaze is a clinical guide to the sedation threshold, with a variability from the measured EEG index well within the test-retest reliability of the test itself. It is recommended as a substitute, therefore, for the onset of slurred speech. Further studies of the retest reliability of the sedation threshold are necessary. RESUME L’apparition d’un nystagmus dans le regard latéral est une mesure clinique de la sedation qui montre une bonne correlation avec l’index electroencepha- 1.1— 1.6— 2.0 >2.0 4 1 1 1.5 empfohlen als Ersatz fiir diejenige basiert auf dem Auftreten von verwischter Sprache. REFERENCES The sedation threshold. A method for estimating tension in psychiatric patients. EEG Clin. Neurophysiol, 1954, 6: 221-233. THORPE, J. G. and BARKER, J. C. Objectivity of the sedation threshold. A.M.A. Arch. Neurol. Psychiat, 1957, 78: 194-196. WEINSTEIN, E. A., KAHN, R. L., SUGARMAN, L. and LINN, L. The diagnostic use of amobarbital sodium (“Amytal Sodium”) in brain disease. Amer. J. Psychiat, 1953, 109: 889-895. SHAGASS, C. threshold. sedation the of index M. Lateral as an FINK, nystagmus Reference: gaze physiol, 1958, 10: 162-163. EEG Olin. Neuro- 63:3 �‘ “W 9.13.5? W W ma w Mai mm 0 �mmmmtwmwmmmmmeum MWW,wmnwummmmflm-uwm amummm,mmmauammmmumfimaummv Wtwmfmm. wmvmpumwmmmwmmtz), Wm ”memmwzmmmmumdmmml *mt Warm. {fiwo‘hWtWt 92mm“ wwwmxmmmwmtamm.nw mmumwmetummmummmm fifiwmmm. mmmmwnmmmmmww mmawmmmumm,mmwawmwwm WW: hwqmmefiMgMWWWth mmmmawmeapmmmmm. MW“ aim “Wamflmdmuaf mammmmotdw. uwmduobmmtmmdw fiWmumlmgwmmmtthm numwummmmmmwnWMvmmmm ‘ V “.mm,mimmmmmummmmm MW m 3mm mmmfi mm um um am it mom mummymmummmwmmmawwmnmw mramquWWamrmWWflanummu. Mm MMMmmmmum,ummymm£-nmm.mum mmmmzflmmwwnwamuum we. mmwmmmmatmmmmwxma mummmm,hommzmwmwwmmmm mm. m mumm WWW Mme mm mm m «1’ �mammammmzmmam. mammmflmm. thmmm wwmbmwem(wmmmum)mmrmwt Wmummrmmthnwmmwmh ”W; m Mmummwwfipmf- mmwammtmfiu Wmmwmmumtwmmw mmmm«mhmammmwmwwma mmmmmthmwtmmmmmumuu mm Wu awn w We: m: m WW“ Mum umwamwmmmwmmmmm mm mmmwmmmmmwmmt �«2w «mum 11. W m mm (as) mmmmuwmmwummmmmmow,m humammmuwmmmmwmwwwa wwwmmm. hmmwmmwmmmuum M,WWM$WWW£W wumtmmm ummm. MMW‘Wflanmmwmnm W‘s-mm“ �mwas-mmmummsummmw ummmmwwmmuw. “MW unmm, Wm,mmmwfiww. WW �' 1_ W ' ”W «mummy MW “mm.“ wmmm.muwg mm Wigwam m3. é» 3n & 199:. W”; WW 4: ’ “ ' �W WWW Emmtxy WM? 13' 1957‘ W9; Miter, Section or Awhim Baumlm 5:. , AM. 29th a mu ham, W Wm, DP. Roy W mum. 0mm. 7 of ‘ ‘\ \ 16,, Dear Dr. Grimmer: W Inmadmzhoramtmmloafmmdmrmm pmblem. undead short 45an my am vb» m nth-mung an ”gamut of tho «mum tgnsumtofl this that. cmMahala," we are md to “(nativity at w M15192: than 111th this tout, u an as our solution to pufllol mama “the be of help to note W this note is I: the taunt. at pinned to follow your momma. would be for the Archives, I m Fink, 1w. K3563 �PUBLICATION OFFICE AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET CHICAGO IO. ILLINOIS AUSTIN SMITH, EDITOR, A. M A. SCIENTIFIC PUBLICATIONS A. M. A. ArChives Of NEUROLOGY and PSYCHIATRY GILBERT s. COOPER, MANAGING EDITOR A. M. A. SPECIALTY JOURNALS SECTION ON PSYCHIATRY DR. EDITORIAL BOARD RCY R. GRINKER $R., M.D. CHIEF EDITOR. CHICAGO STANLEY COBB, M.D.. BOSTON GEORGE E. GARDNER, M.D.. BOSTON ““353?st JOHN WHITEHORN, M.D., BALTIMORE Institute for Psychosomatic and Psychiatric Research 29th Street and Ellis Avenue, Chicago 16 September 20, 1957 Max Fink, M.D. Department of Experimental Psychiatry Hillside HOSpital 75-59 263rd Street Glen Oaks, New York Dear Doctor Fink: it will not be possible to publish and we like to backlog, large have a wide selection of papers on many subjects and feel that we have published already all that seems important on the sedation threshold test as devised by Shagass.. I the in your paper am very sorry, but ARCHIVES. We have a Regretfully yours, Roy R. Grin er, M.D. Editor~in-Chief for Psychiatry RRszm enclosure �3.er Dr. Mort 3. Sam, General Putnamtu Boa: (7&3 {’4’ BOWEN, ah. 1957. Hospital, Mt Du:- Dr. Scarab: In vnading : recent. article on the ”mmuvity of the Station Threshold" in the Archives or Barclay and Paychntx-y, we were mud to parallel «panama with we test, as well as our 301an to the problm. I would appreciate your enumeration of this short clinical not» for the Section of 61mm. uni laboratory Notes of the mm m EEG hum]... Simon]: you", mm, 130th HE‘BJB or menu-m1 Paychutry; “on. �3-8200 EXT. 380 TEL. LAFAYETTE ROBERT s. SCHWAB. M.D. MASSACHUSETTS GENERAL HOSPITAL BOSTON 14 September 27, 1957 Dr. Max Fink 75-59 263rd Street Hillside Hospital Glen Oaks, New York _ C.N. #61 Dear Dr. Fink: received and I would like to conditionally accept for Clinical Notes in the EEG Journal as it stands subject to the approval Your manuscript has been it of the Bditor—in—Chief, Herbert Jasper. MW Yours very RSS:mc sincerely, Robert S. Schwab, M.D. �1g 33 ‘12, McGILL UNIVERSITY MONTREAL Department of Electrophysiology Allan Memorial Institute, 1025 Pine Avenue'West, Montreal. September 30 1957 Dr.Max Fink, Hillside Hospital, 75-59 263rd Street, Glen Oaks, New York. Dear Max, to see you for your note on the nystagmus. It was nice at Zurich, and I hope that we shall be able to meet Thank you again soon. My best regards. Sincerely, Cw CS/ef % , C. Shagass, M.D. �12/3/58 Discussion: Dr. Shagass Dr. H. Fink - Hillside HOSpital Dr. Thompson, Members and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass.‘ This study, like its predecessors, relates neurophysiologic indices to behavioral measures this area of psychiatry, reflects a welcome application science to clinical problems. a and in of basic appropriate to examine this report in the perspective of recent concepts in experimental psychiatry. During the 1930's, when electroencephalography was a new science considerable effort It seems in relating EEG patterns to "personality types" or ”diagnoses,” without success. With more refined instrumentation, there have been sporadic re-assessments without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he was expended related the amount of barbiturate necessary, under standard conditions of rate of administration and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG and behavior but between a measure of reactivity or responsivity of clinical behavior. We may carry this description a bit-further. The electroencephalogram is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure of the reactivity, or reSponsivity, or bufibring the EEG and �of the biochemical enzymatic systems flat make up the nervOus system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety of phrenotrOpic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafle adaptability. One application of these technics highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,who reported their ihitial observations on the significant relationships between schizophrenic behavior was and the reactivity of insulin. These of the glucose-enzyme systems to the authors carefully noted that there stress was no relationship between the initial levels of their biochemical measures and behavior. Dr. Shagass' earlier studies of the sedation threshold - end-point - are clearly within this tradition. His report today is also in this general tradition, but instead of a neurophysiologic index of clear definition has utilized a clinical index ~ lack of a verbal motor response to a verbal command - as the end-point. In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as "sleep") with the affective state of the individual at the time of the experiment. He has observed that the more fearful,disturbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce using an EEG �-3- quieter, more indifferent, inactive and retarded patient is, the less barbiturate is necessary for sleep. He sleep. a Ehe titration is thus achieving a biochemical titratinn, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatim, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, some of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships I have noted two puzzling relationships. Increasing sleep thresholds are associated, on the one hand, with excitement, worry, restlessness and anger; but also, with clinical improvement in a course of convulsive therapy. Also, in one are somewhat cloudy. patient, transient induced psychosis sharp drop in threshold, while in the same a LSD is associated with patient, fear of a treatment, restlessness and increased tension are associated with rising thresholds. I would snapect that these apparent discrepancies arise frOm the non-Specific nature of behavioral reaponse to neuro— physiologic change and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronization; or such psychologig indices of brain function as the perception of embedded figures or OFF; or such behavioral indices as dyadic or syntactic linguistic �-hanalyses. Alternatively, more precise,— operational measures of the behaviorll subsumed under "anger," restlessness,¥ "worry” may proiido, again, the relationships indicated earlier by the sedation threshold studies. Lest these comments be misconstrued, let me say, in closing, that Dr. Shagass is to be warmly congratulated in these studies basis for the developing neurOphysiologicadaptive hypothesis of behavior. His demonstrations of central neurophysiologic reactivity in the sedation threshold are in the best exPerimental traditions. We are eagerly looking forward to further experimental neurophysiologic studies from his new which are providing a firm laboratories in Iowa. �12/3/58 Discussion: Dr. Shagass Dr. H. rink — Hillside Hospital Dr. Thompson, Henbers and Guests: It is always a pleasure to read another chapter in the unfolding saga of sedative tolerance tests as they have been developed by Dr. Shagass. This study, like its predecessors, relates neurophysiologic indices to behavioral measures and in /‘this area of psychiatry, reflects a welcone application or basic science to clinical problems. It seaas appropriate to examine this report in the perspective — of recent concepts in experimental psychiatry. During the 1930's, electroencephalography was a new science considerable effort was expended in relating EEG patterns to ”personality types" or "diagnoses," without success. With more refined instrumentation, there have been sporadic re-assessnents without noticeable success. In the sedation threshold, however, Dr. Shagass, did succeed in achieving such a relationship. In these earlier studies, he related the amount of barbiturate necessary, under standard conditions or rate of administration-and concentration, to induce a specific EEG voltage and frequency change, to the personality profiles of the Handsley-Eysenchian school. It is important to note that the relationship was not between any fixed aspect or index of the EEG when and behavior but between a measure of reactivity or resphnsivity of clinical behavior. The e1ectro~ We may carry this description a bit further. encephalogran is a reflection of central or brain neurochenistry, and the reactivity of the electroencephalogram to any chemical stress, a measure or the reactivity, or responsivity, or buflhring the EEG and �«2e- of the_biochenica1 ensynatic systems fiat make up the nervous system. It is in this organisnic biochemistry that much activity is now directed in experimental psychiatry. The wide variety or phrenotropic agents, the new and more potent hallucinogens, and the expanding technics of enzyme and steroid chemistry are providing experimental psychiatry with research tools of considerafls adaptability. One application or these technics was highlighted yesterday by Dr. Gottlieb and his co-workers at the Lafayette Clinic,vho reported their initial observations the significant refationships between schizophrenic behavior and the reactivity of the glucose-enzyme systems to the stress of insulin. These authors carefully noted that there was no on relationship between the initial levels of their biochemical measures and behavior. earlier studies of the sedation threshold using an EEG endspoint ~ are clearly within this tradition. Bis report today is also in this general tradition, but instead or a neurophysiologic index of clear definition has utilized a clinical index - lack of a verbal notor response to a verbal Dr. Shagass' - as the endnpoint.' In the report today, he has related the amount of pentothal necessary to induce this state of lack of response (which is defined as asleep“) with the affective state or the individual at the tins of the experiment. He has command observed that the more feartn1,distnrbed, tense, angry and worried a subject is, the more barbiturate is necessary to induce �-3sleep. the quieter, gore indifferent, inactive and retarded a patient is, the last barbiturate is necessary for sleep. He titration is/thna achieving a biochemicat titration, and is, in essence, measuring the subject's responsivity or reactivity to barbiturate. By repeating the studies seriatin, he is able to report shifts in this state of reactivity. In his desire to extend the sedation threshold technic to situations in which the EEG was not available, and provide for greater clinical applicability, eons of the precision of the earlier studies has been forfeited. It is not unexpected, considering the lack of precise definition of behavior as well as the endpoint of titration, that the reactivity-clinical relationships are somewhat cloudy. I have noted two finssling relationships. Increasing sleep thresholds are associated, on the one hand, with excitenent, worry, restlessness also, with clinical improvement in a course of convulsive therapy. also, in one patient, a transient LSD induced psychosis is associated with a sharp drop in threshold, while in the sane patient, tear of treatment, restlessness and increased tension are associated with rising thresholds. I would suspect that these apparent discrepancies and anger; but arise from the nonnspecific nature of behavioral response to neuro~ physiologic changa and to the poverty of our descriptive language for behavioral change. I would wonder what shape the curves would take if the change in sleep threshold were plotted against other indices of brain function as predominant EEG frequency pattern or degree of synchronisation; or such-psychologtg indices of brain function as the perception of embedded figures or 61?; or such behavioral indicee as dyadic or syntactic linguistic �l-h‘ analyses. Alternatively, more precise,~ ofierstionsl measures of the behavioral subsumed under ”anger,“ restlessness,1 “worry" hey provide, again, the relationships indiohted esrlier by the sedation threshold studies. Lest these comments he misconstrued, let me say, in closing, that Dr. Shegsss is to be warmly congratulated in those studies which are providing o firm basis for the developing neurophysiologica adsptive hypothesis of behavior. his demonstrations of central neurophysiologio reactivity in the sedation threshold are in the best experimental traditions. we are eagerly looking forward to further experimental neurophysiologic studies from his new laboratories in Iowa. �qt- I ZIN’EIQAL. 614245 ' ‘ QM r r; m Marlyn»; #ng /% 4n Z/{[ 5/ ’f/e. /3~f7 Ska/177m Amt gnaw; E u, . . 7:va E Wu” E :1va E I . m,“ 1W 1W" ‘ quwr—rrw—nw—v /M /W flaw @524: // M" am/ZEWW/éwu Lb 7%“ @43’ W WM &%M/w/’ Aruéda 54% E E E E M7424 - . �W we moved reading the report of Thorpe and ' in the to assess our own W5 /Q1(LLAAjr Barke%ajm issue of the Archives, we were experiences with the sedation threshold, and to (2 report anether clinical guide to the "inflection point" that useful. ' ‘ ’“ n U Following the initial description the adninistration of the amobarbital W / )1 "# WWW Our ’ ' / ' “‘ '* have found, we ,, I _ / " fir of the technique by Shagass we modified flat: is: iifi— our seaside which included test for brain dysfunction (-Weéna-teim, to obtain a measurement of the sedation threshold as well. technique was identical to that of Shagass, with the addition of the measurement of nystagmus on 775: lateral q change gaze which the latter test required. 7h4¢4ww¢16f EEG was done- visually ‘ ‘ in beta amplitude in the in consecutive samples of record, using the additive ruler described by Shagass. In the initial group of patients, two observers were unable to the onset of slurred speech with consistency. identify Disagreement led to administration of amounts of amobarbital greater than was required, with the frequent induction �-2l?!‘ sleep. gaze, As we were also We, ML. Wis-of :_ reliably that this index was we became aware observers, and w/umd 9/ obtaining /“45“¢’7"" nystagmus on ?/ lateral agreed upon by the slur-e W..a.correla.tion withthe sedation thresholdwv W/{Z‘ therefore, omitted the instructions. regarding counting stituted the following instructions. Subjects intervals they would one side and then be requested to were their open and sub- told that at periodic eyes and to look first to the other at pre-arranged fixation points. This to was repeated twice in each direction, usually within ten seconds, while the observer noted the development of Sustained regular nystagmus gaze. Such observation was repeated after The injection of lateral 1 cc of amo— N, ~: ‘ . “42" barbital solution, each on between the 25 and ho seconds of the injection period. administration of barbiturates continued until nystagmus was observed, and. MW ’00 (Lou and then ?WU°: ——————-—_ To more were given. date, we have 91 measurements. ,, difference between the number of thes926an threshold and W W . MW) not!“ the : milligramkl (/19 m7... of ambbarbitaljfo/r Mafia,” for the Onset of nystagmus, reflects-enemi- Differences greater than one unit did not occur in this series. The two measurements 7,2 79/1; following table 4 The arenreliably related by a unit of 0.5 or lessxw Wamflm~ Z... ‘ ' �-3I TABLE Frequency Distribution of Difference in Amount of Amobarbital Necessary to Induce EEG Change and Nystagmus (mg Amobarbital/Kilogram Body Weight) No. Tests .100 .005 0 +0.5 +1.0 l 12 h? 27 h \ ?// ; Test-Retest Reliability: During these studies all» we ' havenhad the opportunity to repeat the sedation threshold measurement three to five times in the intervals.- weekly These measurements were done patient at same in randomly selected patients receiving subconvulsive doses of electrnc current under barbiturate premedicationqi as part of a study of convulsive-subconvulsive electroshock. changes in this group were small - fourteen of the sixteen The were behavioral referred for /z~n/¢‘¢A{4”~*¢¢ég«~0 ' grand mal electroshock within four weeksye7/ngr . ‘ (fl/$4,224. The range of sedation threshold meaSurement?under these conditions noted in Table II. TABLE II Absolute Range of S.T. Values' Range My, Subjects (/4) 0 0.5 1.0 1.5 2.0 o 2 6 2 h >2.S 2 ff’a./§L»«# is �-hBeing unable to ascribe greater é validity . the we determined we have mean sedation threshold for each subject, subjects in the-m mdmadud MM. value. the listed WE: W W one reading than fies any each range of M basis variability ’ mean III TABLE Range Range /o. fiubjects (/5) other, of S.T. Values from the e 0.10.5 0.61.0 o 6 h 1.6- 101'- 1.5 ’ “N‘r‘m-wrv .,.m 52.0 2.0 7 h J Mi."- Mean 1 1 , . ., K.,.fim’WhfiW-am~w-.w:122-w 7 Wat, {is mus-patient;inter-test variability for this test in this series is considerable. test reliability of The electroencephalograpmzhc change is well within the retest variability of test in these subjects. Qéz: the adapted the appearance of nystagmus on m a ; / J1/ J 1/}, C- i ’ / A A f" is / / /z€—— "/5 I I , [KI-A ,5 - ,v clinical guide to a ‘4’; my: M , fl» gray 1.47! /’L! CW/m4‘4flt (331’; fi{ I, ;’(f fl ,Cy «a, ' M; gaze WWK .ma- Asa/2w ,Aaé .4 // My 4 Wfiffeéé: fr!» WI mat?» lateral WRfi—WW the sedation threshold, a; nystagmus as an index of the AA“: iséwtu/MA‘I (2: 7! /)/”/»£¢A/L.( M #63“e/ Ca” we '1’ .11“ fl¢»%flw//L{u¢{304?“:{3’ a? / ,. 3 if '4" ”17’2“" r , _.;__.‘ 4’ "I; a: A" {fi’flg‘t . ,, ,4? Ayifi ”(:4'5‘ Alt—‘3 / A’Jik �, ..‘ )- I *’ Wv .1. C . ya $407M Mann}; 4 M4, /:7 a4“!!- C . 74V galvauE/Zw/ I £44373; 59:7. Z—f: M4. 41% ’7sz /f4/A/75, (”fif) W77er?“ ' #1 %@‘*’5‘“ g CL .‘ «9-9/-'.?33, ‘ /7f¥, M . ‘ / $42M” ~ i ) fltm NA /‘J3, /flf: ff7~ff~c '/ $4,441,, V . flu d {7 . /% (1;.1'5 7. �THE LONG ISLAND JEWISH HOSPITAL 270-05 76th AVENUE Department of MEDICINE 0 NEW HYDE PARK, LONG ISLAND, N. Y. - TELEPHONE: Fleldstone 3-6700 �Suptonbar 21, 1961 ntrtin H. rats, Ph.n. Reiuurch Piyuholosint Paychophurnnaoloxy surviuc Cantu: o: nautnl Bonita lation:1 Institutg Md. Buthnldn 1h, Dcar _ flirtin, tour lattqr regarding 1 r0110! o: it: Iodaiitn thrcihold attack a oynpsthcsia chord, and I an caconr:god to share my Vitus with rat, Buvavcr, tin probla: in acuu plax tad perhaps no as: not anido tan. tin. in Huntington fur a dutuiled diacunuion. Hy interest in tho sedation thronhaid van cooulionnd onrlicr intarout in tho at. 0: intravoaonn snibirhitll an a fast tar brain dynrunation. Hoinltciu and Ichni Donitl at Illa-an c c. ThOIIl, 19 S) In tn. court. of ofcoifiucfioci 05:310., we curriod out many out13¢tau at tho 8.2. .36 can. to it. eontlalion taut sh. inst was phyliylogically and itchnically Hound. Finding dylgrthriu I difficult ondnpoiut, I lubntitnicd nyutccnuu; but in raulity, thin can b: dilponlod wish, ninco tn. acnlurod and-puini in to. EEO tbs 3.3995: by ny aarpud nhoui drunrthrin, corroct ll tar an int: hlvo (out, but thin dittiauliy intr.not inlnrunuBStblo, uni boar: no aigaitiaing rolgtion to the valet at $8. tout. the critic: who have The quantiann It inane trot II it. tlli stunt. in in: can. individual .v-rtiuo? 2. In thuro a charteturiltio tcapanao which boar: a oiguir10§nt1y high corroliticn with n bchnvioral Vlriibli - ntnnly, sh. oililifiottion by psychiatriltl a! tangent: iuia uolclogic (racy-9 1. �0-2- 3. Thirdlr, your quclhiou, “it true, it (8.1.) ahvioualy can b. very alarm! in trtttnaut firodiotion nhndicl'. 1. Out Inn uxp.richou indiohtUI that : high intrh~ individual variabiliir; a limited ran 0 at vuluon tar thc halt (tvclvc point. from 1-6 in half than. and an oqnivocnl EEG 0nd»point in 10-20! a: test: lit?! to nuko tha rnlihbla duturu ainntion if tho 8.!. difficult.’ that. vurinblcn soon inhurout in th. taut danish, and Ira not, in :1 opinion, I luck or know-haw by uh. ohlurvcrl. 2. no. Hy nogahiva unuwar to thin question is partly hhoad on (1); Ind partly on tho uuucl dittioaltios at nonology. in somewhat limplowmiadod to uspuat a high corrolntion It betwocn a 'uinplt’ phyiinloxic rotativity naulurc had a “90:91.3” hypnthctie clhatrnat with '0 Inch inhtront unhigui» 3 hy Ind variability. in: 3.2. may hat bu rnlutcd in diagnosis; aha the 3.T. h. unoful in truttacnt prediction? I think it uh: ha, ~~ not for hhc losicul raglan: anuuily IiVOI, but blcinll of the value of tha tout an I .anctivity” nth-urn. In the pulh tow ybnrn variouu indict: huvo blln nhaua to huar IOll rolatiou to trontnont or to diacnnlis ~hnd ouch influx it halt huh-ulna under tho hgru or a 'ruautivio influx”. HO utatod hhht pationth vhe chowod two or nor. tr laughing «hangs. utter intrtvonoun uncharhitnl war. nor. likely to thaw curly EEO ehnnsun httnr uloetrouhock, had to 3. Evan ihough aha: gruntor dncrucn or hohnviortl church and iuprovonnnt of Cenaunieatign, 126 - 139, 1958). Goldntn pantothnl burnt. tr. 010' ’3'; a o thin in uppchrsaoo in achiIOphronic nnhjocta, and ht! unod tout protnouticclly. Siuilhr mittencutl hart bath midi, in £36 Ctt‘uli nor. quantitttivo Itudinu, by Itil (Erlungun) (Milan), why havu rclntod thn changod EEO putt-run to corehrnl ltrophy on pucnnaoneophulozrtphy. In hnothcr type of studios, tho bland prolhnro rcupan-au to nocholyl and to harshnlin have bath roptahcdly Incgnutod an a dilflnflltic had prognontic 136.3. A cannon bhaiu in thcnc Ithdiou in that u link of reactivity or a alow ranchivihy in zanornlly taunted vith schiloyhruni: 0» brain atrophy ~~ a poor proxnoutic high to: the artillhlo thsrtpiol; whil. high rtnotivity in aquutnd with écprcauivc syndronon ~~10w: [and tauntivprognostic sign with awnilhblh thnrapitu. Than, invoked indux or but hi an high any your prtgnoling a: it: ruaahivity will bchr A high wurrulation with hshhvioral chaugu, had a varinhlo In. with inprOthont rutinzs. (3.0 �.3our views of beteviorel change and inpreveuent ratings, Arch. Gen. Feloniet. g; 259, end 5; 30, 1961) Thus, there is much merit in Shannen 8.1. -- not, in .my View as e diegnoetic index (for age is much more relieble and easier to ascertain), but ea one guide to neurophyeielegic reeetivity -- e eubaect that needs {nether study as e preg- noetic and as]: noeelogicel teal! I trust this in reeponeive to your inquiry. I would 16-1? ?) like to disease it acre fully in doWashington (October the 8.1., in end wenld recommend that if yen get interested on veriene reactivity that you consider 3 eeriee or aeetinge ueeeuree in plyehietry .. the neehelyl test, the 8.2. end the coldnen ee exemplee at the more explicit. My regerde. sincerely yours, Hrcdte ex n , “.5. �I1 I. I. I $5 I [3 EE P1 (3 55 F’ I'T'l\ I. FOR PSYCHIATRIC TREATMENT. TRAINING AND RESEARCH 75-59 263RD A. MILLER, M. D. , , Medical Director JOSEPH S. SIMON KWALWASSER, FIELDSTONE LEON LOWENSTEIN 8-7800 Department Of Experimental Psychiatry M. D. Assoc. Medical Director MAURICE STREET. GLEN OAKS. NEw YORK BACHRACH Honorary Chairman Board of Directors ROY .FOSTER Chairman Board Of DWWOH ALVIN E. COLEMAN Administrator President September 12, 1957. Dr. Roy Grinker, Editor, Section of Psychiatry, A.M.A. Archives Neurology & Psychiatry, 29th Street & Ellis Avenue, Chicago, 16, Illinois. Dear Br. Grinker: In reading the report of issue of the Archives, the sedation threshold, Thorpe and Barker in the latest (August) to assess our own experiences with and to report another clinical guide to the we were moved "inflection point" that we have found useful. During the past two years we have included a measurement of the sedation threshold in our tests of brain function. we initially followed the technique described by Shagass (EEG Clin. Neurophysiol. é: 221-233, l95h). Measurement of the beta amplitude reaponse is done visually in several samples of record using the additive ruler described by Shagass. initial group of patients, two observers were unable to onset of slurred Speech with any consistency. 'We, therefore, the identify omitted this step, and continued drug administration until gradually drowsiness was clearly manifest, combined by a statement by the technician that an increase in beta amplitude in the record had occurred at least 1% In the minutes before. that occasionally amounts of amoreach an inflection point were administered. We, barbital inadequate to therefore, began to note'the onset of nystagmus on lateral gaze as a guide to the sedation threshold. This technique had the drawback Subjects were told that at periodic intervals they would be requested to open their eyes and to look first to one side and then to the other at pre-arranged fixation points. This was repeated twice in each direction, usually within ten seconds, while the observer noted the development of sustained regular nystagmus on lateral gaze. The administration of barbiturates continued until nystagmus was observed, and then 2 cc more were given. The EEG records were then measured for the inflection point by the visual method. AN AFFILIATE OF FEDERATION OF JEWISH PHILANTHROPIES OF NEW YORK �Dr. Roy Grinker (Contd) -2— To date, we have 91 such.measurements. In the following table, the difference between the point of onset of nystagmns (nystagmus index) and the inflection point of beta amplitude change (EEG index) is reported. Difference .100 1 EEG Index s-Nystagmns Index .005 0 +05 +1.0 12 h? 27 h Differences greater than 1.0 unit did not occur. It is apparent that the nystagmus end point for the sedation threshold is reliably related to the EEG end point by a unit of % in more than 90% of the trials. Since the error of the sedation threshold under test - retest conditions is between 0.5 and 1.0 units, this nystagmus index is a satisfactory guide to the sedation threshold, as defined by Shagass. W In our continuing studies of the sedation threshold, we have, therefore, ceased measurement of slurred speech or drowsiness, but have relied on the onset of nystagmns as the clinical guide to this index. I trust that this data may be helpful to other investigators. Sincerely'yours, v ,4 a’V‘wflwc has: MF:JB _ Fink, 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 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 Lateral gaze nystagmus as an index of the sedation threshold. Electroencephalogr Clin Neurophysiol. 1958 Feb;10(1):162-3. Type The nature or genre of the resource Text Identifier An unambiguous reference to the resource within a given context mfp-02-01-002-28-003 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 12 items. 1: [Preprint]. 2: Reprint from Electroencephalography and Clinical Neurophysiology Journal Vol.10, No.1, February 1958. 3: Letter to Dr. Roy Grinker form Fink. 4: Letter from Grinker to Fink. 5: Letter to Dr. Robert S. Schwab from Fink. 6: Letter to Fink from Schwab. 7: Letter to Fink from C[harlie] Shagass. 8: [preprint] to Dr. Thompson, members and guests discussing Dr. Shagass (2 copies). 9: Handwritten notes. 10: Draft with edits. 11:Letter to Martin M. Katz from Fink. 12: Letter to Roy Grinker from 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). 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 Mosquera, Hannah Published