John A Mills
email: millsj@telus.net

Lessons from the periphery

Keywords: adrenochrome hypothesis, Canada, community psychiatr y, deinstitutionalization, Hoffer, LSD, Osmond, Saskatchewan Plan

The gover nment of the Saskatchewan Co-Operative Commonwealth Federation, when elected in 1944, established programmes for the statefunded care of all those suffering from mental illness. It enacted legislation covering the care and treatment of the mentally ill and created a division of the Department of Public Health, the Psychiatric Services Branch (PSB), which both recruited and trained psychiatric staff, meeting the need for nonmedical staff by creating a

Introduction

It is a set of truisms to say that community psychiatry, the profession's 'third revolution', was possible because of the widespread introduction of welfare states following World War II, that the broadening of psychiatry's professional base, especially because of the growing infl uence of psychoanalysis, was a contributing factor, and that the profession's increasing self-confi dence resulting from the introduction of various physical therapies (even if most proved to be ultimately ineffective) played a role. Above all, during World War II not only did British and American psychiatrists develop effective short-term treatments for battlefi eld neurosis but some of them saw the implications for peace-time psychiatry. It is, however, surprising that, in North America, those factors should have been instantiated for the fi rst time in the Canadian province of Saskatchewan.

Saskatchewan is remote from Canada's metropolitan centres; its capital, Regina, is 571 km from the nearest large city, Winnipeg, and 4035 km from Ottawa. Until the 1970s its population was mainly rural and it had no large cities. Moreover, the province, whose principal economic activity had been the growth of wheat and other cereal crops, had been economically devastated by the Depression and by a severe drought in the 1930s. World War II restored Saskatchewan's economy, and the province was set on an upward course with the election of North America's fi rst effective socialist government in 1944.

The new premier, Thomas ('Tommy') Clement Douglas (1904-86) was one of Canada's most brilliant and effective politicians (for biographies of Douglas, see: McLeod and McLeod, 1987; Shackleton, 1975; Stewart, 2003). He embodied the highest version of the ideology driving the form of socialism unique to western North America, which the political sociologist Seymour Martin Lipset (1968) has called 'agrarian socialism'. Douglas was, however, much more than an idealist in that he was a superb proponent of political craft. He was also one of Canada's great administrators with, for example, a complete command of the principles and practices underlying fi scal policies. 1 The Saskatchewan Co-Operative Commonwealth Federation (CCF) came to power with a prior commitment to create some form of medicare, but had assumed no obligations to those suffering from mental illness. Douglas, who had taken the unusual step of combining the offi ces of Premier and Minister of Public Health, was the ultimate architect of the Saskatchewan CCF's programme of mental health (see Hall, 1979). 2 Although we can never know precisely what motivated Douglas to make a mental health programme a priority for the province, it is probable that his desire to improve the lot of the mentally ill can be traced back to his research, as a young man, into eugenics. In 1933 he had completed a Master's thesis in which he had studied the relative reproductive rates of a sample of women committed to the Saskatchewan Hospital Weyburn and of a group of 'normal women'. He found that the inmates had a higher rate of reproduction than the normal sample and drew the conclusions usual for the time, namely, that restrictions such as sterilization should be placed on the reproductive capacities of those suffering from severe forms of mental illness, from mental defi ciency or from forms of social pathology such as alcoholism (McLaren, 1990: 7-9, 166-7).

By the time he acquired political power, Douglas's ideological fervour had softened and become transmuted into a passionately humane concern for all those suffering from illness, whether physical or mental. 3 The transformation of coercive or restrictive attitudes towards mental illness into sympathetic concern was given concrete manifestation in a set of letters he wrote to concerned members of the public repudiating the use of sterilization. 4 Very soon after entering offi ce, Douglas and his government began to set the stage for the introduction of state-funded health programmes. In 1944 Douglas invited the American medical historian Dr Henry Sigerist to tour the province, to write a report describing the current state of the province's health programmes, and to make recommendations for improving them (for a summary of those recommendations, see Dickinson, 1989: 77-82). The government began to enact Sigerist's recommendations with commendable dispatch. In the case of physical health the government was, essentially, faced with the task of rationalizing and universalizing a set of private health insurance schemes, some of which provided comprehensive coverage for their members. 5 As Sigerist had recommended, the government decided that services to the mentally ill should be offered free of charge. It therefore had to rewrite the Act dealing with mental illness (the Mental Hygiene Act of 1936). On 8 April 1950 a new version of the Act granting such a right passed into law. 6 The costs of caring for and treating all those diagnosed as suffering from mental illness after 1 January 1946 were to be borne by the government. The control of admission to mental institutions constituted the second major difference between the new and the old Acts; in the new one, admission was controlled almost entirely by the medical profession. A section on alcoholism and addiction constituted the third major difference between the old and the new Acts. In addition to committing itself to bearing the fi nancial costs of mental illness, the government broadened the scope of application of the Act by including a section on voluntary patients, provided that such people arrived at a mental institution with a letter from a physician recommending treatment.

Douglas and his government knew that, in order to ensure adequate health care, they had to create a fully fl edged College of Medicine which, in turn, would have to have a close association with a university hospital. They therefore provided the required funding to the University of Saskatchewan, 7 enabling it to open the College in 1952. The College's Department of Psychiatry started operating on 1 July 1955.

Building a mental health programme presented the government with a formidable task. The facilities and services available comprised two overcrowded mental institutions (at Weyburn and North Battleford) and a mental health clinic. The medical staff was below complement and often lacked psychiatric training, while the attendants in the mental hospitals were inadequately trained and had poor morale. 8 Consequently, even before expanding and improving the services available to those suffering from mental illness, especially to those who did not require institutionalization, the government had to deal with the severe overcrowding and poor physical conditions in these two mental hospitals. In 1946 they had a total patient population of 4249 and were 100% overcrowded relative to a 1930 baseline (Hall, 1979, VI: 9). Douglas did not fl inch and on 1 November 1946 he appointed Donald Griffi th ('Griff') McKerracher (1909-70) as the province's Commissioner of Mental Health. This was an inspired appointment. Even if McKerracher was clinically naive, appearing to believe that mental illness would succumb to a mixture of care, sympathy, concern and trust, that naivety was more than counterbalanced by the depth and sincerity of his concern for the plight of the mentally ill. Because he was a man of immense charm, he easily persuaded others to share his concerns. 9

The creation of the Saskatchewan Psychiatric Services Branch On 1 April 1950 the Government of Saskatchewan provided McKerracher with the instrument he needed to build a comprehensive programme of community psychiatry by forming a division of the Department of Public Health, the Psychiatric Services Branch (PSB), with McKerracher as the fi rst director. In that role, fi ve achievements stand to McKerracher's credit (Hall, 1979, VI: 15-19, 20-2):

1. He improved the operation of Saskatchewan's mental hospitals. He increased the medical staffs, removed the worst wards, abolished the use of isolation and mechanical restraints as means of controlling patients, and introduced pilot programmes such as trial leaves and the relaxation of criteria determining the release of patients. 2. He developed a system of permanent outpatient clinics, unique in North America at the time. As a result of the CMHA's decisive role, Saskatchewan was exceptional not only in being the fi rst Canadian province to introduce a comprehensive programme for the humane treatment of mental illness, it was also exceptional in that the CMHA (Sask) acted as a powerful advocate for those suffering from mental illness: in attempting to ensure that mental health services were improved, in funding research into mental illness, in educating the public about the nature of mental illness, and, to some extent, in providing mental health services. CMHA (Sask) had close links with both the government (Douglas and all his cabinet were members) and with the PSB (all the senior psychiatrists were members). Moreover, at the height of its infl uence in the late 1950s CMHA (Sask) had 15 branches and a membership of 50,000, and its leading fi gures were energetic, articulate and committed.

In principle, it should have enhanced levels of mental health care in the province, especially through its public education programmes. Certainly, McKerracher used the CMHA (Sask) to lay the foundations for programmes to support released institutionalized patients. He approached Marjorie Cooper, later to become a CCF Member of the Legislative Assembly, who persuaded Agnes Davidson of the Regina branch of the CHHA (Sask) to institute a system of volunteer visitors at Weyburn (the fi rst visit was in May 1952). Once the service had been successfully established, it was extended to North Battleford. By 1960 the Regina group comprised 800 regular visitors. (Hall, 1979, VI: 9) [START_REF]Saskatchewan's two mental hospitals[END_REF] Although McKerracher toyed with a plan to build a third large mental hospital in Saskatoon, a prominent feature of his career was his commitment to community psychiatry, despite the unpropitious situation facing him when he arrived in Saskatchewan. [START_REF]For a history of the Saskatchewan government's fl irtation with the idea of a third mental hospital[END_REF] However, he rapidly regained his confi dence in the ultimate value of community psychiatry. But his most striking attributes were his self-confi dence and his faith in his powers to persuade others of the value of his programmes and policies. That self-confi dence set an enduring stamp on Saskatchewan psychiatry for roughly twenty years. For example, in order to meet his staffi ng requirements, McKerracher rapidly began to train psychiatrists himself, a bold move because, when he started his programme, the University of Saskatchewan's medical school was at best embryonic. Even so, McKerracher's was the only in-province training programme in psychiatry to be certifi ed by the Royal College of Physicians and Surgeons. Two of the psychiatrists he trained, Dr Abram Hoffer (b. 1917) and Dr John Cumming (b. 1917), became prominent in the profession, while others such Dr Nick Chwelos had successful careers. In addition, instead of following the Canadian tradition of building on an affi liation with the USA, McKerracher persuaded psychiatrists from Britain and some other countries to work in Saskatchewan. On the whole, those who joined the PSB did so because they were committed to the ideals of community psychiatry and so they established innovative programmes which in turn attracted other talented psychiatrists to work in the province. Overall, despite recurrent recruiting problems, staffi ng levels remained adequate. For example, in 1958, 1959 and 1960 the PSB's medical staff numbered between 55 and 57 (20 of whom were psychiatrists), while the number of nursing and other patient care staff remained constant at 1156 (Final Report …, 1962: 23).

The Saskatchewan Plan

On 1 July 1955 McKerracher took up the post of Head of the Department of Psychiatry at the University of Saskatchewan. He was succeeded as Director of the PSB by Frederick Samuel ('Sam') Lawson (1903-70). Lawson was one of North America's most prominent community psychiatrists, and his is the name most strongly associated with the Saskatchewan Plan, a means for delivering psychiatric services to a dispersed rural population.

The Plan first took shape in some informal discussions between McKerracher, Lawson and the Medical Superintendent of Weyburn, Humphry Osmond (Kahan, 1965: 82). In its most comprehensive version, as developed by Lawson and some of the head offi ce staff of the PSB, the Plan called for the division of the province into two urban (Regina and Saskatoon) and six rural mental health districts, each serving a mean population of about 73,000 and of such a size that no patient would have lived more than 130 km from a mental hospital (Lawson, 1957, 1958, 1967; Lawson and Izumi, 1965; McMillan, 1957; Rands, 1960). Outside the two largest urban centres those services were to have been centred on small purpose-built mental hospitals (in the fi rst version of the plan, the size of the hospitals would have varied from 238 to 448 beds). Besides providing institutional care and treatment, the hospitals were to have served as the centres for travelling clinics staffed by psychiatrists, social workers and psychiatric nurses, so that most of each region's treatment would have been delivered within the community rather than at its hospital.

The start of Lawson's tenure as the Director of the PSB coincided with the presentation to the government of a set of highly disturbing reports about the situation at the Saskatchewan Hospital, Weyburn. [START_REF]The Saskatchewan Hospital Survey[END_REF] The hospital was appallingly unhygienic, standards of care, even at a very basic physical level, were disgraceful, while all the menial tasks were carried out by a group of aging, largely male patients -in fact, their lives were hardly different from those of their counterparts in the large mental hospitals of the mid-nineteenth to mid-twentieth centuries. The Deputy Minister of Public Health, Dr F. Burns Roth, asked Lawson to generate policies for dealing with the situation. Lawson responded by producing an outline of the Saskatchewan Plan and presenting it as his only option. 15 Had the government followed Lawson's recommendations it would have used up almost all funds available for new capital expenditure and almost all the expected budgetary increments for a decade (Hall, 1979, IV: 40). Since Saskatchewan's per capita expenditures on mental patients were already the highest in Canada, the government could not accept Lawson's recommendations. His response was to elicit support from the CMHA (Sask), which launched itself on an extensive lobbying campaign. To make matters worse, Lawson gave a speech to a CMHA meeting in which he criticized the government for what he saw as inhumane treatment of those suffering from mental illness. [START_REF]For a discussion of that episode and some of its aftermaths[END_REF] Privately, Douglas was furious, but he had to swallow his rage because, as Roth pointed out to him, it would be well-nigh impossible to fi nd a replacement for Lawson.

Ultimately, and begrudgingly, the government did build one regional psychiatric centre at Yorkton. [START_REF] Kahan | For a comprehensive history of the background to that project[END_REF] In addition, because of the considerable freedom of action granted to the PSB and its senior staff, attenuated versions of the Saskatchewan Plan were put into effect. In 1963-66 the Plan reached its apogee in the work of Hugh Lafave and Frederic Grunberg, respectively Medical Superintendent and Clinical Director of the Saskatchewan Hospital, Weyburn. Lafave and Grunberg reduced the Hospital's patient population from 1519 to 421 in those three years. This 72% reduction was the highest rate of de-institutionalization ever recorded in any mental institution anywhere in the world (Hall, 1979, VI: 40). Moreover, the patients were not merely discharged but were placed in approved homes under the overall supervision of psychiatric nurses, so that Sigerist's and McKerracher's policies did fi nd their ultimate fulfi lment.

Psychiatric research in Saskatchewan

Innovative work in community psychiatry in a remote Canadian province is surprising enough. Even more surprisingly, Saskatchewan instituted Canada's fi rst provincially funded psychiatric research programme. To add yet more surprises, Saskatchewan researchers were prodigiously productive and much of the research was of high quality. [START_REF]An incomplete 1962 bibliography lists about 240 items concerning research in schizophrenia alone[END_REF] Indeed, for a short time Saskatchewan was one of the world's leading centres for research into the neurochemical origins of schizophrenia.

Humphry Fortescue Osmond (1917-2004) had realized that the observed effects of lysergic acid diethlyamine-25 (LSD), which at that time were taken to be its psychotomimetic attributes, provided a possible avenue towards the understanding of the neurochemical origins of schizophrenia.

He and the biochemist John Smythies had suggested that some naturally occurring analogue of LSD might be the psychopharmacologic agent causing schizophrenic symptoms (Osmond and Smythies, 1952). Osmond and Smythies were, however, unable to secure research funding, whereas McKerracher did promise them funding and in 1951 appointed Osmond to a post at Weyburn. When he arrived in Saskatchewan, Osmond met Hoffer, who besides having an MD had a PhD in biochemistry; his thesis subject had been the B vitamins. As a result of Hoffer's and Osmond's collaboration with a University of Saskatchewan biochemist, Duncan Hutcheon, they began to explore the metabolic pathways of adrenalin (epinephrine) because of its chemical similarities to LSD. Hutcheon suggested that a breakdown product of adrenalin, adrenochrome (or the chemically similar adrenolutin), could be the active psychogenic agent. Heroically, Hoffer and Osmond injected themselves, their wives and some of their research associates with adrenochrome and convinced themselves that it had psychotomimetic qualities.

The Hoffer-Osmond adrenochrome theory is a version of what is known as the transmethlyation hypothesis. In order to understand the hypothesis one has to know, fi rst, that adrenalin (epinephrine) is a catecholamine and that all catecholamines are monamines, that is, they have only one amine (NH 2 ) group. Second, all catecholamines have the same nucleus (catechol), which consists of a benzene ring with two hydroxy side-chains; the nucleus also provides a site for the addition of the amine side-chain. Third, catecholamines differ from one another in the presence or absence of methyl (CH 4 ) groups, either at some point on the benzene ring or within the amine side-chain. Furthermore, the methyl group can either be attached to an oxygen molecule (O-methylation) or to a nitrogen molecule (N-methylation). Fourth, and most crucially, both the addition and subtraction of methyl groups and the site of the bonding alters a catecholamine's biochemical and hence its psychopharmacological properties (Healy, 2002: 182-95).

The adrenochrome theory states that adrenochrome, one of adrenaline's breakdown products, is the psychogenic agent in schizophrenia. Supposedly, in the schizophrenic brain, but not in the normal brain, adrenochrome breaks down relatively slowly and its accumulation causes schizophrenic symptoms (Hoffer and Osmond, 1959, 1960, 1967: 225-6; Hoffer, Osmond and Smythies, 1954; Osmond and Hoffer, 1961/2, 1966). Hoffer went even further by stating that massive doses of nicotinic acid could counteract the effects of over-secretion of adrenochrome by reducing the numbers of potential methyl donors in the brain and thereby reducing the amounts of adrenalin (and hence of adrenochrome) produced. Therefore, Hoffer and Osmond had proposed not just a theory for the origins of schizophrenia but a chemically-based therapy. It should also be noted that Hoffer believed, and continues to believe, that schizophrenia could be cured and not merely managed psychopharmacologically. Almost as soon as the University Hospital opened in Saskatoon, Hoffer established a laboratory there and conducted a wide-ranging programme of research. Among his other achievements, he carried out psychiatry's fi rst double-blind test into the effi cacy of nicotinic acid therapy and reported that it was effective.

Hoffer and Osmond's adrenochrome theory was the world's fi rst theoretically based and empirically testable theory of the biological origins of schizophrenia, and therefore it attracted substantial research funding. [START_REF] Hoffer Told Me | that his research funding had totalled about $500,000[END_REF] David Healy (2002: 185-6) commented: … Hoffer, Osmond, and Smythies … produced a coherent theory of schizophrenia, along with a treatment that appeared to produce some benefi ts and certainly provoked considerable interest. In addition, their ideas tapped straight into an increasing public awareness of the hallucinogens, which as a group were referred to as the psychedelic drugs, a term coined by Osmond. The heady buzz that resulted made Saskatchewan in the 1950s one of the focal points of the psychiatric universe.

However, eventually Hoffer's claims could not be substantiated and the theory fell into disrepute. [START_REF]Hoffer's obduracy has excluded him from his rightful place in the history of neuroscience[END_REF] Crucially, no laboratory other than Hoffer's ever detected adrenochrome in blood samples. A team from the American National Institute of Mental Health visited the Saskatoon laboratory and concluded that Hoffer's data were an artefact of ascorbic acid in his blood samples. Because Hoffer refused to retract his assertions, organizers of international meetings ceased to invite him or his researchers to present papers. In 1961 Theodore L. Sourkes, a biochemist at the Department of Psychiatry, McGill University, wrote a review article on the biochemistry of mental illness in which he cited several articles presenting evidence fatal to the adrenochrome theory (Sourkes, 1961). Worst of all, the CMHA, which had supported Hoffer hitherto, funded a series of studies which conclusively demonstrated that nicotinic acid therapy was ineffective (Ban, 1971a, 1971b; Ban and Lehrmann, 1971).

Saskatchewan researchers did not neglect research into the psychological characteristics of LSD itself. When that programme began, almost nothing was known about the appropriate dosage levels and possible side effects of LSD. The psychiatrist Nick Chwelos and the psychologist Duncan Blewett therefore self-administered LSD and recruited some volunteers into their initial programme. As a result of their work they drew up a protocol for LSD's use in psychotherapy. [START_REF] Blewett | Handbook for the Therapeutic Use of Lysergic Acid Diethylamide 25: Individual and Group Procedures[END_REF] Chwelos, Blewett and some of their colleagues also made informal use of the drug by ingesting it and then walking through the wards at Weyburn in order, as they believed, to experience and to develop some understanding of the inner world of the schizophrenic. They also carried out some informal research into the properties of LSD as a psychotherapeutic agent, especially in group therapy sessions in which both therapist and patients ingested the drug. The only formal programme using LSD as a therapeutic programme was the treatment of alcoholism; for a summary of that work, see Hoffer and Osmond, 1967: 155-68. In community psychiatry, Saskatchewan researchers carried out an idiosyncratic set of research programmes (some of the work was reviewed by McKerracher, 1969). For example, McKerracher devoted most of his research career to demonstrating, by instituting the required medical procedures and training programmes, that almost all care of the mentally ill could take place during relatively brief stays in psychiatric wards in general hospitals, often under the care of general practitioners or even as part of a medical practice, so that only intractable patients (such as those suffering from senile dementia) would have been assigned to mental hospitals (McCorkell and McKerracher, 1962; McKerracher, Smith, Coburn and McDonald, 1965; Smith and McKerracher, 1967). One can call such a programme a branch of community psychiatry only in the sense that, had it been successful, all care of the mentally ill would have taken place in communities outside mental hospitals. McKerracher's most successful venture was his initiation of two programmes, one for an urban and one for a rural practice, in which general practitioners were assigned beds in the psychiatric ward at the University Hospital, Saskatoon, and, essentially, trained to work as psychiatrists. In particular, they were encouraged to give their psychiatric patients as much care in their offi ces as possible The programmes greatly reduced the need for in-hospital care and appeared to have been therapeutically successful. Regrettably, they were not used elsewhere in Saskatchewan (or in Canada, so far as I know). Colin M. Smith (b. 1927) was the other leading community psychiatrist in Saskatchewan. [START_REF] Smith | the Director of the PSB. 23. For an account of token economies[END_REF] His research work largely consisted of followup studies of those discharged from mental hospitals (e.g., Levey and Smith, 1965; Smith and McKerracher, 1963, 1964/5; Smith, McKerracher and Demay, 1964).

Saskatchewan was also the site of the fi rst extensive programme exploring attitudes towards mental illness. Like so much of the other research in Saskatchewan, the research was action-oriented in that the researchers, Elaine and John Cumming, attempted to change attitudes in order to see if people could be made receptive to the dispersal of institutionalized mental patients into the broader community (Cumming and Cumming, 1957). Although their attempt to induce favourable attitudes to mental illness failed, their ambitious study and their discussions of the reasons why they failed opened the way for others to study the problem.

In the area of general research into the psychology and sociology of mental illness, Osmond gathered together a group of researchers at Weyburn who were largely left to their own devices to work on areas ancillary to psychiatric practice proper. I will deal here only with the work of Robert Sommer and of Teodor Ayllon. Sommer carried out ground-breaking research, both substantively and methodologically. His studies of the role of relative spatial confi gurations in human social interactions laid the foundations for social distance theory, which offers a comprehensive account of the role played by the relative social spacing of participants in face-to-face interactions, both interpersonally and cross-culturally (see especially Sommer, 1959). Methodologically, Sommer showed his fellow social scientists how to carry out research projects, providing useful practical guidance to client groups and how to orient research projects towards practical ends without sacrifi cing methodological rigour (Sommer, 1999). Overall, his work at Weyburn cannot be fully recaptured from his published work. He devoted his early career to a concerted and broadly-based attempt to improve the lot of those consigned to mental hospitals, both the patients and the staff. For example, he collaborated with Osmond and the architect Kiyo Izumi in planning small mental hospitals designed to avoid what were seen as the iatrogenic characteristics of large institutions such as Weyburn.

Ayllon laid the foundation for his later work on what became known as token economies at Weyburn. 23 A token economy is, in essence, a means for socializing severely psychotic, institutionalized mental patients; Ayllon's token economies represented one of the best-conceived examples of the application of the techniques of behaviour modifi cation. At Weyburn, Ayllon trained nurses to act as socializing agents. He persuaded them to praise desirable behaviour or to associate minor rewards with it and to ignore undesirable behaviour. In general, patients in his programme became relatively tractable and displayed relatively little overt pathology. [START_REF] Ayllon | s work at Weyburn[END_REF] An evaluation of the CCF's mental health programmes Saskatchewan's mental health programmes were designed to meet the needs of the immediate post-World War II era within a particular ideological framework and set of practices. In part, then, any attempt to assess the success and value of the PSB's programmes must be made within that framework. Furthermore, given the freedom of action accorded to senior PSB psychiatrists, any historian has to take into account their personalities and their interactions with one another. At the same time, one can ask how the PSB's policies can be fi tted into some broad ideological and conceptual framework and, above all, one can ask whether or not those policies provided lessons for the future, especially for modes of dealing with the mentally ill beyond the walls of large mental hospitals.

At the outset one has to say that, whatever the defects of the Saskatchewan CCF's psychiatric programmes, they were characterized by a high level of professional competence and by a genuine concern for those suffering from mental illness. Douglas, both as Premier and as a Minister of Public Health, did everything in his power to assist the PSB to develop and operate an effective mental health programme, while his two successors as Ministers of Public Health (Tom J. Bentley and Walter Erb) showed an equally high level of dedication. In F. Burns Roth, the government had the services of a superb public servant with an astonishing grasp of the detailed workings of the PSB, combined with a willingness to delegate authority to the psychiatristbureaucrats working under him, thereby helping to maintain the PSB's morale. Chuck Jillings and Stanley Rands, although professionally trained as psychologists, were given control of the day-to-day operations of the PSB's head offi ce and discharged their duties admirably. Many gifted psychiatrists, other than those I have named so far, worked in Saskatchewan.

To the psychiatrists and medical bureaucrats of the 1950s and 1960s, the Saskatchewan government's mental health policies must have seemed successful. A reading of the annual reports of the PSB shows that, in almost every successive year from 1946 to 1964, existing services were progressively expanded, that new services were added, and that services increased their reach, especially by adding travelling clinics in the rural areas. 25 Lawson crisply summarized the PSB's achievements up to 1958. [START_REF] Dowding | Lawson was responding to a request from Douglas[END_REF] Those suffering from mental retardation, who had been housed under appallingly bad conditions in the basement of the Saskatchewan Hospital, Weyburn, in 1944 were moved to a separate institution at Moose Jaw. Even though admission rates at Weyburn and North Battleford had increased between 1944 and 1958, by the end of that year the total population in both hospitals had fallen by 900 (and was to fall steeply in the early 1960s). In 1944, discharge rates stood at 62.5% of admissions, where the corresponding fi gure for 1957 was 83.9%. Weyburn and North Battleford had been extensively remodelled; new wards had been added, and more therapy was being undertaken. In addition, a wing for mental patients suffering from TB had been added at Weyburn and two wings for ambulatory elderly patients at North Battleford. Staffi ng programmes had been solved, and (as is evident from earlier sections of this paper) the staff was of generally high quality. The proportion of psychiatrically trained nursing staff at Weyburn and North Battleford was higher than it was anywhere else in Canada; about 90% of the mental hospital nursing staff were graduates of Saskatchewan's psychiatric nursing programme. The administration of the mental hospitals had been reorganized in order to introduce procedures specifi cally designed to deal with the mentally ill and to serve the needs of the staff. Above all, treatment in outpatient facilities had greatly increased. With respect to those treated in hospitals, in 1945 the number of patients treated at the one facility available was 275; the comparable fi gure for 1958 was 1053, and in the same year 2715 patients were treated in four full-time and ten part-time or travelling clinics, which also gave consultative services to general practitioners.

Furthermore, Saskatchewan's policies towards those suffering from mental disorders or defects differed radically from those in other Canadian provinces. 27 In addition, Saskatchewan's treatment of them differed markedly from Alberta's and British Columbia's. In Saskatchewan, the government eventually built a large facility for the education of all patients who could benefi t from such a programme and who could be placed in sheltered employment, while ensuring that more severe cases were given adequate care. Moreover, in the Department of Psychiatry at the University of Saskatchewan, it created a programme whose staff was trained to recognize early signs of mental deficiency and who trained parents to care for their affl icted children. Alberta and British Columbia, in contrast, used sterilization as one means of dealing with the 'threat' of mental defi ciency. Both passed legislation permitting sexual sterilization, Alberta in 1928 and British Columbia in 1933 (both Acts were repealed in 1972). 28 Towards the end of its period in offi ce, the Saskatchewan CCF government enacted legislation offering comprehensive protection of the rights of those suffering from mental illness. 29 In particular, the 1961 Mental Health Act contained clauses making voluntary admission possible; the Act proved to be the model, albeit after a considerable delay, for other Canadian provinces. 30 It was also noteworthy because it was promulgated only after very thorough and wide-reaching consultations with PSB psychiatrists and a thorough review by the offi ce of the Attorney-General.

Even so, it cannot be said that the Saskatchewan CCF government's mental health programmes of the 1950s and 1960s were successful in every respect. At the simplest level, it is surprising that, despite the large budget allocated to mental health, the conditions at the province's two large psychiatric hospitals remained so bad until well into the 1950s. Indeed, levels of sanitation at Weyburn were so low that it seems that only the patients' immune systems prevented a severe outbreak of infectious disease.

More comprehensively, there is considerable evidence showing that by 1968 Saskatchewan's mental health situation was in a state of crisis (see, e.g., Smith, 1971). 31 The senior PSB psychiatrists played out complex roles within the system. Saskatchewan's allure attracted several strong-minded men with strong opinions about the nature of mental illness and the means for dealing with it (especially McKerracher, Hoffer, Osmond and Lawson). Because the system was so open and because it placed such trust in the capacities of its senior staff, each tended to develop his own programmes with comparatively little contact or consultation, resulting in serious ineffi ciencies. Those problems were exacerbated because there was no strong central bureaucracy that could have held the balance between what were in effect semi-independent fi efdoms. Matters were made worse because both McKerracher and Hoffer directly appealed to Douglas whenever they encountered a serious problem.

McKerracher, for example, once he became head of the Department of Psychiatry, actively pursued his programme training general practitioners to act as psychiatrists. The programme did not become integrated into the PSB's programmes partly because McKerracher was fully occupied with the life and internal politics of the College of Medicine and of the University Hospital and partly because Douglas appealed to McKerracher for help in his confl ict with Lawson over the Saskatchewan Plan. McKerracher, believing that purpose-built mental hospitals (the centrepiece of the Plan) were unnecessary, recommended the virtues of his own programme to Douglas, thereby infuriating Lawson and ending their relationship. 32 Lawson, despite his geniality and his intense loyalty to his senior staff, was by no means without faults. For one thing, in my opinion (though not necessarily in the opinion of some of my informants) he pursued his version of community psychiatry implacably and without taking any account of its potentially ruinous effect on the provincial budget. For another, he showed serious failures as an administrator. Because of his loyalty to his senior staff, he was blind both to their defi ciencies and to the impact of those defi ciencies on the morale and effectiveness of the non-medical staff. 33 Hoffer was pre-eminent among those psychiatrists who enhanced Saskatchewan's psychiatric reputation. His unusual combination of ideological fervour, biochemical knowledge, grasp of scientifi c practice, and psychiatric expertise ensured that, for a few years at least, the Hoffer-Osmond adrenochrome theory of the origin of schizophrenia occupied a prominent place on the neuropharmacological stage. However, Hoffer pursued his programmes with the most ruthless disregard for the opinions of others. He refused to address concerns expressed about his methods or to explore versions of the transmethlyation hypothesis alternative to his. Above all, he consistently attempted to discount the considerable body of evidence demonstrating that nicotinic acid therapy was ineffective. Despite all the evidence, he believed that schizophrenia could be cured, and he retreated into a world of his own, with an idiosyncratic diagnostic system and therapeutic method. As a result, he alienated himself not just from Saskatchewan's medical fraternity but even from his fellow PSB psychiatrists.

Largely as a result of the role played within it by Lawson and Hoffer, the CMHA (Sask) -which potentially should have been a strong advocate for the rights and welfare of the mentally ill -was drawn into the confl ict over the Saskatchewan Plan and almost entirely devoted itself to the promotion of a particular version of the Plan. Furthermore, CMHA (Sask) had an unduly close relationship with the PSB: for some years CMHA (Sask)'s Executive Secretary was Hoffer's brother-in-law, and also one of Hoffer's sisters, Elsie Kahan, played a prominent role in CMHA and as an advocate for her brother's research and therapeutic programmes. Moreover, Hoffer used the CMHA (Sask) to promote his biologically-based therapy for schizophrenia. Those links gave the government the impression that it was not receiving dispassionate advice from its own employees, while the obduracy of the CMHA infuriated Douglas and his cabinet. They therefore refused to implement the Saskatchewan Plan fully and CMHA (Sask) withered away.

In order to become and remain fully effective, the Saskatchewan mental health programme had to retain the services not just of the psychiatrists needed to staff it but of psychiatrists with particular interests and types of expertise. Those psychiatrists who joined the PSB in its early years did so only because it offered them the opportunity to engage in innovative practices and in research. 34 When the practices that were at fi rst innovative had become routine, the programme's capacity for attracting new staff declined. At the same time, the psychiatrists working in Saskatchewan were lured away, either to other Canadian provinces or to the USA. 35 Had Saskatchewan developed a comprehensive programme of psychiatric research centred on a research institute, it might have retained the services of the types of psychiatrists it needed.

Hoffer and the CMHA (Sask) did propose the creation of a large research institute, 36 but for various reasons the idea never came to fruition. One could probably say that fi scal considerations alone nullifi ed the proposal. In 1964 the CCF lost power to a Liberal government who demanded careful accountability from all the government's existing and proposed programmes. Such accountability, it would appear, would not have been forthcoming in the case of a psychiatric research unit because there is no evidence that Lawson and his staff suggested what types of research the institute might have undertaken. Instead, the archival evidence suggests that Lawson delegated the planning of the institute's proposed activities to Hoffer. 37 This meant that the research would have been devoted to a narrowly conceived biochemical programme, when the need was for a broad-based programme in community psychiatry. Furthermore, it was proposed that the institute should come under the ultimate supervision of the University of Saskatchewan's College of Medicine. The medical faculty's hostility to Hoffer ensured that it never became a reality.

The personal histories of the senior PSB staff and the policies they promoted can be fully understood only if they are placed within some reasonably broad interpretive framework. Wolfensberger (1972) provides us with one starting point by proposing several models of deviancy which he defi ned very broadly; he wrote: 'A person can be said to be deviant if he is perceived as being signifi cantly different from others in some respect that is considered of relative importance, and if this difference is negatively valued.' (Wolfensberger, 1972: 12). Given their degree of professional commitment, their intelligence and their status within psychiatry, the PSB psychiatrists had implicit models of deviancy, which, one could argue, helped to shape their practice. Thus, both McKerracher and Lawson regarded the mentally ill as objects of pity. For example, it is very clear from his annual reports that Lawson wanted those suffering from mental illness to be treated in exactly the same way as those suffering from physical illnesses and wanted their physical living conditions to match of those in society at large. Moreover, both were immune to what Wolfensberger (1972: 20) called 'the sour charity approach' (which would have meant incarcerating the chronically mentally ill in institutions stripped of all pleasant amenities). One could also, perhaps, characterize the confl ict between Douglas and Lawson over the implementation of the Saskatchewan Plan within the framework of that model, given that attitudes from the eugenics era appeared to linger within Douglas's psyche.

As they were trained in medicine, all the PSB psychiatrists saw the mentally ill from the standpoint of another of Wolfensberger's models, the deviant as a diseased organism. Wolfensberger (1972: 20-1) characterized two forms of the diseased organism model, one in which the mentally ill are accorded roughly the same treatment as sick animals and another in which they are accorded a fully human status. Once again, the latter variant drove the practice of McKerracher, Lawson and many of the PSB psychiatrists, psychologists, psychiatric nurses and psychiatric social workers.

One can follow the implications of Wolfensberger's diseased organism model further by asking whether those treating the mentally ill or those responsible for providing funds for their welfare placed client populations within the area of clinical medicine or within the public health system. 38 Given the public health system's ancestry in the provision of minimal care to, or even the segregation of, those considered to be deviant, a public health model carried at least the connotations of some sort of second-order or residual care. Moreover, public health systems tend to deliver fairly poor levels of service in dispersed and poorly co-ordinated treatment centres. Even McKerracher, with his insistence that most psychiatric problems could be treated initially in general hospitals, demanded high levels of care.

However, the fact that the work of the PSB was infused with a set of worthy principles is only signifi cant if those principles manifested themselves in potentially effective practices and could have yielded tangible benefi ts for clients. Beyond that, one should also ask whether the system was suffi ciently robust to carry itself into the de-institutionalized era of contemporary psychiatry and whether the PSB's work carried any lessons for the future.

The answer has to be that, at least in terms of policies, the PSB devised a system that was robust and potentially effective. Long before the major tranquillizers were available, McKerracher had undertaken three policy initiatives that laid the framework for the practices of the de-institutionalized era: he had set up a programme for training psychiatric nurses within Saskatchewan; initially with the assistance of the CMHA (Sask) he had begun to create a network of approved homes; and, partly with the assistance of the CMHA and partly by fostering research, he had attempted to prepare Saskatchewan's people to receive the mentally ill into their midst. So, when Lafave and Grunberg began to discharge large numbers of mental patients from Weyburn, they did not go into a social vacuum.

Saskatchewan psychiatric practice in the early 1960s, then, contrasted starkly with that of other Canadian provinces and the rest of the world. 39 Eventually, other Canadian provinces adopted Saskatchewan's policies. Goodwin noted that, in Canada overall from 1970 to 1980, only 0.11% of Ministry of Health funds were spent on community mental health programmes; by the late 1980s the proportion lay in the range 10-30% and only in Saskatchewan was it greater than 50% (Goodwin, 1997: 14, 101-2).

In part, that psychiatric practice formed part of an area in which Saskatchewan excelled, namely, the micro-management of governmentdelivered services. 40 Based on a trial study initiated in 1962, discussions with the appropriate trade unions and a later review by the Saskatchewan Public Service Commission, two new categories of psychiatric nurse, Community Psychiatric Nurses I and II, were created and training programmes initiated. As their titles suggest, these nurses were deployed in the community and not in mental institutions. A former director of psychiatric nursing programmes in Saskatchewan, Malcolm ('Max') Schreder (1985: 6) 41 commented:

Psychiatric nurses, through their training, have educational preparation in the dynamics of human behaviour, a broad understanding of psychiatric and emotional disorders and consequently the manifestation of symptoms, a keen sense of understanding of interactions in the emotional milieu, and the manipulation of the environment to promote healthy interaction along with a sound basic knowledge of psychiatric treatment including chemotherapy. In addition, the psychiatric nurses in this province tend to be the most stable members of the community psychiatric team since they remain in the position for long periods of time. … The program in community psychiatric nursing therefore provides for continuity of care in the community. Psychiatric nurses provide understanding, support, and guidance to the patient and key fi gures in his/her environment, counseling in daily living activities and, above all, in being a helping person in whom the patients can build their trust. The role of the psychiatric nurse in the community is a crucial one. They are the persons on the spot making regular home visits and fulfi lling the 'traditional helping role.'

The Saskatchewan CCF government demonstrated that it was possible to devise and enact policies for the care and treatment of the mentally ill in community settings. A close and extensive reading the archival record, combined with interviews with the surviving members of those who worked in the PSB during the period I have reviewed, should allow historians to discover why the programmes were viable and what lessons they bear for the future. Regrettably, it may well be the case that Saskatchewan's policies cannot be replicated. The CCF cabinet and Saskatchewan's senior bureaucrats provided what may well have been a unique working environment in which a great deal of trust was placed in government employees and in which many professionals enjoyed considerable freedom of action. At the same time, the government did its best to maintain good working relationships with its unionized personnel. Even so, if contemporary medical bureaucrats could be persuaded to acquaint themselves with what was achieved in Saskatchewan they might be inspired to attempt to replicate it.

Finally, I hope that this paper provides a memorial to the achievements of those who worked for the PSB in its days of glory. I have met or corresponded with many of them, and all were proud of their achievements -and so they should be.

Notes

1. Douglas's virtues were not as apparent to his contemporaries as they are today, nor did the policies of his government induce universal consent. When the CCF ran for re-election under its new name, the New Democratic Party (NDP), in 1964 it was defeated and did not regain power until 1971. Even worse, Douglas, who had been elected leader of the Federal NDP, was badly defeated in a Regina constituency in the Federal election of 1962 (he was eventually elected to parliament in a constituency in British Columbia). 2. Hall's document is a long and detailed history of the introduction of medicare in Saskatchewan, written for the province's Department of Health in 1978-79. I could not fi nd a copy in the Saskatchewan Provincial Archives or the Archives of the University of Saskatchewan, so I am most grateful to Dr Terry Russell and Mrs Sharon Russell for lending me their copy. 3. Douglas expounded a particularly robust form of eugenics, typical of the time. However, like other left-wing eugenicists, such as J. B. S. Haldane, he ceased to advocate sterilization policies once he had visited Nazi Germany and heard of its draconian sterilization policies and its use of euthanasia. On the other hand, despite Douglas's sincere Christianity, it would appear that he did have a lingering tendency to deny full humanity to certain groups (a premise underlying policies such as the sterilization of the 'mentally unfi t'). One of his biographers, Walter Stewart (2003), detected lingering racism in Douglas's attitudes; for example, he refused to condemn the internment and seizure of the property of Japanese-born Canadians during World War II. 4. See Douglas's correspondence on this matter: Douglas Papers, R-33.5 III. 134.

Saskatchewan Archives Board, Regina, Saskatchewan, Canada. 5. Hall (1979, III) and Houston (2002) give accounts of the pre-medicare era in Saskatchewan.

The political responses in Western North America to the Great Depression and to the years of drought which, fortuitously, accompanied it were complex and varied. There is an intimate connection between agrarian socialism and highly conservative movements such as social credit which, although it eschewed any government regulation of business or industry, urged capitalists to share some of their profi ts with the general populace (Finlay and Sprague, 1997: 380). Social credit governments were elected in Alberta in 1935 and in 1952 in British Columbia. 6. Government of Saskatchewan, An Act Respecting Mentally Defective, Mentally Ill and Other Persons (cited as: The Mental Hygiene Act), 1950. 7. For a history of the University of Saskatchewan, see Hayden, 1983. 8. These staffi ng problems are discussed at length by Dickinson, 1989: 82-132. 9. For an obituary of McKerracher, see Canadian Psychiatric Association Journal, 15: 246 (1970) Hospital, Saskatoon (3 Mar. 2003). 10. Typically, the Saskatchewan programme was more comprehensively organized and better integrated into the staffi ng framework of the Department of Public Health than it was for information about services offered in Saskatchewan for those suffering from mental illness; Douglas Papers, R-33.5 III. 127, File 14-8, Saskatchewan Archives Board. 27. For conditions in Ontario, Alberta and Nova Scotia, respectively, see: Simmons, 1990; LaJeunesse, 2002; Fingard and Rutherford, 2005. 28 -33.5, File 14-26). Dickinson (1989: 157-8) quotes a passage from this letter.

Frank Coburn told me of the breach between McKerracher and Lawson (Coburn, interview with the author, Saskatoon, October 2000). 33. One example of Lawson's failure to deal with staffi ng and morale problems can be found in the Douglas Papers (R-33.1 XIV. 554, four folders. Saskatchewan Archives Board). For some years, the non-medical staff at the Saskatchewan Hospital, North Battleford, had been in confl ict with the medical staff. The Government came to know of those problems, which reached a crisis in 1958, from the local Member of the Legislative Assembly and not through the PSB. Douglas expressed considerable displeasure with Lawson's failure to discharge his administrative duties. 34. Burns Roth commented: 'We must be perfectly frank and recognize that, given a choice, no psychiatrist would come to Weyburn, North Battleford or any other smaller centre in this province because of the weather, the social and cultural amenities or the living conditions.' (Memorandum to Erb, 6 July 1961, Douglas Papers, R-33.1 XIV. 554, Folder 4, Saskatchewan Archives Board.) 35. Burns Roth further commented: 'The facts are that other areas are rapidly catching up and the balance of attraction as between professional stimulation on the one hand and the social amenities and improved salaries on the other is going against us.' (Ibid., see Note 34) 36. Hoffer told me that he asked Douglas and the then Federal Minister of Health, J. Waldo Monteith, for funds for the proposed institute. Both, according to him, agreed (Hoffer, interview with the author, Victoria, 28 July 2000). 37. That evidence is to be found in the Papers and Correspondence of the Department of Psychiatry, University of Saskatchewan (Archives of the University of Saskatchewan, Saskatoon) and in the Walter Erb Papers, GR 91. File 013Y1, Saskatchewan Archives Board. 38. For a review of this issue, see Burnham, 2006. 39. See, especially, Goodwin, 1997: ch. 6. For an especially searing depiction of deinstitutionalization, see Burnham, 2002. 40. For an overall account of the Saskatchewan civil service in the CCF era, see Johnson, 2004. 41. I am most grateful to Art Gondziola, who sent me a copy of Schreder's paper.

  . I derived my opinions of McKerracher's character from interviews with Dr Frank Coburn, Saskatoon (Oct. 2000) and with Dr Ian McDonald, The Royal University

  . For the provisions for sexual sterilization in Alberta, see the province's The Sexual Sterilization Act, which was enacted in 1928. For similar provisions in British Columbia, see that province's Sexual Sterilization Act, enacted in 1933. For a discussion of eugenics in Canada, see McLaren, 1990. 29. Government of Saskatchewan, An Act respecting Mentally Disordered Persons (cited as The Mental Health Act), 1961. 30. In Canada as a whole, it was only in the 1970s that a majority of mental patients were voluntarily admitted (Goodwin, 1997: 92). 31. For a thorough review of the CCF government's psychiatric programmes, see Shervert H. Frazier and Alex D. Pokorny (1968) 'Report of a Consultation to the Minister of Public Health on the Psychiatric Services of Saskatchewan' (unpublished). Gordon Grant Papers, Collection R-45, fi le 90, Saskatchewan Archives Board. 32. See the long letter which McKerracher wrote to Douglas on 29 March 1957 (Douglas Papers, R

Acknowledgements

The research for this article was partially assisted by a grant from the Department of Psychology, University of Saskatchewan. The author would like to thank the journal's two referees for their very helpful comments on the fi rst draft of this article.

programme for the training of psychiatric nurses in Saskatchewan. The PSB devised the Saskatchewan Plan for the delivery of rural services, centred on small mental hospitals of a revolutionary design. Even though never fully instantiated, the Plan commanded worldwide attention. Saskatchewan was also remarkable for its research programmes, covering almost all aspects of psychiatry.


Edward Shorter

Hysteria and catatonia as motor disorders in historical context

It is difficult to imagine motor symptoms in psychiatry as different as hysteria and catatonia. The mechanism of hysteria is presumed to be psychogenic, while catatonia has always been considered to be among the most organic syndromes in psychiatry. Yet hysteria and catatonia have historically been regarded as allied conditions, an observation borne out by recent developments in neuroscience as well as by a growing awareness that the presentation of both conditions has changed over the years. In hysteria, the main shift has been from motor symptoms to sensory complaints such as chronic fatigue; in catatonia, the major change has been the virtual disappearance of negativistic or oppositional behaviour. It is possible that catatonia as well as hysteria may be responsive to changing cultural norms.

K e y w o r d s : catatonia; cultural influences; hysteria; motor symptoms; negativism

It would be difficult to conceive of motor symptoms in psychiatry as different as hysteria and catatonia. In hysteria, the mechanism is presumed to be psychogenic. The mind, for reasons of its own, conceives a deficit; this is transformed into a physical incapacity such as a hysterical paralysis, which the patient perceives as organic in nature and for which the patient seeks medical help. This is a good working definition of hysterical illness, although it is hard to improve upon Joseph [START_REF] Babinski | Définition de l'hystérie[END_REF] formulation that hysteria is any illness that could be induced by suggestion and abolished by persuasion. Thus hysteria was really the work of the suggestible imagination.

Catatonia, by contrast, has always been seen as organic as measles. Karl Kahlbaum, who gave us the first modern description of the disease in 1874, believed catatonia to progress downhill into dementia, by definition as an organic process. And such recent observers as Max Fink and Michael Taylor, in a monograph proposing the revival of catatonia as an independent illness entity, speak of it as 'motor system dysfunction' involving brain pathophysiology perhaps situated in the circuitry linking the anterior frontal lobe to the basal ganglia (Fink and Taylor, 2003: 33, 181).

Yet it is possible that catatonia and hysteria have more in common than has conventionally been assumed. Hysteria can result in profound physical deficits, and an epoch such as ours that seeks insight increasingly from the neurosciences finds it unlikely that such deficits are the product of a few idle thoughts alone, without accompanying underlying brain changes. The adage stands unimpaired that 'There is no twisted thought without a twisted molecule.'

Similarly, there must be some mental processing in catatonia. The mind inevitably intervenes between neurons and behaviour, and the editing of neural impulses surely informs neurological illness to some extent, though not perhaps to the same extent as psychiatric. Thus, even catatonic patients must pick and choose among which underlying neural impulses they decide to transform into behaviour. This formulation will arouse the ire of some, I realize, for it does invoke an increasingly outdated mind-body distinction. Many psychiatrists argue that the notion of mind without brain is erroneous. As one critic states, There is no mind. It is a metaphor that is now dated. The 'mind' is just those brain functions of which we are aware. When people refer to their mind they mean feelings and emotion, internal language, memory, thinking. There is a neuroscience for all that. (Taylor, 2006) Yes, and yes but. A neuroscience model of higher cognitive functioning must somehow deal with the phenomenon of suggestion. When we contemplate changes in the underlying brain processes that supposedly produce hysteria and catatonia, we must allow in some manner for the influence of suggestion. When symptoms change historically, it is doubtlessly owing to the suggestion that cultural change creates. Thus, suggestion influences behaviour -and either we must find the 'suggestion centre' in the brain, or we must allow that culture matters. This issue of historical change in supposedly organic symptoms places the history of hysteria and catatonia front and centre. There is in mental medicine a tradition of seeing hysteria and catatonia as allied conditions, though few investigators are mindful of this today. As French psychiatrist Henri Baruk, chief of the Charenton mental hospital, said in 1970 about the relationship of catatonia and hysteria: in both there is some kind of disturbed personality, that is to say, no longer acting of free will but acting under the influence of a pathological force. … These are the characteristics that distinguish psychiatric disorders from organic and neurological disorders, and it is why the explanations of catatonia, as those of hysteria, have oscillated between two opposing poles: on the one hand, between the tendency to neurologize psychiatry and to reduce these two types of disorders to a probably functional lesion of the brain centres. … On the other hand, [there is] the psychogenic tendency, which consists of explaining every-thing by psychological motives and to treat illness as a kind of simulation. Each of these two tendencies is in error …' [START_REF] Baruk | La catatonie de Kahlbaum, la schizophrénie et la révision de la nosographie psychiatrique[END_REF](Baruk, : 1719). 1 After Baruk, the kinship between the two disorders tended to be forgotten. Yet two recent developments have brought the related nature of hysteria and catatonia onto the table again. One is the budding neuroscience of hysteria. Sean Spence and coworkers at Cornell Medical Center in New York and at Queen Square in London found that patients with hysterical motor deficits on the left side exhibited hypofunction in the left anterior prefrontal cortex, and feigners on the right [START_REF] Spence | Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement[END_REF]. Matthew [START_REF] Broome | A neuroscience of hysteria?[END_REF] has recently summarized research into motor hysteria, pointing to hypotheses that indict deficits in the formation of the intention to move, or the preparation of that intention before the intention is actually executed as movement.

The other development is the budding awareness that not only does hysteria change historically, but that catatonia seems to change as well. Measles does not change historically, at least as regards the pathophysiology of viral illness. For catatonia, the most presumably organic of all psychiatric syndromes, to change significantly its presentation over the years means that a good deal more mental processing of its symptoms is occurring than we have conventionally assumed.

In a previous work [START_REF] Shorter | From Paralysis to Fatigue: A History of Psychosomatic Illness in the Modern Era[END_REF] I have dealt at length with probable changes in the presentation of hysteria over the years, and here the question may be quickly reviewed. Basically, before the last decades of the nineteenth century, hysteria seems to have had a formidable motor component, phantom paralyses magicked away by the saints, and conjured away by the hypnotherapists of the nineteenth century being familiar territory for medical historians.

It goes without saying that even today we know hysteria has a significant motor component in the form of neurologically unexplained symptomstremors, dyskinesias, and paralyses of all kinds. Yet the dramatic forms of motor hysteria of the past seem unusual nowadays. It is really beyond the compass of quotidian medical experience today for young women to wake up unable to move their legs after receiving bad news the previous evening. It does happen, to be sure, but it is an object of such medical curiosity as to bring the entire department flocking for a view after the patient is admitted. Similarly, the 'sofa cases' of yore -upper-middle-class women who would 'take to their beds,' as the saying went, and remain 'shut-ins' for decadesare now unfamiliar except for those with major psychiatric diagnoses such as chronic psychosis. The cloistered world of chronic fatigue syndrome is a bit of an exception to this generalization. Yet even they do not take to their beds in the belief that they are paralysed but remain mobile enough at least to attend meetings of their chronic fatigue support groups.

In hysteria, the main historic change seems to be a shift of symptoms from the motor side of the central nervous system to the sensory side, in the form of such symptoms as chronic fatigue and headache. The reasons for this change are complex, but doubtlessly include the introduction in 1896 of the reflex named after Joseph Babinski (that made it possible to 'disprove' a hysterical paralysis); there was also a new social style for women after World War I that elevated the energetic, loosely clad, tennis-playing young 'flapper' and sent the corset-gusseted Victorian 'lady' into exile. The dynamic young women of the 1920s did not develop the florid hysterical paralyses of the past. It was incompatible with their image.

A caveat: this hypothesized transition in the symptoms of hysteria has never been validated with solid epidemiological data. But clinical evidence of the frequency of hysterical paralyses in the nineteenth century is overwhelming, and may not simply be ignored. And such functional sensory complaints as fatigue and chronic pain did not loom large in the daily experience of nineteenth-century physicians, who had to cope with an avalanche of infective illness. It is possible that the claimed transition is an artefact of ascertainment: what patients do not present to the doctor will not be medically reported; what the doctor does not see as clinically significant will likewise be ignored. Yet at the moment, the evidence on behalf of the symptom transition in functional illness seems pretty sound.

Catatonia, by contrast, is a quite different kettle of fish. No observer, of whom I am aware, has ever claimed that the symptoms of catatonia have changed significantly. Yet there does seem to have been one major shift: catatonic negativism has been vastly reduced. When Kahlbaum introduced the diagnosis of catatonia in 1874 he said, 'What is notable about the symptoms in the sphere of activity and volition is an early tendency to negation.' He commented on the 'prominence of negative mental declarations and negative behavioural traits.' 'There is probably no patient', he said, 'in whom this symptom of the tendency to negation is not present in some manner' (Kahlbaum, 1874: 46-7).

In his Allgemeine Psychopathologie in 1913, Karl Jaspers at Heidelberg placed this 'negativism' in the context of the larger symptom picture of catatonia. The 'catatonic complex of symptoms', as Jaspers called it, included:

(1) either stupor or excitement; (2) either verbigeration in speaking and writing, stereotypies and mannered movements, or bizarre fixed positions such as Schnauzkrampf; (3) either negativism or automatic responses to commands (Jaspers, 1913: 281). Thus not all patients exhibited negativism, meaning oppositional behaviour; some answered instantly to orders and suggestions (some also switched back and forth between the two responses). Yet for Jaspers, negativism in the sense of doing the opposite of what one was told was part of a fixed behavioural layer in the syndrome of catatonia.

What did this kind of negativistic behaviour consist of? Emil Kraepelin, in the fifth edition of his famous textbook, gave quite an expansive characterization of Negativismus, consisting of mutism, the patients being 'unresponsive to every external intervention'. 'Any effort to alter the position or movement of the patient encounters … resistance.' 'Their muscles tense up when you try to move them. The patients give contrary responses to orders, and often do the opposite of what they are told. They often refuse food, pressing their lips together at the spoon's approach.' Some even refuse to walk, 'letting themselves topple stiffly over as soon as you get them upright. In other cases they march with rigid knees, on the tips of their toes, on the foot's lateral margin, with legs spread apart, the upper body starkly bent over …' (Kraepelin, 1896: 444-6). Some of this behaviour could be redistributed to other catatonic symptoms such as mannerism. Yet for Kraepelin the essential point was the patients' resistance to correction. Karl Kleist later referred to passive and active resistance of the muscles to movement, not just in catatonia but in a number of focal neurological lesions, as 'Gegenhalten' [START_REF] Kleist | Gegenhalten (motorischer Negativismus), Zwangsgreifen und Thalamus opticus[END_REF].

Also part of their negativism, Kraepelin said, was their unhygienic toilet behaviour. 'They retain urine and faeces, often for a long time, and then suddenly let go without taking the slighest notice of where they might be in order to avoid unpleasant consequences' (Kraepelin, 1896: 444). This lament about catatonics, who would retain faeces for long periods and then suddenly discharge their bowels, was common.

Yet such comments on contrarian behaviour in catatonia, especially on disagreeable behaviour with excrement, were not confined to Kraepelinians. Among catatonia specialists, few were as sceptical of Kraepelin's grand constructs as Warsaw psychiatrist Maurycy Urstein. Yet Urstein's catatonic patients could well have been Kraepelin's. Urstein (1912: 636) wrote:

Of diagnostic interest [in catatonia] is above all the general tendency to negation. A comment on the pleasing appearance of the female patient has the result that she immediately begins refusing food. Although the patients wish a restoration of health, they are fearful of being considered recovered and militate for sick status. … Similarly the catatonic patient manages to achieve, even given otherwise orderly external appearances, the evacuation of urine and faeces in his clothes … Thus, negativism in these strikingly contrarian forms arrested the attention of the founding students of psychopathology. In his 1916 textbook, Eugen Bleuler, Professor of Psychiatry in Zurich, considered negativism 'a very common and very unpleasant symptom of schizophrenia'. 'If the patients are supposed to get up, they want to stay in bed; if they are supposed to stay in bed, they want to get up. In response to orders or according to the routines of the institution they neither want to get dressed, nor to get undressed, nor to come to dinner, nor leave the table.' In catatonic negativism the patients did, in other words, the exact opposite of what they were told. 'In some cases you can reliably get the patients to perform the desired activity if you forbid it or order them to do the opposite.' (Bleuler, 1916: 305-6).

How common was negativism? In Johannes Lange's catalogue of catatonic symptoms, among 100 patients with manic-depressive illness, Negativismus occurred 13 times (Lange, 1922: 10). The commonest catatonic symptom in this group was mannerism (in 37 of the 100 patients). Thus Negativismus was about a third as frequent as manneristic behaviour. (By contrast, only 5 of the 100 had catalepsy.)

Negativism began relatively early to be seen more as a neurological than as a behavioural symptom. In 1900 Breslau neurologist Carl Wernicke rebaptized Kahlbaum's catatonia 'akinetic motility psychosis' (or, alternatively, 'akinetic and hyperkinetic cyclical motility psychosis'). Wernicke (1906: 395-424) limited the negativism component of the syndrome to active opposition to changes in muscle position, so that the patients, for example, would strenuously resist clinicians' efforts to open their eyelids or widen their jaws for purposes of feeding.

The passive act of oppositional hypertonus, or counterpull, of catatonia became widely noted only after World War I, as we have seen above. But this involuntary phenomenon of passive resistance to movement did indeed become part of the symptom picture of negativism. In his 1927 textbook Johannes Lange mentioned 'Gegenhalten'. 'In Gegenhalten we find a group of disorders in which psychological explanations fail completely. Here the issues are neurological in nature.' Lange commented on the frequency of Gegenhalten in organic brain patients, a phenomenon that 'obliges us to look at psychotic negativisms from this aspect' (Lange, 1927: 534).

Even as late as World War II, Kleist's student Karl Leonhard found negativism common in catatonia. This kind of contrary behaviour, he said, seemed completely involuntary. Even if you were specially nice to the patients, they would still behave negativistically, but with something of an embarrassed smile. There is 'a willingness predominantly in the smile, but an unwillingness in behaviour' (Leonhard, 1942: 120). Thus negativism did not come from negative affect; it was driven by deeper neural sources.

After World War II, negativism in the sense of contrary behaviour seems to disappear from catatonia, at least from careful clinical descriptions of it. To be sure, Willy Meyer-Gross's 1954 textbook does comment on negativism in 'catatonic schizophrenia', with particular emphasis on the patients' soiling of their beds and linen (Mayer-Gross, Slater and Roth, 1954: 248). Yet Mayer-Gross's clinical experience drew heavily upon his Heidelberg days, and the passage does not necessarily represent the reality of clinical life in British mental hospitals in the 1950s.

The term 'negativism' has, of course, been conserved. But it has become the object of a classical historical switch. Used mainly today in schizophrenia, it has come to mean affective flattening, quasi mutism and avolitional apathy (Peralta and Cuesta, 2001a). It no longer refers to what the classic authorities called negativism, or der Negativismus, which means doing the opposite of what one is asked and deliberately making oneself a nuisance (through such behaviour as refusing to eat and then stealing one's neighbour's food). Some authorities, do use 'oppositionism' for what the heritage texts termed negativism, but neither the term oppositionism nor classical oppositional behaviour is very common today: 14% in a sample of catatonic patients in Spain, for example (Peralta and Cuesta, 2001b). One rating scale of catatonia buries oppositionism (active and passive Negativismus) together with 14 other 'behavioural' characteristics [START_REF] Northoff | Catatonia as a psychomotor syndrome: a rating scale and extrapyramidal motor symptoms[END_REF]. When in 2003 Max Fink and Michael Taylor brought out their overview of catatonia, they did mention negativism, but mainly in the context of Gegenhalten (the example of behavioural negativism they offered was from 1815) (Fink and Taylor, 2003: 2-3, 20).

What have we learned from this exercise in comparing hysteria and catatonia, aside from the need not to be overly dogmatic in juxtaposing 'psychogenic' and 'somatogenic'? It is no surprise when such phenomena of suggestion as hysteria change over the years, in response to changed cultural circumstances. But it is a bit eye-opening to see syndromes with a profound organic basis such as catatonia changing as well. Could catatonia respond to changed circumstances? And if so, what might some of these changes be?

One must distinguish between 'internal' and 'external' changes. Internal changes refer to the medical management of catatonia and its vicissitudes over the years. Thomas Ban (2005), a veteran psychopharmacologist, calls attention to the introduction of the neuroleptics. 'At the time I started psychiatry [1950s], catatonic manifestations were blatantly present. But by the time I did my research in catatonia in the early 1980s, the symptoms had to be elicited because they were decreased in intensity by neuroleptics.' Ban thought the introduction of the barbiturates might have initiated a similar change in hysteria.

Yet the mind responds as well to external changes in culture and society, not just to shifts in medical management. Within catatonia, negativism is interesting precisely because it involves behaviour, some of it neurally driven, some mentally driven. Negativism might have made sense to patients in the context of the authoritarian mental hospitals of the nineteenth century, where the patients were given 'orders'. Negativism then perhaps represented an illnessdriven act of defiance. Yet in the context of post-World War II psychiatrywith reformed institutions managed by patient-friendly teams where discussions replaced commands -negativism no longer made sense. On open-door wards run by agreeable nurses, defiance might have seemed inappropriate, just as defecating in bed was, somehow, no longer on. We do not expect measles to be culturally edited, but catatonia may be different from measles.

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Acknowledgements

For comments on an earlier version, the author would like to thank Thomas Ban, Tom Bolwig, Max Fink, Jon Stone and Michael Alan Taylor.

Note

1. All translations are by the author.