Madhouse: A Tragic Tale of Megalomania and Modern Medicine
http://www.100md.com
《新英格兰医药杂志》
Andrew Scull, a professor of sociology at the University of California, San Diego, tells a fascinating story — really several stories — about the history of psychiatry, the personal and professional lives of several famous psychiatrists, and the limitations and failures in the oversight of the care of the disadvantaged. He argues against placing too much trust in experts, but he actually makes a strong case for the value of expert clinical research and the danger of ignoring its findings.
Henry Cotton, a disciple of Adolf Meyer, the chairman of the department of psychiatry at Johns Hopkins University, was medical director of Trenton State Hospital (now known as Trenton Psychiatric Hospital) from 1907 until 1930. His mission was to make psychiatry science-based, to treat and cure rather than merely house and care for the mentally ill, and to bring psychiatry into the fold of contemporary medicine. Persuaded by the advances in bacteriology and general medicine and the recently discovered role of syphilis in psychiatric illness, Cotton became convinced that psychiatric patients suffered from the toxic products of hitherto unrecognized focal infections. The treatment, and even prevention, of psychiatric disorders required removing the foci, usually surgically, by extracting teeth, draining sinuses, removing tonsils, and operating on gallbladders, genitalia, stomachs, and especially colons. Hundreds of patients were so "treated"; many died, and others did poorly (although he insisted that they prospered). Cotton eventually fell from grace, largely because of unrelated administrative problems, but he first demonstrated the sincerity of his convictions by having surgical procedures performed on his wife, his two sons, and himself. His personal tale includes a psychotic episode and the suicide of both his sons.
The third psychiatrist central to this story, Phyllis Greenacre, was later to become one of the most distinguished American psychoanalysts, but the reader meets her in 1916 when she is leaving her dysfunctional family in Chicago for psychiatric training under Meyer. She faces multiple challenges — being a woman in a man's world, a Chicagoan in the East Coast establishment, and a psychiatrist in a medical world. She earns Meyer's respect and even gets him to endorse her marriage to Johns Hopkins psychobiologist Curt Richter and her plan to be mother, wife, and professional woman — rare in the Hopkins world of the 1920s. However, there was little practical reward, in either title or money. She protested, and in 1924 Meyer proposed a solution, arranging a stipend for her to conduct "a study of Cotton's work on focal infection and insanity." The Trenton hospital's board of managers wanted to bolster Cotton's status and had asked Meyer, the most acclaimed academic psychiatrist in the nation, to supervise the project.
Greenacre's findings were devastating. Cotton's clinical data were flawed and the statistics misleading. Mortality was higher than reported, positive effects less frequent, and informed consent virtually nonexistent. Cotton had been administering ineffective, dangerous treatments to unwilling patients, maintaining inadequate records, and yet proclaiming success to a gullible audience. Meyer agreed; however, his subsequent behavior was astonishing — the report was never released. He insisted that Cotton review it first, but Cotton never did so, simply denying the facts and insisting that he was right. Greenacre protested, but a messy divorce and professional setbacks distracted her (although the entire episode may have liberated her from Meyer and catalyzed her psychoanalytic career).
Scull tells these stories with journalistic intensity and rhetorical flourish. He emphasizes several conclusions, but perhaps not the most important ones. He argues with Cotton's biologic reductionism — but the problem was not reductionism; it was that Cotton was wrong. Cotton's theory was no more reductionist than that of modern psychopharmacology. Scull fails to emphasize how little Cotton's work had to do with real science; the ideas were borrowed from contemporary medicine, but the results were never tested scientifically — the same error that was made later with psychosurgery. Greenacre's research exposed the problem, but Meyer deferred to professional etiquette rather than science. Strangely for a sociologist, Scull fails to discuss the inadequate professional and administrative structures that allowed this tragedy to continue unchecked. Cotton's board failed to supervise him and then failed to demand the final report. Medical scientists who depend on public support have always exaggerated their hopes and successes and minimized their failures; otherwise, they fail to garner that support. Cotton was playing the game, but without adequate checks and balances.
The story is interesting, is well told, and offers important lessons on how not to structure a clinical research program.
Robert Michels, M.D.
Cornell University
New York, NY 10021
rmichels@med.cornell.edu(By Andrew Scull. 360 pp.,)
Henry Cotton, a disciple of Adolf Meyer, the chairman of the department of psychiatry at Johns Hopkins University, was medical director of Trenton State Hospital (now known as Trenton Psychiatric Hospital) from 1907 until 1930. His mission was to make psychiatry science-based, to treat and cure rather than merely house and care for the mentally ill, and to bring psychiatry into the fold of contemporary medicine. Persuaded by the advances in bacteriology and general medicine and the recently discovered role of syphilis in psychiatric illness, Cotton became convinced that psychiatric patients suffered from the toxic products of hitherto unrecognized focal infections. The treatment, and even prevention, of psychiatric disorders required removing the foci, usually surgically, by extracting teeth, draining sinuses, removing tonsils, and operating on gallbladders, genitalia, stomachs, and especially colons. Hundreds of patients were so "treated"; many died, and others did poorly (although he insisted that they prospered). Cotton eventually fell from grace, largely because of unrelated administrative problems, but he first demonstrated the sincerity of his convictions by having surgical procedures performed on his wife, his two sons, and himself. His personal tale includes a psychotic episode and the suicide of both his sons.
The third psychiatrist central to this story, Phyllis Greenacre, was later to become one of the most distinguished American psychoanalysts, but the reader meets her in 1916 when she is leaving her dysfunctional family in Chicago for psychiatric training under Meyer. She faces multiple challenges — being a woman in a man's world, a Chicagoan in the East Coast establishment, and a psychiatrist in a medical world. She earns Meyer's respect and even gets him to endorse her marriage to Johns Hopkins psychobiologist Curt Richter and her plan to be mother, wife, and professional woman — rare in the Hopkins world of the 1920s. However, there was little practical reward, in either title or money. She protested, and in 1924 Meyer proposed a solution, arranging a stipend for her to conduct "a study of Cotton's work on focal infection and insanity." The Trenton hospital's board of managers wanted to bolster Cotton's status and had asked Meyer, the most acclaimed academic psychiatrist in the nation, to supervise the project.
Greenacre's findings were devastating. Cotton's clinical data were flawed and the statistics misleading. Mortality was higher than reported, positive effects less frequent, and informed consent virtually nonexistent. Cotton had been administering ineffective, dangerous treatments to unwilling patients, maintaining inadequate records, and yet proclaiming success to a gullible audience. Meyer agreed; however, his subsequent behavior was astonishing — the report was never released. He insisted that Cotton review it first, but Cotton never did so, simply denying the facts and insisting that he was right. Greenacre protested, but a messy divorce and professional setbacks distracted her (although the entire episode may have liberated her from Meyer and catalyzed her psychoanalytic career).
Scull tells these stories with journalistic intensity and rhetorical flourish. He emphasizes several conclusions, but perhaps not the most important ones. He argues with Cotton's biologic reductionism — but the problem was not reductionism; it was that Cotton was wrong. Cotton's theory was no more reductionist than that of modern psychopharmacology. Scull fails to emphasize how little Cotton's work had to do with real science; the ideas were borrowed from contemporary medicine, but the results were never tested scientifically — the same error that was made later with psychosurgery. Greenacre's research exposed the problem, but Meyer deferred to professional etiquette rather than science. Strangely for a sociologist, Scull fails to discuss the inadequate professional and administrative structures that allowed this tragedy to continue unchecked. Cotton's board failed to supervise him and then failed to demand the final report. Medical scientists who depend on public support have always exaggerated their hopes and successes and minimized their failures; otherwise, they fail to garner that support. Cotton was playing the game, but without adequate checks and balances.
The story is interesting, is well told, and offers important lessons on how not to structure a clinical research program.
Robert Michels, M.D.
Cornell University
New York, NY 10021
rmichels@med.cornell.edu(By Andrew Scull. 360 pp.,)