Rear view mirrors often contain the printed admonition that "objects in this mirror may be closer than they appear." Historical accounts of events nearly a century ago should also come with a disclaimer: "There is no history, only "histories" or accounts of past happenings as one person imagined them to be." Madhouse is the story of medical research gone overzealous; of needed oversight and peer sanctions being ineffective. Madhouse provides an account of Dr. Henry Cotton, a psychiatrist in search of a physical cause for mental illness. He performed surgery on numerous patients with the belief that their conditions were caused by focal infections.
There is little question that scientific understanding does not move forward with the objectivity and logical progress that would best serve humankind. There are personalities and careers at stake, political influences and reputations, and of course the dogma of any science on any given day. Even today, much of medical practice has yet to be substantiated by randomized clinical trial, yet it presses on doing the best that it can. This is especially true in psychiatry. There are dangers in looking only for molecular or cellular explanations of disease at the expense of considering the consequences on the everyday life of the patient.
Although Scull's "account" makes for sensational reading, and contains interesting historical facts about the personalities and events of the time; what it lacks is what no historian can really provide and what every psychiatrist should be concerned with. There are spaces of "meaning" between the events of a life that only the individuals involved can truly know. Did Dr. Cotton intentionally harm these patients, or did he honestly believe that the eradication of infection would help them recover?
Medical "science" is filled with examples, some of them now occurring, of experimental or unsubstantiated approaches done on the basis of anecdotal evidence or pure hope in the outcome. There is a sad tale about the use of ECT or "shock therapy" that was used broadly in psychiatry in this country (even within the past 30 years) with little understanding of the physiological mechanisms underlying its occasional efficacy. When people have illnesses, they seek help, they trust their caregivers and often they submit to procedures with high levels of risk because no other known remedy exists. At one point in the early history of medicine, it was believed that blood letting was beneficial. Shall all practices of the past be condemned because the knowledge of the day was primitive? The wisdom of today's knowledge should never be used as a standard to judge the ignorance of an earlier time. Rather, it should inform us about the caution that should be exercised in in our current and future behaviors.
While the "story" offered by Scull is compelling, it can be claimed that he makes assertions and conclusions that are as unsubstantiated as the procedures he describes. Is Madhouse a novel or a scientific account? Is it written to inform objectively or to sensationalize as part of a crusade? Just as all good historical accounts must carefully describe the events and contexts of the time being described, so too must "Madhouse" and its conclusions be viewed in the context of our age. Excessive hyperbole may be a personality trait that affects megalomaniacs and "historians' alike. Happily, for readers, the antidote is to take one person's account with a few grains of sodium chloride. More context and less generalization would provide a more balanced (and for me) enjoyable read.
As a psychiatric resident, I thought I might find something of educational value in this book. Instead I found a full-scale assault on psychiatry and psychiatrists. Although the book appears well researched, I found the author to have surprisingly little understanding or appreciation of modern psychiatric treatment. This, combined with his crusade against psychiatry, leads to spurious conclusions, broad generalizations and inferences that are misleading and untrue. I would not recommend this book to anyone.
