Lately, I’ve been researching into cases of malpractice between doctors and patients, medical legislation, and the role of the NHS- all part of my EPQ research. There was one piece of information that I found particularly interesting and want to share it with you all today. This post is all about Henry Cotton and his approach to mental health in the 20th century. Dr Henry Andrews Cotton, born in 1876 and died in May 1933, was an American psychiatrist and the medical director of New Jersey State Hospital at Trenton from 1907 to 1930. He thought insanity is caused by infection and he tried to cure it by removing patients’ teeth, tonsils, stomachs, gallbladders, colons, testicles and ovaries. As a result, he and his staff practiced experimental “surgical bacteriology” on patients, which included the routine removal of some or all of patients’ teeth, their tonsils, and frequently spleens, colons, ovaries, and other organs as I stated above. These practices on patients and those who had poor mental health continued for a long until careful statistical reviews demonstrated that these treatments caused very high mortality and morbidity as a result of these aggressive and dangerous measures, falsifying Cotton’s theory and approach to mental health.
Mental health is, without a doubt, one of the most important things in the medical profession especially in society today with Mental Health Awareness days and weeks, charities supporting mental health such as MIND and fundraising events that take place annually to help those suffering from mental health disorders. In fact, it can be said that mental health is seen as just as important as physical health in modern society. However, as great as that sounds for us now, mental health wasn’t seen in such a way a few decades and centuries ago. Mental health tended to be an illness caused by evil spirits or a punishment from God. Those who suffered mental health were seen as ‘bad people’ and had to undergo particular treatments such as trepernation and ‘cleansing’ procedures. Society focused more on the treatment on mental health rather than finding a cure as it was not seen as important. As time progressed, particularly in the 19th century, mental health was of a higher importance than that of Ancient Egypt or the Prehistoric era, however people were not treated properly or to the best of a doctor’s ability mainly due to the idea that if you can’t see it, it isn’t important and can be brushed aside. If you think about it, physical health is visible to the naked eye so doctors and nurses can rapidly place ointments and bandages on wounds to prevent the wound from worsening and to reduce its severity. Whereas with mental health, there is no physical evidence at first and it’s much more difficult and changing to ‘cure’ and treat.
Henry A. Cotton had studied in Europe and was a student of Dr. Adolf Meyer of Johns Hopkins School of Medicine, who dominated and was extremely well-known for his skills in American psychiatry in the early 1900s. Based on the observation that patients with high fever often turn delusional or begin hallucinating, Cotton was introduced to the idea of the possibility of infections (which used to be viewed as the key concept of scientific medicine) being a biological cause of behavioral abnormalities, in contrast to eugenic theories which emphasized heredity and traumas. This inspired Cotton to become the leading practitioner of the new approach in the United States.
After becoming medical director of Trenton State Hospital at the age of 30, Cotton instituted many progressive ideas. These included abolishing mechanical restraints and implementing meetings of daily staff to thrash out patient care. Cotton began to implement the emerging medical theory of infection-based psychological disorders by pulling patients’ teeth, as he suspected them to be harboring infections. If this failed to cure a patient, he sought sources of infection in tonsils and sinuses in the body and Cotton was often found to be telling patients that tonsillectomy was recommended as additional treatment. If a cure was not achieved after these procedures, other organs were suspected of harboring infection. Testicles, ovaries, gall bladders, stomachs, spleens, cervixes, and especially colons were suspected as the focus of infection and were removed surgically. All of which I probably assume that you are aware of and the key functions of them.
During Cotton’s time, there weren’t many scientific methods such as control groups, double-blind experiences so medical research didn’t greatly occur during Cotton’s lifetime which affected his method of thinking and his surgical procedures. He reported wonderful success with his procedures, with cure rates of 85%; this, in conjunction with the feeling at the time that investigating such biological causes was the state of the art of medicine, brought him a great deal of attention, and worldwide praise. He was honored at medical institutions and associations in the United States, the United Kingdom, and Europe and asked to make presentations about his work and to share information with the others who practiced the same or similar methods. Patients, or their families, begged to be treated at Trenton, and those who could not, demanded that their own doctors treat them with these new wonder cures. In June 1922, the New York Times wrote in a review of Cotton’s published lectures:
“At the State Hospital at Trenton, N.J., 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… there is hope, high hope… for the future.”
Unfortunately, in an era before antibiotics surgery resulted in a very high rate of postoperative morbidity and mortality, largely from infection. Among his patients at this time was Margaret Fisher, who was a daughter of wealthy and famed Yale economist, Irving Fisher, who believed in the well-known hygienic movement of the period. Diagnosed by physicians in Bloomingdale Asylum as schizophrenic, which was before the modern development of some pharmaceutical agents, Fisher had his daughter transferred to Trenton for treatment done by Henry Cotton. However, because Cotton attributed her condition to a “marked retention of fecal matter in the cecal colon with marked enlargement of the colon in this area” , she was subjected to a series of colonial surgeries before dying of a streptococcal infection in 1919. This sudden, expected and , without a doubt, sad death caused the death to be a dangerous form of surgery. It recognized by some patients in the institution, who, despite their mental illness, developed a very rational fear of the surgical procedures, some resisting violently as they were forced into the operating theater in complete contradiction of what are now commonly accepted medical ethics. A inferior attitude and the permission of the family of seriously insane patients was the basis of intervention at the time. Dr. Meyer, head of the most respected psychiatric clinic and training institution for psychiatrists in the United States, at Johns Hopkins University, accepted the theory. He was encouraged by a like-minded member of the state board of trustees who oversaw Trenton State Hospital to provide an independent professional review of the work of Cotton’s staff. Meyer commissioned another of his former students who practiced psychiatry on his staff at the Phipps Clinic, Dr. Phyllis Greenacre, to critique Cotton’s work. Her study began in the fall of 1924 just after Meyer visited the hospital and privately had expressed concern about the statistical methods being applied to provide an assessment of Cotton’s work. Cotton’s staff made no effort to facilitate the study. She realized that the appearance and behavior of almost all of the psychotic patients was disturbing to her because their teeth had been removed, making it difficult for them to eat or speak. Further reports cast serious doubt on Cotton’s reported results; she found the staff records to be chaotic and the data to be internally contradictory. In 1925 criticism of the hospital reached the New Jersey State Senate, which launched an investigation with testimony from unhappy former patients and employees of the hospital. Countering the criticism, the trustees of the hospital confirmed their confidence in the staff and director, and presented extensive professional praise of the hospital and the procedures followed under the direction of Cotton, whom they considered a pioneer.
On September 24, 1925, The New York Times stated that, “eminent physicians and surgeons testified that the New Jersey State Hospital for the Insane was the most progressive institution in the world for the care of the insane, and that the newer method of treating the insane by the removal of focal infection placed the institution in a unique position with respect to hospitals for the mentally ill” and related accolades given in support of Henry A. Cotton by many professionals and politicians.
Falling ill during the public hearing, some assert that Cotton suffered a nervous breakdown, diagnosed himself as suffering from several infected teeth, which he promptly had removed, pronounced himself cured, and returned to work. Soon Cotton opened a private hospital in Trenton which did a hugely lucrative business treating mentally ill members of rich families seeking the most modern treatments for their conditions. Meyer reassigned Greenacre without completing her report and resisted her efforts to complete the report. Admitting a shared belief in the possibility that focal sepsis might be the source of mental illness, Meyer never pressed his protege to confront the scientific analysis of the erroneous statistics the hospital staff provided to Cotton, his silence guaranteeing continuance of the practices. Later Cotton would occasionally admit to death rates as high as 30% in his published papers. It appears that the true death rates were closer to 45% and that Cotton never fully recognized the errors his staff made in analyzing his work. Furthermore, in October 1930, Cotton was retired from the state hospital and was appointed medical director emeritus. Although this ended the abominable surgeries which were so dangerous before the discovery of antibiotics, the hospital continued to adhere to Cotton’s humane treatment guidelines and, to carry out his less risky medical procedures until the late 1950s. Henry A. Cotton continued to direct the staff at Charles Hospital until his death.
In the early 1930s Cotton’s rate of postoperative mortality began to be a matter of professional debate in the state department of institutions by some concerned that he intended to press to resume his position at the state hospital. Another report on Cotton’s work was begun in 1932 by Emil Frankel. He noted that he had seen Greenacre’s report and agreed with it substantially, but his report also failed to be completed. Henry A. Cotton died suddenly of a heart attack in 1933 and was lauded in The New York Times and the local press, as well as international professional publications, for having been a pioneer seeking a better path for the treatment of the patients in mental hospitals.
What do you think of this situation involving Henry Cotton and how do you think it has influenced surgery and anatomy in society today?