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Madhouse: A Tragic Tale of Megalomaniaand Modern Medicine

Andrew ScullYale University Press; 2005.360 pp, US$18.00

Enthusiasts of psychiatric treat-ments have sometimes been ac-cused of using attractive theories

to shroud weak bodies of evidence. Butwhen Dr. Henry Cotton, chief psychia-trist at the Trent State Mental Hospital inNew Jersey from 1916 to 1933 relied on“focal sepsis” to justify his extreme treat-ments, a weak theory was used to coverone of the 20th century’s major scandals.

The idea that hidden infection couldcause madness had its roots in folk be-liefs about auto-intoxication and seemedplausible to the public and to physicianswho were eager to help the mentally ill.

Cotton claimed that new develop-ments in bacteriology allowed him toidentify infected patients (potentialtreatment responders), while modernsurgery offered a definitive solution.Despite initial opposition, he movedforward with a campaign of aggressivediagnosis and surgery on hundreds ofpatients, removing teeth, tonsils, andsometimes sexual organs and colons(not necessarily in that order or re-stricted to a single procedure). Cottonreported an 85% cure rate for insanity inthe 1920s, when his more circumspectcolleagues could only wish for similarresults. Few sounded the alarm whenhis outcomes were not replicated atother centres, and more than a decadewent by before it was widely learnedthat Cotton’s success rested on an unre-ported 30% mortality rate and an unre-alistically broad definition of cure.

Andrew Scull’s book shows how atheory-based intervention was promotedto the popular press, hospital administra-tors and politicians, all hoping for a fast,cost-effective solution to mental illness.He also illustrates how the needs of soci-ety’s most vulnerable members weretrumped by personal ambitions and pro-fessional loyalties reaching to the highest

levels of American medicine, allowingthe suppression of key scientific evi-dence for more than 10 years.

While some might argue that the caseof Henry Cotton is a tragic, but isolatedevent, others may wonder why similarsocial forces appear to coalesce fromtime to time, catalyzing unfortunate situ-ations and obscuring the basic ideals ofthe medical profession. Just as the hor-rors of Trent State in the 1920s and1930s were winding down, the lobotomycraze, another tale of surgical enthusiasmwith a charismatic self-promoter actingon a poorly tested theory, was beginning.Is the social organization of medicinepartly to blame for malpractice? Will ourcurrent regulatory system protect us frominterventions based on hope-infused the-ories rather than solid evidence? As oneline of social enquiry into this complexproblem, medical history appears to havemore to offer than curiosities from thepast. In the words of the great British his-torian William Stubbs, “the roots of thepresent lie deep in the past, and nothingin the past is dead to the man who learnshow the present comes to be.”

Dorian Deshauer MDAssociate Editor, PracticeCMAJ

An anatomy of malpractice

Review

Humanities

CMAJ • MAY 26, 2009 • 180(11)© 2009 Canadian Medical Association or its licensors

1139

Metaphors are easy. What it isn’t:no fingertip sworls, so the policearen’t interested;

no long lines or abrupt breakslike palm-reading;

no fuzzy snowstorm screen like acrystal ball;

no crazy QRS dowsing. No onecan even tell

that the heart is beating: thelights may be on,

that’s all. You need a pulse for that. You need more

than chicken scratch, and whatof the exploring heart,

the intrepid muscle with a wandering baseline?

No habla anglais. Ne parle pas.

What it is: a detective story.The private dicks are part of it.There is a gravedigger

shovelling the Q wave’s six feet,the long plot of a pause.

It is a history: grizzled, from aGrizzly Adams.

But in the end it is an ocean, anocean of waveforms,

an ocean that stretches acrossthe basin of a life.

Each feeler P, P of reconnaissance, P of preceding,

leads to the enormous yes of adon’t-give-me-a complex,

then the billowing blanket of aST segment

sloping up or down dependingon bed angle.

Bedside, I peer at the tracing

and think lifestyle modification,lifestyle modification, whatevery heart needs

is the amplitude of truth. But I’mnot looking for truth.

I’m looking for closed-mouthmoments and the wave

of goodbye, goodbye, which thepolice would be interested in,

there is an order to stay withinthe city,

but it is unenforceable.

Shane Neilson MDFamily physicianGuelph, Ontario

Readingelectrocardiograms

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