Henry Cotton’s Surgical Bacteriology — Yanking Teeth and Colons, Killing a Third of Patients

Beginning around 1916 at the New Jersey State Hospital in Trenton, its medical director Henry Andrews Cotton announced that insanity was not a disease of the mind but a hidden bacterial infection — “focal sepsis” — seeded in the teeth, tonsils, sinuses, stomach, spleen, cervix, and above all the colon, and curable by cutting those organs out; the gap between his claimed 85 percent cure rate and the documented reality, in which his colon resections killed on the order of 30 percent of patients and cured essentially none, is the entire case. Cotton extracted teeth by the tens of thousands and performed serial abdominal surgeries on institutionalized, frequently non-consenting psychiatric patients, on the theory that a “detoxified” body would yield a sound mind.

The practice was not a fringe horror tolerated in obscurity. It was celebrated. Cotton, a protégé of the most powerful American psychiatrist of the era, Adolf Meyer of Johns Hopkins, was lauded in the press as a humane reformer who had abolished mechanical restraint and replaced it with “scientific” surgical cure. His 1921 book, The Defective, Delinquent and Insane, packaged focal-sepsis theory as the frontier of psychiatry, and visiting clinicians from Britain and the United States toured Trenton to watch the operations.

The reckoning was assembled but then buried. In 1924–25 Meyer commissioned a former student, the psychiatrist Phyllis Greenacre, to audit Cotton’s results; she tracked his surgical patients and found the records chaotic, the cure claims unsupported, the recovery rate no better — in fact worse — than for unoperated patients, and the mortality catastrophic. Meyer suppressed her report rather than publish it, protecting Cotton and his own reputation, and the surgeries continued for years. Only Cotton’s retirement in 1930 and his death in May 1933 finally ended them. The focal-infection theory of insanity collapsed entirely thereafter, and “surgical bacteriology” survives now as a textbook case of how a charismatic clinician, a surrogate endpoint, and a senior authority’s cowardice can sustain a lethal, evidence-free operation on the powerless for the better part of two decades.

Routine Episiotomy — the Preventive Cut That Caused the Very Tears It Promised to Stop

In 1920 the Chicago obstetrician Joseph Bolivar DeLee, in a paper titled “The Prophylactic Forceps Operation,” urged physicians to cut the perineum of laboring women as a routine to spare them the worse damage of a ragged spontaneous tear — and the gap between that protective promise and the eventual evidence is the entire case. By the late twentieth century the operation DeLee reasoned his way into was one of the most common surgical procedures performed on American women, done on the order of a third of all vaginal deliveries (60.9% in 1979) and on a clear majority of first-time mothers, almost none told there was no trial behind it.

The justification was intuitive: a clean, controlled incision must heal better than a jagged laceration, and a pre-emptive cut must protect the pelvic floor against future prolapse and incontinence. The intuition was wrong in the most consequential way. When the procedure was finally tested against the comparator it had skipped for decades — selective use, cutting only on indication — the routine cut did not prevent severe trauma. A midline episiotomy extended the wound straight toward the anal sphincter and rectum, so the prophylactic incision was itself causally linked to the third- and fourth-degree tears it was meant to forestall.

The reckoning was slow because the practice was entrenched, not because the data were ambiguous. A 1983 interpretive review of more than 350 sources spanning 1860 to 1980 found no defensible evidence for routine use; the 1993 Argentine Episiotomy Trial, a randomized study of 2,606 women, showed routine use conferred no benefit and more harm; and the 2005 AHRQ-commissioned systematic review in JAMA closed the question, finding routine episiotomy improved no immediate outcome and prevented no incontinence or prolapse. In April 2006 the American College of Obstetricians and Gynecologists issued Practice Bulletin No. 71, recommending the routine be restricted. The procedure was not banned — it retains narrow, evidence-based indications — but its eighty-year career as a default was abandoned. It stands as obstetrics’ cleanest case of a plausible, near-universal intervention adopted on reasoning and reversed only by the trial that should have come first.