Gas Chamber Technology Was Perfected in Psychiatric Hospitals Before It Reached the Death Camps

Source: Lex Fridman Podcast | Published: 2026-09-17T00:34:47Z

Henry Cotton's stomach-removal surgeries at a New Jersey asylum carried a 45% mortality rate — yet the New York Times hailed it as a breakthrough, and patients still flocked from across America for treatment.

A Diagnostic System Never Built on Science

Before 1980, psychiatrists across America routinely gave wildly different diagnoses to the same patient. The problem had been buried in the professional literature for years until David Rosenhan's study landed in Science and blew the lid off — he sent "pseudopatients" into psychiatric hospitals, and nearly all of them were diagnosed with schizophrenia, with one receiving a bipolar diagnosis. Every last one was healthy.

DSM-III followed. Led by Columbia University's Robert Spitzer, it introduced a symptom-checklist logic: meet six of ten criteria, and you have major depressive disorder. The system's virtue was reliability — whether you were in New York or Seattle, facing the same patient, doctors should reach the same conclusion. But reliability and validity are not the same thing. You can measure the wrong thing with great precision.

The system satisfied pharmaceutical companies, insurers, and patients' families alike, because it offered certainty. But it never moved beyond symptom description, never touched the underlying mechanisms of disease. DSM-III went through multiple revisions; each edition added diagnostic categories. By DSM-5, researchers had already found substantial overlap in genetic markers between schizophrenia, bipolar disorder, and autism — categories treated as distinct diseases for decades, whose boundaries may never have existed at all.

Thomas Insel, after 13 years running the NIMH, said in a pre-departure interview: "I've funded a lot of cool science. Geneticists and neuroscientists have done fascinating work. After spending $20 billion, the lives of people with mental illness have not improved one iota."

The Asylum: From Sanctuary to Warehouse

In the mid-19th century, the mental asylum was born in a spirit of radical optimism. Its founders believed that if they rescued patients from prisons and attics, gave them a therapeutic environment, directed them toward labor, and helped them rebuild self-control, they could cure sixty, seventy, eighty percent of cases.

The problem was arithmetic. Each year, thirty or forty percent of patients were discharged; the chronic cases stayed behind. The following year brought a new cohort, and another set of chronic patients remained. Year after year, the proportion of long-stay patients grew while new admissions shrank, until the institution was defined entirely by those who could not recover. By the late 19th century, the advertised cure rates had collapsed to ten or twelve percent — but doctors could not acknowledge this as their failure.

So the narrative shifted. Doctors began saying: it's not that we can't cure them — it's that these people aren't worth curing. Mental illness was reframed as biological degeneration. Patients were evolutionary throwbacks, defective in mind, inferior by nature. Given that, locking them away was no longer treatment — it was quarantine, protecting society from contamination by "defective genes."

This was the founding logic of sterilization. States passed laws one by one. By the 1960s, more than 60,000 psychiatric patients in America had been forcibly sterilized. California's numbers were particularly staggering.

The Nazi Gas Chambers Began in Psychiatric Hospitals

What came after sterilization?

A British psychiatrist left behind this remark: if his patients were a litter of puppies, he would put them in a sack, attach a lead weight, and drown them in a pond — because they were mongrels, not purebreds. This kind of language was not rare in the academic journals and public lectures of the era.

Under a democracy, such language stayed rhetorical. There were enough checks to stop it from becoming policy. Nazi Germany had no such checks. Hitler designated psychiatric patients "useless eaters" and launched Aktion T4 — named for Tiergartenstraße 4 in Berlin, where the program was secretly drafted.

The mentally ill were the first victims of the Final Solution. They were loaded onto "death vans" disguised as public buses and transported to psychiatric centers across Germany for systematic murder. The technology of the gas chamber — including the technique of disguising it as a shower room — was developed in the killing of psychiatric patients. It was later transferred to the concentration camps. The death toll may have reached 250,000.

Behind this lay a traceable intellectual lineage. American theories about the biological inferiority of the mentally ill traveled to Germany through Rockefeller Foundation-funded research. The German geneticist Ernst Rüdin, who received that funding, became the central architect of Hitler's forced sterilization law, and ultimately a supporter of murdering psychiatric patients outright.

Curing Syphilis With Malaria, and a Nobel Prize for It

In the early 20th century, as many as 25 percent of psychiatric hospital residents were actually suffering from a condition called general paresis — the third stage of syphilis, when Treponema pallidum invades the brain. Patients gradually lost the ability to walk, swallow, and speak, while developing grandiose delusions: they believed themselves to be Napoleon, Jesus, or the wealthiest person alive.

Austrian physician Julius Wagner-Jauregg had long believed that fever could cure mental illness. He had tried rat-bite fever and typhoid vaccines — nothing worked. Near the end of World War I, his hospital admitted an Italian prisoner of war with malaria. Wagner-Jauregg drew the man's blood and injected it into a group of paretic patients, giving them malaria, letting them burn with fever for days — then declared them cured.

He later admitted those claims had been greatly exaggerated, but in an era before the randomized controlled trial, no one had the scientific tools to check him. Malaria therapy spread rapidly across Britain, Germany, and the United States. Some psychiatric hospitals kept live mosquito colonies. Patients were bound, placed in darkened rooms, and left to be bitten — then came the fever and shaking, a near-fatal illness allowed to run its course.

In 1927, Wagner-Jauregg was awarded the Nobel Prize in Medicine.

The therapy did not disappear because it was disproved. It disappeared because penicillin was invented — and no one needed to fight infection with infection anymore.

Pull Teeth, Remove Stomachs, Claim an 80% Cure Rate

In 1916, Henry Cotton took over Trenton State Hospital in New Jersey. He was a reformer — he removed the chains, minimized straitjackets, and genuinely wanted to heal patients. He subscribed to a theory: low-grade infections lurking throughout the body continuously released toxins into the bloodstream, and those toxins, reaching the brain, caused mental collapse.

The prescription was logical, if the premise held: find the infection, remove it, and the patient recovers.

Step one: pull teeth. Teeth sit close to the brain and are prone to infection. Patients' teeth were extracted in bulk. The patients did not improve. Perhaps the theory was right and the true source of infection simply hadn't been found yet.

Step two: remove the tonsils. Also prone to infection. Excised. No improvement.

Step three: Cotton began removing stomachs, spleens, and colons. In one paper, he wrote: "The stomach is like a concrete mixer on a building site — it can be dispensed with." He claimed this regimen cured 80 percent of his patients.

The New York Times called it a major breakthrough. Princeton University Press and Oxford University Press published his lecture transcripts. Wealthy patients came from across America to receive this "new treatment."

The real numbers were excavated only later: patients who underwent abdominal surgery had a mortality rate of 45 percent within one year.

Cotton died of a heart attack in 1933. The three men who succeeded him abandoned abdominal surgery but continued extracting teeth. Scull tracked down the dentist who had come to work at the hospital in 1916 — he retired in 1960, a career of 44 years, with perhaps hundreds of thousands of teeth pulled by his own hand. When Scull interviewed him, he remained entirely certain that Cotton deserved the Nobel Prize.

Insulin Coma Therapy: Treatment That Required Round-the-Clock Bedside Watch

The discovery of insulin in the 1920s transformed the lives of diabetics — one of the genuine breakthroughs of 20th-century medicine. Not a cure, but a way to make a once-fatal disease livable.

Insulin had a side effect: too much of it and a patient lost consciousness. A physician named Sakel, working at a German detox clinic, had grown accustomed to using mild coma to ease patients through withdrawal. Later, working in Austria, he decided to apply the method to schizophrenia.

His protocol involved pushing patients into deep coma — sometimes for hours, sometimes days — then reviving them with glucose. Patients frequently convulsed during the process; Sakel interpreted the seizures as evidence the treatment was working. He claimed an 80 percent cure rate.

Insulin coma therapy spread across Europe and America from 1933 onward. What limited its adoption wasn't skepticism but sheer labor intensity — patients hovered constantly at the edge of death, requiring unbroken bedside monitoring, ready for immediate intervention the moment blood sugar dropped too far.

There was evidence the therapy damaged brain cells. When Sakel was informed of this, he replied: "That may well be true — we're killing the very cells that are causing the schizophrenia." The first randomized controlled trial to formally test the therapy didn't arrive until the 1950s. It failed.

Among those who received insulin coma therapy was a man named John Nash — the real person behind A Beautiful Mind, one of the greatest mathematicians of the 20th century. The hospital had also planned to lobotomize him. It never did.

The Slaughterhouse Revelation: The Birth of ECT

The story of electroconvulsive therapy begins with pigs.

Two Italian psychiatrists, Cerletti and Bini, wanted to use electrical current to induce seizures as a treatment for schizophrenia — based on an assumption later proved wrong: that epilepsy and schizophrenia could not coexist. Experimenting on dogs, they initially placed one electrode on the head and another on the rectum, sending current through the entire body. The dogs' hearts stopped. They died.

Someone suggested a visit to the Rome slaughterhouse. They went, and watched pigs conveyed upside-down along a line, two electrodes clamped to the head, current applied, the pig convulsing and losing consciousness — then its throat was cut and the meat went to market. The current passed only through the brain, not the heart. The pig didn't die.

They replicated the method on dogs. It worked. Then they found a homeless man wandering through Rome's train station and began their experiment. The first jolt wasn't strong enough — nothing happened. The two physicians, pale, retreated to a corner. Should they increase the voltage? Yes. The patient heard them discussing it and said: "Don't try it again — it'll kill me." They increased it anyway.

The patient seized, stopped breathing. Everyone in the room believed it was over. Then he began breathing again on his own, and when he came around, he was lucid. The doctors believed they had witnessed a miracle.

That was ECT in 1938. It spread across Europe and America quickly, though it soon became apparent that its benefits for schizophrenia were limited, while its effects on severe depression — especially in patients at risk of suicide — were comparatively meaningful.

In the psychiatric hospitals of the 1940s through the 1960s, ECT was deployed more often as a control mechanism than a treatment. Non-compliant patients were wheeled in for electroshock as a deterrent to others. This was the "unmodified" era — no muscle relaxants — and patients convulsed violently; fractured spines and broken hips were not uncommon.

In 1975, One Flew Over the Cuckoo's Nest lodged this history into collective memory. Jack Nicholson's McMurphy undergoes ECT on screen, is subsequently lobotomized, and is finally smothered with a pillow. For decades afterward, that film constituted the entirety of most people's knowledge of electroconvulsive therapy.

Freud Comes to America, America Doesn't Much Care

In 1909, Sigmund Freud boarded a German ocean liner with Jung and another disciple and crossed the Atlantic to attend a conference at Clark University in Massachusetts. He privately despised America — he called it "the land of dollars," found American women too assertive and self-important, and complained the food gave him indigestion.

But he came. Jung had persuaded him.

Freud delivered five lectures in German — the American academics in attendance all read German, which in that era was a basic professional credential, German medicine being the most advanced in the world. The philosopher William James came and listened. He was not particularly impressed.

Mainstream American psychiatry paid almost no attention to Freud's arrival. Psychiatrists at the time were locked inside asylums managing severely ill patients, and they believed mental illness was a biological disease of the brain. What use was "talking therapy" for a brain disease? Absurd.

Psychoanalysis found its audience elsewhere: among intellectuals, artists, writers. Freud wrote his case histories like short stories — a quality he acknowledged had made serious scientists wary of him. But novelists, playwrights, painters — they loved the framework of the unconscious, repression, desire. Jung secured the wealthiest American clients (including members of the McCormick and Rockefeller families); Freud's patients were somewhat less affluent.

By 1930, there were perhaps 300 psychoanalysts in North America. They met with each patient five times a week, fifty minutes a session — an arrangement that could never reach the hundreds of thousands of severely ill patients in the asylums. What actually changed the numbers was Hitler. His persecution of Jews — and analysts were disproportionately Jewish — sent waves of practitioners fleeing to Britain and America, roughly doubling the profession overnight.

Cognitive Behavioral Therapy: Cheaper, Shorter, Measurable

World War II fundamentally reshaped American psychiatry. When the war ended, vast numbers of physicians who had been pressed into service were forced to learn psychotherapy quickly to manage the flood of combat trauma. Upon discharge, they opened private practices and had no desire to return to asylums. By 1958, roughly 80 percent of psychiatrists were working in outpatient settings.

Meanwhile, clinical psychologists saw an opening. Psychoanalysis was long and expensive — five years at minimum — and its outcomes were impossible to measure. When analysts were asked whether their treatment worked, the answer was always "it's complicated." Clinical psychologists offered a different logic: treat specific symptoms, design reproducible protocols, measure results.

This was the origin of cognitive behavioral therapy. CBT had no interest in the deep personality structures Freud described. It focused instead on identifying which response patterns were dysfunctional right now, then offering concrete exercises to build new habits. Treatment ran in weeks, not years. It could be packaged into training programs, measured, replicated.

Aaron Beck was a central figure. Trained originally in psychoanalysis, he grew disillusioned and became one of CBT's foundational architects. He was also among the first to systematically study the reliability problem in psychiatric diagnosis — he helped push DSM-III into existence while simultaneously building the theoretical framework for CBT on a parallel track. He lived to 100 and was still lecturing in his final years.

CBT's limitations are real. Its effectiveness is reasonably established for mild to moderate emotional problems. For severe schizophrenia, the evidence is essentially absent. Even its effects on depression earn only "low to moderate confidence" ratings in systematic reviews such as those from the Cochrane Collaboration. Still, the UK's NICE guidelines recommend CBT as a first-line treatment for mild to moderate depression over medication — comparable efficacy, without the side effects.

Chlorpromazine: An Accident That Reshaped an Industry

In the early 1950s, the French pharmaceutical company Rhône-Poulenc had a compound called chlorpromazine on its hands. The molecule had been synthesized back in the 1880s; no one had known what to do with it. They tried it as an antihistamine, tried it for eczema. Nothing impressive.

A French naval surgeon named Henri Laborit got hold of it and found that preoperative patients who received it became unusually calm — not anesthetized, just genuinely indifferent. He wrote to a relative working at a Paris psychiatric hospital and described it as "a chemical lobotomy." At the time, lobotomy had not yet become a term of condemnation.

His relative told Delay and Deniker, who worked at Sainte-Anne, Paris's largest psychiatric hospital. They tried chlorpromazine, pushed the dose higher and higher, until patients who had been breaking furniture and completely out of control went quiet. The hospital treated it as a management tool, not a therapy.

The drug entered North America through Quebec psychiatrist Heinz Lehmann. American physicians initially mistrusted European medicine; the first two companies approached by Rhône-Poulenc declined the licensing rights. SmithKline & French bought it and sold two million units within two years, transforming from a minor company into a major one as generics followed.

Chlorpromazine became Thorazine, later rechristened an "antipsychotic" — a name implying it struck at the root of psychosis. In fact, it was only effective against "positive symptoms" (hallucinations, delusions) and had almost no effect on "negative symptoms" (apathy, poverty of speech, inability to connect with others) — which are the primary drivers of diminished quality of life for most patients.

The CATIE study in 2005 — government-funded, with no pharmaceutical backing — found that newer-generation antipsychotics were no more effective than the original cheap drugs from decades earlier. More striking: between 67 and 82 percent of trial participants, depending on the specific drug, dropped out mid-study. Either the drug wasn't working, or the side effects were intolerable.

Antidepressants, and the Difference Between Statistical Significance and Clinical Meaning

The discovery of antidepressants was also accidental. In the 1950s, doctors treating patients with advanced tuberculosis noticed that a class of drugs left these otherwise depressed, dying patients in unexpectedly elevated moods — dancing. That thread eventually led to an entire category of antidepressants.

Prozac arrived in the late 1980s with a clear message: depression is caused by insufficient serotonin in the brain, and SSRIs restore it. The pharmaceutical industry sold this story extraordinarily effectively. Depression went from a small market to psychiatry's most common diagnosis.

But a problem had long been underreported: in controlled trial after controlled trial, SSRIs outperformed placebo with statistical significance — while the clinically meaningful improvement was often marginal. A one-to-two point improvement on a 60-point depression scale can be statistically significant while having negligible impact on a patient's actual life.

The side effect profile includes emotional blunting — peaks and valleys both flattened; sexual dysfunction, which in some patients persists after discontinuation; and withdrawal, which for some is a nightmare — depression worse than before treatment, bizarre neurological symptoms, trapping patients in long-term drug dependence.

The pharmaceutical industry's conduct throughout this period is extensively documented: suppressing unfavorable data, publishing only the two successful trials required for FDA approval (while withholding thirteen failed ones), manipulating research results. The resulting settlements have run into the billions.

Where Does Psychiatry Go From Here

Scull has said he views the current enthusiasm around ketamine and psychedelics with unease — that particular rhetoric about "finally, a cure" is something he has heard too many times before: the 80 percent cure rates of the early asylums, the 80 percent cure rates of insulin coma therapy, the 80 percent cure rates of Henry Cotton's surgeries. Each time it was "this time is different." Each time someone received accolades. Each time the truth arrived late.

He believes psychiatry needs to expand its research horizon beyond drugs and neuroscience: toward psychosocial support, public policy, helping patients' families, building genuinely effective community support for severely ill patients rather than cycling them through streets, jails, and cheap motels. The three largest "psychiatric inpatient centers" in the United States today are Los Angeles County Jail, Cook County Jail in Chicago, and Rikers Island in New York.

If mental illness does have a biological component — which Scull believes it does — then the quiet withdrawal of major pharmaceutical companies from this research space, having exhausted the available molecular targets, is a particularly troubling development. What remains is a handful of small startups.

After $20 billion and an entire generation of researchers spending decades on the problem, Scull believes we remain in the early stages of a very long journey. Not pessimism — honesty. Progress, he says, has never come from overstating what we've achieved. It comes from acknowledging what we still don't know, and pressing forward anyway.