D B Double

Andrew Scull

Yale University Press, £18.95, pp 352

ISBN 0 300 10729 3

Surgery may not be the most obvious treatment for mental illness. Surgeons are people who find it extremely rewarding to act and see the impact of their actions on their patients. However, operating on the body may not have very specific effects on a disordered mind. This fact has not hindered enthusiasts intervening surgically believing their outcomes to be positive. Such excesses have been tragic, as is well known in the history of lobotomy (see review of The Lobotomist in this week’s BMJ).

Less well known is the phase of surgery on other parts of the body that preceded that on the brain itself. Madhouse is a biographical history of Henry Cotton (1876-1933), an eminent and notorious American psychiatrist, who believed that the cause of mental illness was the systemic effects of largely hidden chronic infections. Septic foci, therefore, must be searched for and eradicated. Particular attention was paid to the teeth and tonsils. Even if many people were sceptical about the causal connection, Cotton argued that detoxification was none the less beneficial, and that patients were relieved when they found that their mental condition was due to poisoning by infection. Cotton's theory of focal infection may have met its demise because of the drastic, and not infrequently fatal, operation of colectomy.

This well written book emphasises the extent to which it is misleading to view Cotton as essentially a maverick. He received considerable support from the psychiatric profession. For example, he benefited from the interest and admiration of Adolf Meyer, regarded as the dean of American psychiatry in the first half of the 20th century. Meyer wrote Cotton's obituary, concluding that he had "an extraordinary record of achievement." Meyer suppressed a report of the poor outcome of Cotton's work in the forlorn hope that he could persuade Cotton to accept the reality of his results.

The entanglement of Meyer in this tale is significant as his psychobiological approach at least theoretically stands in contrast to Cotton's insistence that we have to recognise the physical nature of functional mental disturbance. For instance, Meyer regarded Cotton's claims as somewhat extreme, suggesting they went "beyond what I personally believe to be my experience." None the less Meyer's justification for experimenting with the aggressive treatment was the results, complaining that there were not the resources to evaluate the procedures extensively. We may think we are protected from the dangers and blindness of wish-fulfilling expectations in the era of the randomised controlled trial. However, simplistic and biologically reductionist accounts of mental disorder, which underpinned the work of Cotton, still sustain modern pharmacotherapy. For example, it is commonly said that psychotropic medication corrects chemical imbalances in the brain. This theory is as much without proof and requires as much faith and self deception as that of Cotton. Perhaps we can learn from our sense of outrage about the events described in this book. I think the lesson is that a psychosocial understanding of mental illness, if it is to be influential, needs also to have a strong ethical foundation.