The British Journal of Psychiatry. Berrios GE. The scientific origins of electroconvulsive therapy: a conceptual history. Variation of plasma cortisol levels in patients with depression after treatment with bilateral electroconvulsive therapy. Trends Psychiatry Psychother. Babini VP. Looking back: Italian psychiatry from its origins to Law of J Nerv Ment Dis. The history of Italian psychiatry during Fascism. Ugo Cerletti : an early Italian father of electroshock and a pioneer in many other ways.
May 18, Robert M. Its value was mainly observable in mild mental disturbances, particularly neuroses. But beginning in the s these methods began to be supplemented by physical approaches using drugs, electroconvulsive therapy, and surgery.
The knowledge that head trauma, convulsions and high fever could be good for improving mental disturbances is not new in Medicine. Hippocrates was the first to note that malaria-induced convulsions in insane patients was able to cure them. In the Middle Ages, some physicians observed the same phenomenon after a severe bout of fever; such as after cholera epidemics in insane asylums.
In , a physician named Roess claimed improvement in mental patients after inocculation with smallpox vaccine. Furthermore, many physicans along the centuries have noted that there are very few epileptics who are also schizophrenic, and a biological theory on the incompatibility of convulsions and mental disease slowly evolved. In addition, for centuries physicians had been fascinated with the idea of treating mental and neurological diseases by using electricity.
Between and , four methods for producing physiological shock were discovered, tested and used in the psychiatric practice, all of them in Europe:. The advent of treatment of the psychoses by using physiological shock increased the opposition between two schools of thought within psychiatry: the psychological and biological ones. The " psychological school " interpreted mental disease as being due to deviations in the personality, problems in rearing and childhood, discontrol of internal drives, etc.
This school was typified by psychoanalysis, founded by Sigmund Freud in the beginning of the 20th. The " biological school ", instead, considered that mental diseases, particularly the psychoses, were caused by pathological alterations of the brain, chemical or structural. Consequently, the approaches to therapy by each school were markedly different. The success of shock therapy, which was evidently due to some drastic alteration in the internal environment of the brain and on the functions of the neural cells, was a strong argument in favor of the biological causation of many mental diseases.
The first researcher to systematically pursue the link between fever and mental disease was the Austrian physician Julius Wagner von Jauregg. He observed that insane patients improved considerably after surviving to severe typhoid fever, erisipella or tuberculosis infections. Impressed by the coincidence that all of these patients had episodes of high fever and inconscience, he started to do experiments with many methods of inducing fever, such as infection by erisipella, injections of tuberculin, typhoid, etc.
Wagner-Jauregg's first breakthrough came when he began treating general paresis, a exceedingly severe and common neuropsychiatric disease caused by advanced neurosyphillis, whose cause was unknown at the time.
Paresis, also called dementia paralytica, was an incurable and almost always fatal disease, and the insane asylums were full with patients with it, due to the inexistence of effective treatments for syphillis.
It was accompanied by marked and progressive neurological and mental degeneration, including convulsions, ataxia motor incoordination , speech deficits and general and widespread paralysis.
Mentally, it caused mania, depression, paranoia and violent behavior, including suicide, delusions, loss of memory, disorientation, and apathy. The breaktrough was inspired by a startling series of medical discoveries in microbiology, In , Ronald Ross had discovered in India that malaria was caused by a parasite transmitted by the Anopheles mosquito.
In , Schaudinn, in Germany, discovered the pathogenic agent for syphillis, the Treponema pallidum. In the same year, Karl Landsteiner proved that fever was able to kill the syphillis-causing spirochetes.
In the next year, Wassermann discovered the sorological test for syphillis which is used to detect the infection very early, and in it was used for the first time for testing the cerebrospinal fluid. In , after attempts at the chemotherapy of syphillis, Paul Ehrlich achieved success with salvarsan or the " Compound", on the basis of arsenic, which was the first scientifically designed substance to be used against microbes.
Finally, in , Noguchi and Moore demonstrated that general paresis was in fact an infection of the nervous system by syphillis, and this was the first time in medical history that a kind of mental disturbance, or madness, could be traced to a biological alteration of the brain!
The "biological" school of psychiatry had scored a tremendous victory. Nowadays, dementia paralytica is a rare complication of syphillis, and Wagner-Jauregg's treatment has been supplanted by the use of antibiotics. T he second breakthrough in the shock treatment of psychosis was achieved in by a young Polish neurophysiologist and neuropsychiatrist named Manfred J. While an internist in the Lichterfelde Hospital for Mental Diseases, in Berlin, Germany, he provoked a superficial coma in a morphine-addicted woman, using an injection of insulin, and obtained a remarkable recovery of her mental faculties.
Insulin had been discovered in by two Canadian medical researchers, Frederick Banting and Charles Best , as the hormone fabricated by the pancreas which is responsible for maintaining the equilibrium of glucose in the body.
The lack of insulin causes diabetes, or hyperglicemia excess of glucose , while its natural or artificial excess causes hypoglicemia, which leads to a coma and to convulsions, due to the deficit of glucose in the brain cells. Sakel discovered accidentally, by causing convulsions with an overdose of insulin, that the treatment was efficient with patients afflicted with psychosis, particularly schizophrenia.
In he began to perfection what was to become the "Sakel's Technique" for treating schizophrenics, first in Vienna, at the University Neuropsychiatric Clinic, and after , in the United States. The official communication of his technique was made on September , and was enthusiastically received. Until then, no biological treatment for schizophrenia was available. Sakel's approach was a practical and workable physiological method to attack this most debilitating and cruel mental disease.
This was to be one the most important contributions ever to be made to psychiatry. Two large studies carried out in the USA in and gave him fame and helped his technique to rapidly spread out around the world. Initial enthusiasm was followed by a decrease in the use of insulin coma therapy, after further controlled studies showed that real cure was not achieved and that improvements were many times temporary.
However, since Sakel's method is the gentler and less deleterious of all somatic techniques, it was still in use in many countries until recently. In , in the same year that Sakel announced officially his results with the insulin coma therapy, a young Hungarian physician named Ladislaus von Meduna, working at the Interacademic Institute of Psychiatric Research, in Budapest, started what would become an entirely new approach to physiological shock in the treatment of mental disease.
Unaware of Sakel's investigations, Meduna studied the brains and the mental health histories of schizophrenics and epileptics and noted that there seemed to exist a "biological antagonism" between these two diseases of the brain.
Meduna reasoned, then, that "pure" artificially induced epileptic convulsions could be able to "cure" schizophrenia. He then began testing several kinds of convulsant drugs on animals and then on patients. His goal was to achieve completely controllable and reproducible convulsions. The first substance he tested, in , was camphor, but the results were not reliable.
He tested also strychnine, thebain, pilocarpin and pentilenetetrazol also known as metrazol, or cardiazol , always injecting them intramuscularly. Sakel had used many of these drugs together with insulin, in order to enhance the convulsions, but never alone. However, Meduna's aims were achieved only when he experimented with intravenous injections of metrazol. Convulsions ensued quickly and violently, and were dose-dependent. From this point on, two camps were firmly established in relation to physiological shock therapy: those who defended insulin coma therapy and those who sided with metrazol-induced convulsions.
Metrazol was cheaper, much easier to use and more reliable to induce convulsions. Insulin coma required five to nine hours of hospitalization and close follow-up, but it was easily controlled and stopped with injections of glucose or adrenalin, when needed.
Metrazol was stronger and more difficult to control. Meduna was also forced to immigrate to Chicago, in the USA, in , and from there he continued his research on metrazol convulsions. I am a historian of psychiatry, and I have published a book on the history of ECT.
I had, like many people, been exposed only to the frightening images of ECT, and I grew interested in the history of the treatment after learning how many clinicians and patients consider it a valuable treatment. My book asks the question: Why has this treatment been so controversial?
ECT works by using electricity to induce seizures. This is certainly a counterintuitive way of treating illness. But many medical treatments, such as chemotherapy for cancer, require us to undergo terrible physical experiences for therapeutic purposes. The conflicts over ECT have other sources. ECT was invented in Italy in the late s. Psychiatrists had already discovered that inducing seizures could relieve symptoms of mental illness. Before ECT, this was done with the use of chemicals, usually one called Metrazol.
By many reports, patients experienced a feeling of terror after taking Metrazol , just before the seizure started. A Cleveland psychiatrist who was active then once told me that the doctors and nurses used to chase the patients around the room to get them to take Metrazol.
Ironically, given that ECT would become iconic as a frightening treatment, the Italian researchers who proposed using electricity instead were searching for a safer, more humane and less fearsome method of inducing the seizures.
Their colleagues, internationally, believed they had succeeded. Within only a few years of its invention, ECT was widely used in mental hospitals all over the world. Many depictions of ECT in film and television have portrayed the therapy as an abusive form of control.
There is probably no fictional story that so haunts our consciousness of a medical treatment.
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