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In 1938, Ugo Cerletti obtained permission to experiment with electricity on pigs in a slaughterhouse. "Except for the fortuitous and fortunate circumstances of pigs' pseudo-butchery," he wrote, electroshock would not have been born." (12) Cerletti did not bother to obtain permission to experiment on the first human subject, a schizophrenic who after the initial shock said "Non una seconda! Mortifere." (not again; it will kill me). Cerletti nevertheless proceeded to a higher level and a longer time, and so ECT was born. Cerletti admitted that he was frightened at first and thought that ECT should be abolished, but later he started to use it indiscriminately.
In 1942, Cerletti and his colleague Bini advocated the method of "annihilation," which consisted of a series of (unmodified) ECTs many times a day for many days. They claimed good results in obsessive and paranoid states and in psychogenic depression. In fact, Cerletti had discovered nothing, as both electricity and fits were already known. No scientist, he believed that he discovered a panacea, reporting success with ECT in toxemia, progressive paralysis, parkinsonism, asthma, multiple sclerosis, itch, alopecia, and psoriasis. (12) By the time of his death in 1963, neither Cerletti nor his contemporaries had learned how ECT worked. The inheritors of ECT continue the same lack of understanding today.
Insulin coma and pentetrazol-induced fits, heretofore treatments of choice for schizophrenia, are not therapies any longer, and ECT is not a treatment for schizophrenia. The fact of the matter is that the pioneers of all these shock treatments contributed nothing to the understanding of mental illness, which contemporary psychiatrists are still trying to comprehend and treat on a scientific basis.
ELECTRICITY, CONVULSIONS, THE BODY, AND THE BRAIN
For its proponents, ECT is a relatively simple procedure. Electrodes are attached to the subject's head, either at the temples (bilateral ECT) or at the front and back of one side (unilateral ECT). When the current is turned on for 1 second, at 70 to 150 volts and 500 to 900 milliamperes, the power produced is roughly that required to light a 100-watt bulb. In a human being, the consequence of this electricity is an artificially induced epileptic fit. Modified ECT was introduced as a humane improvement on earlier versions of convulsive therapy to eliminate the elements of fear and terror. In modified ECT, muscle relaxant and general anesthesia are supposed to make the patient less fearful and feel nothing. Nonetheless, 39% of patients thought it was a frightening treatment. (13) These induced fits are associated with many physiologic events, including electroencephalographic (EEG) changes, increased cerebral blood flow, bradycardia followed by tachycardia and hypertension, and throbbing headache. Many patients report temporary or prolonged loss of memory, a sign of acute brain syndrome.
Since early in the history of ECT, we have known that insulin coma or pentetrazol shock can cause brain damage. (14) Bini reported severe and widespread brain damage in experimental animals treated with electroshock. (15) EEG studies showed generalized slowing following ECT that takes weeks to disappear and may persist even longer in rare cases. (16) Calloway and Dolan raised the issue of frontal lobe atrophy in patients previously treated with ECT. (17) The memory deficits after ECT may persist in some patients. (18)
Fink, an advocate of ECT, argues that the risks of ECT amnesia and organic brain syndrome are "trivial" (19) and can be reduced by hyperoxygenation, unilateral ECT over the nondominant hemisphere, and the use of minimal induction currents. (20) Earlier, Fink had indicated that post-ECT amnesia and organic brain syndrome were "not trivial." ECT advocates blame the modification for decreasing the efficacy of the treatment. (21) In the United States, the issue of unilateral ECT reflected class differences. In Massachusetts in 1980, ECT was bilateral in 90% of patients in public hospitals and in only 39% of patients in private hospitals. (22)
Templer compared the issue of ECT brain damage to that of boxing. He wrote that "ECT is not the only domain in which change to the human brain is denied or de-emphasised on the grounds that this damage is minor, occurs in a very small percentage of cases or is primarily a matter of the past." (23)
There has been less scientific investigation into the effect of ECT on other body functions and morbidity. Various animal studies showed significant results that may be important in psychoimmunology-an area of investigation that is more neglected in psychiatry than in any other field of medicine. Although it is difficult to move from an animal model to the human system, animal models frequently demonstrate the role of a range of variables in disease onset. Rats subjected to electrical stress showed significant diminution in the strength of their lymphocyte response that could not be explained by an elevation in adrenal corticosteroids. Even adrenalectomized rats had a similar decrease in lymphocyte response after electric shock (24) ; other studies have confirmed immunologic change following electric shock in animals.
USE AND ABUSE OF ECT IN SCHIZOPHRENIA
Initial claims that cardiazol convulsions and insulin coma were successful in the treatment of schizophrenia were not universally shared. Some researchers found that these interventions were worse than no treatment. (26)
For more than 50 years, psychiatrists used ECT as therapy for schizophrenia, even though there is no evidence that ECT alters the schizophrenic process. (27) In the 1950s, ECT was reported to be no better than hospitalization alone (28) or anesthesia alone. (29) At the beginning of the 1960s, the era of ECT in schizophrenia was fast drawing to a close as ECT abuses were brought to light by patients and pressure groups. In 1967, however, Cotter described symptomatic improvement in 130 schizophrenic Vietnamese men who refused to work in a psychiatric hospital and received ECT at a rate of three shocks per week. (30) Cotter concluded that "the result may simply be due to patients' dislike and fear of ECT," but he further claimed that "the objective of motivating these patients to work was achieved." (30)
Most contemporary psychiatrists consider the use of ECT in schizophrenia as inappropriate, but some believe that ECT is at least equal to other therapies in this illness. (31)
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