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        Conditions of life and death of psychiatric patients in France during World War II: euthanasia or collateral casualties?
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        Conditions of life and death of psychiatric patients in France during World War II: euthanasia or collateral casualties?
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        Conditions of life and death of psychiatric patients in France during World War II: euthanasia or collateral casualties?
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Abstract

Between 1940 and 1944, an estimated 48,588 patients resident in French psychiatric hospitals died of starvation. Standard prisons, while facing similar problems, did not experience the same number of deaths by starvation, partly due to their ability to develop a black market for food and rations. Patients in psychiatric hospitals, on the other hand, were completely at the mercy of their doctors and the personnel in charge. At Hôpital du Vinatier, a psychiatric facility in Lyon, the mortality rate increased sharply from 1940 to 1944. In 1942, the worst year, 42% of patients died of hunger and exposure. In the end, more than 2,000 patients died at Vinatier. Was this due to a supposed lack of rations, or was it something more sinister? In Germany at the same time, tens of thousands of psychiatric patients died of purposeful starvation in psychiatric hospitals as part of the Nazi program of psychiatric euthanasia. Was the same thing occurring in Lyon?

Introduction

Euthanasia of tens of thousands of German psychiatric patients (as many as 200,000) by the Nazis in the T4 and other related programs is now well known. 1 , 2 It is also widely known that more than 48,000 French psychiatric patients died of hunger, exposure, indifference, and oblivion during the early 1940s while France was under Nazi control and while gassing, cremation, and starvation of children with disabilities was occurring inside Germany. 3 , 4 In 1936, before the start of World War II and the Nazi occupation of France, Alexis Carrel, an American Nobel Prize Winner of French descent, published Man: The Unknown, 5 in which the horror of psychiatric eugenics—with mass involuntary sterilization of psychiatric patients—was made plain for all to see. He would go on to become one of the main intellectual forces in the Vichy government. However, at the same time his book was published, and when the world had already halted involuntary sterilization of psychiatric patients, Nazi psychiatrists moved from sterilization to euthanasia of disabled patients, and tens of thousands made their way to gas chambers or were killed by involuntary starvation or barbiturate overdose as the notorious T4 operation and its successors got underway in Germany. 1 , 2

Was psychiatric euthanasia by starvation occurring simultaneously in Nazi-occupied France? The figures speak for themselves: 48,588 additional deaths in psychiatric hospitals occurred between 1940 and 1944. In order to have a better understanding of these events, it is helpful to look into one of these hospitals, the Hôpital du Vinatier, a psychiatric facility in Lyon, the country’s second largest city, in the center of France, and where the principal author of the present article (PL) spent many years as a practicing psychiatrist. The present manuscript will refer to original materials referenced and reproduced in an account written by the principal author based on the real history of people who lived at Hôpital du Vinatier in Lyon-Bron during World War II. 6 Dr. Lemoine has also researched the hospital files at Vinatier and interviewed survivors involved with the hospital during that era. In addition, the book contains several facsimiles and documents (many in French and others in English or German), including: an introduction to Rochaix’s report, extracts of Vinatier’s report to de Gaulle, a letter from a representative of the general council, and more. The reader is referred to the book 6 for more detailed references and documents. What follows herein is a summary of the story of Vinatier from the authors’ perspectives, published now in English, so that a shorter version can reach more readers.

The Context

In 1938, as the rumors of war began to take shape, the board of the Hôpital du Vinatier decided to purchase 300 gasmasks for some of its personnel (i.e., employees and working patients). The latter were considered “good patients” by hospital personnel, because without them the hospital could not function. These “good patients” were in charge of day-to-day chores and supplies: cleaning, washing up, farming, laundry, and domestic service for the directors and doctors. How about the other 2,900 patients in the event of a gas attack? Hospital policy was as follows: “They had to take refuge in the ditches,” 6 a measure whose effectiveness against poison gas was highly questionable, since combat gas was designed to accumulate in trenches. This was a year before the war, but not one voice was raised in protest against the policy. All this seems to indicate a willingness to sacrifice psychiatric patients for the good of others.

According to accounts of the time, money did not run short at the hospital. 6 Far from it. That same year, on March 28, 1938, Hôpital du Vinatier purchased a bas relief by Jean Chorel, a well-known Lyonnais sculptor. It was an imitation stone proof of his “Les Boeufs” [The Oxen], a gold medalist at the Salon de Paris of 1934. Instead of purchasing this relief, many doctors had requested that the money be allocated for purchase of an X-ray device on account of the high incidence of pulmonary tuberculosis. Their request was met with a staunch refusal.

To set the background and environment in which Vinatier functioned at that time, in 1938, Professor Anthelme Rochaix, who held the chair of Hygienics at the University of Lyon and was also the brother of a psychiatrist and the head doctor at Hôpital du Vinatier, was commissioned by the authorities to write a report entitled “A Report on the Struggle Against Pathological Heredity.” The report read as follows: “Life expectancy amongst human beings is getting considerably longer. In consequence of which there is an increase in the number of degenerate and defective beings, i.e., the dregs of the earth, who, as a result of the suppression of the law of natural selection, contribute to the degeneracy of the race and become a heavy burden for the community.” 6 The remainder of the report is rather moderate and merely raises queries.

Times of Crisis

According to the official version of events, all these wasted lives (i.e., 2,000 additional deaths at Hôpital du Vinatier alone), hinge on a sheer “omission” by the Vichy government—namely, an inability to provide enough food for all. The dietary requirements (1,427 calories, as stated on official ration cards), which the entire French population was supposed to be provided, were not enough. Only the ingenuity of the civilian population helped them to survive: the development of a black market, small plots of land rented out for gardening, relatives in the countryside, etc. People were hungry, but they did not starve since the comparative death rate among the civilian population was no higher than 1% during the war.

A map was made of all hospitals, convalescent homes, sanatoriums, and other sanitary institutions, though it left out psychiatric hospitals and prisons. Conventional prisons, it seems, were able to set up an efficient black market because the mortality rate among prisoners remained stable. Unfortunately, insane patients had neither the financial nor psychological means. They fell like flies. Between December of 1939 and March of 1946, 47.7 % of psychiatric patients at the hospital in Isère starved to death. 4 In 1942 alone, 41.98% of patients at the Hôpital du Vinatier were carried away amid the turmoil. 6 In terms of percentages, it is perhaps the worst massacre in the history of France.

In 1944, near the end of the war, because of the great number of deaths among psychiatric patients, there was a lot of free space at the Hôpital du Vinatier, and so a neurology unit was transferred there. As these neurology patients were not mentally ill, the directorship found it only too natural to grant them larger rations than those given to other inpatients. Once again, no one dared utter a word of protest. Only the pharmacist and a few doctors bravely tried to fight this injustice, but their means were very limited. Once again, this indicated the willingness of hospital officials to sacrifice the mentally ill for more “meritorious” patients.

There had been no actual proof of official intention in terms of eugenics, no documents, no “smoking gun.” 6 The historian Isabelle von Bueitzingslowen was granted permission by Hôpital Vinatier to conduct a research project that would enable denial of any intentionality involved in the “psychiatric hecatomb,” to determine that there was no policy of purposely sacrificing the mentally ill for the good of the many. She found exactly the same number of casualties as had been previously widely reported (2,000 additional deaths) but argued that, since she could find no official documents condoning or ordering a policy of purposely starving psychiatric patients so that the food could be used by others, these deaths and the starvation that occurred could not have been intentional. 7 For her, the absence of evidence was evidence of absence. Recall, however, that Hitler himself strictly forbade any issuance of written documents related to the T4 project of euthanasia in Germany, and instead “medicalized” it, while having psychiatrists administer the means of death under the guise of treatment. 1 , 2

Thus, the most widespread explanation put forward for the deaths at Vinatier during this era was a lack of food. But that is a difficult conclusion to support because at Vinatier there was a hospital farm, in fact the finest in the region (about 800,000 square meters, or about 200 acres, plus 80 cows and 600 pigs), which, if well managed, would have produced enough food to avoid starvation among Vinatier patients. Before the war, in fact, the farm provided a third of the food supplies for the patients as well as additional rations given as bonuses for nurses. Though initially in a state of collapse at the beginning of World War II, the farm nevertheless all the while continued to sell foodstuffs to the outside world. The psychiatric patients at Vinatier were literally starving in the midst of plenty. Was this an accident, thousands of “collateral casualties,” or was it due to a policy of psychiatric euthanasia by starvation, sacrificing the mentally ill so that the food could go to others? One had to wait until 1942 for a change of management at Vinatier, when at last a competent person was appointed, and the following year, in 1943, food production picked up considerably. The mortality rate at Vinatier also began to drop at the same time.

To a great extent, the problem of patients starving at Vinatier was completely denied at the time. According to Dr. P. Scherrer, following his experience at Auxerre, “the nurses who lived through this period try and forget by denying these impossible deaths.” 8 The majority of nurses who worked at Vinatier during this era and were interviewed by our principal author remain persuaded that it was all due to a “strange epidemic.”

The Post-War Years

In 1946, probably spurred on by General de Gaulle, the government requested a report from all hospitals “concerning the years of crisis.” Hôpital du Vinatier’s report was issued in 1947. All aspects were mentioned: the admissions, the discharges, the deaths. “The hospital has constantly applied rationing according to the plan by the Office of General Supplies.” 6 The message could not have been clearer. The response from the Regional Council was no less explicit and needs no comment: “All the departmental counselors have been given this extremely interesting report. Your local commission insisted on praising the board of Hôpital du Vinatier for having succeeded in submitting such a comprehensive document on the functioning of your hospital.” 6 Officially, starvation of psychiatric patients (strictly applying rationing of calories to psychiatric patients) was thus condoned. No others were so rationed. Did this imply that the lives of psychiatric patients were less worthwhile and deserved rationing and starvation while others did not?

A Parallel between France and Germany?

On September 1, 1939, Hitler gave orders to start operation T4. 2 Psychiatric experts in Germany analyzed the medical files of patients in order to sort out the curable from the incurably ill. Within only a few months, many tens of thousands of patients, mostly children, deemed to be incurable, were exterminated in gas chambers built inside the psychiatric hospitals. 1 , 2 The families were then informed that their relatives had been carried off by an infectious disease and that their corpses had been cremated in order to avoid any risk of epidemic. However, the secret program was soon laid wide open. The German population began to protest against the active gassing of patients. Petitions flooded in, sometimes even from advocates of Nazism who could not bear their relatives being exterminated. So the Nazis turned to “wild euthanasia,” which encouraged continued death to psychiatric patients but no longer centrally administered, so that the gassing and cremation stopped, and a program of starvation was instituted. 1 , 2 Obviously, in retrospect, the Nazis had bigger plans for how to use gassing and cremation in Poland and other concentration camps for the “Final Solution.” Allowing psychiatric patients to starve death was “more natural” and therefore more likely to be accepted and understood by the general population, and this would disguise the fact that this was really a form of euthanasia. In the final analysis, more than 200,000 mentally ill Germans died in this manner during the war. 1 , 2 An order was also given not to keep any written records of the program.

The Stands Taken by the Allies

In the newspaper La Raison in 1952, 9 there was an eyewitness account of a 1947 conversation at the Nuremberg trials with a Dr. Pfanmueller, a psychiatrist and the director of an asylum. 1 , 2 One witness, a Mr. Lehner, quoted Pfanmueller thus:

To me, of course, as a national socialist, these creatures represent but a burden on the healthy body of our country. We do not get rid of them by means of poison or injections, as that would provide the foreign press with hate propaganda. No. Our method is a lot simpler and far more natural, as you may see.

After speaking these words, Pfanmueller dragged a child out of bed. As he displayed the infant like one might a dead hare, he said that this would still take another two or three days:

I can still vividly remember this fat man, grinning sardonically, holding in his large hands this small skeleton breathing amongst other starving children. Dr. Pfanmueller stated that they would not be abruptly deprived of food, though the rations would be gradually reduced.

The Nuremberg prosecutor examining Pfanmueller on the witness stand made some calculations: ”Thus, between November 12th and December 1st, 1940, you have sent more than two thousand questionnaires. By working ten hours a day, you would have been able to do a hundred and one a day, spending five minutes on each.” 6 , 9 This only goes to prove that such assessments were more than cursory, to say the least. 1 , 2

On November 8, 1949, Die Neue Zeitung published an article concerning Pfanmueller, whom the Court of Assizes of Munich had just sentenced to six years imprisonment. 1 , 2 , 6 , 9 The court judged that “the extermination of mentally ill patients was not murder but manslaughter that may have been involuntary.” 1 , 2 So Pfanmueller was spared the death penalty and given a relatively light sentence.

It seems clear here that, on the one hand, under certain ideological conditions during a crisis situation of World War II, psychiatrists may have knowingly allowed patients to starve to death or even killed them with their own hands. 1 , 2 On the other hand, after the war was over in 1946–1947, Western authorities considered there to be a difference between the life of someone who was mentally ill and that of a mentally healthy or so-called “normal person.” Purposely causing the death of a mentally ill person was not murder, but involuntary manslaughter?

The Question of Eugenics

One question appears to be essential: Were the starvation deaths of psychiatric patients a case of euthanasia in France in general, or at Vinatier in particular? One must not lose sight of the fact that everything regarding the extermination of mentally ill persons had to be kept strictly secret, which has made historical research most difficult. The Nazis strongly insisted on this, as clearly indicated in several documents printed in the review La Raison. 1 , 2 , 6 Orders in this Nazi operation were mostly given orally. Besides, it was reported in the same issue 6 that “Late in 1942, the directors of psychiatric asylums in Germany were given orders to slowly starve these useless eaters to death. This method was found to be excellent, as death seemed natural.”

The parallel with the situation in France is indeed disturbing. As of yet, there is no definitive proof that when Hitler became aware of the public reaction regarding gas chamber exterminations he then applied the same policy of starvation of mentally ill patients in occupied countries as well. Nevertheless, it is difficult to believe that the Nazis—who applied racist and eugenic policies with regard to a number of minority groups in France—would have made an exception for the mentally ill. Yet, one could suggest the possibility that the policy applied in France resulted using the same methods: no written orders and only oral instructions to a certain number of directors of psychiatric asylums who were considered reliable. For instance, the prefect in Lyon, a Mr. Angeli, faithful to Pierre Laval (a prominent minister in Marshall Petain’s Vichy government), was a Nazi henchman and notorious collaborator who was later imprisoned and sentenced to death during the Liberation. The director of Hôpital du Vinatier came from the staff of the Prefecture of Lyon, who had been appointed before the war. The attitude of this director was ambiguous: the man in charge of the farm was a prisoner of war, who appointed someone else who was incompetent and who did not seem to worry about the drop-off in agricultural production. He lowered the wages of patient workers without explanation, despite the hospital’s enormous financial assets. He also did not support the black market and stuck strictly to the official ration policies.

According to Odier, 4

Vichy’s project, if there has ever been any at all, did not aim at systematic extermination. So then at this stage, if we are not speaking of intentional extermination, could we not at least speak of negligence? Those who had degraded lives—such as they were believed to be—were gradually led to voluntary euthanasia. In fact, this project may well have intended to rid psychiatric hospitals of the incurably ill in order to free up resources for those individuals that the institution still had great hopes to heal. When it came down to diseases detected at an early stage in children, it was deemed necessary to separate the curable from the incurably ill, and the doctors’ help was requested by the General Supplies Office. Fifty years removed from the event, it is nonetheless difficult to say if that selection indeed took place. In case it did happen, one can understand why the doctors have kept silent about it.

This assertion is supported by an official social services document from the Department of Health, 22nd Sanitary District, General Director’s Office, at the directorship of Saint-Robert’s Psychiatric Asylum in Grenoble:

As regards additional milk or low-fat cheese, ask your doctors to name the beneficiaries according to a distinct order as follows: treatable patients, i.e., those who will, after receiving adequate treatment and a short stay at your hospital, be able to regain their freedom and take up their former places in society as well as their previous occupations. These are the ones who ought to take food again. However, for those who will soon be terminally ill, and of whom I have seen a great number during my last visit, it is not possible to make a dent in the General Food Supplies, as they are in difficulties at the present time. 6

Had there really been a deliberate policy of active euthanasia of psychiatric patients in France? Such authors as Dr. Lucien Bonnafé (1912–2003) 6 do not hesitate to take that plunge:

Considerable overcrowding in psychiatric hospitals was already a problem before the war. The fascist policy of “assistance” to the mentally ill as applied by the occupied forces and the Vichy government was a way to come up with a drastic solution: 40,000 mental patients died of hunger and exposure during the war.

Professor Rochaix’s inconclusive report (mentioned and referenced 6 above), which was requested and backed by the authorities at that time, displays the eugenic atmosphere that was prevalent before the war. The refusal to purchase gasmasks for unemployed patients, accompanied by the recommendation that able-bodied patients be sent to the wide ditches, only confirms an intention to exterminate. At the very least, it conveyed a certain degree of cynicism tinged with heedlessness. Many additional clues are also provided about the eugenic climate of the time, such as the absence of official protest when the supervisory board decided to allot extra food supplies to the transferred patients under the pretext that they were entitled to it since they were not psychiatric patients. In addition, there were unjustified budget cuts concerning “recreational activities for the patients.”

In addition, it is interesting to make a comparison with what took place at other similar hospitals that were able to avoid the increased number of deaths. In Saint-Jean de Dieu (a private psychiatric hospital in Lyon, 3 km from Vinatier), at the hospital Sainte Marie du Puy in Rodez, and at the psychiatric hospital in Saint Alban, a similar slaughter was avoided by the determination and imagination of those in charge. They were able to inflict punishment for food theft, cultivate every available plot of land, and encourage the black market. At Vinatier, they let the farm fall into ruin, and only the staff took advantage of cultivated plots. Food thefts by the staff seemed to have been significant, but they were not subject to strong punishment. It was not until 1942 that a new director was nominated and a competent farm manager appointed. Within a year, the mortality curve was inverted dramatically. Also in 1942, a new recommendation by the Department of State for Health authorized psychiatric hospitals to provide supplementary food in psychiatric hospitals.

During the Liberation, there was no official reaction to what happened to these psychiatric patients. No inquiry was called for by the new government, though the truth was immediately disclosed. On September 26, 1945, a Mr. Billoux, Minister of Health, stated the following in a speech at the Vélodrome d’Hiver: “The number of mentally ill persons has decreased substantially since 1939. One must take into account the fact that many of those hospitalized at psychiatric asylums have literally starved to death.” 6 One Dr. Dugoujon, 6 a departmental counselor and a friend of Jean Moulin (a greatly respected hero and martyr of the Resistance), congratulated Vinatier’s directorship on their “extremely interesting report.” Quite recently, in fact, he told the principal author that, at the time of the Liberation, “I had not read this report, as we had other fish to fry!”

Even in times of peace, anti-psychiatric racism is an underlying problem that lurks in the shadows. This can be seen, for instance, by the sterilization of sick people, carried out without personal consent in the early 20th century in France, Sweden, and the United States. It is also attested to by the exclusion of coverage of mental illness in certain insurance contracts today. But in times of crisis, this is even more brutally expressed, as can be seen based on the evidence of psychiatric gulags and recent events that occurred in Romania.

Psychiatric eugenics can be found in a more or less assertive, conscious manner, in every man, because “aliéné” (an insane person) means, etymologically, “the other” (from Latin “alienus”). This represents the unbearable madness that we all fear lies within each of us. A lunatic is also the weakest one among us, making him the ideal scapegoat. The histories of insanity and of civilizations are one and the same, because the manner in which society treats the insane reflects its representations of otherness. According to R. Girard from Stanford University, when a community goes through a crisis and its identity structures are put in jeopardy, the need arises for a sacrificial victim whose appointment will be based first and foremost on the notion of difference. 6 Even if they are compelled by widespread tensions beyond their grasp, which they are generally not conscious of, decision makers do not usually make generous gifts to the most different of citizens—the mentally ill. The “Other,” “l’Aliéné,” is the ideal victim—discreet and silent.

The concept of “the other” is certainly not a new one. World War II was not the first time it was prominent, nor will it be the last. By pushing a group of people into the category of the “other,” it is much easier to dehumanize them and thereby justify any actions, no matter how vile, committed against them. This method of “othering” has been used successfully by propaganda campaigns throughout history to justify racism, sexism, war, and many of the most gruesome acts of violence. It can be seen in action constantly throughout the globe: in long-running civil wars, in arguments over whether or not to accept refugees during times of crisis, or during political campaigns when both sides attack each another. Everyone wants someone to blame for things not being as they should be. Having a common enemy to hate can provide a strong bond among allies.

One of the most complicated examples of this phenomenon today would be terrorism and the work of the so-called Islamic State. ISIL has been quite masterful at employing propaganda campaigns through social media and viral videos. Following the lead of many who came before them, they first created a group that would serve as “the other.” In their case, it is not only the “West” but also those in the Middle East who do not share their values: Christians, Jews, Yazidis, and the “wrong kind of Muslims” (i.e., Shiites). Members of these groups are lumped together as having the wrong values, and are then dehumanized, demonized, and made to be seen as the reason for all the problems that exist in the world. Any violent acts committed against the so-called “others” can then be not only justified but perceived as more than warranted—as righteous.

One of the most important lessons, then, that the T4 program and its effects in Germany, in France, and globally teaches us is how crucial it is to admit to our mistakes instead of denying them or trying to hide from them—how vital it is to acknowledge an ugly truth and admit to ourselves that humankind has an enormous propensity for weakness and brutality. In this way, we can hopefully remember that each of us is, in fact, an “other.”

Disclosures

Patrick Lemoine does not have anything to disclose.

Stephen M. Stahl, M.D., Ph.D., is an adjunct professor of psychiatry at the University of California–San Diego, an honorary visiting senior fellow at the University of Cambridge (UK), and director of psychopharmacology for the California Department of State Hospitals. Over the past 36 months, he has served as a consultant to Acadia, Alkermes, Allergan, Arbor Pharmaceutcials, AstraZeneca, Avanir, Axovant, Axsome, Biogen, Biomarin, Biopharma, Celgene, DepoMed, Dey, EnVivo, Fanapt, Forest, Forum, Genomind, Innovative Science Solutions, Intra-Cellular Therapies, Jazz, Lilly, Lundbeck , Merck, Novartis, Noveida, Orexigen, Otsuka, PamLabs, Perrigo, Pierre Fabre , Reviva, Servier, Shire, Sprout, Sunovion, Taisho, Takeda, Teva, Tonix, Trius, and Vanda. He is a board member of RCT Logic and Genomind. He has served on the speakers bureaus for Astra Zeneca, Dey Pharma, EnVivo, Eli Lilly, Forum, Genentech, Janssen, Lundbeck, Merck, Otsuka, PamLabs, Pfizer Israel, Servier, Sunovion, and Takeda. He has received research and/or grant support from Acadia, Alkermes, AssureX, Astra Zeneca, Arbor Pharmaceuticals, Avanir, Axovant, Biogen, Braeburn Pharmaceuticals, BristolMyer Squibb, Celgene, CeNeRx, Cephalon, Dey, Eli Lilly, EnVivo, Forest, Forum, GenOmind, Glaxo Smith Kline, Intra-Cellular Therapies, ISSWSH, Janssen, JayMac, Jazz, Lundbeck, Merck, Mylan, Neurocrine, Neuronetics, Novartis, Otsuka, PamLabs, Pfizer, Reviva, Roche, Sepracor, Servier, Shire, Sprout, Sunovion, TMS NeuroHealth Centers, Takeda, Teva, Tonix, Vanda, Valeant, and Wyeth. He also holds stock options from Genomind and Adamas.

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