Electric neurostimulation in sleep disorders - yesterday and today. A comparative analysis of historical and contemporary case reports and clinical studies

BACKGROUND

Insomnia is a widespread symptom of many psychiatric and neurological disorders, but can also be a clinically relevant disorder of its own. The application of low-dose electricity as a treatment for both has had a long history, dating back to the 19th century, but has seen somewhat of a renaissance in therapies such as tDCS.

OBJECTIVE

The aim of this publication was to identify and present original works from the second half of the 19th century as well as contemporary studies that investigated the therapeutic value of electricity in treating sleep disorders.

METHODS

While the nine historical sources identified mostly presented impressive successes in treatment, the nine modern publications had much more heterogeneous and moderate results.

RESULTS

The discussion of these differences refers to the scientific discourse of the late 19th century about the placebo-effect and the role of suggestibility in the therapeutic process and outcome.

CONCLUSION

In conclusion profound parallels can be seen between treatment innovations and methodological discussions in the 1880-1890s and nowadays.

Joseph Franz Domin (1754-1819) and His Contribution to Electrotherapy

Joseph Franz Domin (1754-1819) as the croatian theologian and philosopher is primary animist (vitalist), and in practice he has worked as physicist - mechanist, although the humoral theory at that time will be a foundation of medical philosophy more than twenty centuries from Hippocrates to the half of 19^th century and Virchow's cellular theory. Besides his academic and researcher's work he has been working on electrotherapy of numerous conditions and diseases about which he has published (cephalea, neuralgia, paresis, plegias, pterigyum oculi, rheumatisms, Gicht, epilepsia, arthralgias, febres etc). The latter is undoubtedly progressive natural scientific theory which at that time have widely spread at Habsburgs Monarchy Universities and as proof between first and second Wien's medical school by integration of other scientific branches (physics and chemistry) in medicine. According to the various researchers Domin was an author of the first electrotherapy manual published in Zagreb, practitioner of electrotherapy in pregalvanic era in contemporary Austrian empire and for sure a scientist who have left a significant remark in contemporary applied physics in medicine, which continued in professional and scientific elaborations not until the end of the 19^th century.

The Use of Electrotherapeutics in Ophthalmology

PURPOSE

To present a perspective on the use of electrotherapeutics in the history of ophthalmology along with the development of novel contemporary ophthalmic instrumentation.

DESIGN

Perspective study.

METHODS

We reviewed historical journals, articles, and books discussing the use of electricity and electrotherapeutics in ophthalmology.

RESULTS

Electrotherapeutic applications have been researched and used to treat ocular diseases as far back as the 18th century. By the 20th century, research in electrotherapeutics in ophthalmology had caught the eye of Edward Jackson, the first president of the American Academy of Ophthalmology and Otolaryngology and first editor of the present (third) series American Journal of Ophthalmology. Edward Jackson published an extensive review on this topic and reported a variety of modalities used to treat ocular diseases.

CONCLUSIONS

While many early therapeutic uses of electricity did not produce effective and replicable results, studies on electrical stimulation of the eye provided the foundation for the development of clinically significant vision enhancing and restoring instrumentation.

History of Cranial Nerve-Implanted Stimulators in Otolaryngology

This article aims to clearly understand the historical development of cranial nerve-implanted stimulators in otolaryngology. The authors also discuss cranial nerve history; initial theory of the functional concept of animal spirit; electrical nerve impulse theory; first electrical otolaryngology cranial nerve stimulation devices; and the development of implanted stimulators.

Gastric Electrical Stimulator for Treatment of Gastroparesis

Patients with gastroparesis sometimes suffer from intractable nausea and vomiting, abdominal pain, and bloating, as well as a host of other symptoms that can often be difficult to control. Initially, patients are treated conservatively; some do well with conservative management but unfortunately some do not. Over the years, studies have shown the benefits of gastric electrical stimulation, which often results in symptomatic improvement and improvement in gastric emptying times. This article discusses the history of gastric electrical stimulation and its use in clinical practice to help those suffering from gastroparesis that is refractory to conservative medical management.

The Medical Battery in The United States (1870-1920): Electrotherapy at Home and in the Clinic

This paper focuses on the history of a portable shock-producing electrotherapeutic device known as the medical battery (1870-1920), which provided both direct and alternating current and was thought to cure a wide variety of ailments. The product occupied a unique space at the nexus of medicine, consumerism and quackery: it was simultaneously considered a legitimate device by medical professionals who practiced electrotherapeutics, yet identical versions were sold directly to consumers, often via newspaper advertisements and with cure-all marketing language. Indeed, as I show in this paper, the line between what was considered a medical device and a consumer product was often blurred. Even though medical textbooks and journals never mentioned (much less promoted) the home use of electricity, every reputable electrotherapy instrument manufacturer sold a "family battery" for patients to use on themselves at home. While a handful of physicians spoke out against the use of electricity by the laity-as they felt it undermined the image of electrotherapy as a skilled medical procedure-existing evidence suggests that many physicians were likely recommending the home use of medical electricity to their patients. Taken together, this paper shows how the professional ideals of electrotherapeutics were not always aligned with physicians' actual practices.

Medical Machines as Symbols of Science?: Promoting Electrotherapy in Victorian Canada

This article tackles a common assumption in the historiography of medical technology, that new medical instruments in the nineteenth century were universally seen as symbols of the scientific nature of medical practice. The article examines the strategies used by Jenny Trout, the first woman in Canada licensed to practice medicine, and J. Adams, a homeopathic physician, to advertise electrotherapy to the residents of Toronto in the 1870s and 1880s. While electrotherapy involved complex electrical technology, the doctors in this study did not draw attention to their instruments as proof of the legitimacy of their practice. In fact the technology is almost entirely absent from their promotional texts. While both doctors wanted their practice to be associated with scientific medicine, neither saw their instruments as immediately or obviously symbolic of science.

Electrotherapy in the treatment of patients affected by rabies: experiments conducted at the "Maggiore" hospital of Milan in 1865

During the nineteenth century, the scientific context of rabies treatment was weak due to the lack of the literature on specific nosology of the rabies disease, and unspecific and ineffective therapy approaches. Electrotherapy already represented an important therapeutic approach for nervous system diseases, although not specifically for rabies. In the present paper, the authors discuss the use of electrotherapy in the treatment of humans affected by rabies in an experimental study conducted at the Maggiore Hospital of Milan, with the aim of establishing the discovery of a possible specific therapy. By analyzing the printed scientific sources available in the Braidense Library of Milan, the authors describe four experiments conducted on patients of different ages. Symptoms and effects both during and after the electrotherapy are also highlighted. The experiments demonstrated that electricity is not an effective therapy in the treatment of rabies, being rather able to cause serious functional and organic alterations in all the patients. Analyzing the Milanese experiments, the authors reported specific Italian history of a scientific and medical approach to rabies at the end of the 18th century, which led to the promotion of health education, reinforced prevention strategies and opened the way to the vaccination era.

[Electrotherapy for headaches]

Neuromodulation is being applied increasingly for the treatment of drug resistant headache. Although these techniques are often considered high-tech, electrotherapy for headache has a long history; electric fish have been used for headache treatment since the first century CE. During the eighteenth and nineteenth century, static electricity was a treatment for a wide variety of neuropsychiatric disorders including headache. The efficacy of electrotherapy, however, has been disputed continuously, since opponents were of the opinion that the positive results could be attributed to suggestion. At the beginning of the twentieth century, the electric treatment of headache gradually disappeared. In recent years, there has been a resurgence in the use of electrotherapy, along with the efficacy debate. With this historical review we wish to emphasize the importance of placebo-controlled studies, not only in terms of electrotherapy of headache, but also for the evaluation of neuromodulation for other disorders.

'Recharge my exhausted batteries': Overbeck's Rejuvenator, Patenting, and Public Medical Consumers, 1924-37

Although historians have shown that there has been a complex and multi-layered relationship between the body, medicine and the force of electricity, many avenues remain to be explored. One of the most prominent of these is the way in which electrotherapy technologies were marketed to a wide variety of different end users and intermediaries. This paper offers the first historical analysis of one such device - the Overbeck Rejuvenator - a 1920s electrotherapy machine designed for use by the general public. Its inventor, Otto Overbeck, was not a medical man and this enabled him to use aggressive strategies of newspaper advertising, using testimonials to market his product alongside appeals to his own scientific authority. He commissioned the prestigious Ediswan Company to manufacture the Rejuvenator on a large scale, and took out patents in eleven countries to persuade users of the efficacy of the device. In response to Overbeck's activities, the British Medical Association enlisted an electrical engineer to examine the Rejuvenator, contacted practitioners whose endorsements were being used in publicity material, and denied Overbeck permission to advertise in the British Medical Journal. Despite this, the Rejuvenator brought its inventor wealth and notoriety, and helped redefine the concept of 'rejuvenation', even if the professional reception of such a device was almost universally hostile. This paper shows how the marketing, patenting and publishing of Overbeck combined to persuade members of the laity to try the Rejuvenator as an alternative form of therapy, bypassing the medical profession in the process.

German battle casualties: the treatment of functional somatic disorders during World War I

World War I witnessed the admission of large numbers of German soldiers with neurological symptoms for which there was no obvious organic cause. This posed a considerable challenge for the military and medical authorities and resulted in an active discussion on the etiology and treatment of these disorders. Current historiography is reliant on published physician accounts, and this represents the first study of treatment approaches based on original case notes. We analyzed patient records from two leading departments of academic psychiatry in Germany, those at Berlin and Jena, in conjunction with the contemporaneous medical literature. Treatment, which can be broadly classified into reward and punishment, suggestion, affective shock, cognitive learning, and physiological methods, was developed in the context of the emerging fields of animal learning and neurophysiology. A further innovative feature was the use of quantitative methods to assess outcomes. These measures showed good response rates, though most cured patients were not sent back to battle because of their presumed psychopathic constitution. While some treatments appear unnecessarily harsh from today's perspective and were also criticized by leading psychiatrists of the time, the concentration of effort and involvement of so many senior doctors led to the development of psychotherapeutic methods that were to influence the field of psychiatric therapy for decades to come.

Deep brain stimulationfor movement disorders

Movement disorders remain the primary indication for the use of intracranial neurostimulation techniques. This review will discuss the history of this technology as well as the mechanisms of action, current clinical indications, and future prospects for the treatment of movement disorders.

Electrical treatment of spinal cord injuries in the 18th and 19th centuries

Two centuries ago, electricity was being used for the treatment of paraplegia and trials were taking place in France. This study aims to identify cases of traumatic paraplegia treated with electricity in the 19th century in order to assess the therapeutic benefit. Only four such cases were identified, none with a complete transection of the spinal cord since these patients would have died from pressure sores and urinary tract infections. The personalities involved, William Gull, William Erb, Guillaume Duchenne and Cyril Henry Golding Bird are portrayed and contemporaneous views on electrotherapy analysed. While the four patients apparently benefited from the treatment, the lack of follow-up and the incomplete data prevented a definitive conclusion on the therapeutic value of electrical treatment in traumatic paraplegia.

William James Morton [1845-1920]: like father, like son (?)

William Thomas Green Morton, the man most commonly associated with the introduction of anesthesia in 1846, fathered William James Morton. William James Morton's contributions to society were substantial. He conducted pioneering work in radiology, radiation oncology, and therapeutic electricity. He authored numerous textbooks and articles, and he was an editor of a journal on human behavior. His expertise on diamond mining led to an error in judgment that resulted in a felony conviction. We examine his career and contributions to society, and consider his career in light of his father, William Thomas Green Morton.

The galvanic treatment of deafness and the trials at the Berlin Royal Deaf-Mute Asylum in 1802

In 1802, the director of the Berlin Royal Deaf-Mute Asylum, Ernst Adolph Eschke, performed an experiment to investigate the possibility of curing deafness by means of galvanism. This article explores the hope for a cure for deafness that was connected to the voltaic pile, and concludes that the treatment was based on insufficient knowledge of the aetiology of deafness. Furthermore, it uncovers the competition between the medical and the pedagogic approach to deafness that resulted from the purported cure. Comparing the approaches of different directors of galvanic experiments, divergences in attitudes between the medical and pedagogic realms are revealed. This is explained with reference to the contrasting motives and experiences of educational and medical professionals: the former had reasons to resist a cure to protect their profession, whereas the latter hoped for a medical breakthrough. Since the former had personal and long-lasting relationships to deaf people, while the latter only had brief encounters with deaf patients, the physicians were also more prone to objectify their trial subjects. The report from Eschke's trials is presented as an early document of deaf reactions to attempts to restore their hearing, showing that resistance to medical interventions were prevalent among the deaf already in the early nineteenth century.

French neuropsychiatry in the Great War: between moral support and electricity

In World War I, an unprecedented number of soldiers were suffering from nervous disturbances, known as war psychoneuroses. Mechanisms of commotion, emotion, and suggestion were defined in order to explain these disturbances. In France, emphasis was placed on the mechanism of suggestion, based on pithiatism, introduced by Joseph Babinski (1857-1932) before the war to highlight the concept of suggestion and its hazy border with simulation. As a result, many soldiers suffering from war neuroses became considered as simulators or malingerers who were merely attempting to escape the front. A medical-military collusion ensued with the aim of sending as many of these nervous cases back to the front as possible through the use of painful or experimental therapies. Aggressive therapies flourished including torpillage, a particularly painful form of electrotherapy developed by Clovis Vincent (1879-1947) and subsequently by Gustave Roussy (1874-1948). At the end of the war, some psychiatrists, such as Paul Sollier (1861-1933), Georges Dumas (1866-1946), and Paul Voivenel (1880-1975), developed a more psychological approach. In Great Britain, where Charles Myers (1873-1946) coined the term shell shock in 1915 to describe these cases, psychological theories were more successful. In Germany, aggressive therapies developed by Fritz Kaufmann (1875-1941) emerged in the second part of the war. In Austria, the future Nobel Prize winner Julius Wagner-Jauregg (1857-1940) was accused of performing violent therapies on patients with war neuroses. These methods, which now seem barbarian or inhuman, were largely accepted at the time in the medical community and today should be judged with caution given the cultural, patriotic, and medical background of the Great War.

Neuromuscular electrostimulation techniques: historical aspects and current possibilities in treatment of pain and muscle waisting

Application of electricity for pain treatment dates back to thousands of years BC. The Ancient Egyptians and later the Greeks and Romans recognized that electrical fishes are capable of generating electric shocks for relief of pain. In the 18th and 19th centuries these natural producers of electricity were replaced by man-made electrical devices. This happened in following phases. The first was the application of static electrical currents (called Franklinism), which was produced by a friction generator. Christian Kratzenstein was the first to apply it medically, followed shortly by Benjamin Franklin. The second phase was Galvanism. This method applied a direct electrical current to the skin by chemical means, applied a direct and pulsed electrical current to the skin. In the third phase the electrical current was induced intermittently and in alternate directions (called Faradism). The fourth stage was the use of high frequency currents (called d'Arsonvalisation). The 19th century was the "golden age" of electrotherapy. It was used for countless dental, neurological, psychiatric and gynecological disturbances. However, at beginning of the 20th century electrotherapy fell from grace. It was dismissed as lacking a scientific basis and being used also by quacks and charlatans for unserious aims. Furthermore, the development of effective analgesic drugs decreased the interest in electricity. In the second half of the 20th century electrotherapy underwent a revival. Based on animal experiments and clinical investigations, its neurophysiological mechanisms were elucidated in more details. The pain relieving action of electricity was explained in particular by two main mechanisms: first, segmental inhibition of pain signals to the brain in the dorsal horn of the spinal cord and second, activation of the descending inhibitory pathway with enhanced release of endogenous opioids and other neurochemical compounds (serotonin, noradrenaline, gamma aminobutyric acid (GABA), acetylcholine and adenosine). The modern electrotherapy of neuromusculo- skeletal pain is based in particular on the following types: transcutaneous electrical nerve stimulation (TENS), percutaneous electrical nerve stimulation (PENS or electro-acupuncture) and spinal cord stimulation (SCS). In mild to moderate pain, TENS and PENS are effective methods, whereas SCS is very useful for therapy of refractory neuropathic or ischemic pain. In 2005, high tone external muscle stimulation (HTEMS) was introduced. In diabetic peripheral neuropathy, its analgesic action was more pronounced than TENS application. HTEMS appeared also to have value in the therapy of symptomatic peripheral neuropathy in end-stage renal disease (ESRD). Besides its pain-relieving effect, electrical stimulation is of major importance for prevention or treatment of muscle dysfunction and sarcopenia. In controlled clinical studies electrical myostimulation (EMS) has been shown to be effective against the sarcopenia of patients with chronic congestive heart disease, diabetes, chronic obstructive pulmonary disease and ESRD.

The electrical excitability of the brain: toward the emergence of an experiment

In 1870, Eduard Hitzig and Gustav Fritsch performed experiments on dogs by which they were able to produce movement through electrical stimulation of specific parts of the cerebral cortex. Contemporaries regarded the experiment as a milestone in the controversially discussed issue of cerebral localization of functions even though this experiment came as a surprise to the community of experimental physiologists who had rejected localization for several decades after the antiphrenological work of the physiologist Pierre Flourens. In this article, I will argue that the context in which this experiment emerged was not so much the French localization debate of the 1860s but rather practical demands in clinical medicine, notably in electrotherapy. At the time of the experiment, Hitzig worked as a medical practitioner in Berlin and was interested in an anatomical and physiological explanation of the specific symptoms of one of his patients. The unpredictable outcome of this interest was the discovery of the electrical excitability of the cortex. Whereas experimental physiologists dominated the discussion on cerebral localization in Germany before 1870, the situation shifted after the publication of Fritsch and Hitzig's paper. Concrete medical necessities forced the discussion about localization and it was mainly due to the authority of clinical physicians that the localization of mental qualities in the brain became a cornerstone of brain research.

[Electrical stimulation of the heart: history, current trends and prospects]

Part 1 of this review is devoted to the history of development of temporary and continuous electric stimulation (ES) of the heart. Up-to-date concepts of bradyarrhythmia are considered along with the most important techniques for its management with the use of two-chamber and frequency-adaptive systems. Algorithms for the choice of optimal ES regimes taking account of the type of bradyarrhythmia are discussed. Current concepts of physiological ES of the heart are considered. The authors describe their own experience with the application of ES of the heart.

Moxa in nineteenth-century medical practice

While we may think of moxa as a therapeutic technique that has been introduced to the United States in the last few decades of the twentieth century, this oriental healing procedure that applies the heat of burning herbs to acupuncture points was first employed in the United States by American physicians nearly two hundred years ago. Conceptualized as a counter-irritation method, moxa was used to treat a range of conditions, including inflammation, organ dysfunction, pain, and paralysis. Moxa's presence in nineteenth-century medicine was neither widespread nor of long duration, however, and notes of its use appear in medical records and doctors' daybooks only from the 1820s to the 1840s. Ultimately, moxa would be replaced by new procedures such as galvanism and the electro-magnetic machine. The tale of how doctors acquired and used moxa in the early nineteenth century is interesting in its own right. But the story of why this treatment was abandoned ties moxa to the larger saga of medicine's paradigm shift to bio-medical science and technology.

Impotence in the 18th and 19th century: concepts of etiology and approaches to therapy

The old word impotence is derived from the Latin word impotencia, which literally translated means "lack of power." Impotence, in the course of the history, has been attributed to mental pathology, anxiety, or demons or witches. Historically, the pharmacological treatments for impotence started in Greek times, when a myriad of herbal medications were applied locally to the genitals to enhance "sexual strength." In the 18th century, theories about the main factors inducing impotence saw it as an abnormal state of the fibers, a defect in the solid or liquid substances or a bad structure (tumor, inflammation, abscess, ulcer or foreign body). According to these mechanisms, when impotence depended on the state of the muscular fibers, treatment included a tepid bath and a clyster. In very fat or very weak people, who get particularly tired, it was important to use the remedies able to give energy to the fibers, such as ferrous mineral waters, for a month. Moreover, other suggestions were to ride a horse, to sleep few hours, to breathe good country air, to take a purge every 2 weeks, to drink half a glass of wine from Borgogne or to distract the mind continuously. In the 19th century, therapies regarding impotence included slight electric stimulation through the application of stimulators on the scrotum in the testis or epididymis areas, until pain was induced. In the same period, another method for treating impotence was flagellation. This method consisted of little flagellations with leather strips.

The role of The Gentleman's Magazine in the dissemination of knowledge about electric fish in the eighteenth century

Although torpedoes and Malopterurus, a Nile catfish, had been described and even used medically in antiquity, their discharges were poorly understood before the second half of the eighteenth century. It was then that their actions, along with those of certain South American "eels," became firmly associated with electricity. The realization that an animal could produce electricity marked a turning point in the history of neurophysiology, which had long described nerve actions with recourse to animal spirits. By examining The Gentleman's Magazine during the period when electric fish were becoming electrical, one can begin to appreciate how new discoveries about these unusual creatures captured the imagination of scientists and were filtered down to the literate public.

Interventional neurophysiology and an implantable system for neurostimulation of the sacral area

Surgical or interventional neurophysiology is a term commonly used to refer to a large number of neurosurgical procedures involving the brain, cranial nerves, spinal cord and peripheral nervous system which, to be efficient and safe, demand specific neurophysiological know-how. As a result of the development of these procedures and their increasing use in the operating room, the role of clinical neurophysiology, traditionally diagnostic, has been extended. With the advent of 'neurostimulation' and 'neuromodulation', some neurophysiological techniques have, in themselves, progressively become more therapeutic, the therapeutic alteration of nervous system activity being achieved not only by surgical ablation or medication but also through electrophysiological means via implanted or non-implanted devices, whose development was made possible by extensive studies in the field of neurophysiology. The first application of electrical stimulation in urology opened up the way for progress in the therapeutic direction. Moreover, with regard to the mechanism of action underlying neuromodulation, the application of neurophysiology and neuroimaging procedures has contributed to understanding of the neural control mechanism of visceral (e.g. lower urinary tract) function. In our experience, the advent of sacral neuromodulation for lower urinary tract dysfunction and the use of neurophysiology has made it possible to shed light on the pathophysiological mechanisms of neuro-urological disorders, allowing us to assess and validate new therapeutic approaches and finally to develop a new method and device for chronic pudendal nerve stimulation.

[Electrotherapy and uterine fibroids]

At the end of the 19th century, uterine fibroids cause huge therapeutic issues: on the one hand they can reach an impressive massive volume; on the other hand they provoke endless haemorrhages. Dr Apostoli develops galvanotherapy which becomes the reference in French and international medicine before its rapid downfall as gynaecological surgery makes great progress at the beginning of the 20th Century.

Electrotherapy and mental illness: then and now

Today electrotherapy has reappeared as a therapy of choice for the treatment of depression and other forms of mental illness. It had de facto vanished from allopathic medicine from the 1920s to the end of the century. The debates about electrotherapy mirror the question of whether mental illness was somatic and to be treated by somatic means or psychological to be treated with psychotherapy. Sigmund Freud's move from an advocate to an opponent of electrotherapy is exemplary for a shift in attitude and the decline of electrotherapy. With the re-somaticization of mental illness over the past decades has come the reappearance of somatic therapies such as electrotherapy.

Electrotherapy and the Human Voice: A Literature Review of the Historical Origins and Contemporary Applications

SUMMARY

The present article surveys the literature on the electrotherapy treatment for voice disorders from the mid-18th century to World War I (1914--1918) and the post 1970s reappearance of such therapies. The reappearance of electrotherapy as treatment for voice disorders in the past 20 years has been heralded as a major breakthrough. In light of our reading of the scientific literature of the 19th century, it can be shown to repeat many of the presuppositions of electrotherapists of that time. The current resurgence of interest and research in electrical stimulation of the larynx is buoyed by technological innovations analogous to those in the 19th century. Although the current state of research has enhanced our understanding of vocal fold physiology, it does not necessarily provide a new therapeutic approach as a survey of the most recent literature shows.

[Nikola Tesla in medicine, too]

Using primary and secondary sources we have shown in this paper the influence of Nikola Tesla's work on the field of medicine. The description of his experiments conduced within secondary-school education programs aimed to present the popularization of his work in Croatia. Although Tesla was dedicated primarily to physics and was not directly involved in biomedical research, his work significantly contributed to paving the way of medical physics particularly radiology and high-frequency electrotherapy.

[Birth of medical electricity]

In the mid-eighteenth century Jallabert treated an hemiplegia using electrostatic electricity and published the patient's recovery. Immediately, physicians and clergymen started to use the Nollet's machine to treat many neurological diseases and published their results. The Galvani's constant was also a medical seism when he though the had discovered animal electricity. Galvanism entered immediately medical practice for a long time.

Surgical therapy of neurogenic detrusor overactivity (hyperreflexia) in paraplegic patients by sacral deafferentation and implant driven micturition by sacral anterior root stimulation: methods, indications, results, complications, and future prospects

Spinal cord injured patients with a suprasacral lesion usually develop a spastic bladder. The neurogenic detrusor overactivity (NDO) and the overactive external sphincter cause incontinence and threaten these patients with recurrent urinary tract infections (UTI), renal failure and autonomic dysreflexia. All of these severe disturbances may be well managed by sacral deafferentation (SDAF) and implantation of a sacral anterior root stimulator (SARS). Since September 1986 to December 2002, 464 paraplegic patients (220 females, 244 males) received a SDAF-SARS. The SDAF was done intradurally in almost all cases, which means that we used a single operation field to do a two-stages procedure (SDAF and SARS). The results include data on 440 patients with a mean follow-up of 8.6 years (18 months to 18 years) until December 2004. The complete deafferentation was successful in 95.2%. Of these patients, 420 paraplegics use the SARS for voiding, (frequency 4.7 per day) and 401 for defecation (frequency 4.7 per week). Continence was achieved in 364 patients (83%). UTIs decreased from 6.3 per year preoperatively to 1.2 per year postoperatively. Kidney function remained stable. Early complications were 6 CSF leaks and 5 implant infections. Late compli cations included receiver or cable failures and required surgical repair in 44 patients. A step-by-step program for trouble-shooting distinguishes implant failure from myogenic or neurogenic failure. SDAF is able to restore the reservoir function of urinary bladder and makes the patient achieve continence. Autonomic dysreflexia disappeared in most cases. By accurate adjustment of stimulation parameters, it is possible for the patient to have a low resistance micturition. The microsurgical technique requires intensive education. In addition, the therapist should be able to manage late complications.

Designed electromagnetic pulsed therapy: Clinical applications

First reduced to science by Maxwell in 1865, electromagnetic technology as therapy received little interest from basic scientists or clinicians until the 1980s. It now promises applications that include mitigation of inflammation (electrochemistry) and stimulation of classes of genes following onset of illness and injury (electrogenomics). The use of electromagnetism to stop inflammation and restore tissue seems a logical phenomenology, that is, stop the inflammation, then upregulate classes of restorative gene loci to initiate healing. Studies in the fields of MRI and NMR have aided the understanding of cell response to low energy EMF inputs via electromagnetically responsive elements. Understanding protein iterations, that is, how they process information to direct energy, we can maximize technology to aid restorative intervention, a promising step forward over current paradigms of therapy.

Electricity in the treatment of nervous system disease

Electricity has been used in medicine for almost two millenniums beginning with electrical chocks from the torpedo fish and ending with the implantation of neuromodulators and neuroprostheses. These implantable stimulators aim to improve functional independence and quality of life in various groups of disabled people. New indications for neuromodulation are still evolving and the field is rapidly advancing. Thanks to modern science and computer technology, electrotherapy has reached a degree of sophistication where it can be applied relatively safely and effectively in a variety of nervous system diseases, including pain, movement disorders, epilepsy, Tourette syndrome, psychiatric disease, addiction, coma, urinary incontinence, impotence, infertility, respiratory paralysis, tinnitus and blindness.

John Wesley (1708-91)

John Wesley was a competent physician, quite capable of the diagnosis and care of patients. His Primitive Physic provides a picture of therapy in the eighteenth century but he rejected the bleeding and purging which were common at that time. He was ahead of his time in his emphasis on hygiene, cleanliness and simple living. In this he has been regarded as a pioneer of preventive medicine. He was in the forefront of the philanthropic movement in his provision of Dispensaries for the poor and his care of the sick and elderly. In spite of this he does not seem to have had a direct influence on the physicians of the day. Loudon does not mention him in his Origins and Growth of the Dispensary Movement in England and Clarke only gives him a passing reference in his History of The Royal College of Physicians. He experimented with electrotherapy and it seems likely he was one of those who saw that electricity could be the 'greatest step forward' in medicine as a whole.

Revealing sparks: John Wesley and the religious utility of electrical healing

In the eighteenth century, dramatic electrical performances were favourite entertainments for the upper classes, yet the therapeutic uses of electricity also reached the lower strata of society. This change in the social composition of electrical audiences attracted the attention of John Wesley, who became interested in the subject in the late 1740s. The paper analyses Wesley's involvement in the medical applications of electricity by taking into account his theological views and his proselytizing strategies. It sets his advocacy of medical electricity in the context of his philanthropic endeavours aimed at the sick poor, connecting them to his attempts to spread Methodism especially among the lower classes. It is argued that the healing virtues of electricity entailed a revision of the morality of electrical experiment which made electric sparks powerful resources for the popularization of the Methodist way of life, based on discipline, obedience to established authorities and love and fear of God.

Vagal nerve stimulation for refractory epilepsy in children: indications and experience at The Hospital for Sick Children

OBJECTIVES

The management of intractable epilepsy in children is a challenging problem. For those patients who do not respond to antiepileptic drugs and are not candidates for epilepsy surgery, vagal nerve stimulation (VNS), can be a viable alternative for reducing seizure frequency. We have reviewed the historical and clinical background of VNS treatment. We also include our experience at The Hospital for Sick Children in children who underwent VNS implantation.

METHODS

Forty-one children underwent VNS implantation for epilepsy over 6 years. After a mean follow-up of 31 months, 15 (38%) patients had a seizure frequency reduction of more than 90%. Fifteen (38%) children failed to respond to the VNS treatment. The device was removed in five children: in one, due to late infection; the other four could not tolerate the side effects of chronic VNS therapy. Two patients required reimplantation due to electrode failure. The most common side effects in our series were cough and vocal disturbances.

CONCLUSIONS

Our results show that VNS implantation can be a safe and effective alternative therapy for children with drug-resistant epilepsy who are not candidates for epilepsy surgery.

Benjamin Franklin, electricity, and the palsies: on the 300th anniversary of his birth

Benjamin Franklin was involved not only with the nature of electricity but with its possible medical utility. He conducted electrical experiments on people with palsies, notably those caused by stroke, to see if electricity from machines could restore movement. Franklin recognized that electricity was not the miraculous cure it was hoped to be, and he presented his findings in 1757 as communication to the Royal Society. Although he did not provide names or individual case studies in this communication, subsequently published in 1758, his personal letters reveal that he treated at least two important colonists: James Logan, William Penn's secretary and a prominent public official in Pennsylvania, and Jonathan Belcher, governor of several provinces. Franklin's private letters shed light on how he conducted his clinical "tryals" and why he drew the conclusions he did in his report to the Royal Society.

Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects

Vagal nerve stimulation (VNS) is an approved treatment for epilepsy and is currently under investigation as a therapy for other disorders, including depression, anxiety and Alzheimer's disease. This review examines the pre-clinical and clinical literature relating to VNS. A brief historical perspective is given, followed by consideration of the efficacy of the various clinical applications of VNS. Finally, what is known about the mechanism by which VNS exerts clinical benefit is considered. It is concluded that although the precise mechanism of action of VNS is still unknown, the search for the mechanism has the potential to lend new insight into the neuropathology of depression. It is important that prior assumptions about the influence of VNS on particular aspects of brain function do not constrain the investigations.