According
to old Chinese advice, it is wise never to discuss politics or religion even
amongst best friends. Religious belief
can often blur judgement in the wisest of people. In psychiatry it is sometimes
not easy. This is particularly true in cases of florid psychosis, which often presents with symptoms of hallucination, delusion and
even vision.
I remember my early days of psychiatry
in a mental hospital in Hong Kong. Yes, it was
the days of 2000-bed hospitals. Yes, it was the days of Medical Superintendents
who had supreme power and all doctors of whatever rank and experience were
Mental Health Officers with special authority to sign papers for compulsory
admissions. The forensic unit was contained within the same complex.
Those were the days when we encountered
psychosis in the raw so to speak. All
the colony’s really mad people were admitted to this one place set in the
furthest corner of the colony. In our year seven of us decided without much
discussion that we all wanted to go into psychiatry. That was over 10% and all
had quite idealistic reasons. It was perhaps a bit of a disappointment to our
parents that we did not pursue a more conventional specialty that might provide
us with more status and financial reward. Then there was the fear of
contamination that somehow one might become mad too. Recent day medical
students are said to shy away from psychiatry for these same reasons.
Education seems to have little effect
on superstition.
I can vividly remember the day when
three coach loads of a particular church descended at the front entrance to our
hospital. We had one of those grand gates which somehow were never locked.
Those that needed to be locked up would have been detained in their individual
hospital wards. The hospital had extensive grounds, and was the only non-high
rise public hospital in Hong Kong. Wards were
individual self-contained buildings spread like a horseshoe, and in all there
were eighteen of them. The wards were given numbers without names but the
numbers served the same purpose: 3 was for acute male, 11 for GPI’s and so on and so forth.
Only the maximum security wards were air-conditioned
to satisfy prison standards.
In the middle of the horseshoe was the
main medical block – the Medical Superintendent’s suite and the different staff
rooms. Then there was the administration block where the kitchens were located.
Laundry, refuse disposal etc. were a bit away from the main buildings, so was
the Mortuary. Yes, there was a Mort. On call doctors carried out post mortems
and very rarely would any outside pathologist be called in. There was much
trust in doctors then. As there
were dementia wards, people did die of natural causes especially when the
weather changed.
In a matter of a few weeks we learned a
good deal. We learned a good deal about acute psychosis. We also learned a good deal about the other end of the spectrum,
that of chronicity and dementia. We also became aware that suddenly we were no
longer lowly medical students. Even though we were still junior we had certain
status. Now someone cleaned our car every day for a small fee. The guards at
the gate saluted you. The local restaurants knew there was a new group of
doctors who would lunch regularly. Even the local shopkeepers gave us special
treatment.
Imagine the shock when three coach
loads of church people descended upon this Institution to challenge one of its
doctors. The patient in question was a
girl, and amongst other psychotic symptoms she had a vision. She was admitted
the night before as she became unmanageable at home. She was sectioned and was now in the care of the team to which
one of my good friends belonged. As luck would have it he was a devout
Christian and managed to defuse the situation. Yes, she could be having a
vision. Yes all necessary investigation would be carried out including that of
the nervous system as she might have a brain tumour. Yes, please continue to
pray for her. Yes, it could be the work of the devil.
There was no brain tumour.
There was no religious vision.
The prayers worked. She had a good doctor – my friend. She was put on Stelazine.
Some time in early February of 1978 I
was called to do a Home Visit on a thirteen year old girl by Dr Pinkerton, a
paediatric consultant. Dr Pinkerton had been the local Paed for years and was
generally well regarded. She had, in my short time as consultant, referred a
couple of cases, most notably that of a Tourette syndrome and a boy with
non-stoppable hiccups. Both cases put me in her A-list and I gathered that not
many were on that list. Needless to say I realised too that her cases were
never straightforward or simple. Those
she would have dealt with herself. The girl had upper arm stiffness on the left
side and Dr Pinkerton could not find much else wrong with her, and so it
crossed her mind that perhaps there was something psychiatrically wrong. The girl was also carrying out some strange rituals
around the house and Dr Pinkerton did wonder about psychosis or even catatonia.
One of my two clinics was in this so
called “new town”. Basically it was an idea conceived after the war in about
1949. The idea was that if people were moved out of the inner city their life
would improve. Because they often moved
the same people from the same area to the exact same street in the new town the
problems travelled with them. Old foes stayed in the same streets as warring
neighbours. Yet generations of Local Councils continued to move people into
newer housing estates, not understanding why they never managed to solve the
problem. I had visited a few of these
new towns.
The family I had to visit luckily did
not have any enemies but they only moved three months ago and felt very
isolated. They moved from a very tough neighbourhood in London not to get away from difficult
neighbours. They moved because their daughter did not fit in. She was a timid
shy adolescent who did not do normal South London
teenage things and was becoming ostracised. She was not into drugs, smoking or
drinking or even sex. To her peers she
was a weirdo. After the move, father was
able to find a job at the local airport and mother worked part time as a dinner
lady at the local school. Feeling isolated, they went with a neighbour to a
local church group and both parents had recently been converted.
I was asked very early on by mother,
although father did try to stop her, if this might be the work of the devil.
She heard that the devil was always trying to do nasty things to anyone who had
just become a Christian although she also heard that it could sometimes be God
himself wanting to test her faith.
Memories about my friend and the vision
girl flooded back and I had not even had a chance to see what the problem was.
I saw what mum meant. The girl was
ignoring my presence. She was mumbling to herself and pacing around the room
with a semi-fixed gaze. She held her left arm stiff in a half-raised position
and was going round the room as if looking for bits of dirt on the wall and
rubbing it. It started about two days
before when the parents came home from a church prayer meeting to find her non
responsive. Since then she had had sips of water but hardly ate anything. Dr
Pinkerton came out straight away to see her and called me in.
There was really no significant medical
or psychiatric history in the family. She was an only child with the history of
the usual childhood ailments. She was average at school though the year before
she was not performing well because of problems with other girls. Both parents
were healthy although I noticed that mum was nursing a cold sore.
I did wonder if catatonia was making a come back but the golden rule in psychiatry, as in
General Medicine, is: if in doubt, observe.
I told mother that it might be better
if we got her into hospital for observation. After all they probably needed a break
as they did not have any sleep properly since this started.
The parents did try to take turns to catch some sleep but as father still had
to go into work it was very exhausting.
“But it would not be the mental
hospital.”
“No, it would be one of my beds in the
paediatric ward, although it would not be the same hospital as Dr Pinkerton’s.”
“Anything would do, Doctor. We leave it
in your hands.”
Even when we did not know what was
going on, we had learned how to keep that from our patients. Was it cheating or
was it just good doctoring? Patient’s confidence in you is as important as your
medical knowledge. Perhaps that is why doctors are not doing so well nowadays.
“You will sort her out, won’t you,
doctor?”
“Sure we shall. In hospital we can run
a few tests including those on the brain just in case and then we can proceed
with treatment.”
“Have you seen cases like this before?”
“Sure, not that many but we sure have.”
What
else could I have said? To be honest, I am only a junior consultant and I have
never seen anything like this before, any further question?
“I know you are good. You have helped the boy with the swearing at
our church. He now hardly swears.”
My goodness. It is a small place. I have been here only three months and people
already know.
All I knew was it would be easy enough
if it was indeed the start of a psychotic illness and all would be all right
though sad.
I must first exclude rare but serious
neurological conditions.
I had no idea what was to hit me in the
next twenty four hours.
The hospital to which she was admitted
was built during the war by Canadian soldiers. It was unusual for an English Hospital as all the wards were built of
Red Cedar. All the wards were linked by covered walkways. Over time we all
became very fond of it - a true cottage hospital. Everybody was friendly.
Consultations were easy to arrange in such a place; I had used my two bed
allocation regularly and had developed a good working relationship with the
paediatric nursing staff. In fact the Tourette boy was one of the first
admitted for observation and proved to be a great hit. Most had never heard of
such cases and the few that had had never seen one. Then I had the boy who
refused to eat what most others liked and I soon became the psychiatrist that
brought interesting cases.
They could not wait for my next case.
Maybe not.
Sister Clark used to be at University College
Hospital in London where I had the good fortune of
gaining some paediatric training. She moved here to look after her eighty eight
year old mother. We knew we were in safe hands as there was nothing to replace
a good Sister on any ward. They reminded us of important things to look out for
and basically if we were not too pompous they would look after us. That way we
tended not to miss a thing clinically.
When I reached the ward after my day’s
clinic, Sister took me to the nursing station. She said the girl was either
pregnant or she had a full bladder. A quick examination revealed a soft mass up
her umbilical level.
How stupid of me. Remember: every
female of child bearing age is pregnant until proved otherwise. Mother’s
reassurance that she was not like the other girls fooled me. She must have
found it difficult to tell her parents and therefore was in such a difficult
psychiatric state. Faking mental illness would be one good way out.
I thought: great! At least I could deliver. Pregnancy test and OB consult and that would be it.
But hang on. Would mother not notice
her sickness if she was this big? Would she not have complained about other
symptoms? Something was not fitting in. And she still looked pre-pubescent.
Perhaps we should catheterise her. She
had not been seen to use the toilet for hours although she was not drinking
much. She was still going round in her room – we gave her the side room and a
nurse – and we put on an input output chart so we knew. The new junior doctor’s
car broke down so she was late in examining her.
Bother, I forgot it was changeover
time, when new doctors came in for their new six-month rotation. This is one of the days of the year not to be
ill.
“Good work Sister. What do we do
without you?”
Sister did the catheterisation but only
got about 150ml. The mass was still there.
I phoned Ob-Gyn. The consultant had left
for home, but I got her Senior Registrar.
He came over. Yes, it was possible that
she was pregnant but unlikely as there were no breast changes. He would hate to
do an X-ray but that seemed justified in the case of an undiagnosed abdominal
mass.
My mind was racing now. Sometimes you
do have to believe what you see. Sometimes you have to believe the parents. She
was not one of those girls. She could not be pregnant. So now we had to go
through the differential diagnosis for abdominal mass in a young girl of
thirteen.
Ovarian cyst was the obvious one.
This big?
Possible.
No. It cannot be.
The x-ray came back. The tell tale
tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair,
sometimes, even a jaw and tongue. I guessed just a split second
before the results came back. How annoying.
Working diagnosis: Teratoma with possible toxic psychosis.
Emergency operation was arranged. Yes,
she would be fine a little while after the operation, I reassured the parents.
The paediatric junior arrived and took
some history and did a quick physical before she was prepared for the theatre.
This petite doctor with a very babyish face told me that on her first day in
her last job she had to do an emergency tracheotomy. This time she had been on
call for the last three nights and the battery in her old Mini could not cope
with the heavy frost so she had to wait for AA before coming. She was most
apologetic for not having got in earlier.
She asked if I had seen many toxic
psychosis cases and I asked if she had
come across any in her psychiatric placement. As with all good psychiatrists
answering a question with another is in our blood and here it worked well.
Neither of us knew what was to hit us
next.
At 2 A.M. I had a call from her.
“Your patient – I mean our patient
could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen
but she could not be aroused. Any
ideas?”
“Call the paediatrician on call in the
regional paediatric unit and I will be in.”
What happened? I asked myself as I drove to the hospital.
What had we done? This was fast
becoming a nightmare situation.
What was I going to say to the parents?
Something else was going on here, and I
was not happy because I did not know what it was. I was supposed to know and I
generally did. After all I was the consultant now.
Thank goodness she could breathe
without assistance. That was the first thing I noticed. I saw mother in the
corner obviously in tears. She asked if her daughter would be all right. I
cannot remember what I said but knowing myself I could not have said anything
too discouraging. But then I knew I was in tricky territory and it was unlikely
to be the territory of a child psychiatrist.
A good doctor is one who is not afraid
to ask for help but he must also know where to ask.
“Get me Great Ormond Street.”
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they
had no beds so I thought I should ring up my classmate at GOS and she talked to
her SR who said “send her in”.”
Who needs consultants when juniors have
that kind of network? This girl will do
well.
“Everything has been set up. The
ambulance will be here in about half an hour and if it is all right I would
like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring
her daughter to the best children’s hospital in England if not in the world and the
doctor would stay with her in the ambulance. She would be fine.
When I got into work later that day, my
secretary asked how my patient was as she heard from her friend that the church
was going to hold a 24-hour vigil for her.
Trust my secretary. She knew someone
from the same church and she always had the knack of extracting information
first hand.
“They say this may be the work of the
devil as the doctors and surgeons all did the right things and removed this big
tumour but the devil must have got to her.”
I did have a vague fear that there
might have been some anaesthetic accident but quickly told myself off for
thinking along that line. I knew all the anaesthetists and such a thing could
never have happened.
I was back at the hospital to deal with
an overdose case. The junior was there
and we had a chat in Sister’s office.
They had to ventilate her. That was the
first thing she told me. I thanked her for going up there and she said it was
scary but she felt important and the mother who was in the ambulance could not
thank her enough.
She was impressed with mother’s faith
and trust in God.
She said mother was near to tears. It
was bad enough to have such a large Teratoma and then to have the patient unconscious
with no one knowing what was going on was very frightening.
“I have seen some deaths as a medical
student but never since I was registered. I do not want this to be my first.”
I knew the feeling well but what could
I say? A doctor has to face it some time.
“Do you believe there is God?” She
asked
“Do you really think I can answer that
one?”
“Well, you have more experience.”
“To me it is like reading a good book.
You would not know until the end.”
“So you mean I am not going to know
until then.”
“Interpret whichever way you like. I
remember Jung in his Memoir gave quite an
account on the Holy Trinity. There were
seventeen bishops in Jung’s family including his own father. Jung had always been
puzzled by deity and the bible and most of all by the concept of the Holy
Trinity. I know many religious philosophers struggle with that too. By some
accident he had access to his father’s inner library. He saw this folder
clearly marked Holy Trinity. The relief was phenomenal. He could now have the
answer. He hesitated before opening the folder.”
“What did the folder contain?”
“See, you want the last chapter. I
wanted to know as well. The folder contained pieces of blank paper.”
“That was it?”
“That was it.”
“Well. My view is this. We are here. We
live. We help others to live and maybe we do not ask too many questions and we
might or might not in the end know the answer.”
“But do you think this girl is going to
live though? I do not want this girl to be my first death. It would be so
awful.”
“Neither do I. I keep saying to myself
that it is now over seventy two hours and she is still alive and I do know that
some cases of viral encephalitis can be very dramatic in
presentation and recovery.”
“But which virus?”
“The nearest I have is Herpes.”
“Mother’s cold sore.”
“You have noticed that too.”
“I was with her for a long time.”
We had our own prayer for her too. Let
it be Herpes encephalitis and all would be well.
I left the hospital feeling slightly
strange. I just had a philosophical encounter with a young doctor. How strange it
is that threats of death always get one thinking about these things.
The girl remained unconscious although
the word was that the EEG was more hopeful than was first thought. GOS decided to transfer her next door to Queen Square - National Hospital for Nervous Diseases. A lumber
puncture was done and the initial findings were in keeping with viral
encephalitis. They were now trying to grow the virus. They also wanted Queen Square to
decide on assisted ventilation.
There was now a candlelight vigil at
the church and it was hoped that there would always be a lit candle until she
came home. The story was in the local paper and radio. Faith was now on field
test if not on trial. The doctors were not. They had done their best.
On the 10th day the
ventilator came off, and she was able to breathe without support.
They then started a vigil in the girl’s
home.
By the 23rd day, as my
optimism was about to give in, word came from the hospital that she became conscious.
It became big news in the papers.
When mother came home from London, she came to see my
secretary to give her the details. She told my secretary that she always knew
that her daughter would live.
No virus was ever isolated and her
diagnosis on discharge was that she had a variant of Encephalitis Lethargica.
“Did you agree with the diagnosis?” The
junior asked me when I saw her next.
“Why should I be arguing with the best
neurological centre in the world? It is harder to argue with a variant of
Lethargica. However the next few months or years will be important. If she is
well then Herpes fits in better and often it is an allergic type of reaction on
first exposure. But if she is like those in Awakenings, then Encephalitis
Lethargica.”
I saw her at the local hospital rehab a
couple of times. Initially there were a good deal of residual symptoms
including awkward gait and dis-inhibition. She became better and was moved to a
specialised centre and that was the last I heard of her.
Ten years later mother came to see my
secretary and left a photo. It was a photo of her daughter and her new baby.
She had been working at the local bank since she left school, met a very nice
man and now she had a baby. Mother thought I might remember them and perhaps I
would be pleased with the outcome.
I was very pleased for them too but I
would hate for anyone to put faith or god to such a test too often.
GPI - General paresis of the insane. A
now-rare neuropsychiatric disorder affecting the brain and central nervous
system. A late complication of syphilis.
Stelazine - trifluoperazine hydrochloride, an antipsychotic widely used for
schizophrenia before the new generation of drugs came on the
market.
Tourette syndrome -
Over 100 years ago, the French physician Georges Gilles de la Tourette wrote an
article in which he described nine individuals who, since childhood, had suffered
from involuntary movements and sounds and compulsive rituals or behaviours. In
his honor, this constellation of symptoms was named Gilles de la Tourette's
Syndrome. Today, we recognize that Tourette's is a spectrum disorder, with some
people having a few tics and others having tics plus features of other
conditions such as obsessions, compulsions, inattention, impulsivity, mood
variability. Once thought to be a rare condition, Tourette's is a fairly common
childhood-onset condition.
http://www.tourettesyndrome.net/tourette.htm
Catatonia - Catatonia is a disturbance of motor behaviour that can have either
a psychological or neurological cause. Its most well-known form involves a
rigid, immobile position that is held by a person for a considerable length of
time— often days, weeks, or longer. It can also refer to agitated, purposeless
motor activity that is not stimulated by something in the environment. A less
extreme form of catatonia involves very slow motor activity. Often, the
physical posture of a catatonic individual is unusual and/or inappropriate, and
the individual may hold a posture if placed in it by someone else.
http://www.minddisorders.com/Br-Del/Catatonia.html
Teratoma – Teratomas are tumors comprising more than a single cell type derived
from more than one germ layer. Usually, dermoid cysts contain representative
tissues of the three embryonic germ cell layers: ectoderm, mesoderm and
endoderm. Sebaceous material, hairs, cartilages, teeth, even thyroid tissue are
frequently observed. A well-formed jaw and tongue has been reported. Teratomas
of other organs have also been reported to contain teeth.
lumbar puncture – A lumbar puncture (also called a spinal tap) is a procedure
to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the
brain and spinal cord.
Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”
