Mass killing under the guise of ECT: the darkest chapter in the history of biological psychiatry

Introduction

Convulsive therapy was devised and introduced as a psychiatric treatment by Laszlo Meduna, a Hungarian psychiatrist, in 1934 (Meduna, 1935). He initially used camphor and later cardiazol for seizure induction (Gazdag et al., 2009). Most patients experienced increasingly extreme fear and tension during the relatively long time between the injection of the substance and the fit. Furthermore, the considerable individual differences in the required doses of these seizure-inducing agents challenged clinicians and resulted in a high rate of ineffective-seizure induction. These difficulties restricted the spread of chemically induced convulsive therapy. Ugo Cerletti and Lucio Bini offered a solution to these problems with the introduction of electric seizure induction into clinical practice in Rome in 1938 (Cerletti and Bini, 1938). This new technique, electroconvulsive therapy (ECT), spread rapidly all over the developed world, including Austria and Germany (Rzesnitzek, 2013).

The history of convulsive therapy in Austria

In the period 1920–40, Central Europe, particularly Hungary and Austria, was at the forefront of the development of biological treatment methods in psychiatry; in Austria, the Psychiatric Clinic of the University of Vienna, led by Otto Pötzl (1877–1962), was an important scientific centre. Pötzl succeeded Wagner-Jauregg, who retired in 1928; he had been the recipient of the first Nobel Prize in psychiatry for the introduction of malarial treatment of general paresis of the insane. Pötzl was open to the new psychiatric treatment methods that were being introduced at the time, and it was in his Clinic that Manfred Sakel conducted his experiments with insulin coma therapy (Sakel, 1933). Meduna’s chemically-induced convulsive therapy was also introduced in Vienna soon after its discovery, and became the topic of intensive research (Birkmayer, 1939). Publications on ECT from the Vienna Clinic were among the first in the German-language literature (Holzer, 1941; see Heintz, 2004).

Not long after convulsive therapy and ECT had spread throughout Europe and the USA, the extermination of people with intellectual disabilities and severe psychiatric disorders (euphemistically referred to as euthanasia), whose lives were regarded as worthless by the Nazi ideology, commenced in Germany in September 1939 (Klee, 2010). A secret organization created for the purpose of exterminating psychiatric patients (later known under the code name ‘T4’) established six sites throughout the German Reich, where over the next two years around 70,000 psychiatric patients were rounded up from all over Germany and killed on an industrial scale in gas chambers (Klee, 2010). This centralized extermination was stopped in August 1941 by Hitler due to public outcry, but the killings continued in many psychiatric institutions and nursing homes, a practice referred to as ‘decentralized euthanasia’ (Klee, 2010).

The Nazi political and medical establishment regarded ECT favourably, as the early, overoptimistic reports promised a very effective treatment. ECT was expected to help to empty psychiatric institutions, thereby relieving the state of the burden of looking after psychiatric patients and freeing up hospital beds for wounded soldiers. The Nazi health authorities and the secret T4 organization promoted the use of ECT. This is reflected in a circular written by Dr Herbert Linden, a high-ranking official responsible for coordination with T4 at the Ministry of the Interior, encouraging the distribution of ECT devices, which were not always readily available under wartime conditions (Linden, 1942).

In Austria, which was annexed by Nazi Germany after the Anschluss of March 1938, the interest in ECT increased due to the support of the T4 organization (Linden, 1942). The Department of Psychiatry at the University of Vienna played a leading role in this process, with the development of its own ECT machine by one of Pötzl’s assistants, Dr Wolfgang Holzer (Czech, 2014). He constructed two models of ECT devices, called ‘Elkra I’ and the portable ‘Elkra II’ (Holzer, 1941). These machines were manufactured and sold by the Viennese firm F. Reiner & Co., in direct competition with the market leader at the time, Siemens AG.

ECT as a cover for mass killings

Many German and Austrian psychiatrists were in favour of the Nazi ‘racial hygiene’ measures, most notoriously the forced sterilization of over 360,000 men and women between 1934 and 1945 (Bock, 1986). Some of the leading figures of contemporary psychiatry, including Carl Schneider, who held the prestigious Chair of Psychiatry at Heidelberg University, actively participated as ‘Gutachter’ (experts) in the extermination of treatment-resistant psychiatric patients by selecting them for the gas chamber based on questionnaires (van den Bussche, 2015). A number of psychiatrists, particularly those working at the T4 killing centres, took an even more active, hands-on part in the killings, but none with more murderous enthusiasm than Dr Emil Gelny.

Dr Gelny (1890–1961) was a devoted member of the NSDAP (the Nazi party) and of the SA, its paramilitary wing. He received his medical degree in 1915 and worked as a general practitioner until 1943, when he was granted a specialist qualification in psychiatry after a three month clinical training at Pötzl’s clinic (Czech, 2016: 17). Using his political connections in the regional NSDAP, Gelny soon took control of the two psychiatric hospitals in Lower Austria, first in Gugging and later in Mauer-Öhling. He started working in Gugging on 1 November 1943, and shortly afterwards he started killing patients by administering lethal doses of morphine or barbiturates. He also attempted to kill patients by injecting compressed air into their veins, but this method proved to be impractical (Verfahren gegen Dr. Josef Mayer und andere, 1946). Patient files show that the first applications of ECT for therapeutic purposes in Gugging were documented around the time of Gelny’s arrival, although there is no definite proof that he was responsible for its introduction (Heil- und Pflegeanstalt Gugging, 1943).

In 1944 Gelny embarked on killing patients with an ECT machine, something that was not practised anywhere else before or after, and remains unprecedented in the 82-year-long history of convulsive therapy. He modified Holzer’s ECT machine, adding four extra electrodes made by the hospital’s locksmith, which he fastened onto a victim’s wrists and ankles to administer lethal electric shocks.

Demonstrations in Gugging

According to the testimonials of Karl Kammerer and Johann Thalauer, two male nurses at Gugging Psychiatric Hospital, Dr Gelny first used the modified ECT machine to kill patients on Ward 6 in April 1944. On this occasion, he killed six male patients to demonstrate the method to an unidentified visitor; a few weeks later, two female patients were killed in the same way in the presence of four visitors (Czech, 2016: 27–8). After the war, during an interrogation by state police, Kammerer (1945) identified two of the four visitors:

Im Sommer 1944 kam Dr. Gelny mit einigen Herren (glaublich mit dem Direktor der Heilanstalt Am Steinhof und dem Konstrukteur des Schockapparates Dr. Holzer, Assistenzarzt der Klinik Pötzl) und machten [sic] mit zwei Frauen Experimente. Dieselben starben an den Folgen des Experiments. ¹

Dr Holzer participated in the demonstration apparently on his own initiative. He showed a keen interest in ECT and ‘euthanasia’ and was in contact with the clandestine T4 organization, as documented by a manuscript entitled ‘Vorschlag zur Gründung einer Forschungsanstalt für aktive Therapie der Nerven- und Geisteskrankheiten’, which Holzer (1944) submitted to Herbert Linden, liaison officer for T4 at the Ministry of the Interior. In this text, Holzer referred explicitly to the ‘current problem of euthanasia’. He pointed out that a ‘rash legal implementation’ could put an end to the search for new therapy methods and the ‘centuries-long efforts to improve the fate of the insane’. However, he also argued, with twisted logic, that only an intensive search for therapeutic options would give the state the moral legitimacy to approach the euthanasia problem in the context of psychosis (Czech, 2016: 28).

Between 3 and 6 July 1944, the Kanzlei des Führers, the organization behind T4, arranged a meeting for doctors and officials in Vienna, with ‘euthanasia’ at the top of the agenda. The meeting reportedly involved 30–40 people, most of whom were directors of psychiatric hospitals and nursing homes throughout the German Reich. The participants also visited Gugging, where Dr Gelny demonstrated the efficiency of his newly introduced method by killing a patient with his converted ECT machine in front of this professional audience (Czech, 2016: 28). There is evidence from other testimonials that at least one more demonstration took place in late summer, but no later than autumn 1944, in the presence of, among others, Professor Paul Nitsche, T4’s medical director, and Karl Brandt, Hitler’s personal physician and general commissioner of sanitation and health, one of the main organizers of T4 (Czech, 2016: 29).

Mass murder in Mauer-Öhling

In November 1944, Dr Gelny took control of Mauer-Öhling, the second psychiatric hospital in Lower Austria, and also started killing patients there with lethal injections (Czech, 2016: 31). On 8 or 9 April 1945, after several weeks of absence, Gelny returned to Mauer-Öhling from Gugging, which had by that time already been occupied by the Soviet Red Army. The purpose of his visit was generally known in the institution: the head nurse of Pavilion 1 at Mauer-Öhling had informed staff in March 1945 that Dr Gelny would be coming to kill patients, and threatened anyone who spoke about it with death.

As mentioned earlier, ECT had been used at Mauer-Öhling for medical treatment before Gelny’s arrival. When he launched his new wave of killings in Mauer-Öhling, he used the modified ECT device that he had earlier developed at Gugging. He murdered 149 patients during the final days of the war: 77 men in Pavilion 1 and 72 women in Pavilion 2. On the men’s side of the hospital, ECT could only be administered in Pavilion 1, as the treatment required sockets with a higher electric current, which were installed there in 1944. On the women’s side Pavilion 2 was equipped accordingly, initially also for medical treatment. Accompanied by a nurse, Gelny went through the hospital compiling lists of his next victims. In Pavilions 1 and 2 a room was provided for the killings, each with 10 beds. Nursing staff were instructed to escort patients there individually. They were put on a bed and fitted with head electrodes, as though to carry out routine ECT for therapeutic purposes. Once the patient became unconscious from the first stimulation, the additional electrodes were fitted and Gelny delivered the lethal electric stimulus. (During the post-war trial, the nurses denied having fitted the electrodes themselves, shifting all the responsibility onto Dr Gelny, who was still at large; see Verfahren gegen Dr. Josef Mayer und andere, 1946). Death set in within 10 minutes, after which the corpse was wrapped up in a sheet and hidden behind a screen, so that the next victim would not suspect what was about to happen. Only at night were the corpses collected and buried secretly in the cemetery, naked, and without a coffin. Collecting and burying the bodies was done partly by patients and partly by labourers employed by the institution.

The death toll of patients in both institutions – including deaths in the gas chamber of the nearby T4 killing centre Hartheim and killings by electricity, poisoning and systematic starvation and neglect – has been estimated to amount to 2100 people in Gugging and 2700 in Mauer-Öhling (Czech, 2016: 25, 34).

Discussion

Since its introduction in 1934, convulsive therapy has saved tens of thousands of lives and alleviated the agony of millions. It has also been misused by administering it indiscriminately: based on flimsy indications, or in extremely high numbers, or without anaesthesia or muscle relaxation, or even for punishment. In the early days some rogue or zealous psychiatrists may have killed patients, albeit inadvertently, through ignorance or carelessness. However, we are not aware of any other instance where an ECT machine was used by a medical practitioner with the clearly defined purpose of exterminating patients on an almost industrial scale, driven by an inhuman ideological principle of eliminating sick human beings whose lives were regarded as ‘not worth living’. We know of only one other instance: in Auschwitz, where ECT was allegedly used for deadly experiments on prisoners (Lifton, 1986; Pasternak, 2006; Völklein, 1999).

The relationship between ECT and the National Socialists’ murders euphemistically referred to as ‘euthanasia’ is complex, and goes beyond Dr Gelny’s mass killings with an ECT machine modified specifically for that purpose. Many psychiatrists who were passively or actively involved in the euthanasia killings sought to promote active therapeutic methods to overcome the helplessness of their discipline in the face of severe mental illness (Schmuhl, 1994). As Sandner (2006) argued, increased research activity and ‘active therapies’ (insulin coma, cardiazol, work therapy and ECT) played a crucial role in attempting to overcome the crisis of legitimacy that German psychiatrists faced in the 1940s due to their active participation in the extermination of their most vulnerable patients (van den Bussche, 2015).

Nazi health authorities, including the secret T4 organization, actively supported the use of ECT, which helped to redefine the distinction between ‘curable’ and ‘incurable’ patients (Hohendorf, 2013). Paul Nitsche, T4’s medical director, expressed the connection between therapy and mass murder: ‘Es ist doch herrlich, wenn wir in den Anstalten den Ballast loswerden und nun richtige Therapie treiben können’ ² (Klee, 2010).

At this point, we are not in a position to determine whether Gelny’s fanaticism embedded in the Nazi ideology alone can explain his actions, or to what extent, if any, psychopathological factors should be taken into account to understand his murderous spree. In any case, Gelny must have had a compelling and intimidating presence and a persuasive power, as no hospital staff member openly objected to the mass killings, and some even lent a helping hand. His intent from the beginning was to kill psychiatric patients in Gugging and Mauer-Öhling. We believe it is unlikely that Gelny’s prior aim was to torture his victims with ECT, as Friedlander (1995: 169) assumed. In 1943/44, administering ECT without anaesthesia or a muscle relaxant was standard practice, so it can hardly be considered as an intentional torture.

Shortly after Gelny took up his position in November 1943, he began to implement his plan by overdosing patients with morphine, hyoscine and barbiturates. Although this was effective, he changed the method of killing in 1944 (Czech, 2016: 27), mainly due to the cost of the marked increase in drug consumption. In addition, the huge amount of medication that Gelny needed was not always readily available under wartime conditions; therefore, he had to search for an alternative killing method. He might have reduced the patients’ resistance by explaining that they would receive ECT for therapeutic reasons. Besides its easy availability and cost-effectiveness, a further important factor was that ECT could be camouflaged as a medical procedure to reduce patients’ suspicion, at a time when many correctly feared that drugs were used to kill them.

The use of ECT as a method of killing is a crucial detail in the history of the ‘decentralized euthanasia’ phase of the National Socialist extermination campaign targeting psychiatric patients, even if only a fraction of the overall number of victims died by modified ECT: far more psychiatric patients died from lethal doses of drugs, systematic neglect, and malnutrition. Yet Gelny’s horrific abuse has cast a long shadow on ECT and provided ammunition for the antipsychiatry movement to militate against biological treatment methods in general and ECT in particular (Röder, Kubillus and Burwell, 1995). In addition to several other factors, ECT’s connection with Nazi crimes might be partly responsible for its continuing negative image (Sienaert, 2016; Takács, Ungvari and Gazdag, 2012), which scares patients suffering from severe, pharmacotherapy-resistant depression and prevents them from consenting to ECT. In this way, Gelny’s crime continues to have a negative impact on patients’ lives today.