Adventures in Human Being

by Gavin Francis

  In 1934 a pair of Italian psychiatrists working in Rome – Ugo Cerletti and Lucio Bini – began to experiment with electricity instead of Cardiazol as a way of inducing seizures. Their first attempts involved electrocuting dogs by inserting electrodes in the mouth and anus. The dogs often died, and Bini realized that electric current traversing the heart was triggering fatal cardiac arrest. He moved to passing the current between the dogs’ temples, observing that slaughterhouses in Rome used electricity in this way to stun pigs before killing them.

  It took the two men a while to establish the correct voltage and current to shock a human being into a full epileptic seizure without causing death. In 1938 Mussolini was classifying political dissidents as insane, and Hitler was implementing the sterilization of those with epilepsy, schizophrenia and alcohol dependency – Cerletti is reported to have been a subscriber to a fascist magazine. It’s within this toxic political context that Cerletti and Bini selected their first patient: a man described in a later report as “S.E.,” who had been picked up babbling and hallucinating in Stazione Termini, the great railway station in Rome.

  Cerletti was an academic with a strong reputation and a chair at the Psychiatric Institute in Rome, but he was so anxious about the experimental nature of ECT that his trial was conducted in secret. Using equipment built together with Bini, and informed by their experiments on dogs, S.E. was restrained and a shock was administered – 80 volts of alternating current administered for just 0.25 seconds. It failed to induce a seizure, and as Cerletti prepared to increase the duration of the shock S.E. is said to have responded, “Careful, the first was pestiferous, the second will be mortiferous!” The duration was increased a further two times – to 0.5 and 0.75 seconds, but was again unsuccessful. It was only when they upped the voltage to 110 that the shock worked, and S.E. had a full grand mal seizure (meaning loss of consciousness and sustained jerking of the limbs).

  Reports vary. One has it that after the seizure had passed, S.E. sat up with “a vague smile” and, to the question of what had been happening to him, replied lucidly, “I don’t know, perhaps I have been asleep.” Another has him singing a popular song, and yet another that he said only “something unemotional about dying.” But all of them agree that he became more coherent; over two subsequent months they gave him ten more shocks of what they decided to call “electroshock therapy” (EST). On follow-up, a year later, S.E. claimed that he was “very well,” though his wife said that “sometimes during the night he would speak as though in answer to voices.”

  S.E. was the first, but there would be thousands more. As with many new treatments in medicine, doctors became its advocates before side-effect profiles and specific indications had been clearly worked out. (The same was happening to lobotomy victims, who were often returned to their institutions after surgery without any follow-up.) Cerletti and Bini had recommended ECT in schizophrenia, and only ten or twelve shocks, but soon treatment courses into the hundreds were being prescribed, and its indications broadened to combat the miseries of depression, anxiety, obsessive-compulsive disorder, hypochondriasis, drug addiction, alcoholism, anorexia, and conversion disorder (an extreme manifestation of psychosomatic symptoms). It was trialed in children, and to “cure” homosexuality. In the US there were reports from state asylums where it was used as a punishment, on patients who had not finished their meal, or on those who had exhibited threatening behavior. ECT was advised particularly in cases where patients did not have sufficient health insurance for a full course of antidepressant drugs, and to reduce labor costs on a ward. One controversial program used repetitive ECT on a sedated patient to reduce cognitive function to the level of an infant. The aim was to “depattern” the individual, who could start again as a “blank slate” without psychopathology. Its author, Ewen Cameron, was later shown to have received funding from the CIA to develop “brainwashing” techniques in which ECT would play a part.

  WHY WAS IT SO DIFFICULT for Cerletti and Bini to gauge the right amount of electricity to induce a seizure? The human skull is a strong resister, comparable to the silicon used in electronics, and the threshold to elicit a grand mal seizure can vary as much as fivefold between different individuals because of the electrical particularities of the brain and scalp. For the first forty years of the therapy there were also great variations in the equipment used to provide the electricity: some used a mains-generated sine wave of alternating current, minimally modified from the wall socket, while others provided a brief train of DC pulses. These more “efficient” machines provoked seizures with less electricity, but psychiatrists found that they had to increase the voltage above that required purely for seizure elicitation or the therapy didn’t seem to work. One of the common side effects was difficulty in speech after the seizure, thought to be caused by stunning the dominant hemisphere of the brain (in most people the left hemisphere). Attempts were made to circumvent this by applying electricity only to the right hemisphere (“unilateral ECT”), but again, the current would have to be raised above that required purely to trigger the seizure or the treatment was less effective. It appeared that the passage of electric current itself, not just the seizure, was doing something to affect the mental state of patients.

  Neuroscientists can examine brain function with electroencephalograms (EEGs), which graph small changes in the electrical output of the brain by measuring at the surface of the scalp. Understanding the delicacy of neuronal function with an EEG is about as sensitive as figuring out social relationships within a city by flying over it in a bomber plane but, like airplane images, EEGs can convey useful information. During seizures, networks of brain cells detonate in a whirling, chaotic frenzy; the smooth meandering lines of the resting EEG switch suddenly to peaked and jagged forms, like the flames of a firestorm sweeping through the brain.

  Over a usual course of ECT (in Britain and the US now just six to twelve treatments) the brainwaves between seizure treatments become slower, and the voltage and current required to trigger each seizure rises. Neurons communicate with one another across microscopic gaps called synapses, by releasing tiny quantities of chemicals called neurotransmitters. Studies in animals have shown that as a treatment course of ECT progresses, neurons become more sensitive to those neurotransmitters that dampen seizures but more resistant to neurotransmitters that encourage convulsions. It’s as if the brain alters its own chemistry in an attempt to reduce the likelihood of further seizures. This alteration in brain chemistry creates poorly understood but reliably reproducible changes in mental and emotional experience.

  How could changing the electrical state of the brain help those in a state of extreme mental distress? Is it the effect of the electricity itself that is of benefit, the changes in neurotransmitters caused by the seizures, or the circumstances around receiving the treatment? ECT disrupts some of the neuronal connections involved in memory, and memories around the time of treatment can be lost. Some psychiatrists have proposed that the loss of memories might even be partially responsible for the therapeutic benefits of ECT (and some patients have gone into treatment believing that the objective of the procedure was the extinction of bad memories). Other psychiatrists think that an increase in the level of certain neurotransmitters in the brain has a specific antidepressant effect. Some Freudian-minded thinkers have gone as far as proposing that the seemingly drastic nature of ECT works by offering redemption from feelings of intense guilt – a position not too distant from that of the ancient Greeks.

  It’s as if we’re back with Paracelsus: seizures are a way of engaging with the spiritual, and invoking them with electricity offers a shortcut to a different state of being.

  IT’S MORE THAN EIGHTY YEARS since Cerletti’s furtive experiments with ECT, and some critics have voiced concern that the treatment is still conducted largely in secret – that it’s still an arcane rite rather than a modern, medical therapy. It’s as controversial as ever, though the mechanics of it are no more gruesome or distasteful than many other perfectly accepte
d medical or surgical procedures. For example, no one protests when surgeons use electricity to cauterize oozing blood vessels, but then cautery doesn’t produce the unsettling transformation of a seizure.

  In the last few years, psychiatrists in Scotland have tried to address the secrecy with which ECT has traditionally been carried out by setting up an open network to examine, audit and assess the experience of everyone in Scotland who receives it. The Scottish ECT Accreditation Network (SEAN) has, since 2009, published annual online anonymized reports from every hospital and clinic in Scotland that administers ECT. The psychiatrists of SEAN don’t want it hidden away, stigmatized and cloaked in mystery – they’ve opened their work to public scrutiny in a way that other medical specialties would do well to emulate.

  The reputation of the treatment in the popular imagination has been darkened by literature: in Ken Kesey’s One Flew Over The Cuckoo’s Nest, it’s an instrument of torture, while for Sylvia Plath in The Bell Jar it’s alternately terrifying and transcendental – terrifying when administered by an uncaring doctor, and transcendental when delivered by someone more compassionate. For Plath, ECT is both sacred and profane, punishment and cure – for her fictional protagonist in The Bell Jar, it seems to have the power of both damnation and redemption.* It’s notable that in many of the deeply negative accounts of ECT in literature, the recipient wasn’t sedated and anesthetized for the treatment – modern patient experience is for most people far more benign.

  See, in particular, Sylvia Plath’s poem “The Hanging Man.”

  In mental health, more than in other, more “physical” specialties, it can be difficult to define what constitutes recovery – the concept itself is slippery and whether it is achieved depends on who is asking. When Simon Edwards began to talk he described only aspects of the hospital – its food, the beds, how well he had slept. But then details about his life and his slide into despair began to emerge. “It came over me so slowly,” he said. “For a long time I think I didn’t notice anything was wrong. It was like a heaviness on me, a suffocating fog.” Within three weeks of starting treatment, he was gaining weight. “What changed?” I asked him, “How do you feel different?”

  “Before, I could hardly move,” he said. “I felt so weighed down. But now there’s a space between me and that heaviness, a clear space.” He’d lost all memory of the days around the beginning of the treatment, and couldn’t remember our first meeting. But he was no longer tormented by the belief that he was rotting from the inside; within a month of starting the treatment he was ready to go home.

  On his final morning in the hospital I went to say goodbye. His wife was there, helping with his jacket, and fussing over his lapels.

  “I’m fine,” he said tetchily, “I can do it.”

  “I don’t know where he’s been,” she said to me, “but it’s good to have him back.”

  The more I began to talk about ECT with others, the more I found stories similar to that of Mr. Edwards. A friend told me how helpful it had been for her grandmother; another of how her uncle’s life had been saved by it. ECT is a powerful therapy – socially, psychologically and neurologically. It can cause confusion and memory loss, and disrupt the coherence of your thought. But when your habitual state is one of penetrating, paralyzing misery, having the coherence of your thought disrupted may, by some, be experienced as a reprieve.

  ECT is most likely to help you if your depression is in some way “psychotic” (you have beliefs that are manifestly untrue, such as that you are rotting from the inside) or “retarded” (you sit silently, staring at the wall) – Mr. Edwards was precisely in the group most likely to benefit. It fares less well if your misery matches one of the other headings in the evolving catalog of despair (there are currently twenty or thirty of these, listed under F.32–F.39 in the International Classification of Diseases). Lucy Tallon, a woman who suffered recurrent bouts of depression for more than ten years, has written of how ECT was “miraculous” in its effects – hinting at a sanctifying experience. She backs up her position by quoting Carrie Fisher, another advocate of shock therapy, for whom it “punched the dark lights out of my depression.”

  But for every positive experience of ECT that is published, there seem to be two or three that are negative; and the people with severe psychotic depression – those most likely to benefit – are perhaps the least likely to share their stories. And, as Plath attested in The Bell Jar, the way in which doctors speak to their patients – how compassionate, empathetic and supportive they are – can have as much influence on recovery as the physical treatment prescribed. From this perspective, increasingly recognized in psychiatric research, it’s not the therapy that makes the biggest difference but the therapist.

  As in many areas of psychiatry, Freud got there first: “All physicians, yourselves included, are continually practicing psychotherapy, even when you have no intention of doing so and are not aware of it.” There’s nothing sacred about seizures, but there just might be something sacred about a good doctor-patient relationship.

  HEAD

  3

  EYE: A RENAISSANCE OF VISION

  Of all the things that have happened to me,

  I think the least important was having been blind.

  James Joyce, as quoted by J. L. Borges

  MY OFFICE IN EDINBURGH has a large, east-facing window, and for most of the year I examine my patients in natural light. The exception is when a patient complains of a deterioration in their sight, and I want to look inside their eyes with an ophthalmoscope. Then it’s necessary to close the blinds and feel my way in the darkness, hands outstretched, back toward the chair where the patient sits. The ophthalmoscope fires a beam of light through a small aperture, I place it close against my own eye then move within millimeters of the patient’s. There are few examinations more intimate: my cheek often brushes theirs, and usually both of us, through politeness, end up holding our breath.

  It’s an unsettling experience, projecting an image of someone’s inner eye so neatly into your own, retina examining retina through the intermediary of the lens. It can be disorientating too: gazing down the axis of the beam is like looking up into the night sky with an eyeglass. If the central retinal vein is blocked, the resultant scarlet hemorrhages are described in the textbooks as “stormy sunset appearance.” I sometimes see pale retinal spots caused by diabetes, and they’re reminiscent of cumulus clouds. In patients with high blood pressure the branching, silvered shine on the retinal arteries resembles jagged forks of lightning. The first time I looked into the curved vault of a patient’s eyeball I was reminded of those medieval diagrams that showed the heavens as an upturned bowl.

  Ancient Greek opinion was that vision was possible because of a divine fire within the eye – the lens was a kind of transmitter that beamed energy into the world. The flashing reflections in eyes seen by firelight seemed to confirm this theory, held by the Greek poet and philosopher Empedocles as long as two and a half thousand years ago. Part way through a series of metaphors comparing the eye with the moon and sun, he wrote: “As when a man, about to go forth, prepares a light and kindles a blaze of flaming fire … just so the Fire primeval once lay hid in the round pupil of the eye.”

  Two centuries later Plato thought the same, though Aristotle, who believed that light was unique in obeying the same laws whether in heaven or earth, began to question the theory – if our eyes themselves clothe the world with light, why can we not see in the dark? In the thirteenth century, English philosopher Roger Bacon hedged his bets: the soul reaches out from the lens in a projection that “ennobles” our environment, but that environment projects itself back into the eyes.

  By the seventeenth century, classical perspectives on vision were giving way. Astronomers, whose very business was the elucidation and understanding of light, were peering into the eye in order to better comprehend the stars. The astronomer-mystic Johannes Kepler was the first to write about how an image of the world was projected upside down and back to fron
t onto the retina. When Isaac Newton was working out the motion of the planets around the sun he embarked on dramatic experiments to test the reliability of his own vision. Inserting a long, blunt needle (a “bodkin”) into his own eye socket between the bone and the eyeball, he described how wiggling it around distorted his vision. Understanding didn’t progress a great deal from Newton until the twentieth century, when quantum theory and Einstein’s relativity theories began again transforming our understanding of how light works.

  If you are sitting reading this in the sunshine, the photons reaching your retina were born, just eight and a half minutes ago, through nuclear fusion in the core of the sun. Five minutes ago they were streaking past the orbit of Mercury; two and a half minutes ago they outran Venus. Those not intercepted by the earth will pass the orbit of Mars in about four minutes’ time, and Saturn in just over an hour. After this journey across space, and in unchanging time (because, as Einstein figured out, moving at the speed of light brings time to a standstill), the sun’s white light envelops the world around us and breaks into a multicolored scatter. That scatter is funneled by the cornea and the lens of the eye before tumbling onto the safety net of the retina. The energy of that impact causes proteins within the net to bend, starting a chain reaction, which, if enough proteins twist, leads to the firing of a single retinal nerve, and the perception of a single scintilla of light.

  We can taste what’s in our mouths, touch what’s within our reach, smell within hundreds of meters and hear within tens of miles. But it’s only through our vision that we are in communication with the sun and stars.

  JORGE LUIS BORGES’S The Book of Imaginary Beings was first published two years after its author succumbed to the “slow nightfall” of blindness, which he had been suffering since birth through a combination of cataracts and retinal detachments. I couldn’t have looked into Borges’s eyes with an ophthalmoscope: the vault of his retina was collapsing, and clouds of cataract forming in his lens would have obscured the view.