From the slaughterhouse to the madhouse

PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICE VOLUME 8, #1, SPRING, 1971

FROM THE SLAUGHTERHOUSE TO THE MADHOUSE THOMAS S. SZASZ State University of New York Syracuse, N.Y.

I Like all widely-shared beliefs with important social consequences, the belief in "mental illness" as a medical disorder is embedded in our language, supported and reflected by it.

Thus, we call problems in living "mental illnesses"; individuals who consult psychiatrists or are compelled to submit to them by force or fraud are "mental patients," their complaints or the complaints of others about them are "mental symptoms," and the conditions imputed to them that allegedly "cause" and "explain" their conduct are "mental diseases" (among these, "schizophrenia" occupies an especially important position); we call psychiatric inquiries, whether invited by consenting clients or imposed on them against their will, "diagnoses," and psychiatric interventions "treatments"; finally, we call the setting in which psychiatric encounters take place "medical offices," "clinics," and "hospitals." And since we even have a National Institute of Mental Health it is easy to see why the rightthinking person considers it unthinkable that there might be no such thing as mental health or mental illness. If that were so, we would be the victims of our own folly, (Szasz, 1961).

No! It is better that we maintain, and if necessary, fortify our fictions.

Many illustrious physicians have labored, and continue to labor, on strengthening the medical fiction of mental illness: the result is the very real fortress that is Institutional Psychiatry, (Szasz, 1970). As I showed in The Manufacture of Madness, (Szasz, 1963), the most highly esteemed psychiatrists are those who have forged the best weapons for defending and broadening the justifications for the medical claims and pretensions of their profession. Their "discoveries"—from unchaining the madman to shocking, lobotomizing, and tranquilizing him—constitute the history of 64

the psychiatric "therapeutics" of "mental illness."

This brief note is intended to review the origin of one such discovery—that of electric shock treatment; and to suggest that this procedure is paradigmatic of the interventions of Institutional Psychiatry: based on force and fraud, and justified by "medical necessity," the prime purpose of psychiatric treatments— whether utilizing drugs, electricity, surgery, or confinement, especially if imposed on unconsenting clients—is to authenticate the subject as a "patient," the psychiatrist as a "doctor," and the intervention as a form of "treatment."

The cost of this fictionalization runs high: it requires the sacrifice of the patient as a person; of the psychiatrist as a critical thinker and moral agent; and of the legal system as a protector of the citizen from the abuse of state power, (Szasz, 1963).

II The Italian psychiatrist Ugo Cerletti is credited with the introduction of electroshock therapy into psychiatry. In an essay on the discovery of this treatment, he described the work that led to its development as follows: "Vanni informed me that at the slaughterhouse in Rome hogs were killed by electric current. Such information seemed to confirm my doubts regarding the danger of electric applications to man. I went to the slaughterhouse to observe this so-called electric slaughtering, and I saw that the hogs were clamped at the temples with big metallic tongs which were hooked up to an electric current (125 volts). As soon as the hogs were clamped by the tongs, they fell unconscious, stiffened, then after a few seconds they were shaken by convulsions in the same way as our experimental dogs. During this period of unconsciousness (epileptic coma), the butcher stabbed and bled the animals without difficulty. Therefore, it was not true that the animals were killed by the electric current: the latter was used, at the suggestion of the Society for the Prevention of Cruelty to Animals, so that the hogs might be killed painlessly.

FROM THE SLAUGHTERHOUSE TO THE MADHOUSE

It occurred to me that the hogs of the slaughterhouse could furnish the most valuable material for my experiments. And I conceived, moreover, the idea of reversing the former experimental procedure: while on dogs my aim had been the use of minimal quantity of current capable of inducing a seizure without harm to the animal, I now decided to establish the time duration, voltage, and the method of application that would be necessary to produce the death of the animal. Electric current would therefore be applied through the skull, in different directions, and through the trunk for several minutes. My first observation was that the animals rarely died, and then only when the duration of electric current flowed through the body and not through the head. The animals that received the severest treatment remained rigid during the flow of the electric current, then after a violent convulsive seizure they would lie on their sides for a while, sometimes for several minutes, and finally they would attempt to rise. After many attempts of increasing efficiency, they would succeed in standing up and making a few hesitant steps until they were able to run away. These observations gave me convincing evidence of the harmlessness of a few tenths of a second of application through the head of a 12 5-volt electric current, which was more than sufficient to insure a complete convulsive seizure.

At this point I felt we could venture to experiment on man, and I instructed my assistants to be on the alert for the selection of a suitable subject.

On April IS, 1938, the Police Commissioner of Rome sent a man to our Institute with the following note: 'S.E., 39 years old, engineer, resident of Milan, was arrested at the railroad station while wandering about without a ticket on trains ready for departure.

He does not appear to be in full possession of his mental faculties, and I am sending him to your hospital to be kept there under observation. . . .' The condition of the patient on April 18 was as follows: lucid, well-oriented. He describes with neologisms deliriant ideas of being telepathically influenced with related sensorial disturbances; his mimicry is correlated to the meaning of his words; mood indifferent to environment, low affective reserves; physical and neurologic examination negative; presents conspicuous hypacusic and cataract in L.E. A diagnosis of schizophrenic syndrome was made based on his passive behavior, incoherence, low affective reserves, hallucinations, deliriant ideas of being influenced, neologisms.

This subject was chosen for the first experiment of induced electric convulsions in man. Two large electrodes were applied to the frontoparietal regions, and I decided to start cautiously with a low-intensity current of 80 volts for 0.2 seconds. As soon as the current was introduced, the patient reacted with a jolt and his body muscles stiffened; then he fell back on the bed without loss of consciousness. He started to sing abruptly at the top of his voice, then he quieted down.

Naturally, we, who were conducting the experiment were under great emotional strain and felt that we had already taken quite a risk. Nevertheless, it was quite evident to all of us that we have been using a

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too low voltage. It was proposed that we should allow the patient to have some rest and repeat the experiment the next day. All at once, the patient, who evidently had been following our conversation, said clearly and solemnly, without his usual gibberish: 'Not another one! It's deadly!'

I confess that such explicit admonition under such circumstances, and so emphatic and commanding, coming from a person whose enigmatic jargon had until then been very difficult to understand, shook my determination to carry on with the experiment. But it was just this fear of yielding to a superstitious notion that caused me to make up my mind. The electrodes were applied again, and a 110-volt discharge was applied for 0.2 seconds" (Cerletti, 19S6).

Ill Like all honest self-disclosures, Cerletti's account of his discovery of electric shock treatment is perhaps more revealing than he realized or would have wished. I shall list certain facts mentioned by Cerletti, and some inferences based on them, which seem to me particularly significant.

1. Electroshocking of hogs was an empirically discovered method for tranquilizing and subduing the animals, so that they could be butchered without the excitement and squealing which they normally exhibit.

2. The first human being on whom electroshock was tried was a man, identified only by his initials, "S.E.," by his occupation, "engineer," by the city of his residence, "Milan," and, significantly, by the psychiatric diagnosis attached to him, "schizophrenia."

3. S.E. was a complete stranger to Cerletti, whose help he did not seek (and whose intervention he later rejected). In actuality, S.E. was a prisoner: he had been "arrested" by the police for "wandering about," and instead of being tried for his offense, he was sent to Cerletti.

4. Although sent to the hospital expressly "for observation," Cerletti flagrantly disobeyed the instructions of the Police Commissioner of Rome: instead of observing S.E., he used him as an experimental subject for electroshock.

5. Cerletti does not mention having obtained permission for his experiment from anyone. It would appear that having received the prisoner from the police, Cerletti immediately regarded him as his "patient" and himself as the sole judge of the sort of "treat-

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THOMAS S. SZASZ

ment" his "patient" should have. Thus Cerletti writes that "we, who were conducting the experiment, were under great emotional strain and felt that we had already taken quite a risk"; but he says nothing about the risk to which S.E. had been subjected without his consent.

6. Throughout the experiment, S.E. was treated as a thing or an animal. He had no control whatever over his fate. When, after the first shock, he announced "clearly and solemnly: 'Not another one! It's deadly!'" his seemingly entirely rational communication had no effect on those who were experimenting on him.

7. In short, the first person on whom electroshock therapy was tried was neither a human volunteer; nor a regular (voluntary or committed) mental patient, with whose history, personality, and family the psychiatrists were familiar; nor a prisoner convicted of crime subsequently declared mentally ill and under the jurisdication of a court. These facts are important because, as a professor of psychiatry at the University of Rome, Cerletti must have had access to many "schizophrenic" patients who might have been potential candidates for his experimental treatment.

IV Although the circumstances surrounding the discovery of electroshock therapy are revealing, they may be placed in fuller perspective by noting a few facts about the discoverer, Ugo Cerletti.

Cerletti was born in Cornigliano, Italy, on September 26, 1877, and died in Rome, on July 25, 1963. He studied medicine in Turin and Rome, and received his medical degree in Rome in 1901. First, he did special work in histopathology and neuropathology. Then, he studied clinical psychiatry under Kraepelin and was captivated by him. In 1933, he became interested in Meduna's work on schizophrenia, and became an enthusiastic advocate of the hypothesis of the incompatibility of schizophrenia and epilepsy. In 1935, following his appointment as Professor of Psychiatry at the University of Rome, Cerletti began his experiments on induced convulsions. In collaboration with Professor Bini, he devised the first electroshock apparatus, and, in April 1938,

they administered the first electric convulsion to man, described above.

In Cerletti's obituary, Ferrucio di Cori (1963) appraised the significance of electroshock treatment as follows: "[Cerletti's] new method was widely investigated and universally accepted throughout the world. . . .

Countless lives, suffering, and tragedies had been spared."

Cerletti continued to work on electroshock until he died. "He formulated a theory that the humoral and hormonal changes provoked in the brain by the epileptic attack lead to the formation of substances which he called 'acroagonines'—substances of extreme defense. These substances, when injected into the patient, would have therapeutic effects similar to those resulting from electroshock" (di Cori, 1963).

Ayd (1963) has recorded another interesting aspect of history's first electroshock treatment. Cerletti was apparently in the habit of recalling that memorable experience. "As he described what transpired," writes Ayd, "he remarked, 'When I saw the patient's reaction, I thought to myself: This ought to be abolished! Ever since I have looked forward to the time when another treatment would replace electroshock.'" But if Cerletti had thought this, why did he say it only to himself? Neither Cerletti, nor other advocates of electroshock, ever spoke or wrote publicly about abolishing this "treatment."

V As the history of Anna O. and Breuer, (Szasz, 1963) is paradigmatic of a truly personal encounter between patient and doctor, so the history of S.E. and Cerletti is paradigmatic of a truly impersonal contact between dehumanized subject and medical experimenter. As the former exemplifies the voluntary relationship between "neurotic" and "psychotherapist," so the latter exemplifies the involuntary relationship between "psychotic" and "institutional psychiatrist." It is a measure of the moral decline of the psychiatric profession that these fundamental distinctions—between person and object, physician and alienist, voluntary and involuntary psychiatric interventions—were better appreciated, in practice if not in theory, during the

FROM THE SLAUGHTERHOUSE TO THE MADHOUSE

early decades of this century than they are at present, (Szasz, 1970).

The invention of electroshock is modern therapeutic totalitarianism in statu nascendi: the mental patient, a non-person, is handed over to psychiatrists by the police, and is "treated" by them without his consent. The social circumstances in which electroshock treatment was developed are consistent with its "therapeutic" action. If a man wishes to punish and subdue another, he does not ask his permission. Nor can the public, in a society that permits and even encourages this type of human relationship because it is "therapeutic," expect the law to protect the victim.

REFERENCES AYD, F. T. JR., Guest editorial: Ugo Cerletti, M.D.

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1877-1963, Psychosotnatics, 4, A-6-A-7, Nov.Dec, 1963.

CERLETTI, U. "Electroshock Therapy," in, A. M. Sackler, M. D. Sackler, R. R. Sackler, and Marti-Ibanez F. (Editors): The Great Physiodynatnic Therapies in Psychiatry: An Historical Reappraisal, Chapter 4, pp. 91-120, New York, Hoeber-Harper, 1956, pp. 92-94.

DI CORI, FERRUCIO, In Memoriam (Cerletti), Journal

of Neuropsychiatry, 5, 1-2, Sept.-Oct., 1963.

SZASZ, T. S. The Myth of Mental Illness, New York: Hoeber-Harper, 1961.

SZASZ, T. S. Law, Liberty, and Psychiatry, New York: Macmillan, 1963.

SZASZ, T. S. The concept of transference, Internat.

J. Psycho-Anal., 44, 432-443,1963.

SZASZ, T. S. The Manufacture of Madness, New York: Harper & Row, 1970, p. xvii.

SZASZ, T. S. Law, Liberty, and Psychiatry; Psychiatric Justice, New York: Macmillan, 1965; and Ideology and Insanity, Garden City, N.Y.: Doubleday Anchor, 1970.