Eur. J. Psychiat. Vol. 27, N.° 4, (231-239) 2013

Keywords: Cerletti; Bini; ECT; Depression; Schizo- phrenia; History.

A translation of “L’Elettroshock” by Cerletti & Bini, with an introduction

Antonio Metastasio MD, MSc, MRCpsych* David Dodwell MSc** * Nortfolk and Suffolk NHS Foundation Trust ** Cambridgeshire and Peterborough NHS Foundation Trust UNITED KINGDOM

ABSTRACT – The year 2013 marks the 75th anniversary of the invention of ECT. This paper provides a translation of the 1938 publication by Cerletti and Bini, with an intro- duction. The authors thought that it would be helpful, in the debate about ECT, to make accessible to people unfamiliar with Italian the first public account of ECT made by Cer- letti and Bini in front of the Royal Medical Academy of in May 1938. The intro- duction and translated paper refer to the methodical approach to the development of ECT, based on the scientific opinions and technological processes of the time, as well as the drive to provide treatment which is both cheaper and more acceptable to patients. The in- troduction also comments on changing attitudes to what remains an efficacious treatment. ECT has been wrongly represented as an obsolete, unscientific treatment more akin to a torture than to a therapy: some explanations for this are suggested.

Received: 23 April 2012 Revised: 9 March 2013 Accepted: 26 March 2013

Introduction viding an English translation of the first pub- lic account of ECT carried out by Cerletti and Bini in May 1938 in front of the Royal Med- This year marks 75 years since the inven- ical Academy of Rome1. tion of electroconvulsive therapy and the first publication about it. This treatment, with lit- Electroconvulsive therapy (ECT) –first tle modification of the original protocol, is known as electroshock– was one of the ear- still in use throughout the world. We thought liest physical psychiatric treatments which it apposite to mark this anniversary by pro- continues to be in use today, as it is currently 232 ANTONIO METASTASIO AND DAVID DODWELL regarded as both specific and more effective founder and editor of the “Archivio generale di than placebo2. The technique was developed neurologia, psichiatria e psicoanalisi” which in the 1930s by and his collab- published, in one of its last issues, the paper orators (among them, Lucio Bini, who was a that is the subject of this article. The journal clinician as well as designing the apparatus)3. was confiscated and closed in 1938. In 1939 The research team led by Cerletti was the first the journal reopened as “Archivio di psicolo- to use electricity to induce . gia, neurologia, psichiatria e psicoterapia” with no references to psychoanalysis (in dis- grace due to Freud’s ancestry) and with a Social and service background new Editor - Agostino Gemelli9. to ECT In England and Wales, it was the peak of the In the 1930s, Europe and the USA were asylum era: mental illness in-patients num- 10,11 not only in the midst of “the great depres- bered over 140,000 from 1930 to 1955 . sion” (with a consequent shortage in funding The atmosphere of therapeutic nihilism (and 12 for health care and increased demand), but later optimism) is clearly described by Rollin . also witnessed the raise of eugenics and to- It was reported that the head of the Maudsley talitarian movements. In Germany mainly, (Britain’s new academic psychiatric centre) but also in the USA, the eugenics movement refused to recruit staff who had spent much was advocating forced sterilization; Nazi time in asylums, believing they would have 13 Germany went on to develop a “euthanasia” become inured to disillusioned inactivity . In programme, in which hundreds of thousands this context, a more successful treatment of of people with mental disorders were killed4,5. mental disorders was desperately needed. In Italy, however, the fascist regime did not put a particular emphasis in the problem of Research scientific background mental health (although intervening heavily to ECT in other aspects of health care, e.g. infec- tious disease) and therefore clinical psychia- The development of ECT was a confluence try and psychiatric research were under- of two distinct themes in physical treatment funded with a consequent shortage of beds, –the use of electricity and the value of shock– an overcrowding of asylums (where living brought together by research interest in conditions were often abominable), and a cul- epilepsy and convulsions. tural stagnation of the discipline6,7. The situ- Medical uses for electricity generated by ation was so severe in Italy that in 1942, Cer- fish or eels were described by ancient Ro- letti refused to become the president of the mans14. Therapeutic applications of electric- Italian Psychiatric Society, in protest against ity were current from soon after modern dis- these conditions (despite pressure from politi- covery of electricity in the 18th century15 cians)8. It should be added that, after 1938, and continued to be used in and Italian and psychoanalysis were psychiatry in the later 19th and earlier 20th also affected by the introduction in of the in- centuries16. famous “racial laws”, which caused the ex- pulsion from their institutions of numerous In the 1920s, the concept of shock as a academics and clinicians of Jewish religion or physical treatment for mental disorders resur- ancestry. Among these were Marco Levi Bian- faced. After the successful treatment of neu- chini, director of the Asylum of Nocera and the rosyphilis by Von Jauregg (by inoculating A TRANSLATION OF “LʼELETTROSHOCK” BY CERLETTI & BINI, WITH AN INTRODUCTION 233 ), introduced insulin ment was dangerous, expensive and very lit- shock by administering large doses of insulin tle tolerated by patients: they complained of to induce a coma. Sakel’s treatment included a feeling of impending death between the in- people with addiction, neuroses, psychopathy, jection of Cardiazol and the onset of seizures. and psychosis17. He was aware hypoglycae- Cerletti and his co-workers (including Bini mia could lead to a convulsion, and discussed and Kalinowsky) travelled to and Bu- making a convulsion more likely by omitting dapest, met Meduna’s team, and started to barbiturates and by adding Cardiazol, but did use his techniques in Rome. not seem to ascribe relative therapeutic value Interestingly, Cerletti seems to have been to the shock or the convulsion (if it occu - surprised by the fact that Meduna did not rred)18. The patients that recovered from the use electricity to induce seizures. The re- insulin administration, showed, in many search that led to the first experiments with cases, an improvement in their condition. The ECT had been started by Cerletti and his technique needed several treatments and was team in Genoa in 1934 working on the effects very expensive and dangerous. Numerous pa- of electricity. They started by using animals tients died or experienced severe harm, and (dogs and pigs) and established the safety of insulin was extremely expensive18. the technique through histopathological stud- There was a century old observation and ies of the dogs’ brains to confirm absence of theory, then championed by Ladislas Me du - brain damage. Only after this preparatory na19, of a “biological antagonism” between work did they conduct the first experiment on 1,6,8,23 epilepsy and . (Although we a human being in April 1938 in Rome . now know that individuals with epilepsy have an increased risk of schizophrenia and vice versa20-22, at that time the large asylums had The “rise and fall” of ECT patients who could be grouped diagnosti- Following its first description in 1938, cally, one large group being dementia prae- ECT spread across different countries in the cox/schizophrenia, and another being epilep- span of a few months: blueprints of machines tics: at an institutional level, the groups did were disseminated to , Holland, and show “antagonism”). Working in Budapest, England in 1939, and ECT was practised in after histopathological studies on epilepsy the U.S. from 1940. In 1943, it was noted that and schizophrenia, Meduna started treating 350 publications had already appeared24. The individuals affected by schizophrenia with speed of diffusion appears remarkable, espe- chemicals which induced seizures. He first cially considering the political tensions of used camphor, and subsequently adopted a Europe in 1938 (although psychosurgery also synthetic derivative called Cardiazol in Eu- spread from Moniz in Lisbon in 1936 to Free- rope and Metrazol in the USA. The first suc- man in USA by 1942, with over 10,000 op- cessful trial was in 1934 and subsequently the erations having been carried out in UK by treatment spread internationally. While Sakel 195425. ECT became widely accepted and was inconsistent about the rationale of insulin used in psychiatric practice26. treatment (sometimes stating it was the shock, sometimes stating it was the seizures in- The first patient ever treated (in April duced), Meduna had a clear theoretical model 1938) was diagnosed as schizophrenic27. about the antagonism between epilepsy and Some of the earliest English language publi- schizophrenia. Unfortunately Meduna’s treat- cations on ECT involved only schizophrenic 234 ANTONIO METASTASIO AND DAVID DODWELL patients28,29; however, subsequently reported 3. It is conceivable that the rapid spread of series included diagnoses of mania, depres- the technology led to it being employed sion, and neurosis, as well as hysteria30 and by staff with inadequate skill or training: organic states31. Even in the late 1930s and for example, in Sylvia Plath’s fiction- early 1940s, there was a view that Cardiazol alised autobiography (first published and ECT were of greatest and most specific 1963), she describes remaining con- benefit in patients with severe depression32. scious and experiencing considerable The deployment of ECT became increasingly pain, suggesting faulty procedure44. focussed on depressive illness: a 1980 British 33 4. Non-convulsive electricity was used survey listed 83% of courses were prescribed clinically as an aversive stimulus in be- for depressive disorders, 13% for schizo- haviour modification45. phrenia, and 2% for mania. Current English guidance34 accepts depression as the only 5. The Milgram study of conformity to evidence-based indication, whilst supporting authority46 involved a potent mix of occasional use in mania (despite evidence of non-convulsive electric shocks, pun- benefit35 and tolerability36 in schizophrenia). ishment, mindless obedience, and turn- ing a blind eye to potential harm. Following its initial success, when ECT was widely accepted by clinicians and the 6. Non-convulsive electricity has also public, the treatment later became controver- been used non-clinically in true torture: sial and largely lost the support of public one view argues this was pioneered in opinion. During the rise of the antipsychiatry the 1950s and adopted by US forces in movement it was portrayed as barbaric, and the 1960s47. often represented as a punishment by un- A scientifically semi-literate population skilled and cruel psychiatrists on patients who easily confuses these distinct issues, none of 37 did not conform to the norm . By 1982, there which should discredit correctly used ECT; 38 was reference to prejudice against ECT . sadly, such confusion continues until today48. 39 ECT appears to be in decline in Europe . The issues above arose during the 1950s and The facts of ECT were unchanged, and 1960s in a social context of rising antipsy- we suggest a number of non-rational factors chiatry, reflected in adverse media portrayals were involved in these attitudinal and repu- (e.g. ECT as an individual punishment within tational changes, including the confusion of a punitive asylum regime49 and multiple re- convulsive and non-convulsive uses of elec- gressive ECT as a cause of severe amnesia, tricity. personality change, and loss of intelligence50. 1. If the number of therapeutic options is We conclude that since the early 1960s, limited, the available options are liable there has been a negative narrative around to be overused or used outside their ac- ECT –that it is an anti-therapeutic punish- cepted remit (just as currently happens ment– a negative narrative determined by so- with medication40): some over-use and cial, not scientific, factors. over-enthusiasm has been acknowl- edged by advocates of ECT41. The role of this account 2. ECT has been abused occasionally to manage an unruly patient or apparently as Considering the importance that ECT has a punishment rather than a therapy42,43. had, and continues to have, in the therapeutic A TRANSLATION OF “LʼELETTROSHOCK” BY CERLETTI & BINI, WITH AN INTRODUCTION 235 armamentarium of psychiatry, we think it im- document available to the larger public. We portant to remember the intellectual pathway hope also that this paper will contribute to the that led to the development of ECT. The gen- debate about the future of ECT and of psy- esis of the invention in fact was neither bar- chiatric treatment at a time of economic and baric nor accidental but was the outcome of political uncertainty, acknowledging the systematic studies on the effect of seizures on changes in both scientific opinion and clini- the Central Nervous System begun centuries cal practice. earlier and built on by Cerletti’s team using a technology that was advanced for the time and It should be noted that the paper takes the with a solid scientific basis for the time8. form of an anonymous report of a presenta- tion by Cerletti and Bini, although Cerletti The first public account of ECT is extre- and Bini are credited as authors and it states mely interesting, because it summarizes the they approved the report. scientific pathway that led to ECT and de- scribes the early technique in considerable Translation of L’Elettroshock by Ugo Cer- detail. Everybody that has performed or wit- letti and Lucio Bini published in 1938 in nessed an ECT session would clearly recog- Archivio Generale di Neurologia, Psichia- nize the phases (tonic contraction; tonic- tria e Psychoanalisi, 19: 266-268. clonic contractions; and subsequent muscle relaxation) described here. Clinic for Nervous and Mental Disorders, Royal University of Rome, directed by Prof. Reading the first public account of ECT is Ugo Cerletti. also fascinating because it shows how psy- chiatry was then facing problems similar to the ones we are facing now. It is often for- gotten that induced seizures were already Electroshock used prior to ECT: a key driver for the de- velopment of ECT was to find better tolera- bility compared to the pre-existing treatments Summary of the original oral communication (seizures induced by Cardiazol and insulin) made by Cerletti and Bini at the Royal Med- and with lower costs (limited to the cost of ical Academy of Rome on May the 28th 1938, the device only). Pre World War II Psychia- published with the consent of the authors. try was facing, mutatis mutandis, a similar problem to the one that contemporary psy- Cerletti firstly expounded the reasons why, chiatry is facing: shortage of funding and the among different modern treatments for schiz- need for new effective treatments with fewer ophrenia and other psychoses, convulsive side-effects. The need for innovative, safe therapy with Cardiazol became so popular. It and better tolerated treatment was over- is predominantly practical reasons that make whelming and ECT was the first of such it preferable to hypoglycaemic coma in many treatments available. This is probably the ex- cases: less responsibility for the doctor; med- planation for the surprisingly rapid spread ical assistance is needed for much less time; of ECT after only a few months from its pre- a smaller number of sessions is required; sentation in May 1938. there is much less cost. Cerletti mentioned the more or less severe (although uncom- Translating into English the very first pub- mon) incidents that happened after rapid, lication on ECT will make this important massive injections of Cardiazol. Cerletti also 236 ANTONIO METASTASIO AND DAVID DODWELL highlighted a significant side-effect caused by ments carried out with dogs, testing the min- Cardiazol during the latency period (between imum and maximum current intensity which the injection and the induction of the ); could be used, the duration of the current, and the patient experiences a most disturbing the solution to the awkward problem of the feeling of imminent death. This distress positioning of the electrodes. makes a lot of patients reluctant to be treated. In this way, it became possible to proceed Also, during the post-ictal period, the pres- to experiments in human beings and conse- ence of Cardiazol in the body causes a state quently determine the optimal conditions for of psychomotor agitation lasting some hours. inducing an epileptic seizure. A technical For these reasons, Cerletti dedicated him- protocol to standardize the epileptic seizure self to researching easier and less toxic ways is still under study, especially to minimize the to cause epileptic convulsions. For several risk for the patient in view of individual dif- years, in Genoa, he carried out experimental ferences. Numerous experiments with hu- studies of epilepsy, provoking epileptic man beings were performed over a period of seizures in animals (in particular in dogs) by two months: according to the different elec- using electricity. He used domestic electricity tric resistance, these employed currents with (alternating current at 125 V) for a fraction of intensities between 300 and 600 mA, poten- a second, with two electrodes, placed one in tial differences between 80 and 115 Volts, and the mouth and the other in the rectum (Viale). durations of 0.5 – 0.7 seconds. This technique, and the physio-pathological The ictus caused in this way looks like a results from many dogs, were published by a typical epileptic seizure. Loss of conscious- pupil of Cerletti’s in 1934 (Chiauzzi, Patho- ness instantaneously follows delivery of the logica XXVI). Cerletti continued the experi- current; without screaming, the patient has a ments in Rome in 1935 with the support of Dr strong, generalized, tonic contraction: torso, L. Bini, a very experienced electrical engineer, legs, arms and hands go into a semiflexed who built a simple but practical apparatus to spasm. At first, the face becomes red, then precisely control the duration of the current and pale and eventually cyanotic: breathing stops. its voltage. Subsequently, trials were made of The heart rate is regular. After about 30 sec- passing the current through the head, a tech- onds, the colour of the face returns to normal, nique previously used by other researchers and then becomes strongly congested. Then (Prevost, etc.). Bini thus used this technique the limbs and the face display spastic tremors extensively in a large number of dogs. that quickly become clonic muscular con- When convulsive therapy with Cardiazol tractions, which extend to all the body mus- was announced (Sakel, Meduna), Prof. Cer- cles with variable intensity and last one or letti immediately thought of using electricity two minutes. It is necessary, therefore, to in- for the same purpose. Important progress to- sert a rubber bite to prevent the tongue being wards a clinical use of this technique was bitten. Sometimes there is foaming at the made possible by numerous experiments on mouth, ejaculation of sperm, incontinence of pigs, under all sorts of different conditions, urine and faeces. Afterwards, there is a phase using the simple street electricity device em- of muscular relaxation with stertorous breath- ployed in abattoirs to render animals uncon- ing. The state of unconsciousness lightens scious before slaughter by means of an gradually and the patient becomes more alert, epileptiform shock. The authors therefore re- relaxes the jaw, moves the eyes and begins to peated in bigger animals the same experi- answer to verbal stimuli. After 5 minutes he A TRANSLATION OF “LʼELETTROSHOCK” BY CERLETTI & BINI, WITH AN INTRODUCTION 237 can talk but remains clouded. After 8 – 10 dose the duration and the intensity of the minutes the patient is completely himself. If current appropriately. The electrodes are ap- not disturbed, he falls asleep and after a few plied using a special coif designed to obtain hours wakes up completely restored. perfect application to the skull and to mini- mize dispersion of the current. The advantage of this method, from our present knowledge, is the immediate and ab- Bini referred to the particular effects of the solute loss of consciousness of the subject, current on animals in different experimental lasting for all the length of the treatment. The conditions and about the limits of the method’s patients, if asked about their experience, state safety. Bini finally discussed the various ef- they do not remember anything but having fects observed in human beings, depending slept. Also absent is the state of sub-threshold on different intensities and durations of the arousal that often follows a treatment with current. Cardiazol. After ECT, the subjects sleep longer than those injected with Cardiazol, and after In front of the Academy, at the end of the waking are calm and in a good mood. 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