Elimination

A professor of surgery in Edinburgh in the 1850s confided that patients entering hospital for surgery were ‘exposed to more chances of death than was the English soldier on the field of Waterloo’. By the end of the 19th century, however, Joseph Lister had introduced an effective antisepsis routine, and this, combined with anaesthesia, had transformed surgery (though mortality rates were still high). Surgeons were becoming heroes: in the United States, William and Charles Mayo, the founders of the Mayo Clinic in Rochester, had become household names and millionaires. The cultural resonance of surgery was the more powerful in a period haunted by biological metaphors, in which nations were seen as bodies, vulnerable to various forms of contamination. One of the greatest challenges to the health of the national body was posed by the mentally ill: the cost of caring for this group exceeded that for all other patients put together. There was a need to reduce the amount of money spent on the mentally ill and to modernise the discipline of psychiatry, just as surgery had been brought up to date.

Andrew Scull’s splendid new book, entertaining and disturbing in equal measure, is an account of the career of Henry Aloysius Cotton, an ebullient, ambitious American psychiatrist who met this challenge. Scull, whose usual territory is British asylums of the 19th century, has turned his attention to the goings on at Trenton State Hospital in New Jersey, where Cotton held sway from 1907 until his death in 1933. But this isn’t a parochial tale: its tentacles reach across the Atlantic, as well as into the heartland of American psychiatry, where the Swiss-born Adolf Meyer, professor of psychiatry at Johns Hopkins University, exerted an enormous influence for much of the first half of the 20th century. Cotton was his protégé, and Meyer’s presence lurks throughout this book.

Since the late 19th century, the bacteriological revolution had produced dramatic results. Might not insanity, it was now asked, be caused by bacteria spread through the body from hidden reservoirs of focal infections? After all, those who believed that insanity was hereditary had already been confounded by the discovery that paresis – ‘general paralysis of the insane’ – was a feature of the terminal stage of syphilis and was, to a degree at least, responsive to drug treatment. The bacteriological paradigm found an ardent advocate in Frank Billings, president of the American Medical Association at the turn of the century, who declared war on sepsis, urging surgical intervention, from the teeth to the tonsils to the intestines, to ‘make sure that all sources of focal infection have been obliterated’. Billings was not alone. In Britain, the surgeon William Arbuthnot Lane produced papers with titles such as ‘The Sewage System of the Human Body’, warning darkly against the dangers of autointoxication and the ‘flooding of the circulation with filthy material’, and calling for an assault on constipation – with surgical intervention where necessary – and the cleansing of the cloacal regions through diet and frequent defecation. From his base at Battle Creek Sanitarium in Michigan, John Harvey Kellogg, physician, dietary reformer, founder of the breakfast cereal empire and author of such tracts as ‘The Itinerary of a Breakfast’, proselytised against the debilitating consequences of ‘civilised’ diet, leisure and defecatory positions, all of which had flooded the gut with ‘the most horrible and loathsome poisons’.

When Cotton was appointed superintendent of Trenton State Hospital in 1907, there was certainly plenty of cleaning up to be done: the hospital was filthy; the result had been a typhoid epidemic. Cotton assured his mentor, Meyer, that he planned complete reform, and before long he had secured the funds to build an operating theatre and laboratory facilities, and had recruited a battery of outside consultants including four physicians, four surgeons, three gynaecologists, a gastroenterologist, a neurologist, a laryngologist, a rhinologist, two ophthalmologists, a dentist, a genito-urinary surgeon, a pathologist and a bacteriologist.

The teeth, and then the tonsils, were the early targets of Cotton’s interventions: in 1921 the hospital dentists performed 6472 extractions, an average of about ten per admission. Cotton proclaimed the success of these procedures, but still there were recalcitrant cases, and he concluded that the war on sepsis must be taken further, to the ‘stomach, duodenum, small intestine, gall bladder, appendix and colon, as well as to the genito-urinary tract’. He insisted, too, that the stomach and the large bowel were easily dispensable.

Outside consultants started to perform exploratory laparotomies, surgical incisions through the abdominal wall that yielded, Cotton reported (Scull intimates that his claims were dubious from the outset), evidence of ‘a great variety of intestinal lesions’, indicating that many of the inmates were really ‘chronic intestinal invalids in whom the psychic phenomena were purely secondary to an unrecognised . . . disease in a congenitally misshapen and deformed bowel’. A more intensive programme of abdominal surgery was then embarked on, and culminated in operations aimed at what Cotton described as the ‘developmental reconstruction of the colon’. More than 30 per cent of these colon operations resulted in the patient’s death, but Cotton maintained that the mortality rate reflected ‘a much lower vitality’ among the insane.

‘The cures in the last seven years,’ Cotton pronounced in 1925, ‘averaged 87 per cent, which in terms of dollars and cents, represented a saving to the state . . . of about a million dollars.’ He did not shrink from applying his doctrines in his own family. When his two sons started to display behavioural peculiarities, he removed not only their diseased teeth, but all their permanent ones, and also performed abdominal surgery on his younger son.

The British medical establishment urged Cotton on to new surgical feats. In tribute to his achievement in inaugurating a ‘new era of antisepsis in mental disorders’, the British surgeon William Hunter coined the term ‘septic psychosis’. Speaking before the Medical Society of London, Cotton claimed that the ‘serious lesions of the colon’ which many of his patients suffered from meant that the only course open to him was ‘elimination’: Scull notes the term’s unfortunate double meaning, and that the remarkably high mortality rate in these colectomy operations wasn’t commented on by the audience of British psychiatrists. Cotton’s work, the revered Frederick Mott declared, ‘showed emphatically the importance of the bowel as a source of chronic infection’. One prominent and colourful devotee of focal sepsis was Thomas Chivers Graves, medical superintendent of the Rubery Hill and Hollymoor Asylums in Birmingham, who ‘aggressively treated all the mental patients hospitalised in the Birmingham area along Cotton’s lines’ until after the Second World War. Even Cotton was surprised to discover that Graves extracted his patients’ teeth without any local or general anaesthetic and that, as far as he could tell, ‘the patients did not seem to object’.

Would-be critics easily found themselves wrong-footed, for it was perverse, surely, to object to measures designed to place ‘the patient in as perfect physical condition as possible’. All the same, Cotton’s career was blighted by a succession of scandals and inquiries. Families alleged to the Bright Committee, which investigated the hospital’s affairs, that their relatives had been killed by neglect or abuse, and the hospital undertaker testified that he routinely covered up wounds and abrasions on bodies from the asylum. Around this time, in the mid-1920s, Phyllis Greenacre, subsequently a distinguished psychoanalyst but then an uncertain young psychiatrist, was dispatched to Trenton by Meyer to undertake a review of Cotton’s methods. One of the most shocking aspects of the Trenton regime, and one that registered forcibly with Greenacre when she arrived there, was that having been stripped of all their teeth the vast majority of the patients were returned to the wards without replacements:

These patients were all devoid of teeth, and they had not been given dentures. That was why their speech was slurred and so difficult to comprehend – and why their sunken faces gave even the youngest among them the appearance of premature age. One of them unexpectedly grinned at the elegant young woman who had stopped to inspect him. She saw only his gums, and recoiled in shock. Like others on the ward, he seemed thin and malnourished. Small wonder, she thought, for how on earth did they manage to eat?

Greenacre found that in fact there were many more recoveries among Cotton’s untreated, or partially treated, patients than among those he had treated. Other critics rebutted Cotton’s claims, finding that the relief of constipation did not bring about any improvement in the course of psychosis and failing to identify any infections that might account for the mental conditions of their patients. None of this threw Cotton off course and in the late 1920s he became, if anything, more aggressive in the ‘elimination’ of supposed sites of infection, insisting that relapses served merely to demonstrate that only a complete ‘cleansing’ would suffice. Cotton died prematurely from a heart attack in 1933 but the tradition that he had inaugurated continued for a good while afterwards.

As Scull acknowledges, the idea that focal sepsis could cause chronic disease was not the folly of an isolated adventurer: some of the best medical minds of Cotton’s generation found it plausible and promising. Cotton’s onslaught against his patients was one of many audacious solutions to social problems proposed in the interwar years, in medicine as in other spheres, notions that blurred the boundary between the scientific and the criminal, the professional and the political. Scull recounts the story of Julius Wagner von Jauregg, who was threatened with prosecution for the barbaric electrical treatment he had inflicted on recalcitrant soldiers in the First World War. He was rescued by Freud, who helped turn Wagner von Jauregg’s attention to finding a malarial treatment for tertiary syphilis, for which he was awarded a Nobel Prize in 1927. Wagner von Jauregg was a role model for Henry Cotton, and also for other somatic enthusiasts, such as the Polish psychiatrist Manfred Sakel, who began to experiment with insulin coma therapy in 1933, and the Hungarian Ladislaus Meduna, who treated schizophrenia with a drug soon to be known in the United States as metrazol, which was notorious for its violent and convulsing effects. The most egregious of these remedies, however, was lobotomy, the severing of nerve tracts in the frontal lobes of the brain, which also won a Nobel Prize for its inventor, the Portuguese Egas Moniz. Now discredited, it was never less than controversial even in its heyday, but it won many adherents and defenders, among them Adolf Meyer.

Though he is careful to avoid anachronistic judgments, Scull maintains that the evidence available in the public domain even at the time ought to have been sufficient to bring an end to Cotton’s barbarous procedures. And Meyer didn’t only ‘cover up the parade of death and debility that Cotton had left behind him’ but called for Cotton’s work ‘to be carried on’. It is understandable that Scull is indignant, and he is right to be so. But it is not obvious that Meyer did ‘know’ the facts as Scull presents them. Indeed, the problem may be the obverse: that Meyer was unable, along with most others of his profession and generation, to perceive with sufficient moral clarity what was really going on. What comes through most strongly when one delves into this murky period is just how difficult it was for doctors, as much as for anyone else, to find their moral bearings. Meyer, it appears, never quite gave up his belief in focal sepsis. I had for long rather esteemed him, but I will never look on him in the same light again.