1030790

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HPY0010.1177/0957154X211030790History of PsychiatryConseglieri and Villasante

Article

History of Psychiatry

Shock therapies in Spain (1939–

1­–17
© The Author(s) 2021
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DOI: 10.1177/0957154X211030790
https://doi.org/10.1177/0957154X211030790
Isabel National Mental Asylum in journals.sagepub.com/home/hpy

Leganés

Ana Conseglieri
Hospital Universitario Infanta Cristina (Parla), Spain

Olga Villasante
Hospital Universitario Severo Ochoa (Leganés), Spain

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;

Corresponding author:
Ana Conseglieri, Hospital Universitario Infanta Cristina, Av. 9 de Junio, 2, Parla, Madrid, 28981, Spain.
Email: ana.conseglieri@salud.madrid.org
2 History of Psychiatry 00(0)

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 reorgani-
zation 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 psy-
chiatric care (Villasante, 2003). The objective is to discuss the therapeutic measures used, by ana-
lysing 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 leucoto-
mies.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 analy-
sis 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 asy-
lum 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,
Conseglieri and Villasante 3

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 dicta-
torship (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 depart-
ments 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, denounc-
ing 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 admit-
ted 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 begin-
ning 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 syn-
drome (Peraita, 1947; see also Huertas and Del Cura, 2010). Peraita also helped with the general
4 History of Psychiatry 00(0)

architectural renovation of the establishment,4 incorporating an X-ray service, laboratories, occu-

pational 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 seculariza-
tion 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 estab-
lishments, 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 fre-
quent 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 fami-
lies 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 neuropsy-
chiatric 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 dif-
fered 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:
Conseglieri and Villasante 5

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 mor-
tality 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 expe-
rienced 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 collabo-
rated 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 work-
shops: ‘higher rations have been provided for those patients who have to do hard work (occupa-
tional 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
6 History of Psychiatry 00(0)

medical records, the notes on their use were brief: a description of the treatment without document-
ing 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 turpen-
tine, 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 follow-
ing 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 poison-
ing (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 schizo-
phrenia 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 incon-
clusive 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 combi-
nation 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
Conseglieri and Villasante 7

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 hospi-
tals (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 dif-
ficult technique that required qualified staff, due to complications resulting from prolonged admin-
istration 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 treat-
ment 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 tech-
nique 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 tempera-
ture 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 apa-
thy or indifference. Much more normal affectivity’.15 One week after this examination, the treat-
ment 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 suffer-
ing severe epileptic episodes and agitation after comas.16
8 History of Psychiatry 00(0)

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 electrophysiolo-
gist 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
Conseglieri and Villasante 9

Figure 2.  Electroshock treatment form, SINMA in Leganés: patient with manic depressive psychosis
treated in June 1946 (source: HA, HUJG).

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.
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 leucot-
omy 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 tech-
nique 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).
10 History of Psychiatry 00(0)

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 cir-
cuits, 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, obses-
sive 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 historio-
graphical 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 psy-
chiatrist 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 leucoto-
mies 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
Conseglieri and Villasante 11

that at least four of the leucotomized patients died during this period, and only two were dis-
charged, 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 pres-
entation ‘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 dif-
ferent 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 practi-
cally 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 Peraita19,20

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
12 History of Psychiatry 00(0)

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 treat-
ments 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 com-
parative historiography and a broader vision of the practice of psychiatry in the first years of
Franco’s dictatorship.

Declaration of conflicting interests

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

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publica-
tion 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
  1. We are following the proposal of Javier Tusell (2005), who discussed Francoism in decades, with the first
period from 1939 to 1951.
  2. In our work on clinical records, we have used the theoretical and methodological framework proposed
by Huertas (2001); for another example, see Beveridge, 1995a, 1995b.
  3. Reglamento Orgánico para el Régimen y Gobierno de Gobierno Interior del Manicomio de Santa Isabel
de Leganés de 1941. Boletín Oficial del Estado, 3 Nov. 1941, 311: 8697–8701.
  4. [Spain] Ministry of Education, Culture and Sports. General Administration Archive, General Directorate
of Devastated Regions Fund, box F/04223, 01.
 5. Historical Archive of Hospital Universitario José Germain (hereafter HA, HUJG), Box Facultative
Headship ‘Offices of the Government Ministry’.
 6. HA, HUJG, Box Facultative Headship ‘statistics’, Official document of the National Institute of
Statistics, Census of Beneficence and Health Establishments, 2 Nov. 1949.
 7. Boletín Oficial del Estado, 14 Feb. 1939, 45: 856–859.
  8. HA, HUJG, medical record 1183 and 1472.
  9. HA, HUJG, medical record 1433.
10. HA, HUJG, Box Facultative Headship ‘Offices of the Government Ministry’.
11. 1940: Bromide 1 gram per day and Luminal 10 centigrams per day; HA, HUJG, medical record 1226.
12. HA, HUJG, medical record 1480.
13. The difficulty in obtaining penicillin during the post-war years led to the use of methods that recovered
it from the urine of treated patients, in order to reuse it.
Conseglieri and Villasante 13

14. HA, HUJG, medical record 1199.

15. HA, HUJG, medical record 1569.
16. HA, HUJG, medical record 765; this patient who had schizophrenia was admitted in 1925 and treated in
1944.
17. The medical records are used as a documentary source for the women admitted to the Asylum of Navarra,
where malaria therapy, insulin therapy, camphor shocks, cardiazol and leucotomies were used; Aztarain-
Díez, 2005: 204–7.
18. HA, HUJG, medical record 447.
19. She was a 32-year-old single woman with paranoid schizophrenia who died of encephalitis 1953, due to
intestinal haemorrhage secondary to leucotomy. She had entered SINMA in December 1944 and she was
treated with electroshock and later with leucotomy. HA, HUJG, medical record 1452.
20. HA, HUJG, medical record 1191.
21. HA, HUJG, medical record 1246.

References
(a) Archival sources
Archivo Histórico del Hospital Universitario José Germain – HUJG (called Instituto Psiquiátrico Servicios
de Salud Mental José Germain until Nov. 2020): Medical records, 1 April 1939 to 31 December 1952;
Statistical files, 1939–1952; other documents signed by doctors or administrators.
Archivo General de la Administración de Alcalá de Henares (AGA), Fondo del Ministerio del Interior (antes
Ministerio de Gobernación): reference code (08) 21 44/3108.

(b) Primary published sources

Almeida-Amaral N (1946) El método quirúrgico de Moniz (leucotomía) en la terapéutica de las enfermedades
mentales. Actas Luso-españolas de Neurología y Psiquiatría 5: 147–155.
Anonymous (1931) [Official government note]. Gaceta de Madrid (2 Dic., 336): 1376–1377.
Barcia-Goyanes JJ and Domingo-Simó F (1951) Nuestra experiencia de la leucotomia en enfermedades men-
tales. Medicina Española 26: 79–90.
Bourne H (1953) The insulin myth. The Lancet 265: 964–968.
Cerletti U (1952) Indications respectives des methodes de choc. In: Ey H, Marty P and Desclaux P (eds)
Thérapeutique Biologique (Rapports parus avant le Congrés), Editions du Congrès Internacionale de
Psychiatrie, t. 4. Paris: Hermann et Cie, 11–15.
Cerletti U and Bini L (1938) Un nuevo metodo di shockterapie “L’elettro-shock”. Bolletino della Accademia
Medica di Roma 64: 136–138.
Cushing H (1936) From a Surgeon’s Journal. Boston, MA: Little, Brown and Co.
Echeverría-Urrutia J (1948) Notas para un estudio psiquiátrico de Guipúzcoa. Guipúzcoa, Spain: Excma.
Diputación de Guipúzcoa, 99–164; reprinted in Norte de Salud Mental 22: 76–83 (2005).
Ey H, Marty P and Desclaux P (eds) (1952) Thérapeutique Biologique (Comptes rendues des séances),
Premier Congrès Mondial de Psychiatrie, t. 4, Paris: Hermann et Cie.
Freeman W (1948) Funciones de los lóbulos frontales según resultados de la leucotomía prefrontal. Actas
Luso-españolas de Neurología y Psiquiatría 7: 299–306.
Freeman W (1957) Frontal lobotomy 1936–1956: a follow-up study of 3000 patients from one to twenty
years. American Journal of Psychiatry 113: 877–886.
Freeman W and Watts JM (1946) Psicocirugía. Buenos Aires: Ed. Médico-Quirúrgica; originally published
in English in 1941.
González-Ferradas M (1943) La asistencia psiquiátrica en España. Semana Médica Española 117: 1–10.
Jessner L, Ryan VG and Solomon HC (1941) Shock Treatment in Psychiatry: A Manual. New York: Grune
& Stratton Inc.
Llopis B (1946) Psicosis pelagros. Barcelona: Ed. Científico-Médica.
López-Ibor JJ (1948) Indicaciones restringidas de la leucotomía. Actas Luso-españolas de Neurología y
Psiquiatría 7: 307–311.
14 History of Psychiatry 00(0)

López-Ibor JJ and Peraita P (1951) Indicaciones restringidas de la leucotomía según nuestra experiencia.
Revista española de Oto-Neuro Oftalmología y Neurocirugía 10(55): 187–191.
Marco-Merenciano F (1942) Estudio comparado de las esquizofrenias por el cardiazol y el electrochoque.
Actas Españolas de Neurología y Psiquiatría 3: 214–216.
Marco-Merenciano F and Ruis-Vivó JM (1940) El electroshock en psiquiatría. Actas Españolas de Neurología
y Psiquiatría 1(3–4): 193–198.
Meduna LJ von (1938) General discussion of the cardiazol therapy. American Journal of Psychiatry
94(suppl.): 40–50.
Moniz E (1936) Les prémieres tentatives operatorires dans le traitement de certaines psychoses. L’encephale
31: 1–29.
Obrador-Alcalde S (1947) Las modernas intervenciones quirúrgicas en Psiquiatría. Madrid: Paz Montalvo.
Peraita M (1943) La clínica de las neuropatías carenciales observadas en Madrid. Actas Españolas de
Neurología y Psiquiatría 4: 32–53.
Peraita M (1946) Deficiency neuropathies observed in Madrid during the civil war (1936–1939). British
Medical Journal 23: 784.
Peraita M (1947) El complejo sintomático de Madrid: síndrome parestésico-causálgico. Revista Clínica
Española 26(4): 225–234.
Peraita M and Fernández-Sanz A (1946) Sobre el tratamiento de la parálisis general progresiva mediante la
administración intrarraquidea de penicilina. Revista Clínica Española 2(20): 2, 144–145.
Polatin P, Friedman M, Harris M and Horwitz W (1939) Vertebral fractures produced by Metrazol-induced
convulsions in the treatment of psychiatric disorders. JAMA 112(17): 1684–1687.
Prieto-Vidal A (1941) La convulsión eléctrica como tratamiento en psiquiatría (Primeros ensayos). Semana
Medica Española 115: 591–602.
Sakel M (1937) The methodical use of hypoglycemia in the treatment of psychoses. American Journal of
Psychiatry 151: 240–247.
Simon H (1937) Tratamiento ocupacional de los enfermos mentales, trans. by R. Sarró arcelona: Salvat edi-
tores; originally published in German in 1929.
Vallejo-Nágera A (1940) Tratamientos de las enfermedades mentales. Valladolid: Librería Santarén.
Vallejo-Nágera A (1944) Tratado de psiquiatría I, Psicopatología general. Barcelona/Buenos Aires: Ed.
Salvat.
Vilanova X (1946) El tratamiento de la penicilina por la sífilis. Actas Dermo sifiliográficas 38: 221–269.
Villacián JM and Sánchez-García A (1940) Un año de cardiazolterapia. Actas Españolas de Neurología y
Psiquiatría 1: 60–68.
Wagner-Jauregg J (1922) The treatment of general paresis by inoculation of malaria. Journal of Nervous and
Mental Disease 55(5): 369–375.

(c) Secondary published sources

Álvarez-Uría F (1983) Miserables y locos. Medicina mental y orden social en la España del siglo XIX.
Barcelona: Tusquets.
Aztarain-Díez J (2005) El nacimiento y consolidación de la asistencia psiquiátrica en Navarra (1868–1954).
Pamplona: Fondo de Publicaciones del Gobierno de Navarra; accessed (10 Jan. 2020) at: http://www.
navarra.es/NR/rdonlyres/75A3F123-4396-4BDF-B487-299EF1C5EC36/146494/Asistenciapsiquiatrica.
pdf
Barrios-Flores LF (2007) Origen, evolución y crisis de la institución psiquiátrico penitenciaria. Revista de la
AEN 27(100): 473–500.
Berrios GE (1991) Psychosurgery in Britain and elsewhere: a conceptual history. In: Berrios GE and Freeman
H (eds) 150 Years of British Psychiatry, 1841–1991. London: Gaskell, 180–196.
Berrios GE (1997) The scientific origins of electroconvulsive therapy: a conceptual history. History of
Psychiatry 8: 105–119.
Beveridge A (1995a) Madness in Victorian Edinburgh. A study of patients admitted to the Royal Edinburgh
Asylum under Thomas Clouston (1873–1908), Part I. History of Psychiatry 6(1): 21–54.
Beveridge A (1995b) Madness in Victorian Edinburgh. A study of patients admitted to the Royal Edinburgh
Asylum under Thomas Clouston (1873–1908), Part II. History of Psychiatry 6(2): 133–156.
Conseglieri and Villasante 15

Breggin PR (2007) Brain Disabling Treatments in Psychiatry: Drugs, Electroshock, and the Psycho-
Pharmaceutical Complex, 2nd edn. New York: Springer.
Brown EM (2000) Why Wagner-Jauregg won the Nobel Prize for discovering malaria therapy for General
Paresis of the Insane. History of Psychiatry 11(4): 371–382.
Campos R (2003) Criminalidad y locura: el cura Galeote. Frenia 3(2): 111–146.
Campos R (2012) El caso Morillo: crimen locura y subjetividad en la España de la Restauración. Madrid:
CSIC-Frenia.
Campos R and González de Pablo A (2016) Psiquiatría e higiene mental en el primer franquismo. Madrid:
Catarata.
Campos R and Huertas R (2012) Medicina mental y eugenesia: los fundamentos ideológicos de la psiquiatría
franquista en la obra de Antonio Vallejo-Nágera. Historia del presente 20: 11–22.
Candela R (2017) El Manicomio Nacional de Leganés en el primer tercio del siglo XX (1931–1936): organi-
zación asistencial, aspectos demográficos, clínicos y terapéuticos de la población internada. Tesis doc-
toral, Universidad Complutense de Madrid; accessed (10 Jan. 2020) at: http://eprints.ucm.es/47119/1/
T39810.pdf
Candela R and Villasante O (2018) Pacientes “penales” en instituciones psiquiátricas: cien años del Manicomio
Nacional de Leganés (1852–1952). Dynamis 38(1): 163–187.
Comelles JM (1988) La Razón y la sinrazón. Asistencia psiquiátrica y desarrollo del Estado en la España
contemporánea. Barcelona: PPU.
Conseglieri A (2008) La introducción de las nuevas medidas terapéuticas: entre la laborterapia y el electro-
shock en el manicomio de Santa Isabel. Frenia 8: 131–160.
Conseglieri A (2013a) El Manicomio Nacional de Leganés en la posguerra española (1939–1952). Aspectos
organizativos y clínicos asistenciales. Unpublished doctoral thesis, Universidad Complutense de Madrid;
accessed (25 Jan. 2020) at: https://eprints.ucm.es/24531/1/T35082.pdf
Conseglieri A (2013b) Manuel Peraíta Peraíta: director facultativo del Manicomio Nacional de Leganés
(1944–1950). In: Simón D, Gómez C, Cibeira A and Villasante O (eds) Razón, locura y sociedad.
Una mirada a la historia desde el siglo XXI. Madrid: Asociación Española de Neuropsiquiatría,
365–373.
Conseglieri A (2013c) Las letras de la locura: cartas y dibujos de pacientes en el Manicomio Nacional de
Leganés (1939–1952). In: Simón D, Gómez C, Cibeira A and Villasante O (eds) Razón, locura y socie-
dad. Una mirada a la historia desde el siglo XXI. Madrid: Asociación Española de Neuropsiquiatría,
355–363.
Conseglieri A, Villasante O and Del Cura I (2007) El manicomio nacional de Leganés en la posguerra.
Aspectos organizativos y clínicos asistenciales. In: Campos R, Montiel L and Huertas R (eds) Medicina,
Ideología e Historia en España (siglos XVI–XXI). Madrid: CSIC, 555–568.
Conseglieri A, Villasante O and Vázquez de la Torre P (2016) El Manicomio Nacional de Leganés en la
posguerra. Viejas y Nuevas Prácticas. In: Campos R and González de Pablo A (eds) Psiquiatría e higiene
mental en el primer franquismo. Madrid: Catarata, 175–204.
Del Cura M (2011) Medicina y pedagogía. La construcción de la categoría “infancia anormal” en España
(1900–1939). Madrid: CSIC.
Del Cura M (2016) Futuros ciudadanos: psiquiatría infantil y subjetivación de la norma en la España del
primer tercio del siglo XX. Revista Culturas Psi/Psy Cultures 7: 45–68.
Del Cura I and Huertas R (2008) The siege of Madrid (1937–1939). Nutritional and clinical studies during the
Spanish Civil War. Food and History 6(1): 193–214.
Dualde F (2007) Legislación y asistencia psiquiátricas durante el franquismo: consideraciones particulares
acerca de la esquizofrenia. Cronos 10: 89–136.
Dukakis K and Tye L (2006) Shock: The Healing Power of Electroconvulsive Therapy. New York: Avery.
Duro-Sánchez A and Villasante O (2016) “La asistencia al enfermo mental” de Luis Valenciano: la profe-
sionalización del cuidado al enfermo mental durante la Segunda República Española. Cultura de los
cuidados: Revista de enfermería y humanidades 44: 51–62.
Fennell P (1996) Treatment without Consent: Law, Psychiatry, and the Treatment of Mentally Disordered
People since 1845. London: Routledge.
Fink M (1984) Meduna and the origins of convulsive therapy. American Journal Psychiatry 141: 1034–1041.
16 History of Psychiatry 00(0)

García-Cantalapiedra MJ (1992) Historia del Hospital Psiquiátrico de Valladolid. Valladolid: Diputación de

Valladolid.
García-Díaz C (2019) Mujeres, locura y psiquiatría: la sala 20 del Manicomio Provincial de Málaga (1909–
1950). Unpublished doctoral thesis, Universidad de Málaga.
Giner-Martí R and Navarro-Pérez J (1997) Los inicios de la psicocirugía en España. La escuela valenciana.
In: La locura y sus instituciones. Valencia: Diputación de Valencia, 337–356.
Golcman A (2017) Legitimar psiquiatras antes que curar pacientes. Las terapias de shock en Buenos Aires,
Argentina (1930–1970). Asclepio 69(1): 1–15; accessed (20 Feb. 2020) at: http://asclepio.revistas.csic.
es/index.php/asclepio/article/view/731/1126
González E (1977) A psiquiatría Galega e Conxo. Madrid: Ediciones Rueiro.
González de Pablo A (1987) Sobre la génesis del orden psiquiátrico en la posguerra española: la implantación
de la psiquiatría de Heidelberg en España. Revista de la AEN 7(23): 633–647.
González-Duro E (1997) Las instituciones psiquiátricas durante la época franquista. In: VV. AA., La locura
y sus instituciones. Valencia: Diputación de Valencia, 425–452.
Huertas R (1998) Mental health and psychiatric care in the Second Spanish Republic. History of Psychiatry
9(33): 51–64.
Huertas R (2001) Las historias clínicas como fuente para la historia de la psiquiatría: posibles acercamientos
metodológicos. Frenia 1(2): 7–37.
Huertas R (2006) Hambre, enfermedad y locura: la aportación de Bartolomé Llopis al conocimiento de la
psicosis pelagrosa. Frenia 6(1): 79–107.
Huertas R (2013) Another history for another psychiatry: the patient’s view. Culture & History 2(1): e020;
doi: http://dx.doi.org/10.3989/chdj.2013.021
Huertas R (2017a) En los inicios de la psiquiatría franquista: el Congreso Nacional de Neurologia y Psiquiatría
(Barcelona, 1942). Dynamis 37(1): 23–43.
Huertas R (2017b) Nido de víboras: en torno a los tratamientos biológicos en psiquiatría anteriores a
los psicofármacos. e-átopos 3: 68–86; accessed (20 Dec. 2019) at: http://www.atopos.es/images/
eatopos3/4eatopos3.pdf
Huertas R and Del Cura I (2010) Deficiency neuropathy in wartime: The “Paraesthetic-Causalgic Syndrome”
described by Manuel Peraita during the Spanish Civil War. Journal of the History of the Neurosciences
19: 173–181.
James FE (1992) Insulin treatment in psychiatry. History of Psychiatry 3(10): 221–235.
Jones K (2000) Insulin coma therapy in schizophrenia. Journal of the Royal Society of Medicine 93(3):
147–149.
Jordá-Moscardo E, Rey-González A and Angosto-Saura T (2007) La psiquiatría franquista y del exilio en el
I Congreso Mundial de Psiquiatría. París, 1950. In: Campos R, Villasante O and Huertas R (eds) De la
“Edad de Plata» al exilio construcción y «reconstrucción” de la psiquiatría española. Madrid: Frenia,
377–394.
Kotowicz Z (2008) Psychosurgery in Italy, 1936–39. History of Psychiatry 19(4): 476–489.
Lobo Antunes J (2010) Egas Moniz – Uma Biografía. Portugal: Gradita.
López de Lerma J and Díaz-Gómez M (2000) Hospital psiquiátrico sagrado corazón de Jesús, hoy complejo
asistencial Benito Menni (1881–2000). Más de un siglo de psiquiatría. Madrid: Fareso.
Molero-Mesa J (1994) Enfermedad y previsión social en España bajo el primer franquismo (1939–1952). El
frustrado seguro obligatorio contra la tuberculosis. Dynamis 14: 199–225.
Mollejo-Aparicio E (2011) Historia del Manicomio de Santa Isabel. Evolución de los diagnósticos y tratami-
entos de 1852 a 1936. Madrid: Ilustre Colegio Oficial de Médicos de Madrid.
Novella E and Campos R (2017) From mental hygiene to mental health: ideology, discourses and practices in
Franco’s Spain (1939–75). History of Psychiatry 28(4): 443–459.
Odier S (1995) Saint-Egrève, des horreurs de Vichy à la médicalisation d’un asile (1930–1960). Bulletin du
Centre Pierre Léon d’histoire économique et sociale 2(3): 117–126.
Odier S (2007) La surmortalité des asiles d’aliénés français durant la seconde guerre mondiale (1940–1945).
Frenia 7: 145–166.
Ögren K and Sandlund M (2005) Psychosurgery in Sweden 1944–1964. Journal of the History of the
Neurosciences 14: 353–367.
Ottosson JO and Fink M (2004) Ethics in Electroconvulsive Therapy. New York: Brunner-Routledge.
Conseglieri and Villasante 17

Passione R (2004) Italian psychiatry in an international context: Ugo Cerletti and the case of electroshock.
History of Psychiatry 15(1): 83–104.
Ploumpidis D, Tsiamis C and Poulakou-Rebelskou E (2005) History of leucotomies in Greece. History of
Psychiatry 26(1): 80–87.
Porter R (1985) The patient’s view: doing medical history from below. Theory and Society 14(2): 175–198.
Pressman JD (1998) Last Resort: Psychosurgery and the Limits of Medicine. New York: Cambridge
University Press.
Shorter EA (1997) History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John
Wiley & Sons.
Suzuki A (2003) A brain hospital in Tokyo and its private and public patients, 1926–1945. History of
Psychiatry 14(3): 337–360.
Szasz T (2007) Coercion as a Cure: A Critical History of Psychiatry. New Brunswick, NJ: Transaction
Publishers.
Tierno R (2008) Demografía psiquiátrica y movimientos de la población del Manicomio Nacional de Santa
Isabel (1931–1952). Frenia 8: 97–129.
Tierno R (2019) El Manicomio Nacional de Leganés durante la Segunda República (1931–1936): organi-
zación de la asistencia y práctica clínica. Tesis doctoral, Universidad Complutense de Madrid; accessed
(10 Jan. 2020) at: https://eprints.ucm.es/57799/1/T41447.pdf
Tusell J (2005) Dictadura franquista y democracia. Barcelona: Crítica.
Ucha-Udabe R, López-Muñoz F and Álamo C (2006) Sedantes e hipnóticos (II). El relevante papel
histórico y farmacológico de los barbitúricos. In: López Muñoz F and Álamo C (eds) Historia de la
psicofarmacología, Vol. 2. Madrid: Panamericana, 845–873.
Valenciano-Gayá L (1978) Parálisis general progresiva. Acmé, declinación y riesgo. Psicopatología. Murcia:
Diputación Provincial.
Valenstein ED (1986) Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical
Treatments for Mental Illness. New York: Basic Books.
Vázquez de la Torre P (2013) El Manicomio Nacional de Santa Isabel en Leganés durante la Guerra Civil
española (1936–1939). Población manicomial y prácticas asistenciales. Thesis doctoral, Universidad
Complutense de Madrid; accessed (10 Jan. 2020) at https://eprints.ucm.es/21076/
Vázquez de la Torre P and Villasante O (2016) Psychiatric care at a national mental institution during the
Spanish Civil War (1936–39): Santa Isabel de Leganés. History of Psychiatry 27(1): 51–64.
Villasante O (2003) The unfulfilled project of the Model Mental Hospital in Spain: fifty years of the Santa
Isabel Madhouse, Leganés (1851–1900). History of Psychiatry 14(1): 3–23.
Villasante O (2004) La malarioterapia, ¿un tratamiento revolucionario? El Médico 919: 68–76; accessed
(27 Nov. 2019) at: http://elmedicointeractivo.com/malarioterapia-tratamiento-revolucionario-
20110919190158029688/
Villasante O (2008) Orden y norma en el Manicomio de Leganés (1851–1900): el discurrir diario del paciente
decimonónico. Frenia 8(1): 33–68.
Villasante O (2013) Primeros intentos de profesionalización de la enfermería psiquiátrica: de la Segunda
República a la Posguerra Española. In: Simón D, Gómez C, Cibeira A and Villasante O (eds) Razón,
locura y sociedad. Una mirada a la historia desde el siglo XXI. Madrid: Asociación Española de
Neuropsiquiatría, 315–329.
Villasante O (2020a) Malaria therapy in Spain: 100 years after its introduction as a treatment for the general paral-
ysis of the insane. History of Psychiatry 31(3): 325–340; doi: https://doi.org/10.1177/0957154X20918824
Villasante O (2020b) La evaluación psicotécnica de los enfermeros psiquiátricos en España (1930–1972):
¿una tarea “moral”? Revista de Historia de la Psicología 41(1): 2–11.
Villasante O, Candela R, Conseglieri A, Vázquez de la Torre P, Tierno R and Huertas R (2018) Cartas desde
el manicomio. Experiencias de internamiento en la Casa de Santa Isabel de Leganés. Madrid: Catarata.
Villasante O, Vázquez de la Torre P, Conseglieri A and Huertas R (2016) Letras retenidas. Experiencias de
internamiento en las cartas de los pacientes del Manicomio de Santa Isabel de Leganés, Madrid (1900–
1950). Revista Culturas Psi/Psy Cultures 6: 118–137; accessed (20 Jan. 2020) at: https://digital.csic.es/
bitstream/10261/203799/1/Letras%20retenidas_2016.pdf
Whitaker R (2002) Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the
Mentally Ill. New York: Basic Books.