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Medical tests in the sanatoriums and nursing homes of National Socialism

                                                                                                                         Marie Holtmann, Ruhr-Universität Bochum

The video reportage “Sichten und Vernichten – Psychiatrie im Dritten Reich” by Ernst Klee and Gunnar Petrich (1988), shows a doctor performing several tests on a little girl. The child sits undressed on a couch covered with a sheet while the doctor stands beside. A second person stands at the head of the couch and holds the child’s back with both hands. The attending physician turns the patient’s head far to the left and right while she tries to resist by hand movements. While turning right, the child almost slips off the seat but is held by the second person. It can be seen that the doctor seems to strobe the child’s head with his fingers.

The same doctor and the same girl as described in the first scene can now be seen in the following position: The doctor, standing, holds the child by the hips with both hands, the girl’s back is turned toward him. He flings the child several times from the floor to the ceiling while she struggles with her legs and arms. Further, the child is in the doctor’s grip as well, though now lying on her back and held only by the right hand. With his left hand, the doctor grasps the child’s head and bends it far forward toward her chest, as well as far back toward her neck. The girl’s mouth is open, implying that she may be crying. She continues to kick with her legs, her toes are bent like claws.

The described documentary film scene shows the general treatment-practical situation in the sanatoriums and nursing homes from 1933 to 1945. The room is equipped with beds lined up next to each other. Nurses walk through the rows. It is observable that the inmates are lying in small beds with raised edges, possibly to prevent them from falling out. The patients are tightly covered and are apparently taken care of by the medical staff.

Figure 1: Sichten und Vernichten (YouTube, Lewis Kline, 2017, 8:44)

Delimation and classification

This paper will focus on the therapeutic medical applications carried out in the human experiments in many concentration camps and on the inmates of psychiatric institutions under National Socialism. The aim was not primarily to improve the patients’ state of health or to release them. These applications include e.g. forced sterilisation, insulin coma therapy, cardiazole convulsive therapy and electroconvulsive therapy, which had already been developed and carried out before the Nazi regime, but were taken up, continued and modified under National Socialism (Blasius, 1994, pp.149-151; Gawlich, 2018, p.9). Various brain electrical examinations and the encephalography of the time, a procedure in which cerebrospinal fluid was extracted from patients and air was injected, are part of these experiments. The psychiatric treatment of these people classified as inferior, and their systematic killing is related to the euthanasia carried out from 1941 onwards, which aimed to destroy life unworthy of living (Blasius, 1994, p.182). However, there is a distinction since the focus was on the fastest possible elimination and a  healing motive was no longer visible. In this article, common psychiatric human experimentation during the Nazi era is of interest, where research and the healing motive were intertwined, and scientific progress was given clear priority over healing and the individual’s well-being. I want to illustrate this in the following by describing selected experiments and related medical-psychiatric procedures. This description will be made from a praxeological perspective since it can be assumed that these human experiments are to be understood as a supra-individual practice based on the material reviewed. A praxeological perspective is understood as the study of social action against the background of acting bodies (Wikipedia 2020; e.g. Reckwitz, 2003; Haasis & Rieske, 2015). The following step should clarify why this described practice is considered as violence. Furthermore, its circumstances, preconditions, ways of interpretation and justifications should be contextualized.

Figure 2: Reichsgesetzblatt of 25th July 1933 (Wikimedia Commons, 2018)

The Law for the Prevention of Offspring with Hereditary Diseases of 1933 was the origin of the experiments conducted in the sanatoriums, which stated that all people who exhibited the diseases listed therein could be forced to undergo sterilization at their request or under the orders of a guardian or attending physician. Behind the law’s provisions to produce a so-called strong Aryan national body was an idea of man, which diminished the value of those who could not produce offspring conforming to the norm and whom themselves did not fall within this framework, i.e. who were considered hereditarily ill according to the understanding of that time. The wording of this law left room for interpretation as to which groups were subject to the law and thus also to the right to be committed to a psychiatric institution. ‘Congenital imbecility’ and the vague concept of idiocy made it possible for the government and doctors to commit any person they wanted forcibly. Moreover, this law opened the doors to research the origins of hereditary diseases unrestrictedly and without the boundaries set by ethical guidelines. This includes the encephalography mentioned above (Klinda, 2010).

Figure 3: „Hier trägst du mit“ (Lernen aus der Geschichte, 2011)

Figure 3 from the Illustrated Monthly Magazine for German Folklore (Illustrierte Monatsschrift für deutsches Volkstum) shows a young man standing hunched under the weight of a wooden beam on which two other persons, each at one end, are sitting. The person carried on the left sits there in a bent posture, looking into the distance, his face haggard and his eyes deep in their sockets. The person on the right appears to be looking down at the person carrying and has a dark face with animal features. The carrier has light hair and a muscular build. He is looking at the ground in front of him. In the background, which looks very small compared to the person carrying in the middle of the picture, you can see bright, imposing-looking buildings and a wall. The text on the picture reads: “Here you carry. A hereditary patient costs an average of RM 50,000 by the time he reaches the age of 60” [translated by PP]. Here one can observe how the Law for the Prevention of Offspring with so-called Hereditary Diseases was popularized among the population – and thus also among the medical profession. The two persons on the wooden beam, who obviously fall under this law, press down the healthy, German body, which suffers under the load but does not fall.

Insulin coma therapy

Insulin coma therapy or insulin shock therapy was developed and applied by the Viennese physician Manfred Sakel in 1933. This method can be placed before the use of Cardiazole Convulsion therapy, which is also considered shock therapy. However, both forms did not become established in sanatoria and nursing homes until a few years later, in the second half of the 1930s. The discussions by Manfred Sakel and Karl Dussik refer to the more or less standard implementation of the procedure in Vienna shortly after it was developed. Coma therapy in its radicalized, disciplinary form was adopted in the NS. This and the therapy with Cardiazol are understood in this respect as practices similar to human experimentation since they were less subject to a healing motive than to the research and experimentation interest of the so-called relentless medicine in the NS.

The heavy overdose of insulin provided an artificial reduction of the sugar content in the blood so that a comatose state up to epileptiform seizures could be provoked mainly for the treatment of schizophrenia. This assumption was based on the belief of an antagonism between epilepsy and schizophrenia. To put it simply, where epilepsy was present, schizophrenia could not exist. Thus artificially induced epileptic seizures were supposed to displace schizophrenia from the organism. However, the patients were not treated immediately with a constant amount of insulin but gradually brought up to the individual coma limit. They were then shock-treated daily, usually in a series of a few days, with the amount of insulin administered being reduced again towards the end (Setzer, 2009, p.20; Blasius, 1994, p.165; Klinda, 2010, p.71; Gawlich, 2018, pp.59-60). The shock itself lasted for approximately 1-4 hours, depending on how well the patients responded. Shock symptoms first appeared between 45 minutes and five hours. To end hypoglycemia, patients were mostly given glucose or sugar water, which increased the cost of treatment (Hill, 2008, p.72; Dussik & Sakel, 1935, p.410). Accordingly, the treatment can be roughly divided into four phases. In the first phase, insulin was administered intramuscularly only one to three times daily, depending on the patient’s response. This was always done in the morning on an empty stomach, after which the patients were not allowed to eat any food containing carbohydrates for about four hours. In the second phase, also depending on the response to the insulin, it was decided whether to give and increase the units every or every second day. This was continued until the desired deep coma. The difference with phase 1 is that only a morning daily dose was injected as standard. If a shock-inducing amount was achieved, this could be maintained. If the patient’s adaptation (sensitization up to resistance) to the drug took place, the dose, which was mostly between 20 and 260 units, also had to be adjusted. If the coma was broken through a sugar solution, this took place with a nasal probe. The types of shock or coma were divided into wet and dry shock. Wet shock means the desired insulin coma, and dry shock means the onset of epileptiform seizures, i.e. seizures similar to epilepsy but not triggered by it. These should be promptly interrupted. In the contemporary explanations of the medical profession, reference is made to the absolute necessity of an antidote, e.g. in the form of adrenaline or, if necessary, artificial respiration. However, some views regarded dry epileptiform shock as conducive to therapy. Comas could be repeated up to seventy times and beyond. In the third phase, the patient was given one rest day per week or several days off in the case of very severe previous shocks. However, this could also be omitted. In the last phase, the amount of insulin was gradually reduced until a dischargeable state was reached. Up to five patients were together in the doctor’s office during treatment (Dussik & Sakel, 1935, pp.409-411).

According to Sakel and Dussik, the adjustment of the individual insulin dose proved to be difficult since it is only possible through processual learning on the respective patient. This implies possible wrong decisions, overdoses or incorrect and too late termination of the shock state. These problems could be counteracted through close observation by the medical staff. Furthermore,  the provision of special shock equipmentis indicated:

1. 2 Injektionsspritzen zu mindestens 10 ccm.

2. 1 Injektionsspritze zu 2 ccm.

3. 6 Nadeln (intravenös).

4. 3 Nadeln zur intramuskulären Injektion.

5. 5 Originalpackungen 33% Traubenzucker in Ampullen.

6. 5 Ampullen Adrenalin 1:1000, 1 mg.

7. Kardiazol, Lobelin, Coffein in Ampullen.

8. Feilen zur Öffnung der Ampullen.

9. Tupfer, Äther zur Desinfektion.

10. Schlauch zur Venenstauung.

11. 2 Becher mit stark gezuckerter Milch

(Wasser oder Tee). (Etwa 15 bis

20 dkg Zucker.)

12. Nährtrichter und Nährsonde.

13. Glycerin oder Paraffinö1.

14. 1 Eiterschale.

15. 1 Glasspritze 150 ccm.

16. Mehrere Streifen blauen Lackmuspapiers.

17. 1 Eßlöffel oder Mundöffner.

18. Blutdruckmesser.

(Dussik & Sakel, 1935, p.411, Tab.9)

If the necessary artefacts and close follow-up by the medical attendants were given, the application was assumed to be largely harmless. The artifacts were medical equipment like it was with encephalography and electroconvulsive therapy. Here, the aspects of pre-and post-treatment were added, for which instruments were also needed, distinguishing insulin coma treatment from the other applications. Glucose (solutions) had to be available first of all for the aftercare. In addition, a spoon was required for instilling these agents. For the precaution of a failing coma, preparations were provided for emergency intravenous administration. A distinction in the function of the instruments is apparent. One is used to induce the coma (shock) itself, and the other is used for the (mindful) care of the patient afterward as well as for the termination of the shock if necessary.

The onset of coma was marked by profuse sweating, followed by drowsiness to the point of fainting, which indicated the usual shock cycle. The state of coma set in lastly, which the discretion of the physician could extend. In Sakel’s and Dussik’s 1935 remarks, several observed histories of illness are presented in which psychotic patients were treated with the insulin cure. It is noticeable that for each course of therapy, a complete improvement in condition was documented and finally ended with discharge. A recurring concept in this context is the insight into the illness (i.e. the patient’s admission of being ill and thus open to therapy). This seems to be of central interest to the success of the application. The physicians continue to document some deaths that occurred after the application. However, according to them, there have been very few cases, and external reasons were sought to explain the deaths. These included bronchitis and death from heart failure, attributed to circulatory stress after treatment (ibid., p.412).

In addition, the doctors explicitly referred to the positive effect of the therapy:

“The patients recovered physically very intensively, showed considerable weight gains as expected, which, however, exceeded a desirable level only in isolated cases, literally blossomed and, with a few exceptions, did not find the treatment unpleasant. […] Resistance to the shock treatment is rare and usually occurrs only at the beginning. The treatment is not described by the patients as highly unpleasant. There is no indication of the “agonies” which some supposing to be the result of shock” [translated by PP] (ibid., pp.413, 415).

This effect, which seems positive at first glance (which may have been presented too one-sidedly by the medical profession, which increases the problematic nature of such primary sources), can be explained by partly irreversible alteration in the neural pathways in the brain and resulting brain damage since the comas were performed far too often and far too deeply. The ambivalence between lasting behavioral improvement and high risks also led to an ambivalent attitude in the medical profession. Some were utterly convinced by the successes of the method, while others were reluctant to use it or even rigorously rejected it (Panfilova, 2005, pp.69-72, 91). The consequences of deep coma and epileptiform seizure, if any, were largely unknown at the time. Panfilova (2005) explains in her work that the greatest danger of insulin coma was not so much damage to the central nervous system but much more to the circulatory system. Furthermore, she states that the number of deaths was reportedly deficient concerning the severity of the procedure and its supposed effectiveness. According to proponents, side effects such as impaired carbohydrate metabolism, eye damage, gait disturbances, somatic insulin resistance, brain damage, and insulin death were rare but must be treated with caution. Nevertheless, they were possible (ibid., pp.93, 96-104).

The cardiazole convulsive therapy

Cardiazole convulsive treatment appeared a year later as insulin coma therapy in 1934 and was developed by Ladislas J. Meduna, who recommended 20 to 25 applications as the ideal number of convulsions. It became popular due to its lower cost, reduced need for medical personnel, and ease of administration. Cardiazole, which acts also as a circulatory stimulant in small amounts, was aimed to induce an epileptiform seizure by injecting the drug intravenously. Curing schizophrenia or similar psychoses was the main focus of the treatment. The seizing that occurred was more severe than with insulin treatment, and injuries were frequent. It was often accompanied by coughing spasms and blue discoloration of the face (Schott & Tölle, 2006, p.193; Rzesnitzek, 2013, p.1176; Blasius, 1994, p.165; Gawlich, 2018, pp.62-63).

In Forschbach’s work (1938) on cardiazole convulsions, it becomes apparent that Meduna’s recommendation on the number of convulsions was exceeded at his discretion. Patients were always treated at the same time. The immobilization of nervous or anxious persons is mentioned as a problem because the administration of additional sedatives doubled the number of injections compared to the onset of convulsions. The application itself (in most cases twice a week) proceeded as follows: It was started with a cardiazole amount of 4ccm in a 10% solution. Before and during the convulsion, heart rate and other bodily functions such as respiration were monitored and mostly documented. If no seizure was induced by administering the drug, the physicians injected again with the same dose or increased by 1ccm. This amount was adopted as the basis for the subsequent seizure (usually a few days later). Thus, for the next application, one would start with 5cc of Cardiazol and inject 6cc if the seizure was unsuccessful. However, this cannot be observed for every stage since the initial dose was often kept constant for the next application. Nevertheless, Institutions and physicians varied the doses.

In many cases, insulin coma therapy was administered during the treatment break, or it was combined with cardiazole application from the beginning (Forschbach, 1938, pp.723-724; Ebner, 2010, p.117). The convulsion was initiated by a rapid increase in heart rate and a consequent rapid rise in blood pressure. In addition, cardiac arrhythmias increased blood sugar and pupillary rigidity, profuse sweating and loss of saliva and urine could be observed. The last three symptoms, however, are described by Forschbach as vegetative disturbances. However, the trigger of those disturbances was assumed to be in the patient’s physique and not in the preparation. During therapy, short-lived cardiac arrest or death of the patient frequently occurred (Forschbach, 1938, p.728). If the patients did not respond to the drug after several attempts, the therapy was stopped. In order to keep the risk of injury during convulsions low (which, however, often could not prevent bone fractures and other injuries), the treated persons were fixed lying on arms and legs. In addition, a so-called biting wedge (Beißkeil) was placed between their teeth. Cardiazol was injected into the vein in the crook of the arm, and after a few minutes, the convulsions set in. Among the unwanted side effects were the clogging and obliteration of the arteries by the drug itself. Repeated, rapid successive administration exacerbated this. In addition, nausea, drowsiness, headache, and severe fatigue set in, as well as fear of death occurring between the injection and the spasm:

“If unconsciousness did not occur, the patients noticed an agonizing feeling of annihilation, which made them therefore afraid of the treatment” [translated by PP] (Heinrich & Klieser 1995, p.5, quoted from Setzer, 2009, p.20).

The occurred memory problematics that followed in many cases were a specific problem, although the medical profession generally welcomed amnesic states. The reason for this was the assumption that the treatment let them forgot the psychotic contents or that patients were so preoccupied with it that they repressed their mental problems. However, patients found amnesia particularly unpleasant. There was consensus among medical professionals that cardiazole shock therapy was considered less promising than insulin coma therapy (Panfilova, 2005, pp.15-16; Ebner, 2010, pp.45-47; eddywieand, n.d.).

The encephalography

Encephalography, or more precisely pneumoencephalography, was understood to be the removal of cerebrospinal fluid (CSF) and the subsequent air injection, which allowed the brain structures to be seen more clearly on X-rays. This made it a predominantly diagnostic procedure, in which the size of the ventricles in the brain are used as a guide for present hereditary diseases. It was first discovered by Walter Edward Dandy in 1919, but is no longer used today as it can be classified as exceedingly painful and dangerous (Wikipedia, 2020). In 1935, the psychiatrist and neurologist Rudolf Lemke investigated the course of psychoses and schizophrenia against the background of genetic research (hereditary health report) (Hinz-Wessels, 2004, p.82, cited in Klinda, 2010, p.109). In particular, he was interested in the possible lingering in a stage of the disease or the question of whether the condition of the affected person would deteriorate progressively to the final stage (meaning that the usefulness for the German community is no longer given).

In this context, there is repeated reference to progressing personality destruction resulting from the disease’s episodes (Lemke, 1936, pp.89, 113). In his report on encephalography, the physician documented his research interest and his previous experiences in the field of schizophrenia. He additionally addressed theories of the connection between schizophrenia and physique. The prognosis of being able to eradicate psychoses through forced sterilization throughout society was at the center of the experiments and can be traced back to the eugenic ideas that were pursued in a radicalized manner  with  Law for the Prevention of Offspring with Hereditary Diseases.

Lemke spoke of his experiences with schizophrenia, which he was able to make with patients in his clinic as early as 1902 and which formed the basis for his later researches. He also referred to the experiences of his predecessor Walter Jacobi, who published encephalographic findings from several patients in 1928. In the case of the air injections carried out by Lemke himself, he refers to the fact that they were well tolerated by the persons concerned and that no long-lasting side effects occurred. The treatment took place in a sitting position and was suboccipital, i.e. the extraction was taken over the back of the upper neck, directly under the back of the head. He also mentioned that people who have already had an encephalography by him could be treated again. Thus, people who had already undergone the procedure had to undergo it a second time (ibid., p.106). A lumbar cannulation needle was used to drain the cerebrospinal fluid, and a standard injection syringe of the period was used for the air injection. According to Klinda’s (2010) elaborations, the equipment and accessories for the treatment were kept significantly reduced. The materials such as the syringe and cannulation needle had a different functional area in origin. For example, people used the hypodermic syringe to draw blood. This equipment, however, refers to the treatises of the internist Adolf Bingel, who further developed pneumoencephalography. Klinda states that in later applications, instruments specially designed for the technique were also used (ibid., p.32). Here, the different ways of performing the cerebrospinal fluid extraction have already become apparent, because according to Bingel’s suggestion, the cannulation was not performed suboccipital, but lumbal, i.e. in the lower back region. During this procedure, a glass funnel was used, into which the fluid flowed, as well as a rubber hose that connected the funnel to the glass tube located on the cannula. In the following years after Bingel’s suggestion in 1921, various apparatus modifications were made to make the application less complicated for the practitioner and the medical staff.

To achieve the central objective of the treatment – the X-ray image – X-ray plates were placed directly next to or behind the patients, depending on their sitting or lying position. As a result, the skull could be seen either frontally or from the back or from the profile on the X-ray image. Previously, patients were not allowed to eat, and if necessary, they were given a sedative, for example Luminal (Klinda, 2010, p.38). Furthermore, Klinda describes the procedures after the application. In most cases, strong side effects such as headaches and severe nausea were mentioned in the research of medical practitioners, such as Adolf Bingel, and the countermeasures to counteract them. To reduce headaches, it was recommended that treated patients should be placed in a horizontal position with the head lower than the hips. In addition, bed rest and warmth of at least one day were ordered.

As with electroconvulsive therapy, there were no generally valid, standardised guidelines on the exact procedure of the diagnostics, the amount of cerebrospinal fluid withdrawal, which cannula site should be used when, and how to deal with the side effects that might occur. Once again, there is a great deal of room for decisions on the side of the treating physicians, who, at their own discretion, carried out the most suitable version of the treatment on the patient. Encephalogography was established, as already indicated, before the beginning of National Socialism. It was also becoming increasingly popular in other countries. During the Third Reich, however, the method, as Klinda formulates, was radicalised to the extent that it was “frequently used on children with developmental disorders and epilepsy and on patients with schizophrenia against the background of racial ideology and the eugenics movement” [translated by PP] (ibid., p.76). This means that encephalography was used to diagnose a hereditary disease in cases that were at first sight ambiguous. The procedure as such was adapted to the desired result, i.e. the detection of diseased genetic material, so that, for example, more contrast medium was used for a healthy person and encephalography was performed more often. At that time, the use of encephalography on children was also introduced in the Charités and sanatoriums of the NS, mostly in the so-called children’s specialist departments set up there. Among them were the Wittenauer sanatoriums (ibid., pp.112, 115-116):

“In general, the encephalography was performed under anesthesia with Ether or Evipan (hexobarbital). The cannulation and air injection were first performed in the lumbar region and usually only when insufficient CSF was obtained this way, did one resort to occipital or ventricular cannulation. The amount of CSF extracted and the air injected varied between 100-270 cm3, sometimes more than double of what was recommended in the literature at that time. Most of the complications can be attributed to the anaesthesia, but another part was related to the air injection” [translated by PP] (Klinda, 2010, p.133)

It can be seen that the implementation in children differs from that in adults in some aspects: The physicians’ scope for decision-making seemed to have increased once again, for instance, in the event of a failed removal, a new cannulation was carried out at a different part of the body. In addition, a much narrower conception of what a normal encephalogram should look like emerged. The medical criteria were modified to such an extent that only a few children were found to be healthy. The experimental nature of pneumoencephalography can be particularly well illustrated by the variation of the procedures in the clinics. Among other things, an alternative use of the contrast medium took place. Instead of air, the patients were given the proportionately radioactive X-ray contrast medium Thorotrast, which led to death in many cases. In addition, an excessive inflow with air could be detected, in which the ratio between extracted cerebral fluid and injected air was strongly unequal – an overpressure was created in the head of the affected person, whereby the brain structures appeared more clearly (ibid., pp.144-150.).

Even with children admitted to the sanatoriums, the application was often carried out several times due to failed attempts or experimental functions. The deaths due to the procedure are partly listed and confirmed, but since the documented number was surprisingly low and there were significant discrepancies in the records, it is impossible to say whether this corresponds to reality. Its use’s side effects in children were mainly reported to be severe seizures, unconsciousness, circulatory weakness, fever, swelling of the brain, vomiting, and meningitis. Headache and nausea were thus among the more harmless of the consequences. Thus, it can be observed that there were major differences between pneumoencephalography shortly before the NS period and within it. Central to this seems to be the adherence to scientific recommendations for a successful, preferably problem-free application and the resulting scope for decision-making. The more experimental possibilities were granted to the medical profession – not least due to the severe illnesses of the Reichsauschuss children admitted between 1942 and 1945, whom the government placed in so-called children’s specialist wards in order to experiment on them because of their disabilities, which were classified as severe, and finally to kill them in the course of child euthanasia (Trieba, 2015) – the more dangerous the method as such became.

The electroconvulsive therapy

Electroconvulsive therapy (ECT), which has been used in psychiatric wards since 1938, replaced cardiazole convulsive therapy within a short period, particularly in treating patients diagnosed as schizophrenic. Fundamental to ECT implementation was an artefact specially developed for the method, the so-called ECT device. It was a transformer equipped with a timer and was back then one of the most modern therapeutic devices. The machine’s essential functional elements were the switches that controlled the amperage and the current flow, as well as the power connections for the cables that ran into the electrodes. These electrodes were attached to a rubber belt around the head of the treated person.  The patient’s got bite protectors to prevent injuries. (Gawlich, 2018, p.10-12). Before the usage of the device, the patient and electrodes had to be prepared. It involved shaving the head where the electrodes should be placed. Additionally, the skin was washed in that area to prevent the formation of grease and subsequently rubbed with a saline liquid. The cloth towels or sponges that were placed over the electrodes were also dipped in this saline solution. The patient lay either on his back or positioned sideways during preparation and execution. It depended on the number of treated people at the same time. If many patients were connected to a device simultaneously due to a shortage of medical staff, they laid on their sides facing away from each other(ibid., pp.251-256).

When the doctor pressed the button on the machine, the current flowed through the electrodes into the patient’s body, causing epileptiform seizures. These included mentioned convulsions and twitching in the face and body. Patients often lost control of all bodily functions, excreted urine and excrement, and profuse salivation were observable. Due to the intense physical spasm, it was sometimes necessary for caregivers to restrain the persons treated. In most cases, the patients lost consciousness during the treatment. The number of electric shocks varied depending on the patient’s reaction. The current intensity was also based on this principle, meaning that if the person being treated did not have a seizure, both the current intensity and the number of shocks were increased until the desirable reaction occurred (Gawlich, 2018, pp.10-12, pp.251-256; Accornero, 1988, p.47; Setzer, 2009, p.21). The nurse prepared and held the patient while the doctor stood at the machine and pressed the button. There was usually a slow approach to the individual stimulus threshold in the standard procedure of connecting an individual patient to the ECT machine. This preliminary experiment was done by measuring the cranial resistance through a resistance drum (Widerstandstrommel) attached to the device, a so-called potentiometer, which regulated the intensity of the stimulus (Gawlich, 2018, p.166; Ewald and Haddenbrock, 1942, p.640). This legitimate the interpretation that in some psychiatries, the sensitivities of the treated were not completely suppressed.

Due to the lack of staff at the beginning of the 1940s, remote triggering was established for many patients at the Eglfing-Haar sanatorium and nursing home in Bavaria. The doctor was now at a greater distance as he stood at the ECT machine at one point in the room, releasing the stimulus to many people at once. Gawlich (2018) suggests that, in addition, the specific preparation of patients was dispensed to a greater extent. Shaving and degreasing the areas were eliminated. Aids such as back cushions or wedges to prevent fractures or other injuries were omitted as well. The procedure was generalized to the extent that all persons connected to the device received the same electric shock, regardless of individual resistance. It not only increased the distance between doctor and patient but also reduced the knowledge of the stimulus. In contrast, part of the individual treatment was to approach, learn and practise the treatment in the right way. Before applying ECT to people, there were no guidelines or instructions regarding the strength and number of electric shocks. This could only be learned through trial and error (ibid., p.256). Even without the generalized group therapeutic application, the exact course of treatment was at the discretion of the respective clinicians. For example, Ewald and Haddenbrock (1942) documented the exemplary use of the ECT device on patients and thus the latitude they had in making decisions. They used a conductive paste instead of saline solution to prepare the electrodes since using a solution would have taken longer. Furthermore, they did not shave the skin, arguing that the stimulus would have to bridge a further distance without it, and the current strength could thus be easily increased. The rubber belt around the head, which was usually attached to the electrodes, also seemed unnecessary.

The course of treatment was not the only part of the electroshock therapy. The documentation as part of the practice and as a record-keeping practice was done unequally precisely. The notes concerning the individual patient included urine test results, Wassermann test results (Wikipedia, 2021) and fever and weight curves. The often established seizure table contained information on the intensity and duration of the current, the severity of the seizure, the latency period and whether back pain occurred after the application. Referral slips for ECT were also sometimes included in the transcript. However, these detailed records tend to represent the ideal of a generalized record-keeping technique. In reality, the schemes and the aspects whose notation was deemed necessary at all varied wildly (Gawlich, 2018, pp.80-88). Max Gawlich highlights that in the missing parts of the documentation and the treatment, the doctors were unwilling to adhere to the tabular specifications of the patient forms. A reason may be the predominant focus on research rather than cure and treatment in the 1940s, as reports of the effects of ECT can be found more frequently than individual treatment courses and responses. The treatment logic on the patient tended to be to adapt him to institutional habits and sedate him to the point where he was ready for discharge. A spasm that did not take place or was incomplete was ascribed to the patient. This was termed a failed shock. Ewald and Haddenbrock (1942) suggest in their transcript that failed shock occurs in particularly severe mental disorders or is due to a peculiarity in the patient’s anatomy.

The combination of conscientious preparation, the attempt to avoid injury, and the individual stimulus threshold approach indicates a particular healing or improvement motive. However, the fact that many facilities also dispensed with preparation and stimulus regulation and reverted to a standard current strength shows a diversity in the use of the device across facilities and medical professionals. Ewald’s and Haddenbrock’s comments also show this ambivalence:

“Unfortunately, Holzer does not use this method to find indications for the most accurate dosage level above average but works in practical therapy with the extraordinarily high ,,normal” dose of 110 volts and 1 sec. cycle time! Together with Pötzl, he considers cramp failures to be therapeutically questionable and therefore admits that he prefers to accept the considerable overdosage. This exaggerated timidity of abortive seizures and underestimating an overdose is not quite understandable, even considering the majority of authors. Nor do we share Holzer’s view that the clinical delimitation of what is to be understood by a “complete shock” is not yet uniform” [translated by PP] (Ewald & Haddenbrock, 1942, p.641).

It becomes apparent here that the two doctors disapproved of a predecessor’s view that total shock should be provoked under all circumstances. Their plea for patient protection in ECT contradicts their lack of care in omitting, for example, shaving and rubber belts.

Medical tests as historical practices

Following Andreas Reckwitz (2003), social practices are understood as an interplay of three different essential elements: First, the implicit, partly informal logic of the practice, which is anchored in social knowledge and skills; second, its materiality in terms of bodies and objects (artifacts); and third, the interplay of routine and unpredictability. Since praxis theory is perceived as a cultural theory, considering medical testing in the Third Reich against the background of praxeology is conclusive.

National Socialism formed a kind of culture of its own: if one argues with Ernst Boesch (1991) and the symbolic action theory, where culture is generally understood as doing, i.e. a field with possibilities and conditions for actions,  then the NS formed a very own and new field of action specifications and limitations (Blasius, 1994, pp.145-147). Within praxeology and its assumption of the collective knowledge of culture as “practical knowledge and skills” (Reckwitz, 2003, p.289), NS can be interpreted as new, implicit, unquestioned knowledge structures. Reckwitz also refers to the informal logic of practice as the first characteristic of social practices. The social – not necessarily accompanied by interactivity – is anchored in practical knowledge and is repeatedly reproduced.  The social is thought of as supra-individual regulations, which enable the action of individual subjects at all (ibid., p.287). How is it now possible to show that the above medical applications were an informal, implicitly logical practice?

First of all, I  refer to the practically acquired knowledge of the medical profession. The practice was carried out within the professional framework of a group of people. The doctors were the means, i.e. the link between institutional regulations, even legal anchors, and the executed the practice on the victims of violence. The know-how for the therapies had already been learned, only requiring further reproduction from patient to patient. However, the “knowledge-based activity” (ibid., p.292) of the medical practitioners, fed by the explicitly prevailing rules of the NS, had to be reinterpreted and applied individually repeatedly, as the individual case required a new composition of necessary practices. Therefore, since the doctors had discretion, they had to determine which therapy seemed appropriate for which inmates. This requires repeatability of practice, which nevertheless had to be open to deviation in its routine. The question of intentionality, which is a primary focus dealing with violence, is not central here (ibid., p.293).

Secondly, the materiality of practices connecting body and artefact is essential. As a practice dealing with objects and with one’s own body, medical applications are heavily influenced by bodies and corporeality, but also by artefacts (ibid., p.291-292): the medical practitioner must know how to use his or her own body in order to act on the inmates in the desired way. Moreover, he must be able to use the required set of instruments skillfully. That also resulted from the doctors’ professional training and experience. There was a couch in the room where the treated, fixed or not fixed, sat or lay in almost every treatment. Thus, the couch itself contained an inherent intention of use that did not need to be questioned. Depending on the therapy in question, instruments that could not be carried out were located in the room. The ECT machine, for example, made the application possible in the first place (ibid., p.289.) The doctor pressing the button on the machine formed the second instance. Insulin coma therapy, as a further example, would not have worked as well without the drug being introduced into the body to affect it. The therapeutic procedures are shown here as recurrent routinised relations between the actors (doctors and patients) and the objects (artefacts) in use. The linking of several different activities that can be considered in their entirety as a treatment process – practice of preparing the material, the patient, aftercare, administering the remedy, writing it down – shows the multidimensionality of the practices.

In this context, thirdly, the simultaneous “systematic unpredictability” (ibid., p.282) of the learned, incorporated scripts should be pointed out, as well as the field of tension that arises from routine and re-creation. Each social practice is located “between a relative ‘closedness’ of repetition and a relative ‘openness’ to failure, reinterpretation and conflictuality of everyday accomplishment” [translated by PP] (ibid., p.294). The acquired know-how of the actors shows in a regularity that is applied repeatedly in patterns. However, in each routine individual application, a reinterpretation may be required due to uncertainty. The resulting reinterpretation also arises from the incorporated script of the users; and here, their autonomy becomes particularly clear. It is the same case with medical procedures. Due to minutely different compositions, any treatment would most likely require a minor reinterpretation of its scope. For example, in the case of adverse dry shock, the physician would have to react immediately, applying and redeveloping his knowledge to the new situation. The leeway of decision-making of individual physicians makes it evident that e.g. the removable amount of cerebrospinal fluid and the amount of injected air also exhibited unpredictability concerning the decision to act and the uncertainty of consequences. The learning and appropriation of a practice become relevant here. Furthermore, the temporality of the practice becomes implicit since it always allows a potential shift of meaning in the future or the outcome through the uncertain prediction (ibid., p.295).

Fundamental to the determination of past practices is also the explicitly historical praxeological view, which represents a historical research perspective according to Haasis and Rieske (2015). In this context, historically common practices must be understood and reconstructed from the particular living environment of the actors at the time. What supra-individual structures were dominant, what were fixed and fluid norms? What was the discourse in society as a whole? How did the agents act with their bodies and the artifacts?

What did their everyday life look like, and how did this shape social practices? To what extent were these routinized? In short, what was their supra-individual context? These patterns can be addressed through the features of historicity, materiality (which let us recognize practices) and processuality (which can prove practices) (Haasis & Rieske, 2015, pp.13-17, 38).

The materiality of medical practices under National Socialism expressed itself through the reciprocal relationship of bodies to each other and to the artifacts used, as already described. Bodies that influenced bodies and artefacts that impacted bodies through bodily operation are one identifying feature; the other consists in the written and oral, and often also photographic and videographic transmission. Documents that emerged from the practice of medical notation provide evidence that the applications were carried out, but they must be treated with caution. The possible underlying motivation of the agents to document for the benefit of themselves or the superior structures should be taken into account. These records merely offer (not necessarily accurate) representations of the past (ibid., p.27). This was also a particular problem while writing this article: Contrary to expectations, the source material, especially primary sources such as doctors’ reports, files or eyewitness testimonies regarding the actual performance of the tests, turned out to be fragmentary. There are indeed countless sources about the general power dynamics in the Third Reich and how they were developed, as well as about conditions in the concentration camps. As far as the sanatoriums and nursing homes were concerned, accessing relevant material under the given circumstances was not easy. On the one hand, this may be due to the less widespread process of dealing with the physically and mentally ill, including euthanasia. On the other hand, it is conceivable that many original documents simply no longer exist or that the persons concerned had died before they were allowed to reveal them. In addition, it was striking that some potential original documents could only be obtained for a fee, such as the treatises of the Nazi psychiatrist Carl Schneider on the psychology of people with schizophrenia. Therefore, it was only possible to a limited extent to identify microstructural characteristics and commonalities of the given primary sources.

Continuing, the aspect of processuality should help place the exemplary actions as practices, i.e. showing the supra-individual validity. The collectively shared, supra-individually continued and interpreted determines actions as routinized. They are considered everyday practices that (should) endure over an unforeseeable period (ibid., p.33-34).  Hence, it can be seen that therapeutic-experimental applications were perceived as duly across a wide range of actors. The majority of psychiatric institutions and the medical profession applied it against the background of eugenic-ideological thought and its legalities. Historicity as the last characteristic of historical practices considers contemporary knowledge. This means that the former structures and orders must be placed in the context of the analysis. What has been considered important at the time, what was available to society (of National Socialism in Germany) as norms, logic of action, language, exemplariness? What was understood, what was not understood? Which patterns of social actions were common? What did the discourse on this look like (ibid., p.38)? The distinct culture in the Third Reich, implemented particular hierarchies of thought and values. For example, one’s life value was invoked as the usefulness to society as a whole, which was linked to the individual’s ability and willingness to work. In this way, stigmatization, exclusion and violence processes were legitimized and asserted, which served as the ground for their implementation in individual cases. Physically and mentally ill people were denied the right to freedom, integrity, equality of opportunity, and to say no! That meant that it was possible to apply the medical practices legally. The purported aim was to improve their condition, applying experimental-scientific research, not concerning pain and death. According to Haasis and Rieske, one can say that the equality of a human being became incomprehensible through eugenic thought (ibid. p. 39).

The medical applications as violent practices

How can we now determine that the four methods presented were violent practices? Since there is an almost unmanageable variety of definitions of violence, I will start by referring to Popitz’s (1992, p.48) definition of violence to provide a guideline for classification. Popitz defines violence as an “action of power that leads to the deliberate physical injury of others, regardless of whether it has its meaning for the actor in the execution itself or […], translated into threats, is intended to lead to permanent subjugation (as a binding power of action)”. As far as individual violence is concerned, I focus primarily on physical violence, which intentionally seeks to damage or restrict the integrity of the human physique. Common to many definitions is that there must be an imbalance of power to execute violence. The powerful disposes of the powerless in every conceivable way. The intentionality of a harmful act is also discussed repeatedly. Does the perpetrator need to know the effects and consequences of one’s actions for the victim? Moreover, if this is not the case, is it then still violence? It is possible to consider violating a person’s physical and mental integrity unknowingly as violence if one agues with Johan Galtung (1975). He describes e.g. tolerating conditions of injury, unequal living conditions, and the failure to provide help of any kind as structural violence.

More generally, violence operates through the devaluation of life and the valorization of power (Christ & Gudehus, 2013, pp.2-10; Heitmeyer & Hagan, 2002, p.19). This hierarchical relationship does not only appear in malicious intentions involving the body. In the case of medical procedures in Nazi psychiatric wards, it is evident that certain lives were devalued – reflecting on the common designation of mentally or physically impaired people at the time as lives unworthy clarifies it. If one argues with Volker Bonschier (2007), who also includes the restriction of freedom of movement under violence, it can be clearly stated that violent relationships prevailed in psychiatric institutions. Within these institutions, this can represent the first state of power action over other persons, on which all others build.

The patients’ treatments cannot be considered solely from the point of view of the respective doctor who carried them out and had the power of decision at that moment. The condition that prevailed in the sanatoriums and nursing homes was first and foremost institutionalized, or more precisely, state violence (and, in Galtung’s view, also structural relations of violence, since the wholly unequal opportunities and conditions of life manifested themselves in the usability of the individual for Germany). In the case of state violence, the state’s monopoly uses its power for functions of order and repression, which often have an ideological background and are common in dictatorships (Imbusch, 2002, pp.47-49). The ideological engine emerged in a decree with the Law for the Prevention of  Offspring with Hereditary Diseases. It institutionally determined which people were allowed to be sterilized due to various so-called diseases. One paragraph stated that this could be done under duress if a court decision was made and the person concerned refused. Thus the doctrine of the pure body, which was endangered by the persons concerned, was established as a guideline and now had to be implemented in the asylums. That is why the doctors of the sanatoriums and nursing homes could research or punish the inmates at their discretion through various therapeutic measures. The ability to work was fundamental to this: “Common to all therapies was the underlying motive to shock the inmates of the sanatoria and nursing homes into being fit for work to such an extent that they would benefit, at least for some time” [translated by PP] (Setzer, 2009, p. 7).

This shock function includes, above all, the application of cardiazole shock, insulin therapy and electroconvulsive therapy. Encephalography as a predominantly diagnostic procedure, which was often also used experimentally, occupies a particular position in the ideology of racial hygiene because it enabled one to come closer to the hereditary eradication of mental illnesses, especially schizophrenia. Insulin coma therapy and cardiazole convulsive therapy were not prioritized because they stood in the way of the sterilization law and euthanasia. Symptomatic amelioration of the disease and discharge of the patients as supposedly healthy individuals was not the primary goal. It would have contradicted the eradication of the individuals and ancestral lineages afflicted with these diseases.

That the medical crimes were committed as state violence seems obvious. However, can one also speak of the practice of force on the individual level? Did the doctors actually, in terms of the definition established, practice violence? Did they know about the side effects, consequences, anxiety and the actual motive behind it? Did the applications occur with a willful intent to harm and against the will of the patients? Since the individual motives of the doctors cannot be reconstructed, these questions cannot be answered clearly. However, they can be approached through the therapy and implementation characteristics. The primary feature of the practices was, on the one hand, the exclusive application to defenceless persons. That means people who had come to a sanatorium and nursing home by various means, often on the instructions of a family member or a doctor’s order. This included those whose mental impairment was such that they could not object to their treatment. Encephalography, for example, was in most cases performed only on those who were ill or suspected of being so. Moreover, since this procedure, as described, was probably very unpleasant to endure, it can be assumed that it was done – in many cases – against the will of those being treated. It may also be due to the organization of the mental institutions themselves. These were mainly difficult to observe for people uninvolved, and it was even more difficult to object to the treatments there (Klinda, 2010, pp.157-158). Furthermore, Klinda speaks of minor patients who had even less opportunity to object. However, due to bureaucratic regulations, parental consent usually had to be obtained at the beginning of the stay. This was, however, very general and did not list any explicit treatment methods. In other words, the parents gave their general consent to everything done in the institution. Furthermore, Klinda stresses cases in which parents objected to the repeated encephalographic application. This was documented in the child’s files, but the encephalography was performed again (ibid., p.159). Individuals who were capable of contradicting their treatment, however, were accused of not being aware of the illness: “With regard to the psychosis that has been undergone, there must be an awareness of the illness. – In these cases one has the impression of cure” [translated by PP] (Sakel & Dussik, 1935, p.361). If this insight was missing, according to the treating physicians, no healing could take place, which meant that an objection to the therapies only proved that no improvement had occurred – and thus the treatment had to be continued.

The moment of disciplining that accompanied the therapies must not be neglected as well: “People in the asylum were often faced with the alternative of either being ‘shocked’ clubbable or being killed” [translated by PP] (Rzesnitzek, 2013, p.1175). A reference to the lack of insight discussed above can be seen. Education towards the insight of being useless for the national body and the resulting necessity of merciless therapy seems to have played a central role. Within these ideological structures, structural violence seems to have been a prerequisite for physical violence because without the prior classification into a specific group – that of being superfluous and obstructive – no physical use of violence took place.

Furthermore, the question arises whether the therapies of the sanatoriums and nursing homes can be considered effective at all. As already mentioned above, the effectiveness consisted rather in the complete adaptation of the patients to the requirements of the institutions and doctors. This goes along with the most complete immobilization possible using electricity or medication. Perhaps a learning effect took place among those treated, leading them to be as unobtrusive as possible. The increasing number of references in the doctors’ documentation to the fact that the patients took part in the institution’s life without resistance after the treatment and fitted in could indicate this. Whether the doctors knew that the heavy use of insulin and cardiazole would not bring about a real improvement in the patient’s condition, but only a temporary disappearance of the symptoms – which was accompanied by significant risks – is unclear. Presumptions in the direction were admittedly made, and there were indeed critics of the shock therapies who pointed out the pseudo-efficacy and negative consequences (Panfilova, 2005, p.70). The applications were nevertheless carried out, possibly due to the government regulations that applied to the sanatoriums. However, doctors who performed them in their psychiatric wards rarely expressed doubts about the methods. This doubt regarding the action’s mechanisms of the therapies refers to the experimental character of these as a focal moment. The medical profession did not know what was involved precisely, so they tested it on those where it was possible (outside of animal experiments). The tests described at the beginning, performed by a doctor on a blind child, clearly against his will and in pain, illustrate this character. A connection can be made to the power imbalance that precedes the use of violence: the child, incapacitated, diseased and defenceless, represents an experimental object without consequences. On the one hand, the general mercilessness “without regard to danger or pain” (Rzesnitzek, 2014, p.1175) that characterized the therapies at this time, and their extreme implementation, raises doubts about the healing motive and the cluelessness of the individual doctors. On the other hand, the health efficacy of the procedures and the simple lack of knowledge about their risks can be questioned to the extent that the frequency of applications decreased sharply after the National Socialist period (Klinda, 2010, p.175).

Summary and outlook

The medical-therapeutic procedures described here, similar to human experiments, should be understood as violent practices. Violent because, as has been pointed out, several forms of violence existed parallelly, which caused immense harm, regardless of the knowledge about them or the motive of the criminals. Institutionalised, state, structural and individual violence can be identified. In addition, the aspect of collective consequences of violence can be highlighted here. These result because a specific group of perpetrators commits crimes against a collective because its individuals belong to a particular community. The corresponding collective suffers from these consequences across generations, which go beyond the sum of individual suffering so that disintegration processes are related to these collective traumas (Oettler, 2013, p.252). Medical procedures are further to be understood, concerning praxeological research, as social-historical practices. They exhibit a supra-individualized routinization and processuality with an inherent unpredictability to the procedures themselves. They applied within the framework of the medical profession against the background of underlying, incorporated knowledge. They were dependent on the reciprocal dynamics of bodies and artifacts in use, evidencing their materiality. Moreover, they turned out to be multidimensional practices. Not only did they include performance on the body per se, but the named documentation activities were also significant. Furthermore, justification practices of the medical practitioners about an alleged healing motive can be discerned.

In this respect, a contribution that explicitly deals with such practices could be profitable. Disciplinary and punitive practices and the goals of immobilization also seemed to be closely interwoven with medical procedures. After all, it was possible to treat an inmate deemed abusive under the pretext of curative intent. The framework was provided by the social stigmatization practices of the Nazi regime, which labeled disabled and mentally ill people as ballast for the emerging German nation, attacking the national body from within. As mentioned above, in the practice-theoretical section of this paper, it would therefore also be profitable to look at the discourses, opinions, and prevailing orders of knowledge and values within the Nazi bourgeoisie. A comparative cultural study of the adoption and use of these and other violent therapies would be equally worthwhile. The procedural implementations in Vienna, among other places mentioned elsewhere, suggest that while these were adopted, further developed, and radicalized in Nazi Germany, they were also used in other countries and contexts. The purposes and motives behind these would certainly prove exceedingly interesting, especially concerning electroshock therapy in the United States (Hedrich, 2014). 

Furthermore, a comparison between the Nazi and the post-war periods should be sought, especially before the current revelations about the human rights violation in post-war psychiatric hospitals (Eilert, 2012, pp.29-30). Which practices were adopted from the Nazi period until well the 1970s, on which understanding of values of illness and improvement were these built, were these significantly shaped by Nazi thought, although they were not dependent on it? How could these value systems and the resulting actions continue to exist? Or was this development an inevitable or at least logical consequence of National Socialism? Concerning this, the further use of knowledge acquired in the Nazi regime, which was obtained, among other things, through the practices discussed here, should also be considered. Thus, it might seem obvious that these findings would be titled under forbidden knowledge, but there are clear links to contemporary forms of therapy, for example, electroconvulsive therapy for depression (Kara, 2017). Moreover, the fact that encephalography almost completely disappeared from the medical repertoire since it has been proven dangerous argues for further use of the knowledge gained. A paper dealing in detail with such adoption of tabooed knowledge would be of great benefit.


Marie Holtmann studies in the master program Social Science (Culture & Person) at the Ruhr-Universität Bochum (April 2021)


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