THE BACTERIOLOGICAL REVOLUTION in medicine that took place in the closing decades of the nineteenth century, like most intellectual revolutions, did not succeed overnight. For years, conservative medical men had resisted the implications of the work of Louis Pasteur and Robert Koch, and the warnings about the perils of pus that emanated from that apostle of antiseptic surgery, Joseph Lister. But by the dawn of the twentieth century, the gospel of “germs” was sweeping all before it. Medicine embraced the laboratory as the source of cultural authority. Bacteriological models of disease brought gains in etiological understanding and, to a more limited degree, in therapeutic efficacy. The upshot was that physicians and surgeons, donning the mantle of the new science, found their prestige and prospects soaring. And yet there were diseases and disorders that remained recalcitrant, resistant to the new paradigm and frustratingly beyond the reach of modern therapeutics: rheumatism and arthritis, for example, and atherosclerosis and nephritis, not to mention serious mental illness.
The triumph of the germ theory of disease had heightened the sense that the future of medicine lay in discoveries in the laboratory, rather than at the bedside.1 Bacteriological models of disease very often invoked the idea that it was not necessarily the bacteria themselves that caused disease, but the damage the toxins they unleashed wrought upon vulnerable bodies. Many who embraced the new alliance with science saw focal sepsis—the presence of unobserved low-grade infections lurking in the corners and crevices of the human body, pumping out poisons via the bloodstream and the lymphatic system—as the likely cause of a host of chronic disorders whose etiology remained baffling and mysterious. Among the most prominent supporters of this view were the Philadelphia neurologist Francis X. Dercum, and Frank Billings, dean of the Rush Medical School from 1901 until 1924, and professor of medicine at the University of Chicago.2
It was Henry Cotton who took the lead in applying ideas about focal sepsis to the treatment of psychosis. Cotton had an impressive pedigree for a young psychiatrist. He had trained under Adolf Meyer at Worcester State Hospital, one of those Meyer hoped would become the leaders of a new psychiatry. Meyer continued to promote his career in the following years, sponsoring his move to Germany, where he worked at Emil Kraepelin’s Munich clinic. German training was de rigueur in these years for those who aspired to join the elite circles in American medicine, but it was still relatively rare among psychiatrists. Cotton’s training included work on sectioning the brains of patients who had died from General Paralysis of the Insane (GPI), and he may have been exposed to Kraepelin’s speculations on the possible infectious origins of psychosis. Most certainly, the experience reinforced his commitment to discovering the biological roots of mental disorder.
On returning to the United States, Cotton’s glittering résumé and the enthusiastic support of Adolf Meyer secured him the position of superintendent of the New Jersey State Hospital at Trenton, an unusual accomplishment for a young man barely in his thirties. He inherited an overcrowded institution that had had only two superintendents since its foundation in 1848, a backward establishment that routinely employed chains and other forms of mechanical restraint to impose some semblance of order. The superintendent Cotton replaced, John Wesley Ward, preferred tending to his collection of seashells to caring for the patients he was nominally charged with treating. Trained long before the bacteriological revolution in medicine, he openly disdained the modern notion that microscopic organisms caused disease.
That skepticism proved Ward’s downfall. Lack of attention to elementary sanitation—the dairy attached to the asylum farm was filthy, swarming with flies and encrusted with excrement, and the water supply contaminated with human waste—meant that dysentery was endemic, and then the hospital suffered an outbreak of typhoid fever. Patients developed prolonged high fevers and chills, agonizing muscular pains and seizures, and soon the epidemic spread to the staff. Deaths mounted. The asylum discharged its untreated sewage into the Delaware River, from which the city of Trenton drew its water. Making matters worse, rumors began to circulate of a cover-up of murders of patients by hospital attendants. Ward was forced to resign.
Cotton moved swiftly to banish all traces of the ancien régime. Mechanical restraint was abolished, the institution’s water-supply and waste-disposal systems improved, and occupational therapy was introduced to rouse both patients and staff from their torpor. Above all, Cotton sought to connect the asylum to the world of modern medicine. A new operating theater was opened, together with laboratories and a professional library that gave the medical staff access to contemporary medical research. The physicians met frequently to discuss cases and were encouraged to attend medical congresses and contribute to the professional literature. Meyer’s detailed case notes were introduced, and two full-time social workers were employed. Cotton even succeeded in luring one of Meyer’s chief assistants, Clarence Farrar, to forsake his Hopkins appointment and join the Trenton staff.3 Modern psychiatry was on the march.
Except that the expected progress failed to materialize. Cotton, undaunted, was determined to make therapeutic progress. He had attempted to circumvent the failure of Salvarsan to produce therapeutic results in cases of GPI by drilling holes in his patients’ skulls and injecting the drug directly into the cranium. Beginning in 1916, he took things a step further. Others had speculated that insanity might have an infectious origin, and the demonstration that GPI was the product of syphilitic infection had shown that some asylum inmates’ illnesses were the product of bacterial disease. It was time to move beyond speculation and to launch an assault on the reservoirs of chronic infections that Cotton was certain must be poisoning his patients’ brains.4
Billings’s lectures on focal sepsis at Stanford had just appeared in print and may have provided not just the inspiration to move forward, but specific targets to pursue.5 Billings had mentioned the teeth and tonsils as likely sources of overlooked infections. “Deplorable as the loss of teeth may be,” he wrote, “that misfortune is justified if it is necessary to obliterate the infectious focus which is a continued menace to the general health.… Too often the tonsillar tissue in children and also in some adults is a culture medium of pathogenic bacteria and as such is a constant source of danger as a portal of entry of infectious bacteria through the lymph and blood streams to the tissues of the body.… [E]ntire removal is the only safe procedure.”6 Physicians at such august institutions as the Mayo Clinic in Minnesota and Johns Hopkins (in the person of the great William Osler’s successor, Llewellys Barker) endorsed these conclusions.7 So Cotton had respectable company as he launched his assault on what he was convinced were the sources of all forms of madness, from the mildest to the most severe.
COTTON’S 1916 Annual Report on the Trenton Asylum contained a brief passage in which he commented that “we have found that focal infections and the absorption of toxins may appear in the etiology of certain groups primarily held to be purely psychogenic in origin.” The first fifty patients whose teeth had been removed had not, he confessed, seemed much better, but he was undeterred. The following year, he reported on twenty-five patients whose teeth and tonsils had been removed, claiming that twenty-four of the twenty-five had subsequently been discharged as recovered. Unerupted and impacted teeth, teeth with infected roots and abscesses, decayed or carious teeth, apparently healthy teeth with periodontitis, poorly filled teeth, sclerotic teeth, teeth with crowns—all should be regarded with deep suspicion, and, if possible, removed. Modern cosmetic dentistry was a menace. It left in place what were in reality still-decaying teeth, and subterranean pathology continued to undermine health. “It seems incredible,” Cotton remarked, “but it is nonetheless a fact, that the dental schools of today are teaching the installation of gold crowns, fixed bridge work, pivot teeth or Richmond crowns, all of which have been definitively proven to be a serious menace to the individual’s health. To paraphrase an old proverb, ‘Unhealthy is the tooth that wears a crown.’ ”8
Suitably encouraged by what he claimed were remarkable therapeutic results, he announced proudly, “We started literally to ‘clean up’ our patients of all foci of chronic sepsis.”9 X-rays, laboratory analyses, and the regular resort to surgical interventions in the operating theater marked Trenton as a mental hospital where the most advanced medical technology of the era—technology most general hospitals had not yet begun to employ—was mobilized to cure what others deemed hopeless conditions. The key, Cotton argued, was germs. Germs and pus. When many of his patients stubbornly refused to recover, he was undeterred. Other hidden sites of infection had to be tracked down and eliminated. Harmful bacteria had been swallowed and disseminated to other sites in the body. So tonsils and teeth were soon joined by spleens and stomachs, colons and cervixes, as he ruthlessly pursued the goal of a thorough cleansing of the patients’ bodies. Colons were the most prominent target, but it was increasingly clear that there were simply too many lesions in too many sites for a single surgical procedure to suffice.10
Cotton’s program of surgical bacteriology even extended to organs others saw as untouchable. Experience had taught him, for example, that the stomach “is one of the least important organs of the body.… The principal function of the stomach is the storage and motility, each easily dispensed with.… The stomach is for all the world like a cement mixer often used in the erection of large buildings and just about as necessary. The large bowel is, similarly, for storage and we can dispense with it just as freely as with the stomach.”11 By 1921, Cotton had removed a half dozen thyroid glands. For reasons he could not fathom, he found that colons were infected twice as often in female patients, and the cervix, he reported, was also a potent site of low-grade infections. It was these factors that explained the disproportionate number of women who underwent operations.12 Patients often needed several rounds of surgery, since a failure to recover often indicated other hidden reservoirs of infection. One patient admitted for depression and anxiety set some sort of record, for she successively underwent a gastroenterostomy for a stomach ulcer, a thyroidectomy, a complete colectomy, a removal of both ovaries and fallopian tubes, enucleation of her cervix, and a series of “vaccine” treatments designed to address any lingering and overlooked problems. Cotton was nothing if not persistent, and his persistence paid off. Mrs. Llewellyn was at length discharged as cured.13
In laying the foundation for all these interventions, Cotton emphasized not just the virtue of using the most advanced medical technology to track down lurking sepsis, but also the importance of an array of specialists—four surgeons, three gynecologists, a laryngologist, a rhinologist, two ophthalmologists, a dentist, a genito-urinary surgeon, an oral surgeon, a pathologist, and a bacteriologist, not to mention six assistant physicians and a roentgenologist (or specialist in X-rays). Small wonder that when Cotton opened two new wards in 1921, the ceremony was attended by the presidents of both the American Medical Association (Hubert Work) and the American Psychiatric Association (Albert Barrett of Michigan). Work pronounced Trenton one of the “great institutions” in the country: “This is a general hospital, really the first one I ever saw. It excludes nothing. It regards mental alienation as a symptom, as most physicians regard delirium in a fever.… It does not make a bit of difference what the name for a condition is, provided the cause of that condition is found and eliminated.” Here, at last, was a place where “the treatment of the psychoses is surrounded by medical science and not set apart from any part of it.”14
Work’s endorsement was highly significant, and not just because of his prominence in American medicine. President Harding would soon appoint him to his cabinet, and later Work successfully managed Herbert Hoover’s candidacy for the presidency in 1928. Others were equally enthusiastic, including another physician-turned-politician, Senator Royal Copeland, who had previously served as the head of New York City’s Department of Health. Copeland wrote a widely syndicated health advice column, “Your Health,” and often used it to warn of “the perils of pus infection.” Cotton’s work drew particular praise from him on several occasions, an opinion that, he claimed, followed on ward inspections, conversations with patients, and observations of surgical operations: “I have never seen an institution conducted in a better way. There is every consideration given to the latest medical methods, and we should commend its work in every way possible.”15
John Harvey Kellogg, the physician who headed the famous Battle Creek Sanitarium in Michigan, would have preferred that Cotton’s campaign against focal sepsis extend to the exclusion of meat from his patients’ diet, since he saw the putrefaction of dead-animal matter in the intestines as a major source of focal sepsis. But still he offered his support for Cotton’s pioneering assault on the roots of mental disorder.16 And while both Copeland and Kellogg were viewed with some suspicion by many medical men as publicity hounds and (in the case of Kellogg) a food faddist, their influence with the public was considerable.17
There were murmurs of discontent from some of Cotton’s fellow psychiatrists about his mono-causal approach to madness, though the force of their objections was lessened by their simultaneous acknowledgment, as Richard Hutchings, superintendent of the Utica State Hospital in New York, put it, that “there cannot be two opinions as to the advisability of removing sources of infection, whether located in the tonsils, at the roots of the teeth, or elsewhere.”18 Other asylum superintendents eagerly endorsed Cotton’s findings, their opinions solicited by the prominent journalist Albert Shaw, a close friend and confidant of Woodrow Wilson during his years as president and subsequently editor of Wilson’s papers and speeches. Charles Page of Danvers State Hospital in Massachusetts, where Cotton had worked earlier in his career, wrote of his pride in his former assistant and the way he had accumulated “a mass of indisputable facts to … establish … cause and effect, between bacterial toxins and functional insanity.” His encomiums were echoed by the superintendents of King’s Park State Hospital on Long Island, the Arkansas State Hospital, and the Veteran’s Hospital Number 24 in Palo Alto, California.19 The governor of New York was so impressed by Cotton’s work that he sent a three-man commission to examine and report on the work at Trenton, resulting in a special state appropriation to fund a resident dentist at all of New York’s mental hospitals.20
In the early 1920s, Cotton secured two prestigious platforms from which to proclaim his message that “the insane are physically sick.”21 For a number of years, he had lectured on psychopathology to Princeton undergraduates, and two of his most prominent supporters (and sometime trustees of the Trenton State Hospital) were the eminent neurologist and psychiatrist Stewart Paton and the chair of Princeton’s Biology Department, Edwin Conklin. The two men had nominated him for a signal honor, the invitation to deliver the prestigious Louis Clark Vanuxem Foundation Lecture Series at the university.
ON JANUARY 11, 1921, at 4:30 p.m., Cotton rose to deliver the first of four lectures. Nearly 400 people had assembled to hear him. They learned that at the state hospital, not far from the Princeton campus, a full-fledged surgical assault on sepsis was now the order of the day. Each year, thousands of teeth and tonsils were extracted, and scores of colons and other internal organs were removed. The payoff, Cotton proclaimed, was a massive increase in the number of cures, and equally major savings for the state’s treasury. When the New York Times reviewed the published version of the lectures in June 1922, its reviewer, Thomas Quinn Beesley, had no doubt of their importance. “At the State Hospital at Trenton, New Jersey, under the brilliant leadership of the medical director, Dr. Henry A. Cotton, there is on foot the most searching, aggressive, and profound scientific investigation that has yet been made of the whole field of mental and nervous disorders.” Across the country, others had given way to despair, as rates of mental illness grew four times as fast as the general population increase, the Times noted. But thanks to Cotton, “there is hope, high hope … for the future.”22
Desperate for relief from the demons that tormented them (or their nearest and dearest) and dazzled by the seemingly authoritative reports emanating from Trenton, patients and their families urgently sought to share in the new miracle cures. Affluent madmen and madwomen flocked to Trenton—where their willingness to pay premium rates for the attention of Cotton and his consultants made them a highly desirable commodity. Meanwhile, across the country psychiatrists found themselves besieged by supplicants seeking the new wonder cure. Frantic families urged that teeth, tonsils, and guts be ransacked for the source of the germs that prompted hallucinations and delusions, ranting and raving, and depression. For so long, madness had seemed a condition beyond help, a source of stigma and shame. If modern biological science had revealed that it was just another physical affliction, no more than the effects of bacterial poisoning of the brain, then deliverance might be at hand.
Across the Atlantic, news of Cotton’s work had attracted much attention, and in the late spring of 1923 he sailed for Britain, invited to address the Medico-Psychological Association, the professional organization of Britain’s psychiatrists. A number of British physicians and surgeons had by then embraced the doctrine of focal sepsis, as had the head of the city of Birmingham’s mental hospitals, Thomas Chivers Graves. Cotton was greeted as psychiatry’s savior. Illustrating his lecture with a chart of the various locations where chronic infections might lurk, and with X-ray photographs of infected teeth and colons, Cotton spoke at length of the challenges he had faced in overcoming skeptics, genuflecting toward British figures who had previously acknowledged the systemic problems low-grade infections could bring in their train. His own ruthless pursuit and elimination of sepsis had had the happiest of outcomes, he assured his audience. Relying on the most recent advances of scientific medicine—gastric analyses and serology, bacteriological work and X-rays, serums and vaccines, and above all the miracles of modern aseptic surgery—and employing the surgeon’s scalpel and the dentist’s forceps, he claimed to have increased “our recoveries … from 37 percent to 85 percent.”23
Rather than considering the various forms of psychosis as different types of illness, madness ought rather to be seen as “a symptom, and often a terminal symptom of a long-continued chronic sepsis or masked infection, the accumulating toxaemia of which acts directly or indirectly on the brain-cells.” What appeared to be different diseases were in fact simply the reflections of the ways “the psychosis is modified by several factors: first, the duration of the sepsis, the severity of the toxaemia produced, plus the patient’s resistance, or lack of resistance, to septic processes.” One could thus reject competing accounts of the origins of mental illness. Blaming insanity on defective heredity had been “a cloak to mask our ignorance of other factors,” he claimed, which “has had the most unhappy result of stifling investigation, and retarding constructive work.” As for psychoanalysis (and here his audience was united in its approval of his critique), “the extravagant claims made by its advocates are without foundation or justification. Freudism has proven to be a tremendous handicap to psychiatry.”24
A parade of eminent British physicians hastened to praise Cotton. “Wholly admirable,” said the Edinburgh physician Chalmers Watson, except that he thought the proportion of mental patients with diseased colons was considerably higher than the 20 percent Cotton had estimated. In Watson’s view, more rather than less abdominal surgery would be needed to reach the 80 or 90 percent cure rate Cotton’s work made possible. Sir Frederick Mott FRS, the head of the pathological laboratories for all of London’s mental hospitals, was equally complimentary. Cotton’s specimens of bowel disease “closely resembled those which he, Sir Frederick, had seen in his own experience” and the “beautiful pictures and photographs … were most convincing. He referred especially to the beautiful radiograms of teeth and of the bowel conditions.” William Hunter, a prominent surgeon, added his own encomiums: “The striking individual and statistical results described by Dr. Cotton placed the matter beyond all reasonable doubt. It only remained to put measures against sepsis into routine operation not merely in isolated cases, but in all cases of insanity.”25
Summing up the day’s proceedings, the newly elected head of British psychiatry, Edwin Goodall, enthusiastically endorsed Cotton’s remarkable work. His American guest’s new therapeutic ideas “should have served to draw members from the alluring and tempting pastures of psychogenesis back to the narrower, steeper, more rugged and arduous, yet straighter paths, of general medicine.… Before seeking to summon spirits from the vasty deep and one’s subliminal consciousness, let members remember that they were brought up as materialists and biologists; let them, before plunging into those depths, exhaust every material means for dealing with and curing their mental patients.” After all, “here presented today, were results which no-one could deny; seeing was believing.”26
Responding to these tributes, Henry Cotton graciously acknowledged the role British physicians had played in drawing attention to the importance of focal sepsis. His was an approach, like theirs, which insisted on the importance of “real science” as opposed to “the metaphysical, fantastical and otherwise objectionable theory of psychoanalysis.” Speculation must give way before “the facts.” “In our own institution we have a recovery rate of 37 percent up to 1918; but when we put into our work the clearing up of focal sepsis we have, in the last five years, increased that to 85 percent recovery rate.… These figures are based on very conservative facts, and are not due to enthusiasm.”27 It appeared to virtually all in attendance that a new era in psychiatry had dawned.
HENRY COTTON WAS A MASTER at securing publicity for his work. At times, this brought trouble in its wake. One of his earliest publications on focal sepsis was meant to appear in the Psychiatric Bulletin, the official organ of the New York Psychiatric Institute, but when Cotton boasted about his findings to a journalist, not even Adolf Meyer’s intervention could save him from the wrath of its editors.28 He was forced to take the paper elsewhere but seemed undeterred by the experience. Public education came first, or so he rationalized. The longer focal sepsis lingered, the more likely the damage to the brain would become so extensive as to preclude the cure that was otherwise possible. His claims to cure large fractions of those he treated circulated widely, drawing growing numbers of patients to Trenton, many coming from great distances.
The case of Margaret Fisher, one of the first private patients to be transferred to Trenton, illustrates the eagerness with which even highly educated and well-connected people arrived, bringing with them relations in desperate need of miraculous new remedies. Margaret was the daughter of Irving Fisher, a Yale professor lionized by Joseph Schumpeter as “the greatest economist the United States has produced.”29 Fisher was an arrogant, ruthless, and domineering man who made and eventually lost a fortune exceeding $10 million (more than $150 million in today’s money). He enjoyed access to the highest circles of American society, and he embraced a host of causes, including Prohibition, eugenics, dietary reform, and the extension of the human life span.
Fisher developed close ties with John Harvey Kellogg, with whom he shared interests in “race betterment” and in the value of a healthy, fiber-filled diet. Beginning in the early 1900s, Fisher began to take his family to Kellogg’s establishment each year to partake of the cure. It was an increasingly popular pilgrimage undertaken by many politicians and captains of industry. Hydrotherapy, exercise, a vegetarian diet, close attention to the working of the bowels—all these central elements of Kellogg’s regimen became a regular part of the Fisher family routine. As a dutiful daughter, Margaret embraced such healthy practices at her father’s urging. Still living at home as she entered her twenties and serving as an unpaid office assistant to her father, Margaret seems to have undergone a slow mental deterioration beginning about 1916. The changes were subtle at first, the onset of her symptoms insidious and easy to overlook or rationalize. Only in retrospect did her parents come to see them as signs of incipient pathology.
On April 27, 1918, three days before her twenty-fourth birthday, Margaret became engaged to be married. Her parents were delighted, and Margaret’s father, having checked the young man’s pedigree for a family history of insanity or criminal activity with one of his oldest friends, urged her to marry as soon as possible. But the prospect seems to have unhinged her. Within days, as Cotton later noted in the last of his Vanuxem lectures (without mentioning Margaret by name), she began to babble “queer things about portents and was afraid her fiancé would not come back [from the war].” “She soon began to talk at random about ‘God, Christ, and immortality,’ ” and began to have auditory hallucinations. Her conduct was peculiar in many ways. Her condition gradually worsened, and on June 1 she was sent to a private hospital.30
Thus far, the Fishers had defined her condition as a temporary nervous prostration and had kept her out of any sort of psychiatric facility. Once hospitalized, as Cotton’s case notes recorded, “she became much worse, and could not be controlled.” Her parents’ hands were forced. Fisher and his wife concluded that “it was necessary to send her to the Bloomingdale Asylum” in White Plains, long regarded as a suitable institution for those of their social class. Admitted on June 27, Margaret was “pensive and preoccupied, and at times depressed. She responded slowly to questions and when aroused was irrelevant.”31
Her psychiatrists soon despaired of her prospects. Noting the “acute distortion of the patient’s personality with marked distortion in thinking, peculiar behavior, and disharmony between mood and thought content,” they concluded that her psychosis “seems more nearly related to the schizophrenic disorders than to the exhaustive or manic-depressive disorders.” These were important and potentially devastating diagnostic distinctions. Schizophrenia in this era was widely considered to be an incurable condition, and the Fishers were informed that “a recovery without defect symptoms seems improbable.”32 It was not a verdict Irving Fisher was willing to accept. He promptly arranged for Margaret to be released from Bloomingdale on March 29, 1919. Later that day, she was spirited out of state and admitted as a private patient to Trenton State Hospital.
Over the years, Fisher had maintained close contact with John Harvey Kellogg. In August 1914, the two men had jointly organized the First International Congress on Racial Betterment in Battle Creek, and Fisher had written for Kellogg’s magazine, Good Health. Kellogg, like Cotton, emphasized the nefarious influences of decayed teeth and also the poisons that lurked in the bowels. So when Fisher learned of Cotton’s assertions about the etiological connections between focal sepsis and insanity, and the possibility of intervening to cure the apparently hopeless mental patient through a program of surgical bacteriology, he was primed to accept those claims.
Neurologically, Cotton reported, Margaret Fisher appeared to be normal. But there was ominous evidence of “marked retention of fecal matter in the colon with marked enlargement of the colon in this area.” “Because of her resistiveness, X-ray studies of the intestinal tract could not be made,” but Cotton was convinced that the source of a substantial portion of her problems had been uncovered. Proceeding further, he found evidence that her “cervix was eroded.” Deeply suspect as well were two unerupted molars, which Cotton immediately insisted must be extracted. He next approached the Fishers for permission to perform “an exploratory laparotomy”—a surgical opening of the abdomen to examine the internal organs—“based upon the physical examination and the fact of long-continued constipation.”33
Irving Fisher and his wife were eager to embrace this physical account of their daughter’s disorder. It was in close accord with their own beliefs about human health, and a far more hopeful prognosis than the one the doctors at the Bloomingdale Asylum had delivered. Still, they hesitated to endorse so drastic a remedy as surgery on Margaret’s bowels. They announced that they “preferred to wait till other means such as vaccines and serum should be exhausted.”34
In August, however, they did consent to the removal of a portion of Margaret’s cervix, after being advised of the presence of “pure colon bacillus” in her tissues. The operation was performed by Cotton’s assistant, Dr. Robert Stone, on August 15, 1919. The following day, Fisher and Cotton took the train to Battle Creek to consult Kellogg on how next to proceed. Cotton was clearly doing all he could to overcome Fisher’s hesitations about further surgery for his daughter. Fisher wrote to his wife, “Dr. C. doesn’t think M. will suffer any pain. The uterus, like the intestines and other internal organs, has few nerves.… I suspect that the colon bacillus is the little demon most to blame.”35 Two days later, another letter hinted that Mrs. Fisher had harbored such suspicions long before Margaret had been referred to Trenton for treatment: “I imagine,” Irving Fisher wrote, “that you have been as right as anyone that constipation is the key.”36
Yet still Margaret’s parents hesitated. Back at the hospital, Cotton acknowledged that “the family preferred to wait. So in September, another course of antistreptococous [sic] treatment was given.”37 Again, he urged surgery on the bowels. Again, Fisher temporized. “As to operating on M.,” he wrote to his wife in early October, “we’ll talk it over with Dr. C. and each other.”38 And then events took the decision out of their hands.
Cotton obtained another batch of “vaccine” prepared for him by the nearby Squibb Company. In all probability, it was this intervention that produced a fatal crisis, the result of a failure to kill the streptococci before injecting them into poor Margaret’s body. In any event, in late October Margaret exhibited symptoms of inflammation of the lungs, and a deep-seated abscess developed over the ribs on her left side—an abscess that, when lanced and cultured, Cotton recorded, “gave pure streptococcus—the same type found in the teeth and stomach. The condition of the patient did not improve and her temperature continued to be high. She failed rapidly and died on Nov. 7, 1919,” a little more than seven months after she had been admitted to Cotton’s care.39
Despite Margaret’s death, Cotton believed that her case demonstrated the septic origins of psychosis. Fisher, though devastated by his daughter’s death, continued to believe in Cotton’s theories and to insist that there had been a physical cause of her mental breakdown. “Even in later years,” according to one of his biographers, Robert Loring Allen, “he wrote his friend Will Eliot that some form of toxemia causes a nervous breakdown.”40 Of course, such sustained faith was a natural defense mechanism in the face of the choices he had made and the treatments he had authorized.
FISHER WAS NOT ALONE. Legions of other well-to-do Americans followed in his footsteps, so many that the number of private patients showing up in Trenton to receive treatment began to exceed the capacity of the state hospital to receive them. As their ranks swelled, Henry Cotton seized the opportunity to open a private hospital in Trenton. Henceforth, the bulk of his paying patients were referred to this facility for their treatment.
In one important respect, Henry Cotton’s approach to Margaret Fisher’s treatment was at variance with his usual procedures. In her case, he had taken great pains to consult with her family and to accede to their wishes when they sought to delay or avoid certain forms of treatment for their daughter. As a general rule, however, Cotton ignored objections from patients and their families and was quite open about doing so. Such protests were, he claimed, short-sighted and ignorant. If they were voiced by patients, their madness had rendered them incapable of rendering a valid choice, and if by their families, they could be dismissed as the product of a lack of medical knowledge: “If we wish to eradicate focal infections, we must bear in mind that it is only by being persistent, often against the wishes of the patient … [that we can] expect our efforts to be successful. Failure in these cases at once casts discredit upon the theory, when the reason lies in the fact that we have not been radical enough.”41 He was blunter still in one of his Annual Reports. Psychoanalysts, he pointed out, often sought to excuse their therapeutic failures by blaming patients’ resistances and their refusal to cooperate with the talking cure. His approach suffered from no such obstacles: “We offer no such excuse for our work because patients who are resistive and non-cooperative can be given an anesthetic and the work of deseptization thoroughly carried out.”42
The outcome in Margaret Fisher’s case was sadly not in the least unusual. From the very first reports Cotton made in the professional literature about abdominal operations to cure psychosis, he had acknowledged large numbers of deaths. When he and John Draper (the surgeon Cotton had brought in to New York to perform the surgery) reported on the seventy-nine cases they had operated on between mid-1919 and mid-1920, they acknowledged that twenty-three had “died as a result of the operation,” generally from peritonitis.43 Elsewhere, when Cotton reported on a series of fifty cases of what he called “developmental reconstruction of the colon,” he noted that fourteen more (28 percent of the total) had died.44 A year later, he recorded some improvement of the mortality rates, down to “about twenty-five percent” (again with “many of the deaths being due to “peritonitis”).45 But the improvement, if any, was short-lived. A 1922 paper given to the American Psychiatric Association reported on a larger series of 250 colon operations, with 30 percent of these patients having died.46 (Cotton had by now decided to perform his own surgery.) At his extraordinarily well-received lecture in London to the assembled British psychiatrists, Cotton provided two more sets of statistics: the first for total colectomies (133 cases with 44 deaths); the second for a less extensive operation, resection of the right side of the colon (148 cases with 59 deaths).47
The mortality statistics might seem high, but Cotton assured his audience that they were tolerable, since they were “largely due to the very poor physical condition of most of the patients.”48 It was an explanation the diverse audiences he addressed seem to have accepted without demur. On no occasion was there any comment or criticism directed at the proportion of patients who had died from the surgery. Indeed, in London, more than one speaker complained that Cotton had perhaps been too conservative in performing abdominal surgery on only 20 percent of his patients, and suggested a more extensive use of colectomies was in order.49
Cotton’s claims about the success of his treatment had, however, begun to attract criticism in some quarters on other grounds. At the annual meeting of the American Psychiatric Association in Montreal in 1922, a Columbia bacteriologist, Nicholas Kopeloff, and the assistant director of the New York Psychiatric Institute, Clarence Cheyney, delivered a paper reporting on their attempt to replicate Cotton’s work. Eschewing abdominal surgery as too risky, they had subjected a group of patients to defocalization. Teeth and tonsils had been extracted, and where there was some evidence of infection, gynecological surgery performed. Alongside those treated to eliminate focal sepsis, they had constructed a control group matched as to age, sex, and psychiatric diagnosis and prognosis. They pronounced themselves unable to discover any evidence that removal of sepsis had any positive effects.50
Cotton spoke afterward and simply dismissed their findings as the product of their conservative approach and unwillingness to search out sepsis wherever it lay. Besides, he noted, Kopeloff lacked the necessary medical training to evaluate the evidence, being a mere PhD. A fierce discussion ensued. Some clearly saw Cotton as an enthusiast, though even they did not raise doubts about the wisdom of removing sepsis. Many others rallied to his defense, and a burst of applause greeted one of the final speakers, who urged: “We want this matter to go on. We want Dr. Cotton to proceed with his investigation; to present facts and not mere opinions. If there is anything in it we want to help him. (Applause.) We do not want to put ourselves in a position of opposition to anything that promises benefit or good to our patients.… We need to do more of the work Dr. Cotton is doing.”51 Recognizing that most were lining up behind Cotton, Bernard Glueck, who had suggested the formation of a committee to investigate the work at Trenton, rose to withdraw his motion, protesting that he had never meant his proposal to be seen as “putting a check on [Dr. Cotton’s] work.”52
There was evidence, however, of mounting concern among some senior figures in the field. Their objections were not to his experimentation on vulnerable human beings, or his boasts about ignoring the objections of patients and their families, or the alarming rate of death among his patients. Rather, what upset them was “the rather remarkable, and in the minds of many, unethical, exploitation of the methods and results claimed at Trenton in a lay periodical … in such a manner as to minimize the value of Dr. Cotton’s fellow members.… The value of Dr. Cotton’s work and the soundness of his conclusions, cannot be measured or discussed, with any good to the public or the profession in lay journals or the daily press.”53
Sensing that a hostile outside investigation of Cotton’s work might be forthcoming, the Trenton Hospital’s board, proud of their superintendent’s accomplishments and the attention they had drawn, decided to forestall that eventuality by commissioning an outside investigation of their own. They approached Adolf Meyer to conduct it—a curious choice if they wanted an independent review, since Meyer was Cotton’s mentor, had written an approving foreword to the published version of the Vanuxem lectures, and remained on close terms with his protégé throughout his career.54 Meyer at first wrote that he was too busy but then agreed to second one of his chief assistants, Phyllis Greenacre, to the day-to-day work and to oversee the project. For eighteen months, Greenacre labored to reexamine Cotton’s claims, traveling around New Jersey, Pennsylvania, and New York to check on the condition of former patients, and constructing detailed summaries of treatments and outcome.
A meeting between Greenacre, Cotton, and Meyer to discuss her findings had to be postponed for some months when Cotton suffered a breakdown. Packed off to Hot Springs, Arkansas, to recover, he arranged for some of his teeth to be pulled to eliminate the focal sepsis that must surely be at the root of his mental troubles. When he at last arrived in Baltimore and came to Meyer’s office, the meeting proved tense. Greenacre’s detailed report was uncompromising and unambiguous in its findings. And quite devastating.
The three principals met over three uncomfortable days. Meyer mostly sat silent while Greenacre reviewed what she had found. Cotton bullied and blustered and, when he found he could not silence or intimidate a woman many years his junior, stormed out and took the train back to Trenton.
Greenacre reported that recoveries, contrary to Cotton’s claims of an 85 percent cure rate, were few and far between, and her findings were “somewhat paradoxical in that … the least treatment was found in the recovered cases and the most thorough treatment among the unimproved and dead groups.” Beyond this, death was all too often the direct sequel of the surgery, whether from shock, from peritonitis, or from postoperative complications that included uncontrollable diarrhea. “There is,” she concluded, “practically no evidence of positive results obtained by detoxication methods.”55
One might have expected that this would have marked the end of the affair. Nothing of the kind. Meyer suppressed Greenacre’s report, and it never surfaced. The hospital board at Trenton, which also possessed a copy of her detailed findings, simply sided with their superintendent. And Cotton resumed his defocalization, pursuing infected teeth, tonsils, and colons with the same enthusiasm as before.
In mid-1927, Cotton sailed for Britain, invited to appear at a joint meeting of the British Medical Association and the Royal Medico-Psychological Association in Edinburgh. Once more, he was lionized by the great and good of British medicine. The year 1927 marked the centenary of the birth of Lord Lister, the man who had introduced antiseptic surgery, and Cotton was hailed as the new Lister of psychiatry, the man who had launched “a desperate frontal attack with horse, foot, and artillery … on the whole field of the sepsis … in the teeth, the tonsils, nasal sinuses, stomach, intestine and colon, and the genito-urinary tract, with the result of doubling the number of his discharges, and reducing the average stay in hospital from ten months to three months.”56
What was needed now, as Cotton himself had urged, was a campaign of prophylaxis, eliminating suspicious teeth and tonsils and operating on children suffering from constipation to head off future mental troubles. Demonstrating how completely he was convinced by his own argument, Cotton arranged to have his wife’s and his two children’s teeth extracted, and when his younger son suffered from constipation, to have his son’s colon resected. Sadly, the prophylaxis did not succeed. Both Adolph Cotton and his brother Henry later committed suicide.
Back in the United States, where his British triumph had made the papers, Cotton was honored by the State of New Jersey for his twenty years as superintendent of their flagship state hospital. The dinner was a splendid occasion, attended by the governor and over 400 invited guests. The rich continued to flock to Trenton in search of Cotton’s miracle cures, and they were mostly operated on at his private facility. Meanwhile, he attacked the problems of the state-hospital patients with renewed ferocity. He was increasingly convinced that he had not been “radical enough.” X-rays and inspections of patients’ mouths were not sufficient. Previously, he had lacked the courage of his convictions, but no such inhibitions restrained him now:
Many dentists would hesitate to extract vital [healthy] teeth and for some years we followed this practice. But we have found within the last year that many of our failures were due to the fact that we allowed vital teeth to remain in the mouth although we had extracted a large number of devitalized teeth, which were infected. It has become the rule now that if a patient is found to have a considerable number of infected teeth complete extraction must be done in order to eradicate all infection in the mouth.… [W]e have by necessity become more radical.57
The same logic applied to other regions of the body, “for there can be no question that infection originating in the mouth, especially in the teeth and tonsils, migrates to other parts of the body setting up secondary foci of infection.”58
“Our success,” he noted, “has been due to a combination of methods, all directed to the elimination of all sources of infection.” Closer inspection had revealed that 76 percent of his female patients had infected cervixes. Problems involving the “lower intestinal tract” were even more common, identifiable by “sluggishness and delay due to the toxic effects of chronic infections on the musculature of the colon.… [A]t least 86 percent [of both male and female patients] will be found to have internal stasis and toxemia.” Perhaps fortunately, he had discovered that in many cases these putrefactive processes and the mental illnesses they spawned could be forestalled by a new treatment he had discovered, “massive colonic irrigations, 15–20 gallons in a treatment.” So successful had these proved that “each case right after admission [is] being given colonic irrigations as soon as possible.” And if they didn’t recover, resection of their colons was the obvious next step.59
As the mutilations and deaths continued to accumulate, Meyer kept a tight lid on Greenacre’s findings. Another of his assistants, Solomon Katzenelbogen, traveled to Trenton to view Cotton’s work for himself. On his return, Katzenelbogen reported on what he had seen to his chief. He had been startled to see how careless the diagnostic processes at the hospital were. The staff’s response was that “the accurate discrimination between different types of psychosis matters very little, for the reason that any psychosis would be of septic origin.”60 He found patients were being given typhoid vaccines for dubious reasons. “The patients have fever, chills, and they quiet down,” he reported. “Those who have insight and had once the injection [sic] are threatened with being given a second one if they do not behave. The menace works well.” Colonic surgery was performed on the least excuse, with the “certainty of finding abnormalities in the removed colons and adhesions on laparotomy.”
Walking the wards, Katzenelbogen reported, was a sobering experience:
I felt sad, seeing hundreds of people without teeth. Only a very few have sets of false teeth. The hospital takes care as to the pulling out of teeth, but does not provide false teeth.… The extraction of teeth does great harm to those who cannot afford to pay for a set of false teeth, and these patients are numerous. While in the hospital they suffer from indigestion … not being able to masticate their food. At home, recovered, these poor people have the same troubles, not being in a position to choose food which they would be able to eat without teeth. In addition, they are ashamed of being without teeth, since in their communities it is known to be a token of a previous sojourn in the State Hospital. They abstain from mixing with other people, refuse to go out and look for a job.… Thus, many of those recovered develop a reactive depression.61
Meyer read Katzenelbogen’s report, filed it, and sat on his hands. Though the psychiatric profession, with some exceptions, had grown increasingly skeptical of Cotton’s claims, the most influential psychiatrist in the country remained determined to avoid scandal.62
On May 8, 1933, the Trenton Evening Times reported some sad and unexpected news. While lunching at his club, Henry Cotton had suffered a heart attack and was dead. The following day, its obituary paid tribute to a psychiatrist who had brought so much attention to the state: “Thousands of people who have suffered from mental affliction owe him an enduring debt of gratitude for … displacing confusion and despair with hope and confidence.” The paper further suggested that all must lament the loss of “this great pioneer whose humanitarian influence was, and will continue to be, of such monumental proportions.”63
His successors at Trenton, all former assistants, continued to profess their fealty to the doctrine of focal sepsis. Abdominal surgery was quietly abandoned almost immediately, but the use of vaccines, colonic irrigations, and the extraction of teeth and tonsils continued to be an extensive part of the therapeutic armamentarium employed by the hospital’s staff well into the 1950s, alongside a host of other somatic treatments that entered American psychiatry in the 1930s. Absent Henry Cotton’s loud proselytization, it was these more up-to-date remedies the profession came to embrace.
But Adolf Meyer was not content to let his protégé’s efforts simply fade from view. He volunteered to write Cotton’s obituary for the American Journal of Psychiatry. Here the formidable Swiss-German psychiatrist who dominated American psychiatry for the first half of the twentieth century delivered his verdict. The profession, he wrote, had suffered “an outstanding and premature [loss].” Henry Cotton had been “a man of action and results.… [H]e made an extraordinary record of achievement. His views and practices were a vigorous challenge which stood non-compromisingly for an almost unitary explanation by focal infection, supported by the testimony of a number of patients and a number of colleagues.” Meyer acknowledged that these claims had been controversial. But what Cotton had achieved “at Trenton State Hospital is a most remarkable achievement of the pioneer spirit” and one could only lament the premature departure of “one of the most stimulating figures of our generation” with his work “only partially fulfilled.”64
Thus was the trail of maimed and dead bodies and the record of thousands of patients treated against their wills summarized for the profession at large. An independent study of the results of Cotton’s colonectomies conducted just before his death (and never published) concluded that the extraordinary mortality rates he acknowledged significantly underestimated the carnage he left in his wake, putting the actual death rate at more than 44 percent.65