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

Henry Cotton is not someone about whom many psychiatrists learn during their training. However, if the author of this meticulously researched and largely well written biography were to have his way, Cotton's career would serve as a cautionary tale for the profession. Cotton was the superintendent of the Trenton State Hospital in New Jersy in the late 1920s and early 1930s. While in this position, he was perhaps the most enthusiastic American advocate of the theory that mental illness was caused by toxins produced by unrecognized focal infections. To cure his patients of their psychiatric disorders, he began by removing infected teeth; when this did not succeed, Cotton, relentlessly following the logic of his theory, literally dug deeper, removing tonsils and then other organs, including colons. Even mortality rates of 30 percent from colonectomies did not deter him.

Andrew Scull tells Cotton's story, which he compares to a gothic tale, in two parts. The first is an account of Cotton's life and work to the point of his greatest prominence. While he had his critics, he was admired and imitated, and his procedure was sought after by people who could afford the best. Scull gives some reasons for the appeal of this treatment. First, as an activist treatment, it brought the hope of a cure, discharge from the state hospital, and savings for the state. As a biological treatment, it also promised to solidify psychiatry's claim to being a medical specialty, and to counter the wild speculations of psychoanalysis.

The second part of Scull's tale relates the efforts of Cotton's mentor, Adolf Meyer, and Meyer's student Phyllis Greenacre, to evaluate Cotton's work and to deal with their very disturbing findings. Scull includes a fascinating narrative of Greenacre's early career, which provides a vivid picture of what it was like for a woman to become a doctor in the early twentieth century. Greenacre, who later became an eminent psychoanalyst, documented that Cotton's treatment was both ineffective and harmful. The vivid narratives of her driving to former patients' homes to gather follow-up information is one of the most engaging parts of this book. Tragically, however, Meyer did not allow her to publish her data, hoping that he could somehow get Cotton to agree with her devastating critique. This is a chilling account of how difficult it has often been for doctors to rein in bad practices.

In many ways Cotton is an easy target for a historian writing from the vantage point of the twenty-first century. As Scull presents him, he is an arrogant, uncritical enthusiast. Scull's presentations of the other two main characters in the drama are far more interesting. Greenacre is the heroine of the piece, struggling against terrific odds to preserve her family, her career, and her sanity. Meyer, the dean of American psychiatry in the 1920s, seems mysteriously unable to act, even though he recognizes the validity of Greenacre's data.

Scull, a sociologist, clearly hopes that this biography will have resonance in our "era where simplistic and biologically reductionistic accounts of mental disorder enjoy widespread currency" (p. xii). He seems so eager to show how destructive Cotton was, however, that he leaves the impression that he is just writing about a bad doctor and the ineffective efforts to control him. He does not provide sufficent contextualization to show how biologically reductionistic ideas, and not Cotton's abuse of them, resulted in the tragedies that this book recounts. That said, this is a book that well demonstrates how therapeutic enthusiasms can blind doctors. As such, it is a book that I hope will find a place in medical training programs as well as in history seminars.