Despite the official statistics, when Angus MacPhee entered Inverness Asylum there were another 50,000 adult schizophrenics in Scotland and probably 3,000 in the north and western Highlands and Islands. Some were quietly struggling to accommodate a mild or half-awakened version of the disorder; some were diagnosed and treated; some were homeless and drunk in the country lanes and on the city streets; others were fighting lonely battles in ordinary homes against their chaotic lives.
‘In this hospital and in many others throughout the country,’ said Dr Joanne Sutherland, a psychiatrist at Inverness, ‘there was a population in the long-stay wards of people who had a chronic form of schizophrenia. They came into hospital in this disturbed, distressed state which went on sometimes for months. In time the very active phase quietened down, but it took often a very long time, and once that had settled the person was sometimes really very impaired, and sometimes just a shell of what they used to be.’
Angus MacPhee, the man who as a fit and fresh-faced six-foot-tall youth had joined the Lovat Scouts, was confused and was very often scared stiff. Away from all the familiar comforts of home, in the darkest periods of his illness he was almost permanently frightened. He was then frightened of everything and of nothing, of things which were not there and were always there. He could wake up frightened, he could go to bed frightened, and the relatively healthy cannot imagine his dreams. He was afflicted by chronic fear. He was no longer sure who he was.
Other, later, simple schizophrenics have used the friendly computer flickering in the corner of the room to tell a dozen moderated psychiatric internet forums how they felt. In 2009 one sufferer explained: ‘It’s a rare type of schizophrenia consisting mainly of negative symptoms such as lack of emotions (blunted affect), lack of pleasure (anhedonia), lack of motivation and persistence (avolition), poverty of speech (alogia), trouble concentrating and social withdrawal. With no positive symptoms such as hallucinations and delusions.’
In the candid world of twenty-first-century online psychiatric forums, simple schizophrenics became sensitive to the assertion that they were little more than jumped-up depressives. ‘The two main differences between simple schizophrenia and apathetic depression,’ said the same victim, ‘are that one cannot recover spontaneously from simple schizophrenia, and simple schizophrenics don’t care much about their condition – it’s called “la belle indifference” . . .
‘I seem to get this belle indifference more and more, and decreasingly often care about me not feeling anything. Really, I feel like I let everything go – my entire life and the entire world. My emptiness is then even supplanted by an almost trancelike state of carelessness, though it never lasts long . . . It feels like falling asleep.’
‘There isn’t a “fine line” between depression and severe negative symptoms of schizophrenia,’ said another simple schizophrenic, ‘when I haven’t been consistently or even moderately depressed for over four years.’
‘I have “simple” schizophrenia,’ said another,
i.e. the type without positive symptoms . . . I’ve had it for over a decade . . . taken that long for someone to figure out what was wrong with me. Now the negative symptoms have progressed to the point that I can’t take care of myself or really do anything.
I’m trying medication but it seems the likelihood of it helping is very low, because of no positive symptoms. I partly wish I had positive symptoms, just so I could have been diagnosed when I was around 13–14 (when my gradual loss of mental functioning seemed to start), instead of being 24 and only just now trying medication.
I’m on quetiapine at the moment, doesn’t seem to make any difference whatsoever (been on it around a month I guess). Tried aripiprazole first, but that wasn’t a good experience . . . akathisia mostly, but it also made me really indecisive, for some reason.
I suppose exercise would help but I can’t get myself to just do it. Motivation, desire, they’re irrelevant, I just can’t get myself to do things, blah . . . I have a very high IQ in certain areas, but it’s useless because I can’t study, can’t concentrate. I feel like I could do anything I want, if I could just . . . do things.
Really I just wish there was hope, maybe in the idea that the medication might be able to help me, I just need to be patient . . . but I feel like it won’t. I think it’s common knowledge that it won’t.
The disorientation, social withdrawal and poverty of speech suffered by Angus MacPhee were considered in the late 1940s and 1950s to be symptoms rather than primary conditions. They were therefore treated incidentally. It was believed that a long-term cure for or alleviation of his schizophrenia could be found only by addressing some root cause which, once identified and removed, would take away with it the patient’s distress.
In the short term, his doctors had the familiar problem of how to ease Angus MacPhee’s burden while they searched in vain for his primary condition.
From the middle of the nineteenth century to the closure of the asylum at the end of the twentieth century, physicians and psychiatrists at Inverness engaged in a search for the least harmful and most effective (the two were not often found in the same drug) ‘hypnotics’ with which to calm their troubled patients. They wrestled simultaneously with the ethical question of how much their patients should be calmed. ‘It is conceived that if quietitude is gained, everything is gained,’ wrote Inverness Asylum’s superintendent Thomas Aitken as early as 1875, ‘yet no greater error nor graver error could be made.’ Opiates in the form of laudanum or diacetylmorphine (which was legally marketed in Britain under the tradename ‘Heroin’ until 1924) were often used to soothe excitable people inside and outside asylums, but their use was disapproved at Inverness by Dr Aitken.
Instead, the superintendent recommended the ‘sparing’ application of such anti-convulsants and sedatives as potassium bromide and a proto-homeopathic euphoric tincture of the plant hyoscyamus. The nurses, attendants and doctors had another weapon. A large amount of alcohol was consumed in Inverness Asylum. In the accounting year 1866 to 1867 the 233 patients drank 17,265 pints of table beer, 681 bottles of bitter and 1,136 pints of porter. They also took delivery of 350 bottles of fortified wine and 304 bottles of spirits, mostly whisky. Two hundred and sixty-five pounds of pipe tobacco helped it on its way. Even allowing for some use by the staff, that gave each patient 81 pints of beer, a bottle of port and a bottle of whisky a year. It may have helped some of them to sleep at Hogmanay.
In 1884 Dr Aitken welcomed the arrival in Britain of paraldehyde. Paraldehyde, an effective hypnotic/sedative which would be used into the second half of the twentieth century, was safe and non-addictive. It had one notable drawback. A third of any paraldehyde dose is excreted through the lungs, and vaporises in the recipient’s breath. That caused – as Thomas Aitken noted at Inverness Asylum – night wards full of men and women who had taken this ‘best sleep compeller’ to smell intolerably bad.
From the 1930s onwards paraldehyde was augmented by other treatments. Insulin, more popularly a therapy for diabetes, was administered to mental patients because of its incidental qualities of memory-enhancement. Tranquillising psychiatric medications – anti-psychotics or neuroleptics – became more plentiful and more sophisticated. And electroconvulsive therapy became widespread.
All of those were used at Inverness while Angus MacPhee was being treated there for schizophrenia. Electroconvulsive therapy was initially welcomed as a potential cure for the primary condition, rather than just another euphoric or hypnotic alleviation of the symptoms. It was a rocket-age solution: it would zap the root cause. During Angus MacPhee’s time, ECT became one of the most controversial treatments in twentieth-century medicine.
Convulsive therapy was not new. In the first half of the sixteenth century the Swiss physician Philippus Aureolus Theophrastus Bombastus von Hohenheim, who was better known as Paracelsus, induced therapeutic seizures in psychiatric patients with an oral administration of camphor. Late in the eighteenth century ‘mania’ was treated in the same
way in Vienna by Leopold von Auenbrugger. In 1785 William Oliver published an ‘Account of the Effects of Camphor in a Case of Insanity’ in the London Medical Journal.
Camphor was all very well. It certainly induced seizures, because it was a highly toxic chemical. By the same token, camphor was unreliable. Although ‘maniacs’ who had been made to swallow camphor, and then had convulsions, subsequently displayed interesting signs of mental adjustment, they could also fall physically ill or die. Oral dosages were difficult to regulate. Too little would fail to provoke a worthwhile seizure; too much would poison the patient.
In the 1930s the father of twentieth-century convulsive therapy, Ladislas Meduna, gave controlled intramuscular injections of camphor oil to more than 100 sufferers from dementia praecox or schizophrenia. Meduna’s response rates were high. More than half of those who had been ill for less than a decade showed significant signs of recovery. It was decided that convulsions cured schizophrenics. The only remaining question was how to administer the convulsions.
In 1964 Martin Whittet, the physician superintendent at Inverness, claimed that 150 years earlier Dr Kennedy of the Northern Infirmary in the Highlands had treated ‘with good effect’ two mental patients by electric shocks. If so, Dr Kennedy was a lost prophet. The credit for supplanting camphor with electricity in convulsive therapy went to two Italian neurologists in the 1930s.
In April 1938, having tested electrical convulsions on animals, Ugo Cerletti and Lucio Bini found their human subject: a registered schizophrenic, a delusional and incoherent vagrant who was helplessly wandering the streets of Rome. Cerletti and Bini hooked him up to the electrodes and gave him eleven shocks. He recovered. He then enthusiastically endorsed his treatment. Most happily, a follow-up examination 12 months later discovered him to be well and in employment.
For almost 40 years after Cerletti and Bini’s breakthrough in Italy, electroconvulsive therapy not only replaced camphor and most other chemical agents; it became the golden bullet of schizophrenia. The transformational effects of electric-shock treatment were noted throughout the developed world. ECT equipment was installed from Indianapolis to Inverness. It was certainly a palliative: its effects were immediate. It seemed also, by adjusting neurological impulses, to provide a treatment of the primary condition: a malfunctioning brain. In its earlier applications, electroconvulsive therapy has been likened to kicking a broken television set. It was crude but oddly effective, because like a broken television set a completely broken mind can only improve. Often the appropriate circuits were reconnected.
Not everybody was convinced. A new wave of anti-depressant medicines was developed in the 1950s and 1960s. The instinctive preference of some doctors, psychiatrists and lay people for pharmaceuticals and psychotherapy over electric shocks was confirmed in 1975, when a Hollywood film was released.
No other piece of celluloid fiction can have made so huge an impact on clinical practice as One Flew Over the Cuckoo’s Nest. It was adapted from a novel of the same name by Ken Kesey, which had been published 13 years earlier. Kesey was a member of the American beat generation who drifted into the hippy era of the 1960s. While working as a night attendant at a California hospital he reached the conclusion that the institution’s mentally ill patients were no sicker than he was. They were, he decided, simply social outcasts. As the wider community could not accommodate them, it institutionalised and then suppressed and controlled them with powerful drugs and compulsory electric-shock treatment.
The book and then the film of One Flew Over the Cuckoo’s Nest projected that opinion to the world. It was comfortably digested. It was in chime with the zeitgeist. Electroconvulsive therapy was easily misrepresented and lampooned. The cartoon image of a mental patient with wild eyes and frazzled, electrocuted hair became internationally familiar. It did not help with public relations that ECT on humans had been pioneered by one of the European Fascist regimes of the 1930s. The number of patients treated with ECT fell dramatically, until the storm blew over and it began to grow again.
But the Cuckoo’s Nest Effect would never entirely disappear. A sense that society had violently overreacted to people like Angus MacPhee lingered about electroconvulsive therapy. The sense became a prejudice. It was unscientific and largely unjustifiable forensically. A majority of schizophrenics treated with advanced ECT into the twenty-first century – which rather than kicking the television set, focused on specific parts of the malfunctioning brain – continued to register marked improvements, and to credit their treatment for the easing of their pain. But outside their hospital walls the image of Nurse Ratched and her lobotomised victims in One Flew Over the Cuckoo’s Nest would not go away. It was just too good not to be true.
After his admission to Inverness District Asylum on Hogmanay 1946, Angus MacPhee was involuntarily given electroconvulsive therapy and two episodes of ‘prolonged narcosis’, possibly at the same time. Prolonged narcosis, or continuous sleep treatment, or somatic therapeutics, was achieved by injecting patients regularly with barbiturates so that they were unconscious or stupified for an indeterminate length of time. The narcosis could be prolonged from a few days to several weeks.
It was a popular treatment for mental illness in Europe in the first half of the twentieth century, and was often combined with ECT. Sleep treatment was primarily the inspiration of the Swiss psychiatrist Jakob Klaesi. While working at the Psychiatric University Institute at Basel in the early 1920s Klaesi theorised that the symptoms of mental illness could be more intimately connected to the primary condition than had previously been realised.
If the hallmark symptoms of schizophrenia were expressions of an over-active nervous system, then narcotic depression of the nervous system might do more than just subdue the patient and make the nurses’ lives easier. It could also alleviate the basic primary condition, at least to the extent that the patient was amenable to other treatments.
‘Klaesi injected a total of 26 schizophrenic patients with a barbiturate mixture,’ wrote the psychiatric historian Mary de Young, ‘to keep them in a state of prolonged narcosis for ten days . . . Eight of the patients improved well enough to either be discharged or transferred to another, less closely supervised, asylum ward; but three of the patients died. Although Klaesi argued their deaths were due to pre-existing medical conditions and not the therapeutic, the fact remained that in all subsequent uses of the barbiturates to produce prolonged narcosis, the mortality rate hovered between 3 and 5 per cent.’
For those reasons and others, sleep treatment fell out of fashion in the later twentieth century. But between the 1940s and the 1970s it found its most celebrated and controversial champion in the British psychiatrist William Sargant. As head of the department of psychological medicine at St Thomas’s teaching hospital in London after 1948, Sargant established a 22-bed ‘sleep ward’. He used prolonged narcosis not only for its own supposed benefits, but also to make patients amenable to other treatments such as electroconvulsive therapy.
‘Many patients unable to tolerate a long course of ECT,’ Sargant wrote in 1972, ‘can do so when anxiety is relieved by narcosis . . . What is so valuable is that they generally have no memory about the actual length of the treatment or the numbers of ECT used . . . After 3 or 4 treatments they may ask for ECT to be discontinued because of an increasing dread of further treatments. Combining sleep with ECT avoids this . . .’
‘For several years past,’ he said, ‘we have been treating severe resistant depression with long periods of sleep treatment. We can now keep patients asleep or very drowsy for up to 3 months if necessary. During sleep treatment we also give them ECT and anti-depressant drugs.’
Despite constant monitoring of their sleeping forms, patients died under William Sargant’s regime in London. Those mortalities and the transparent abuse of the human rights of people who were given extreme treatments without their consent or against their will led to the discrediting and discontinuation of prolonged narcosis.
But while it was still commo
nplace, at Inverness in the late 1940s Angus MacPhee was twice sent into a long sleep with injections of barbiturates. On at least one of those occasions – and probably during both of them – he was given electroconvulsive therapy while he was unconscious or semi-conscious.
It did not kill him. It may even have helped to ease his state of mind. In 1950 Angus MacPhee was reported to be ‘disorientated – odd habits, washes slippers, little change in condition’, but there was no recorded repetition of the ‘manic episodes’ that had provoked his admission to the asylum. He was soon taken off all medication. The only drugs which he would take in later life were for the physical disabilities that came with old age. In 1993 it was decided that he had suffered in the 1940s from an ‘affective disorder and that the initial illness was a manic episode’.
An affective disorder does not preclude schizophrenia, but it is a more refined and less permanent diagnosis. Affective disorders are ‘characterized by dramatic changes or extremes of mood. Affective disorders may include manic (elevated, expansive, or irritable mood with hyperactivity, pressured speech, and inflated self-esteem) or depressive (dejected mood with disinterest in life, sleep disturbance, agitation, and feelings of worthlessness or guilt) episodes, and often combinations of the two.’
By 1993 they had probably discovered what afflicted Angus MacPhee. By the 1990s, the specialists also noted, he had become ‘institutionalised’.
In the late 1940s he was simply another mystifying soul. Disorientated by ECT, barbiturates and neuroleptic drugs, Angus MacPhee went to work on the hospital farm. There he would evolve a therapy of his own.
The Silent Weaver Page 8