9/20/2005

Book: Madhouse: A Tragic Tale of Megalomania and Modern Medicine

"Cotton was not, in fact, a sadistic monster; he simply believed that everything he did was for his patients' benefit. Inconvenient facts were either rationalized ..or simply ignored, while he tried to massage the statistics. When patients failed to improve, it must, he thought, [it must] have been because he had not been radical enough. Any objections from patients or relatives were brushed aside. "

Sounds familiar ? I could swear I was reading about Perle, Wolfowitz or other neocon... -- law


by Andrew Scull, reviewed by Times Literary Supplement

Andrew Scull reminds us in Madhouse.. of the mostly unfortunate fate of the mentally ill throughout history -- "to be considered insane is a kind of social, mental and metaphysical death". The nineteenth century's answer, at least in industrialized societies, was the asylum.. Scull describes the early twentieth-century asylum as a "noisy and noisome cemetery of the still-breathing"...

By the standards of the time, Scull's protagonist Dr Henry Cotton was a well-trained psychiatrist.. He was full of energy and furor therapeuticus; he had been convinced from a young age that he was destined for greatness.

Scientific medicine was in its earliest stages; the bacteriological revolution begun by Louis Pasteur and Robert Koch led to the discovery in 1913 of the syphilitic organism. This was found to be the cause of one of the most deadly mental disorders, General Paralysis of the Insane (GPI). But if that was so, others might also have a similar cause; perhaps they all had.

Until then, psychiatry had been sunk in a nihilistic pessimism in which heredity was seen as the universal cause of insanity, while "degeneration" theory predicted that in each genetic line, things were liable to worsen with each succeeding generation. Cotton sought a way out of this impasse, and thought he had found it in the fairly recent doctrine of "focal sepsis". Originated by physicians and surgeons, some of them British, this asserted that chronic, masked infections at various sites in the body released toxins into the bloodstream which could reach other organs, including the brain.

Is there "any proved difference", Cotton asked, "between the transient delusions arising from typhoid and alcoholic intoxications and the fixed delusions of dementia praecox (schizophrenia) and manic-depressive insanity"? In 1918, that was a perfectly reasonable question.

Since prevention is better than cure, and since the treatment of insanity was manifestly unsuccessful, the doctrine of "mental hygiene" had emerged at this time in America.. Cotton thought that his approach would not only cure people who were mentally ill, but would also prevent others from developing such an affliction.

So began his assault on focal sepsis.. The New Jersey State government was generous in paying for these clinical extras .. The bureaucrats saw a chance of both political and financial gain if patients could be cured and then discharged. At the time, mental hospitals accounted for ..one-third of the State budget.

Cotton's first target was teeth, initially only those showing signs of infection. His weakness, though, like that of many enthusiasts, was that he did not know when to stop. If teeth were not already infected, they might be later, so it was safer to remove them all. And bad teeth would obviously infect saliva, which would carry toxins into the digestive tract. Here, the best option seemed to be the colon.. so first partial colectomies were done and later complete removals. Additionally, there were sinuses to be drained, tonsils to be taken out.. Attempts were also made to treat the alleged infections medically, but in the pre-sulphonamide era there was no effective way of doing this.

Meanwhile back in Baltimore, [Cotton's boss] Meyer .. had privately begun to have increasing doubts about Cotton.. Meyer arranged for ..an independent assessment of his work. ..the results were devastating: the true "recovery" rate was no more than 32 per cent, while ..the drastic treatment [resulted in] an astonishing post-operative mortality of 45 per cent among those mentally ill patients who had lost their colons...

Cotton was not, in fact, a sadistic monster; he simply believed that everything he did was for his patients' benefit. Inconvenient facts were either rationalized (for example, "the very poor physical condition of most patients") or simply ignored, while he tried to massage the statistics. When patients failed to improve, it must, he thought, have been because he had not been radical enough. Any objections from patients or relatives were brushed aside. Eventually, though, the State government decided that its prestigious project was becoming an embarrassment: Cotton was moved sideways, the complex surgical operations stopped and the whole programme wound down. Henry Cotton died soon afterwards.


Powell's Books - Review-a-Day - Madhouse: A Tragic Tale of Megalomania and Modern Medicine by Andrew Scull, reviewed by Times Literary Supplement

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