As seen in the Providence Journal - an overview of one of the earlier criminals of psychiatry
In a book review for the New England Journal of Medicine, Robert Michels, M.D., described the book, Madhouse, by Andrew Scull (Yale University Press), as a compelling set of "lessons on how not to structure a clinical research program." While this is certainly true, I took home a different message -- one much more troubling because it speaks to us now.
The "madhouse" in the title refers to the Trenton State Hospital, and the book is about Henry Cotton, M.D., psychiatrist acolyte of the famous Adolf Meyer, former chairman of the psychiatry department of Johns Hopkins Medical School, and one of the leaders of American psychiatry. After completing medical school Cotton studied with Meyer when he was working in Worcester.
When Meyer moved to Hopkins, Cotton did not move with him, but was later brought in, somewhat under Meyer's wing, to run a state psychiatric hospital in New Jersey, in 1909. His mission was to help establish a scientific basis for the practice of psychiatry. In the early 20th Century, there were no rational treatments for the insane, and psychiatry was evidently disparaged as a field of mere care-taking.
In Europe there was a move following Freud to establish a psychological basis for mental illness, whereas those Americans not under the influence of psychoanalysis were motivated to seek organic causes, building on the scientific breakthrough that general paralyis and dementia of the insane was caused by syphilis.
Cotton latched on to the theory of focal infection as the basis for virtually all psychotic illnesses. He denigrated the notion that heredity had any influence at all, or even that environment was important. The sole cause of psychosis was focal, he argued, and to the "untrained," occult, infection.
As a neurologist, I hesitate to go overboard in disparaging theories that are 100 years old, especially when they are so close to theories we invoke today; yet this theory, as I will explain, is indicative of something other than poor logic. We neurologists use the catch phrase "toxic/metabolic" for a lot of our consults. We find a patient to be delirious, to have worsening aphasia or Parkinson's disease, or multiple sclerosis, but without new focal abnormalities.
We conclude that the problem is either metabolic, from deranged electrolytes, liver failure, hypoxia or some other similar cause, or we say that it's toxic, because of occult infection, non-occult infection, drug or medication mishap. We don't know the connection between pneumonia and worsened Parkinson's disease. So far as I'm aware it's never been studied, yet I'd bet my life that this connection exists, and I'd venture to say that every neurologist would agree.
We even have a "critical-care neuropathy" and a "critical-care myopathy" (a little better defined) -- that is, an actual "diagnosis" (i.e., name) for a condition that seems to occur in very sick people in intensive-care units, for reasons unknown. So, even in the 21st Century, we invoke an "evil-humor" theory not much different than that of Hippocrates or Galen, or even Henry Cotton. I have no problem with this.
Cotton, however, took it a step further. Nowadays we use the "toxic/metabolic" diagnosis as an interpretation of the current condition, counsel restraint and make sure that the focus is on the underlying medical condition that we think is causing the bad humors. Cotton believed that occult infections were almost omnipresent.
They primarily affected the teeth, he thought, even when X-rays revealed no abnormalities. They also affected the abdomen, especially the colon.
Reflecting an unstated but obvious primitive belief that feces were the source of illness, he used colectomies or extremely aggressive enemas with gallons of fluid to destroy the source of infection. His institution aggressively courted public attention and actually garnered a large clientele of private patients.
What was so disturbing, however, is not that he embraced this theory, but rather that he clung to it until his death, fighting against people who doubted him, backed up continually by his former mentor, Meyer.
Assessors had reviewed his work and concluded that his mortality rate, over 30 percent initially, then down to something over 20 percent in physically healthy young people, and his reduced rate of "cure," as measured by hospital discharge, compared to the usual passive observation, was the opposite of what he claimed in public.
This is the crime. Cotton was clearly megalomaniacal. He even had his teenage sons' teeth removed entirely for fear that they might be harboring hidden infections that signal the onset of a mental illness. He then subjected one of his sons to an abdominal operation when his behavior again started to raise concern. (They both committed suicide.) Here was a man of conviction: Unfortunately that conviction wasn't dispassionate logic.
When Cotton was challenged on his high mortality rate for colectomies, he puzzled about this until he had a dramatic insight. The cause for the deaths was, of course, peritonitis. He was operating in the pre-antibiotic era. One day he operated on two young, healthy psychotic patients. One survived and the other died.
He noted that the one who survived lacked teeth, having failed that first surgical treatment for psychosis, but the second had only had a few teeth removed.
The problem was that the remaining teeth were the source of the pathogen for the peritonitis. From then on all abdominal surgery was preceded by the extraction of all teeth.
Yet, despite these blatant crimes, Henry Cotton had only minor limitations placed on him. He lost his position as superintendent and instead became director of clinical research, where he continued to perform his surgeries, often on unwilling people. Hysterectomies, cholecystectomies, right-sided colectomies, left-sided colectomies, and massive numbers of tonsillectomies were all treatments for behavioral disorders, psychotic or otherwise, even when family members tried to intervene. But usually this took place only after the teeth had been extracted.
We all know that many medical crimes have taken place in the United States. Psychiatry will forever be tainted by the thousands of lobotomies performed, although public-health programs like the Tuskegee syphilis project were even more heinous.
The question in the Cotton story is: Where were the authorities? Why did Meyer not step in? When Cotton died unexpectedly, while still a fierce advocate of his focal-infection theory, Meyer lionized him, as did the psychiatry journals. Why did the state authorities in New Jersey not intervene? How could a medical staff believe for 20 years what their own eyes told them was wrong, even while they maimed and tortured the most helpless among us?
Was it that the insane counted less? Recall that this was a time when eugenics was a popular topic throughout the Western world, ending only when Hitler gave it a bad name. Cotton actually argued against a eugenics solution to psychosis; he knew the etiology, and it wasn't inherited: It was bad teeth.
I become disturbed whenever I learn about things like this. We haven't changed much in the past hundred years. We will always have unethical doctors among us. These stories always make me wonder what things we do today that will be looked at by our grandchildren as equally egregious.
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