Acta Medica Mediterranea, 2017, 33: 1051

THE HISTORY OF THE SALENTO’S MENTAL HOSPITAL AND THE USE OF SOMATIC THERAPIES

MARIA ROSA MONTINARI,* SERGIO MINELLI** *Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy - **ASL Lecce, D.S.S. n. 52, Lecce, Italy

ABSTRACT

In this article, we are going to retrace the history of the Salento’s Mental Hospital, one of the largest psychiatric facilities in Southern Italy and we whilst addressing the use of somatic therapies in this institution. The Provincial Mental Hospital of Terra d’Otranto, established since 1897, started operation in1901, under the direction of Dr. Giovanni Libertini. In 1931, after the advent of fascism, with the split of the Lecce Province into three provinces (Lecce, Brindisi and Taranto), The Mental Hospital turned into a hospital consortium, called The Interprovincial Psychiatric Hospital of Salento (OPIS) and subsequently, from 1985 to 1998, The Psychiatric Hospital “Giovanni Libertini”. At The Interprovincial Psychiatric Hospital of Salento (O.P.I.S.) somatic therapies, and in particular Electroconvulsive Therapy (ECT), were widely used. Afterwards, in the 1950s, with the advent of psychotropic drugs (neuroleptics, antidepressants, MAO inhibitors tricyclics, benzodiazepines), the success of somatic therapies and in particular of ECT decreased significantly. The recent renewed interest in somatic therapies - again considered in the most advanced scientific studies and used in a large number of renowned hospitals and universities - is linked to the considerable deepening of the biological knowledge of such thera- pies and to drug resistance of many psychiatric illnesses. Therefore, we considered it opportune to historically analyze the use of somatic therapies in one of the most important psychia- tric institutions of Southern Italy.

Keywords: Salento’s mental hospital, history, somatic therapies, Electroconvulsive Therapy (ECT).

DOI: 10.19193/0393-6384_2017_6_166 Received December 30, 2016; Accepted June 20, 2017

Introduction The problem of assistance and care of the mentally ill did not exist. Only from the XIX century - after the The main concern of society was to keep sepa- demonological conception of mental disorders - rate, segregated and excluded, those who for vari- psychiatric illnesses were considered morbid forms ous reasons could be dangerous, cause harm to oth- in the strict sense. Before then, an ethical-religious ers, or were unable to provide for their mainte- model was widely spread that saw psychiatric ill- nance. nesses as expressions of magic, divine or demonic Then the madness was often confused with influences; so the mentally ill were reputed pos- other economic, social or health conditions which sessed individuals that had to be exorcised. These made some people unable to live adequately in civil people represented a threat, a social danger that was society. necessary to isolate from the rest of society, even at With the medicalized reading of mental health the cost of segregation, the use of violent methods, problems, structures dedicated to the care of psy- and the suspension of all rights. chiatric patients began to spread. 1052 Maria Rosa Montinari, Sergio Minelli

In most cases, the mental hospitals were countryside and villages and often belonged to poor derived from pre-existent structures (hospitals, hos- families, who could not bear the burden of their pices, convents), but in some cases the buildings care. In addition, there wasn’t an adequate structure were built ex novo: the reference model was the where the insane were kept even only temporarily, Panopticon, designed by the English philosopher- waiting to find an asylum to house them elsewhere. jurist Jeremy Bentham in 1791. In July 1879, the Public Administration began In Italy - in keeping with the social mandate of searching for a suitable building, which was identi- the law of 1904 - the asylum was mainly a contain- fied in the workhouse of Lecce, (State Archives of er in which to hide and check the waste of society. Lecce, Sheet 120, Envelope 26) located in the ex- Curative purposes were secondary to the main pur- Convent of The Olivetans, suppressed - like the pose of social control. other convents - by the law dated 7 July 1866. The Obviously, even the history of the Salento's temporary admission of the “poor idiots” was orga- Mental Hospital reflected the political - health nized into four “custody rooms”, adequately pro- choices of time. vided with padded walls and restraint beds (ibi- The birth of the Provincial of dem). Terra d' Otranto in Lecce, its transformation into The medical director, Giuseppe Vigneri, guar- Interprovincial Psychiatric Hospital of Salento anteed that those rooms were fit to contain furious before and then in the Psychiatric Hospital fools and structured in such a way that the insane “Giovanni Libertini” are, in fact, a sign of the evo- could not harm themselves or others. However, the lution of Psychiatric Institutions(1). alienated could stop in the custody rooms for up to In this article, we retrace the history of the ten days, then having to be sent to a real mental Salento’s Mental Hospital and we particularly want hospital, in particular to the Aversa’s Mental to study the use of somatic therapies in this institu- Hospital (Institute since 1813), to which the tion, treatments widely used in until the Provincial Deputation of Lecce paid onerous hospi- 1950s and then abandoned because they are consid- tal fees, with the right to check, at any time, that ered obsolete and outdated. This interest is derived adequate treatment was offered to the patients from the finding that, in recent years, somatic thera- (State Archives of Lecce, Sheet 151, Envelope 34). pies in psychiatry are again considered in the most Doctor Vigneri was the first to have the idea of advanced scientific studies and are used in a large setting up a mental hospital in Lecce: he was cer- number of renowned hospitals and universities. tainly discouraged by the difficulties in which he The currently most used and interesting was forced to operate, disheartened by the paucity somatic therapies include, in addition to of the means and overburdened by the growing Electroconvulsive Therapy (ECT) note: Magnetic demand for admission by the population. This idea Therapy (MST), Transcranial Magnetic was later acquired by the provincial administrators. Stimulation (TMS), deep Transcranial Magnetic In Lecce there was another convent available, Stimulation (deep TMS), Transcranial Direct that of the Friars Alcantarini which - according to Current Stimulation (tDCS), Vagus Nerve the above-mentioned law of 7 July 1866 - had been Stimulation (VNS). surrendered to the Provincial Administration. The Also at the Interprovincial Psychiatric Alcantarini’s Convent - originally defined as the Hospital of Salento (O.P.I.S.), one of the largest Convent of St. James as it is adjacent to the psychiatric facilities in southern Italy, somatic ther- homonymous church - was a building built by apies, and in particular ECT, were widely used. Ferrante of Aragon in the second half of the fif- teenth century. In 1614 it was then donated by History of Salento’s mental hospital Philip III of Spain to the Alcantarini, a Franciscan congregation of Spanish origin, who had dedicated The Provincial Lunatic Asylum of Terra the complex to St. Pasquale. d’Otranto, 1897-1930(1,2,3,4). (Manicomio The official transfer of the convent at Lecce Provinciale di Terra d’Otranto, 1897-1930) Province took place on 23 September 1870, with At the end of the nineteenth century, there was the obligation to use it as an asylum of beggary. an urgent need to establish a provincial mental hos- Instead, in contravention of this clause, from March pital even in the land of Otranto. At that time, the 1871 until August 1881, some premises were tem- many mentally ill were probably scattered in the porarily granted in use at the Practical School of The history of Salento’s mental hospital and the use of somatic therapies 1053

Agriculture. Finally, in 1887 and for 10 years, the In later years (from 1903 to 1930) the hospital structure was utilized as a barrack hosting the 84th - after the initial adaptations of the ex-convent of Infantry Regiment. San Pasquale - was enlarged, further renovated with Only ten years later, with a return note of 29 other pavilions, other services and other beds. In July 1897, it was finally returned to the Province. particular, the construction of the laundry room and Meanwhile, on 3 January 1895, in a historic ses- workshop, the 2nd Women and Men's Pavilion, the sion, the Provincial Council of Terra d’Otranto Medicine, the showroom and the warehouse build- unanimously voted to institute a mental hospital in ings was realized. Consequently, in addition to the Province of Lecce and on 1 December 1897 the patients, also the staff responsible for their care Provincial Deputation presented to the council an increased. articulated project, with cost estimates, for the adaptation of the buildings of the ex-convent St. The Interprovincial Psychiatric Hospital of Pasquale, drawn up by the engineer Luigi Libertini. Salento, 1931-1985 The Libertini engineer took advantage of the spe- (Ospedale Psichiatrico Interprovinciale cialist counseling of the psychiatrist Giovanni Salentino, O.P.I.S., 1931-1985) Libertini, who in turn went to Naples and Florence after: to request clarification to his famous masters The Psychiatric Hospital “Giovanni Professors Bianchi (State Archives of Lecce, Sheet Libertini”, 1985-1998(1,2,3,4,5) 147, Envelope 33) e Tanzi. (Presidio Ospedaliero Psichiatrico "Giovanni In 1900, the works of completion of the hospi- Libertini”, 1985-1998) tal could be considered concluded: in the ex-con- In 1931, after the advent of fascism, with the vent the alienated found a rational placement, split of the Lecce Province into three provinces divided according to their typology. There was a (Lecce, Brindisi and Taranto), the mental hospital separate sector for the quieter patients, another for turned into a hospital consortium, called The the agitated ones another for the filthy, one Interprovincial Psychiatric Hospital of Salento detached for women in the south of the former con- (O.P.I.S.). The O.P.I.S. could carry out the functions vent. The facility could accommodate about 200 of hospitalization and care of the mentally ill inde- people: The Provincial Mental Hospital of Terra d' pendently, with its own administrative and judicial Otranto started operations in March 1901, under the organization, according to the provisions of law 14 direction of Dr. Giovanni Libertini. The doctors February 1904 n. 36 and the subsequent regulation who took care of the patients in the hospital were on asylums and alienates of R. D. n. 615, 16 August three at that time, since there was a team formed by 1909. A hospital consortium management was the head physician and two medical assistants. deliberated, one which included the participation of In the same year an internal regulation was the now autonomous provincial administrations of also approved (State Archives of Lecce, Sheet 2699, Lecce, Brindisi and Taranto in the management Envelope 502), replaced on 29 May 1907 by anoth- expenses, in relation to the number of patients for er more organic regulation, promulgated on the each province. So, it was called “psychiatric hospi- basis of the law 14 February 1904 n. 36, with which tal” what until then had always defined lunatic asy- it was possible to organize the internal life of the lum. However, the typical lunatic asylum imprint hospital. The regulation established very precisely was obviously bound to last. the functioning of the mental hospital, the organiza- The fame and prestige of the hospital tional chart, employees’ duties, service hours and increased, but there was scarcity of means and staff. rest days. The director of those years, Professor Gullotta, The hospital staff was subject to very strict tried to buffer the urgency as much as possible, ask- rules, frequent checks, heavy work shifts and severe ing the intervention of administration and sternly disciplinary measures, especially if a patient monitoring the staff. escaped or died, due to negligence of staff; the Meanwhile, the hospital was further expanded working climate was of sacrifice and self-denial. to cope with the continuous increase in the number The culture was founded on hard work and effort. of hospitalizations and in 1939 - with the direction Only a few years later better working condi- of Professor Umberto De Giacomo - the construc- tions were introduced, with increased benefits and tion of the Villa Salento pavilion, for paying rest days. patients, was also realized. De Giacomo adopted 1054 Maria Rosa Montinari, Sergio Minelli the most innovative care systems of those years peutic purposes. and, at the same time, adopted a new distribution of Among the methods most widely used there patients, based on sex, census and psychiatric were baths in icy water, the surgical dissection of pathology. segments of the frontal cortex, the induction of Another significant reform by the new director fever, the reduction in blood volume using leeches. was a drastic reduction in the use of coercive sys- These methods were based on coarse etiological or tems, the use of ergotherapy and the establishment physiopathological assumptions, such as changes in of a diagnostic and radiological laboratory. the cardiovascular system, the possible disposal of After the departure of De Giacomo, the hospi- toxins, the activation of the immune system by tal management was entrusted in 1954 to Professor fever, etc. Zara, who held this position until 1966. However, it was only between 1930 and 1940 Between the 50s and the 60s, medical equip- that psychiatry lived a real revolution: the scientific ment, such as the radio-diagnostic and the elec- community acquired a very important fact: the troencephalography, were implemented. In the three existence of an antagonism between psychotic Provinces the number of mental hygiene laborato- symptoms and . Moreover, such antago- ries increased, until in 1961 - in step with the times nism had been intuited from ancient times: - the socio-therapeutic assistance service for the Hippocrates discussed it in 400 B.C, Shakespeare sick was established also at the O.P.I.S. described it in “Otello” in 1600. Paracelsus, during In the 1960s, patients increased from 900 to the 16th century, gave camphor by mouth to cause 1300, so it was necessary to open new medical convulsions and cure madness. Convulsions caused facilities. It was then decided to use the structure of by chemical substances, in particular camphor in the ex-Tessilmarod in Strudà (Lecce), which was oil, were described in the 18th and 19th cen- used to accommodate 200 tranquil chronic patients; turies(7,8). at the same time, an agricultural colony of rehabili- In 1934, Ladislaw Meduna (a Hungarian neu- tation was established in Latiano (Brindisi), where ropsychiatrist) first suggested an inverse relation- 50 patients were accompanied by specialized agri- ship between and epilepsy. He noted cultural workers. that of six thousand schizophrenic patients only 20 In 1965 the ancient convent complex was fur- had seizures, and that epileptic patients who subse- ther being restructured, the old premises of the quently developed psychotic symptoms had a sig- ground floor were transformed into refectories. In nificant reduction of seizures. Previously, he had 1974, a new large four-storey building with a studied post mortem material and concluded that in polygonal profile was built and destined for admin- the brains of the epileptics “there were tremendous istrative offices. changes .., just the opposite of those found in schiz- In 1985 the Regional Law n. 33 entrusted all ophrenia”(9). His pathological results have never psychiatric services to the USL and ended the been substantiated, but they led him to build on the OPIS, renamed The Psychiatric Hospital "Giovanni tradition of somatic treatments and suggest that Libertini. In 1992, the detached section of Strudà artificially induced attacks might be therapeutically was also closed and the sick were welcomed in the useful in schizophrenia. Trying to cure schizo- Second renovated men’s pavilion. In 1998, the phrenic patients by inducing seizures, he adminis- event “Apriticielo” marked the end of the mental tered camphor in oil to a patient with catatonic hospital of Lecce. schizophrenia, causing a 60 second seizure. The patient fully recovered after a short series of these Somatic Therapies treatments; five more patients were treated during the year. Camphor was replaced by cardiazol(8) and Historical aspects the treatment spread throughout Europe. Somatic therapies have very ancient roots(6). However, Meduna repeated, without knowing The systematic use of somatic therapies has been it, an experiment already attempted: in 1785 Oliver documented since the eighteenth century. At that reported giving camphor to a patient with mania, time nobody had any knowledge of how to actually and after a generalized convulsion the patient treat mental disorders. Empirical evidence showed recovered temporarily(10). that certain conditions improved the symptoms and The idea of applying electricity on the skull of for this reason such situations were used for thera- psychiatric patients was born as a result of the The history of Salento’s mental hospital and the use of somatic therapies 1055 extremely unpleasant sensations experienced by ment for mental illness. people treated with Cardiazol, that led researchers From the ‘40s to the ‘50s, ECT was widely to investigate alternative methods of inducing used everywhere along with other somatic thera- seizures. Before then - though only since 1933 – pies, including insulin coma and psychosurgery, there was insulin therapy, devised by Manfred J. that were being used to cure severely ill patients for Sakel (1900-57): but insulin therapy caused a high a large spectrum of mental disorders(16). risk of irreversible neurological damage, up to the ECT, introduced during a period of exception- terminal coma. al therapeutic optimism in psychiatry, became the Even, prefrontal leucotomy - introduced in pillar of somatic therapies for psychiatric diseases 1936 by Antonio E. Moniz (1874-1955) - was also during the ‘40s and ‘50s. As already mentioned, used and renamed a few years later by other somatic therapies were used during this peri- Walter Freeman. Drastic and irreversible, lobotomy od, but ECT was the only treatment that prospered was also an expensive treatment. and spread(8,17,18,19). In this context, the Italian neuropsychiatrist However, mismanagement of this instrument Ugo Cerletti (1867-1963) suggested the electro- had disturbing consequences and there was a total convulsive therapy ( ECT), specifically as therapy abuse and misuse of such therapeutic tool. for schizophrenia(11,12). ECT was applied not only to patients with Ugo Cerletti identified in the electricity the schizophrenia or affective disorders, but in people most effective way to induce seizures and tried the with any type of neuropsychiatric disorder: in the way to make the passage of electricity required to demented, in drug addicts, in alcoholics and even cause convulsions harmless. The outcome of this in patients with syphilis. research was the invention, in 1938 - in collabora- Moreover, since there were no anesthetic tion with Lucio Bini (1908-1964) - of the electro- drugs, the treatment was very painful and with convulsive therapy (ECT). He induced a tonic- important side effects that could not be avoided. clonic seizure, by applying electrical stimulation at low intensity to the scalp of the patient and Somatic therapies at the O.P.I.S. observed in many cases, after such treatment, a rapid and surprising improvement in both psychotic Also at the O.P.I.S., at the end of the 1930s, and affective symptoms. shock therapy was established, with the use of Cerletti and Bini subsequently succeeded in pyretic therapy, cardiazol-therapy (with intravenous defining the parameters necessary for applying injections at the dose of one every three days, for a electricity directly to the human scalp(7,13). total of 10 days) and then with ECT in 1939. So it The impact of the discovery was extraordinary required a great preparation on behalf of the opera- and ECT, around the world - in a context in which tors and a considerable experience. therapeutic resources for severe mental disorders Of the 140 cases handled in 1939, largely were very scarce - was considered the cure for all schizophrenic forms, 40 were healing, while the mental illnesses. Thus “electroconvulsive” therapy remaining patients, half of them improved and half was born. remained unchanged. However, the percentage of Lothar Kalinowsky(14,15), a Jewish psychiatrist nearly 64% of favorable outcomes was a more than fleeing from Nazi Europe, had the opportunity to satisfying result. Insulin shock, instead, proved not stay in and learn the method, which then only more complex and difficult to practice, but applied in the U.S.: he might have been the first to also more expensive and less effective(1). introduce ECT in the United States. Treatment with fever, or sulfur-pyretic therapy, Around 1940, Kalinowsky obtained an assign- gave very few positive results, around 30%. ment at the New York State Psychiatric Institute Malarial-therapy for progressive paralysis(20) where he began treating patients with ECT(8) and and also attempts for intravenous or intra-rachidian from that time through the 1950s, ECT was widely vaccinations were also practiced in addition to vari- used in the United States. ous symptomatic therapies such as sedatives, ton- ECT completely supplanted the chemical ics, iodine, calcium - vitamin, hormons, etc. treatments - despite periodic attempts with new Altogether, in that year, 459 subjects were substances (atropine, scopolamine, flurotin) - and, treated with the most varied methods suggested by in a few years, became the most used somatic treat- psychiatric science of the time. 1056 Maria Rosa Montinari, Sergio Minelli

The writings of Professor Umberto De peutic tool, however it gave the opportunity to neu- Giacomo, the Hospital Director, reveal satisfaction rophysiologists and neurosurgeons to perform in- and justified pride in reporting the favorable, albeit depth studies on the processes of motor and sensor partial, results obtained with such therapies. activity, learning etc. In the postwar period, the most commonly Afterwards, in the 1950s, with the advent of used therapeutic means was the ECT, administered psychotropic drugs (neuroleptics, antidepressants, almost to half of the patients, with “the most bril- MAO inhibitors tricyclics, benzodiazepines), the liant results, especially in melancholic, hysterical success of somatic therapies and in particular of ECT and acute schizophrenic psychoses” (De Giacomo). decreased significantly, despite two technical The number of patients reached a peak of 322 in improvements: the narcosis-curarization, which had 1946. eliminated the risk of fractures and dislocations and Convulsive therapy with cardiazol, instead, had made the treatment much less dramatic, and the declined for reasons of practicality, until reduced to unilateral application of electrodes in order to reduce the treatment of a very few cases. Even intravenous post-shock confusion and memory disorders(21). acetylcholine therapy was abandoned for lack of Therefore ECT, widely used until the 1950s, results. Insulin coma had a period of recovery. The following the spread of psycho-pharmacology, ini- -therapy was still utilized for the progres- tially was bitterly criticized and then partially for- sive paralysis associated with bismuth and get. arsenobenzene injections. In 1948, the Italian Society of Psychiatry Conclusions entrusted to Prof. De Giacomo the task of explain- ing the changes induced by modern therapies in the Somatic therapies, as we have seen, have very various forms of schizophrenia: his scientific report ancient roots; many of these were used between the was very applauded and particularly appreciated by ‘40s and ‘50s of the twentieth century, but in par- the medical press. This gave luster and official ticular ECT had the greater spread in psychiatry. recognition to the OPIS, considered as cutting edge The recent renewed interest in somatic thera- and put before the major Italian university clinics. pies - used extensively in the past and then long Another important international scientific forgotten - is primarily linked to the considerable event was the first World Congress of deepening of the biological knowledge of such ther- held in in 1950, where the apies. New techniques of neuroimaging and recent same professor De Giacomo participated in repre- applications of bioengineering have allowed to senting O.P.I.S. and where he kept a report on toxic identify the brain areas affected by a particular experimental catatonia (i.e. on pathological states mental illness, proposing a possible treatment with caused experimentally with various substances), somatic therapies in the areas involved. obtaining flattering consensus from the scientific Secondly - despite the extraordinary and for- world. midable successes of neuro-psicopharmacology - Likewise, at the National Congress of the some mental illnesses are drug-resistant(22,23) and Italian Society of Psychiatry in Taormina in 1951, potentially susceptible to treatment (in addition to he gave a very detailed report on the technique and drugs) with other therapeutic approaches(24,25,26) able results of 18 psycho-surgical interventions per- to change the physiology of the brain through phys- formed on hospitalized patients. ical (electricity, magnetic, radiation) and/or biologi- The scientific and moral prestige of the cal means (nutrition therapies, relaxation tech- Psychiatric Hospital of Salento was high and in line niques, music therapy, acupuncture and more). with the latest therapeutic methods of the era. Even Based on these considerations, it has seemed in later years, the O.P.I.S. was reputed to be the quite poignant to us to analyze the use of ancient largest and most important psychiatric institution in somatic therapies in one of the most important psy- South Italy. chiatric institutions of southern Italy such as the Another therapeutic advance of this hospital OPIS and retrace the history of this hospital from throughout Italy was the Roentgen irradiation of its very beginning. diencephalo, according to the Guiraud technique for the treatment of certain psychoses(1). This technique was not successful as a thera- The history of Salento’s mental hospital and the use of somatic therapies 1057

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