Madhouse: A Tragic Tale of Megalomania and Modern Medicine (review)

This is a beautifully written book about the life and times of Henry Cotton, one of the pre-eminent psychiatrists in twentieth-century North America. In Madhouse, Andrew Scull carefully reconstructs Cotton's controversial causal theory of mental illness—the theory of focal sepsis—and his even more controversial treatment regimen of "defocalization." One of the book's strengths lies in Scull's skillful contextualization of this abhorrent episode in the history of psychiatry, one in which thousands of patients were (largely without their consent) subjected to a battery of treatments including "exodontias," tonsillectomy, intestinal, cervical, and colon surgery. For Scull, this psychiatric ordeal reveals much about the destructive potential of unconstrained psychiatric power, about asylum doctors' professional preoccupations with status in the wider medical world, and about the shortcomings of scientific medicine more generally in the early twentieth century. These more analytical aspects of Scull's biography (which will, no doubt, generate controversy) are woven together with a truly fascinating narrative of interactions among research scientists, medical students, medical doctors, and patients, in and around the Trenton State Psychiatric Hospital and the Phipps Clinic at Johns Hopkins University.

Scull depicts Henry Cotton as someone whose personal drive, arrogance, educational opportunities, and orientation to professional psychiatry combined to form his radical approach to mental illness. For Scull, the explosive potential of this combination was embodied in the close personal and professional relationship between Cotton and Adolf Meyer. Cotton owed his position as head of the Trenton State Hospital to Meyer's influence, and he spent a great deal of energy proving to his mentor that he had been successfully groomed for greatness in scientific psychiatry. Through a close examination of the correspondence between Cotton and Meyer, Scull reconstructs Cotton's burning desire to defeat mental illness with scientific research and treatment, his increasingly biological orientation to the "disease," and Meyer's growing personal skepticism and unease at Cotton's departure from Meyer's own multicausal approach. Scull is highly critical of Meyer in particular, and of the psychiatric profession more generally, for turning a blind eye to Cotton's treatments in the face of strong scientific proof that there was indeed no method to Cotton's madness. Over the 1910s and 1920s, as Cotton's surgical response became more radical and frequently employed, mortality rates became shockingly high. For example, between 1919 and 1922, it is clear from Cotton's own statistics (which are later shown to be seriously unreliable) that the mortality rate for colon resections was between 25% and 30% (52).

Eventually, Meyer was sufficiently disturbed by Cotton's activities to appoint Phyllis Greenacre (her own life story a fascinating component of the book) to investigate the veracity of Cotton's optimistic claims that with such radical interventions he had cured more insanity than any of his psychiatrist colleagues. But despite Greenacre's conclusive refutation of Cotton's work in her 1925 report, Meyer was still hesitant to assist in pulling the psychiatric plug on his former student. Meyer, it seemed, clung to the belief that Cotton's work still held scientific value, at the same time that he appeared truly consternated at the professional damage that a scandal might inflict if exposed after this long. Meanwhile, Cotton's blind conviction that he was right, along with the support for the general theory of focal sepsis that he seemed to garner from many (if not all) of his English, American, and Canadian colleagues, had made him what his nineteenth-century predecessors would surely have described as monomaniacal in his relentless pursuit of defocalization. Although by the end of his career the weight of evidence and opinion (both pubic and scientific) had begun to erode Cotton's direct power over his patients, it was his own death in 1933 that finally ended the worst of his treatments.

In the last chapter of the book, Scull forcefully argues that "Henry Cotton's experiments on his patients were not an isolated...