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

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...