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Book Reviews   |    
Madhouse: A Tragic Tale of Megalomania and Modern Medicine
Reviewed by Jeffrey L. Geller
Psychiatric Services 2006; doi: 10.1176/appi.ps.57.7.1054
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by Andrew Scull; New Haven, Connecticut, Yale University Press, 2005, 360 pages, $30

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School, Worcester.

Removal of all the teeth, tonsils, adenoids, the stomach, cervix, gallbladder, ovaries, fallopian tubes, uterus, thyroid gland, spleen, seminal vesicles, pericolonic membranes, hemorrhoids, and appendix. Treatment with course of typhoid vaccine, massive colonic irrigation—15 to 20 gallons per treatment over six to eight hours per day, draining sinuses, calcium therapy, fever treatment, and electrical coagulation of the cervix. These were the methods that were used to treat insanity under the direction of Henry Cotton during his tenure as Superintendent of Trenton State Hospital from 1907 until 1930.

Andrew Scull, who masterfully tells Cotton's tale, presents the framework for Madhouse in so poetic a fashion it is worth repeating: "Whether ranting and raving, or melancholy and withdrawn, madmen and madwomen have experienced and provoked an explosive mixture of commotion and disarray, guilt and despair, stigma and shame. For hoi polloi and literary folk alike, the crazy may on occasion become figures of fun, but in the shadows lurks a darker perspective, from which they are viewed as an explosive mix of menace and misery." From Cotton's perspective he was treating what he believed to be the root cause of all insanity, namely focal infection or "the perils of puss infection."

Cotton, like many asylum superintendents of his day, was to some degree "trapped within the walls of the asylum as surely as most of the patients." With single-minded directedness and spurning the Kraepelinian approach to differential diagnosis, Cotton proceeded with virtually unrestrained therapeutic intervention aimed entirely at removing the sources of infection. His arrogant self-appraisal reflected his absolute certainty in his approach, which led him to consciously, or unconsciously, misreport outcomes such that within 12 months of adopting his counter-infection interventions, Cotton claimed recovery rates had increased by 23 percent. As he utilized his approach more extensively he claimed cure rates as high as 85 percent.

Cotton brought favorable publicity to Trenton State Hospital. He brought a financial windfall to the hospital, as private paying patients came from out of state. The publicity, money, and his "passion for publicity and his propensity for insistent self-promotion" brought Cotton great support from the board of Trenton State Hospital, which had many illustrious members. Nothing could stand in Cotton's way, including patients' and families' consent as Scull indicates: "Protests from patients and their families must be ruthlessly pushed aside as shortsighted preferences reflecting the patient's mental disturbance and incompetence, or the imperfect knowledge of their families."

Cotton was not without critics. Many psychiatrists of his era were aghast at his approaches and his apparent unwillingness to have his methodology and outcomes evaluated by those external to the endeavors. J. K. Hall, a prominent southern psychiatrist, referring to Cotton's efforts in 1922, indicated that "the world has been overflowing with lots of damn fool theories, and I think it is important for the welfare of humanity that some of us doctors at least retain what little sense we have and try to keep our feet on the ground."

Although Cotton has the lead in this drama, Phyllis Greenacre and Adolf Meyer are two other major players of interest. When the challenges to Cotton became so great that an external review was required, Cotton turned to his mentor, Meyer, who sent one of his young psychiatrists, Greenacre, to Trenton State Hospital to conduct a review of the data. Her report, which if released would have demonstrated that Cotton's approaches had absolutely no scientific basis, was squelched by Meyer who most certainly knew that as he sat on the report more people were dying at the hands of the surgeons at Trenton State Hospital. Although Cotton reported excellent therapeutic outcomes, he also acknowledged high mortality rates.

In this drama Cotton can be seen as a blinded zealot, well-meaning in his efforts but quite mistaken in his approach. Cotton made it very clear that his aim was to free persons with serious mental illnesses from state hospital life and return them to what we refer to in current parlance as "the community." Greenacre was a victim. Her extensive work was never allowed to see the light of day. She did go on to an illustrious career, which was quite different from her early efforts. The real villain in this tale is Meyer.

Nowhere have I read, nor do I believe has it ever been made quite so clear as in Scull's book, that Meyer could be portrayed as a narcissistic, controlling, manipulative, self-interested individual who was willing to put ethical concerns secondary to his own career. Scull describes Meyer as "dominant," "castrating," instilling fear in his students and mentees, and responsible for a cover-up. Scull provides all the groundwork for the reader to conclude that Meyer was deceitful, disreputable, and perhaps despicable.

Scull provides a very well written account of early 20th century American psychiatry and supplies interesting information on the personalities, the therapeutic approaches, the ethics, the public and private interface, and the politics of that era. Perhaps his most disquieting conclusion is that although there might have been professional disagreements between psychiatrists who subscribed to Cotton's monocausal account of psychosis and those who did not. There might also have been disagreements between those who were moving away from biologic bases for psychiatry towards psychodynamic understandings and those who were not, but virtually nobody within the profession raised a red flag that said "you can't experiment on patients" or "you can't operate on patients without consent." As Scull himself points out, "scarcely anyone doubted his [Cotton's] right to experiment on his patients or raised in any serious or sustained manner any questions about the propriety of maiming and mangling the bodies of the mad."

Scull points out that although Madhouse brings to light long suppressed information, Cotton was not alone in endorsing dramatic invasive interventions for mental illness. Other such interventions of the 20th century include insulin shock, metrozolinduced convulsions, lobotomy, oophorectomy, inoculations with malaria vaccine, and others. Scull also implies that it is easy to look back and see the folly in the naïve, perhaps inconsiderate and insensitive interventions of the past.

But who are we to say that people of the future will not look back at our less than remarkable interventions and be aghast at the use of medications that induce tardive dyskinesia, our polypharmacy buckshot approach to intractable psychosis, abandonment of persons with mental illnesses to heating grates on the street or cots in a prison, and the ability to allow persons with chronic mental illness to live in the community without ever making them part of the community? How different are we from Cotton and his peers, all of whom thought they were acting in the best interest of individuals with serious mental illness?

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