Summary The authors, basing their work on original documents, present a reconstruction of the discovery of electroconvulsive therapy by Prof. Ugo Cerletti and his team. An imaginary interview takes place between an interviewer and the Italian Professor, in his study at the University of Rome in 1940, two years after the introduction of E.S.

April 1940, Rome I meet Professor Ugo Cerletti in his study at the University of Rome. He is a tall, smart and friendly man, who lookes younger than his 63 years. Since he brought out his Electroshock therapy, two years ago, Prof. Cerletti has become world famous. For those who are unaware of his origins I will provide below some biographical information, before reporting the content of our dialogue.

Ugo Cerletti, the son of an agricultural engineer, was born in Veneto, at Conegliano, on September 26th, 1877. He studied Medicine at Rome and Turin. He specialized in mental and neurological diseases attending the relevant European "sanctuaries". First of all he stayed with Pierre Marie and Dupr« in Paris, then with Kraepelin, Nissl and Alzheimer in Heidelberg and Munich. Cerletti devoted himself to research and technological innovation, inventing before the First World War, the white, camouflage winter suits that were used by the Italian Army. He became the Head of the Neurobiological Institute, which is attached to the mental Institute of Milan.

In 1924 he was given a lecturing post in Neuropsychiatry in Bari. From there he moved to Genoa in 1928 where he took over the Professorship fron Enrico Morselli and finally, in 1935, he came to Rome University to occupy the prestigious chair of Director of the Department of Mental and Neurological Diseases.

Q. "Professor, this time two years ago, together with your team you started experimenting with Electroshock as a therapy for mental illness. Would you like to tell us how you made such a discovery"?

A. "The story of Electroshock is quite straightforward. Like every other neurologist, I have always given prime importance to the study of epilepsy, since it is linked to many areas of Neurology and Psychiatry. Besides, in 1931, in Genoa, I carried out some research on the sclerotic lesion of Hammon's horn, which is characteristic of this illness. I decided to handle this problem by carrying out experiments on animals. After repeatedly inducing epileptic fits in these animals for short and long periods of time I would then study the reactions of their Hammon's horn from a histopathological point of view. In order to avoid brain damage I didn't adopt direct methods of stimulation or use convulsive toxics. I used, instead, the method employed by many physiologists, especially on dogs, where an epileptic fit is induced by passing an electric current of 125 volts through the body.

Q. "Was it difficult to perfect this technique?"

A. "During the first attempts I lost many dogs due to atrial fibrillation following the electric shock. Then I learned to dose times better and therefore obtained a very large number of case histories. On the basis of the semiology of the attacks, I thought it was important to prove beforehand their absolute correspondence to the standard epileptic fit suffered by man and in 1934, I got a student of mine, called Chiauzzi, to publish a piece of work concerning the technique perfected by us. In 1935 I moved here to Rome and took up the experimentsonce more, along with my assistant Doctor Bini. In order to avoid killing the animals we perfected a simple mechanism. which measured both how long it took for the current to pass through the body and also its tension".

Q. "How did you progress from these studies on epilepsy, induced by electric shocks, to the application of this technique in the treatment of human psychiatric pathologies?"

A. "It was, in fact, during these years that the convulsive therapy for schizophrenia, using an injection of Cardiazol appeared. I immediately tried out this treatment on our patients together with the therapy using hypoglycaemic coma. The daily confrontation with the dogs who had been made epileptic by Electroshock treatment naturally gave me the idea of a possible similar application on man. However, this idea was, for a long time, only considered in theory, because all our knowledge concerning the noxious effects of strong electric currents on the human organism made us reject any attempts".

Q: "What was it that made you change your mind?"

A: "One day I heard that at the Rome slaughterhouse "they were killing pigs with the electric current used for lighting". And it was almost as if to justify to myself my own inertia that I decided to go to the slaughterhouse to witness these "electroexecutions". I saw some butchers moving about among the pigs, holding in both hands a large pair of pincers, which had at both ends two discs, spiked with small, blunted, metallic tips. When they got near to the animals, they opened the jaws of the pincers and quickly grasped the front part of the pig's head between the tips of the discs. 70-80 volts were then sent through the electric cable. As soon as the animals had been got hold of, they fell rigid to the ground without even uttering a sound and shortly after, began to present general clonic shocks. Once on the ground, the butcher made a deep incision in their necks so that the pigs bled to death before regaining consciousness".

Q: "Therefore it was not true that they killed the pigs by electric current?"

A:" Certainly not. The current did not serve that purpose. It was simply to eliminate as humanely as possible, any form of suffering while the animals' throats were being cut".

Q:"What did you do next?"

A: "I asked for -and obtained -from the man in charge of the slaughterhouse a permit, which allowed me to use the big electric pincers. I tried them out many times on animals to see the effects of the current passing through various dimensions of heads and I was able to confirm what we had discovered in dogs, namely, that at tensions ranging from 70 to 125 volts, the brain can stand the current well, even when the passage time was substantially increased. In fact, all the pigs regained consciousness, even if there were a few, which were slow in doing so. Those that were subjected to the electric current for several seconds, when the convulsive attack was over, managed to stand up after a few awkward attempts and join their companions as if nothing had happened".

Q: "What conclusion did you draw from this experience?"

A: "What I saw and experimented at the slaughterhouse on a considerable number of pigs corresponded exactly to what we had discovered with the dogs. That is to say that the passing of an alternating current of 125 volts through the head for a fraction of second causes epileptic forms of attacks which don't endanger life and which don't cause any relevant problems. Since we were dealing with mammals of a notably different size and structure and, since I had been able to widely experiment with different methods of application to the head and also with very long times of application, without any apparent danger, my presumption seemed more justified. This presumption was that we could do likewise with humans, applying the electric current as we had studied, without much danger to the patient. So I decided to go ahead and try it out".

Q: "When did this happen?"

A: "It happened two years ago, in April 1938. At that time the Police sent a man in his forties to our Department. He had been stopped at the railway station while he was wandering from one train to another without a ticket. As this person was behaving in a very odd way, answering questions put to him in a very strange language which was completely incomprehensible, he was sent to us. Here we were able to gather that he was suffering from hallucinations and delirious ideas about being under some kind of influence. Apart from that, he was lucid and well oriented but, at the same time, apathetic and lacking in willpower. He passively adapted to life on the ward, where he was almost always found lying contentedly on his bed murmuring in his jargon. We diagnosed him as schizophrenic. The somatic examination showed that his general physical condition was good. It was on this patient that I carried out my first experiment with Electroshock".

Q: "Would you like to explain the procedure of that first attempt?" A: "Having fixed two electrodes, which were well soaked in saline solution, with an elastic band to the frontal parietal area, we cautiously started with a low current: 80 volts for 1/5 of a second. Once the charge was sent, the patient immediately gave a jump, accompanied by a stiffening of all his muscles, which were semiflexed. Then the patient fell back onto the bed without losing consciousness. He immediately started singing at the top of his voice and then he calmed down".

Q: "What was your reaction?"

A: "We were all very emotional. We realized that we had already dared a lot, but it was also clear that, bearing in mind our experiences with animals, we had kept the voltage too low and therefore we considered repeating the experiment and increasing the voltage. Somebody suggested leaving the patient to rest and postponing another dose until the following day. Suddenly the patient, who had obviously been listening to what we were saying, said in a clear and serious voice : "Not another one! You will kill me!"

Q: "How did you react?"

A: "I must confess that, given the situation and the great responsibility, this explicit, unequivocal warning coming from a patient, who up until a moment before could not make himself understood in his enigmatic jargon, somewhat shook my determination, moreso because one of the others present again proposed suspending the experiment. However, the fear of giving in to a superstitious idea made me decide. I put the cap on the patient again and we sent a charge of 110 volts for 1/5 of a second. The patient immediately had a very brief general spasm and, after an instant had the most common type of epileptic seizure. We all waited with bated breath during the tonic phase and were truly depressed during the whole of his apnoea, where there was an interruption in breathing and a deathlike cyanosis of the face – which, if upsetting in a spontaneous epileptic fit, seemed to us, in this case, distressingly unending. Finally, after a croaky inspiration and the first clonic jerks, the blood circulated better in our veins and we saw to our great satisfaction, the characteristic reawakening "in stages" of his consciousness. The patient sat up and looked at us calmly and smiled as if to ask us what we wanted with him. We asked him. "What has happened to you"? and he replied "I don't know, perhaps I have been sleeping".

Q: "Did you continue the treatment on this patient?"

A:"Certainly. On May 25th after 6 Electroshocks he appeared to the doctors as respectful and orderly, he was lucid, had clear ideas and he no longer expressed himself in neologisms. We were even able to get exact information from him regarding himself and his previous illnesses. After 11 complete and 9 incomplete electroshocks, the man could be termed as being cured or, to be more precise, according to the most prudent terminology in use, he showed a "complete remission". Not only did the hallucinations and delirious ideas disappear, along with a complete normalization of his behaviour, but it was also very comforting to see in him a spontaneous desire to make himself useful and a spirit of initiative, which was reflected in a continuous and truly concrete will to help other patients and the nurses. He was discharged on 19th June, 1938".

Q: "Given the result of that first attempt, I imagine that during these two years you have continued experimenting".

A: "Certainly. We have carried out thousands of shocks on patients suffering from different mental pathologies and at the same time, we have continued experimenting on animals to try and understand on the one hand the activating mechanism of the therapy and any irreparable organic alterations caused to the brain; on the other, the therapeutic indications".

Q: "Would you like to tell me briefly about the conclusions you have drawn from all your experiences to date?"

A: "Electroshock does not seem to cause irreversible lesions to the brain. Compared with other techniques it is easier to use, less dangerous and requiring the minimum of expense. The two pathologies which up to now have given optimal therapeutic results using shock and paticularly E.S. are, schizophrenia, especially in initial acute forms and even more, manic-depressive phrenosis especially in its depressive form. As far as the activating mechanism is concerned I have formed this idea: electroshock violently arouses all those nervous reactions, which belong to the field of cerebral functions philogenetically organised to guard and defend life. The violent activation of the above-mentioned mechanisms has the effect of powerfully reviving, stimulating and bringing back onto an active level, all the neuro-psychism that is composed of reflex, instinctive and affective reactions which make us function well in our relationships with others, yet which lies dormant and inert in mental illnesses like schizophrenia and serious forms of depression. These however, are only working hypotheses on which it would be worth working and matching one's strength in future in order to better understand the activating mechanism of Electroshock and to find possible new applications".

Q: "I would like to thank you very much for devoting me some of your time and I hope I will be able to talk to you again on this subject".A: "It's been a pleasure. I also hope to discuss this subject again, perhaps comparing my own experiences with those of other people who have tried out my discovery. Goodbye".