‘Killing Cures’: An Exchange

To the Editors:

I’m happy to see Sherwin Nuland’s long review of my book Madhouse: A Tragic Tale of Megalomania and Modern Medicine [NYR, August 11], but I’m surprised to find it so full of elementary factual errors: Is it really so hard, for example, to spell Adolf Meyer’s name correctly, or to remember that he was professor of psychiatry at Hopkins, not head of its department of medicine?

Nuland’s most serious errors, however, are his claims that “even as [Cotton] was starting his notorious campaign against ‘focal sepsis’…that conception of disease had begun to crumble” and that Cotton was scientifically discredited by the time of his death. On the contrary, more than a decade after Cotton’s depredations had begun, leading figures at such centers of scientific medicine as the Mayo Clinic, Johns Hopkins University, and the University of Chicago continued to advertise their belief in the importance of focal sepsis.

When Cotton visited Britain in 1927, at a joint session of the British Medical Association and the Royal Medico-Psychological Association, the great and the good of British medicine and surgery rose as one to hail him as the Lord Lister of twentieth-century psychiatry, the man whose theories and practice were successfully bringing mad-doctoring into the realm of scientific medicine. Their fellow countryman Thomas Chivers Graves, as enthusiastic a proponent of focal sepsis as Cotton, was the longest-serving president of the Royal Medico-Psychological Association in its history, and used his period in office, 1940–1944, to proselytize endlessly in behalf of the doctrine. At Trenton State Hospital, Cotton’s base of operations, tooth extractions and tonsillectomies were still being performed to eliminate sepsis in the late 1950s. And as a surgeon, and a child of the 1930s and 1940s, Nuland must surely be aware that outside the marginal realm of psychiatry, millions of tonsils long were sacrificed on this particular altar.

Why does his misreading of the past matter? Because claiming that the romance with focal sepsis was an isolated and transient affair allows Nuland to present Cotton’s doctrines, like the lobotomies that are the other focus of his review, as a momentary aberration, a trivial sideshow in the march of medical progress. Such distortions of the historical record are much beloved by retired clinicians who dabble in the history of their discipline, but we accept them at our peril.

So far as psychiatry is concerned, we once again live in an era where simplistic and biologically reductionist accounts of mental disorder enjoy widespread currency. Patients and their families have learned to attribute their travails to biochemical abnormalities, to faulty neurotransmitters, and to genetic defects, and to look to their doctors for the magic potions that ensure “better living through chemistry.” Pills have replaced talk as the dominant response to disturbances of emotion, cognition, and behavior.

The revolution in treatment has been fomented and furthered by the vast expansion of a massively profitable psychopharmaceutic industry. The psychiatric profession has scurried to do its part, claiming that mental illnesses are specific, identifiably different diseases, each allegedly amenable to treatment with a particular class of drugs or magic bullets. Yet the whole conceptual edifice rests on the shakiest of foundations, and the treatments themselves are decidedly less efficacious than the public relations representatives of Big Pharma would have us believe.

Meanwhile, at the level of language, both psychiatry and popular culture have become saturated with biological talk. In the words of the eminent historian of psychopharmacology David Healy, biobabble has replaced psychobabble. And talk, ironically, is by and large what the real foundation of the biological revolution in psychiatry amounts to. The etiology of most mental disorder remains as mysterious as ever. Despite all the recent advances in basic neuroscience, we have made remarkably little progress in understanding depression, and the sources of schizophrenia, or the schizophrenias, remain wrapped in the same obscurity. Nor do we possess a balanced assessment of what the new generation of drugs accomplish, or why they work (to the extent that they do).

If Cotton’s work rested upon ill-grounded speculation, so too do our contemporary psychiatric therapeutics, and we would do well to ponder the implications of this state of affairs, rather than smugly assuming we have now entered a new realm of scientific enlightenment.

Andrew Scull
Department of Sociology
University of California, San Diego

Sherwin B. Nuland repliess:

I plead guilty as charged, though only to the first two of Andrew Scull’s accusations: the misspelling of Adolf Meyer’s name and my failure to catch a small editorial change made to my submitted text, which resulted in that distinguished psychiatrist’s being erroneously declared chairman of the Hopkins department of medicine. But as to my review “misreading the past” or being “full of elementary factual errors?” Hardly. Rather, it is Scull who has made the errors and misread not only the past but my review, my viewpoint, and even my qualifications to critique his book. Worst of all, he seems to have misread his own pages.

First to the question of Henry Cotton’s continuing stature and acclaim as his campaign wore on. Clearly, Scull is exercised over my pointing out that his description of the reasons for his subject’s downfall is “history just a bit out of context,” and he attempts to make the reader believe that Cotton continued to receive unanimous approbation at a time when I say that the speculations behind his doctrine were already being discredited. According to Madhouse: A Tragic Tale of Megalomania and Modern Medicine, Cotton “first became acquainted with the notion of focal sepsis in relation to disease” around 1916. By then, the theory’s validity, always thought questionable by many authorities, had aroused plenty of skepticism, especially in the United States. Even Scull admits that the notion of focal sepsis was most accepted among “eminent British medical men, unlike their American counterparts.”

Many (but by no means all) physicians in Britain were still enthusiastic about Cotton’s work in 1927, which explains his warm reception at the British medical meeting held in Edinburgh that year. However, nowhere in Scull’s book does he presume to make the claim here stated in his letter, namely that “the great and good of British medicine and surgery rose as one to hail him,” etc., at the meeting. Instead, his text describes what he calls “an apparently approving audience,” and refers to the apparent approval as a “consensus.” A consensus is by definition not unanimous, nor does it lead to a standing ovation of the sort Scull describes, especially when Cotton’s mentor, Adolf Meyer, had avoided controversy by staying in London, “skulking at a safe distance from the Edinburgh symposium, and thus making sure he was not drawn into the debate [italics mine] on the merits of treating focal sepsis to cure madness.”

At least one speaker at the Edinburgh meeting, the psychiatrist D.K. Henderson, who had spent several years working in the United States, argued to scattered applause so strong that it “interrupted portions of [his] commentary” that the notion of septic psychosis threatened to “make British psychiatry the laughing-stock of the world,” and called it, as did so many others in those days, “a very dangerous leap in imagination.” Already in 1913, when the London surgeon William Arbuthnot Lane was knighted for his practice of removing great lengths of intestine in pursuit of focal sepsis (an operation that would become one of Cotton’s favorites), disagreement was raging among his colleagues over what many correctly considered a jerry-built theory. Far earlier than that, George Bernard Shaw in The Doctors’ Dilemma (1906) had entertained knowledgeable audiences by ridiculing the appendectomists who were removing untold numbers of the so-called “nuciform sac” with the justification that the surgery cured or prevented chronic diseases of various sorts, including psychiatric ones, all in accordance with the theory of focal sepsis. The ridicule depended on viewers in the stalls knowing that such operations were exercises in bad judgment. All of this, including Shaw’s play and the controversy over Lane—which preceded Cotton’s work—scarcely adds up to an image of a man winning and continuing to win the approval of leaders of scientific medicine or even of the educated public.

Though Scull struggles mightily in his letter to prove me wrong, his only success is to accomplish what he accuses me of doing, namely distorting the record. In this regard, he might benefit from rereading—more carefully this time—my review of his book. Far from presenting Cotton’s “romance with focal sepsis” as “an isolated and transient affair,” I have traced its origins as far back as ancient Egypt; its various manifestations continue even today, including the high colonic irrigations that are a staple of spas and advertisements in certain health magazines. However, Scull’s choice of the epidemic of tonsillectomies of the 1930s and 1940s to illustrate the endurance of the notion of focal sepsis is an unfortunate one, since, to use his words, he “must surely be aware” that the vast majority of tonsils were sacrificed not on the altar of Cotton’s theories, but because they were incorrectly assumed to be the cause of persistent sinus, ear, mastoid, nasal, and similar upper respiratory infections in their immediate anatomical neighborhood.

A rereading of my review might also convince Scull that its entire thrust is precisely the opposite of what he implies. Beginning with its first sentence, the essay points to the careers of both Henry Cotton and Walter Freeman as cautionary tales, lessons for those who continue to see panaceas in every new medical discovery and the unjustified conjectures that so often arise following upon it. He would also find that my view of psychiatric progress shares aspects with his own, which might have saved him writing several of the paragraphs in his angry and needlessly pessimistic attack.

But no response to a letter like Scull’s can fail to point out that ad hominem nastiness is the refuge of those whose debating points are unconvincing. Personal insult intended to weaken another’s position is an ineffective way to bolster a tottering argument. Especially is this true of gibes as undisguised and resentful as Scull’s relegation of me to the ranks of “retired clinicians who dabble in the history of their discipline.” Some of those many who have read or quoted my writings in the literature of medical history; or my fellow faculty members in Yale’s Section of the History of Medicine; or the historians who submitted manuscripts to the Journal of the History of Medicine and Allied Sciences during the twenty-seven years of my tenure as the chairman of its Board of Managers or my five years as its associate editor; or the leadership of the American Association for the History of Medicine, which has chosen to appoint me to a number of critical committees including its governing council at various times during the almost thirty years of my membership—these are men and women who would be amused at such ignorant silliness, as would the students who have taken my course in the history of scientific medicine at either Yale or New York University.

Nevertheless, I should point out that more than a few of the physician-dabblers for whom Scull has such contempt have been responsible not only for the founding of the discipline he would like to restrict to certain of his Ph.D. academic colleagues but also for some of its most important advances. To mention only several whose names might be familiar to a narrow-fielded and obviously myopic social historian, they would include William Welch, John Fulton, Saul Jarcho, and, in Scull’s own field of psychiatric history, Stanley Jackson, a working psychiatrist who was also a former president of the American Association for the History of Medicine, the leading organization of its kind in the United States.

To the Editors:

As one who was associated with Dr. Walter Freeman as his office assistant in 1945 and 1946 when he was performing transorbital lobotomies in his office, I would like to comment on some aspects of Sherwin Nuland’s review of Jack El-Hai’s book The Lobotomist. Although there is no doubt that a very important motivation for his precipitate plunge into a lobotomy crusade on the basis of scanty and inadequate evidence of its possible efficacy was Freeman’s driving ambition and desire for fame (he was the grandson of the Civil War surgeon W.W. Keen), his actions can also be accounted for in a more justifiable way. At that time, psychiatric hospitals all over the country (including St. Elizabeth’s in Washington, D.C., where he had been a consultant) were warehouses for thousands of patients suffering from serious disorders for which there was no effective treatment. This is acknowledged in the review but it is hard to appreciate its urgency unless you were there to witness it.

I question Nuland’s statement that the operation left “many patients docile, unmotivated, and indifferent to their surroundings.” Rather, especially after Dr. Freeman abandoned surgical lobotomy for the somewhat hit-or-miss transorbital procedure, I believe that follow-up results would show that some patients were helped, some were harmed, but for most the operation had little effect, one way or the other.

It seems to me to require a considerable stretch for Freeman to be consigned by El-Hai, as quoted by Nuland, to a rank in infamy second only to Josef Mengele, “the angel of death in Auschwitz,” as the most scorned physician of the twentieth century. Mengele was not the only Nazi doctor, and we don’t have to go further than our own country to find doctors who employed the pseudoscience of eugenics to justify the sterilization of those considered mentally unfit, thus offering a model for Nazi euthanasia and genocide. There may have also been an ideological element in the condemnation of Freeman generated by the rejection of any treatment other than psychotherapy by the then-dominant psychoanalytic establishment.

Paul Chodoff, M.D.
Bethesda, Maryland

Sherwin B. Nuland replies:

Dr. Chodoff brings up some important issues, which deserve further discussion and perhaps more emphasis than my review might have given them.

There is no question that he is correct in pointing out that the Freeman lobotomy provided the possibility of hope in the face of an overcrowded system of institutional care that had little else of therapeutic value to offer its patients. Whatever may have been the virtues of the analytically oriented psychotherapy of the day, all but a very few of the vast numbers of people warehoused in state and private asylums were beyond any help that it or other contemporary treatments might give. These were desperate times. Superintendents and medical staff initially saw lobotomy as a potential route toward cure or at least discharge to a community environment.

And there is also no question that many people not only benefited from the procedure but were actually cured, at least in the sense of being able to resume a normal life. Though some relapsed, a significant proportion did not, and continued indefinitely without clinical evidence of residual illness. I hope there was nothing in my review that could have been construed otherwise. There is strong evidence that Freeman was only exaggerating a little when he claimed, as I stated in my essay, that lobotomy benefited about a third of those subjected to it. He had thousands of letters from grateful patients and families to bolster his assertion.

But I stand firmly behind my statement that “the operation was not as successful as originally thought, and furthermore was leaving many patients docile, unmotivated, and indifferent to their surroundings.” There is plenty of documentation to be found for this in El-Hai’s bibliography, as well as in a volume he seems to have overlooked, Joel Braslow’s 1997 study, Mental Ills and Bodily Cures.¹ In addition, Dr. Chodoff and other interested readers may wish to consult the two books generally considered the most comprehensive studies of the lobotomy, Elliot Valenstein’s Great and Desperate Cures² and the most authoritative of all, Jack Pressman’s Last Resort,³ which won the esteemed Welch Medal of the American Association for the History of Medicine after its publication in 1998.

To add anecdote to documentation, older readers will recall the tragic outcome of Joseph P. Kennedy’s insistence on lobotomy for his somewhat retarded daughter, Rosemary, who remained thereafter much as described in the statement disputed by Dr. Chodoff. A graphic example of a similar failure was presented by Tennessee Williams in his drama The Glass Menagerie, in which is to be found a thinly disguised portrayal of the author’s lobotomized sister, in the character of the crippled Laura. To turn to fiction, Ken Kesey’s 1962 best seller, One Flew Over the Cuckoo’s Nest, described the demented apathy of a lobotomized inmate that would have been familiar to many readers because it had by then so often been identified as a permanent effect of the procedure.

As for comparing Freeman to the notorious Dr. Mengele, that is El-Hai’s conceit, not mine. When Dr. Chodoff rereads my review, he will find the statement, “But Freeman was never the monster he is nowadays reputed to have been, and he was certainly no Mengele.”