Henry Cotton (doctor)

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Henry Andrews Cotton, M.D. (1876–May 1933) was an American psychiatrist and the medical director of New Jersey State Hospital at Trenton (previously named New Jersey State Lunatic Asylum, now known as Trenton Psychiatric Hospital) in Trenton, New Jersey between 1907 and 1930. He embraced the promising concept of scientific medicine that was emerging among physicians at the turn of the twentieth century, which included a belief that insanity was the result of untreated infections in the body, and to treat them he directed his dental and medical staff to practice "surgical bacteriology" on the patients, often experimentally in nature.

Henry A. Cotton had studied in Europe under Emil Kraepelin and Alois Alzheimer, considered the pioneers of the day, and was a prize student of Dr. Adolf Meyer of Johns Hopkins School of Medicine, who dominated American psychiatry in the early 1900s. Based on the observation that patients with high fever often turn delusional or hallucinating, Meyer introduced the possibility of infections (then viewed as the cutting edge concept of scientific medicine) being a biological cause of behavioral abnormalities, in contrast to eugenic theories which emphasized heredity and to Freud's theories of childhood traumas. Cotton would become the leading practitioner of the new approach in the United States.

After becoming medical director of Trenton State Hospital at the remarkable age of only 30, Henry A. Cotton began to institute many progressive ideas, such as abolishing mechanical restraints that had created nightmare conditions in asylums for hundreds of years and implementing daily staff meetings to discuss patient care. Cotton began to implement these newly emerging medical theories by having patients' teeth removed if they were suspected of harboring hidden infections. In the event that this failed to cure a patient, he sought sources of infection in tonsils and sinuses and often a 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 might be suspected as the focus of infection and removed surgically. This was before even rudimentary scientific methods such as control groups -- much less double-blind experiments -- existed, statistical methodology for applications in human behavior and medical research did not emerge during the lifetime of Cotton. He could only follow faulty methods to compile data, much of it allowing for projection of anticipated results. 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. The state acknowledged the savings in expenses to taxpayers from the new treatments and cures. In June of 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 postoperative infection. Among his patients at this time was Margaret Fisher, daughter of wealthy and famed Yale economist Irving Fisher, who believed in the hygienic movement of the period. Diagnosed by physicians in Bloomingdale Asylum as schizophrenic, which was untreatable until the modern development of some pharmaceutical agents, Fisher had his daughter transferred to Trenton, 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" for which she was subjected to a series of colonic surgeries before dying of a streptococcal infection in 1919. The danger of surgery was 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 paternalistic attitude and the permission of the family of seriously insane patients was the basis of intervention at the time.

Differences of professional opinion existed among psychiatrists regarding focal sepsis as a cause of psychosis and not all believed in the benefits of surgical intervention to achieve cures. 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. The arrival of a woman without significant credentials to critique his work must have been perceived as an affront by the prominent (and presumably male-chauvinistic) psychiatrist. His staff made no effort to facilitate the study. Only remote and uncomfortable facilities were provided.

From the outset, Greenacre's reports were critical, with regard to both the hospital, which she felt was as unwholesome as the typical asylum, and Cotton, whom she found "singularly peculiar". 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.

In October of 1930 Cotton was retired from the state hospital and was appointed medical director emeritus. Although this ended the abdominal 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.

Many diverse theories about the source of mental illness flourished during this time. Other new treatments included several types of shock therapy and the prefrontal lobotomies that are considered so abhorrent today. After World War II the introduction of pharmaceuticals that could calm the most difficult aspects of psychosis began to diminish such extreme treatments in an effort to cope with mental illness, although progress toward prevention of psychosis has not advanced. Viewing treatments from the vantage point of one hundred years later could hardly be expected to fail to reveal clumsy attempts based upon the current scientific knowledge. Recent attempts to deal with obesity using surgical intervention similar to that performed by Henry Cotton may be seen to be just as inadvisable in one hundred years. Who knows what will take the place of the brutal disfigurement of women suffering from breast cancer or the castration of men suffering from prostate cancer?

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.