Finding Sanity

by Greg de Moore

  There is a sense of incredible frustration in John’s thinking and actions. That having achieved so much with his first patient, he refuses to let go; he won’t lose a success that was recently his, and now might just be drifting away from his outstretched grasp.

  Two days later John found Bill curled up in bed. His rectum extruded from his body; the pinkish foul protrusion was pushed back in. Sometimes Bill seemed quite well to John. Often he was not.

  By the middle of December, against expectations, John reported that Bill was much improved. Rejuvenated, Bill roamed the asylum grounds, and plans were made to give him leave in Melbourne.

  Bill had alienated his family with his antics over 30 years, and it was unlikely he could return to them for leave. The problem then, as always, was that outside the asylum there was little warmth and support for the mentally ill. Bill’s brutal decades wandering about Melbourne, often lost and sometimes psychotic, were evidence enough of that.

  In an effort to change this, a new place of refuge for the mentally ill, a hostel, was opened in Melbourne. The Argus, the city’s soi-disant leading newspaper, spread the word. No less than the Governor of Victoria, Sir Dallas Brooks, was called upon to open this mental health refuge—named Trelowarren—a slender link between asylum and community. The announcement graced the social pages of the newspaper, wedged above a paragraph announcing that a certain Miss Lillian Guest was to marry a certain Mr Mervyn David (after a ‘kitchen tea’ of cherry and cream) and below a tribute to Mrs Ivy Wedgwood, Victoria’s first woman senator.

  Bill took full advantage of this new ‘society column’ refuge, though its social flutterings in the press were unlikely to have concerned him, and he was transferred there temporarily on 20 January 1950. He returned to his ward at Bundoora after two weeks, apparently bolstered by the experience of Melbourne city life.

  As Bill was still quite well in late February 1950, John Cade reduced his lithium to try to reduce the continuing side effects.

  In the first week of March, Bill was manic again, his thoughts frothing about. He cursed John and he cursed the medication.

  As if scribbling for an unseen jury, which would in future cast a judgemental eye, John Cade wrote, sadly philosophical: ‘Under all the circumstances it seems that [Bill] would be better off as a carefree restless case of mania rather than the dyspeptic, frail, little man he looks on adequate lithium.’ John, for posterity, then underlines in his notes: ‘Lithium discontinued.’

  Bill’s manic embers once more ignited.

  And again John vacillated. It seems that thoughts flooded in and lathered at the edges of his uncertain mind and again he debated with himself about using lithium. Threading his way through conflicting emotions, he summed up his dilemma: ‘His state seems as much a menace to life as any possible toxic effects of lithium.’ And so, into the furnace, John casts lithium for the last time, prescribing it on 12 May.

  It made little difference. Bill ate almost nothing, and his flesh fell away. His friable skin started to crack and break away like flakes of rust. In his half-demented state, he picked at his skin; infected sores sprang up in crops over his body. His bony wrists and ankles—mere spindles poking out from beneath his sheet—were wrapped in bandages. Odd mannerisms returned: Bill repeatedly ripped off his clothes only to put them on again.

  Bill sank into a still state; lithium was stopped. Deep into that night he wafted into lost consciousness. Two partial fits presaged his whole body breaking into a prolonged epileptic convulsion. John, present at Bill’s bedside, drew up a syringe filled with phenobarbitone, and injected the contents into whatever meaty spot he could find in Bill’s body. The convulsions stilled. In a final attempt to resurrect Bill, a feeding tube was inserted through one of his nostrils and threaded down his gullet and into his stomach. Badly needed nutrition—probably milk, eggs and broth—was poured in.

  Bill was paralysed between life and death, until late in the evening on 23 May 1950 when all trace of life leached away.

  Bill lay on his sepulchral bed, the skin of his face—like parchment—drawn over the hollows of his cheeks. He had always had the dimensions of a jockey, but never more so than now, and his miserly 5 feet 5 inches shrivelled into a ball.

  To the pathologist who performed the autopsy, Bill was an ‘elderly man’. But Bill (to anyone who’d known him) had been ‘old’ for years. With laughable irony, the pathologist announced Bill’s brain as normal, at least normal to the crude means of examining a brain at a pathologist’s disposal in the middle of the twentieth century.

  The coronial inquest into the death of Bill Brand was held on Thursday 26 October, a cool and cloudy Melbourne day. No one seemed to know Bill’s exact age. To the various witnesses he was 50, or 52 or even 54. It was an imprecise way to die.

  There remained a final twist in Bill’s life.

  In the month before he died, the Repatriation Board met to consider Bill’s application for a full war pension. It was the umpteenth time—over the last 30 years—they’d met to decide on this. In an ironic postscript, the judicial eye of the Repatriation Board accepted Bill as totally and permanently incapacitated from his war service: Bill Brand’s pension would be raised to its maximum value. Bill had spent 30 years of his life begging for this pension, but, for Bill Brand, the Repatriation Board’s decision was all too late. Official approval came on 25 May, two days after Bill’s death, for a payment he would never receive.

  PART 4

  After the Face, the

  Hands Reveal Most

  FUNNY FARM

  Nut farm at most,

  To those with money

  A Health Resort,

  To those who are poor

  Medicare Hotel,

  For those in the know.

  All you need to realise

  in Truth and Fact is

  it’s time out from

  Reality,

  Sent by the

  ‘Quack’.

  Just get better everyone

  ‘Quack, quack, quack’.

  Written by ‘J.R.’ while in a manic state,

  ‘in tribute to my Doc and nurses’

  20

  On the day of the coronial inquest, the weather forecast was for a depression over south-eastern Australia, and John could have been forgiven for thinking he was smack-bang in the middle of it. By the time he travelled to the city morgue to present his account of his clinical care of the dead man, John, we can imagine, was nervy, replaying his version of events over and over. John knew he’d dabbled with a novel medicine, a crude and untested treatment. He himself had imbibed lithium, drinking it, secretly, in isolation. Dozens of guinea pigs were injected with it; they, for the most part, were buried deep beneath the grounds of a mental hospital. By today’s standards, none of this was adequate preparation for using lithium on a suffering human being. But in circumstances where other therapies had proven ineffective, John proceeded to prescribe lithium. Now his first patient, Bill Brand, was also dead, and the reasons for this were about to be delved into publicly. Although some of his patients on lithium seemed to thrive, John must have been sensitive to the potential for public scandal and professional disgrace. This was the situation he faced when he sat before the hard-headed coroner in the Melbourne morgue that October day.

  Given his predicament, it is only natural to ask how a man might react in such a tight spot. Would he try to manipulate the evidence, or, if desperate enough, even falsify it? Would he do anything to point the bone away from himself? More likely, he’d do the very human thing we all employ in moments of self-preservation—subtly shift the emphasis here and there to present ourselves in the best possible light. Perhaps, if John was a treacherous man, he might shed blame entirely on to someone or something else. So how, in this very uncomfortable moment, did John Cade respond to the Coroner’s interrogation?

  What he did was what we might have hoped for in a man who lived life with stone-edged integrity. If John felt giddy as he prepared for the coroner, his not
es do not reveal it. Rather, he settled the commotion in his mind, and responded to the cross-examination with a taut, one-page synopsis of Bill Brand’s medical history. John’s characteristic steady script—concise and without any hint of deception—told how he had prescribed lithium for Bill; that it resulted in remarkable improvement, but was discontinued due to side effects. He did not embroider the truth; he did not gloss over any anomaly or justify his actions. There is not a crooked sentence or a contorted syllable in his deposition. It was as clean-cut as the man himself. If John were an artist, he’d be a minimalist; embellishment was never his game. A less scrupulous man may have been tempted to fudge the cause of death, or at least to limit the guilt attributed to lithium. John did nothing of the sort. When it came to his opinion as to the cause of death he squared up to his responsibilities and wrote with the certainty of biblical authority (and presumably his God watched over his shoulder) that death was due to the combined effects of lithium toxicity, starvation and chronic mania. No flinching, no excuses. You could not have asked for a more brutally honest response in a situation where a man might have been seduced into deception. If nothing else, John Cade showed himself to be a man of unquestionable probity.

  When his son Jack reflected on his father’s deposition, there was no surprise: ‘My father was a very proper person . . . if he had a legal concern he would have put it straight, not shillyshallied around, or hiding anything. He was always very upfront on those things.’

  A patient’s death means a lot to a doctor, especially when that doctor’s treatment caused the death. Even more so when that treatment is bravely or perhaps recklessly plucked from nowhere. None of us, unless we have power over life and death, can truly comprehend the emotions that coursed through John’s mind, but there is little doubt that he was profoundly wounded by the death of Bill Brand. Whatever troubling thoughts John held about Bill’s death, they remained captive within his breast, and were never shared with friends, family or colleagues. It might be said that sometimes the impact on a doctor is measured not by how often he talks about a patient’s death but, rather, how he seeks to avoid it, and John, in all his subsequent writings, never penned a further word about the death of the first man he treated with lithium.

  While John pondered the death of Bill Brand, on the other side of the world and seemingly unbeknown to John, lithium was under scrutiny.

  The problem started innocently enough—with table salt. The same salt we nonchalantly and typically in excess sprinkle on our fish and chips, the salt we taste on our tongues every time we take a dip in the ocean. Indeed, this salt can be found just about everywhere. And everyone knows that table salt, chemically speaking, is sodium chloride.

  Table salt was about to play an important role in the history of lithium and mental illness. By the late 1940s, patients who suffered from high blood pressure were advised to cut their consumption of salt. Reducing salt intake cuts blood pressure and eases the burden on the heart as the heart pumps blood around the body. So around the world, patients with hypertension were placed on low-salt diets. These diets, if you’ve ever been condemned to try them, are pretty bland to the taste. In the United States—where every consumer-driven niche is a commercial opportunity—alert companies scanned about for an alternative to table salt: something that would give a flavour-some taste to food but wouldn’t increase blood pressure. Any solution to this problem would rake in millions of dollars; American capitalism found this solution without drawing breath.

  Soon, at least four different American companies believed they’d struck a savoury bonanza. While experimenting with alternatives to table salt they came across lithium, discovering that if you replaced sodium with lithium in table salt you produced a substance that also has a salty taste—lithium chloride. The solution seemed obvious: instead of sodium chloride on your fish and chips, just lavish lithium chloride on it. The taste would rejuvenate the dullest of diets, and, importantly, there would be no damage to your heart or rise in blood pressure. Lithium chloride was marketed in the United States under proprietary names such as Foodsal and Westsal. Post-war affluent America, with its ample and ever-expanding middle-class girth, could shovel in this new salt by the tonne.

  It all seemed innocuous enough. That is, until things started to go terribly wrong.

  In March, 1949—a year after John started his experimental lithium treatment of Bill Brand—four research papers were published in The Journal of the American Medical Association: each paper suggested that lithium was a poison. The ominous research told the stories of sixteen patients, all of whom showered the salt substitute—lithium chloride—on their food. These articles make for graphic reading. Patients started to shake and were rendered incapable of holding a knife and fork; others dissolved into convulsions, and some staggered about, unable to find their balance. A few slurred their words before collapsing into a coma. Three died; others nearly did so, but clung to life after heroic medical measures. Lithium in each and every case was dangled as the culprit.

  A news flash from Chicago listed four deaths from lithium. These were the above deaths, plus one other, and they warned of more to come.

  Further news of lithium’s toxicity swarmed through the US medical community, and, before long, the entire nation knew of it. In one blow, lithium was a name virtually no American wanted to be associated with: no doctor, no patient and certainly no politician.

  The political response was fearsome and swift; federal agents rummaged through pharmacies and warehouses clearing out supplies. The New York Times reported that 40 health inspectors scoured over 4000 pharmacies and over 400 health food shops.

  New York City’s Commissioner of Health, Dr Harry S. Mustard—sporting an impeccably correct name for a food crisis—warned and ‘appealed to all persons having lithium chloride salts to destroy them at once’.

  Time magazine chimed in and broadcast to the nation the US Food and Drug Administration’s directive: ‘Stop using this dangerous poison at once.’ Newspapers from Chicago to New York to Arizona ran articles alerting the population and advising doctors. All was confusion, except on one point of certainty: all fingers pointed at lithium.

  Lithium was rooted out from pharmacies, health shops and warehouses and—most of all—from the American diet.

  And, of course, being the United States, following this national delirium of fear there threatened a furious flood of lawsuits. In a flash, lithium was gone.

  But in all of this monumental mayhem, one question was trampled upon and rarely asked: Why was lithium, this savoury substitute the Americans were contorting themselves to banish, so readily available in the United States anyway? If it was poisonous, how was it already so freely available in the marketplace?

  The answer, it turns out, is that lithium, in one form or other, had long been in the American diet. Lithium was not regarded as a drug, but as a health-promoting dietary supplement. This meant that in the 1940s Americans didn’t need a doctor’s prescription to get lithium; all they had to do was to walk into a health food store and simply ask for it. And its presence in the American diet goes well back, at least to the nineteenth century. Lithium spilled into the New World from the nineteenth-century drawing rooms of Victorian England, where it had been lauded for its supposed magical healing powers and as a general ‘pick-me-up’ tonic for many years. But it was in the United States that lithium secured its strongest commercial foothold; during the late nineteenth and early twentieth century, lithium was consumed in a manner scarcely believable.

  It all started with the bottling and selling of naturally occurring mineral waters, riding upon the back of natural springs around the world. Then, of all things, came lithium beer, brewed and marketed in Wisconsin; and in 1929, in the weeks before Wall Street crashed, the popular soda drink, 7-Up, was launched, boasting lithium as an ingredient. The truth is, lithium was plentiful in the American diet by the 1940s; it’s just that most people didn’t know it; and, more importantly, no one was dying from it.

  O
nly when lithium chloride—marketed as a salt substitute for cardiac patients—was swallowed in vast amounts did its toxicity surface. That’s when people died and everyone took notice. So in 1949 when a shrill New York Times shrieked that lithium was ‘a dangerous poison’ and had killed four people; and that ‘more deadly salt’ had been safely sequestered, it was as if toxic waste from a nuclear test zone was contaminating the nation’s food bowl. There was nowhere for lithium in the United States to go—other than oblivion. And that is where it duly went.

  It would be over twenty years before lithium was reintroduced to the United States as a medical therapy. Meanwhile, Australia’s isolation in the 1950s would serve lithium well. For in Melbourne, nearly 13,000 kilometres from the United States, lithium lingered in the back wards of a handful of psychiatric hospitals. All it needed was a doctor willing to use it . . .

  21

  Forces gathered to pulverise lithium back into the earth’s crust, not only in the United States, as we have seen, but also back home in Australia. Within weeks of John’s lithium paper coming out in The Medical Journal of Australia, a note by John appeared as a loose insertion in another publication, the newsletter sent to psychiatrists in Australia four times a year.

  It is not hard to imagine that a man who introduces a novel and potentially brilliant treatment might have his detractors as well as his admirers. And in this relatively small circle of competitive Australian psychiatrists, John could count both. The insertion records John asking his fellow psychiatrists that, if they used lithium, could they monitor patients for toxic effects and pass any observations back to him. It was a prudent and, we suspect, a slightly worried communication. There is no doubt that while John savoured the idea of lithium’s promise, the reported deaths and then the banning of lithium in the United States left him wavering, anxious as to the outcome of further treatments.