Starved to Death? Nutrition in Asylums During the World Wars

A BSTRACT The aim of this study was to compare nutritional conditions in Swedish mental hospitals and institutions for ‘‘feebleminded’’ people during the two world wars with those in German institutions of the same era. During World War I, lack of food in Germany and Sweden led to high death rates at institutions containing many patients. During World War II, the Nazis used star v ation as a means of killing disabled people. Restriction of food occurred e v en before the war began, and continued in pri v ate initiati v es e v en though the official ‘‘euthanasia program’’ had ceased. In Sweden, rationing due to the war affected the nutritional conditions in institutions. There was, howe v er, no di v ision of inmates into ‘‘worthy’’ or ‘‘unworthy’’ eaters. Despite weight losses, there are no signs of higher death rates at Swedish institutions, except at Vipeholm. The discussion in the mass media about ‘‘killing disabled persons’’ at institutions and comparing their conditions to Nazi Germany seems to be based on statistical misconceptions. There is a report from Ku¨ckenmu¨hler (cid:1) / the institution at Stettin, about the institution’s conditions during the war years. Now the truth can be told openly, it turns out to be very painful. The miserable nutritional conditions resulted in a strong increase in mortality. Dr Jodiche, medical superintendent, reports that whereas the mortality under normal conditions was 80 (cid:1) / 90 deaths per year, during the war years it doubled, tripled or even increased tenfold to 185 deaths per year! The daily food ration was reduced to approximately 1400 calories, less than half of normal, but not even this reduced rationing could be maintained. Gradually, the institution was depopulated, and its abnormal population diminished so much that the buildings were made available to the town of Stettin for other patients, who were sometimes as many as 400 ( NTA Fra alle lande 1919:172).

Two years after the mass-media focus on Swedish sterilization politics, Swedish journalists revealed a new historical disaster; statistics showing that patients at mental hospitals died in far higher numbers during World War II (WWII) than before the war. Close examination of the medical files at one hospital confirmed journalists' suspicions that patients had deliberately been given too little food, resulting in a high death rate. Parallels were soon drawn with Nazi Germany (Kanger 1999a,b, Anstrin 2000. This interpretation was challenged, but the basic question as to what really happened at the Swedish institutions during WWII was never fully investigated. There is still a lack of empirical knowledge about whether mentally ill and ''feebleminded'' patients in Sweden died in higher numbers during WWII.
We know that scarcity of food caused high death rates and poor conditions at institutions for disabled people during WWI in Germany and in Sweden. The reasons for the poor situation concerning nutrition, however, vary with time. During WWI, patients died in high numbers due to lack of food. This shortage of food also affected people living outside institutions and many people, in both Sweden and in Germany, experienced hardship caused by the difficulty of obtaining enough food. However, dying from malnutrition is not necessarily a consequence only of poor access to food, it also occurs as a result of unequal distribution of food. In Nazi Germany, food was denied to certain categories of people, such as ''feebleminded'' and mentally ill patients at institutions, and it became a conscious means of murder, disguised under the term ''euthanasia''.
This article focuses on institutionalized ''feebleminded'' and mentally ill patients' nutritional conditions during the two world wars. The high rates of mortality of disabled people in German institutions have already been the subject of several studies. The mortality rates and conditions at Swedish institutions, on the other hand, have not been discussed in detail or put into context. The study is empirical in its content. Of course, results from this study might be analysed and included in the context of more theoretical research and the immense body of research into Nazism. However, for now, this is not the purpose of this article. Instead, the focus is on presenting empirical data about conditions in institutions for ''feebleminded'' and mentally ill patients during the wars, with respect to the patients' access to food. I use the words ''feebleminded'' and ''mentally ill'' in accordance with their use at that time, since modern terms do not necessarily correspond to the same categorization (Noll 1995).
A comparative perspective has been taken, both geographically and chronologically, using data from Germany and Sweden covering a period of almost half a century. One reason for comparing Sweden with Germany is the cultural and scientific exchange between the two countries that existed at the beginning of the last century. There were many similarities between the two states in urbanization, social structure and family patterns, up until the Nazis' seizure of power (Weingart 1999). Nevertheless, comparisons have their problems. For instance, the different national systems of institutional care raise problems concerning statistics. Despite the difficulties, a comparison between the two countries is interesting, and comparative studies between Sweden and Germany have been made earlier, e.g. concerning sterilization politics, where exact figures are also hard to find. Yet the results have brought up new questions and provided new knowledge (Roll-Hansen 1999). The focus of this article is on Swedish institutions for ''feebleminded'' and mental patients during the two world wars, in comparison with German institutions.
The article first discusses the sources of research, then the two countries and their national policies towards ''feebleminded'' and mentally ill people during the two world wars. Finally, there is a brief discussion about similarities and differences between the countries and the reasons for the situation in the institutions.

Sources
The sources used in this article are statistical data and official reports, such as annual reports from the Inspector of the Medical Board in Sweden. The first inspector was appointed in 1902. He had responsibility for mental healthcare, as well as care of ''feebleminded'' patients until 1931, when two inspectors were appointed. From then on, one inspector took responsibility for mental patients and the other was in charge of ''feebleminded'' patients. The Nutrition in Asylums During the World Wars 3 inspector visited the institutions in order to supervise medical treatment and ensure that no maltreatment occurred. Complaints and requests for improvements were written down in reports, which are kept in the National Archives in Stockholm today.
Another source of information is the annual reports to the Medical Board written by the directors of the institutions. They contain information about new buildings, the number of patients working and what kinds of work they were doing, medical treatments and the patients' general state of health. Under the title ''state of health'', somatic illnesses, such as epidemic diseases, were recorded, together with information about the quality and quantity of food, and the patients' weights. Sometimes, weight lists and menus were included with the reports.
In order to comprehend some of the professional debates about mental and ''feebleminded'' care a Scandinavian journal, Nyt Tidsskrift om abnormvaesenet (NTA) (The New Journal of the Abnormal Being) was studied. This journal published articles by pedagogues as well as doctors. The German journals Zeitschrift fü r Soziale Hygiene, Fü rsorge-und Krankenhauswesen (Journal of Social Hygiene, Social-and Hospital Care) and Psychologische Neurologische Wochenschrift (PNW) (Psychological and Neurological Weekly) were also studied.
The data concerning Germany have been taken mostly from secondary literature. There is a interesting study concerning the ''hunger murders'' at German institutions, written by Heinz Faulstich (1998). He used sources from local archives all over Germany and focused on the Nazis' use of starvation as a means of murder.

Germany
From 1881 to 1913 the number of hospitals for ''feebleminded'', epileptic and mentally ill people in Germany increased by 145%. This figure can be compared with the 106% increase in ordinary hospitals. The increase in hospitals and inmates imply that more people were defined as ''ill''. The reasons for this are many. Some argue that the higher demands of an industrial society separated the working-able from those who could not keep up with the new pace of life. Other explanations are the misuse of alcohol or more careful registration of patients in the hospitals (Walter 1996). In this context, ongoing discussions about definitions of diagnoses must be included, since no official agreement existed about which criteria a certain diagnosis included. In particular, different levels of ''feeblemindedness'', i.e. so-called ''idiocy'', ''imbecility'' and ''debility'', were difficult to separate before the use of intelligence tests became more common.
Many of the German institutions were large compared with Swedish ones (Lauritzen 1917). They also had quite a mixed group of patients; ''feebleminded'', mentally ill and blind people could live in the same institutions. Very few doctors had an interest in the care of ''feebleminded'' or mentally ill patients in the 19th century, compared with teachers, who took a more optimistic view of the inmates' chances of learning (Meyer 1983). However, progress within psychiatry increased doctors' interest in mental institutions and led to the introduction of new medical treatments for these patients.
Before World War I (WWI), the most common treatment in mental institutions was bed treatment, e.g. lying in bed and rest. The aim was to create a relaxing environment, but also to stimulate blood circulation through a horizontal position and the warmth of the bed (Jö nsson 1998). The introduction of bed therapy in psychiatry also emphasized its kinship with somatic care. A problem for psychiatrists was to achieve the same status as somatic doctors, and so the use of wards containing rows of beds emphasized the similarities between the somatic and psychiatric care (Faulstich 1993).
Other treatments and therapies were introduced slowly. In 1905, Dr Hermann Simon introduced and argued for ''occupational theory'', which challenged the idea of rest. Instead, he argued that patients benefited from work and activity (Walter 1996). Simon was initially quite alone in advocating the advantages of this new therapy and many of his colleagues were sceptical, still arguing for bed treatment.

Germany During WWI
The outbreak of war in 1914 had serious consequences for institutions for the ''feebleminded'' and mentally ill. The lack of food and the need for more hospital beds for injured soldiers led to high death rates in these institutions (Walter 1996). During the war years, many Germans suffered from lack of food and lost weight, but for the weakest, the hardship caused death. In 1917 all the inmates in some institutions for elderly people died. Another vulnerable group was newborn babies (Faulstich 1993).
There were several reasons why inmates suffered from starvation during WWI. An important factor was the hunger blockade of foreign food supplies addressed to Germany. Besides this, a poor harvest in the summer of 1916 led to a complete lack of potatoes in the winter of 1916Á/17. Furthermore, through a decision of Kriegsernä hrungsrat, patients in mental hospitals and institutions for the ''feebleminded'' were not given extra portions, unlike somatic patients (Faulstich 1993). This decision meant that the mentally ill patients were given the same food rations as the general public, even though some doctors argued that agitated and overexcited patients required higher levels of nutrition than healthy people.
Food rationing affected the patients more than it did the general public, since the inmates had no chance of getting extra food from farming or the black market. This made them highly dependent on the meals the institutions provided. The difficulty of obtaining food lowered their resistance to illnesses and many deaths were caused by tuberculosis, gastroenterological and cardiac diseases (Walter 1996). Opportunities for the patients to obtain adequate care also decreased because many doctors and staff members were drafted into the armed forces (NTA 1915:237).
The directors of the German institutions for the ''feebleminded'' published annual reports, occasionally summarized in the Scandinavian journal Nyt Nutrition in Asylums During the World Wars 5 Tidsskrift for abnormvaesenet. During the war, some very depressing reports were published; for example, in 1919 the following news item was published: There is a report from Kü ckenmü hler Á/ the institution at Stettin, about the institution's conditions during the war years. Now the truth can be told openly, it turns out to be very painful. The miserable nutritional conditions resulted in a strong increase in mortality. Dr Jodiche, medical superintendent, reports that whereas the mortality under normal conditions was 80 Á/90 deaths per year, during the war years it doubled, tripled or even increased tenfold to 185 deaths per year! The daily food ration was reduced to approximately 1400 calories, less than half of normal, but not even this reduced rationing could be maintained. Gradually, the institution was depopulated, and its abnormal population diminished so much that the buildings were made available to the town of Stettin for other patients, who were sometimes as many as 400 (NTA Fra alle lande 1919:172).
Unfortunately, many institutions did not write annual reports during the war years, so there is little information about starvation or poor living conditions at a local level (Faulstich 1993). Hans Ludwig Siemens estimates the number of victims to be 70,000. He used the medical statistics for Germany for 1914Á/19, subtracted 5.5% each year as a ''normal'' death rate from the registered deaths, and concluded that 71,787 patients were victims of the wartime conditions in the institutions (Siemens 1987).

The Weimar Republic
Because of the high death rates during the war, many hospitals closed down. The hardships of the war also meant that almost no new methods and therapies were tried (Siemens 1987). The problems of obtaining food continued, despite the end of the war. A Danish teacher who visited two German institutions in 1920 confirmed the poverty. She wrote an article about the scarcity of bread and the absence of sugar, and that meals consisted mostly of potatoes and porridge (NTA, Bendsen 1920:102Á/104). The poor situation was also highlighted in a plea, published in Nyt Tidsskrift fö r Abnormvaesenet in 1921, in which a German teacher asked Danish institutions to invite German ''feebleminded'' children to visit during the summer (Henvendelse 1921:55).
It was not until the mid-1920s that the downtrend stopped and more patients were taken into care (Siemens 1987). However, the old therapy, which demanded beds and was rather personnel-intensive, was expensive. The need for cheaper treatment, and a higher throughput, forced changes in care. This development shows an acceptance of new influences, but the main reason for the change was purely economic, even though the doctors often claimed therapeutic advantages as the prime reason and economic advantages as secondary (PNW, Schmidt 1935:18, PNW, Knab 1931. At this time, Hermann Simon's occupational therapy, as well as care outside the institutions, was introduced to a greater extent. Family care had already been used before WWI, but declined during the war. It was introduced into practice again during the second half of the 1920s (Siemens 1991). The open care led to the possibility of including more patients in the system and the work carried out by patients at the hospitals helped to save money. Other ways of enabling the inclusion of more patients within the system were to reduce the duration of treatment and make early discharges (Faulstich 1993).
Despite tough budgets, there was also progress concerning the medical treatments within psychiatry in the 1930s. The doctors began to elaborate with so-called ''shock therapies''. Bodily shocks, provoked by electricity, insulin or fever, gave hopes of improvement for the patients and some patients became better. The ''cured'' patients were of course a success for the doctors, but they also made it obvious that some patients were never going to get better. They did not respond to the new therapies and these ''incurable'' patients became a failure to psychiatry, medically as well as economically (Burleigh 1996). The division between ''curable'' and ''incurable'' patients became important in forthcoming politics; as did the division between those who could work and those who could not.
The medical progresses initiated a discussion about what kind of treatment institutions for ''incurable'' patients should offer. It was argued that patients who had a chance of being cured should have effective care in order to be reintegrated within society, whereas chronically ill patients should be given the cheapest kind of care (Siemens 1991). Another answer to this question was published in a book that has been given much more attention recently than when it was first published. It was the first book arguing for putting an end to the ''incurable'' patients' lives, in the name of ''euthanasia'' (Bindling & Hoche 1920).

Psychiatric Care During the Nazi Era
The economic pressure and changes in treatment and medical care had begun before the Nazi take-over. Already by the end of the 1920s, psychiatrists were open to eugenic measures, such as sterilization, for disabled people. This was not in any way a typical German development, but part of the eugenic movement occurring in many European and American countries.
One means of lowering costs at the institutions was to save money on food or other basic needs of the patients. The cost per patient, which had already been reduced during the economic crisis, was lowered even more in 1935 (Hö lzer 2000). Thus even before WWII the patients were suffering from poor living conditions. Siemens (1987) argues that the death rates at the German institutions increased from 5.0% in 1933 to 6.6% in 1939.
The size of food rations at the institutions were regulated by the work the patients were able to carry out; the more work, the more food. In Saxony, fatreduced and meatless meals, ''Sonderkost'', were introduced for the incurable patients in 1938 (Thom 1991). This Sonderkost, together with poor conditions, had already caused a higher death rate at one of the institutions in Saxony in 1939(Hö lzer 2000. Experiments with nutrition as a means of discrimination between ''worthy eaters'' and the ''not-worthy'' was therefore in use before the outbreak of WWII. Articles in professional journals about the need for savings and cuts within psychiatric care often ended with glossy arguments such as ''. . .im engeren Rahmen fü r die Anstalt, im weiteren fü r Volk Nutrition in Asylums During the World Wars 7 und Vaterland.'' (in narrower settings for the institutions, in wider for the people and the native country) (PNW, Mö ckel & Schweickert 1937:428). T-4 From 1939, the killing of disabled people was organized and institutionalized under the term ''euthanasia'' (see Brill 1994). The first target group was disabled children, younger than 3 years. Within a year, ''euthanasia'' was enlarged to include adult disabled people. The operation was called T-4 after Tiergartenstraße 4 in Berlin, where the administration was located (Schmuhl 1987). Hitler gave the order in October 1939, but it was backdated to 1st September, in order to harmonize with Germany's foreign policy Á/ the invasion of Poland. '' Aktion T-4'' was a bureaucratic and well-organized operation. Forms, one for each patient, were sent out to all institutions. These forms asked for information about diagnosis, health status, race and capacity to work and were completed by the doctors. Most space was given to a question about the patient's working capacity, which highlights the focus on the ability to work and be useful (Roer & Henkel 1986). The completed forms were then sent to Berlin, where staff marked those patients who should be killed. These names were passed on to another organization, which arranged for the patients' transportation. In order to be able to complete all transports, a system of several ''Zwischenanstalten'' was organized. These hospitals were used as waiting areas for patients before they were sent to one of six different killing centres (Schilter 1999).
The T-4 organization ended in the summer of 1941. Again, domestic politics were dependent upon the circumstances of the foreign policy. This time, problems in the war against the Soviet Union and the bombing by the British Royal Air Force forced changes in the racial war within Germany (Sü ß 2003). In any case, in the long run it was impossible to conceal Aktion T-4 from public knowledge. Relatives of the victims received confusing information, residents near to the killing centres became suspicious and families contacted clergymen or judicial authorities. The problems at the fronts made it difficult for the Nazis to continue the killings. They could not risk having a population that questioned its regime (Burleigh & Wippermann 1991). Sieglind Ellger-Rü ttgardt (1991) emphasizes that public resistance to the killing of disabled people was unique. The murder of other categories of people during the Nazi era never caused public protests that actually changed the practice. She argues that this fact has been too little noted in historical research.

The Second Phase of ''Euthanasia''
The end of the T-4 organization did not end the killing of disabled people. Central planning for mass murder of mental and ''feebleminded'' patients ceased, but the killing took regional variations because of private initiatives by doctors and bureaucrats. The local use of ''euthanasia'' has led to the term ''wild euthanasia'' in reference to this period. Sieglind Ellger-Rü ttgardt (1991) argues that it is important to include the personal initiatives of doctors that led to ''wild euthanasia'' in a discussion about acceptance and resistance during the Nazi era and in a debate about personal responsibility.
During the second phase of ''euthanasia'', starvation became a cheap way of killing patients. The close connection between insufficient nutrition and mortality had been understood since WWI. Some of the doctors in charge of the murders during WWII had been young doctors during WWI, experiencing the mass deaths at the institutions (Faulstich 1993). In other words, they knew what they were doing by reducing the quantities of food to a minimum. Heinz Faulstich has described the development during the WWII as a three-step hunger system against incurable or not-working able patients. The first step involved a reduced war diet. The second step, from 1942, resulted in even greater reduction in order to favour working patients. According to Faulstich, the death rates increased 4Á/5% at several institutions (1998). Not only did the poor nutrition, but also the poor hygiene and the overcrowded wards, affect the death rate at the hospitals. A graph of death rates and occupied beds from Hadamar, one of the big killing-centres, shows a close correlation between peaks of many patients and a high number of deaths (Roer & Henkel 1986). The third step was special hunger diets, which, in combination with sedatives, led to death. Patients were put in special wards where almost no food was distributed. The consequences of the small portions of soup provided were not only hunger and weakness, but also painful diarrhoea (Faulstich 1998).
Despite the fall of the Nazis, the deaths at the institutions continued for several years. The lack of treatment and the suffering of the patients during the Nazi era resulted in sickness, vulnerability and low resistance to disease. Thereby, the consequences of the actions of the Nazis continued even though the war was over. Another reason was the continuation of scarcity of food. The four countries that governed Germany had different policies concerning the maintenance of their military troops; whether or not the zone should provide them, as well as the local people, with food. France and the Soviet Union fed their troops local food, which led to less food being available for the local people. In 1945, the death rates reached 32% in the Soviet zone, 24% in the French zone, 19.5% in the British zone and 19.5% in the American zone. In 1947, the Soviet zone still had a death rate of 24%, whereas the British zone had a death rate of 8%. It was not until 1949, that the death rate was less than 9% in all zones (Faulstich 1998).
To summarize: the hardships experienced during WWI continued during the economic crises of the 1930s. The need for cheaper care opened up new treatments within psychiatry. Medical progress was, of course, an accomplishment for the doctors, but at the same time the successes led to the classification of certain patients as ''incurable''. Ability to work became a sign of health and working capacity gradually became more important than medical diagnoses. This development had occurred already in the 1930s. The Nazis expanded these ideas to an extreme that led to the setting-up of ''euthanasia''. During the period of ''wild euthanasia'' working ability Nutrition in Asylums During the World Wars 9 became a regulator of access to food. At many institutions, patients were sent to special ''hunger-wards''.
Thus far we have discussed the situation concerning food for disabled people in Germany. Let us now turn to developments in Sweden.

Sweden
The Swedish care of ''feebleminded'' and mentally ill people was, like that in Germany, organized by several different administrators; by the state as well as local communities, private individuals and organizations. The size of the asylums differed a great deal; from just a couple of inmates to several hundred patients. The different asylums and hospitals were supervised by a Medical Board and aimed to separate ''feebleminded'' from mentally ill patients.
Every fifth year, from the end of the 19th century until the 1960s, the Scandinavian countries held a meeting about ''abnormal care'', which included ''feebleminded'', ''blind'', ''deaf'' and ''dumb'' people and some other categories that changed over the years. The purpose of the conferences was to discuss new research and to learn from each other. Doctors, as well as teachers and politicians gathered for these conferences. The care of both ''abnormal'' and ''feebleminded'' people differed in the Nordic countries. In the early 20th century, the Danish system was built on large institutions led by doctors. The Danish legal system was also seen as the most advanced in Scandinavia. In Sweden, the care was divided into smaller institutions. It was also common that the leader was a teacher.
In 1916, Nyt Tidsskrift for abnormvaesenet ran two articles about the nutritional situation during the war at Danish and Swedish institutions for ''feebleminded'' patients (Mö ller Larsen 1916:80Á/81, Holmquist 1916:111Á/ 117). The Danish situation appears to have been worse than that in Sweden. The Swedish asylums included in the survey reported that changes had been made in the menus; coffee was excluded, fish was eaten instead of meat, butter was exchanged for margarine and oats were replaced by wheat, but there was still a sufficient quantity of food. The high prices were considered a bigger problem than that of obtaining enough food. Most of the institutions also complained about the high cost of heating, due to the high price of charcoal.
The same picture of tough, but not alarming, times is given in the annual reports from the ''feebleminded'' asylums. They contain hardly any information about diseases or deaths due to poor nutrition, but almost all institutions report weight losses. Many reports focus largely on weight, and sometimes weight tables listing all the patients were sent in. This is explained by a question in the questionnaire that explicitly asks for the patients' weights.
From the end of 1918 and during 1919, weights seem to be normal again and the menus kept to a normal standard. A menu from Fridhem, in southern Sweden, in 1919, shows that the inmates were given porridge for breakfast, stewed fruit as a morning snack, a lunch of meat or fish with potatoes and soup. In the afternoon, they were given coffee, tea or hot chocolate and sandwich and in the evening they were served porridge. 1 A doctor from an institution in northern Sweden reports: ''the food has been good, appropriate and sufficient.'' 2

Mental Hospitals During WWI
Conditions in the Swedish mental hospitals during WWI were much harder and the insufficient food together with diseases caused a high number of deaths. As soon as the war started, it affected the economic situation at the mental hospitals. Already by 1914, the institutions had to reduce their expenses. The Medical Board ordered the directors to reduce the amount of flour and corn in all portions and to make sure that waste was reduced to a minimum (SOS 1914:12). Initially, the cuts were not perceived as a threat to the health status of the patients. Nevertheless, in 1915, there were alarming reports about patients suffering from malnutrition.
In 1917, the correlation between the poor nutrition and the increase in deaths was noted. In this year, the death rate was 9% at the state hospitals, compared with 6% in 1914 (SOS 1914(SOS , 1917. The patients also suffered from extraordinarily hard conditions in 1917, since many hospitals ran out of potatoes. ''It should not be seen as unreasonable that this unusual high rise in mortality can be related to the reduction of food and the rationing.'' 3 However, the problems escalated even more and in 1918, the death rate reached 14%. The reason was not only a deficit of food, but also the devastating consequences of Spanish influenza. Influenza appeared simultaneously at several locations in Sweden during the last months of 1918. At least 9% of the Swedish population became ill. Worst stricken was Kristinehamn's hospital, where 56% of the patients became ill. In all, oneeighth of patients suffering from influenza died. In 1918, Spanish influenza caused 20% of all deaths at the mental hospitals (SOS 1918:9). Usually, deaths at hospitals were caused by complications of tuberculosis or typhoid fever. During WWI approximately one-third of all deaths at mental hospitals were caused by tuberculosis, and pneumonia caused 11Á/15% of all deaths.
Insufficient nutrition continued to cause problems in 1918. At many hospitals, patients were kept in bed because of their physical weakness due to insufficient food, but bed treatment was also a way of preventing patients from being too lively, which demanded more energy. 4 Many ''diseases of crises'' as the doctors called the oedema, intestinal diseases and other diseases caused by insufficient nourishment, were reported. There were also more deaths than normal and the doctors concluded that the mortality was a direct consequence of malnutrition. 5 During 1919, conditions improved at the mental hospitals. This was seen clearly in the annual reports, where the death rates were reported to decline (Fig. 1) and the food reached standards equivalent to that served before the war.
To conclude, the death rates were extremely high at the mental hospitals during WWI, whereas the inmates at the asylums survived. One of the reasons why the institutions for ''feebleminded'' coped better than the mental Nutrition in Asylums During the World Wars 11 hospitals during the war was their access to gardening. Many of the institutions were situated in the countryside and had opportunities for horticulture. Another important reason was the size of the institutions. Only 6 of the 60 institutions for the ''feebleminded'' that sent in reports, had more than 90 inmates. This figure might be compared with the big state mental hospitals, where only 6 of the 16 hospitals had less than 300 patients, and 3 had more than 1000 patients.

Interwar Period
In Sweden, as in Germany, there was fear about the increase in people who were diagnosed as ''feebleminded'' or mentally ill. The need for more beds in hospitals seemed to be a never-ending problem. In a report in 1924, the Medical Board argued that the need for beds at state mental hospitals was 6260 in 1902, but 15,580 in 1924but 15,580 in (SOS 1925. The plea for more institutions led to the building of several hospitals during the interwar period. Four new state mental hospitals were built for, in all, 3500 patients and three new hospitals for anti-social ''feebleminded'' were opened in the 1930s. All this construction of new hospitals meant expenses for the Swedish state, compared with Germany where heavy cuts took place during the same period. However, the willingness in Sweden to invest money in institutions should not be interpreted as a sign of humanity. It was an attempt to control and diminish the perils of ''feebleminded'' and mentally ill people. The perception of ''feeblemindedness'' as a menace to society existed in Sweden as well as in Germany.  14 16 1914 1916 1918 1920 1922 1924 1926 1928 1930 1932 1934 1936 1938 1940 1942 1944 1946 1948 1950 Sources: SOS, Hälso-och sjukvård. Tabeller avseende befintliga och avförda patienter på statliga sinnessjukhus, 1914-1950.

K. Engwall
As already seen, Germany influenced the development of Swedish psychiatry, at least until the 1930s. Many of the new medical treatments used in Germany were also practised in Sweden (Jö nsson 1998). Swedes went to Germany to learn about Hermann Simon's occupational therapy (Walter 1996, Bjö rck 1928. Additionally, Scandinavian teachers were invited to participate in German courses about teaching of ''feebleminded'' people in the 1920s and 1930s. In addition to the Swedish interest in German care and education, there was also German interest in the Scandinavian countries. In 1920, there was a long article about Swedish psychiatric care in Zeitschrift fü r Soziale Hygiene, Fü rsorge-und Krankenhauswesen (Haustein 1920:119Á/129). It discussed the high death rates during WWI, the organization of asylums and family care.
Many of the measures within the psychiatry and care of ''feebleminded'' persons were similar in Germany and Sweden, such as shock therapies, open treatment, and institutionalization, but there were also differences. These differences led to criticism from both sides during the 1930s. One of these issues was the different practice and laws of sterilization. Germany was criticized for turning social indications into eugenic (NTA, Wildenskov 1937:21), whereas the main criticism in the German articles concerned the allowance of sterilization based on social indications (PNW, Steinwallner 1935:295). An explanation for the German opposition concerning the social indication was Germany's ''need'' for more citizens. From a German perspective, sterilization of people who might have children without eugenic problems seemed to be a waste of resources (Faith Weiss 1990).
At the same time as ''feebleminded'' people were presented in a negative and fearful way in Sweden, there was also an ongoing debate about mandatory schooling for ''feebleminded'' children. In this discussion, the view of ''feebleminded'' people seems to have been more positive than in the debate about institutions and sterilization (Areschough 2000). Agitation for schools for ''feebleminded'' children hints about a view of this category as people worth giving an education or practical training.
The German discussion of euthanasia had no counterpart in Sweden, even if some people argued in favour of it, since they believed that the life of an ''idiot'' could not be considered a human life and that death would be a relief for the ''idiot'', their family and society. A Member of Parliament brought it up once when he argued in parliament that sterilization might be the first step towards ''euthanasia''. 6 Alfred Petrén, inspector of the care of ''feebleminded'' and a promoter of institutions and sterilization, objected strongly to the suspicion: Since that point of view now has been officially depicted, I shall answer what I always answer persons, who after a visit in an institution for idiots, utter the thought: should it not be better to deprive these helpless individuals, who only are a burden to society, their lives? Á/ My answer is, that one certain obstacle raises to such a thought's realization and that is the love of the parents. The parents are normally strongly attached to these children. 7 Nutrition in Asylums During the World Wars 13 Neither does the German use of euthanasia seem to have caused much discussion in Scandinavia. In Nyt Tidsskrift for abnormvaesenet the debate about euthanasia in Germany was discussed only a couple of times (e.g. Garboe 1928:36Á/37, Wad 1937. However, the book by Binding and Hoche, in which ''euthanasia'' was discussed, was questioned. The reviewer, the Danish doctor Christian Keller, argued that this suggestion must be seen as a result of the German economic crisis (NTA Keller 1926: 60Á/62).

Mental Hospitals During WWII
When WWII began, there were political debates and discussions in Sweden about disabled people; new institutions had opened, new treatments were used, new laws concerning castration and education were discussed. Despite hard times, these discussions continued during the war.
The first reports from the mental hospitals during WWII do not mention food as a severe problem. Other issues, such as the construction of air raid shelters, lack of male staff due to drafting, etc, seemed to have been more urgent. The shortage of petrol also prevented the staff from visiting the patients in family care. 8 Prior to 1941, reports about food shortage were rare, but when they appeared, the patients were already suffering from severe weight losses. 9 The lack of sufficient food in combination with overcrowded wards and a shortage of detergents made the patients easy targets for infections and diseases. Many hospitals saw the rise of tuberculosis as an immediate consequence of these circumstances. According to the annual reports, the problem concerning nutrition appears to have been concentrated in the period 1941Á/43. There were reports of weight losses from many hospitals. At Marieberg the doctor's statistics showed losses of approximately 8%. 10 Another doctor wrote: ''The patients' nutritional condition caused some worries during the first half of the year, concerning considerable weight losses, which have been hard to master. . .'' 11 The situation improved a little during the autumn, according to the Inspector. At Säter, the doctor pointed out that the food had deteriorated both quantitatively and qualitatively due to the restrictions ''whereby an evident decrease of weights have taken place and which in some cases been particularly conspicuous.'' 12 An exception to this downtrend concerning weights was Umedalen, which in 1942 had patients who started to gain weight again. The doctor gives an interesting explanation; arguing that the patients got used to the vegetarian food and thereby ate their portions. 13 Despite the more stable situation concerning the patients' weights from 1943, there were still infections and somatic diseases at the hospitals, which many doctors put down to low resistance due to poor nutrition. Many of the big hospitals had epidemics of influenza every winter. In 1940, approximately 200 patients at Källshagens hospital caught influenza and a few patients died. 14 The influenza did not only affect the patients, but also the staff. In addition to influenza, nausea and diarrhoea, tuberculosis was a problem. During 1941 and, several reports complain about the rise of tuberculosis. Almost every report that speaks of a high rate of tuberculosis correlates the illness with poor food and lack of detergents.

Institutions for ''Feebleminded'' Patients During WWII
Weight losses were also common at the institutions for the ''feebleminded'', but varied a great deal between different asylums. Like the mental hospitals, the food problems started in 1941 and continued for the following 2 years. Some reports show that the inmates lost weight for a shorter period and recovered a couple of months later. 15 Many institutions have attached weight curves to the reports, which not only show the average weight, but also the weight for each individual. In comparison with the mental hospitals, the shortage of food was not as alarming. Some patients were given extra rations or special food to improve their physical status, which shows that there were possibilities to act and a will to handle the situation. Institutions mention their own gardening and good harvests as a vital complement to their cooking. 16 The food problems seem to have been solved during the last years of the war, but one institution also reports small weight losses in 1945. The doctor explains this by referring to the problems of buying some food, but also to the inmates' refusal to eat unusual food. 17

Mortality Rate at Swedish Institutions
So far we have seen how the institutions dealt with weight losses during WWII. What about the death rate? In spite of weight problems, the lack of food did not cause an increase in mortality at the mental or ''feebleminded'' institutions, except at Vipeholm, which is discussed below. At some institutions the number of deaths increased, but so did the total number of patients. Therefore, the death rate as a percentage did not change. This might seem surprising, since newspapers have had several articles about the high death rates at institutions. However, the statistics used to illustrate the increases in mortality have shown only the figures for the number of deaths and have not taken into consideration that the total number of patients also increased.
An important difference from the German situation during the Nazi era, apart from the lack of higher death tolls, was the attempt to obtain more food for the patients. The scarcity of food was seen as problematic. There is no argument in the reports for giving the patients less food because of lower human worth or distributing food in relation to working ability. Instead, there are thorough analyses of the weights of patients and how to prevent further weight losses.

Vipeholms Sjukhus
There is an exception concerning the death rates among the mental hospitals. During WWII, Vipeholms sjukhus had a higher mortality than before the Nutrition in Asylums During the World Wars 15 war. The hospital opened in 1937 and, despite its status as a state mental hospital, its patients were ''feebleminded''; the inmates were diagnosed as ''anti-social idiots''. On the scale of ''feeblemindedness'', ''idiots'' were seen as the ones with the lowest intellectual ability. The reason for organizing care for ''anti-social idiots'' in the form of a mental hospital was the fact that Sweden had no law admitting care without consent for ''feebleminded'' persons, and this was a way to get around the problem (Engwall 2000).
Many of the patients at Vipeholm were considered to be in need of a high level of supervision and to be very weak and demanding of personnel. In 1940 the doctor argued that the risk of accidents among this clientele was very high. 18 An increase in number of deaths occurred in 1941 and 1942 (Fig. 2). The doctor concluded that the deaths occurred among the ''most primitive groups'' and that changes in nutrition would not have been enough to cause death among ''normal'' patients, but for these patients the changes were fatal due to their ''biological inferiority''. 19 Many of the medical files of patients of Vipeholm contain information about weight, and this information has been used by journalists when discussing the deaths at the institution. However, what is not seen when studying only one hospital is that the patients at Vipeholm seem to have been very thin compared with patients at other institutions, even before the weight losses. In 1939, the average weight of a male patient at Vipeholm was 56.2 kg, compared with the average for male patients at Mariebergs sjukhus, which was 68 kg. At Vipeholm the female patients weighed on average 49.5 kg in 1939, whereas the female patients at Marieberg reached  1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 Sources: SOS, Hälso-och sjukvård. Tabeller avseende befintliga och avförda patienter, Vipeholms sjukhus, 1936-1950.  Engwall 58.5 kg in 1940. 20 In other words, the patients at Vipeholm had greater difficulty in coping with weight losses due to their poor weight status. In 1942, the average calories per day per patient were 2407 in Vipeholm, which is not low compared with other hospitals. There is, of course, a difference between how much energy a portion contains and how much nutrition a person can extract. For patients in need of assistance, such as help with feeding themselves or cutting up food, the lack of personnel might affect their nutritional status. Some patients might also have had difficulties with chewing and swallowing. There is reason to believe that some patients at Vipeholm needed some kind of assistance with the meals, since experiments with chopping the food carefully, adding extra vitamins and calcium were made in 1942. However, according to the doctor these attempts did not affect the death rates. 21 Despite the doctor's initial denial of a correlation between the increase in deaths and poorer food, he concluded in 1943 that some improvements in the food might be the reason for the more normal death rate among the weakest patients. 22 In 1943, the Inspector of the Medical Board had ordered more meat to be provided to the patients at Vipeholm. 23 This decision probably had some impact, because from 1944 the death rates went down to much lower rates.

Conclusion
Patients at institutions died in high numbers during WWI in Germany and Sweden. The war led to scarcity of food, and inmates who only had access to the meals served at the institutions were affected in a direct way. Additionally, Spanish influenza killed many people, both in institutions and in general society. However, inmates were more vulnerable, both with respect to access to food and the risk of catching Spanish influenza, because of their institutional living.
A difference between Germany and Sweden during WWI was Germany's need for soldiers. This hardened the general public's views about inmates at institutions, who were not exposed to drafting. People put into question why the best young men should offer their lives in combat whereas ''useless'' inmates should be safe and eat the food that the soldiers needed much more (Schmuhl 1987). This discussion opened up a much more hostile debate during and after the war concerning the status of the ''feebleminded'' and mentally ill people in Germany, compared with Sweden. We have already seen that several measures that made conditions for people with disabilities much worse were already in place before the Nazis seized power.
In Sweden, several actions were also taken to control ''feebleminded'' and mentally ill people. A sterilization law and a castration law affected these categories to a high extent. However, the organized murder at German institutions called ''euthanasia'', in which denial of food was a part, is not comparable with the treatment of inmates of Swedish institutions during WWII. The German stress on ability to work, which overshadowed medical diagnoses, never gained the same acceptance in Sweden.

Nutrition in Asylums During the World Wars 17
A strong indicator of the separate politics is the fact that the death rate among disabled inmates in Sweden did not increase during WWII, with the exception of Vipeholm. There are also other indicators. The ongoing debate about schooling for ''feebleminded'' children, which resulted in a law about compulsory schooling for educable ''feebleminded'' children in 1944, showed that the Swedish state had quite different interests from the policies of Nazi Germany, where similar schools were closed down (Myschker 1983). The Swedish law, which forbade ''feebleminded'' and mentally ill persons to marry was changed in 1945, and made it possible to apply for permission to marry (sometimes upon condition of sterilization). It signals at least a vague interest in disabled people, even if the main purpose of the change was to make sterilization more attractive. The annual reports also highlight the scarcity of food as a problem and there is no evidence of denying food to certain categories of patients.
So what about Vipeholm? Are the deaths at Vipeholm an expression of conscious killing, comparable with the situation in the German institutions (c.f. Frykman 1999, Tydén 2002? It is easy to find similarities between Vipeholm and Nazi asylums, for example the use of language when talking about patients, and the low weights of the patients. Nevertheless, there are aspects of the reports that emphasize differences, such as the introduction of, and pleas for, more education for the patients. There are also attempts to provide the patients with leisure activities, such as movies, playing football, singing, etc., and there are repeated requests for more caretakers and better premises. All these pleas might seem to indicate quite modern care, but in comparison to the standards of today the care was in many ways dehumanizing. The perception of the patients at Vipeholm as less valuable than other people is also clearly documented in the huge ''scientific'' experiment which started in 1945, trying to find correlations between eating habits and caries. The more unethical aspects of this experiment included giving some of the patients a lot of sweets in order to provoke caries. The experiments ended in 1953 (Frykman 1998).
Conscious and organized killing of disabled people through starvation, in accordance with the situation in Nazi Germany, is not seen in Sweden, even if Swedish doctors sometimes sympathized with Nazism. The view, however, of ''feebleminded'' and mentally ill people as having lower human worth and as a burden on society was common and was also accepted in Sweden. This perception is seen in many of the official reports. The categorization of ''feebleminded'' and mental patients as different from other Swedes also becomes clear in the ''Vipeholm experiment''. At the Nü rnberg trials, ethics within medicine were discussed and the Nazi medical experiments were banned. Nevertheless, these discussions about ethics were not seen as relevant concerning the patients at Vipeholm.
As already mentioned, very few articles have been published about Nazi ''euthanasia'' in Nyt Tidsskrift om abnormvaesenet. However, there is one article worth quoting. It was written in 1951 by a Danish doctor arguing against euthanasia. He tells of on of his young students of medicine, who claimed that it was a ''total waste doing everything to keep the idiots in asylums alive, at the same time as the best young men were killed in the battlefields''. The doctor agreed with him, but added that the idiocy was not keeping the ''feebleminded'' patients alive, but killing the best men (NTA, Schwalbe-Hansen 1951:43Á/44).