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Times Literary Supplement
Sunday, September 18th, 2005


Madhouse: A Tragic Tale of Megalomania and Modern Medicine


Infectious lunacy

A review by Hugh Freeman

Andrew Scull reminds us in Madhouse, as he has in previous works, of the mostly unfortunate fate of the mentally ill throughout history -- "to be considered insane is a kind of social, mental and metaphysical death". The nineteenth century's answer, at least in industrialized societies, was the asylum. Beginning as a small, optimistic institution, it gradually sank under the steadily growing burden of those with chronic illness. As the numbers of long-stay residents grew, so optimism converted to unrelieved pessimism. Scull describes the early twentieth-century asylum as a "noisy and noisome cemetery of the still-breathing", which perhaps conceals the fact that a reasonable proportion of those admitted always left within a matter of months. It also has to be remembered, though we are not reminded of it by Scull, that many of those who came into the asylum already had serious problems of physical illness, untreated elsewhere.

Professor Scull is an English sociologist who has worked for many years in San Diego, California. His principal interest is the history of psychiatry not sociology as it is generally understood, perhaps. He first burst on the academic world with his highlypolemical Decarceration (1977), an account of the rise and fall of the asylum strongly informed by a Marxist economic determinism which saw an apparently medical innovation as in fact the removal of non-productive individuals from the labour market. With the passage of time, this political dimension has gradually slipped below the radar, though it has never been specifically disavowed. Scull's research so far has focused mainly on British psychiatry of the nineteenth-century; and Madhouse is his first book which is almost entirely focused on the United States of America.

By the standards of the time, Scull's protagonist Dr Henry Cotton was a well-trained psychiatrist; in particular, he had had experience in the leading American academic department, that of Adolf Meyer at Johns Hopkins Medical School. Meyer was a Swiss who had retained Teutonic habits of authoritarianism; he terrorized his subordinates but, like many bullies, gave in easily when meeting a strong and dogmatic personality, as Cotton turned out to be. With Meyer's help, Cotton obtained the superintendency of Trenton State Hospital in New Jersey, when still relatively young; this was one of the plum jobs in American psychiatry. He was full of energy and furor therapeuticus; he had been convinced from a young age that he was destined for greatness.

Scientific medicine was in its earliest stages; the bacteriological revolution begun by Louis Pasteur and Robert Koch led to the discovery in 1913 of the syphilitic organism. This was found to be the cause of one of the most deadly mental disorders, General Paralysis of the Insane (GPI). But if that was so, others might also have a similar cause; perhaps they all had. Until then, psychiatry had been sunk in a nihilistic pessimism in which heredity was seen as the universal cause of insanity, while "degeneration" theory predicted that in each genetic line, things were liable to worsen with each succeeding generation. Cotton sought a way out of this impasse, and thought he had found it in the fairly recent doctrine of "focal sepsis". Originated by physicians and surgeons, some of them British, this asserted that chronic, masked infections at various sites in the body released toxins into the bloodstream which could reach other organs, including the brain. Is there "any proved difference", Cotton asked, "between the transient delusions arising from typhoid and alcoholic intoxications and the fixed delusions of dementia praecox (schizophrenia) and manic-depressive insanity"? In 1918, that was a perfectly reasonable question.

Since prevention is better than cure, and since the treatment of insanity was manifestly unsuccessful, the doctrine of "mental hygiene" had emerged at this time in America. The trouble was that no one really knew how to prevent mental illness (a situation which is not much changed today). However, Cotton thought that his approach would not only cure people who were mentally ill, but would also prevent others from developing such an affliction.

So began his assault on focal sepsis, for which he recruited medical and surgical specialists, as well as adding pathological and X-ray investigations, which were largely unknown then in mental hospitals. The New Jersey State government was generous in paying for these clinical extras even though they actually revealed rather little. The bureaucrats saw a chance of both political and financial gain if patients could be cured and then discharged. At the time, mental hospitals accounted for the improbably large percentage of one-third of the State budget.

Cotton's first target was teeth, initially only those showing signs of infection. His weakness, though, like that of many enthusiasts, was that he did not know when to stop. If teeth were not already infected, they might be later, so it was safer to remove them all. And bad teeth would obviously infect saliva, which would carry toxins into the digestive tract. Here, the best option seemed to be the colon, because it was not the most essential organ; so first partial colectomies were done and later complete removals. Additionally, there were sinuses to be drained, tonsils to be taken out, and uterine cervices to be cleared. The results delighted Cotton, who reported that 85 per cent of his cases had recovered; he claimed to be following them up carefully, though it later turned out that this was not the case. Attempts were also made to treat the alleged infections medically, but in the pre-sulphonamide era there was no effective way of doing this. Meanwhile back in Baltimore, Meyer evinced strong public support for the enterprise but had privately begun to have increasing doubts about Cotton's messianic drive to operate come what may. With Cotton's agreement, Meyer arranged for a young assistant, Phyllis Greenacre, to do an independent assessment of his work. This was completed in 1925 and the results were devastating: the true "recovery" rate was no more than 32 per cent, while among the many ill effects of the drastic treatment was an astonishing post-operative mortality of 45 per cent among those mentally ill patients who had lost their colons. Cotton's furious reaction to the unwelcome data was predictable; what could not have been expected, though, was Meyer's failure to allow the publication of the findings or to make any attempt to restrain Cotton's activities.

Cotton was not, in fact, a sadistic monster; he simply believed that everything he did was for his patients' benefit. Inconvenient facts were either rationalized (for example, "the very poor physical condition of most patients") or simply ignored, while he tried to massage the statistics. When patients failed to improve, it must, he thought, have been because he had not been radical enough. Any objections from patients or relatives were brushed aside. Eventually, though, the State government decided that its prestigious project was becoming an embarrassment: Cotton was moved sideways, the complex surgical operations stopped and the whole programme wound down. Henry Cotton died soon afterwards.

Madhouse is fascinating. Scull's detection is impressive; it extends over years. He writes that it is a "long-suppressed story", but gives no indication as to who suppressed it. Clearly it was a terrible business, but more important now are the general lessons that may be learnt from it. "Placing a treatment in its cultural, political, and scientific context", Scull declares, far from serving to rationalize what occurred, simply "succeeds in demonstrating the full enormity of what its proponents and their fellow-travellers wrought". But William Cullen, the great physician of the Scottish Enlightenment, wisely remarked that "no man can go much further than the state of science at his particular period allows him". Until the 1940s, the overwhelming task of medicine was to attempt the management of infection. It has tended to be forgotten until recently that chronic, untreatable infections were then a common source of ill-health and misery. The medical establishment worldwide focused on this. Andrew Scull pours scorn -- much of it unjustified -- on pre-1950 methods of dealing with the masses sunk in chronic mental illness: the malaria treatment of GPI, convulsive techniques including ECT, and psychosurgery. Yet the progress of medicine has depended significantly on unconventional enthusiasts: some were right and many others, including Cotton, turned out to be wrong. The performance of psychiatry has been no worse than that in other branches of medicine. Since the randomized controlled trial arrived in the 1950s and evidence-based medicine more recently, not to mention the endless obstacle course that faces new medicine, innovation in medical treatment has become no easy matter. Cotton was greatly admired by doctors in the early years, but the fact is that hardly anyone followed his example.

In the 1980s, a young Australian surgeon suggested something that aroused incredulity. Peptic ulcer, he said, that scourge of adults in Western countries, was promoted by infection with Heliobacter, which had been overlooked. By adding antibiotics to existing medication, he revolutionized the treatment of digestive ulceration and brought relief to millions. What he had found, in fact, was focal sepsis.

Hugh Freeman is a psychiatrist and former Editor of the British Journal of Psychiatry. His most recent book is A Century of Psychiatry, 1999. He is an Honorary Visiting Fellow at Green College, Oxford.

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