Chapter 20: Mysteries of the mind

One of the really difficult challenges of rural and remote practice occurs when asked to assist the police in the examination of an alleged assault victim. Invariably the assault is genuine but rarely the victim may present with a bogus claim. This will usually be in the setting of a secondary gain (e.g. financial) but may also occur when the patient has some form of psychiatric illness.

‘Maddy’, aged 17, was brought in by the police with a claim that she was allegedly assaulted by a man with a ‘stay-sharp’ knife (Kille, 1986; 1991). On examination there was an unusual pattern of superficial wounds on the chest and legs.

Only two months after starting country practice I had a phone call from the local police requesting help in an emergency at a nearby farmhouse. Public servants and a constable had been serving legal documents on a man when he suddenly retreated to the house and began threatening everyone with a shotgun.

The patient

I knew about Jim, a 49-year-old widowed farmer and a legend in the district. A war hero, he was awarded for bravery as a pilot of Lancaster bombers over Germany but about 1944 he suffered a ‘nervous breakdown’. He developed paranoid schizophrenia and with regular exacerbations he spent a total of 12 years in psychiatric institutions. He had been discharged from his most recent committal six months previously on chlorpromazine and benzhexol medication but had not been taking the drugs.

The local community was afraid of him, but he enjoyed the love of his devoted mother who lived on an adjacent farm.

The conflict

Jim had been extremely disturbed when the local dam was built because the state authorities had annexed a considerable portion of his precious dairying farmland. He resisted all attempts at negotiation and his irrational confrontations with government agencies precipitated many admissions to hospital.

The confrontation

As I drove up to the house I could see at the window the silhouette of a very large man with a gun. I was conscious of two neatly dressed public servants hiding behind a shed, obviously disconcerted by the cow dung and turkey excreta adorning their polished shoes. Ruddy-faced Returned Services League executives peered from behind bales of hay.

Jim became agitated about the policeman despite the fact that he was a genial officer and sympathetic towards him (even though the officer carried some of Jim’s shotgun pellets in his anatomy). Finally Jim agreed to see this inexperienced, nervous doctor—alone.

‘Give him a knockout shot, Doc, Hollywood style’, whispered the constable. ‘Let’s know when he’s bombed out.’

The agitated and garrulous patient seemed to relax with me. My apprehension eased, but there was no doubt he was mentally disturbed.

‘I don’t need any injection, Doc. Give it to those blokes outside: they’re Nazi agents. Can you get the prime minister? I’d like to talk to him.’

We chatted aimlessly for about 20 minutes. When I felt I had his trust I drew up a syringe of 100 mg chlorpromazine hydrochloride and shot it into his arm. Minutes passed: no reaction. Half an hour later he was still hyperactive, talking vehemently as he watched for the ‘enemy’ outside and fiddled with the gun and ammunition he had refused to surrender to me.

He gave me permission to go out and speak to the policeman and I discovered to my delight that reinforcements had arrived. With new instructions, I returned and distracted Jim as a burly policeman crept through the back door to claim him with a crushing bear hug. Jim departed for the long drive to Melbourne, his police escort conveying a ‘certificate of recommendation’ from me.

Home again

Five months later Jim was discharged from hospital, this time on a massive chlorpromazine regimen. He was warm and friendly but (not surprisingly) rather sedated and dyskinetic.

Knowing he would not continue taking the drugs, I planned to give him fortnightly injections of fluphenazine with the help of the district nurse. The treatment worked well and Jim enjoyed social harmony and an adequate existence on the farm.

‘Wolf ’

Jim’s rehabilitation was not without incident. About three years had passed when the nurse told me she was concerned about Jim: he seemed to be ‘high’, hallucinating about seeing a wolf in the bush. We possibly had black panthers (escapees from circuses) in the Gippsland bush but not wolves.

I went out to the farm and saw a new and exotic complex of pools: Jim was farming young alpine trout. He was adamant about seeing a great wolf when visiting the trout streams deep in the bush. I went to his mother for an opinion. ‘Doctor, I’m so pleased. Jim is just fine. It’s wonderful.’ Nevertheless I decided to increase his dose of fluphenazine.

One evening about a week later there was an urgent knocking on my back door. There was Jim, looking pleased and a little superior, preparing to drag in the not quite cold corpse of a huge blood-spattered animal, enormous canines protruding from its large skull.

‘I got him, Doc! You didn’t believe me did you?’

Although not a wolf, it was a canine species unfamiliar to me and a most eerie sight.

A 65-year-old retired farmer used to see me occasionally, with a multitude of complaints: most of them caused by his psychosis. He had been a manic-depressive for many years taking Parnate and lithium carbonate. In his manic phases often he would stop all medication—to the detriment of his precarious equanimity. His wife had left him; he was desolate and became unkempt and thin.

One time he complained of shoulder pains and some vague chest pains and said as usual that he could not understand why his wife would not come back to him. He had begged her and offered to make the house more comfortable. (He had recently been in trouble with the shire health surveyor for slaughtering sheep in his backyard and hawking the carcases around the town. His neighbours had complained.)

I listened impatiently to his rambling complaints, hoping that soon he would ask for a repeat of his tablets and go. Then he said that he had trouble passing water and had to get up every hour at night, but over a year ago he had fixed it with a pencil. Now he was having trouble again.

I glanced back through his history to find that I had felt his prostate two years previously and had noted that it was soft and not enlarged, and that the urethral groove was not filled in. Recently, he had been taken off his Parnate by an assistant and prescribed imipramine.

I repeated the rectal examination confirming the previous findings. I said to him as he was getting dressed: ‘What did you mean when you said you fixed it with a pencil?’ He replied: ‘I put a pencil in it’.

It was up on the couch again and I could feel a hard, 3 cm area along the distal urethra—the pencil.

The next day in theatre under a general anaesthetic a urethrotomy produced a lead pencil ‘sans lead’.

Concretions had narrowed but not completely blocked the lumen of his improvised irrigation regulator. After the catheter had been removed three days later he regained normal micturition.

Kevin C, a 49-year-old carpenter, presented with multiple problems including weakness, malaise, weight loss, headaches, muscular aches and pains, anorexia, shortness of breath and thoracic back pain. X-ray revealed a small pulmonary mass adjacent to T₅. Biopsy of this mass was positive for mesothelioma. He visited a city hospital for assessment and subsequently chemotherapy. He was discharged to our small hospital where the course of intravenous chemotherapy was to be continued.

Breaking through the brick wall

Each day I would talk to Kevin about his feelings and his understanding of his problem, but he was evasive, silent and uncommunicative. He continued to be morose and ill, and continued to complain of a deterioration in symptoms. I became weary of ‘not getting through to him’, and so one day I entered his room alone, closed the door, sat down beside his bed, looked him directly in the eye and said, ‘Look Kevin, this silence is not helping any of us. Something is bothering you—it’s time to tell me about it’.

He took a deep breath and said, ‘I know I’ve had it but I am a lost soul. I’ve been living in sin. I’m not really married to Ruth. Everyone thinks we are but we’ve been living together with our kids for 26 years’. He then went on to say that he came from a strict Catholic family, and he felt he had cheated everybody and was doomed when he faced his judge in the next world. This was the big break we wanted. I spent a long time explaining to him that God is a forgiving God and his problem was not really a problem at all. I offered to ring the local priest and explain the situation. He seemed delighted about this approach.

As expected the priest’s counselling, reassurance and comfort worked ‘miracles’. Within one week Kevin had received the Catholic sacraments of reconciliation, communion, matrimony and anointing of the sick. All in his hospital room.

The change in that terminally-ill person was dramatic. It was a pleasure to enter his room and enjoy the enriching interaction that can occur with the dying patient. Fortunately, his general health improved (undoubtedly aided by cessation of cytotoxic therapy) and he was able to return home for four months prior to his inevitable death.

Which of us, when confronted with the daunting sight of an acutely psychotic person in full flight, has not at least mentally quivered at the knees and felt like turning and running for cover? Those eyes, with that strange all-knowing look, totally suspicious and distrustful, darting from side to side like a restless flycatcher on a winter’s afternoon; a daunting sight indeed. The arrival of the doctor brings sighs of relief all round. Lay approaches and secular ammunition seem strangely ineffectual, yet how helpless that doctor feels in such situations. Quiet conversation, logical explanations and advice seem totally unacceptable, but it is the sole responsibility of the doctor to solve the problem—truly a High Noon situation. Just as for John Bunyan’s pilgrim, so too for the general practitioner: ‘Who would true valour see let him come hither’ (Bunyan, 1927).

One who, like me, has been fortunate to live and practise in the same district for several years would find it interesting to look back on some of these difficult cases and see how the people, their situations and problems have resolved. Some such cases follow.

CHAS

An intelligent 35-year-old bachelor with many talents, especially those associated with the handling and nurturing of plants, Chas loved classical music. Unfortunately, he had a severe personality disorder with associated depression as well as alcohol and drug dependence.

His dramatic episode was a violent confrontation with his brother and devoted mother. The attendant doctor was summoned to a barrage of missiles, namely the entire record collection, one by one, and eventually the record player itself; all this in a neat house with a perfect garden and furniture that was cared for.

The next day Chas was persuaded to have psychiatric treatment in hospital. His life over the years thereafter was a series of highs and lows; and in one of the lows he took a drug overdose with fatal result.

Mrs S

She was a lonely widow with few friends and no job, living in a dingy flat with dull and drab furniture.

This time the projectiles were cups, saucers and cigarettes, as Mrs S stood unkempt, like a true poltergeist spirit, in the corner of uncared-for surroundings. The same day she was persuaded to enter hospital for treatment for her ‘nervous condition’.

After a few admissions she settled on long-term phenothiazines into a zombie-like state. Since two major strokes and relative paraplegia, she lives friendless and penniless in a nursing home.

LIZ

Liz was a hugely obese, highly intelligent ex-schoolteacher. She was in her mid-twenties. All 170 kg of her had married Tim, a young local farmer who was quiet, introspective, flat of affect, with mild schizophrenic tendencies.

They managed to conceive a son who was delivered at Easter. The hospital staff noticed then that Liz was a bit ‘high’ but paid no great attention to it. On returning home the acute psychotic episode erupted: the combination of the historic religious Easter happenings and a ‘message’ that the world was coming to an end guided Liz’s mind towards the thought of sacrificing a newborn son (and his parents). With the help of our local clinic sister, Methodist minister, general practitioner and eventually the police, the baby was removed from Liz and she was ‘persuaded’ to go to the nearby psychiatric unit.

Liz improved sufficiently to be sent home, alas prematurely as she tried to suicide by overdose and cut wrists. This time the general practitioner was successful in arranging voluntary admission.

Some months later we were summoned by the shattered husband because Liz had ‘gone high’ again. We arrived to see her cavorting naked in front of open door and windows to loud pop music, throwing furniture out of the upstairs window to crash down on the garden below. Inside, the house was a mess with graffiti everywhere, smutty and religious; the bathroom door was drawn on from top to bottom. Again she was slowly persuaded to dress and prepare for voluntary readmission.

Years later the (to date) happy ending is comforting. Now, with two children (no puerperal psychosis after the second) Liz is sensible, has good insight, requires no treatment and copes well while studying for an extracurricular high-level degree in education. She remains extremely obese but she has managed to lose an amount of weight by diet and gastric stapling.

Is the psychotic volcano extinct or only temporarily quiescent?

SID

Sid, a man in his 50s, presented one hot, dull, sultry morning in an acute manic state. He was restless, voluble (with unsavoury language), paranoid and looked positively menacing. The episode began in the middle of a busy surgery day and ended at the exit of the premises for all to see. Police help was slow in arriving and counselling was of no avail; eventually, with the help of the tardy officers of the law, he was restrained physically by five people and succumbed slowly to intravenous sedation. His admission to the psychiatric unit was involuntary.

Despite medication, Sid continues to have his ups and downs as a manic-depressive. In the ups he has expensive, expansive, high-flying ideas; in the downs he goes back to the psychiatric unit. His wife aged by 10 years within 12 months.

MRS K

This woman, mother of two boys, had a poor psychiatric family history but managed rather well, if slightly anxiously, until the children reached school age. Then she became actively psychotic with paranoid ideas about her husband, thought disorders and finally a fixation on her general practitioner, expecting him to look after her completely. When disallowed from seeing him because of the embarrassment and upheaval she caused, Mrs K bombarded her general practitioner with strange and suggestive letters.

Mrs K’s illness remains ongoing. Her family disintegrated, she is the centre of a ‘committee of care’ (social workers, GP, school authorities), and a menacing presence to her relatives, the new medical attendant and the community.

After another violent episode Mrs K was taken involuntarily to the neuro-psychiatric unit. Mrs K was discharged and is still within the same community. She lives some sort of existence with relatives in a caravan—acceptable only if she agrees to regular phenothiazine injections.

Most doctors have been tricked by the itinerant pethidine addict, wandering from doctor to doctor in search of one who would be fooled by the Oscar-worthy performance of a renal colic victim. They always find one—usually a fresh-faced newcomer to the trade. This can be a problem in the daily running of a practice.

Pethidine has become a standard analgesic in general practice. It was first synthesised in the search for atropine-like substances, its analgesic properties being a bonus discovery. Its reputation as a spasmolytic is perhaps exaggerated because of its origin. Unfortunately, at first it was said to be less addictive than morphine, but indiscriminate use soon made its addictive properties obvious. Nevertheless, in an acute emergency when a patient presents with the severe pain of classic renal or biliary colic, pethidine is a boon and a standard content of doctors’ little black bags.

Because of pethidine’s well-known addictive property most general practitioners have become careful and discriminatory in storing, handling and prescribing it. However, we still see lots of problems created by its use. We sometimes can be careless, a little blasé or dismissive of people’s problems and, sadly, some patients have been led to a state of dependence on pethidine: two such cases follow.

DUNCAN

Born on the Isle of Skye, Duncan emigrated to Australia after retiring as a piper in the King’s Own Scottish Borderers. He had been a lone piper with the Edinburgh Castle Military Tattoo, an entertainer and a supreme storyteller.

He had a long history of hypertension and had developed severe ischaemic heart disease, eventually with recurrent bouts of angina. A failed cardiac catheterisation had left him with a blocked channel in his right arm and little hope for the future. Undaunted, Duncan swallowed all his medication, had his severe chest pain and became rather fond of his increasing dosage of pethidine injections. It became a standing joke in the practice that Duncan would arrive with severe chest pain and an agonised expression, making grunting noises. One pethidine injection later, he would leap from the chair and swagger smartly to his waiting carriage—usually an ambulance.

Nonetheless, Duncan did have severe ischaemic heart disease and did have genuine severe angina, but he could no longer distinguish between his addiction and his cardiac illness. He was well aware of this and approached me one day in a quieter mood. ‘I’ve become a Highland junkie. What can we do?’ he asked.

Another attempt at cardiac catheterisation was arranged by his specialist physician. The day after the operation he rang me, crestfallen. ‘They’ve failed again. I suppose I’m resigned to pain and pethidine’, he said.

I wrote an impassioned letter to the physician, who was furious at the lack of effort and understanding. He approached the cardiologist personally, who was pressured into doing the procedure himself. Duncan had a successful coronary bypass and when the physician presented his case at a clinical conference, Duncan entered in full Highland dress, with bagpipes blaring as ‘proof of the pudding’. He was no longer pethidine-dependent and no longer had severe bouts of angina.

DOROTHY

Now in her 60s and less than happily married, Dorothy had a difficult hyster-ectomy at the time of her menopause. In 1977 she had an operation to relieve what was thought to be a neoplastic intestinal obstruction but what was in fact adhesions resulting from the hysterectomy. This operation started a series of abdominal interferences that led to her tragic state.

Pethidine, as a remedy for the recurrent abdominal pain, had been used haphazardly and it soon became obvious that Dorothy had become dependent on the drug. There followed numerous admissions to hospital; surgery became impossible, intravenous feeding became parenteral feeding, and pethidine was always used for pain relief. Relations between surgeon, patient and general practitioner became strained and the result was a certificate of assent from the appropriate authority to the use of 150 mg of pethidine tablets per week. Dorothy is a woman whose future is one of pain, addiction, liquid-food concentrate and not much happiness.

The story

Betty, a patient new to the practice, was an obese 49-year-old non-smoker who ran a local block of holiday units with her husband. Her presenting complaint was ‘I haven’t felt right for a long time’.

She proved to be a very unsatisfactory historian. It was a trial even to elicit that the message she was trying to convey was that she was listless, anergic and had trouble managing her usual duties. She answered most questions with clichés or non-sequiturs and when I gently challenged her about this she simply said that she had never been a good talker. Eventually I extracted that what concerned her most was that when watching television she occasionally saw a bluish tinge on the screen.

On examination, the only positive findings apart from her obesity were a blood pressure of 170/100 and a urine test of one plus protein. There was no cardiomegaly, her peripheral circulation was normal, there were no carotid bruits, and ocular and central nervous system examinations appeared normal. I arranged a battery of tests including chest X-ray, ECG, full blood count-erythrocyte sedimentation rate, renal function tests, serum lipids, electrolytes and MCU and arranged to review her 10 days later.

Her husband brought her back in five days. She had become agitated and confused and was complaining of a severe headache. Her blood pressure on this occasion was 170/100 and I admitted her to the local private hospital. Her headache settled without treatment and her blood pressure came rapidly under control on metropolol and prazosin. She became more lucid, but appeared to have particular difficulty finding words––and she left sentences half finished. The results of the tests I had ordered were all normal so my working diagnosis was dysphasia secondary to a cerebrovascular accident.

The referral merry-go-round

In view of her age and the modest elevation in her blood pressure, I referred her to the local physician for his opinion. Over the next two or three months, I received periodic update letters on Betty’s ‘progress’ but saw neither hide nor hair of her.

Serums ‘everything-in-the-world-you-could-imagine’ were duly ordered and found to be normal. The local radiologist got his share with obstinately normal chest X-rays as well as an intravenous pyelogram and CT brain scan.

Trials of six anti-hypertensive drugs alone or in combination normalised her blood pressure but failed to remove the bluish lights that she now saw every time she watched television. Nor did they overcome her lassitude, her inability to initiate activity and her problems with articulation.

She was then referred to a neurosurgeon in Brisbane, who ensured the normality of most of the preceding investigations by repeating them and adding a normal carotid angiogram to the list. I received a copy of the neurosurgeon’s letter to the local physician, agreeing with his impression that it most likely was some ‘sort of vascular or migranous phenomenon’.

Just when it seemed Betty was slipping inexorably on to the physician’s ‘quarterly review till eternity’ list, she developed otitis externa and presented to me again. Making light conversation while writing her prescription for ear drops, I asked about her trip to Brisbane. She replied ‘They think the blue lights are caused by a problem in the blood vessels’, with unusual emphasis on ‘they’.

Suddenly it hit me like a bolt from the blue. ‘Betty, what do you think is causing it?’

‘It’s the police trying to warn me about the young people in the end unit. The police think they’re putting marijuana in the water!’

Haloperidol 5 mg daily dramatically improved her thought disorder and suppressed her paranoid delusions. The blue lights faded and left and she regained her capacity for work.