Finding Sanity

by Greg de Moore

  A third patient—whose durable mania had burned ferociously for five continuous years—was stripped free of all hallucinations and delusions within nine days of starting treatment. Six months later—now a model employee—he found work in the sub-editor’s office at one of the largest newspapers in Melbourne and was pulling in over six pounds a week.

  And then there was the spectacular Polish doctor who (you might remember) startled his psychiatrist on hospital admission with handstands and dazzling somersaults, boasting of his unquenchable need for sex. Six days later, on this wondrous stuff called lithium, he was back to his professional self.

  Other men—some who’d been padlocked and bolted in single rooms in the hospital, some just garrulous pests—were treated with lithium. These were the vagrants, the tradesmen, and the professional men of Melbourne: all afflicted by the same illness, all captives in the same manic bag. Many of these men had been in and out of asylums their entire lives; all improved to some degree on this fabulous lithium solution, and gave satisfaction to John Cade.

  While this blossoming change was taking root in John’s hospital patients, Bill Brand remained at home and at work, healthy.

  We are never told what work Bill returned to: whether it was the whirring of a lathe at the munitions factory, or the hauling of pickled hides out of an acid broth at the tannery or the clawing at hardened earth with a hoe in a local market garden. Whatever it was, Bill’s labour would have been unremittingly hard.

  John requested that Bill report back to the Bundoora Asylum in a fortnight’s time; and while Bill had never been an exemplary soldier, certainly one that rarely snapped to order on command, he dutifully returned to see Dr Cade in two weeks and continued to do so over the next few months.

  The Cade boys remember this buoyant time well, and they kept in touch with ‘Monkey’. Or, more correctly, Bill kept in touch with them. For when Bill came into the asylum to be reviewed by Dr Cade, he called in upon the boys. And they set about playing their old game. The three of them sat upon the same wooden bench they’d always sat on; the boys waiting, expectantly, for ‘Monkey’ to use his magic and pluck a bag of humbugs from his coat pocket so they could play out their well-rehearsed fantasy once again. David still remembers their disappointment:

  Monkey seemed to suddenly become less fun when he was better. He had always been a livewire, making jokes, talking quickly and loudly, and to us as kids that was great fun . . . When he came back on one occasion he didn’t have any humbugs and he told us that the humbugs were not poisonous.

  When the boys, curious and surprised, asked why the humbugs were not poisonous anymore, ‘Monkey’ spat back with a spark of mischief that lit his eyes: ‘That’s why they’re called humbugs!’ But this was only a momentary flash of Monkey’s once eccentric wit. Mostly, the flourishing feats of wordplay that had so captivated the boys in past years were gone.

  To the rest of the world, Bill Brand had never seemed better, but to the boys there was something sad in this change in their old friend, a loss.

  The first sign that something was seriously wrong with Bill came to John in the form of a letter. Bill’s family wrote that he had been ‘excitable and argumentative’ after a ‘trivial row’. John wrote back and asked to see Bill. For us, this method of exchange between family and doctor seems excruciatingly slow. But in 1949, a time of starchy formality and unhurried pace, this was the way in which many families contacted the mental hospital doctor.

  Bill returned to see John and confessed to ceasing his lithium; John restarted it. Bill returned to his family, but no one was sure if he took his lithium or merely pretended to do so: Bill’s truthfulness in the matter was questionable. And then just before Christmas, Bill, having returned home, abandoned (unbeknown to John) his lithium altogether. Mania descended upon him rapidly and on 30 January 1949, his wilting family hauled a sick but spasmodically excitable Bill back to John.

  Years later, John recalled this moment when his first lithium patient, Bill Brand, bowled back into Bundoora, as eye-poppingly manic as ever: ‘It was the most bitter disappointment of my life.’

  John, crestfallen, interrogated Bill. Having assumed he was taking his lithium as prescribed, it was only upon questioning his patient and Bill’s brother that John twigged to the truth of the matter: ‘I . . . found my former patient had become blasé and had stopped taking his lithium tablets.’

  Bill had cherished his leave from the hospital and the liberation from a manic state. But at times he felt physically sick on lithium—a deep pain gnawed away in his abdomen, and the oppression of taking a pill to restore his sanity was a constriction he felt keenly. Lithium had restored Bill’s sanity, but when back to normal an incorrigible Bill lost sight of the need to continue taking his medicine.

  John decided to re-admit Bill to the asylum. Under close supervision, Bill restarted his lithium treatment. Over the next few weeks the metallic salt seeped back into the ex-digger’s body and brain, until three weeks later John pronounced Bill back to ‘normal’. As if to display his worth around the hospital, Bill, like a favoured schoolboy, ran errands between wards and did odd jobs for the nursing staff. Bundoora asylum, more than ever, was now his home again.

  There were still occasional brief moments when Bill’s mind ran off the rails, but by April there was no hint of any mental illness and he remained well for the next six months, pottering about the hospital grounds.

  John worked alone on his lithium experiments during the years from 1946 to 1949. No research assistant or medical colleague shared his shed and he certainly invited no one to help him.

  Despite this isolation, on several occasions, word got out that he was working with lithium. We know that as early as 1948 John mentioned his fledgling work to fellow psychiatrists at medical meetings. What he said is unrecorded and, like so much of what he did in those years, we are left to speculate. All that is known for sure is that John Cade wanted to work without interference. But his manner and insistence on isolation set up a medical response that was both curious and suspicious as to his activities. It was not long before psychiatrists and administrators dropped in to Bundoora to find out what the elusive Dr Cade was up to, their visits severely irritating him.

  Jean remembers the occasional visits from psychiatrists to Bundoora, nosing their way into the Cade household:

  Dr Stoller was the representative of the Army . . . he used to come to visit . . . and John used to come home and say ‘Ah, that Stoller is pretty sneaky . . . he’s sniffing around, he knows there’s something on . . . he said the attendance book gives me away. He’d ask: ‘What are you on John? What are you doing John?’ And John said: ‘I’ll let you know when I know.’

  Occasionally people had an idea he might be on to something and they’d use all sorts of methods of asking him: ‘I gather you’re doing so and so . . . do you want any help?’

  By the start of 1949, John knew that he had uncovered something remarkable in lithium, and with his once-ill patients blooming with health, he was ready to break this silence and write up his work for publication.

  In his research paper, John would argue that lithium, a simple element, could wrangle and tame a specific mental illness—mania. The notion itself was almost unbelievable to many at the time—that lithium, a metal dug from the earth’s crust and made into a solution or a tablet, could do this. Even the idea that something inanimate, a godless chemical, could shape a man’s mind and govern his behaviour was repellent, even against the natural order, to some doctors. This was a time when the causation of mental illness was in the balance: was it mainly psychological, or biochemical, or perhaps the result of social factors like homelessness and poverty? Many of John’s colleagues saw the source of manic depression as stemming from a disturbed family upbringing. To such psychiatrists, it was a mother’s malevolent word or a father’s brutal fist that twisted a child’s upbringing and caused madness. In one motion John was about to challenge these entrenched and cherished beliefs.

 
John knew that his research article would provoke bitter opposition, particularly among those who were enamoured with Sigmund Freud and psychoanalysis. John had studied but rejected psychoanalysis. John was a practical man who slung a Winchester rifle across his shoulder and who scissored his own sons’ hair and who worked in a mental hospital. Psychoanalysis might be fine for the top end of Collins Street, but not in the furnace of an asylum. It had produced negligible success in treating the most severe kinds of mental illness, such as that afflicting Bill. Psychoanalysis would never do for John.

  John Cade had long been irritated by Freud and psychoanalysis. Even before the war, the jargon-filled abstractions of psychoanalysis offended him, and over the subsequent years he had sought to cleanse himself of its seductive ideas. To fully understand his criticism, we have to appreciate that John had read Freud extensively. He jotted notes in the margins of the Freudian books he consumed: thoughtful, sharp annotations. John’s distaste for Freudian theories is evident in these jottings. On one occasion, he scribbled emphatically: ‘Not true. Simply not true.’

  By the time he wrote up his lithium experiment on Bill Brand and his other experimental subjects, John had purged himself of Freud and was clear in his thoughts about chemical causation.

  John had a set routine for writing up his work. Each night, after dinner, he sat down in his favourite oak chair. The chair was a heavy lump of a thing with two broad flat arms. On top of both arms was a circular hollow (with a carved flower design), just large enough for his mug of coffee. With plenty of room for his nightly glass of sherry, and space for an ashtray next to his coffee mug, John puffed away on his Ardath cigarettes, silently composing his manuscript, ringed by the small pleasures in his life.

  The article was to be short and to the point. He thought out clearly what he wanted to say, wiping it clean of anything unnecessary, and, only then, wrote with his Swan fountain pen quickly and with few corrections, until a draft was completed. He had some unusual quirks when it came to writing, and was more than a bit pernickety about the process. John had an aversion to noise, perhaps a troubling residue of the war, but whatever the cause, the Cade household was well-regulated, very neat and never, ever loud. According to Jean, before he sat down to write, John removed any clocks from the room: ‘He was funny about clocks, he couldn’t study in his armchair with a clock going tick, tick, tick on the mantelpiece. So he’d get up and put [it] in the kitchen.’ Even the children’s pet fish, swishing around in a glass bowl of water, annoyed him. Out the bowl went too. Once the dining room was silent—banished of all irritants—he could sit meditatively, and compose on paper the events of a momentous year.

  Once written, he polished his draft in a manner as unusual as the lithium experiments themselves. In a rather formal way he stood in the dining room, his back towards a corner of the room, and—like a minister of religion in an invisible pulpit—he read his manuscript out loud to Jean, a silent congregation of one. In this manner John Cade preached his paper into perfection.

  Cade’s historic paper was published in The Medical Journal of Australia on 3 September 1949. The paper is a masterpiece, his magnum opus. It is everything a scientific paper should be, and so different to just about every modern scientific paper you will ever read. It is a four-page wonder, a manifesto on the treatment of mania; its scope—of life and death—is operatic. It was published without fanfare—just another article in the midst of hundreds—but it would, in due course, be celebrated as the journal’s most cited paper, and for changing the way we think about mental illness.

  If you can read English, then you can understand the allure of Cade’s paper, and that’s the beauty of the thing: anyone can take it in and feel the excitement of the message. It doesn’t fall over itself trying to impress; there are no incomprehensible statistics, just simple numbers any primary-school student would understand. Cade records the lithium treatment of ten manic patients: each one a story. Not all patients treated were a complete success but there are memorable narrative lines of hope in his paper.

  By the following month, word was out that a new treatment—concocted in a shed in an asylum in Melbourne—was being used for mania. Collins Street, that haven of private psychiatrists, an address John turned his back on over ten years earlier, came knocking on his door, keen to share their experiences:

  Dear John,

  I have given lithium citrate to two patients with varying results. The first patient was a recurrent mania who seemed to be remitting when the lithium citrate was commenced. Her subsequent improvement was rapid . . .

  The second patient was not manic and the effect was less impressive.

  Hundreds of kilometres away, in the city of Sydney, the superintendent at Parramatta Mental Hospital, a vast sprawling asylum on the western edges of that city, scribbled a rushed letter to John—a letter of praise, hope and frustration:

  Dear Dr Cade,

  I have been following your work on cases of mania in The Medical Journal of Australia, and note with interest the reference to the use of lithium salts. The drug houses in Sydney . . . have been unable to take an order and I should be glad if you would advise me of a firm from which they are obtainable as I am anxious to use these preparations here. Your results, I feel, promise well and may fill one of the many gaps in present day psychiatric treatment by relieving a very troublesome disorder.

  Yours faithfully,

  Dr F.J. Scanlan

  Curiosity about John’s work was thick in the air. His fellow psychiatrists, who had previously dropped into the Cade home in a desultory manner, now circled en masse. John soon felt the prickle of envy. His wife remembered: ‘John would say to me, “another sticky beak wanting to know what I’m doing . . . they all seem to have an idea that they can help”.’

  It seemed to Jean that there was no end of fellow doctors wanting to share the credit for her husband’s work. Every status-craving psychiatrist sniffed at John’s door to find out what he’d been up to and, like scavenging birds, they flocked about waiting for an opening to snatch their unearned lot.

  John, however, was a man shaped by sturdy values sharpened by war; he was never susceptible to the false charms of those circling around him.

  Bill Brand remained John Cade’s flagship patient, a talisman of lithium’s worth. Bill’s care and the trajectory of his recovery became a barometer for John and he recorded his clinical progress with more care and detail than any of his other patients.

  For the rest of 1949, Bill’s home was the Bundoora asylum. At times he experienced a burning abdominal pain and nausea, and occasionally his mind unfurled into mania, and at these latter points he relapsed into a filthy state, foraging about the asylum bins for food. But for the most part, he was well and by the end of September he’d been free of all signs of mental illness for six months.

  Bill’s entire life had been wayward. Nothing remained smooth for too long before his world capsized, and so it would be on lithium. As he’d done many times before, Bill was about to unravel into loose strings, and dismantle John’s hour of triumph. The first indication that Bill was not well came in October, when he was all over the place—sometimes vomiting, his temper testy, and arguing with John about taking his lithium.

  John’s insistence on prescribing lithium and Bill’s resistance to taking it marked their relationship for months. Finally, an uneasy truce settled between the two men—doctor and patient—and John bent to Bill’s desires and stopped giving lithium to his patient.

  John knew that without lithium Bill would spin off into mania; with it he would remain less manic, but would be physically distressed.

  Each successive day while Bill was off lithium, his mental affliction grew. Mania first showed itself in how Bill spoke: each word was a driving rhythmical expression of his rising manic pulse. A single word soon distended into a sentence; a sentence then exploded into a rambling paragraph. Before long, Bill’s ungovernable surges shoved his unruly mind into full throttle mania and his sentences flew out, inco
ntinent, without beginning or end.

  Within two weeks of stopping lithium, John wrote—taking no joy in the correctness of his clinical prediction of relapse—that Bill was ‘At his best manic manner’, and back to his old quarrelsome self. John found this relapse and defeat intolerable, and responded by restarting lithium.

  John kept escalating the dose of lithium to manage Bill’s symptoms. By late November, Bill was taking 40 grains thrice a day—what we now know, nearly 70 years later, is a massive dose of lithium.

  But as the lithium dose rose, and John frantically looked for improvement, Bill seemed not to improve a jot. John lamented: ‘As noisy and mischievous as ever. It is probable that he is either not taking or quietly rejecting his mixture.’ A thin edge of reproach at Bill’s likely lack of cooperation can be sensed in John’s voice.

  Although John continued to pen his descriptions neatly and concisely, there is an air of dismay evident to a reader of his notes over 60 years later. It is the closest we get to seeing John lose control of his meticulously pared-back emotions.

  At this point John Cade and Bill Brand both seem exhausted, and a bit fed up with one another. In this slumped state John comments that Bill is now ‘saturated at last’. What he meant was that lithium—at its maximum dose—filled Bill’s body, soaking every cell and bathing Bill’s brain. There was nothing more to give.

  But there was a cost to this high dose.

  Bill’s hands shuddered when he raised a cup to his lips and he wobbled as he walked—both side effects of his lithium treatment. He protested at the taking in of food and lost what little flesh he had on his bones; despondent and weeping at times, only occasionally did he brighten up when John chatted to him. In response to the scrap of a man before him, John reluctantly reduced the lithium dose.