A True Madhouse

A new book details the insanity of the practices performed on patients at Trenton State Hospital in the early 20th century.

By: Susan Van Dongen

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   Even more chilling than the thought of being incarcerated when innocent is the idea of being committed to a psychiatric hospital against one’s will. Certainly, these are places where genuine healing can take place, especially now with the breakthroughs in medications. However, the "lunatic asylum" or "bughouse" of the past still conjures a special kind of horror deep down in the gut.
   If you’ve shrugged off those archetypal fears, reading author Andrew Scull’s soon-to-be-published Madhouse: A Tragic Tale of Megalomania and Modern Medicine (Yale University Press, $18) will bring you back to full blown disquietude. The meticulously researched book tells the story of Henry Cotton, superintendent of Trenton State Hospital in the early 20th century, whose radical ideas about healing mental illness led to countless deaths and unspeakable anguish among the patients.
   Madhouse reveals a long-suppressed medical scandal, shocking in its brutality and sobering in its implications. Convinced that he had uncovered the single source of psychosis, Dr. Cotton launched a ruthless campaign to "eliminate the perils of pus infection." Teeth were pulled, tonsils were excised and stomachs, spleens, uteruses and colons were all sacrificed in the assault on "focal sepsis."
   Randall McMurphy and the fictional One Flew Over the Cuckoo Nest crew had it 100 times better than the poor souls at Trenton State.
   Warnings of Dr. Cotton’s macabre practices fell on deaf ears for years until a legislative committee, led by Sen. William Bright, focused its investigations of waste in state government on the hospital’s affairs. That’s when a profusion of gothic horrors came into light.
   "Ex-patients, their families and disaffected former nurses and attendants had surfaced and a litany of lurid tales had filled the pages of the state’s newspapers," Mr. Scull writes. "The scandal had even begun to draw the attention of the august ‘New York Times.’ Stories of patients being beaten, kicked and dragged screaming into the operating room, of trolleys filled with body parts and not a few corpses streaming in the opposite direction, had aroused the archetypal fears of the horrors of the madhouse that always linger just below the surface in our collective unconscious."
   Mr. Scull has written numerous books about the history of treating mental illness, and was working on a tome about "managing lunacy" in Victorian England when he stumbled on a small item about therapeutic practices in the first part of the 20th century.
   "Most of the treatments from those times were ill-conceived and have now been abandoned," Mr. Scull says, speaking from his home in San Diego. "I’ve (written about methods) such as electric shock therapy, lobotomies and insulin comas. Scientists have wondered where the origins of these illnesses came from and tried all sorts of things. Unfortunately, patients’ rights were (weak) up until World War II.
   "I came upon a reference or two to Henry Cotton, and over the years collected a number of materials," he adds. "Some of my Princeton contacts happened to know people in the New Jersey mental health bureaucracy and that got me access to a lot of hospital records."
   With training at the University of Maryland and Johns Hopkins, Dr. Cotton apprenticed in psychiatry at the Sheppard and Enoch Pratt Hospital in Baltimore under the eminent Princetonian Stewart "Felix" Paton. He later obtained an even more prestigious post at the Worcester State Hospital (Worcester, Mass.) under Swiss neuropsychiatrist Adolph Meyer, himself educated in Zurich, Paris and London. Indeed, Trenton State, which had been mismanaged for years, was fortunate to get someone with such excellent scientific credentials.
   Dr. Cotton began as a reformer and a progressive, with at least a few humane ideas about treating patients, for example, abolishing restraints.
   "He wanted to solve the riddle of psychosis, but he was also in despair about the state of mental hospitals he encountered and wanted to find a way forward," Mr. Scull says. "Some of the reforms included doing away with restraints and re-training his doctors. Then he happens upon this idea of focal infections, poisons in the bloodstream that are affecting the brain.
   "Once he’s become convinced of something, he blinds himself to anyone else’s theories," Mr. Scull continues. "If you’re pulling out their teeth and they get better, well that’s OK. If they don’t get better, (the infection) must be somewhere else in the body, or he thought, ‘it was too late, that’s why this person didn’t get better.’ (For scientists like Dr. Cotton) you can find ways to explain why the treatment didn’t work. The danger always was therapeutic enthusiasm."
   One of the most disturbing facts that comes to light in Madhouse is the disproportionate number of women who were operated on.
   "Cotton had three well-equipped operating services, two for women and one for men, which are busy most of the time," Mr. Scull writes.
   One good — or terrible — example is former patient Mrs. Georgiana Phillips. During Dr. Cotton’s trial, she appeared, stating that she had been committed on the grounds of "immorality, indigency and moral insanity" — in other words, prostitution.
   Claiming that she had been sane when shut away and in direct violation of her wishes — and a court order — Mrs. Phillips had been "compelled to undergo a delicate operation while a patient at the state hospital."
   "He removed her ovaries," Mr. Scull says. "This was also a pattern when you look at lobotomies. This is conscious gender bias at work. It’s not that men were exempt from this, but among women patients 60 to 65 percent had their colons removed. Even with gender neutral parts of the body like the colon, women seemed to fall into (Dr. Cotton’s) clutches."
   You might wonder how one would digest and eliminate food without a colon, and Mr. Scull remarks that a patient would simply be left incontinent.
   "This accounts for many of the deaths," he says. "This was murderous. There was nearly a one in two chance for death."
   Dr. Cotton had almost a fetish about pulling teeth. He removed the teeth of his two sons — both of whom would go on to commit suicide — and even had his own removed.
   "This is someone who genuinely believes in what he’s doing," Mr. Scull says, adding that a visitor to Trenton State, who came from Johns Hopkins, observed room after room of patients with no teeth, but also no dentures. "Because they couldn’t chew their food, they were malnourished. In fact, during those times, in New Jersey, if you didn’t have any teeth, people suspected you had been at Trenton State."
   Mr. Scull is a professor of sociology and science studies at the University of California in San Diego. He is the author or co-author of nine books, the most recent (before Madhouse) being Customers and Patrons of the Mad Trade: The Management of Lunacy in Eighteenth Century London (University of California Press, 2003), which he co-wrote with Jonathan Andrews. He earned his doctorate in sociology from Princeton University in 1974.
   Even with the gruesome pseudo-science and the growing number of casualties at Trenton State, Mr. Scull writes that until the news spread, families cheerfully sent their kin to be treated.
   "There was a belief that mental illness was a biological problem and could be treated," Mr. Scull says. "Very wealthy and intelligent people brought their family members to these centers. Yale professor and economist Irving Fisher brought his daughter to Trenton State for treatment and Cotton killed her."
   Mr. Fisher had been an advocate of vegetarianism, exercise, hydrotherapy and paying attention to healthy bowels. In fact, he was good friends with John Harvey Kellogg and took his family to Kellogg’s health center in Battle Creek, Mich.
   "He only wanted the best for his child," Mr. Scull says. "That case in particular helps us understand how educated people saw the logic in (Dr. Cotton’s practices). But patients were so vulnerable and controls were non-existent. Medical treatment has changed some, but even today patients put themselves in the hands and the mercies of doctors. These days, though, there are reviews and we can pull back if we decide we don’t want a treatment. (In Dr. Cotton’s time), once patients had been certified as mentally ill, they lost their rights as a person, lost their autonomy."
Andrew Scull’s Madhouse: A Tragic Tale of Megalomania and Modern Medicine will be available in bookstores and online at www.yalebooks.com beginning Sept. 4.