Shock therapies in Spain (1939–1952) after the Civil War: Santa Isabel National Mental Asylum in Leganés

Abstract

The first third of the twentieth century changed the therapeutical landscape with the emergence of new treatments for the mentally ill in asylums. However, the historiography of their use in Spanish psychiatric establishments has been scarcely studied. The popularization of barbiturate sleep therapies, insulin shock, cardiazol therapy, electroshock and leucotomy spread from the beginning of the century. However, the Spanish Civil War and Spain’s isolation during Franco’s autarky (1939–52) made their implementation difficult. Through historiographic research using medical records as documentary sources, this work analyses the socio-demographic conditions of the asylum population during the first decade of Franco’s dictatorship. The treatments used in Leganés Mental Asylum are described and are compared with those used in other Spanish psychiatric institutions.

Keywords

Aftermath of war psychiatric institutions Santa Isabel National Mental Asylum shock treatments Spain 20th century

Introduction

After the Spanish Civil War (1936–9), Franco ruled the country as an autarky (1939–52), and the development of psychiatry in Spain during this post-war period is the subject of our research. Several investigations during the last decades have analysed some aspects of Spanish psychiatry during the first years of Franco’s dictatorship within the framework of National Catholicism (Campos and Huertas, 2012; Dualde 2007; González de Pablo, 1987; González-Duro, 1997; Novella and Campos, 2017). Recently, Campos and González de Pablo (2016) made a compilation of the various works that discussed psychiatry and mental hygiene in the first years of Franco’s autarky, and they also analysed the changes in psychiatry that took place during the change from the Second Republic to Franco’s autarky (Huertas, 1998). Huertas (2017a) described the reorganization of doctors after the Civil War, at the time of the National Congress of the Society of Neurology and Psychiatry held in Barcelona in 1942. One of the relevant topics at this Congress, attended by well-known doctors such as Juan José López-Ibor, Antonio Vallejo-Nágera and Ramón Sarró, was shock treatments (cardiazol, insulin shock and electroshock).

The therapeutic tools of the period between the two World Wars were malariotherapy proposed by Wagner-Jauregg (1922), the cardiazol therapy of Meduna (Meduna, 1938; see also Fink, 1984), the use of hypoglycaemia or insulin coma (Sakel, 1937), electroshock (Cerletti and Bini, 1938) and prefrontal leucotomy of Egas Moniz (1936). Except for malariotherapy, which was introduced in Spain in 1924 (Villasante, 2004, 2020a), and cardiazol therapy and insulin therapy, which were used at a few institutions during the Civil War, the vast majority of these shock techniques were implemented after it. It is significant to note that, despite the post-war scientific isolation, Spaniards such as Gonzalo Rodríguez-Lafora, Juan José López-Ibor and Marco Merenciano participated in the First International Congress of Psychiatry held in Paris in 1950 (Jordá-Moscardo, Rey-González and Angosto-Saura, 2007); at this meeting the speakers included Ladislau Von Meduna, Manfred Sakel and Ugo Cerletti (Ey, Marty and Desclaux, 1952).

During Franco’s autarky, Spanish psychiatric hospitals were generally overcrowded, had few psychiatrists and professional mental nurses, and their poor economic resources did not always allow them to use treatments (Campos and González de Pablo, 2016; Conseglieri, 2013a). There is still a historiographic gap regarding the introduction of these treatments into clinical practice, although there are some publications that have briefly addressed the therapeutic measures in other Spanish institutions such as those in Ciempozuelos (Madrid), Valladolid and Malaga.

In the present article, we will discuss the introduction of new treatments in Santa Isabel National Mental Asylum (hereafter SINMA) in Leganés, Madrid. Although this is only a case study, we consider that it has historical value because SINMA is a paradigmatic institution of Spanish psychiatric care (Villasante, 2003). The objective is to discuss the therapeutic measures used, by analysing the medical records of the patients who were admitted from 1 April 1939 (end of the Civil War) to 31 December 1952.¹

The total number of medical records consulted was 615, from which socio-demographic and diagnostic variables were extracted, and then analysed using a statistical package (SPSS, version 21). Based on the clinical records, we will address the therapeutic options used in this institution, which included work therapy, drugs and, above all, the beginning of shock therapy and leucotomies.² In addition, other documents, which were attached to the case records and signed by the doctors, have been used, because they add significant information about the treatments. The analysis of patients’ letters and writings kept in the medical records (Villasante et al., 2018: 33) adds a subjective view of the patients (Huertas, 2013; Porter, 1985).

Reorganization of SINMA after the Spanish Civil War

SINMA in Leganés, inaugurated in 1852 under the General Welfare (Ministerio de la Gobernación), was known as ‘Santa Isabel’ because the small, old ‘Casa de Dementes’ was founded in honour of Queen Isabel II (Villasante, 2003, 2008). This establishment, located in a town south of Madrid, has been the subject of numerous investigations that have addressed the characteristics of the asylum population (Candela, 2017; Conseglieri, 2013a; Tierno, 2019; Vázquez de la Torre, 2012), diagnoses or daily life inside the asylum through medical records (Conseglieri, 2008; Tierno, 2008). Despite being a national institution, it was never a large establishment, and at the end of the Civil War it accommodated fewer than 300 patients (Vázquez de la Torre and Villasante, 2016). Its capacity increased to 400 beds, as permitted in the Internal Regulations of 1941, which reorganized the operation of the asylum and the staff rules and functions.³

Despite the apparent break with the period before the Civil War, the main law for the care of the mentally ill, the Republican Decree of July 3, 1931, remained in force throughout Franco’s dictatorship (Huertas, 2016). The main change in this republican legislation was the way patients could be admitted: voluntarily, or by a medical order, or governmental or judicial order.

Since its opening, the patients in SINMA were poor people (Beneficence) and paying patients, as has also been described in other institutions (Beveridge, 1995a, 1995b; Suzuki, 2003). During the Civil War, many of the patients admitted were poor (Vázquez de la Torre and Villasante, 2016), but between 1939 and 1952, 68 per cent of admissions were paying patients. The maximum number of such patients in SINMA was greater, and poor patients remained on a waiting list, with 25 per cent of the free places remaining vacant (Conseglieri, Villasante and Del Cura, 2007). In this way, the fees of patients whose families paid according to category (first or second) provided financial support for the institution, which, throughout its history, had always had budgetary deficits (Álvarez-Uría, 1983: 234). The patients were distributed in different departments with a classification inherited from the French tradition: Calm, Dirty, Agitated and Furious. Most of the patients were ‘calm’, as can be seen in the statistical files or reports which, from 1931, were sent from the asylum to the General Directorate of Beneficence.

In the new Organic Regulation of 1941, unlike the previous Regulation of 1885, the departments of childhood were abolished, as well as those of patients subject to Courts of Justice. In Spain, the absence of psychiatric institutions for children (Del Cura, 2011, 2016) motivated the Head of the Psychiatry Section of the General Directorate of Health to speak out in 1943, denouncing the poor compliance with the regulations and forcing all psychiatric establishments to have specific wards for children (González-Ferradas, 1943). Some hospitals, such as Valladolid, did have a separate ward for the children by the end of the 1940s (García-Cantalapiedra, 1992: 324).

On the other hand, in 1900 a pavilion for the criminal mentally ill was built in Leganés (Candela and Villasante, 2018), since there were practically no criminal psychiatric institutions in Spain (Campos, 2003, 2012: 235). In Madrid, the construction of the Carabanchel Penitentiary Psychiatric Institute did not begin until 1944 (Barrios-Flores, 2007), although only seven patients were admitted between the end of the war, in 1939, and 1952.

SINMA had started in 1852 with a single doctor on its staff, but by the second decade of the twentieth century it had four. During the Civil War, doctors had taken political stances, and only three of them remained at the asylum: Aurelio Mendiguchía-Garriche, Antonio Martín-Vegué and José María Moreno-Rubio; each of them also became mayor of Leganés (Vázquez de la Torre, 2013). Enrique Fernández Sanz, director of the institution during the Second Republic (1931–6) and closely linked to the entire reform movement (Tierno, 2019), left the institution at the beginning of the Civil War and returned in 1943. However, the most significant doctor of this period was the neurologist and psychiatrist Manuel Peraita, who started there in 1944 (Conseglieri et al., 2007). He was the Medical Director until 1949, when an illness prevented him from continuing in his position, and he died shortly afterwards (Conseglieri, 2013b). At the Polyclinic of Deficiency Diseases, Peraita had collaborated with Francisco Grande Covián and the psychiatrist Bartolomé Llopis (Llopis, 1946; see also Huertas, 2006) during the Civil War, describing a series of deficiency neuropathies, among which was the so-called paraesthetic syndrome, causalgia or Madrid syndrome (Peraita, 1947; see also Huertas and Del Cura, 2010). Peraita also helped with the general architectural renovation of the establishment,⁴ incorporating an X-ray service, laboratories, occupational therapy and surgical facilities.⁵

In addition to doctors, the institution had 3 general nurses, 3 administrative staff positions, 43 attendants (unspecified subordinates) and 18 religious Daughters of Charity.⁶ After the Civil War, Franco used an Act, passed on 10 February 1939,⁷ to dismiss non-religious staff (Conseglieri, 2013a). The nurses, with little training, had begun a process of professionalization and secularization during the Second Republic in order to obtain the mental nurse certificate (Duro-Sánchez and Villasante, 2016; Villasante, 2013). However, at the end of the Civil War, the religious orders were reinstated in the institutions, thus lowering costs but also reducing professional training (Comelles, 1988: 165–70; Villasante, 2020b).

A mental hospital population with high mortality

The increase in the demand for psychiatric hospitalization during the Spanish post-war period was practically generalized throughout the country. During the 1940s and until the mid-1950s, new asylums were built; the number of psychiatric beds was 20,000 in 1939, and it increased to 27,140 in 1952 (González-Duro, 1997: 431).

In December 1939, there were 283 patients in SINMA, a number that gradually rose to 368 in 1952, but never reaching the institution’s maximum capacity of 400. Thus, the population of this mental hospital, despite it being a national institution, was small compared with those of other Madrid establishments, such as the Ciempozuelos Asylum, which housed 1,450 women (in 1955), or institutions on the periphery such as the Murcia Psychiatric Hospital, to which 1,034 patients were admitted between 1940 and 1944 (Valenciano-Gayá, 1978: 31–9). It is interesting to note that in 1941, for the first time in the history of SINMA, more women (60 per cent of the total) than men (40 per cent) were admitted. The average age of the patients was 42 years, most of them single and from Madrid, and they stayed for an average of 7.78 years. From 1932, statistics for admitted patients and their diagnoses, based on the Kraepelinian diagnostic classification, were periodically sent to the General Directorate of Health (Anon., 1931). This classification system was maintained after the war when the German influence was dominant in Spain (Vallejo-Nágera, 1944: 335–45). In SINMA, schizophrenia was the most frequent diagnosis, followed by oligophrenia that had increased (Conseglieri, 2013a; Conseglieri, Villasante and Vázquez de la Torre, 2016); the incidence of the latter increased probably because families affected by post-war hunger found it difficult to take care of patients in their homes (Comelles, 1988: 166–8).

Peraita knew of the work of the German psychiatrist Kurt Schneider, and this influenced the increase in the diagnosis of psychopathy, which had been practically non-existent in previous years. From the opening of the asylum until 1939, only eight psychopathic patients had been registered (Mollejo-Aparicio, 2011: 347; Vázquez de la Torre, 2012), compared with 48 patients between 1939 and 1952. Despite the various studies by Peraita (1943, 1946, 1947) on pellagra, only two neuropsychiatric pathologies of deficiency aetiology were diagnosed: one case of pellagra and one of bulbar optic neuritis.⁸ It is likely that the nutritional standards in this asylum were better than those of the poor population of Madrid who became ill due to poor nutrition (Del Cura and Huertas, 2008).

Death within the asylum was the main cause of discharge, and the mortality rates rose from 10.6 per cent in 1940 to 14.98 per cent in 1942. Increases were also observed in other Beneficence establishments, ranging from 6 to 33 per cent (González-Ferradas, 1943). An increase in mortality was also observed in French asylums after World War II (Odier, 1995, 2007). Mortality rates differed according to social class: for poor patients, figures were 19 and 17 per cent in 1941 and 1942, respectively, but for private patients they were 12 and 10 per cent. These results are comparable with those found in a psychiatric population in Ohji Brain Hospital and Komine Hospital in Japan: Suzuki (2003: 349) found that, during World War II, the mortality of public patients (16.8 per cent in 1942 and 46.8 per cent in 1944) was higher than that for private patients (8.5 per cent in 1942 and 19.1 per cent in 1944, respectively).

The most frequent causes of mortality in SINMA were non-infectious cardio-circulatory and neurological diseases (heart failure, strokes, epilepsies). In fact, infectious mortality decreased from 5.9 per cent in 1941 to 1.1 per cent in the early 1950s. The high rates of the first years were probably related to overcrowding, poor hygiene and food conditions. In addition, a campaign for the prevention of tuberculosis had failed (Molero-Mesa, 1994), and there was an increase in mortality due to tuberculosis in Spain and in some establishments in particular, such as the Conxo Asylum in Galicia (González, 1977: 80).

Shortage of money, few treatments

The therapeutic possibilities in psychiatric institutions were undoubtedly linked to the economic hardship of the post-war period. The medical records for the study period show that 28 per cent of patients received treatment, which was only slightly higher than previously when the figure was around 25 per cent (Conseglieri, 2008: 135; Tierno, 2019; Vázquez de la Torre and Villasante, 2016). The profile of a patient receiving treatment was that of a single woman, a private patient who was diagnosed with schizophrenia (this profile was the same for the majority of patients admitted).

Although work therapy had been introduced at SINMA decades earlier, the Spanish edition of Hermann Simon’s book helped to spread knowledge about it (Simon, 1937). Vallejo-Nágera, the highest authority in psychiatry during Franco’s dictatorhip (Campos and Huertas, 2012; Novella and Campos, 2017), described the different methods and recommended its dissemination in Spain (Vallejo-Nágera, 1940: 75–91). Manuel Peraita promoted the improvement of occupational therapy at SINMA, where it had been introduced before the Civil War (Candela, 2017; Tierno, 2019); in 1947 a pavilion was built with sections for carpentry, tailoring, toy-making and shoe-making, mainly for male patients. The women, who since the foundation had been in charge of tasks related to cleaning, cooking and clothing (Villasante, 2008: 59), usually went to a sewing room, although this was not noted in their medical records. However, it was mentioned by Lili, a 32-year-old woman admitted in 1944, in a song that reflected her monotonous life in the institution: ‘and I always go down the hall / from the sewing room to the dining room / from the dining room to the sewing room’;⁹ she also sang of the sadness she experienced due to her separation from her five children (Conseglieri, 2013c; Villasante et al., 2016: 127–8).

In SINMA, the economic collapse after the war led to cuts, such as the withdrawal of stimulant drinks: coffee, wine, tea. The difficulties of food supply worried Manuel Peraita, who had collaborated in studies on deficiency neuropathies in Madrid with Francisco Grande Covián (Del Cura and Huertas, 2008). In 1944, several months after taking up his job, Peraita sent a letter to the General Directorate of Beneficence justifying an increase in food rations for those who worked in the workshops: ‘higher rations have been provided for those patients who have to do hard work (occupational therapy, agricultural tasks, etc.)’.¹⁰

Despite the development of a powerful pharmacological industry during the first decades of the twentieth century, some classic sedatives such as potassium iodide and potassium bromide were still used. However, they were combined with Luminal® (phenobarbital), which had been used since 1920 (Candela, 2017: 478). Phenobarbital and phenyl ethyl barbituric acid (Epilantin®) had been the most frequent treatments for epilepsy (Conseglieri, 2013a: 213) since the introduction of barbiturates in the first decade of the century (Ucha-Udabe, López-Muñoz and Álamo, 2006). In medical records, the notes on their use were brief: a description of the treatment without documenting the effect on the patient.¹¹

The improvement of psychiatric patients after having fever spikes had been observed since Hippocrates, so different methods of pyrethotherapy were introduced in psychiatric institutions. The fixation abscess method, which was used for more than a thousand patients in Ciempozuelos Asylum (Vallejo-Nágera, 1940: 97), was also used in Leganés. The injection of essence of turpentine, morphine, scopolamine, injectable porphyrin or opium tincture in drops – a treatment that was very painful – caused psychomotor agitation. This method has been found in the medical records of 12 patients diagnosed with syphilis, manic-depressive psychosis, oligophrenia, psychopathy or schizophrenia. Among the pyrethotherapeutic methods, malariotherapy was the one that spread worldwide in the third decade of the twentieth century; it had been described in 1917 by Julius Wagner-Jauregg, in 1927 awarded the Nobel Prize in Physiology or Medicine (Brown, 2000). However, this technique, which was hardly used at SINMA (Candela, 2017; Tierno, 2019), was abandoned in the 1940s (Villasante, 2020a). The commercialization of penicillin, which first arrived in Spain in 1944, caused malaria therapy to be abandoned in most institutions. The following year, the first Spanish penicillin was synthesized and, a year later, a case of antibiotic therapy through the spinal route in a patient from Leganés was published (Peraita and Fernández-Sanz, 1946). The patient was a 26-year-old single male patient, admitted in 1945, with general juvenile paralysis; he was treated with intra-spinal penicillin, but the treatment was left unfinished due to the shortage of penicillin during Franco’s autarky.¹² Despite supply problems (Vilanova, 1946: 236),¹³ penicillin was administered to five other patients in the same asylum during the 1940s.

The introduction of cardiazol therapy and insulin coma

An important pathological advance was made in 1934, when the Austrian psychiatrist Ladislaus Joseph von Meduna observed that the brain suffered when poisoned with camphor or lead poisoning (Meduna, 1938). He devised a therapy that used doses of cardiazol – a central nervous system stimulant – injected every three days to cause seizures (Fink, 1984). Meduna found that schizophrenia improved in epileptic patients when they had seizures. These cardiazol therapies were used primarily in the 1940s, together with insulin coma, electroshock and leucotomy, as discussed below (Jessner, Ryan and Solomon, 1941).

Although access to psychiatric treatment was difficult during the Spanish Civil War, in the Provincial Asylum of Valladolid, cardiazol, insulin or a combination of both was used. In November 1938, its director J.M. Villacián published results for 35 patients after one year of treatment (Villacián and Sánchez-García, 1940). He argued that it was a small sample, so results were inconclusive and not as good as Meduna’s. Marco-Merenciano (1942), the director of the Asylum of Valencia, reported remissions in 70 per cent of the 214 schizophrenics treated with cardiazol. Cardiazol was also used in other Spanish asylums such as the Santa Águeda Women’s Sanatorium (Guipúzcoa) (Echeverría-Urrutia, 1948/2005) and in Malaga’s Asylum (García-Díaz, 2019).

Cardiazol was used at SINMA from 1940, but by 1952 only 15 patients (7 per cent) had been treated with it. Most of them were schizophrenic and, on occasions, it was administrated in combination with electroshock and Sakel’s cure. The technique consisted of injecting 0.30–0.40 grams of cardiazol (depending on the patient’s weight), which caused a seizure. If a seizure did not occur, the dose was systematically increased by 0.02–0.04 grams with each injection, until the patient had had 10–13 attacks, and the treatment was repeated after 3–4 weeks (Villacián and Sánchez-García, 1940). In the clinical records of SINMA, the administration guidelines are not detailed, for example ‘administration of cardiazol every three days, 22 injections. No improvement’.¹⁴ Although it is widely known that seizures, often violent and difficult to control, caused fractures in the spine, we have not found descriptions of such side effects in the clinical notes. However, some complications were recorded at the Ciempozuelos Asylum in Madrid: shoulder or jaw dislocations (García-Cantalapiedra, 1992: 230). Also, in other international institutions, such as the New York State Psychiatric Institute, it was revealed in 1939 that 43 per cent of patients treated with cardiazol therapy suffered from vertebral fractures (Polatin, Friedman, Harris and Horwitz, 1939).

It is significant to note that this violent treatment did not have the consent of the patients, who often rejected it by begging the doctor to stop it. In the written testimonies of Leganés we have not found any explicit refusal of the treatment (Villasante et al., 2018: 165–205); however, the director of the Valladolid Asylum collected the heartbreaking testimonies of patients who asked for the treatment to be interrupted, because of the terror and the sensation of death that they experienced between the injections and unconsciousness (Villacián and Sánchez-García, 1940).

Almost simultaneously, in 1935, the Austrian Manfred Sakel had introduced the Sakel cure or insulin coma, which became a widespread treatment in European and American psychiatric hospitals (James, 1992). Its use was popular in the 1940s and 1950s (Jones, 2000), until criticism increased, starting with an article in The Lancet (Bourne, 1953), and it was abandoned at the end of the decade. The classic Sakel technique consisted of four phases (Sakel, 1937), starting with intramuscular injection of increasing doses of insulin until hypoglycaemic shocks were achieved, which were later interrupted by the administration of sugar solution through a nasogastric tube. Generally, when the patient woke up from the coma, he or she showed a mental lucidity which increased after successive comas until clarity persisted during the non-hypoglycaemic interval. Subsequently, the insulin doses were decreased, interrupting the hypoglycaemia. Treatment lasted for 3–6 months, with variable doses between 20 and 200 units (Vallejo-Nágera, 1940: 209), and therapy finished when behavioural changes appeared in the subject. It was considered to be a difficult technique that required qualified staff, due to complications resulting from prolonged administration of insulin in non-diabetic patients.

In Spain the method was first used in 1938 (Villacián and Sánchez-García, 1940), but at SINMA it was not used until 1941. In addition to the need for qualified staff for nursing care – and they were scarce in mental institutions (Villasante, 2020b) – large amounts of insulin and sugar were required, which made it an expensive technique. However, in late 1943 and early 1944, the treatment was frequently used there, despite supply difficulties. First, the insulin had to be imported from Denmark (Insulin Leo®) by the Hygiene Section of the General Directorate of Health, which bought it for public institutions, such as SINMA (Conseglieri, 2013a: 218–19).

At SINMA, Sakel’s technique was introduced almost at the same time as the use of cardiazol, and was administered in 13 per cent of the patients, all of them schizophrenics. Most of this technique was performed together with electroshock. Of the 26 patients from this period who received this treatment, only 6 were discharged as cured or with total remission of symptoms. One of these patients was a woman who was admitted in October 1947 with a diagnosis of schizophrenia and began receiving insulin treatment in February 1948. The method consisted of administering increasing doses of insulin for 6 days a week, starting at 10 units and increasing to 45 units. The number of doses, the number of complete insulin comas elicited, as well as the patient’s temperature were plotted on a graph (Figure 1). In mid-March, the patient’s treatment was suspended and upon examination the doctor concluded: ‘great appearance. No hallucinatory experiences, no apathy or indifference. Much more normal affectivity’.¹⁵ One week after this examination, the treatment was finally suspended due to ‘complete remission of symptoms’, and the patient was discharged shortly after. However, more than two-thirds of the patients did not recover after suffering severe epileptic episodes and agitation after comas.¹⁶

Figure 1.

Sakel treatment form, SINMA in Leganés: patient admitted 1 October 1948; diagnosis: paranoid schizophrenia (source: HA, HUJG).

Electroshock after the war

Electroshock, a technique developed by the Italians Ugo Cerletti and Lucio Bini (1938), consisted of the application of electric shocks to humans, and was described at the Paris Congress of 1950 (Passione, 2004). At this meeting, Cerletti himself described the number of sessions, the biological and psychological effects, and secondary effects such as fractures (Cerletti, 1952). In fact, it was not until 1952, with the introduction of muscle relaxants, that the number of fractures caused by this technique was reduced (Berrios, 1997: 105–119; Shorter, 1997: 281–7).

The treatment, which was easier and cheaper than the other shock therapies, was an advantage in Spain, a country with great economic difficulties after the Civil War. Alfredo Prieto-Vidal (1941) published the first report of Spanish patients treated with electroshock; more than 100 patients at the San Luis de Palencia Psychiatric Sanatorium were treated and the results were similar to those of cardiazol therapy. From then on, there were many reports of the treatment. In the Provincial Asylum of Valencia, patients were treated with a Spanish device designed by the electrophysiologist Ruis-Vivó (Marco-Merenciano, 1942; Marco-Merenciano and Ruis-Vivó, 1940). In fact, at the National Congress of Neurology and Psychiatryin 1942, during the session on ‘New treatments in psychiatry’, professionals were expressly invited to practise electroconvulsive therapy (Huertas, 2017a).

Electroshock was applied for the first time at SINMA in 1944, progressively replacing cardiazol and insulin shock treatments. From then until 1952, it was used on 96 patients, usually as the only treatment (71 patients) (see, e.g., Figure 2). However, in a fifth of them the Sakel cure or the cardiazol cure (21 cases) was also used, in the same way as in other institutions. Without a doubt, it became the most widely used technique, although cure or remission rates did not improve during that decade (Conseglieri, 2013a). The results at SINMA were less successful than those reported in other Spanish publications, probably because many of its patients were considered chronic or incurable.

Figure 2.

Electroshock treatment form, SINMA in Leganés: patient with manic depressive psychosis treated in June 1946 (source: HA, HUJG).

In most of the establishments studied in Spain, electroshock was the most applied treatment, as has been observed among women in the Malaga Asylum (García-Díaz, 2019) and the Ciempozuelos Asylum (López de Lerma and Díaz-Gómez, 2000: 240). In the Women’s Psychiatric Hospital of Santa Águeda (Guipúzcoa), up to 25 per cent of those admitted received electroshock or cardiazol therapy (Echeverría-Urrutia, 1948/2005); in the Asylum of Navarra, it was used for more than 75 per cent of the patients treated.¹⁷ Electroshock and other shock therapies were often used in order to facilitate the practice and effectiveness of other techniques, ranging from leucotomy to psychotherapy (Villacián and Sánchez García, 1940; see also Berrios, 1991; Golcman, 2017).

Treatment with electroshock has continued to the present day, and a number of studies defend its benefits and legitimize its practice (Dukakis and Tye, 2006; Ottosson and Fink, 2004); however, the method has been questioned by some authors, due to its use as a form of control and to avoid ‘alterations’ of behaviour in post-war institutions (Huertas, 2017b). The improvement in the technique and its application under anaesthesia, however, has not prevented some critical voices that have continued to reach out up to the present time (Breggin, 2007: 217–50; Szasz, 2007).

A timid introduction to prefrontal leucotomy

Egas Moniz has been considered the ideologue of prefrontal leucotomy (Berrios, 1991), although neurosurgery had already emerged in the USA at the beginning of the twentieth century with Harvey Cushing (1936). The technique was tested for the first time in November 1935 by Moniz and Almeida-Lima, who performed a prefrontal trepanation in an attempt to interrupt neural circuits, the origin of recurrent ideas of delusions or obsessive disorders (Moniz, 1936). This first description by Moniz included 20 cases, half of which were described as cured. However, Almeida-Amaral (1946) reported that some of them later developed complications (cerebral haemorrhages); he also included some explanatory theories about the efficacy of the technique. However, the Portuguese doctors were not the only ones who performed psychosurgery: in 1938, Emilio Rizzatti performed 100 operations at the Racconigi Hospital in Italy, which was around 10 per cent of the hospital population (Kotowicz, 2008). Also, in Greece at the two public hospitals in Athens, more than 250 leucotomies were performed between 1947 and 1954 (Ploumpidis, Tsiamis and Poulakou-Rebelskou, 2005), and in Sweden at Umedalen there were 561 between 1946 and 1953 (Ögren and Sandlund, 2005).

However, it was the Americans Walter Freeman and James W. Watts who contributed most to the international spread of the technique: over two decades (Freeman and Watts, 1946: 31–8), they performed psychosurgical treatment on 3,000 patients, consolidating it as a psychiatric therapy (Freeman, 1948, 1957). In 1948, Freeman organized the first International Conference on Psychosurgery in Lisbon in honour of Egas Moniz, proposing him for the Nobel Prize in Physiology or Medicine, which was awarded to him the following year (Lobo-Antunes, 2010: 237–8).

In Spain, the main promoter of the technique was Juan J. López-Ibor, who presented 60 cases of leucotomy at the Conference in Lisbon, following two different techniques: that of Almeida Lima (anterior plane) and that of Freeman (posterior section of the frontal lobe, called lobotomy) (López-Ibor, 1948). This prestigious psychiatrist worked with the neurosurgeon Pablo Peraita – brother of the director of SINMA, Manuel Peraita – in the Neuropsychiatric Clinic of the Provincial Hospital of Madrid. Despite its restricted indications – schizophrenia, manic-depressive psychosis, obsessive neurosis and some psychosomatic disorders – these doctors had soon treated 120 patients and had also used transorbital leucotomy (López-Ibor and Peraita, 1951). López-Ibor had also written the preface for Las modernas intervenciones quirúrgicas en Psiquiatría by Sixto Obrador-Alcalde (1947), a book that was widely distributed in Spain. Although there are practically no historiographical studies on the use of leucotomy in Spain, at least 67 interventions were performed at the Ciempozuelos Asylum (López de Lerma and Díaz-Gómez, 2000: 234). Between 1954 and 1959, the neurosurgeon Adolfo Ley used the Poppen technique, a variation of the Moniz technique. At the Asylum of Valencia, the Dean of the Faculty of Medicine Juan Barcia-Goyanes and the psychiatrist Domingo-Simó (1951) made a significant report on 16 ‘incurable’ patients who had been discharged after the intervention. Barcia-Goyanes, who was deeply Catholic, raised some moral questions but that did not prevent him from recommending the technique in patients he considered incurable (Giner-Martí and Navarro-Pérez, 1997: 351–3).

At SINMA, after a surgical room had been installed, the first leucotomies took place in 1944, after other treatments had been ineffective. While Manuel Peraita was director, only 10 leucotomies were performed on patients admitted between 1939 and 1945 (6 schizophrenics, 2 epileptic dementias, 1 epileptic psychosis and 1 oligophrenic). In addition, patients who had been admitted decades earlier were treated, for example a male who was hospitalized in 1916 and leucotomized in July 1944; his clinical history includes daily notes of the post-surgical course.¹⁸ A graph of vital signs was made, and there were neurological and psychiatric examinations; just two months after the intervention, the patient died (Mollejo-Aparicio, 2011: 524–8). The medical records showed that at least four of the leucotomized patients died during this period, and only two were discharged, so the results were more negative than those reported by other Spanish colleagues.

Some works have insisted on the very repressive role of leucotomy, as a symbol of power and psychiatric authoritarianism (Pressman, 1998: 47–146; Valenstein, 1986). There was also some criticism among Spanish doctors, for example by the psychiatrist Pedro Ortiz-Ramos in his presentation ‘Reflections on leucotomy’, delivered when he was admitted to the Royal Academy of Medicine of Granada in 1955. In this speech, Ortiz-Ramos, who had visited the Hospital of Santa Marta (Portugal) where Moniz carried out leucotomies, reported numerous experiences from different countries. He was critical of the neurosurgical technique due to the serious consequences on the personality of the patient and he recommended stopping the ‘excessive experimental craving’ of some doctors (García-Díaz, 2019: 363–73).

The serious consequences probably led to the need for the family’s informed consent for the procedure, regardless of whether the doctors were for or against the performance of this technique (Fennell, 1996: 66–77; Whitaker, 2002: 135–7). Written consent, which until then had been practically non-existent in Spain, also reached SINMA in 1944. The director requested, for the first time, family consent to perform a leucotomy on a woman:

Respectable Sister María, after the treatments carried out on Sister C. from that community, not finding any improvement in the mental process that motivated her confinement, please ask her family so that they give their authorization in writing in order to perform a surgical intervention in the brain that sometimes has improved these kind of mental processes . . . . July 11, 1944. Signed Manuel Peraita^19,20

However, we must point out that the doctor himself exerted real pressure for the leucotomy to be accepted, threatening to cease the hospitalization of the patient if the surgical treatment was not accepted:

. . . it has been decided to carry out an active therapy in this case: LEUCOTOMY. I believe that if you do not accept it, you are not satisfied with our treatment methods and sincerely regretting it, we would propose that you request your final departure . . . . Facultative Director. September 18, 1944²¹

Epilogue

During the first years of Franco’s dictatorship, Spanish psychiatry began a process of national reorganization that started at the National Congress of the Society of Neurology and Psychiatry (in Barcelona, 1942), where one of the topics was shock therapies. In order to assess the differences between the scientific contributions and the actual use of the treatments in institutions, a case study has been used as an example of psychiatric assistance in the first years of Franco’s dictatorship. We consider that the records from SINMA are very valuable, because this paradigmatic institution can be compared with other Spanish asylums such as those at Valladolid, Málaga and Ciempozuelos (Madrid).

The operation of SINMA was marked by the precarious socio-economic situation that existed in Spain after the Civil War. Despite the charitable nature of the institution, the entry of private patients was encouraged to help to mitigate the scarce financial resources allocated by the Directorate of Health. The limitation of the maximum capacity to 400 patients, as established in the Internal Regulations of 1941, avoided the overcrowding described in other Spanish psychiatric institutions. However, mortality in mental health institutions continued in an upward trend that had already begun during the Civil War, peaking in 1942 with a rate of 10–19 per cent, depending on the category of patients (private and poor, respectively). Mortality due to infections, including tuberculosis, decreased significantly throughout the 1940s, although the introduction of penicillin was very limited due to supply difficulties in the post-war period.

The prestigious Manuel Peraita, who was the medical director, not only introduced structural changes such as rooms for surgery and for radiology, but also promoted the introduction of new treatments such as shock therapy. Cardiazol and insulin shock were used from 1940 onwards, with some delay compared with the rest of Europe, mainly in schizophrenic patients. Electroshock, first used in 1944, progressively replaced the previous methods (though sometimes they were administered together), due to its easy application and lower cost. Prefrontal leucotomy was more restricted in use and was applied only after the failure of the other methods, since the risk of death or serious sequelae was higher, an issue that generated ethical debates and the need for consent. Alongside these novel treatments, the patients were given work therapy, although it was not recorded in the clinical record but during the 1940s, various workshops were built and agricultural tasks were carried out.

Although the new shock therapies applied between 1940 and 1952 generated great expectations, they did not improve the cure rates, and most of the patients remained in the institution until their death. More detailed research on other Spanish institutions is necessary in order to allow a comparative historiography and a broader vision of the practice of psychiatry in the first years of Franco’s dictatorship.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research for this article is supported by the public research Project De la Higiene mental a la postpsiquiatría: la construcción de la salud mental colectiva en la España del siglo XX (RTI2018-098006-B-I00). Ministerio de Ciencia, Innovación y Universidades (Spain)/FEDER.

Notes

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