In Madhouse Andrew Scull
turns his attention from the broad sweep of psychiatry that has been his focus
in the past, to a single asylum, and the work of a single alienist, Dr Henry
Cotton. Madhouse is a tale of horror
so terrible it is hard to credit. The book describes a regime of incarceration,
mutilation, degradation and death, carried out in the guise of medicine,
sanctioned and protected by medical and civic authorities even after its
excesses were carefully documented. It involves a cast of characters that would
make a Hollywood blockbuster: eminent society figures, families with dark
secrets, an obsessive zealot, an honorable and heartbroken heroine. The story
of Henry Cotton is one of the convergence of a singular man and a single idea:
madness and focal sepsis. Cotton developed a program of increasingly invasive
and mutilating surgery, ploughing ahead with fundamentalist gusto in the face
of all criticism, and a disturbing mortality rate.

Trenton asylum was little different to many others in the early 20th
century. Overcrowded, neglected, and isolated, it was a place of therapeutic
despair that would aptly fit Scull’s phrase from his earlier work ‘a museum of
madness’. Enter the young Doctor Henry Cotton, fresh from Johns Hopkins medical
school, mentored by one of the most eminent psychiatrists of the time Adolf
Meyer. Cotton was opinionated, bright and ambitious. He had studied in Germany
with Nissl and Alzheimer, two of the great names of neurology. All he needed
was a position that would provide the scope for development of his radical
ideas, and the means to implement them. By some sort of tragic irony, Trenton
Asylum was to provide such an opportunity. Trenton was caught up in a web of
self-serving political gamesmanship that turned up, quite incidentally, major
abuses of patients’ rights. It was also beset by endemic typhoid. Cotton’s
impressive credentials, and his promise to end the abusive practices uncovered
at Trenton that earned him the confidence of the trustees, and the freedom to
pursue his experimental program.   

Cotton had taken from his German experience an idea that had appeared
in various forms in the nineteenth century: that madness was a biological
disease. Cotton wasn’t alone in this conviction, although he rejected other
biological theories such as heredity and degeneracy. Germ theory of disease had
made a huge impact since Lister, and with the discovery of the syphilis
spirochete in 1905. It proved an attractive theory to a society skeptical of
the prevailing psychiatric orthodoxies, psychoanalysis and asylums. Given an
antiseptic theory of madness, with the promise of a high rate of cure, Cotton
found it relatively easy to gain official support and funding. And given the
novel nature of his interventions, Cotton had time on his side. It would take
only enough time and enough surgery to prove that he was right. Beginning with
removal of infected teeth, Cotton’s program expanded to include all teeth,
tonsils, gall bladders, bowels, ovaries, anything that in his view was a
possible seat of infection. He claimed incredible ‘cure’ rates (up to 85%) and
dismissed any criticisms with belligerent counterattack. Cotton’s conviction in
his ideas was total. He manipulated evidence, bullied investigators, and even
dominated the normally intimidating Meyer in the face of suggestions that his
claims were at best unproven.

The quiet heroine of the story is Phyllis Greenacre, a psychiatrist and
researcher who struggled for equal treatment in Meyer’s program at Johns
Hopkins, and whose steadfast application to her work as a researcher at Trenton
provides a moral counterpoint to the ruthless dogmatism of Cotton. Greenacre
was appalled by what she discovered, but Cotton was unmoved. Meyer’s lifelong
suppression of Greenacre’s damning report is a case study in itself. Along with
a handful of critics, Greenacres was able to do little more than protest while Cotton’s
program continued unabated. After a tumultuous inquiry at which Cotton stood to
be publicly exposed, he himself became paranoid and insane, but unlike his
patients at Trenton he was given leave to recover, and eventually returned to
resume his work. In the post depression era the Trenton board could no longer
tolerate Cotton’s maintaining a lucrative private practice while a full time
board employee. He   was sidelined into
‘research’ and preventative work, a move that he resented. Although he continued
to campaign for his focal sepsis theory and associated treatment he was greatly
reduced in status. He died prematurely, and in typically opaque fashion, Meyer
remembered him as ‘one of the most stimulating figures of our generation.’

Support for Cotton’s work was not limited to a closed profession of
psychiatry; nor was it confined to the United States. Medical, surgical and
dental professionals seem, on reflection, to have been pleased to medicalize
psychiatry, something they no doubt saw as enhancing their own status, and
expanding their sphere of influence. Cotton made triumphant appearances in
England and Scotland, where his work was received with acclamation by senior
members of the British medical establishment, such as William Hunter and Chalmers
Watson. Scull recounts the meeting of the Medico-Psychological Society of Great
Britain in 1923, when those who dissented from Cotton’s claims were dismissed
with derision. Madhouse is presented
as a study of medicine (see full title), not of psychiatry per se. Psychiatry
occupies a problematic position within the family of medical specialisms, not
least because it lacks the sort of robust biological evidence of disease that
men such as Cotton sought to provide. But as Scull makes clear, psychiatry does
not have a mortgage on professional self interest. Cotton’s work received
endorsement not only from Meyer and his fellow psychiatrists, but from within
the highest echelons of the contemporary medical establishment.

Scull’s book raises serious ethical issues for the gatekeepers of
knowledge, the editors of professional journals. The American Journal of
Psychiatry played a central role in preserving and elevating Cotton’s
reputation when it was clear that his practices should be subject to
professional censure. As recently as 1999 the same journal published an
historical account of Trenton Hospital that made no mention of Henry Cotton’s
fraudulent data and human rights abuses. In the concluding chapter Scull
attempts to place the Trenton case in the wider context of the history of
psychiatry. He begins by citing Edward Shorter’s somewhat glib analysis in
which Shorter dismisses Cotton as a megalomaniac, and the Trenton experience as
an aberration. Scull will have none of this. He proceeds to catalogue, in a brief
summary, the pursuit of experimental somatic treatments, and their often tragic
results. Perhaps unusually for a sociologist, Scull urges caution in
contextualizing stories such as Cotton’s. He argues that the tendency to
explain events as a product of their time can obscure the extent to which even
within their own historical context, some practices are bizarre, abhorrent or
extreme. If that position is accepted, questions remain about just how a
practice that is outside the norms of its time can gain such widespread
official sanction.

If the historiography of psychiatry is characterized as divided between
the sympathetic histories of the meliorosts on one side, and the revisionists
on the other, then Scull’s work sits firmly within the revisionist tradition.
In his detailed analysis, Scull locates Cotton’s excesses within a history of
medical hubris: exaggerated pride that brooks no alternative, and leads to the
vengeful pursuit of its own ends. Scull cites many examples of equivocal, even
disingenuous medical responses to revelations Henry Cotton’s work. With few
exceptions, even those who express reservations temper their criticism with an
allowance that there is not enough evidence, and that the work should continue.
Scull’s disdain for elements within the medical profession is revealed in
asides that are more journalistic than academic. Lister is twice referred to as
the ‘sainted’ Lister. And after recounting Cotton’s triumphant presentation to
the Medico-Psychological Society of Great Britain, Scull tells us (using rather
mixed imagery):

"Meantime, the assembled black-tie audience
steadily slipped into an alcoholic stupor that cast a benevolent glow over the
interminable verbiage"   

Madhouse is at times written in the style of a novel, with many descriptive
scene-setting passages that bring the text to life. On the first page, Scull
begins "The rain arrived before daybreak on Wednesday August 5, 1925,
finally brought a measure of relief from the sweltering heat and humidity of an
all-too-typical New Jersey summer". The weather and physical surroundings
for Cotton’s address in Great Britain are described in detail, and in chapter
eight, Phyllis Greenacre is introduced as a complete character. We hear about
her family background, her disapproval of her father’s dual life, her ambition
to succeed in the male dominate medical world. Greenacre’s trip to Baltimore is
described in detail, including access to her inner world:

"Gaining momentum, [the train] inched across the drawbridge that
allowed it passage over the Chicago River and headed south and east, out of the
city, towards the Appalachians and the still distant East Coast, carrying
Phyllis to a new life." and "The spectacularly beautiful mountain
scenery…held her entranced for a time, but she was impatient for the journey
to be over, and to begin her new life."

Scull was able to interview Greenacres in researching this book, so it
is perhaps not surprising that she is the most complete of Scull’s cast. It
helps too that she is one character who inspires sympathy, both for the
professional compromise she experienced through Meyer’s suppression of her
research, and the romantic troubles that plagued her personal life. There are
many dramatic twists in the story, and it makes for a thoroughly compelling read.
It would not be at all surprising to see this book adapted for screen.

Whatever the intrigue of Madhouse,
it is first a painstaking reconstruction of a grim and sorry episode in
American psychiatry. The book is meticulously researched and brings to light
many aspects of the history of psychiatry that have significance beyond the
episode under analysis. The freedom of professions to police themselves, the
power accorded to individuals, and the willingness of boards of trustees to
buckle in the face of professional coercion have implications for many areas of
health and social services. Madhouse
should be prescribed reading for mental health professionals.

©
2005 Tony O’Brien

Tony O’Brien is a lecturer
in mental health nursing at the University of Auckland, New Zealand

Categories: Ethics, MentalHealth