Shapeshifters

2

Werewolves: Agitation at the Full Moon

WHEN A NIGHT in the emergency department is particularly blood-soaked with violence, or heavy with psychiatric admissions, it’s common to hear colleagues remark: ‘It must be a full moon.’ On a busy night shift I’ve even stepped outside to check, seeking explanation in the heavens for my busy workload on earth. That the moon has effects not just on the tides or on cycles of human fertility, but on minds, is an ancient belief. Othello says to Emilia, ‘It is the very error of the moon. She comes more near the earth than she was wont and makes men mad.’ James Joyce in Ulysses waxes on the moon’s ‘power to enamour, to mortify, to invest with beauty, to render insane’. That the moon has a transformative effect on the human psyche is a widespread conviction – a variety of studies from India, Iran, Europe and the US have all asserted it. One North American study found that 40 per cent of the general public were convinced that the moon had an influence on the mind; an earlier survey put the rate for mental health professionals at 74 per cent. But statisticians haven’t been able to substantiate the claim: the number of admissions for trauma, or for mania or psychosis (‘lunacy’), are unaffected by the phase of the moon, and there is no connection between a full moon and the frequency of suicide attempts, road accidents or calls to crisis support telephone services. My colleagues in emergency medicine, and those 74 per cent of American mental health professionals, are all wrong.

That the truth runs counter to such a widely held opinion led three Californian psychiatrists to investigate. In a study called ‘The Moon and Madness Reconsidered’, they proposed that before the advent of effective artificial lighting in the nineteenth century, the full moon probably did affect those with precarious mental health, by disturbing quality and duration of sleep. They cited evidence that resting in the dark for fourteen hours a day can terminate or even prevent episodes of manic psychosis, and that even a mild reduction in hours of sleep can worsen mental health and bring on epileptic seizures – something my own patients with bipolar illness and epilepsy have confirmed. Patterns of activity in the brain involved in healthy sleep seem to overlap with patterns associated with good mental health in ways we don’t yet fully understand.

Before artificial lighting, people took advantage of the days around a full moon, because its light was powerful enough to be abroad at night. The Lunar Society of industrialists and intellectuals in eighteenth-century England named itself not for its object of study but because its members found it easier to meet on evenings when the moon was full. But moonlight was also shadowy enough to give a prompt to the fearful imagination. ‘The insane are more agitated at the full of the moon, as they are also at early dawn,’ the French psychiatrist Jean-Étienne Esquirol wrote in the nineteenth century: ‘Does not this brightness produce, in their habitations, an effect of light, which frightens one, rejoices another, and agitates all?’

JOANNE FREDERICK was brought in by ambulance; ‘agitated delirium’ was written across the top of her triage sheet. The medical history came from her flatmate: she’d been suffering with a head cold for a few days, feeling weak and under the weather, and had gone to the pharmacy to buy medicine. It didn’t work: she became weaker, had abdominal pains, and her skin felt as if it was burning. Her urine felt hot and heavy, and was painful to pass. She’d had urine infections in the past, but this was different: a bodily unease had possessed her, spreading up through her torso and out into her limbs. Her legs trembled, her arms lost all their power, and she had a persistent low-grade fever. She arranged an appointment to see her GP, but never made it: her flatmate called an ambulance when she began hallucinating giant lizards on the walls. On the way to hospital in the ambulance she had a seizure and when I met her in the high-dependency unit, she had been sedated.

There are hundreds of reasons that someone might end up with an ‘agitated delirium’: drug overdoses, drug withdrawal, infections, strokes, brain haemorrhage, head injuries, psychiatric disorders, and even some vitamin deficiencies. But all of Joanne’s blood tests came back normal – the CT scan of her brain was unremarkable. As she lay sedated in the high-dependency unit, her flatmate began to tell me more of her story. Joanne lived a fairly quiet life, with a few close friends but keeping largely to herself. She’d been admitted to hospital with a ‘nervous breakdown’ once before; the hospital notes said that she’d had a brief episode of incapacitating panic and anxiety that had resolved after a few days’ rest. She worked as an administrator in the basement of the city council offices – a job she loved because it allowed her to stay out of the sun. ‘She burns really easily,’ said her flatmate, ‘you should see her in the summer – she gets blisters from it.’ Her skin was mottled with brown pigments, particularly across the face and hands, as if coffee granules had been spilled over wet skin.

I was a junior doctor at the time, and for me and the rest of the medical team Joanne’s diagnosis was a puzzle. When the supervising physician arrived to do his rounds he listened carefully to the story of how Joanne had come to be there, and flicked through the hospital notes from her previous admission. He examined her skin closely, leafed through the reams of normal tests, then looked up with a glance of triumph: ‘… we need to check her porphyrins,’ he said.

Porphyrins, critical for both the structure of haemoglobin and chlorophyll, are generated in the body by a series of specialised enzymes that work together like a team of scaffolders. If one of those scaffolders doesn’t work properly, porphyria is the result. Part-formed rings of porphyrin build up in the blood and tissues bringing on ‘crises’, which can be occasioned by drugs, diet, and even a couple of nights of insomnia. Some porphyrins are exquisitely sensitive to light (it’s this property that enables them to absorb the sun’s energy in chlorophyll) and some types of porphyria lead to a blistering inflammation on exposure to the sun, with consequent scarring. The build-up of porphyrins in nerves and the brain causes numbness, paralysis, psychosis and seizures. Another effect of the accumulation of porphyrins in the skin, as yet unexplained, is growth of hair on the forehead and cheeks. Acute porphyria can cause constipation and agonising abdominal pain: it’s not unusual for victims to be brought howling into operating theatres, subjected to unnecessary operations time and again before doctors reach the correct diagnosis.^*

When Joanne’s lab report came back it confirmed soaring levels of porphyrins: it was likely that she had a rare variant of porphyria known as ‘variegate’. Treatment had already begun: rest, avoidance of exacerbating drugs (the cold remedies she’d bought over the counter had probably triggered her crisis) and intravenous fluids. To those we added infusions of glucose. Within three days she had recovered, and was discharged home from the ward with a list of drugs to avoid and an explanation, at last, of why she’d always been sensitive to light.

IN 1964 A CURIOUS PAPER was published in the journal Proceedings of the Royal Society of Medicine by a London neurologist called Lee Illis. In four eloquent and persuasive pages he proposed that the myth of werewolves has been reinforced or even initiated by porphyria. Skin conditions such as hypertrichosis may cause hair to grow over the face and hands, but have no psychiatric manifestations. Rabies in humans may induce an agitated, furious state of mind with biting and hallucinations, but without skin changes. Illis pointed out that people with porphyria avoid direct sunlight, and prefer to go about at night. Crises are precipitated by periods of poor sleep or a change in diet. In severe untreated cases sufferers may have pale, yellowish skin caused by jaundice, scarring of the skin, and hair may even begin to grow across their faces. People with certain types of porphyria may suffer derangements in their mental health and become socially isolated, breeding distrust among the wider community.

In past centuries this constellation of symptoms may have attracted accusations of witchcraft. A French exorcist, Henri Boguet, boasted in his Discours exécrable des Sorciers (1602) of the number of werewolves and witches he had tortured and put to death: six hundred, including scores of children. ‘All these Sorcerers were grievously scratched on the face, arms and legs,’ he wrote, ‘one of them was so disfigured that he could scarcely be recognised as a human being, nor could anyone look at him without shuddering.’ It isn’t inconceivable that a light-sensitive, intermittent kind of madness, transposed to an illiterate, isolated, credulous community, could nourish and perpetuate the fear that human beings can transform into wolves. After all, 74 per cent of mental health professionals believe that the full moon can cause madness.

IN ANCIENT HITTITE LAW, to be banished from a community was to be told, ‘thou art become a wolf’; we still describe certain excluded people as ‘lone wolves’. The first human transformation described in Ovid’s Metamorphoses is of man into wolf, effected by the gods as retribution for ferocity and cannibalism. Though the threat from wolves has all but disappeared from Europe we still turn to them when we need a metaphor for the predatory or the ravenous: we speak of a ‘wolfish grin’ and a ‘wolfish appetite’; children still tremble at the wolf in the ‘Little Red Riding Hood’ story, and the one terrorising the Three Little Pigs. Cave paintings of wolves by our palaeolithic ancestors are among the oldest artworks we know of.

‘Werewolf’ is supposed to refer to the physical transformation of human being into wolf, while the Greek term ‘lycanthropy’ is now reserved, in English, for the psychiatric delusion that one has become a wolf – a form of psychosis. Psychiatrists have broadened the term’s use to take in any delusion that one has been transformed into an animal, but the correct term for that is ‘therianthropy’ from the Greek therion meaning ‘beast’. Pliny thought the idea that people could physically turn into wolves absurd, and that it was only the human mind which was capable of transformation: ‘That men may be transformed into Wolves and restored again to their former shapes, we must confidently believe to be a loud lie.’

King James I of England (James VI of Scotland) had a particular fascination for the occult, and in his book Daemonologie (1597) he wrote of werewolves: ‘by the Greekes they were called lykanthropoi which signifieth men-woolfes. But to tell you simplie my opinion… if anie such thing hath bene, I take it to have proceeded but of a naturall super-abundance of Melancholie.’ Lycanthropy, then, was thought by King James to be a temporary madness, a psychiatric problem, rather than a physical transformation. The Greek physician Marcellus of Sida agreed: he argued that the werewolves reported to frequent the graveyards of Athens after nightfall were not ‘turnskins’ – the Roman term for those who could shape-shift into wolves – but deluded. The Byzantine doctor Paul of Aegina wrote that these lycanthropes could be treated with copious bloodletting, sleep, and sedatives – a set of remedies not too different from the modern treatment of porphyria.

Ancient literature is replete with delusional transformations: one of Virgil’s Eclogues tells of the madness of three sisters, cursed into believing they had become cows: ‘They filled the fields with imaginary lowing… each feared the plough-yoke on her neck and often searched for horns on her smooth brow.’ In the Bible’s Old Testament, King Nebuchadnezzar undergoes an animal transformation following a fit of depression: ‘He was driven from men, and ate grass as oxen, and his body was wet with the dew of heaven, till his hairs had grown like eagles’ feathers, and his nails like birds’ claws.’

In late medieval Europe atrocities like those described by Boguet were relatively common: hundreds of would-be werewolves were put to death at the stake. As the eighteenth and nineteenth centuries wore on, published reports of ‘lycanthropy’ began to fade along with superstitions (and European wolf populations). But the delusion didn’t go away entirely, it just changed form. In 1954 Carl Jung described three sisters who dreamed night after night that their mother had transformed into an animal. He wasn’t surprised when, years later, the mother developed psychotic lycanthropy: the daughters, he reasoned, had unconsciously recognised their mother’s long repressed ‘primitive identity’.

IN OUR OWN TIMES and culture, the most famous literary work to express the horror and the metaphorical potential of animal transformation is Kafka’s The Metamorphosis. Gregor Samsa wakes one day as a ‘monstrous vermin’, an insect-like creature with scurrying legs, horny jaws and a beetle-like shell.^* Samsa’s transformation is irreversible: as a travelling salesman he was trapped in the service of his family, and in his new life as vermin he is physically trapped in his room. As his family agonise over what to do he gets accustomed to his new form, scuttling on his ceiling, and preferring rotting scraps from the floorboards to the plated food his family leave out for him. In the end he goes the way of all vermin, dead on the floorboards, and swept out with the trash.

Kafka’s Metamorphosis resists straightforward interpretations, but speaks to anyone who feels alienated, persecuted and powerless. Samsa’s metamorphosis renders him spatially and socially isolated, like many who suffer profound mental or physical illness. The animal transformations we know of from myth and from folklore traditions tend to carry a semblance of coherence, or even justice, at least within the logic of their own story. But Samsa doesn’t have that consolation: ‘he could think of no way of bringing peace and order to this chaos.’

ONE OF THE ELM TREES near my clinic seems to me different from all the others, not because of its size, or the pattern of its limbs, but because one of my patients once fell twenty feet from it. Gary Hobbes wasn’t normally a tree-climber: he was a young man with schizophrenia who, after taking a cocktail of drugs containing MDMA, became convinced he had transformed into a cat. Witnesses recounted that on the day of his fall he had been prowling the local streets examining the contents of bins before scaling the elm to hiss at passers-by. The police were called; he climbed higher. A dog-walker approached to watch; Gary recoiled and screeched, demonstrating a previously unexpressed terror of dogs. The police were debating how to get him down when he slipped and fell, breaking his wrist on impact. He knocked his head too and lay mewling on the grass, concussed enough to be transferred without incident to the emergency department.

The following morning Gary woke on an orthopaedic ward with a plaster cast on his arm, reluctant to discuss his experience with the hospital psychiatrist. He was discharged back to his supported accommodation – a complex of small apartments with a warden on hand to help. On visits to see how he was getting on I’d spot opened cat-food tins in his kitchen, and wonder if he was eating them. From time to time I’d ask him about that night, but he changed the subject. The last I heard, he’d adopted a couple of street cats as pets, and had cat flaps cut in the apartment door.

Early European and Near Eastern myths are full of animal transformations; some scholars take them as evidence of ancient animal worship. A glance at internet traffic suggests that the veneration of cats and dogs remains as powerful a motivation in human affairs as it ever did. Folklore traditions are full of animal transformations too, from the selkie tales of the Celtic lands, in which humans shape-shift into seals, to the spirit animal transformations of shamanism. Something these stories hold in common is that it’s dangerous to lose one’s hold on the human world: the selkie who spends too long as a seal forfeits their human life; the shaman who is mentally weak, or insufficiently trained, might get stuck in his or her animal skin.

‘THEY ARE ALL BEASTS of burden in a sense,’ wrote Thoreau, ‘made to carry some portion of our thoughts.’ Visit any toy shop, or watch a few television programmes made for children, and you’ll see just how much humanised animals remain part of western culture. From Peter Rabbit to Stuart Little, tiger costumes to face-painting parties, adopting the skin and habits of animals offers children a liberating means of becoming fiercer, or smaller, or faster, or more agile, than they really are. For some adults, the psychosis of therianthropy may offer a comparable escape, a release from the limitations and pressures of human life.

In the late 1980s a group of psychiatrists in Massachusetts published a paper in which they described a series of twelve cases they’d seen over fourteen years at a clinic in suburban Boston. Two had suffered true lycanthropy and become wolves, two had become cats, two had become dogs, and two were ‘unspecified’ (their behaviour was ‘crawling, howling, hooting, clawing, stamping, defaecating’, and ‘crawling, growling, barking’.) Of the remaining four, one had transformed into a tiger, one a rabbit, one a bird, and one – a lifetime keeper of gerbils – became his favourite pet.

There was no predominance of schizophrenia among the patients – eight were categorised as ‘bipolar’, two ‘schizophrenic’, one had a diagnosis of depression and one was described as having a ‘borderline personality’. ‘The presence of lycanthropy had no apparent relation to prognosis,’ the authors noted: ‘the delusion of being transformed into an animal may bode no more ill than any other delusion.’ The most persistent transformation of all was of a young man, age twenty-four, who following a period of alcohol abuse became convinced, like Gary Hobbes, that he was a cat trapped inside a man’s body. At the time the series was published this man had lived in his feline persona uninterruptedly for thirteen years.