The birth of convulsive therapy revisited: a reappraisal of László Meduna's first cohort of patients.

BACKGROUND: The introduction of convulsive therapy (COT) was undoubtedly one of the milestones in the history of psychiatry. Its originator, László Meduna, has become one of the founding fathers of biological psychiatry. METHODS: In his first major publication on COT, Meduna described the short-term treatment outcome of the first 26 schizophrenia patients who underwent camphor- or cardiazol-induced COT; 10 improved significantly, 3 appeared slightly improved, and 13 were unimproved. The original medical notes of 23 of the 26 patients were recently recovered and the patients re-diagnosed by the authors employing ICD-10 criteria. RESULTS: The diagnosis of schizophrenia was confirmed in 15 cases (all but two of them involving prominent catatonic symptomatology), while 2 cases met diagnostic criteria for schizoaffective disorder, 3 for Bipolar Affective Disorder (BAD) with psychotic features, 1 for psychotic depression, and 1 for Acute and Transient Psychotic Disorder (ATPD). In a final case, the most probable diagnosis was schizophrenia. Scrutiny of the notes revealed that 4 schizophrenia patients evidenced slight improvement on COT and in one case the improvement was only transient. A limitation of this study is that the quality of the original files varied considerably and the re-evaluation was done retrospectively. CONCLUSIONS: A very broad concept of schizophrenia in the 1930s explains the discrepancy between the original and the revised results. In line with the current views on the effectiveness of electroconvulsive therapy, catatonic symptoms, but not the core schizophrenic process, showed some improvement while all ATPD, BAD and depressed patients responded to COT.

László Meduna's pilot studies with camphor inductions of seizures: the first 11 patients.

In his autobiography, László Meduna described the first session of convulsive therapy using intramuscular camphor as occurring on January 23, 1934 at Royal National Hungarian Institute of Psychiatric and Neurology at Budapest-Lipótmezo in Hungary. Unearthed records of the patients treated at this institution reveal that Meduna's dose-finding experiments began on January 2, 1934. The symptomatology and history of illness, diagnosis, socio-demographic data, the seizure characteristics, and immediate and long term outcomes of the first 11 patients are described. These first trials elicited seizures in less than half the injections. Seizures of various durations (including missed seizures) and double (tardive) seizures were recorded. Mutism, refusal to eat requiring tube feeding, and other signs of catatonia dominated the psychopathology of 7 of the first 11 patients. Two improved sufficiently to be discharged from the hospital and third patient became fit for occupational therapy. These records exhibit the meticulous systematic nature of the first human trials with induced seizures and the fortuitous nature of the first human trials with induced seizures and the fortuitous nature in patient selection of catatonic patients--an illness that is most responsive to induced seizures.

Sakel versus Meduna: different strokes, different styles of scientific discovery.

It is ironic that Laszlo Meduna and Manfred Sakel made epochal discoveries in psychiatry only two years apart because in most other ways, the two men could hardly be more different. The story of their differences and similarities invites us to consider the personal preconditions for scientific discovery. What common denominators led them to develop treatments, which represent the introduction of convulsive therapy, which remains today the most powerful treatment in psychiatry? Despite the marked differences in their personalities, Sakel and Meduna shared intellectual quickness, drive, and a willingness to take risks, three qualities that, in the case of these individuals at least, came together to revolutionize the treatment of serious psychiatric illness.

[The birth of convulsive therapy]. / A görcskezelés születése.

The history of the first convulsive treatment is summarized here in commemoration of its 75th anniversary. The neuropathological and clinical findings underlying the theoretical basis of the method are reviewed, together with the case histories of the first batch of patients who underwent convulsive therapy. The early indications and effectiveness of convulsive therapy are also discussed. Finally, in a broader context, the role of convulsive treatment in the development of modern biological psychiatry and Laszlo Meduna's contribution to this development touched upon.

[The birth of biological therapy in Hungary: the story of László Meduna's first patient receiving convulsive therapy]. / Biológiai terápia születése Magyarországon: Meduna László "elsô" görcskezelt betegének története.

Convulsive treatment was introduced to psychiatry by László Meduna, a Hungarian neuropsychiatrist. In his autobiography, Meduna gave a detailed description of his first patient who underwent convulsive therapy. According to Meduna's recollections, this patient was L. Zoltán, who after 4 years of fluctuating catatonic stupor received several sessions of camphor-induced convulsive therapy resulting in full remission and discharge from the institution. In this communication, the authors reconstruct L Zoltán's case history from the original case notes, which were recovered from the Archives of the National Institute of Psychiatry and Neurology, Budapest. The case notes show that L. Zoltán received courses of convulsive treatment between 1934 and 1937, first induced with camphor and then with cardiazol. After the first course of treatment the catatonic stupor was resolved and the psychotic symptoms subsided. However, this incomplete remission lasted only for a few months and was followed by a relapse. Despite further courses of convulsive therapy, L. Zoltán never became symptom free again, could never be discharged and died in the institute in 1945. The authors attempt to explain possible reasons for the discrepancies found between Meduna's account and L. Zoltán's case notes.

Estado convulsivo

El estado convulsivo generalizado constituye una emergencia médica que en lo ideal, debería manejarse en una unidad de cuidados intensivos. De acuerdo con la definición moderna del status spilépticus, el tratamiento debe iniciarse cuando una convulsión o una serie de convulsiones persistan por más diez minutos, esto para evitar el daño cerebral que puede empezar a los 30 min. En la actualidad los promedios de mortalidad no deben exceder del 10 al 12 por ciento; los cambios fisiopatogénicos que ocurren en el estado convulsivo generalizado son muy variados y comprenden entre otros la acidosis láctica, y la disfunción autonómica en insuficiencia renal aguda por la mioglobinuria ocasionada por la excesiva actividad muscular de las convulsiones. La etiología del estado convulsivo en un paciente epiléptico es muy variada, entre ellas tenemos la supresión brusca de la medicación anticonvulsivante en un paciente epiléptico, el período de abstinencia en un paciente alcohólico, la meningoencefalitis, aclampsia, insuficiencia renal crónica, encefalopatía hipertensiva y metaólica (hipoglicemia, hiponatremia), los tumores cerebrales y menos frecuentemente los hematomas subdurales crónicos. El esquema terapéutico para el manejo del estado convulsivo comprende la administración de fármacos de acción inmediata como el diazepam intravenoso, midazolam, loracepam, seguido de fenitoína intravenosa a una dosis de impregnación de 20 mg/kg de peso diluída en 100 ml de solución salina normal a una velocidad de 50 mg/min, previo monitoreo de la presión arterial y frecuencia cardíaca. Si persisten las convulsiones, debe administrarse tiopental sódico o un anestésico general como el isofluorante o más recientemente el propofol; también puede ser usado el clonacepam intravenoso

The early history of convulsive therapies in Australia.

The early experience of convulsive therapies in Australia was reported in the Medical Journal of Australia from 1935 to 1950. Cardiazol convulsive therapy, first used in Australia in 1937, appears to have been widely employed. Electroconvulsive therapy, first used here in 1941, rapidly became accepted as a mainstream treatment. Early response rates are discussed, as well as Australian adaptations of European techniques. Clinicians of the day considered the use of these procedures carefully and were circumspect about their future role.