In 1928, my grandfather was admitted to the Clinic for Psychiatry and Nervous Diseases in Vienna for a recurrence of the manic-depressive illness he had suffered from since youth. The clinic director was Julius Wagner-Jauregg who one year earlier had been awarded the Nobel Prize for fever treatment of third stage syphilis, general paresis of the insane.1-3 At that time, Vienna boasted the best doctors in the world. In the first part of the 20th century, four Viennese physicians had been awarded the Nobel Prize in Medicine: Robert Bárány for his elucidation of how the inner ear controls balance (1914), Julius Wagner-Jauregg (1927), Karl Landsteiner for his discovery of the main blood groups (1930), and Otto Loewi for his discovery of acetylcholine (1936).
I do not know what treatment my grandfather received in 1928. Hydrotherapy with cold packs, continuous tub baths, and Scotch douches (alternating hot and cold water) were probably used.4 Manfred Sakel had begun prescribing low doses of insulin to calm patients by 1928 in Vienna,4 but did not start inducing full-blown hypoglycemic comas until the early 1930s5,6 too late for my grandfather. The only available medications would have been barbiturates, bromides, paraldehyde, and chloral hydrate.4 Although Wagner-Juaregg favored somatic treatments over psychological ones, psychotherapy was also available at the time at the Clinic, and had been since 1922.7
When word came that my grandfather was ready for discharge from the Clinic, my father, newly married, was delegated to bring him back to his home in Lodz, Poland. On arrival, my father found his father-in-law “climbing the walls.” My father was certain he would not be able to manage him on the long train ride home. He went to see the director, who assured him that all would be well, that my grandfather would be himself again as soon as he boarded the train. And, the story goes, this turned out to be exact. Wagner-Juaregg, with all his faults, was for evermore worshipped at our house.
By the end of 1928, Wagner-Juaregg had retired from his post as clinic director, to be succeeded by Otto Pötzl. Victor Frankl, the founder of logotherapy,8 when interviewed by Wolfgang Neugebauer in 1993,9 said that Pötzl was a good man who always behaved well towards Frankl (director of the Neurological Department of the Jewish hospital in Vienna from 1938 to 1942 and a former student of Pötzl’s) and toward Jewish patients in general. During the war years, Pötzl apparently did not keep Jews at his own clinic, where they would have been “euthanized,” but sent them instead to the Jewish hospital,9 where they were subsequently killed anyway. My grandfather would not have survived in Vienna regardless of which psychiatrist was in charge. More so than any other professional group, psychiatrists took an active part in the Nazi genocide. They were its scientific leaders, its political advisors, and its consultants. They were the directors of killing institutions, and they operated the gas valves.10
Despite the “merely following orders” claim,11 Austrian physicians took leading roles in gassing patients, starving them to death and giving them lethal injections. They did so for three stated reasons: these patients were a drain on the economy, medical and nursing staff caring for them were needed on the battlefield, and their hospital beds were needed for wounded soldiers. Other potential reasons, such as economic motives, valuing national health above individual life, and a tendency toward blind obedience to authority have been recently put forward.12 Whatever the reasons, Jewish, Roma, “mischling” (mixed race), homosexual, criminal, and asocial patients were killed first. They were considered not only useless, but also racially and morally impure.
According to a report dated July 28, 1939, the following groups of persons were card-indexed for death in Austria9:
- Polizei-Sanitäts-Department (about 60,000 mentally ill people and “psychopaths”).
- Trinkerkataster (registry of alcoholics, 40,000).
- Prostituiertenkataster (registry of prostitutes, about 60,000).
- Zentral-Kinderübernahmsstelle (mainly 40,000 problem children and “psychopathic” children from ”asocial” families).
- Steinhof Hospital (120,000 psychiatric patients).
In all, 320,000 persons were registered in this way, i.e. 15% of the population of the greater metropolitan area of Vienna.9
The horror of what was done to psychiatric patients in Germany and Austria during the War years has been amply documented13-16 and will not be repeated here. What is less known is what happened to psychiatric patients in other parts of Europe during these years.
In the fall of 1939, my father, who was an officer in the short-lived Polish army, was captured by the Russians. He escaped, and made his way through Lithuania into Sweden. Lithuania had been an important center of Jewish intellectual, spiritual, and cultural life since the Middle Ages, but, during the 1930s, in line with many other European countries, Lithuania had turned nationalistic and anti-Semitic. By the end of World War II, 95% of Lithuanian Jews and 100% of Jewish psychiatric patients would be murdered.
During this period, Lithuania was first occupied by the Soviet Union in June 1940 and then by Germany the following June. A country of three million people, it was home to 5,000 mental patients17 many of whom died during the war from malnutrition, lack of heat, or infectious disease. As in other countries, the food ration allotted to psychiatric hospitals was lower than that for general hospitals. Medicines were non-existent unless supplied by relatives. The order to begin exterminating mental patients was given soon after the German invasion. On September 1, 1941, 109 patients of Jewish descent were selected from the Kalvarija mental hospital and taken to the neighboring town of Marijampolė where they were executed. The Unit for Mental Diseases at the Jewish Hospital in Vilnius was liquidated in October 1941. Non-Jewish mental patients were also killed, not en masse, but individually. Persuasive Lithuanians were able to convince the German authorities that the country’s farmers would go on strike if psychiatric patients were killed (since many worked on farms) and would, as a consequence, no longer supply the provisions required by the German military. The Germans yielded. Lithuania was the only German-occupied East European country where mental patients were not almost entirely exterminated.17-21
In Sweden, mental patients were not exterminated either, although many starved for lack of food.22,23 Sweden was, of course, not conquered by the Germans; it maintained a policy of neutrality during World War II and once the war started became a safe haven for Jewish refugees from all over Northern Europe,24 including my father. On the other hand, Sweden’s neighbors, Norway and Denmark, were invaded (in April 1940), but there was no order to kill psychiatric patients in Nordic countries and despite food shortages very few patients died.25,26 The death rate in psychiatric hospitals remained much the same during the German occupation as it had before the war. Perhaps this was because relatively few beds were needed for wounded German soldiers. Scandinavian psychiatric patients may also have been spared because they were Aryans; they belonged on the highest rung of the Nazi scale of “worth.”
My grandfather was born near the border between Poland and Belarus. Had he still lived there in June 1941, he might have been lined up head-to-head with other mentally ill patients so that precious ammunition could be saved by having one bullet shoot through them all. He might have been blown up with dynamite or gassed in a mobile van. The Germans made it a policy to exterminate the mentally ill in most of the countries they occupied, but they reserved the most brutal killings for ethnic populations they considered low on their scale of “worth.” After Jews, Blacks, and Gypsies, Russians would have been at the lowest end of the ethnic scale. Belorussians were not far above.20
All Slavs were considered ‘a race of slaves,’ with Poles coming in only slightly ahead of Byelorussians. In 1938, there were 14,000 psychiatric beds in Poland, distributed among 31 institutions. Twenty-four percent of all hospital beds were psychiatric.27
After attacking Poland on the first of September 1939, the Germans began the systematic murder of all psychiatric patients. They had an organized plan, and it was scrupulously carried out.28 The Polish director of a hospital was first ousted and a German director put in his place. Patients were divided into three categories (Jewish patients, chronically ill patients, patients able to work). Those who could not work were loaded onto trucks by the Schutzstaffel (SS) and driven away. The trucks returned empty. The first such event took place in Świecie where 1,000 patients were taken away. They were shot and local villagers were forced to dig their graves. In Kocborowo, near Gdańsk, over 200 patients were shot on September 22, 1939. After the war, mass graves of murdered patients were excavated in the nearby forest. The next hospital, Owińska, near Poznań, was “cleared” in October 1939. Trucks picked up 25 patients at a time and drove to old Fort VII (a maximum security prison) near Poznan, where the patients were placed in bunkers, each holding 50 people. The bunkers were sealed and the patients were killed (it took between 10 and 20 minutes) with carbon monoxide gas. The prisoners from the Fort buried them. One thousand Owińska patients (children and adults) were killed. In Kochanówka Hospital near Łódź, where our family lived, the Germans gassed 2,200 patients in March 1940 by pumping exhaust fumes into sealed trucks.28
The total number of psychiatric patients murdered by the Nazis in occupied Poland between 1939 and 1945 is estimated at about 16,000. An additional 10,000 patients died of malnutrition.
Two months before the Kochanówka massacre, our family, minus my father but including my grandparents, escaped from Łódź and arrived safely in Trieste in northern Italy.
We stayed briefly in Italy when it was still a non-belligerent state, before Mussolini entered the war on the side of Germany (June 10, 1940). In Rome, Ugo Cerletti and Lucio Bini had administered the first electric convulsive treatment (ECT) in 1938 (29,30). My grandfather might have been given ECT had he become ill in Italy but, it being a Catholic country, he would not have been killed, at least not at first. After July 1943, when the northern half of the country was occupied by the Germans and made into a Nazi puppet state, Jewish psychiatric patients from north Italy were deported to concentration camps and almost all subsequently died in Auschwitz. Patients also died in Italian asylums from hunger and lack of care.31
We were reunited with my father in France in March 1940. Like Italy, France was a Catholic country and no psychiatric patients were deliberately killed by the Vichy collaborationist government. But Alexis Carrel, another Nobel Prize winner (for transplantation of blood vessels) and the darling of Vichy’s Maréchal Pétain, was a staunch advocate of eugenics. He believed that ‘families where there exists syphilis, cancer, tuberculosis, neurosis and feeble-mindedness are more dangerous than those of thieves and assassins,’ as quoted in Birley.32 Psychiatric patients were not killed in France, but they died nevertheless, from starvation. Food rations were less in psychiatric hospitals than they were in other hospitals. Some hospitals were run by religious orders whose monks distributed what little food there was fairly and evenly. But, in many hospitals, the staff or the more dominant patients took more than their share of scarce supplies and, as a result, the more vulnerable patients died, 48,000 in all.32 -35
In June 1940, armed with a Portuguese transit visa, our family crossed from France into Franco’s Spain. Since the Spanish Civil War (1936-39), psychiatric care had deteriorated in Spain. Patients were often neglected and many died from starvation or infection. No one, however, was deliberately killed36 despite Franco’s ideological sympathies with National Socialism. As of June 13, 1940, however, around the time we arrived, Franco moved Spain a step closer to Hitler, from neutrality to non-belligerence.
Our family moved on to neutral Portugal whose dictator, Salazar, was also sympathetic to Hitler. This is the country where neurologist Egas Moniz had developed cerebral angiography in 1927. This technique allows the visualization of blood vessels in the brain. For this achievement, Moniz was nominated twice for the Nobel Prize, but was unsuccessful until 1949, and when the Prize came, it was not for cerebral angiography, but for lobotomy. He first performed this procedure on a human patient in 1936.37,38 My grandfather, who had had recurrent episodes of mania and depression since age 18, stayed stable throughout our flight from Poland and during our 9-month stay in Portugal. He did not, thankfully, need to enter a hospital where a lobotomy might have been contemplated.
The countries of Europe during the 1930s and 1940s were swept away by nationalistic fervor that took on a somewhat different aspect in each country. All embraced eugenics, but variously. Eugenics was a scientific doctrine that was able to justify doing away with ”outsiders” and ”inferiors.” The mentally ill, especially the Jewish mentally ill, fell, in the minds of many, into these two objectionable categories, and they were killed – deliberately in Germany and Austria and some German-occupied territories and indirectly, through starvation and neglect, in many other countries of war-torn Europe. Timing of the German occupation, ethnic composition, and religious faith all played a part in distinguishing countries that did from those that did not exterminate psychiatric patients during World War II. My grandfather, miraculously, survived.
- Brown EM. Why Wagner-Jauregg won the Nobel Prize for discovering malaria therapy for General Paresis of the Insane. Hist Psychiatry. 2000; 11: 371-382.
- Wagner-Jauregg J. The history of the malaria treatment of General Paralysis. Am J Psychiatry. 1945-6; 102: 577-582.
- Whitrow M. Wagner-Jauregg and fever therapy. Med History, 1990; 34: 294-310.
- Braslow JT. History and evidence-based medicine: Lessons from the history of somatic treatments from the 1900s to the 1950s. Mental Health Services Res. 1999; 1: 231-240.
- Sakel M. (1937). A new treatment of schizophrenia. Am J Psychiatry. 1937; 93:829-841.
- Sakel M. The nature and origin of the hypoglycemia treatment of psychoses Am J Psychiatry. 1938; 94(suppl): 24-40.
- Springer A. Historiography and history of psychiatry in Austria. Hist Psychiatry. 1991; 2: 251-261.
- Frankl VE. Man’s Search for Meaning. Boston: Beacon Press, 2006.
- Neugebauer W. Racial Hygiene in Vienna 1938 (published in: wiener klinische wochenschrift, Sonderheft, März 1998) (Dokumentationsarchiv des österreichischen Widerstandes (DÖW), Sammlung “Erzählte Geschichte”, Nr. 823, Interview with Univ. Prof. Dr. Viktor E. Frankl, February 1, 1993) http://www.doew.at/information/mitarbeiter/beitraege/rachyg.html)
- Strous RD. Psychiatry during the Nazi era: ethical lessons for the modern professional. Ann Gen Psychiatry. 2007; 6:8.
- Vansant J. Challenging Austria’s victim narratives. German Quarterly. 1994; 67: 38-57.
- Haque OS, De Freitas J, Viani I, Niederschulte B, Bursztajn HJ. Why did so many German doctors join the Nazi Party early? Int J Law Psychiatry. 2012; 35: 473-479.
- Burleigh M. Death and Deliverance. “Euthanasia” in Germany ca. 1900-1945. Cambridge: Cambridge University Press. 1994.
- Friedländer H. The Origins of Nazi Genocide. From Euthanasia to the Final Solution. Chapel Hill: University of North Carolina Press. 1995.
- Lifton RJ. The Nazi Doctors. Medical Killing and the Psychology of Genocide. London: Macmillan. 1986.
- Kater MH. Doctors under Hitler. Chapel Hill: University of North Carolina Press. 1989.
- Aurimas A, Deminskas A. Psychiatric euthanasia in Lithuania during Nazi occupation. Int J Mental Health. 2006; 35: 76-80.
- Doguzov V, Rusalovs’ka S.The massacre of mental patients in Ukraine 1941-1943. Int J Mental Health. 2007; 36: 105-111.
- Kalling K. Estonian psychiatric hospitals during the German occupation (1941-1944). Int J Mental Health. 2007; 36: 89-98.
- Seeman MV. The fate of psychiatric patients in Belarus during the German occupation. Int J Mental Health. 2006; 35: 75-79.
- Tuters K, Viksna A. The extermination of psychiatric patients in Latvia during World War II. Int J Mental Health. 2006; 35: 72-74.
- Engwall K. Starved to death? Nutrition in asylums during the world wars. Scand J Disability Res. 2005; 7: 2-22.
- Seeman MV. Starvation in psychiatric Institutions in Sweden. Int J Mental Health. 2006-2007; 35: 81-87.
- Wahlback K. Neutrality and morality: the Swedish experience. Am Univ Int Law Rev. 1998;14: 103-121.
- Kragh JV. Danish psychiatry during the Nazi occupation. Int J Mental Health. 2006-2007; 35: 100-109.
- Kringlen E. No extermination of mental patients in Norway during the German occupation 1940-45. Int J Mental Health. 2006; 35: 90-93.
- Puzynski S, Moskalewicz J. Evolution of the mental health care system in Poland. Acta Psychiatr Scand 2001;104 (Suppl 410): 69-73.
- Nasierowski T. In the abyss of death. The extermination of the mentally ill in Poland during the Second World War. Int J Mental Health. 2006; 35: 50-61.
- Cerletti U. Old and new information about electroshock. Am J Psychiatry. 1950; 107: 87-94.
- Endler NS. The origins of electroconvulsive therapy (ECT). Convulsive therapy. 1988; 4: 5-23.
- Peloso PF. Psychiatry and psychiatric patients in Italy during World War II. Int J Mental Health. 2006; 35: 66-80.
- Birley JLT. Famine: the distant shadow over French psychiatry. Br J Psychiatry, 2002; 180: 298-299.
- Bailly-Salin P. The mentally ill under Nazi occupation in France. Int J Mental Health. 2006; 35: 11-25.
- Lafont M. L’Extermination Douce. Ligné: Editions Ligné AREPFI. 1987.
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- Huertas R. Spanish psychiatry. The Second Republic, the Civil War, and the aftermath. Int J Mental Health. 2006-7; 35: 61–72.
- Moniz E. Prefrontal leucotomy in the treatment of mental disorders. Am J Psychiatry. 1937; 93(suppl): 1379-1389.
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MARY V. SEEMAN, MD, is a retired psychiatrist and professor emerita of the University of Toronto, Department of Psychiatry. In 2006, she was made an Officer of the Order of Canada for her contributions to the improvement of mental health in Canadian women. The focus of her work has been the effect of psychosis on women and the effect of gender on psychosis. She has written 300 scientific articles and authored several books on schizophrenia and women’s mental health. Her more recent interest is in the ethics of psychiatry.