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 Rome 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 Ugo Cerletti 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 seizures. 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 neurology and Italian psychiatry 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 malaria), Manfred Sakel 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 Vienna 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 schizophrenia. (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 Paris, 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.