Book Review

A fad insane. Book Review. Madhouse: A Tragic Tale of Megalomania and Modern Medicine by Andrew Scull

The mock-Gothic subtitle of this brilliant piece of medical scholarship - "A Tragic Tale of Megalomania and Modern Medicine" - hardly prepares you for the almost unbelievable horrors that Andrew Scull documents within:

how Dr Henry Cotton, one of the leading psychiatrists in America in the early 20th century, in his grandiose pursuit of a biological basis of mental disorders, maimed, mutilated and killed thousands of patients.

One of the medical elite - trained at Johns Hopkins, apprenticed to the then most eminent leaders in the field of neuropsychiatry, Alois Alzheimer and Adolph Meyer, Cotton was appointed superintendent of the Trenton State Hospital, New Jersey, in 1907. Widely regarded as a "progressive", he immediately set out to revolutionise old- fashioned custodial asylum practices. Psychiatry, then as now, languished at the bottom of the medical hierarchy. At that time, the effectiveness - and status - of general medicine and surgery had been transformed by the discoveries of the bacteriological basis of many diseases. But no comparable scientific breakthrough had occurred in psychiatry.

Of course, Freud and the psychodynamic movement were then laying bare the psychological workings of the psyche, but were generally met with the deepest hostility by most of the psychiatric profession. Instead, bright and brash young psychiatrists such as Henry Cotton saw themselves as "the shock troops of the coming revolution in their profession, men who would bring the tools and techniques of the new scientific, laboratory-based medicine to bear on the recalcitrant problem of madness".

Soon after his appointment, Cotton began to develop his theory that all mental disorders were caused by specific hidden infections, or chronic "focal sepsis". He was not alone in his enthusiasm for this theory. In general medicine, the pursuit of "focal sepsis" as the basis of physical diseases was then very much in vogue. Cotton was determined to join psychiatry to this high-status medical mainstream.

Quickly, Cotton adopted aggressive surgical techniques to root out the "perils of pus infection". He convinced himself that such infections lurked hidden in every nook and cranny of his patients' bodies. Serenely untroubled by the fact that his patients actually showed no conventional signs of these infections, he initiated a ruthless surgical regime of "surgical bacteriology". He pulled out his patients' teeth, excised tonsils, and if that did not improve their mental condition, he set to work operating on their stomachs, removing their spleens, gall bladders, appendices, and in a final assault, their entire colons. Disturbingly, 78 per cent of colectomies were performed on women who also lost their cervices, wombs and ovaries if they persisted in not recovering. For good measure, he also used "malarial therapy" on his patients, injected them with typhoid and other vaccines, and subjected them to repeated, massive colonic irrigations.

In the beginning, Cotton claimed extraordinary success rates for his "treatments", presenting his findings to the American Psychiatric Association meetings and publishing in the psychiatric literature. He did not try to disguise the obvious hazards, acknowledging, for example, that up to 30 per cent of patients subjected to abdominal surgery died as a result. Yet he was allowed by his professional peers to get away with describing such drastic surgical intervention as a "conservative preventative measure", blithely asserting that the stomach was "one of the least important organs in the body", which together with the large bowel, could easily "be dispensed with". What criticism he did encounter, he fought off with a characteristic mixture of bluster and belligerence.

Cotton combined this messianic zeal with an unabated appetite for publicity and self-promotion. As a result, fellow psychiatrists flocked to Trenton to learn more about these miraculous new therapies and large numbers of wealthy families brought their mentally disturbed relatives for private treatment at the hospital. Claiming that his treatment regime cured patients and therefore cut costs, Cotton also found willing allies among state bureaucrats determined to bring the cost efficiencies of modern business management to bear upon public agencies.

His patients, alas, were not part of his fan club. There are harrowing accounts in the book of wards full of toothless patients, unable to digest normal food, gaunt and undernourished, pleading to be spared repeated surgery, desperately trying to hide their symptoms from staff, only to be dragged protesting into the operating theatres.

By the early 1920s, however, Cotton's work was raising concerns among his professional peers and criticism began to mount. In an attempt to pre-empt a more hostile review of his extravagant claims to success, the board of Trenton commissioned a study of Cotton's work and approached Adolph Meyer, who enjoyed international status as one of the most influential psychiatrists of the time. Cotton, however, was also one of his favourite protégés.

Meyer assigned a talented young female doctor, Dr Phyllis Greenacre, to the task. After months of painstaking scientific work, and huge resistance and hostility from Cotton and his associates, her conclusions were devastating. Her report not just detailed a harrowing chronicle of terrible suffering but of quite astonishingly bad outcomes. Cotton's claims of 85 per cent cure rates turned out to be wildly out of accord with the facts.

But Phyllis Greenacre's determination to uncover the truth and expose Cotton was doomed. Under siege from Cotton, and not willing to expose the scandal, the highly political Meyer, although in no doubt himself about the rigour of the findings, silenced her and blocked publication of the report. Meyer remained committed to the "focal sepsis" approach, and, Greenacre came to suspect, almost welcomed Cotton's brand of fanaticism since it allowed a more thorough test of his theories. The welfare of those who endured such experiments hardly entered such medical politics.

The upshot was that Cotton not just continued but intensified his reckless regime of "forced treatments, mass maiming, and death in the services of a therapeutically bankrupt ideal" until his premature death in 1933. Even after his death, his successors, although abandoning abdominal surgery, continued his other surgical "treatments" with unalloyed enthusiasm, and continued the practice of extracting teeth until 1960.

In the same tradition, Trenton also adopted the barbaric practice of lobotomies with great zeal well into the late 1950s.

This is a profoundly sobering book. It is a reminder that the pursuit of simplistic answers is always dangerous. The willingness of self-deluding professionals - and desperate people - to pursue faddish solutions to complex medical and psychological problems presents as much a danger now as it did in Cotton's time.

People flocked to Cotton because his preoccupation with rooting out imagined toxins found a cultural echo in the popular appeal of detoxification diets, "regularity" and thorough cleansing of the colon - plus ça change? But above all, this grim tale is a salutary reminder of the fatal weakness of self-regulation (in any profession) when the establishment closes ranks against would-be whistleblowers who try to expose ethical and scientific lapses of powerful senior figures in the field.

Originally published in The Irish Times. 

Posted: 14 January 2006