Finding Sanity

by Greg de Moore

  If John was at all worried that no Australian doctor would take up lithium, he need not have been. Australia doctors embraced it with extraordinary gusto. Within a year of John’s paper, well over a hundred (perhaps over 200) patients were on lithium around Australia. From Melbourne to Perth to Sydney and back to Melbourne, solutions of lithium were being stirred, shaken and poured. Most of these were prepared in the chain of mental asylums that stretched around the country, but there were also private psychiatrists coming on board. This was a medical world hungry for new treatments and lithium was a glimmer of hope that enticingly stretched before doctors and patients. If it could be shown to work consistently and safely, it would revolutionise the care of the mentally ill. But, as John knew, it was not without possible mortal cost. One such cost, of course, was the death of Bill Brand. The coroner had concluded that death was from ‘broncho-pneumonia following upon lithium poisoning, consequent upon treatment with lithium salts, which the state of health of deceased warranted’.

  Although Australia is a vast land, the psychiatric community in the 1950s was little more than a hundred strong and, like juicy gossip in a small town, news of deaths from an experimental treatment didn’t take long to sweep through to every psychiatrist. It turned out that Bill Brand’s death was not the first from lithium. John must have known of the other two lithium deaths before his own patient, Bill, died. One perished in the Victorian country town of Ballarat, the other in Perth, on the other side of the nation.

  The town of Ballarat rose, spectacularly, from the gold discoveries of the 1850s, when Victoria was one of the wealthiest places on the planet. A rural centre with nearly 50,000 residents in 1950, the town had contracted from its glorious past. A two-hour drive west from Melbourne, its sprawling 83-hectare asylum for the mentally ill was a vast repository for psychiatric patients, which, at its peak, housed close to a thousand inmates. Constructed in 1869 as the Ballarat Industrial School, its building stock was overhauled in the late 1930s. By the early 1950s a visitor to the mishmash of old and new buildings remarked upon how ‘birds rested in the ward ceilings’ and how their droppings constantly ‘fouled the beds’ in which patients slept. Most wards were locked, straitjackets commonplace and windows barred. Remembered for the bitter and biting breezes that skipped in from the waters of nearby Lake Wendouree, patients kept warm by polishing the floors with beeswax and huddling about coal fires in open hearths.

  At Ballarat, a single doctor might attend over 300 patients, making it impossible to offer any kind of meaningful medical care, let alone understanding each man’s or woman’s needs. Indeed this was hardly expected. The doctor who piques our interest was Dr ‘Nick’ (Edgar) Roberts, a stocky, affable man who, in a photo taken some years later, is pictured at the Ballarat Mental Hospital rugged up in thick layers topped by a woollen scarf and sporting a broad-broom moustache: the spitting image of a British sergeant-major.

  Among the throng of human flesh under the care of Dr Roberts was one Mary Niblett, in her late 50s, whose occupation was listed as home duties, though she’d not had a house to clean for the four years since her admission to the asylum. Mary was, at least according to the staff, a terrier of a patient—violent, aggressive and noisy, petulant and demanding, ‘constantly maniacal for the past three years’. With not a hint of her hurricane abating, she was a superb candidate for an experimental treatment. Nick Roberts had read John’s lithium paper—there was probably no Australian psychiatrist who hadn’t—and followed John’s treatment protocol to the chemical letter. And so Mary was started on a solution of lithium citrate on 19 December 1949. To improve its palatability, a sweetener called ‘syrup of orange’ was added, a common asylum trick to entice patients to take medicine. Nursing staff were then given a crisply typed list of toxic lithium symptoms to watch for. One week later, on lithium, Mary was placid and seemingly on the mend. But it was a deceptive calm. A day later she fell ill—clutching her abdomen and vomiting—and could hardly hold a straight line as she walked. Lithium was ceased, but to no avail. Seizures rapidly followed; coma consumed her. Two days later Mary Niblett was dead, the first Australian patient to die from lithium toxicity.

  Dr Roberts wrote up the case in a report he submitted to The Medical Journal of Australia as a warning to other doctors, and, with a sharp mind, suggested that an effective dose of lithium for mania may be too close to the toxic dose. His paper urged doctors to use caution if prescribing lithium.

  The second patient to die from lithium toxicity was Frank Kyd. A former orchardist, Kyd had been in mental hospitals, on the other side of the continent, in Western Australia, for fifteen years; when manic he went on wild and destructive rampages before collapsing into fitful sleeps. After an initial improvement on lithium, Kyd lapsed into the now familiar constellation of toxicity: he was confused, slurred his speech and lurched about like a drunkard at closing time. Shortly afterwards, the nurses could not rouse him. Death soon followed.

  Kyd’s doctor was Bernard Glesinger, an immigrant doctor with an MD from Vienna, who, like Nick Roberts in Ballarat, had read John’s paper and dispensed lithium with an astonishing speed. Within months, Glesinger was pouring lithium into over a hundred patients at Claremont Mental Hospital in Perth. Most did well; only Kyd died. A post-mortem was conducted, but there was no coroner’s inquest. The post-mortem, dealing only with an examination of the body and not with the effects of treatment, was unable to determine the cause of death. That was left to Glesinger, who concluded that lithium toxicity was to blame.

  Frank Kyd died some 2700 kilometres away from Melbourne. Perth—famously parochial and prosperous—is the most isolated city in the most isolated continent on earth. In 1950, when cost and travel time to Perth made it inaccessible to most Australians, Perth could very well have been Timbuktu to those living in Melbourne. Digging metals out of the ground was to become Perth’s passport to prosperity in the twentieth century, but at Claremont Mental Hospital only one metal—lithium—was drawing attention.

  Aspects of what took place at Claremont tell us something about how and why lithium was widely used in Australia at this time. The superintendent was Frank Prendergast, one of John Cade’s closest chums, a fellow alumnus from his university days. It was probably no coincidence that lithium was being used so extensively at Claremont, as John and Frank were in regular contact. But it was a difficult time for Prendergast—a royal commission into ‘cruelty allegations against certain male attendants at the Claremont Mental Hospital’ was under way. And this investigation raised something of interest to us: lithium. It came to light that a ten-year-old boy, ‘a notorious juvenile’ as reported by a journalist in The West Australian, was detained in the hospital. The boy’s treatment included ‘electric shock and lithium’. It seems, if this report is accurate, that just about any patient was fair game for lithium. John Cade, of course, had no control on how lithium might be used in hospitals around Australia. But, if he’d had any inkling of lithium’s questionable use in a child, we can only imagine it would have kindled his nervousness.

  By the time Bill Brand was stretched out on a cold slab in a Melbourne morgue, the rollcall of lithium deaths stood at three. It remains unclear whether this number was an accurate count of deaths caused by lithium at that time. Whereas Victorian law required that every unexpected death in a mental hospital go to the coroner for investigation, this was not the case in every state. The late 1940s and early 1950s was a different age, in which activities in mental hospitals were not under the same scrutiny as today. If three lithium deaths occurred in modern Australian hospitals, it would likely provoke an army of investigative journalists, tell-all documentaries, and a bevy of whistle-blowers. None of this occurred and the early 1950s allowed lithium to survive in the mental hospitals of Australia. Moreover, as a counter to these occasional negative reports on lithium, there were positive medical publications and encouraging clinical observations that fostered enthusiasm for its use.

  One such example of a positive report came
from Sunbury Mental Asylum, on the northern outskirts of Melbourne, where John had lived as a primary-school student back in 1922. Val Ashburner, a psychiatrist at Sunbury, enthused over lithium, finding it such an irresistible option that he siphoned the solution out with stunning results. Twelve of the more than 50 patients to whom he prescribed lithium were liberated of all signs of illness, striding out of the asylum and into the community; none died. So zealous was Ashburner that—like a small outback mining town—the Sunbury hospital pumped no less than 15 pounds (7 kilograms) of the metallic lithium crystal into patients, grain by tiny grain, in rapid time.

  So what did John make of these emerging and highly divergent reports on lithium? There were some remarkable successes mixed with occasional appalling and ugly deaths. Patients were in need of care, but what care was appropriate? Was it reasonable to experiment with lithium when it might eventually harm or kill the patient, even though the result might be remarkably positive for the patient in the short term? In the midst of these questions there was a sense that metropolitan and regional coroners, along with mental hospital doctors and administrators, agreed without saying as much that an experiment was in progress, and was justified. Six decades later, we are left to ponder precisely what John made of it all because, frustratingly, he left behind no personal notes from this time about lithium. Later in his life, when asked about this period he didn’t divulge a great deal, and kept whatever hopes and misgivings he had to himself. So it is with a paucity of such intimate information we fossick through newspapers, peruse private letters, and try to unpick and interpret behaviours and beliefs played out over 60 years ago.

  John, we might speculate, was hopeful about lithium’s future, but it is clear he harboured doubts, even a foreboding, about how it all might end. And along with this undertow of doubt, John was also aware of the many potential critics around him, circling. But mostly there was still an air of curiosity about lithium—had something truly remarkable been unearthed, or, as is so often the case in the history of psychiatry, would it prove to be just another dud and dangerous treatment?

  So, unlike the Americans, who had abandoned lithium, John did not totally toss out his fascination with this soft, white metal. Instead he waited, while lithium’s impact was weighed for better or for worse.

  22

  In some quarters, John’s lithium discovery was seen as just the thing to try to lever the medieval world of psychiatry into the modern penicillin-age of medicine. And for that initiative there were rewards. Medicine, like the military, offers recognition through rank; discipline and chain of command are deeply embedded in both. Just as rising from captain to major was an elevation for John during the war, so in parallel was the elevation from psychiatrist to superintendent in the world of the asylum. In late 1950, almost certainly because of his lithium research, John was promoted to the position of medical superintendent at Bundoora Mental Hospital.

  Although he was a man who frowned upon ostentation and public brouhaha about achievements, John was privately pleased with his ascension. David, his second boy, remembers one particular day at primary school after this promotion when all the children were asked about their father’s occupations: ‘I told everyone my dad was a doctor. I thought that was pretty good. But when I got home and told dad, he said I should have said, “Psychiatrist superintendent of Bundoora Mental Hospital” instead of doctor. He was proud of that.’

  But the clearest evidence we have that his lithium work had drawn favourable attention came when John was invited to deliver two public lectures on psychiatry at the University of Melbourne. Known as the Beattie Smith lectures, this was an outstanding distinction for a young psychiatrist, and it placed his name before the general public. From that point onwards, the name John Cade was a staple in the Melbourne media.

  The brace of Beattie Smith lectures—an annual public event in the city of Melbourne’s calendar—was delivered by a distinguished psychiatrist in an effort to advance the treatment of mental illness. The lectures were named after William Beattie Smith, an English psychiatrist who had migrated to Australia in the 1880s. John’s father remembered Beattie Smith, describing him as a good-looking man of trim build with a closely clipped beard. Soon after arrival, Beattie Smith made Australia home and found work at the Ararat Lunatic Asylum. He proved a man of unconventional turn, who, in addition to his drive to improve medical teaching, insisted that attendants undertake the apparently revolutionary act of wearing uniforms. In his spare time he tilled the arable Ararat soil into a vineyard, which remains today testimony to a fertile and varied mind. At his death, unmarried and wealthy, he bequeathed 1000 pounds for his eponymous annual lectures to be held at the University of Melbourne. So, as announced in The Argus in May 1951, Dr John Cade, medical superintendent of Bundoora Repatriation Hospital, would step onto the podium at the University of Melbourne’s medical school to deliver his first well-prepared public oration. Overnight, John was catapulted into the limelight.

  John was not a man to reveal his inner qualms, never a ‘gossip or blabbermouth’ as Jean so quaintly put it, least of all about what orbited in his own brain. But he was nervous leading up to his first Beattie Smith lecture. This surprised his family, for within the Cade household his equanimity under pressure was legendary. Jean remembered how on one occasion, her husband was speaking before an all-female audience, when partway through his speech John realised that his fly was undone. Without skipping a verbal beat, and in full view of his admiring audience, John casually zipped up his fly, apologised en passant, and continued on imperturbably. Jean remembered his, as always, meticulous preparation in the dining room at their Bundoora home, standing rigidly upright in a corner and rehearsing to his imagined audience, and running through the many iterations to get his words just right:

  I knew he was nervous. So was I. The Beattie Smith lecture . . . was a great honour. John was very exercised in his mind [as to] how he could make it interesting to all the colleagues who would come and yet for the public to enjoy it and understand it.

  He always read them to me. If he was going to stand on a platform he practised standing in the corner of a room and I listened without interrupting. I had listened to his speech many times at home . . . and I would tell him how it felt and how he looked.

  When John arrived at the university’s medical school on the evening of 7 May to deliver the first of two lectures, Jean sat in the front row of the steeply tiered wooden seats—presumably casting a furtive flick of her eyes over her husband’s fly to ensure all was well secured. The university boasts the oldest functioning medical school in the nation. And the old anatomy lecture theatre, over the century, was home to thousands of note-taking students as white-coated prosectors displayed human anatomical specimens for viewing. But on this night it was a psychiatrist on centre stage, and John would take apart the human mind for display. Jean recalled: ‘The place was packed.’

  When introduced, John, dry mouthed, rose to speak. In his habitual style, he looked out over the array of heads before him, not focusing on any one person, and replicated what he’d done so often before with Jean in their Bundoora dining room. In the crammed theatre, journalists from the Melbourne press positioned themselves to take notes on the latest developments in psychiatry. They sensed a revolution in the making.

  John knew some of what he was about to say would ruffle his colleagues and, perhaps, damage his own future. It didn’t matter; he’d speak his mind as he always did. John, gently spoken and clear-minded, drew his sketch of psychiatry as he saw it. He spoke with a fastidious care for words and a love of history. And as he did so, nervousness gave way to unaffected self-assurance. His words rolled out across the auditorium.

  Over the two evenings, a week apart—as reported in the Melbourne newspapers—John ranged across the different fields of psychiatry. But there was one acerbic comment for which John is still most remembered. It was a rebuke of what he saw as a backward step in psychiatry—Sigmund Freud and his therapies: ‘I believe that Fr
eudian psychology has cast a blight upon the minds of men that will last perhaps another 50 years. I can see the hackles of most of my colleagues visibly rising . . .’ Freud was all the rage across the psychiatric world and John Cade knew it. Nonetheless he took aim with his carefully sharpened harpoon and boldly fired at Freud. This was a stirrer’s provocation to roil his fellow psychiatrists.

  Watching his colleagues—drawing their collective breath of indignation and hemmed in by their tiny timber seats in the anatomy theatre—we can only imagine that John, from his podium perch, was almost enjoying the moment.

  When interviewed 50 years later, Jean remembered this precise moment in her husband’s speech with exceptional freshness, and, in whispered tones, she went on that no one applauded what many regarded as blasphemy. In preparing her husband beforehand, and sensing the likely disapproval of his colleagues, she counselled John about criticising Sigmund Freud: ‘You can’t say that about [Freud], he’s the darling. Why don’t you just not mention him . . . But that was John.’ The real issue here was that John pushed hard the notion that serious psychiatric illnesses should be seen like any other medical illness; that its root cause was an underlying physical problem within the brain. But the very idea that illnesses such as mania or schizophrenia were the result of an abnormal Periodic Table of the brain was beyond many of his colleagues. They couldn’t stomach the notion that chemistry lay at the heart of this human behaviour. This was the battle John faced.

  Some of his colleagues were visibly affronted, their contempt plain, refusing to applaud. But it seems the general public and the press lapped it up. John spoke to them in a language so sensible, so down-to-earth, that just for a moment, psychiatry made beautiful sense, leaving in the common person’s mind an image of psychiatry as sturdy, testable, without a hint of gibberish.