Ugo Cerletti and Lucino Bini were the first to introduce the idea of inducing convulsions for therapeutic purposes by using electric currents rather than convulsive drugs.
The history of somatic treatment procedures in psychiatry (specifically, the use of electric currents for therapeutic purposes) has never followed a linear course of development. It is recorded that in 46
The invention of electroconvulsive therapy (ECT) by Ugo Cerletti and Lucino Bini in 1937 was entirely unrelated to earlier investigations on treating mental illness through the use of electric currents. The use of ECT as a treatment for mental illness, rather, must be credited to the Hungarian psychiatrist Ladislas J. Meduna, who first recognized the therapeutic effect of generalized seizures when he induced convulsions with pharmacologic agents.
Much of Meduna’s research was in the neuropathology of schizophrenia, in a school that maintained that schizophrenia was an incurable, endogenous (originating internally), hereditary disease in which cerebral neurons were preferentially attacked. Other mental syndromes, particularly epilepsy, were considered exogenous (originating externally) in origin, and hence curable. Meduna’s attempt to induce seizures in schizophrenics resulted from his hypothesis that there is a biological antagonism between the process that produces epileptic attacks and the process that produces schizophrenia. The effect of the epileptic convulsion is that it changes the chemical constituents in the organism in a way suitable for the cure of schizophrenia.
Consequently, in January of 1934, Meduna treated his first patient with intramuscular camphor in oil, causing the patient to have a seizure fifteen to twenty minutes after the injection. Meduna obtained the first remissions in schizophrenics with camphor in oil. He soon realized, however, that this technique was inconvenient because the patients convulsed only after considerable time, sometimes had more than one seizure, or did not convulse at all. He therefore replaced the camphor injections with intravenous pentylenetetrazol (Metrazol). The pharmacologic convulsive treatment with Metrazol, and some other convulsive drugs,
In 1936, Cerletti, in the Rome Clinic, adopted the Sakel method (named for its inventor, Manfred Sakel) of treating schizophrenia by means of insulin coma (insulin shock treatment).
Cerletti expressed the enthusiastic opinion that “shock treatments” with insulin coma and Metrazol had changed psychiatry from a morbid science into a therapeutically active field, and he immediately developed an extensive research program to investigate electroconvulsive therapy. In his previous research on experimental epilepsy, Cerletti had induced seizures by applying the electrodes to the mouth and anus of dogs. His considerable hesitation about attempting this procedure in humans resulted from the fact that half of the dogs treated in this manner had died. Bini, however, realized that death was caused by the current traveling through the heart. Consequently, when the investigators changed the location of the electrodes to the two temples of the dogs, the heart was no longer within the electric circuit, and no further animals were killed.
It was Bini who had first reported on Cerletti’s studies, at the First International Congress on New Treatments of Schizophrenia, in Münsingen, Switzerland, in 1937, after he heard that electrical current was being used in a Rome slaughterhouse. Bini and Cerletti, however, delayed the clinical application of the treatment and visited the slaughterhouse, where they found that the animals were not killed by means of the electric current but were only stunned with electrodes applied to the head. The animals convulsed, and the actual killing was done before they regained consciousness. After spending two years performing experimental neuropathological studies to rule out brain damage and finding that neither the dogs nor other animals succumbed to the electrically induced convulsions, the researchers considered it safe to proceed with the first application of electroconvulsive therapy to human beings.
The first patient was treated in April, 1938, with a very primitive machine constructed by Bini. Cerletti’s understandable fear of allowing Bini to proceed with the treatment explains why, at first, a minimal amount of eighty volts for one-tenth of a second was applied. Although the application of this voltage led to a short period of unconsciousness, no seizure resulted. A second stimulus of ninety volts for one-tenth of a second led to a somewhat longer “petit mal” (small seizure). After a minute, the patient awakened and began to sing a popular song. When the doctors discussed the prudence of a third stimulus, the patient unemotionally uttered something about dying but did not object to a third, stronger application, which led to a generalized seizure. The patient, a completely incoherent schizophrenic who had not been able to give his physicians any information about himself, received a total of nine treatments. During the two-year period of follow-up treatments, he was leading a normal life and maintained a job as a skilled worker.
After clinical application of electroconvulsive therapy had begun, Cerletti organized a detailed research program, giving assignments to the different members of his staff. Cerletti and Bini published the findings of this program in a monograph (in Italian) in 1942. In that publication, they answered many important questions concerning the procedure, but the monograph remained unknown in American psychiatric literature. Later, Cerletti gave two accounts of his work in English, in 1950 and 1956. These accounts, however, were partly distorted by Cerletti’s belief that the injection of the brain substance of electroshocked animals into psychiatric patients would eliminate the need for convulsions. He assumed that repeated seizures in animals produced a substance in their brains that he called “acroagonine.” Cerletti found that injections of such brain substances also increased the resistance of animals to certain infections. In psychotics, some improvement in affect (emotion) and anxiety was seen, but overall the results of this indirect method to reproduce the therapeutic effect of electroconvulsive therapy remained unsatisfactory.
Cerletti continued his research attempts to improve the electroconvulsive treatment techniques and to understand exactly how the treatment worked. He determined that the cerebral seizure was essential to the clinical results and that neither the currents used to elicit a seizure nor the motor aspects of the convulsion were significant. Anticipating some of the later interest in the hormonal effects of seizures, in 1956 Cerletti suggested that part of the vegetative syndrome induced by electroshock was localized in the diencephalic section of the cerebrospinal axis. Unfortunately, Cerletti never determined electroconvulsive therapy’s exact mode of action.
The development of electroconvulsive therapy had an immediate impact on the psychiatric community. In the late 1930’s and early 1940’s, the new therapy demonstrated by Cerletti and Bini largely replaced pharmacologic convulsive treatment. Moreover, following initial reports of the value of convulsive therapy in the treatment of affective disorders as well as schizophrenia, ECT became the most widely used organic therapy in psychiatry during the years immediately preceding and following World War II. Interest in the convulsive therapies increased with the demands of war. Many physicians were trained in clinical psychiatry by the military, and the convulsive therapies were a significant part of their education as well as their military clinical experience. When patients failed to respond to one therapy, insulin coma and seizure therapy were combined. Some physicians increased the number and frequency of seizure inductions and found positive results—particularly in schizophrenia—to be related to number and frequency of seizures.
The use of electroconvulsive therapy soon began to have a negative impact on some members of the psychiatric community, however. As the side effects of shock therapy as well as prefrontal lobotomy (another organic treatment developed at about the same time as shock therapy and largely used to treat the same disorders) came to be more and more recognized, many maintained that the cure did more harm than the disease. By 1946, accusations of random and/or indiscriminate use of these techniques on patients (to deal with anything from homosexuality to psoriasis) questioned the effectiveness of these organic methods. At that time, the American Group for the Advancement of Psychiatry issued a statement declaring that widespread and dangerous abuses in the use of ECT justified a campaign of professional education in the limitations of the technique and the institution of certain measures of control. In 1978, a task force of the American Psychiatric Association published a report of their findings on electroconvulsive therapy’s effectiveness.
By the 1950’s, psychotropic drugs
Once again, however, a gradual decline in the use of the convulsive therapies occurred, although some scientists continued their studies in reduced numbers. Much research was devoted to understanding the seizure process and improving its safety. The usefulness of intensive treatments in severely ill schizophrenics was reexamined, with follow-up studies finding that those who received intensive treatments exhibited better results in residual symptoms, work records, and rehospitalization rates than did those treated with pharmacotherapy alone.
Whereas insulin coma was virtually abandoned, electroconvulsive therapy continued to be used. Nevertheless, growing concern that ECT may cause irreparable damage to the brain and that its use may contravene or deny patients’ rights to decide knowingly what is done to them led to judicial and legislative challenges to its use, as exemplified by the virtual ban the state of California placed on its use in 1974. Similar concerns voiced in England, Scandinavia, and Holland resulted in additional evaluations.
Ultimately, with improved equipment and techniques of treatment, clarification of the indications, and better education, the incidence of adverse reactions declined. Moreover, some researchers in the early twenty-first century believe that the legacy of this once-experimental psychiatric treatment may eventually lead to a better understanding of brain function and behavior.
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Abrams, Richard. Electroconvulsive Therapy. 4th ed. New York: Oxford University Press, 2002. Standard reference work on the subject covers the biological foundations and clinical applications of the procedure, reflecting state-of-the-art technology. Informative chapter on the history of convulsive therapy highlights the work of Cerletti and Bini. Includes bibliography. -
Breggin, Peter R. Electroshock: Its Brain-Disabling Effects. New York: Springer, 1979. Informative work describes the adverse effects of electroconvulsive therapy (including brain damage) and notes the uses and potential abuses of this form of therapy. Accessible to lay readers as well as clinicians. -
Cerletti, Ugo. “Old and New Information About Electroshock.” American Journal of Psychiatry 107 (1950): 87-94. Article by one of the coinventors of electroshock therapy presents a history of the origin of this practice, offers a firsthand account of the invention, and discusses the first ten years of its application. -
Fink, Max. Electroshock: Restoring the Mind. New York: Oxford University Press, 1999. Explains the use and efficacy of electroconvulsive therapy in the treatment of psychiatric disorders. Also presents a brief history of ECT. Includes comprehensive bibliography and index. -
Kalinowsky, Lothar, and Paul H. Hoch. Shock Treatments, Psychosurgery, and Other Somatic Treatments in Psychiatry. 2d ed. New York: Grune & Stratton, 1952. Lengthy and rather dated work devoted to the organic treatment of psychiatric disorders includes a useful chapter on the historical development of treatment procedures that includes much information on Cerletti and Bini’s work.
Egas Moniz Develops the Prefrontal Lobotomy