The Tragic History of Surgery for Schizophrenia

By Neuroskeptic | January 11, 2015 12:06 pm

A compelling article in the Journal of Medical Biography recounts the story of Bayard Holmes and Henry Cotton, two American “surgeon-psychiatrists” who believed that they could cure schizophrenia by removing parts of their patients’ intestines (and other organs).

What’s more, both men tested their treatments on their own children – with tragic results. The article is by Jonathan Davidson of Duke University.


Holmes and Cotton had a theory to justify their extreme cures: autointoxication. This was the idea that ‘insanity’ was actually a state of chronic intoxication, caused by some mind-altering substance or toxin produced inside the sufferer’s own body.

Proponents of the autointoxication theory didn’t all agree on what this natural hallucinogen was, or on where it came from. Some held that the toxin was generated by the human body’s own glands and organs, while others believed that it was produced by bacteria that had infected the host. Holmes and Cotton fell into the latter camp.

Holmes (1852 – 1924) qualified in homeopathic medicine in Chicago in 1884, but Davidson says that his interests were in bacteriology, not homeopathy. Holmes soon embarked on a research career in microbiology. He later qualified in surgery and lectured at the College of Physicians and Surgeons in Chicago, which later became the University of Illinois College of Medicine. Interested in social issues, he even ran for mayor of Chicago in 1895, but came third.

It seems that Holmes had no particular interest in psychiatry until 1905, when his own son, Ralph, developed dementia praecox (what would now be called schizophrenia) while a student. Holmes was devastated and devoted the rest of his life to researching the disease. He never trained as a psychiatrist, and regarded the profession with contempt. In 1916, he announced that he had found the cause of dementia praecox. He claimed that a particular kind of intestinal blockage was the root cause of the disorder. This blockage, he said, produced bacterial overgrowth that flooded the body with an autotoxin (histamine, he said.)

On the basis of this theory, Holmes devised a surgical treatment for the disorder: making an opening into the intestine (via the appendix) to allow it to be irrigated (washed out) daily, to clear the bacteria and the toxin. Determined to help Ralph, he operated on his son – but he died four days later from complications of the surgery. Yet despite this, Holmes persisted with his surgical ‘cure’. Davidson writes that

Holmes spoke to very few people about the tragedy [of his son’s death]… he even expunged the case from his medical reports. In total, Holmes or his associates operated on 22 patients between 1916 and 1919, claiming several good successes as well as two fatalities. However, Holmes was unwilling to look critically at his findings and when Horry Jones, one of his research colleagues, could not replicate Holmes’ radiological and bacteriological results, Jones fell from grace and was fired.

Dr. Henry Cotton was one generation younger than Holmes. He qualified in medicine in 1899 in Maryland and went on to specialize in psychiatry, before studying in Germany with two legendary figures, Emil Kraepelin and Alois Alzheimer. He returned to the US to become director of an asylum, the Trenton State Hospital in New Jersey.

Like Holmes, Cotton was a convinced believer in the bacterial autointoxication (or ‘focal sepsis’) theory of psychiatric illness, and of surgery for schizophrenia. However, Cotton differed from his predecessor in that

Unlike Holmes who limited his interventions to the intestine, Cotton removed teeth, tonsils, gall bladders, cervices, colons, thyroids and other body parts. All told, Cotton performed 645 colectomies at Trenton with approximately 33% each being for schizophrenia, manic-depressive and mild disorders.

Cotton claimed astonishingly high success rates of over 80% but also acknowledged a mortality rate of 25 – 30%, explaining it away as due to the poor physical condition of patients with chronic psychosis… at times Cotton operated in the absence of consent or in defiance of family wishes.

Despite the enormous body count, Cotton was widely acclaimed as a researcher and psychiatrist, although there were skeptics:

In 1923 a group in New York reported what seems to be the first quasi-randomized controlled trial in psychiatry, to test Cotton’s theories. This study failed to show any difference in outcome between the surgical group and the untreated controls, with response rates being 38% and 47% respectively.

Cotton became a controversial figure, and he eventually lost his post as clinical director of Trenton, although he was allowed to remained as the director of research – and he continued performing surgeries (and teeth extraction) at his private clinic. So keen was Cotton on pulling teeth (to avoid the risk of future infection, and hence, mental illness) that he had all of his own wife and sons’ teeth removed ‘as a precaution’. Sadly, both of his two sons died by suicide, decades later.

Holmes and Cotton seem to have never met, and Cotton never acknowledged any influence from Holmes. Nonetheless, Davidson says, they had a lot in common:

Both men were adroit in working the local political system, each was fixated on focal sepsis as the cause of psychosis, and each came to lose his capacity for objectivity in the pursuit of his goal. Neither man was open to criticism or disagreement […] To continue with such a harmful practice in the face of negative or flawed evidence is more a sign of hubris than of scientific courage.

Cotton died in 1933, nine years after Holmes. Just three years later, in 1936, the Portuguese neurologist Egas Moniz published his first description of leucotomy – the destruction of certain brain pathways – as a treatment for mental illness. Thus began the era of psychosurgery, and the brain rather than the gut became the focus of interest for “surgeon-psychiatrists”.

ResearchBlogging.orgDavidson J (2014). Bayard Holmes (1852-1924) and Henry Cotton (1869-1933): Surgeon-psychiatrists and their tragic quest to cure schizophrenia. Journal of Medical Biography PMID: 25504547

  • Sara Turner

    geesh even with all the medical “mistakes” made nowadays thank goodness we don’t live back in those times!

  • stevedodge833

    The really scary thought is, at one time this was considered modern medicine. Imagine what barbaric procedures patients were going through BEFORE then. Reminds me of that classic MEDIEVAL BARBER sketch on SNL in the 70’s and their lethal healing remedies…”She looks pale….We must bleed her!”

    • TLongmire

      The really scary thought is, at one time this was considered modern medicine. Imagine what barbaric procedures patients are going through NOW. “She looks pale….We must bleed her!” insurance company.

  • Rolf Degen

    In a twisted way, those guys were ahead of their time, locating the origin of schizophrenia in the guts. According to the latest theory, the disorder may indeed be caused by gut bacteria, the microbiome:

    • Neuroskeptic

      Hmm! Interestingly, that paper doesn’t discuss Holmes, Cotton, or the autointoxication theory at all.

    • Lisette M

      The article at the website you’ve referenced here does discuss the relationship between certain intestinal flora & the formation of particular brain chemicals that affect socialization, which, I suppose supports this article. Of course, it makes sense that all precursors of the body’s essential chemicals have to be available &in the correct amounts for the body to be healthy!

      And, you’d think it would be an easy task to just replace the necessary microbes by drinking kefir or unpasteurized yogurt to balance your body’s immune system since the major intestinal flora the article cited as important to colonize are common in those foods.

      However, this theory doesn’t actually seem to be separate from the one that links genetic familial history on the maternal side to the risk of offspring having depression or schizophrenia — both theories seem to fit together.

      But something they don’t really discuss is why the onset of schizophrenia usually occurs in young adults at an age that would suggest they would be out of their parents’ home. Since the study claims that mental disorders are also tied to the shared diet & environment of the home you grow up in, how does it relate to the at risk offspring once they leave home? It’s likely that these young people would change their diets greatly as soon as they’re left alone to make their own decisions.

  • Felonious Grammar

    I can’t help but be irritated at the use of the word “theory” in psychiatry. As far as I can tell, if there are actually any theories in this field, there are few. These men using severe measures based on a loose hypothesis or “whatever popped into their head” is the norm in psychiatry. I mean how could it have been a “theory” before they tested it?

    I don’t think it should be honored when they use the word “theory” for something which has not undergone the rigor of scientific testing.

    • always_none

      There’s no such thing as a “loose hypothesis.” The two doctors in the story were going off their own theories, which were pure speculation–hypotheses never entered the picture at all. How could an idea be a “theory before they tested it?” Because that is the definition of a theory. You need to research your understanding of science a little more.

  • Chris Ryan

    That last para is a doozy. Egas Moniz won a Nobel Prize for “leucotomy,” which is a fancy word for lobotomy—hardly an improvement on tooth extraction and the other lunacies described in this piece.

    • Bill C

      I’d much rather have a tooth extraction than a lobotomy. Though, all the teeth…? Nowadays, probably still would go with the teeth.

  • Richard Noll

    It is wonderful to see Neuroskeptic draw attention to this article on Holmes and Cotton by Jonathan Davidson. Davidson skillfully blends the redults of the archival research conducted on Cotton by Andrew Scull back in the 1980s and that on Holmes which I began to piece together back in 2003. The stories are tragic, but readers must remember to place them within the context of the rise of scientific medicine in the USA in the first two decades of the 20th century. For their era, surgery and other experimental treatments (such as organotherapy — injections of endocrine gland extracts) were rational treatments for chronic psychosis when there were few alternatives. Physicians and families were desperate, and many families begged Cotton in particular for such treatments (as later generations of familes begged physicians for psychosurgery for their chronically ill loved ones).
    I rememebr the day it dawned on me that Holmes, with his Victorian sense of honor, must have tried out his experimental treatment on his son first before doing so on the children of other parents. He never mentioned operating on his son in any publication. I sent off a death certificate request to the State of Illinois and two weeks later had my suspicion confirmed. On the finely printed cards announcing his son’s death Holmes and his wife included the exact dates for the milestones “born,” “became sick,” and “died.” Very sad indeed. But as a father of a beloved son, I can honestly say that sometimes what is done out of love is beyond good and evil.
    Henry Cotton’s trajectory was a different one. Although post-mortem diagnosis is a dangerous method, it is difficult not to view him as a psychopath. Andrew Scull illustrates this well in his initial 1897 articole and 2005 book, Madhouse, on Cotton.

    • Neuroskeptic

      Thanks very much for your comment! That’s some fascinating background.

      I’m not an expert but from reading Davidson’s account I got a “tragic obsession” vibe from Holmes but more of a “psychopath” impression of Cotton.

      • Richard Noll

        Well put! I think that is a fair characterization of the different dispositions of the two men.
        Autointoxication was a broad umbrella assumption of the etiology and pathophysiology of medical diseases. The least successful variant was intestinal autointoxications, but metabolic autointoxication hypotheses morphed into modern endocrinology once the rough parameters of the hormone concept was agreed upon circa 1915. The ovaries and thyroid gland were the foci of surgical interventions for insanity as early as the 1890s. The earliest US newspaper article to discuss dementia praecox in a medical context was an enthusiastic December 1907 report in the NY Times of a “cure” through thyroid surgery by Newdigate Owensby — so in the US, Holmes and Cotton were not by any means the first to try surgical solutions.
        For those who may be interested in these additional stories, they are included in my chapter on Holmes in my book, “American Madness: The Rise and Fall of Dementia Praecox” (Harvard University Press, 2011). Gruesome, but fascinating stuff.

  • Heimdall222

    This sort of “science” fits in well with consertive dogma!

    For the record, here are some ‘truisms’ according to the right-wing fanatics, right-to-life fanatics, Tea Party fanatics, and assorted religious fanatics:
    — There’s no such thing as global warming.
    — The sun revolves around the earth.
    — The earth is flat and was created 6800 years ago.
    — The theory of evolution is an invention of Satan.
    — GMO’s shrink a certain male body part (a common right-wing ailment).
    — Pi is 3.0, even.
    — All mechanical devices are evil, particularly voting machines used by minorities.
    — Birth control is an abomination and deserves agonizing death in a back alley.
    — Homosexuality is a complete abomination, but can be prayed away.
    — VA hospitals are great places to get health care.
    — Texas is a wonderful place to live, especially for white Republican Baptists.
    — Ted Cruz is human and not the spawn of Satan (still under investigation).
    — The Chinese are our friends.
    — Having small government gets us into Heaven.
    — Right-wingers (especially white Republican Baptists) are God’s Chosen People.

    From all indications, that last obviously not being true is what most upsets the conservies. Especially because those nice Jewish folks have already called dibs…!

    As a side comment, did you know that the Tea in Tea Party stands for ‘Totally egregious a$$holes’?

    Or ‘Totally erroneous a$$holes’.

    Take your pick!


      I would think even Jon Stewart would give you credit for this if you sent it to him!!!!!! You have summarized it all so very very well!!! LOLOLOLOL

  • Peter

    Interestingly, this does work in the acute setting. Presentation to the Emergency Department for an acute mental status change (i.e. acting “oddly”) prompts a search for infectious causes (among other possible causes). A very common cause of acute mental status change in elderly nursing home patients is urinary tract infections.

    Although the science of Holmes and Cotton is sorely lacking by today’s standards, the theory that chronic mental status changes could be from low-level infection seems a lot less “crazy” when you have a clear example of it happening acutely.

    It is always important to maintain an open mind to “crazy” theories, yet insist that the theories be backed by research. Leeuwenhoek was ridiculed for his “wee animalcules” (little animals) and “cavorting beasties” – today it’s called microbiology.

    • Neuroskeptic

      This is true.

      My grandfather suffered from recurrent infections in the last years of his life, and they were generally heralded, not by fever, but by delirium and hallucinations. I remember visiting him in hospital once and having a surreal conversation about cats – which he thought he could see all over the place. But once the infection cleared he was quite lucid again.

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About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.


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