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"Old and New Information about Electroshock"
Ugo Cerletti M.D.
American Journal of Psychiatry, 1950.

 

Convulsions were to be induced with a therapeutic aim since the good clinical results obtained by Meduna's method were ascribed to them. For this the old transcranial method followed by physiologists was sufficient. But this idea then, and for a long time to come, appeared Utopian, because of the terror with which the notion of subjecting a man to high-tension currents was regarded. The spectre of the electric chair was in the minds of all and an imposing mass of medical literature enumerated the casualties, often fatal, ensuing upon electric discharges across the human body. Nowadays, after twelve years of experience with electroshock, that terror may seem to have been exaggerated; but cases of death caused by low tensions (forty volts) had been described. Since, to obtain fits in dogs, tensions of around 125 volts were used, moreover with an alternating current which was held to be more dangerous than direct - it seemed evident that these experiments were too near the danger zone to have any possibility of being applied to man. The fact is that no one at the clinic seriously thought of applying electric convulsions to man, even though experiments continued upon dogs, both with electricity and with Cardiazol. So, over a year went by.

Nevertheless I, who had gone to such lengths in striving to preserve dogs from death when given electrically induced convulsions, had now come to the conviction that a discharge of electricity must prove equally harmless to a man if the duration of the current's passage were reduced to a minimum interval. Continually turning the problem over in my mind I felt that I would sooner or later be able to solve it; so much so that in 1937, not being able to go to the Munsingen Congress, I allowed Bini to hint at these vague hopes, and I, myself, at the 1937 Milan Assembly concerning the therapeutics of schizophrenia, announced these hopes that I had been nourishing.

This inactivity in the face of so momentous a question greatly depressed me, so that I immediately jumped at the information, given me by my colleague, Professor Vanni, that 'at the Rome slaughterhouse pigs are killed by electricity'. As though to justify my passiveness and to settle my hopes by facing a real fact, I decided to see this electric slaughtering with my own eyes, and immediately went to the slaughterhouse .

There I was told that the application of a current across the pigs' heads had been in use for some years. The butchers took hold of the pigs near their ears with a large scissor-shaped pair of pincers. The pincers were connected to the lighting plant with wires, and terminated in two teethed disc-electrodes enclosing a sponge wet with water. As they were seized, the pigs fell on their sides and were soon taken by fits (convulsed). Then the butcher, taking advantage of the unconscious state of the animal, gave its neck a deep slash, thus bleeding it to death.

I at once saw that the fits were the same as those I had been producing in dogs, and that these pigs were not being 'killed by electricity', but were bled to death during the epileptic coma.

Since a great number of pigs was available at the slaughterhouse for killing, I now set myself the exact opposite of my former experiments' aims; namely, no longer to make efforts to keep the convulsed animals alive, but rather to determine what the conditions must be for obtaining their death by an electric current. Having obtained authorization for experimenting from the director of the slaughterhouse, Professor Torti, I carried out tests, not only subjecting the pigs to the current for ever-increasing periods of time, but also applying the current in various ways: across the head, across the neck, and across the chest. Various durations (twenty, thirty, sixty or more seconds) were tried. It turned out that the more serious results (prolonged apnea sometimes lasting many minutes and, exceptionally, death) appeared when the current crossed the chest; that this application was not mortal for durations of some tenths of a second; and, finally, that passage of the current across the head, even for long durations, did not have serious consequences. It was found that pigs, even when treated in this last way several times, 'came to' gradually, after a fairly long interval (five to six minutes), then started moving, next made various attempts to get shakily to their feet, and finally ran rapidly to mix with their mates in the pen.

These clear proofs, certain and oft repeated, caused all my doubts to vanish, and without more ado I gave instructions in the clinic to undertake, next day, the experiment upon man. Very likely, except for this fortuitous and fortunate circumstance of pigs' pseudo-electrical butchery, electroshock would not yet have been born.

A schizophrenic of about forty, whose condition was organically sound, was chosen for the first test. He expressed himself exclusively in an incomprehensible gibberish made up of odd neologisms, and since his arrival from Milan by train without a ticket, not a thing had been ascertainable about his identity.

Preparations for the experiment were carried out in an atmosphere of fearful silence bordering on disapproval in the presence of various assistants belonging to the clinic and some outside doctors.

As was our custom with dogs, Bini and I fixed the two electrodes, well wetted in salt solution, by an elastic band to the patient's temples. As a precaution, for our first test, we used a reduced tension (seventy volts) with a duration of 0 2 second. Upon closing the circuit, there was a sudden jump of the patient on his bed with a very short tensing of all his muscles; then he immediately collapsed onto the bed without loss of consciousness. The patient presently started to sing at the top of his voice, then fell silent. It was evident from our long experience with dogs that the voltage had been held too low.

I, bearing in mind the observations with repeated applications of the day before upon pigs, made arrangements for a repetition of the test.

Someone got nervous and suggested whisperingly that the subject be allowed to rest; others advised a new application to be put off to the morrow. Our patient sat quietly in bed, looking about him. Then, of a sudden, hearing the low toned conversation around him, he exclaimed - no longer in his incomprehensible jargon, but in so many clear words and in a solemn tone - 'Not a second. Deadly! '

The situation was such, weighted as it was with responsibility, that this warning, explicit and unequivocal, shook the persons present to the extent that some began to insist upon suspension of the proceedings, Anxiety lest something that amounted to superstition should interfere with my decision urged me on to action. I had the electrodes reapplied, and a 110-volt discharge was sent through for 0.5 second. The immediate, very brief cramping of all the muscles was again seen; after a slight pause, the most typical epileptic fit began to take place. True it is that all had their hearts in their mouths and were truly oppressed during the tonic phase with apnea, ashy paleness, and cadaverous facial cyanosis - an apnea which, if it be awe-inspiring in a spontaneous epileptic fit, now seemed painfully never-ending - until at the first deep, stertorous inhalation, and first clonic shudders, the blood ran more freely in the bystanders' veins as well; and, lastly, to the immense relief of all concerned, was witnessed a characteristic, gradual awakening 'by steps'. The patient sat up of his own accord, looked about him calmly with a vague smile, as though asking what was expected of him. I asked him: 'What has been happening to you?' He answered, with no more gibberish: 'I don't know; perhaps I have been asleep.'

That is how the first epileptic fit experimentally induced in man through the electric stimulus took place. So electroshock was born; for such was the name I forthwith gave it

Bini in 1942 suggested the repetition of ECT many times a day for certain patients, naming the method 'annihilation'. This results in severe amnesic reactions that appear to have a good influence in obsessive states, psychogenic depressions and even in some paranoid cases. 'Clustering' of treatments, shocking daily for three or four days followed by a three-day rest, is less intense but sometimes effectual. The method of annihilation has made possible studies of amnesia and of hallucinations, delirium, and moria occurring during the treatment, relating them to the personality factors in the patients (Bini and Bazzi, Polimanti). Flescher and Virgili have made systematic researches on amnesia and showed that spontaneous memory is more damaged than that of learned, didactic material and that automatic memory is still less disturbed. Depressed and aged patients show disturbances earlier than young or excited patients. The 'annihilation syndrome' has been compared by Cerquetelli and Catalano with the psychopathology following prefrontal leukotomy. They indicate close parallelism with the advantage of reversibility in the case of shock.

These authors have also used shock successively to stop the symptoms of demerol mania quickly, following Mardnotti who used it with success in other forms of toxicomania. Broggi and others have also used ECT in progressive paralysis with at least temporary success. Ruggeri has used ECT in Parkinsonism and DeCrinis in disseminated sclerosis, observing attenuation of hypertonia.

Electroshock has also been applied in certain general physical illnesses though all have a constitutional 'nervous' background. Recovery has been frequently reported in asthma, and Catalano and Cerquetelli, with Tomrnasi, have had success in psoriasis, prurigo, and alopecia areata. Mancioli, after having observed improvement in ozena in a schizophrenic patient treated with shock, found similar improvement after acroagonine injection and is pursuing the research with histological controls.

Two other ideas both of which have perhaps as much relation to poetry as to science must be mentioned. The first is simply that the word 'shock' does not have the same meaning in neuropsychiatry as in general pathology. It is worth noting that any of our therapeutic methods such as prolonged sleep, narcoanalysis, insulin coma, epileptic corna, electronarcosis, etc., have in common the factor of the induction of a state of unconsciousness.

The second idea has to do with the patient's fear of therapy, which leads some to want to stop it. On being asked the reason, they reply: 'I don't know, I am afraid.' 'Afraid of what?' 'I don't know, I have fear.' 'But were you worried, did you feel pain?' 'No, but I have fear.' There must be a vague recollection - organic memory - of the first 'terror-defence' reaction. I believe that name 'terror-defence' expresses the biological significance of epileptic fits. The terror phase, although taking place during unconsciousness, leaves specific bio-chemical and psychological changes in the organism that later emerge generically into the conscious sphere.

This, too, was expressed long ago by Padre Dante,

Qual e colui she somniando vede,

E dope il sogno la passione impressa Rimane,

e Castro alla mente non riede . .'

(Para. XXIII, 58-61)

(As he who while dreaming sees, And after the dream is over, The emotion remains while the picture has faded away. . .)