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Friday, 20.09.2019

Jay D. Amsterdam’s comment on Edward Shorter’s comment

My Experience with Insulin Coma Therapy (ICT) and Other Lost Psychotropic Procedures
 
Barry Blackwell: The Baby and the Bath Water

 

 

I certainly appreciated your very thoughtful comment about Barry Blackwell’s piece on “The Baby and the Bath Water” pertaining to the place of ICT and other lost therapies in our treatment armamentarium. However, there is this historical caveat:

There are no longer many folks still active in the field who have a personal, hands-on knowledge of ICT; and those with experience in this treatment area in the 60s and 70s may not have had the “core” experience of performing ICT in exceedingly sick, hospitalized patients with intractable melancholia or psychotic affective disorders (like they were seen back in the 30s, 40s and 50s).

In this regard, I had the opportunity to perform ICT as a clinical intervention back in 1975 (at the tail end of its therapeutic existence) when I was a young psychiatry resident. I undertook this procedure as part of a “moon lighting” job at a small private psychiatric hospital in NW Philadelphia where it was used as a primary treatment (three days per week) for adolescent and young adult patients with behavior problems (discordant with the expectations of their parents and others). Many of these youngsters had what we would now call “borderline personality disorder,” attention deficit hyperactivity disorder, oppositional defiance disorder or conduct disorder, among others (although the hospital charts rarely carried those sorts of diagnoses and usually bore a diagnosis of schizophrenia, pseudo-neurotic schizophrenia, or some other DSM II Axis I disorder). None of the youngsters that I recall having ever examined, or that I treated with ICT, ever acknowledged having Schneiderian first-rank symptoms of schizophrenia or delirious mania.

The ICT procedure (at that time) was to first secure the patient in his/her bed via a cloth posey-restraint, then start an intravenous line with a solution of 5% dextrose and water, and then inject intravenous regular insulin at a slow infusion in order to produce hypoglycemic “sub-coma seizures” for a period of several minutes (although sub-maximal grand mal seizures frequently occurred). No intra-procedure glucose monitoring was ever performed, no neuromuscular blocker was ever administered and no airway (other than an oral-pharyngeal airway) was placed. Comatose conditions were maintained until the patient showed some degree of limb jerking/fasciculation. I suppose that, at that point, the serum glucose was quite low. A syrupy glucose-laden drink was then administered upon awakening and repeated later in the afternoon. To my observation, no objective benefit was ever seen in the apparent “schizophrenic symptoms” of these youngsters (although this is not what the attending progress notes often portrayed). The usual ICT treatment course was similar to that of ECT therapy (i.e., 6 to 12 sessions), depending upon the rate of symptom resolution. 

The treatment facility was a curious little private psychiatric hospital called Fairmount Farms that was owned and operated, quite authoritatively, by several senior psychiatrists from the Philadelphia psychiatric community (who were trained in the 40s and 50s). It was, for the most part, a private facility for patients who had excellent private insurance and additional funds to meet the costs for private hospitalization.

Although I was not thrilled about doing the ICT procedures, worse was yet to come.   I was on call to “Building X” (that really was its name) where the highly psychotic, demented and detoxifying alcoholics were locked up (quite literally) in “rooms” with a floor-to-ceiling wall of chain-link – open to the ward corridor for ease of observation. I recall being directed to treat patients in Building X with chronic alcohol dependence who were in impending delirium tremens with a concoction known as the “Blockley Cocktail.” This concoction was most likely named after the facility where it was first administered to patients in the 1940s (i.e., the Blockley Building of the Philadelphia General Hospital; which was the anlagen of the original Blockley Almshouse founded in the late 18th century for the indigent and mentally insane and which was later renamed the Philadelphia Almshouse and Hospital, but affectionately referred to as “the Old Blockley’” because it was located then on the site of the Blockley Farm in West Philadelphia). This facility was eventually renamed the Philadelphia General Hospital (PGH) in 1922 which, among its four hospital structures, contained a building named “The Blockley Building.”   When PGH closed its doors in 1977, and the property was purchased by the University of Pennsylvania, the former PGH site and its remaining buildings (including The Blockley Building) became incorporated into the campus of the University of Pennsylvania. Now known formally as Blockley Hall, it houses the administrative offices of the Department of Psychiatry of the Perelman School of Medicine of the University of Pennsylvania (Wikipedia 2017).

The Blockley Cocktail was comprised of a solution of about 85 cc of 50% dextrose and water, 10 units of regular insulin, 50 mg of thiamine and approximately 10 cc of a mixture of other B vitamins and vitamin C. This large syringe was capped with a 14-gauge needle and it was often impossible to even find or cannulate a usable vein in the writhing, jerking, delirious patient to administer the Cocktail. The first time I was instructed to administer one of these glucose concoctions was in the middle of the night when I was paged to Building X by a mean-spirited head-nurse of Building X. I expostulated that undertaking this procedure would almost certainly precipitate a Wernicke-Korsakoff Syndrome, if not death. I told the nurse that I could not ethically perform this procedure. The nurse impatiently glowered at me and quietly stepped into an adjoining office where she calmly called the hospital owner and patient’s attending to let him know what was transpiring. She then handed me the phone, whereby I was forcefully directed by the attending to, first, administer 60 cc of spirit of fermenthia (which turned out to be two shots of Four Roses Whiskey in plastic Maalox cups); and, if that treatment did not work, I was then directed to administer the Blockley Cocktail on the attending’s expressed verbal order and responsibility. I did as directed and learned the next week that the patient had died of his delirium tremens!

Maybe it was the Blockley Cocktail affair, rather than the ICTs, that led to my decision to pursue an academic career in psychoneuroendocrinology and psychopharmacology research. In hind sight, however, this experience was also my first lesson in questionable psychiatric medical ethics; but, unfortunately, not my last (Amsterdam, McHenry and Jureidini 2016)!

 

References

Jay D. Amsterdam, Leemon B. McHenry and Jon N. Jureidini’s commentary: Industry-Corrupted Psychiatric Trials. Barry Blackwell: Corporate Corruption in the Psychopharmaceutical Industry. inhn.org/controversies/barry-blackwell-corporate-corruption-in-the-psychopharmaceutical-industry/jay-d-amsterdam-leemon-b-mchenry-and-jon-n-jureidinis-commentary-industry-corrupted-psychiatric-trials.html.

 

Blockley Almshouse. https://en.wikipedia.org/wiki/Blockley_Almshouse.

 

February 8, 2018