Writing the History of Electroshock Therapy ‘From Below’

The history of electroshock therapy has already been reviewed several times. Intellectual histories, social histories and entangled histories were written about it.

‘Histories of ideas’ of electroshock therapy analyzed the concept of ‘electricity’ as a healing or disciplinary method for war neuroses of soldiers during World War I, or they studied the notion of therapeutic epileptic convulsions and “electroshock” as further “shock therapy” (Kalinowsky 1986; Endler 1988; Berrios 1997; Shorter & Healy 2007). The gap to a social history of electroshock therapy was bridged with Thomas Szaz’ article “From the Slaughterhouse to the Madhouse” that provided an analysis of the situation of the first trial of electroshock therapy in the Psychiatric University Clinic in Rome besides its provocative claim that the idea of the electroshock method had stemmed from electric slaughtering (Szaz 1971). Further social histories described the application of shock treatment in daily hospital practice in the USA (Braslow 1997), others in Europe during the time of National Socialism (Siemen 1999; Bueltzingsloewen 2010; Schmuhl & Roelcke 2013). Within a more complex perspective, the international diffusion of shock therapies in general and electroshock treatment in particular was especially analysed relative to the forced migration of physicians of Jewish origin or faith (Peters 1992; Rzesnitzek 2013, 2015a).

However, a material history of electroshock therapy in terms of a history from below with a focus on screws, electrodes, circuitry and patents still remains a desideratum. With this article we aim to write a history of the medical electroshock therapy technique with its changing electric wirings, electrodes and handlings by applying the Social Construction of Technology (SCOT) theory, which assumes that any technology is determined by contingent social factors (Bijker et al. 1987).

The process of the invention and early diffusion of electroshock therapy in the late 1930s and early 1940s depended strongly on circumstances in medical technology, sales strategies and patents; in sum, a special device design was only a single point in the large field of technical possibilities, reflecting the interpretations of certain relevant actors, among them physicians, technicians and industrial companies. In this line, we use private correspondences and non-official reports of technicians and physicians providing an insight into the various, partly professional, partly political or economic interests involved as a first step in our analysis.

The German company Siemens played a crucial role in introducing the technical process. Sources concerning the patent history of the electroshock apparatuses found in the company’s Archive for Medical Technology (Unternehmensarchiv für Medizintechnik) are used in a second step to illustrate how conflicting economic interests and consecutive legal regulations influenced the clinical introduction of electroshock therapy. In keeping with the Social Construction of Technology (SCOT) concept of “design flexibility”, the analysis of the sources demonstrates how the specific conditions of National Socialism in Europe and resulting changes in patent law as well as the requirements of World War II repeatedly changed and formed the technical details of the electroshock apparatus, deciding which design was considered most suited for clinical use. As a matter of fact, in the case of electroshock therapy, the social process shaping the technique was so adaptable that it turned a therapeutic technique into a method for “euthanasia” killings.

The analysis of the technical aspects of the introduction of electroshock therapy with the different apparatuses developed and the related disputes about patents and sales, therefore enriches and changes not only the understanding of the history of electroshock therapy, but provides an example of a new material history of medical practices (Hess 2000; Hess & Mendelsohn 2014).

The Italian Apparecchio per l‘elettroshock

The first electroshock apparatus was developed in Rome. Against the backdrop of longstanding research on epilepsy, Ugo Cerletti (1877–1963) had entrusted his technically versed assistant doctor Lucio Bini (1908–1964) with animal studies on examining the possibility of safely causing epileptic seizures with electricity. In contrast to the pharmacological induction of epileptic seizures in patients, it promised to be simpler, more reliable and cheaper (Berrios 1997). In this line electroshock was just a variation of the ‘convulsive therapy’ that the Hungarian Ladislav Meduna (1896–1964) had proposed based on the hypothesis of an antagonism of schizophrenia and epilepsy (Meduna 1937).

First results of tests in dogs with an apparatus designed by Bini were given in May 1937 on the occasion of the international conference “The Therapy of Schizophrenia—Insulin Shock, Cardiazol, Permanent sleep” in Switzerland. The trials on patients of the Roman Clinic were presented at the Royal Medical Academy in Rome in May 1938, and published in Italian professional magazines as “electric shock” (“l’elettroshock”). The method was geared to initially applying a weak calibration current to two electrodes fixed at the patient’s head with a special supporting structure to measure the so-called head resistance. On the basis of this value, the suitable level of voltage could subsequently be selected so that the electricity flowing through the patient’s head via the same electrodes for fractions of a second would cause an epileptic seizure.

Given that Meduna’s convulsive therapy was also called “shock therapy”; a name most widely used for Manfred Sakel’s insulin coma therapy (Sakel 1935), the denomination “electroshock” was intuitive (cf. Sogliani 1939).

Although the shock paradigm was one of the oldest therapeutic concepts of psychiatry as a medical discipline (Reil 1808), the shock therapies of the 1930s were mostly assumed to have a distinct therapeutic mechanism compared to the more general impact of the swivelling chair or the cold showers of the nineteenth century (Braunmühl 1941). While insulin coma and pharmacological convulsive therapy were mostly discontinued in Europe during the late 1950s and only continued in few places until the 1970s (Rzesnitzek 2015b), electroshock therapy or electro-convulsive therapy still is a recommended therapy in severe depression and catatonia (Grözinger et al. 2012); its technical equipment purchased mostly from a US company (Abrams 2002).

The first company licensed to produce Bini’s first electroshock model exclusively was the Milanese company Officine Elettrotecniche Italiane Ing. Vittorio Arcioni S.a.s. (Arcioni). Advertising brochures and manuals printed in 1939 were titled “Apparecchio per l‘elettroshock—brevetto Prof. Bini”. Bini had applied for a patent on the electric installation of his apparatus. In Italy, his application from October 1938 was granted in March 1939 naming him as the sole inventor of the apparatus (Fig. 1).Footnote 1 One month later Bini also approached the French patent office, which provided him in early December 1939 with a property right to the circuit of the apparatus under the name “Appareil pour applications électriques”.Footnote 2 In July 1939 Bini moreover applied for protection of invention at the Deutschen Reichspatentamt for his “electric healing device for generating convulsions”.Footnote 3

Fig. 1
figure 1

Italian manual Apparecchio per l‘elettroshock—brevetto Prof. Bini 1939 (Collection Dolhuys, museum van de geest, Haarlem, The Netherlands)

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However, the “ground-breaking method” still met with restraint: “Despite all ingenuity, the technical side of the problem did not seem to have been solved sufficiently” (Selzer 1939). Max Müller (1894–1980), who had organized the Swiss conference on the pharmacological shock therapies, remembered clearly:

After Bini’s lectures, there were still some smaller publications from the Roman Clinic and Italian clinics that did, however, hardly attract any interest either. In addition, another difficult factor was that the apparatus developed by the Italians was a trade secret of company Arcioni in Milan and only difficult to get so that nobody was keen on this apparently risky and still little tested method (Müller 1982: 246).

Nevertheless, Max Müller was to apply the electroshock technique for the first time outside of Italy and launch it in Switzerland. A promotional visit and a letter from the Italian clinic, paid for and written by Lothar Kalinowsky (1899–1992), a German emigrant of Jewish origin, encouraged him to undertake this step (cf. Rzesnitzek 2013, 2015a).

In implementing electroshock at Cerletti’s clinic the Berlin neurologist Kalinowsky had been in charge of observing the “neurological changes during and after the seizure” (Kalinowsky 1977: 154). Kalinowsky had relocated to Italy after losing his prior position at the psychiatric hospital of the Charité in Berlin due to the Law for the Restoration of the Professional Civil Service (Gesetz zur Wiederherstellung des Berufsbeamtentums) passed by the National Socialists on 7 April 1933. As Kalinowsky’s position at Cerletti’s clinic was unpaid, the prospect of receiving a financial income via his silent partnership in Bini’s patents, played a role in Kalinowsky’s commitment towards Max Müller. Even though the capital of his wife allowed a certain lifestyle, Kalinowsky had to generate an income for his family of four. So it was on Kalinowsky’s advice, Max Müller later remembered in his autobiography, that he ordered the “apparecchio per l’elettroshock” from Arcioni with the start of World War II, and started first treatments in November 1939 (Müller 1982: 246).Footnote 4

With the equipment acquired from Arcioni, electroshock therapy (“l’elettroshock”) was also introduced in French-speaking Switzerland early on (Forel 1941). The fear that Italy’s entry into the war would create a bottleneck in the supply prompted Müller to transfer the further technical development to Switzerland, thus providing the Swiss company Purtschert & Co. in Luzern his Arcioni apparatus and ordering its reproduction (Müller 1982: 247).

Diffusion of Electroshock: The Role of Lothar Kalinowsky

The introduction of the pharmacologic shock therapies—such as ‘insulin coma’ and ‘cardiazol convulsive’ therapy—must be considered within the context of the forced emigration of doctors and scientists of Jewish faith or descent due to National Socialism (Peters 1992). And the same applied to the introduction of electroshock, made particularly evident by the impact Kalinowsky had on this process (Rzesnitzek 2013).

Following the aggravation of Italian racial laws in the wake of Pact of Steel, formally known as the Pact of Friendship and Alliance between Germany and Italy, signed between Fascist Italy and Nazi Germany on 22 May 1939, the diplomas of doctor’s of foreign “non-Aryans” were annulled. That deprived Kalinowsky of his professional and economic livelihood, forcing him into another exile via France, the Netherlands, England, and finally to the USA.

Bini and Cerletti were quite interested in taking the method abroad, so Bini provided Kalinowsky with the plans of his apparatus on the trip to Paris and Holland (Abrams 1988: 32). Proving rumours wrong that he had lost the plans en route to Paris (Müller 1982: 247), Kalinowsky delivered them to the renowned French medical technology engineering company Duflot as previously agreed with Henri Claude (1869–1945), the former medical director and chair of the University Hospital Sainte Anne.Footnote 5 Obviously progress in the production took some time in materialising. Kalinowsky wrote to his friend and business partner Bini on 26 May 1940 in Italian:

Since the start of the war they haven’t done anything in Paris. I sent one letter after the other and finally learnt that Henri Claude’s clinic has been closed down. Company Duflot of all things—builder of the first apparatus for the clinic and company of highest rank—now wrote to me that Prof. Claude wants to continue in some places despite the war. In a very energetic letter I replied that I forbid the construction of any other apparatus by all means until they have sent the signed contract to our percentage. I doubt that they will sent it to me because if there will be war between Italy and France, they would not have to pay anymore.Footnote 6

Kalinowsky thus accused Duflot of turning France into the only country not to introduce the method for widespread use, despite the fact that it promised enormous savings for hospitals especially during the war. At the same time Kalinowsky agreed with Bini to decrease the patent fee from 20 to 15 per cent of the sales price so as to create another incentive for Duflot to sign the contract; this, however, was never achieved.

These debates and not just the alleged “difficulty of procuring an original apparatus on the market”, had finally brought about the decision of French psychiatrists to construct a new “French” apparatus of their own: the Sismothère produced by Service Radiologique J. Chillaud. The first tests for that apparatus performed on dogs were presented by Marcel Lapipe, from Hospital Vaugirard, and Jean Rondepierre, psychiatrist at Hospital Ville Evrard on the outskirts of Paris, on the occasion of the meeting of the Societé Médico-Psychologique on 28 April 1941 (Lapipe & Rondepierre 1941). In 1942 another French apparatus with a new technical principle, namely the usage of direct current instead of alternating current, was invented by Paul Delmas-Marsalet, professor of psychiatry in Bordeaux; the apparatus was manufactured in Bordeaux by Solex and patented in France.Footnote 7

Kalinowsky also helped to introduce electroshock therapy in the Netherlands; here, however, with an Arcioni device that had been delivered directly from Italy (Barnhoorn 1940: 292). After reading the first article by Cerletti and Bini, the medical director of the small Dutch psychiatric institution Sint Willibrordusstichting in Heiloo, Johannes Anthonius Joseph Barnhoorn, had contacted Cerletti and ordered an Arcioni apparatus. In April 1939, Arcioni sent the order confirmation with an invoice for the “apparatus for electroshock, patent of Prof Bini” (de Valk 2009). Arriving at Heiloo in July 1939, Kalinowsky was able to teach the electroshock method using that apparatus (Rzesnitzek 2013).

Not even the beginning of World War II could prevent Kalinowsky from selling electroshock therapy. In England, it was the Solus Electric Company, which he advised to build an apparatus according to Bini’s plans (cf. Rzesnitzek 2015a). Psychiatrists of the Warlingham Park Hospital were the first ones to use this Solus apparatus—the “Bini patent”—as they explicitly noted, publishing the results with acknowledgments to Kalinowsky (Shepley & McGregor 1939).

The terrain of the new therapy and its apparatus was already highly competitive in England. In late 1939, another apparatus came into use that had been commissioned by Frederick Golla (1877–1968) and William Grey Walter (1910–1977) from Edison Swan Electric’s (Flemming et al. 1939). When the renowned Royal Society of Medicine invited for a session in January 1940 dedicated to “electrically induced convulsions”, invitee Kalinowsky reported on the two-year experience with Bini’s apparatus in order to convince the audience to acknowledge the English patent Lucio Bini and he had applied for. However, his efforts directed against Walter and Golla finally failed (Anonymous 1940). Walter, a renowned expert in the area of electroencephalography, was a strong rival, who, in his cooperation with Golla, endangered the prospect of Bini’s patent to become the standard of electroshock devices as they signalled doubts as early as 1940 whether the sine wave alternating current Bini had chosen really represented the best possible stimulus form (Golla et al. 1940). What Kalinowsky was particularly concerned about was a modification already carried out by Walter and his colleagues: a change of the electrode construction that they demonstrated in a film at the meeting of the Royal Society of Medicine. The electrodes were fixed at the head of a female patient by means of elastic bands (Anonymous 1940: 105), in contrast to Bini’s electrode-forceps or clip construction, which was a genuine part of his apparatus and patent.

Especially the issue of the altered electrode construction continued to worry Kalinowsky as can be discerned from his letters to Bini from his New York exile:

In England, the patent has not yet been accepted. I have written you about the history of the apparatus by Grey Walter. The “Solus” apparatus they have built with me on the basis of the contract (see the works by Shepley, Mc Gregor) now costs just as much as the apparatus by Arcioni. […] The apparatus built under Grey Walter, costs half as much but I cannot do anything as long as the patent has not been accepted. With reference to it, I would like to ask you for a critical and exact description of this apparatus, which could serve me for proving that the apparatus has its disadvantages […]: they do not start by determining the voltage they want to give but immediately define the milliampere for the treatment. They do not even use a special electrode. So I ask you to inform me about the details of their method and explain to me what I never really understood: Why have you used such a large electrode? (To avoid burnings? To reach a larger area of the brain?)Footnote 8

Kalinowsky’s considerations illustrate that he and Bini had indeed an eye on the market situation and feared a more economical competitor. Yet it also shows how little Kalinowsky was privy to the considerations for the construction of the apparatus. One month later (17 June 1940), Kalinowsky still urged Bini to provide technical arguments against the unwanted English competitor so that he could say “something against this model when it comes to advertising to colleagues!”

Kalinowsky’s “advertising” technique proved successful: the renowned clinical research department of the Columbia University, the New York Psychiatric Institute, where Kalinowsky was already allowed to accompany the studies on electroshock therapy at that time (cf. Rzesnitzek 2015a), exchanged the first apparatus built according to the model by Walter for one manufactured according to Bini’s plans. Although it had also been Bini’s Arcioni construction that had been used for the very first electroshock treatments in the USA, due to the fact that another exiled assistant of Cerletti had been able to bring an Arcioni apparatus with him from Italy to New York, it was never been accepted by the US patent office (Almansi & Impastato 1940; Weiner 1988; Shorter & Healy 2007: 74–76).

The German Pursuit of an Electroshock Apparatus

Meanwhile, Bini and Cerletti had introduced their electroshock research results at the III. International Congress for Neurology that was held in Copenhagen in August 1939—only a few days before the German invasion of Poland (Bini 1939; Cerletti & Bini 1939).

Adolf Bingel (1901–1982), chief physician at the Psychiatric and Mental Hospital of University Erlangen, had attended and was enthusiastic about the possibilities the electroshock apparatus seemed to offer. Still in September 1939, he contacted the head of the electro-medical research laboratory of the Siemens-Reiniger-Werke AG Berlin-Erlangen (SRW or Siemens) in Erlangen, Johannes Pätzold (1907–1980), with the request to construct a device for him. Remarkably, Bingel was not the only congress participant to opt for this approach. The Danish psychiatrist Arild Faurbye (1907–1983) proceeded quite similarly. Upon his return from the Copenhagen Congress Faurbye commissioned a Danish engineer with the reproduction of the Bini model with which he started his first treatments in November 1940 (Kragh 2009).

Similarly, in Erlangen, Bingel did not have to invest much time in persuading the SRW or his medical director and chair of the Erlangen clinic, Friedrich Meggendorfer (1880–1953). On 3 February 1940, Bingel and Meggendorfer could already report on their treatments with an apparatus produced by SRW as “the first German tests” that they had started in December 1939 (Bingel & Meggendorfer 1940; Lang 2013).

Was it really the political situation that arose from the Pact of Steel that facilitated the fast production of the German apparatus by SRW, as Max Müller assumed in his memories? Were the Germans indeed “able to obtain the plans from Arcioni without much ado” (Müller 1982: 247)? Not quite so. In a lecture in June 1940 Meggendorfer explained that it was “only after having overcome some difficulties, the company Siemens-Reiniger was able to make a suitable newly designed apparatus available” (Meggendorfer 1940). “A suitable newly designed apparatus”, not just a replica, because the patent right still did prevent to simply make a copy based on the blueprints, and it was after all Bini, and not Arcioni, who owned the Italian patent and had already applied for the acceptance of his patent in the German Reich too.

However, while waiting for his German patent to be granted, Bini approached SRW himself to promote his electroshock construction. The SRW, a subsidiary of Siemens & Halske AG, was considered an important company for the development and production of medical technology products in the German Reich at that time. In this field, SRW ranked among the leading manufacturers in Europe with a pronounced sales network extending to North and South America (Lang 2013: 218). If one wanted to market license rights with sustainable success in Europe’s largest and most populated economy, it was impossible to sidestep SRW. And this applied even more, the more Hitler’s aggressive expansion policy proceeded and gained momentum.

The SRW showed extraordinary interest in Bini’s promotion of his “electric healing apparatus,” telling Bini that they had decided to produce some of his apparatuses on a trial basis and have them subsequently tested to take up “the on-going production and the sales of such healing apparatuses in case of a favourable result” if need be. Yet it was the primary intention of SRW’s patent department to get a comprehensive overview “in which countries except for Italy, Germany, France and the United States of America” Bini “had additionally searched for protection for his healing apparatus or had already received it”. Therefore, Bini was asked to authorize a patent lawyer appointed by the SRW to learn about the details of the German patent registration. After that, SRW promised to make Bini “a suggestion for an agreement […] with regard to the usage of your protective rights, regarding the new healing apparatus” which would also regulate the licence fees.Footnote 9 However, in Pätzold’s view, the apparatus did not justify any high licence fees since it was possible to build it for a low list price.Footnote 10

German Bypassing of Bini’s Patent Application

While a reconstruction of Bini’s Arcioni model was intensively tested as a SRW prototype in patients for its functionality at the same time in corporation with the Psychiatric University Hospital Erlangen by Bingel and Meggendorfer and the mental asylum Eglfing-Haar by Anton Edler von Braunmühl (1901–1957), Pätzold’s laboratory collected ideas from the clinical trials so as to change Bini’s original construction sufficiently to bypass Bini’s still pending patent (cf. more detailed: Lang 2013).

The laboratory received unexpected assistance from the Dutch SRW sales company Almara N.V., which reported to SRW that a defect Arcioni apparatus had been delivered to them for repair in mid-January 1940 (Lang 2013: 222). The apparatus was examined by the sales engineers “by every trick in the book” and the result was documented in a precise technical description of the associated circuit diagram and photographic printing from the interior of the apparatus. After the repair, they added the complete documentation to their report, which was subsequently sent to Pätzold via the SRW sales headquarters in Berlin. Unaware of the work conducted in Erlangen, Almara wanted to initiate a respective SRW apparatus using the documentation of the Arcioni construction. In the Netherlands, the interest for this apparatus had grown so much that Almara had already taken precautionary measures by asking the patent law firm Vereenigde Octrooibureaux in Den Haag to inform them if trademarks had been registered by Arcioni in Holland.Footnote 11

Meanwhile, the SRW patent department had also searched for a legal way to circumvent Bini’s patent registration. An internal memo suggested that a paper from 1922 by Erich Schilf, who at that time had been working as an assistant of the Psychological Institute at Berlin University, had been instrumental in the technical electroshock development (cf. Schilf 1922).

Schilf had caused epileptic seizures by applying periodic short alternating currents through electrodes placed on the conjunctiva of dogs’ eyes; the animals immediately became unconscious and were able to bear subsequent seizures without any damage.Footnote 12 According to the patent department, the apparatus later developed by Bini contained “nothing really new” in comparison to Schilf’s construction, which is why they came to the conclusion: that “the German patent registration B 188 082 VIIIc/21g by Mr. Bini, if it is combated by us, will probably not lead to the assignment of a patent. It is thus not necessary to acquire rights in the German patent registration of Mr. Bini with reference to our fabrication of respective apparatuses.”

In doing so, the SRW did not only focus on the national market for later sales. In early 1940, the patent department issued a memo indicating that given the fact that Bini had been granted a patent in Italy, a delivery of “our apparatus” to Italy was “not possible offhandedly.” Bini had also applied for a patent in “the USA, England, France and Argentina; however, no patent had been granted in any of those countries so far: For this reason, we are currently not prevented from selling our apparatus also in those countries. All other countries are patent-free.”Footnote 13 SRW had decided to pursue its own electroshock business. The potential licensee had become a competitor Bini could hardly match.Footnote 14 SRW was supported by the National Socialist patent right reform of 1936 that replaced the registration right with the inventor’s right. Thus, only the original inventors could claim the patent.Footnote 15 According to the argument of SRW’s patent department, neither the apparatus nor Bini’s electrodes were new “towards the state of technology” and had originally not been developed by him—thus Bini’s patent application was obviously contradicting the principles of the new National Socialist patent law.

In May 1940 Kalinowsky wrote to Bini that he was “sorry” to hear that Bini did “encounter the same difficulties with the German patent” as he did “in other countries”. Referring to the Pact of Steel, he still wanted “to believe that thanks [!] to the political situation it will be easy to negotiate with Germany”.Footnote 16 Kalinowsky’s knowledge status was outdated by the technical developments. As early as late June 1940, Pätzold presented the German apparatus in a lecture of the Physikalisch-Medizinische-Sozietät of the University of Erlangen under the name of “Konvulsator”. The patent department had chosen the name consciously to distinguish it from the Italian “l’elettroshock.” Moreover, Pätzold had changed the construction in a way that Bini’s patent-relevant elements had been avoided: the circuit spared the preceding resistant measurement and also enabled the direct adjustment of the current in mA—just as in Walter and Golla’s English device (Pätzold 1940).

In reaction to Pätzold’s activities, Bini and Cerletti conducted an extremely offensive verbal altercation in the relevant German journals. Claiming that the Italian resistance measurement was necessary to examine “the good preparation of the sick person, the complete performance of electrodes and the absence of short circuits”, Cerletti and Bini argued that Pätzold’s changes had been done at the cost of security (Cerletti & Bini 1941: 211).

Interestingly, it was once again the electrode support construction that caused the harshest Italian criticism. In contrast to the Italian electrode clip or forceps (Fig. 2a) “compressing the electrodes maximally together pressing them strongly against the skin”, the SRW electrodes were “simply [to] be rested on the head” (Fig. 2b a)—as Bingel and Meggendorfer had proposed and quite similar to the electrode band also already used by Walter and Golla.

Fig. 2
figure 2

a Electrode clip of the Arcioni apparatus according to Cerletti and Bini, without date (Siemens MedArchives, Erlangen, Germany). b Electrodes according to Bingel and Meggendorfer (a) and according to Braunmühl (b), without date (Siemens MedArchives, Erlangen, Germany)

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Bini and Cerletti claimed that this would result in a higher resistance and provoke the risk that current, following the direction of lower resistance, could get to a place rather distant from the electrodes and possibly damage the heart “to a large and irreversible degree” whereby the effect of electricity could be mortal (Cerletti & Bini 1941). However, protective devices such as a surge arrester and a cut-off relay had been built into the Konvulsator (Pätzold 1941).

Consequently, Bini and Cerletti were checkmated; Bini’s construction was technically neither the only nor the best possible in terms of safety, and Bini was not granted a German patent of his “electric healing device for generating convulsions”.

In August 1940 Kalinowsky wrote to Bini from his New York exile and tried to comfort him in his grief about “the sad chapter of patents”. Regarding the financial aspect of his commitment towards the introduction of the new therapy and its apparatus Kalinowsky moreover concluded without any illusions: “Honestly speaking, I am quite sure to never get the money I invested in diverse patents refunded.”Footnote 17 In the meantime yet another innovative device series had been developed in Vienna.

The Vienna Elkra Series

In 1939, the Vienna University Psychiatric Clinic had contracted a talented young physician and graduated technician from Berlin University and had commissioned him to study the Italian electroshock therapy apparatus and to adapt it to the needs of the Vienna clinic (Holzer 1941a).

The “use of electricity in therapy” was one of Wolfgang Holzer’s (1906–1980) major interests. Holzer’s technical examination revealed, for example, that the faraidic inductors, which had received dubious fame for their use in the (suggestive) therapy of World War I “War Tremblers”, were so badly adjusted that the currents they generated could “by no means be used for organised electrotherapy” (Holzer 1940: 484–485).

Applying his technical knowledge to the matter of convulsive therapy, Holzer developed electroshock devices of different functionalities in collaboration with the Vienna company Reiner & Co. relying on the Italian and German publications: first Elkra I, a big stand-alone unit with additional electrode holder, and then Elkra II, which attached the entire apparatus directly to the forceps (Fig. 3). Following preliminary animal testing these new devices were studied on patients of the psychiatric Vienna University Hospital (Holzer 1942: 125).

Even clinics that already owned a Konvulsator were especially interested in Elkra II, as it promised to allow electroshock therapy even in the most unsettled patients. However, “due to the war events it was difficult to get such an apparatus” complained Otto Buchner (Buchner 1942: 97), the medical director of a Vienna Clinic that was especially committed to the new psychiatric shock therapies.

Fig. 3
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Holzer’s development series Elkra, and placing the electrode holder with Elkra I and II (Psychiatrisch-Neurologische Wochenschrift 1941 (43), pp. 372, 373 and 378)

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After Buchner had directly contacted Holzer to offer his help in the study of the clinical benefits of Elkra II, the clinic received the apparatus, which Holzer introduced during a visit to Buchner’s clinic:

The apparatus [Elkra II] itself is the simplest thing you can imagine (see ill.). It consists of a 20 cm-high metal case with the equipment. This is placed on top of a pair of forceps and makes it possible to wedge in the patient’s head by keeping it still just as during a forceps delivery. The apparatus can be kept in the doctor’s hand and through a button the chronometer in the doctor’s hand is pushed. A simple plugging enables the activation of 100 to 150 Volt (Buchner 1942: 98).

His cooperation with Holzer did not, however, prevent Buchner from approaching SRW with the experiences he obtained from working with Elkra II hoping to inspire SRW with his “constant criticism” to absorb the “decisive benefits of the Holzer-apparatus” (Buchner 1942: 98).

Although the circuits of Elkra I and II were based on the original Italian principle of voltage constancy rather than on the principle of current constancy used by SRW (that is, the voltage was pre-set and not the current intensity just like in the Arcioni apparatus),Footnote 18 for Buchner the “decisive benefits” were not in the wiring, but in the arrangements of the electrodes.

Actually, Holzer’s careful investigations since late November 1940 had shown hardly any difference between using voltage (V) or current setting (mA). It was the electrode holder construction that made the important difference in the daily clinical practice.

Buchner did not compare the Elkra “electrode forceps” at random to the “delivery forceps” (Buchner 1942: 98)—Holzer himself had explained that in developing them “the lines of an older pair of forceps had simply been cut off and enhanced by elastic steel bands” (Holzer 1941b: 374). Then circular plates had been attached to them to which the terrycloth-coated electrode plates could be affixed for the treatment with metal pins, which were replaceable in the middle.

In clinical routine, these electrode holders proved to be considerably better than electrode appliances attached by means of headbands because the latter “frequently could not even be attached to unsettled patients” (Holzer et al. 1942: 121). Therefore, Holzer had additionally developed another bridge electrode, which was to facilitate a secure application in case of difficult accessibility to the patient from the side (Holzer et al. 1942: 99; Holzer 1942: 127–129).

As far as the electrode forceps and Holzer’s bridge electrode were concerned, the regulators were directly attached at the vertex of forceps or bridge to adjust and provide electricity supply. Thus the treating physician was able to position the electrodes at the patient’s head and at the same time activate the treatment current without requiring additional staff. This was not possible with Bingel and Meggendorfer’s use of the Konvulsator electrodes; as had been critically pointed out not only by Buchner but also empathically by Braunmühl who possessed in Eglfing Haar the largest clinical routine in electroshock therapy in the German Reich. Hence, Braunmühl helped SRW to develop alternative electrodes that were pressed to the patient’s head and enabled at the same time the current release (Fig. 2b b): Braunmühl’s so-called “mobile electroshock therapy technique” (Braunmühl 1942).

Yet the applicability of electroshock therapy depended not only on electrode holder constructions given that obviously the devices required a power supply. Here, Holzer succeeded in constructing a portable device, since his choice of rectangular alternating currency—instead of the previously used sinus-formed alternating current—reduced the necessary amount of current to induce a seizure so considerably that two anode batteries as power sources were sufficient. The result was a portable electroshock device of 8 kg weight allowing a completely net-independent implementation of electroshock therapy—a substantial practical benefit in clinical application (Holzer 1942: 137–138). In contrast, the Konvulsator II from SRW, available for clinical pre-trials since May 1943, was just a simplified and handy, but not battery-driven device.

Disputes About Electrode Holder Constructions

In the case of Elkra II Holzer had opted mostly—just as Cerletti and Bini before—for an electrode forceps, which he made the integral part of the overall device. However neither Holzer nor Reiner & Co. had considered examining the patent situation of their components for the territory of the German Reich during the development of the apparatus, even though Austria had become officially part of the German Reich with the “Anschluss” (annexation) in 1938. Hence it was ironically SRW who secured a patent for the electrode forceps: the Deutsche Reichspatent (D.R.P.) 578 532 for “the forceps form of the anaesthesia device”, that stemmed from the product folio of the Munich based company Lotterschmid & Weinberger (L&W).Footnote 19

In September 1927 Anton Weinberger, an engineer and L&W shareholder, began his research on electric current pulses, experimenting in particular with the electrical stunning of pigs, assisted by the Munich university veterinarian Max Müller (not to be confused with his psychiatrist namesake from Münsingen). For this purpose L&W developed “stunning tongs” (Fig. 4a and b). The electrodes of these tongs consisted of “serrated metal plates” that were furnished with “inserted rubber sponges,” which were placed at the animals’ temples (Kuppelmayr 1930). To allow for an increased conducive performance, the electrodes’ sponges were dipped into saltwater before releasing the current by pushing a button at one of the forceps grips. The animal was anesthetized within 15–20 s.

Fig. 4
figure 4

a Illustration of pig’s anaesthesia with the electrode holder (excerpt from a French brochure by Lotterschmidt & Weinberger, undated, Siemens MedArchives). b Electrode holder for electrical anaesthesia of pigs, Lotterschmid & Weinberger from the SRW production, 1933. c Electrode holder in the Roman Slaughterhouse, photograph from 1938 (Kansas State Historical Society, Menninger Collection, 118-05-02-13)

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In July 1932 Reiniger, Gebbert & Schall AG Erlangen, a company that would merge with SRW only a couple of months later, entered into a comprehensive sales and supply agreement with L&W. L&W committed to prospectively acquire the entire demand for goods offered by them from the production of SRW that also included the general agency for the entire international sales, except for a few European countries. This also applied to different forms of devices for cattle anaesthesia and their equipment, including an electrode holder type for the electrical anaesthesia of pigs.Footnote 20 In general these products were, however, not sold by the medical engineering brand Siemens-Reiniger but by the subsidiary Ergos Apparate-Vertriebsgesellschaft m.b.H., Berlin (Ergos) that operated occasionally in Italy as well.

As indicated in the business report by Ergos for 1934, electric anaesthesia did “particularly well in Italy and in the Nordic countries”.Footnote 21 The slaughterhouse in Rome, for instance, had equipped itself with the electric anaesthesia by Ergos (Fig. 4c; compare Shorter & Healy 2007: 36). The technique had already played a role in the development of the Italian apparatus, as Cerletti had advised Bini upon his return from the Swiss Conference on the therapy of schizophrenia in May 1937 to study the safety margin of electrical applications to the head not only on dogs, but also at the slaughterhouse before daring the first application in man in April 1938 (Accornero 1988: 44; Shorter & Healy 2007: 36–37).Footnote 22

In 1940 SRW decided to use this patent to protect themselves against potential competitors in the new sales area of electroshock therapy. Wolfgang Holzer and Reiner & Co. realized this when SRW turned to Reiner & Co. to assert claims from their patent on the holder electrode of Elkra I and II. Holzer showed deep concern since this affected after all the future marketing and distribution of “his” development. In a letter to the Vienna SRW branch office, Holzer tried to clarify: “In those days, your director [misnomer] Pätzold saw the electrode holder during his visit to my laboratory, neither at that time nor later found a word of objection […]. After all, it was me who informed your [Mr.] Pätzold at that time about what an electroshock actually was.” Above all:

the subordination of electroshock under the broader term anaesthesia and of patients under animals to be slaughtered […] shall represent a unique curiosity for a leading electromedicine company. It does not apply for the patients in my sphere of influence.Footnote 23

However, Holzer’s harsh procedure did not detain SRW from insisting on their patent claims.Footnote 24 Given the situation Reiner & Co. had no choice but to give in finally: after a dispute that lasted several weeks, the company opted for a contractual agreement with SRW. In the document dated 21 March 1941 SRW agreed to give a “simple non-transmittable licence” on the patent to Reiner & Co. as “registered co-owner” of the D.R.P 578.532, “regarding a ‘device for anaesthetizing animals to be slaughtered’”.Footnote 25 In turn, Reiter & Co. committed themselves to pay a licence fee for all electroshock devices produced and sold by Reiner & Co. Accordingly, the Swiss company Purtschert finally replaced the electrode forceps in favour of a headband for his device “Psychotron”.Footnote 26

One of the reasons that the SRW tried so hard to eliminate the Vienna competitors was that Elkra II was not only more convenient but also much more cost-effective with 390 RM compared to 955 RM for the Konvulsator. As a matter of fact by late June 1941, SRW had sold only fifty Konvulsators, most of them abroad, 23 devices of which were delivered via Almara into the occupied Netherlands. Although at least one device was sold to the Parisian Hôpital des Enfants–Malades, other French institutions favoured the Swiss Purtschert & Co. device (Coffin 2013). Only 18 SRW devices had been sold to psychiatric institutions in the “Großdeutschen Reich,” while a couple of mental hospitals had already purchased a Purtschert or an Elkra II device.Footnote 27 Thus the Elkra II or the Purtschert & Co. apparatus seemed to be the better choice for the future equipment of the mental hospitals of the German Reich.

Aiming to select the best suitable device for the German Reich, the Reich Working Party for Mental Asylums thus tried to evaluate the rivalling models to the Konvulsator, in particular the above-mentioned Purtschert & Co. device and the Elkra II, in November 1942. Information was mostly obtained from the private Waldhaus clinic in Berlin, which possessed both a Purtschert & Co. apparatus as well as an Elkra II.Footnote 28 Moreover, Meggendorfer in Erlangen was asked for his opinion although he had no experience with either the Elkra II or the Purtschert & Co. apparatus. He pointed to the vertebral fractures frequently observed elsewhere with the use of the Purtschert & Co. apparatus, a problem he had not experienced with the Konvulsator.Footnote 29 Notwithstanding that Meggendorfer deemed the Elkra II to be the most cost-effective device, the order went to SRW and their more expensive Konvulsator in late February 1943.Footnote 30 To SRW’s advantage, Meggendorfer had redefined the question of the adequate electroshock therapy device for the German Reich as a problem of vertebral fractures; thus SRW’s Konvulsator won the competition, even if it was more than twice as expensive as Holzer’s Elkra II.

Technical Improvisations: Electroshock in Auschwitz and “Euthanasia” Killings

Clinics that had missed the collective order in spring 1943 were informed by SRW that the delivery period for the electroshock device would be “at least one and a half year”.Footnote 31 The simple technical reason for the delay in the delivery process that also concerned the Reich Working Party for Mental Asylums order was that the Konvulsator had been designed for alternating current; yet many clinics did not have any alternating current available since the in-house electricity grid was exclusively supplied with direct current. Therefore, a direct current converter was necessary. Although SRW did not produce this itself, they had promised to include an accessory device in the delivery, although “special converters could not be obtained in the foreseeable future.”Footnote 32

Considering the supply shortage for medical electroshock technology even in general psychiatric hospitals and asylums shows how much improvisation was necessary to facilitate the use of electroshock therapy in the Auschwitz concentration camp. Although diagnostic label devices as X-ray machines were, for example, available in Auschwitz III, the electroshock apparatus in the working camp of the IG Farben plant in Monowitz was a self-made machine. Given the conditions of total war, the aim of using electroshock therapy was make mentally ill prisoners fit to work again, or in the words of SS physician Horst Fischer (1916–1966) to “incorporate them again into the working process”.Footnote 33

The Polish prisoner physicist Zenon Drohocki (1903–1978), was authorized by Chief SS physician at the Auschwitz concentration camp Eduard Wirths (1909–1945) and Horst Fischer to build together with an imprisoned Dutch Philips engineer an electroshock device for the neuropsychiatric department established by Drohocki (1975). Drohocki was trained in neurology and psychiatry, had done research on electroencephalography in Bern, Brussels and Paris as well as acquired practical experience in electroconvulsive therapy in Grenoble (Dirks 2005: 134; annotation 268). During his attempt to flee from occupied France to Switzerland Drohocki had been arrested and deported to Auschwitz. While Drohocki tried to use electroshock also as an anaesthetic method in surgery to make up for the lack of anaesthetics at Monowitz (Drohocki 1975), the SS interest in the method was to exploit human resources in the service of Nationalist community and warfare (Dirks 2005: 140–141).

An even more revealing example of technical improvisation and the flexibility of design in respect of changing social or health-political interests is the fact that a technically modified electroshock device was used in “euthanasia” killings.Footnote 34 During World War II, about 150 inpatients of the mental hospital Gugging and 150 inpatients of the mental hospital Mauer-Öhling were killed between 1943 and 1945 at the hands of the physician Emil Gelny (1890–1961) with an Elkra II he had converted himself. Gelny had been appointed as medical director for these both Lower-Austrian mental hospitals in October 1943 (Fürstler & Malina 2004).

The employees of these hospitals were tried in 1946 at the national court in Vienna and asked among other things how it had technically been possible to use the therapeutic machine for murder. Holzer, the inventor of the original Elkra II, was appointed as an expert at court.Footnote 35

A technical explanation was indeed needed. After all, it had been the declared aim of all the inventors of the electroshock apparatuses to find a construction which would make “accidents and damages with this new method of treatment impossible”; so that even if “the apparatus is used by someone inexperienced or in a bad condition”, there would be no damage for the patient or the treating person (Cerletti & Bini 1941: 212). Notwithstanding Bini’s criticism of the SRW apparatus, the Konvulsator also had been praised for its “extensive safeguards disabling any damage of the patient or treatment staff by electric current, as far as possible in human terms” (Stolze 1943: 100).

In order to be able to use the available Elkra II for the quiet continuance of patient murder, Gelny had pins and forks made from metal at the locksmith belonging to Gugging.Footnote 36 Gelny connected the pins to one of the electrodes of the electrode holder from the Elkra II in each case so as to divert the current from each of the two sides in the cable connected to it which branched out at a later point of time. The ends of the diverting cables were connected to the forks just as the ends of the continuing cables. Provisionally wrapped with bandaging material, the forks as substitute electrodes were placed at the hands and feet of the sick person selected for murder. Thus the current was no longer limited to flow among the head electrodes through the brain, as planned for therapeutic use. Through the additional electrode construction, veins, muscles and particularly the heart was streamed from hand to hand and foot-to-foot. Hence death occurred, as Holzer explained to the court, “after the previous electroshock with its known phase of unconsciousness”, “due to a combined effect on vital centres and on the heart”.Footnote 37

Those were anything but “slight” changes in a device that Holzer had by no means developed to “inflict torture” (Friedlander 1995: 169),Footnote 38 but based upon the preliminary Italian works to serve as a modern electro-medical therapy free of the side effects of pharmacological convulsion therapy.

Conclusion

A material history of electroshock therapy at the level of construction plans, electrodes and patents shows the ways in which the conditions of Fascism, National Socialism and World War II shaped the introduction of electroshock in a different perspective than the hitherto prevailing ‘histories of ideas’, ‘social’ or ‘entangled’ histories.

Evidently, the idea of electroshock therapy did not come from the slaughterhouse (cf. Szasz 1971; Kalinowsky 1980). However, within the material history of electroshock therapy and all its technical details, the slaughterhouse story or more exactly the debate about the Deutsche Reichspatent for “the forceps form of the anaesthesia device” for animals to be slaughtered, provides a remarkable example for the recesses of the medical technology business. The transfer of the “anaesthesia electrode forceps” patent from the veterinary technical field to the medical sphere of electroshock therapy enabled SRW to resume a leading position on the European electroshock market.

During the early 1940s, the construction of electroshock devices was remarkably little hindered by national frontiers or the fronts of World War II; it was mostly conditioned by material shortages. Yet, technical improvisation allowed the construction of an electroshock apparatus even in Auschwitz; it even helped its reconstruction as a device for “euthanasia” murder.

Which models were constructed, built, promoted and sold in the German Reich and Europe was historically relative and resulted, for instance, from the forced emigration of Jewish scientists following the Nazi rise to power. Another factor were the changes in patent legislation made by the National Socialists.

The aggravated Italian racial laws following the Pact of Steel in May 1939 had forced, for example, Lothar Kalinowsky to leave the Italian exile; on his further immigration he promoted the technique in silent partnership with its inventor Lucio Bini. Taking the blueprints of Bini’s Arcioni device with him on his continued exodus, Kalinowsky encountered more technically talented psychiatrists, especially in England, whose interest in the new research of electroshock made them propose competitive designs. For the German Reich, National Socialist patent legislation facilitated the construction and sale of a German device; Bini’s application for a German patent was simply circumvented.

In England, changing the wiring principle of voltage constancy to current constancy proved to be enough modification to the initial construction to enable bypassing prevailing patent law. Sparing the initial resistance measuring simplified the device also to the benefit of lower costs, sometimes sufficient to propose a lower and therefore more attractive sale’s prize.

Adapting the make-up of the apparatuses to the changing local conditions of specific clinics or hospitals, as, for example, Holzer did for the Vienna University Clinic or Braunmühl in Eglfing Haar, yielded still further technical solutions including even portable devices.

Differing interest of psychiatrists, industrial companies and mental health politics affected the introduction of the electroshock technique—even at the level of screws and wires. The technical variations in electroshock therapy until 1945 were each time a different answer in the quest for the most suited technology for electroshock therapy—be it easy as possible applicability or the extent of side effects, be it the matter of low production and acquisition costs, or even the possible use as a method for “euthanasia”. Financial interest of the involved industrial companies was a major reason to challenge the details of the therapeutic technique as the companies searched for alternative techniques primarily to circumvent fees due to protective patent rights. In doing so considerations of business competition outdid clinical medical interests several times.

In this process, the electroshock therapy technique was so adaptable to diverging interests that it was even reversed from a medical therapy into a method of “euthanasia”; an alienation whose possibility is not attributable to the special suitability of electroshock therapy as such, but to the contextual adaptability of every technology.

Acknowledgments

The authors thank the Unternehmensarchiv für Medizintechnik (Corporate Archive for Medical Technology, cited as Siemens MedArchives, Erlangen, Germany) of the Siemens AG for the access to files, the support during research works and the consent of printing the images. The research was done and the paper written during a position of the corresponding author at the Institute for the History of Medicine at the Charité funded by the joint DFG-ANR-project “early psychosis” under the direction and coordination of Volker Hess (Berlin) and Nicolas Henckes (Paris).