Madhouse: A Tragic Tale of Megalomania and Modern Medicine.

Madhouse: A Tragic Tale of Megalomania and Modern Medicine. By Andrew Scull (New Haven: Yale University Press, 2005. xiii, 360 pp.).

If medicine is, in Lewis Thomas's phrase, "the youngest science," it is also the cruelest. And cruelty, astonishing in scale, bewildering in scope, visited on hundreds of helpless patients before and during the 1920s at New Jersey's Trenton State Hospital, all in the name of scientific treatment for mental disease, is the leitmotif in Andrew Scull's superbly horrifying study of Henry Cotton, Madhouse: A Tragic Tale of Megalomania and Modern Medicine.

While historians of psychiatry have viewed Cotton as a curiosity, Scull places him squarely in the mainstream: a man who led one of America's notable public mental institutions, who spread his gospel of astonishing cures in professional journals and the popular press, who gathered accolades in England and Europe. Unlike most alienists, whose education was haphazard, Cotton entered his field with sterling scientific credentials. Trained at Johns Hopkins and in Munich, where he studied microscopic brain structures with Alois Alzheimer, Cotton became a protege of the eminent Swiss neurologist Adolf Meyer, who was determined to bring modern European laboratory science to bear on mental disease.

Psychiatry was certainly ripe for change. After the golden age of lunacy reform, during the 1840s and 1850s, when Dorothea Dix's argument that confinement in well-ordered hospitals could cure madness seemed plausible, madhouses and mad-doctors drifted into a slow, downward spiral. Few inmates recovered. In consequence, asylum superintendents, the core of the emerging psychiatric profession, became deeply pessimistic about the effectiveness of any therapy. Many came to believe that insanity was a hereditary, degenerative disease from which recovery was impossible. Against this view, Meyer and Cotton posed a novel paradigm based on the germ theory of disease and the new sciences of bacteriology and virology.

What if, they asked, psychoses and dementia were not in themselves diseases, but symptoms of deeper, underlying disorders? What if the proper model for insanity was syphilis, a malady that, in its late stages, might manifest itself as madness, but whose true cause was infection by a microscopic bacillus? These were exciting conjectures. And to Cotton, who arrived at Trenton in 1907, bristling with energy and professional ambition, the prospect of transforming a gloomy warehouse for the mad into a therapeutic hospital, applying the science of Koch and Pasteur, was the chance of a lifetime. So, over the next several years, with unwavering conviction and autocratic authority, he reinvented Trenton State Hospital, changing it from a custodial institution to a center for aggressive intervention.

Cotton's intervention of choice was surgery. How a mad-doctor became a surgeon is fascinating, and Scull deftly describes the intellectual context of the period along with the theories and trends that influenced Cotton's thinking. Of these, the most important was focal infection or focal sepsis, the doctrine that bacteria could furtively attack vulnerable parts of the body, proliferate, and infuse the bloodstream with dangerous toxins. Belief in focal infection (along with asepsis and anesthesia, which made operating safer and less painful) fueled an explosion in surgical procedures. In 1900, for example, tonsillectomy accounted for 0.52 percent of surgeries at the Pennsylvania Hospital; by 1920 the figure soared to 19.02 percent.

In his quest for roots of bacterial infections that poisoned the brain, Cotton began not with tonsils, but teeth. "Without exception, the functional psychotics all have infected teeth," he wrote, and "if a tooth is at all suspicious, we are of the opinion that it should be extracted." Based on this principle, inmates' teeth were pulled. Seldom were they furnished with dentures. So strong was his conviction that Cotton extracted teeth from his two sons and, later, while suffering from angina, ordered his own molars drawn.

Still, this was only the beginning. When toothless patients stubbornly failed to improve, Cotton assumed that foci of infection must lurk elsewhere: "stomach, duodenum, small intestine, gall bladder, appendix, and colon, as well as ... the genitourinary tract." Armed with an X-ray machine, he scanned patients top to bottom. In the year 1920 alone, the hospital recorded 4,201 X-ray films, 4,317 "ordinary" tooth extractions, and 542 tonsillectomies. To augment his capacity, Cotton, whose scalpel technique was largely self-taught, recruited a distinguished surgeon from the Mayo Clinic, and together they embarked on an enormous series of exploratory surgeries. At the height of his career, Cotton performed an incredible quantity of abdominal operations. In 1922, for instance, he reported on a series of 250 operations on the colon alone.

The problem was his results. Among the colon patients that year, by his own report, 15 percent improved, 25 percent recovered, 30 percent were unimproved, and 30 percent died. Nonetheless, he persisted in claiming an overall cure rate of 85 percent, which saved New Jersey millions, he argued, and enabled him to attract wealthy patients to a private practice he set up one the side.

Cotton's statistics, by any standard, were a travesty. The more patients died, the more he touted his operations' success. Aware of the irony, Scull delves at length not only into how Cotton justified inflicting so much mayhem on patients, but how he got away with it for so long. Questions about Cotton's methods and results finally moved state authorities to investigate the hospital. The expert they turned to, however, was none other than Cotton's erstwhile mentor, Adolf Meyer, who, in 1924, sent a young doctor, Phyllis Greenacre, to Trenton to ferret out the facts. Bright, earnest, and indefatigable, she becomes Scull's tragic heroine. Against fierce resistance, Greenacre uncovered exactly what had happened to patients, and how devastating the clinical results had been. Her meticulous report confirmed Cotton's exorbitant death rate and deflated his claims of cures. Yet Meyer, unwilling to see his prominent disciple besmirched, quashed her document. Greenacre's personal and professional life never recovered. Eventually, although Cotton was eased out of his executive position, he died in 1933 with his reputation largely intact, thanks to his profession's code of silence.

Scull's subject, here as in his previous work, is psychiatry and its discontents. Accordingly, he locates Cotton within a cavalcade of misguided innovators whose cures for madness were worse than the disease. More broadly, though, Madhouse is a cautionary tale that applies all too well to medicine and surgery. One recent example: in May 2005, the U.S. Agency for Healthcare Research and Quality (AHRQ) published a comprehensive study of episiotomy (surgical resection of the perineum--the skin between the vaginal opening and the anus). Obstetricians use this procedure in at least one-third of vaginal births in America, ostensibly to help their patents. But the AHRQ could find no evidence of clinical benefit, and much evidence of harms to women, from infection to incontinence. Evidently the youngest science still has a long way to go.

David Gollaher

California Healthcare Institute