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Reverse Medical Engineering of ECT Machines

Reverse Medical Engineering of ECT Machines

Two hospital museums have a few old ECT machines. I discovered that exploring them and trying to learn how they work, give us a clue about the history and development of ECT. This Blog attemtps to free associate in the presence of these machines.
In psychiatry, writing about humans seems to be the state of art but writing about machines is rather an uncommon endeavour. On writing about Electro-Convulsive Therapy (ECT) machines (Sidhom, 2013) it seemed like they could tell so many things ECT devices seem to depict not only the advances in the field of interventional psychiatry (Stetka et al., 2013) but also, advances in electric technology, medical engineering, and design as well. Insulin Coma Therapy tools do not seem to be specific to psychiatry, some metal syringes, however, useful and may be even revolutionary at their time with regards to their efficacy in schizophrenia (Sargant and Slater, 1951);  nasogastric tubes and Insulin, nothing seemed to be specific to psychiatry, neuropsychiatry or neurology. With regards to lobotomy, though procedures as transorbital lobotomy seemed specific to psychiatry the major device used the 'orbitoclast' can be easily mistaken for an ice pick. On the contrary, ECT devices seem to look different and they do not happen to occur in the rest of medicine (Faria, 2013).

The aim was to document some of the history of ECT. The reconstruction of ECT history from devices, may take a bit of reverse engineering, which was not feasible on visiting psychiatric museums. Thus, the process involved inspection of machines, measuring them, reading references, talking with senior consultants, talking with senior nurses and auxiliary nurses, reading the manuals and catalogues of older machines whenever possible. The whole process could be named 'reverse medical engineering', as it is a review of medical equipment as well the process is not strictly reverse engineering, the approach was rather like a medical review.

On inspecting older machines, the first difference that was observed was the absence of monitors. One cannot be sure whether this is due to limitation in technology or not. ECT was firstly administered with very high caution (Kalinowsky, 1958). On reading, I learnt about the location of the monitor. It was the administering doctor. Physical signs e.g. schnauzkrampf, writing finger sign (Roper, 1971) as well as hand watches to monitor the duration of the seizure. It might be prudent to say, but, all ECT machines work by electricity. Simply, no ECT without electricity (Sidhom, 2012), (Sidhom, 2013). However, the opposite is not true, where in Tripoli in the late 1930s and early 1940s, Dr. Felice, an assistant of Cerletti, administered ECT by connecting wires to patients' heads, plugging and unplugging electriciy swiftly (Shorter and Healey, 2007).

The other thing is that all machines use relatively smaller duration e.g. 0.1-1 s., higher amplitude range up to 1 ampere, and all strictly use Sine wave ECT (8.3 ms) except one that has the option of Brief Pulse ECT(1-2 ms) (Weiner et al., 2002) The Sine Wave seemed to have been associated with more cognitive side effects (Scott, 2005). However, given the huge success rates of Sine Wave ECT, one wonders about the comparative efficacy of Sine Wave as compared Brief Pulse (Scott et al., 1992). As ECT advanced, its electrodes broke free from each other, the classical scissors electrodes, and the headphone like electrodes gave way to independent electrodes, which eventually opened up the opportunity for unilateral ECT, d'Elia electrode placement, LART (Swartz and Nelson, 2005) and FEAST, (Nahas et al., 2013). The change from voltage-based with variable current electric dosing to energy-based to the current charge based with constant current, made it uneasy for younger doctors to figure out how did these machines work. The difference is almost the technical translation of the change from electroshock to electro-convulsive therapy. The ECT machine that depicts an important technological development was the Siemens Konvulsator ECT machine. This machine delivered the chopped sine wave which is the direct predecessor of the brief pulse ECT (Robertson and Fergusson, 2006). A couple of machines had the option of cerebral stimulation (Talbot, 1984), though the process was seen as helpful in some cases that received the diagnosis of 'hysteria', the process was perceived as painful. One cannot but wonder whether the pain associated with this non-convulsive procedure have been implicated as one of the iatrogenic aspects of ECT stigma (Sidhom, 2013).  All ECT machines have either cold colours or lighlty saturated warm colours, no fully saturated colours were observed. They are mostly, beige, brown, light blue, grey and black. The oldest ECT machine was the biggest, the newest however is not the smallest. On a metaphoric level, the sizes of ECT machines may reflect on the non-linear history of ECT with regards to its initial popularity, its partial demise, and its quiet come-back (Dahl, 2012).

The ECT machines, do not show linear progression, some aspects that were present in older machines and then disappeared proved to be helpful as the unidirectional ECT (Peterchev, 2010) (Nahas et al, 2012). The smaller size makes the machine more portable however, due to current addition to ECT machine e.g. ECG/EEG/EMG/OMS monitoring may hinder size reduction. Was ECT a simpler procedure? This is quite debatable, with regards to electrophysiologic monitoring, titration, it seems like it was easier. However, with regards to doctors dynamic timing of seizures using methods like ECTONUS method (Rao, 1958), observation of physical signs during ECT, manually overcoming impedance, and personnel needed to guard against fractures during unmodified ECT, it seems like older sine wave unmodified ECT was hardly acquired knowledge and skills.

The future of ECT is unclear, one wonders whether bifrontal, unilateral(El-Islam, 1970), LART, FEAST (Swartz and Nelson, 2005), (Nahas et al., 2013) will be the default as compared to the traditional bilateral bitemporal ECT. Also, will ultrabrief ECT become the default and brief pulse machines will become part of the future museum, or transcranial magnetic stimulation would be the heir of the legacy of interventional psychiatry. On the other hand, given the comparative advantages of ECT over rTMS in terms of dominance due to efficacy in catatonia, psychotic depression (Fink, 2011) will make TMS machine join the museum. The same concerns extend to Magnetic Seizure Therapy (MST), FEAT (Borckardt et al., 2009) and other forms of treatment. I wonder if we can on one day answer the old question of how ECT works, just like how vitamin C guards against scurvy. These are a few concerns about the history and the future of the most effective treatment, and the oldest surviving method of psychiatric treatment.


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