Professor Andrew Scull’s book Madhouse: A Tragic Tale of Megalomania and Modern Medicine (Scull Reference Scull2005) is an extremely well-documented description of the work of Dr Henry Aloysisus Cotton (1876–1933) as superintendent of the New Jersey State Hospital at Trenton (Trenton State Hospital), providing the academic, professional and political context. We believe that this book should be regularly discussed by psychiatrists to reflect on the risks and lessons that can be learned for clinical and research practice.
Cotton: medical training and clinical practice
Cotton had what would have been considered at the time a first-class training. He trained at the University of Maryland and Johns Hopkins University and subsequently at the Worcester State Hospital, under the Swiss neuropsychiatrist Adolf Meyer, who was ‘regarded as the dean of American psychiatry in the first half of the 20th century’ (Double Reference Double2005). In 1906, he worked in Munich, Germany, under Kraepelin, Nissl and Alzheimer (Scull Reference Scull2005: p. 23).
Cotton was the superintendent of Trenton State Hospital, a psychiatric hospital in New Jersey, between 1907 and 1930. On arrival, appalled at a subculture of violence and brutality (Scull Reference Scull2005: p. 24), he rejected the use of mechanical restraint. Within 2 months, a ‘fully-fledged training programme for psychiatric nurses’ was in place and occupational therapy was introduced (Scull Reference Scull2005: p. 25).
Cotton also opposed the theories of degeneration and eugenics current at the time, embracing the bacteriological paradigm whereby mental illness resulted from an undetected focal infection in teeth, tonsils or other organs. Accordingly, he recruited a number of professionals, including doctors (such as physicians, surgeons and gastroenterologists), an oral surgeon and a bacteriologist (Scull Reference Scull2005: ch. 2).
In the process of eradicating the alleged foci of infection, he and his team would operate on hundreds of patients, extracting teeth, tonsils, ileum, colon (with a mortality of 25–30%), thyroid, cervix, seminal vesicles, ovaries and uteruses, with several extractions often carried out on the same patient. An example of this was Ms Margaret Fisher, a young woman who worked as an unpaid office assistant for her father, an eminent economist and professor at Yale University. Her mental state began to gradually deteriorate from 1916, but declined further after her engagement in 1918, and she began to respond to auditory hallucinations and ‘talk at random about God, Christ and immortality’ (Scull Reference Scull2005: p. 82). She was admitted to a general hospital, but did not improve and was subsequently transferred to Trenton State Hospital. Dr Cotton diagnosed colonic faecal retention and enlargement, along with erosion of her cervix and identification of two molars needing extraction. In 1919, she underwent a procedure on her cervix and Cotton urged subsequent surgery on her colon. Her family declined, keen to avoid further surgery, and so she underwent anti-streptococcus injection treatment in September 1919. Shortly after, she developed signs of lung inflammation and was found to have an abscess, which test results showed was filled with streptococcus, likely an iatrogenic injury caused by a failure to kill the bacteria before injecting them into her body. She died on 7 November 1919. Even after her death her father held onto his beliefs in Cotton’s ideas (Scull Reference Scull2005: pp. 81–85).
Cotton became increasingly convinced by the need for preventive work and early treatment, so started removing the infected teeth and tonsils of young people in state institutions and prisons. The need to fight stasis and its associated toxaemia applied to all ages. For example, two children aged 6 and 8 with constipation and – in Cotton’s view – associated antisocial behaviour, showed improved behaviour after having colon surgery (Scull Reference Scull2005: p. 128). Likewise, he removed all of his two sons’ permanent teeth, as well as undertaking abdominal surgery on his younger son when he displayed symptoms that Cotton interpreted as indicative of an abdominal infection. In 1928, Cotton himself was diagnosed with a heart condition (extrasystoles) and angina, which appeared to recover after all his vital teeth were removed (Scull Reference Scull2005: p. 245).
Cotton disseminated his work around the USA, at professional conferences and in academic journals. He visited the UK, lectured at the Medico-Psychological Association of Great Britain and Ireland, and visited the Rubery Hill and Hollymoor mental hospitals in Birmingham, where Thomas Graves was carrying out a similar type of work (Scull Reference Scull2005: ch. 7).
The book describes how some political authorities and colleagues expressed concerns and strong disagreement with Cotton’s work, as well as independent reports that utterly contradicted his claims of mental health recovery after surgical removal of the alleged infectious foci. These highly critical views appeared both in the press and in journals such as the American Journal of Psychiatry. The book also gives details of a thorough assessment carried out of Cotton’s work and results by the physician Dr Phyllis Greenacre, at Adolf Meyer’s request (Scull Reference Scull2005: chs 8 and 9). Greenacre’s report, which completely contradicted Cotton’s claims, remained in Meyer’s possession but was never published.
Themes arising from the book
Undoubtedly, this book’s most important individuals are the victims and survivors of Cotton’s practices. Hundreds or thousands of individuals, both adults and children, were subjected to extraordinarily dangerous surgical procedures. Procedures also took place in countries outside of the USA, including the UK, inspired by Cotton’s claims and self-promotion. Scull’s book vividly describes the stories of specific individuals who suffered this treatment, providing a real human face to the victims of such tragic medical and psychiatric procedures.
Questions to reflect upon
Many questions emerge from the inflicted suffering described. How could such as a radical approach be allowed to start and continue for years? Has psychiatry since become immune to this type of hubris and groupthink, where a self-reinforcing dynamic of fashion (‘the next big thing’) overwhelms clinical practice and academy? Could current neurotechnology, for example, start to move the limits of which interventions are ethically acceptable? A striking theme that runs through the book is the role of Adolf Meyer, who encouraged and never publicly criticised Cotton’s work and claims, despite having, for several years, highly critical reports in his possession. Are the current legal protections of patients’ rights, ethical approvals required for research, the experts by experience’s involvement in research, teaching and training, etc. strong enough?
The dangers of a purely biological approach
Cotton had the preconceived idea that a hidden infection was the cause of mental illness, which he selectively sought to confirm while ignoring any finding that suggested otherwise. By taking such a narrow, purely physicalist approach, Cotton’s hubris and overzealous treatments inevitably dehumanised his patients, by not considering any psychological or social factors. We would invite the reader to reflect on whether a situation like this may resonate with psychiatry today.
The corruption of positive intentions
The book illustrates how motivations that begin from a positive place can become corrupted. Scull provides context to Cotton’s ideas by describing the medical landscape of the time, such as how diseases with psychiatric symptoms but a physical basis had recently been uncovered, such as syphilis. He also outlines the terrible state of most asylums at the time. This context can give rise to positive intentions – such as an awareness of our lack of knowledge and a keenness to find a way of helping such patients. As mentioned above, when Cotton first moved to Trenton State Hospital, he removed the use of mechanical restraints and increased staffing levels, actions we still try to replicate today. Indeed, he was a ‘true believer’ in his theories and submitted his sons and himself to some of the procedures he would apply to patients. However, the book does not shy away from describing the terrible outcomes of Cotton’s actions and how, despite external concerns about the validity of his work, he continued to persist with it, damaging – and even ending – many people’s lives in the process.
The historical context of Cotton’s work
Last but not least, Scull’s book can be seen as a strong reminder of the fact that psychiatry is a deeply socially, culturally and politically embedded practice that needs strong ethical and legal boundaries. Cotton’s work joins other horrific situations, such as the role of psychiatry in the killing of hundreds of thousands of patients in Nazi Germany before the Second World War (Burleigh Reference Burleigh1994) or its use as a repressive political tool in the former Soviet Union (Bloch Reference Bloch and Reddaway1977). Older examples can also be mentioned, such as the diagnosis of drapetomania (‘the disease causing slaves to run away’), described by Dr Samuel A. Cartwright (Cartwright Reference Cartwright1851: p. 707), who commented that it was ‘unknown to our medical authorities, although its diagnostic symptom, the absconding from service, is well known to our planters and overseers, as it was to the ancient Greeks’, and suggested that ‘when sulky and dissatisfied without cause’ they should be ‘whipping them out of it, as a preventive measure against absconding or other bad conduct. It was called whipping the devil out of them’.
We invite colleagues, supervisors, trainees and researchers to explore Dr Cotton’s actions and views, along with the other examples we have mentioned.
Author contributions
Both authors contributed equally to all aspects of this work.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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