Finding Sanity

by Greg de Moore

  27

  When John returned to Melbourne, it was to his family that he first turned his attention. Jack no longer hobbled when he walked and continued to get stronger, lifting weights; he was now rowing at Xavier. David excelled in Maths, boasting to his father of a recent 100 per cent mark in an exam. The two youngest boys played around the grounds of Royal Park. Jean, for her part, immediately re-established order on the domestic front. John’s and Jean’s exuberance at being home with their boys was dimmed by the death of David Cade, John’s father, just a month after their return.

  When John returned to Royal Park hospital, he found it was changing, and doing so fast. Out went the padded isolation rooms. John called them the very essence of the ‘awe and abhorrence’ with which the public regarded mental hospitals. Down came the dilapidated accommodation; up rose a new occupational therapy centre, an entertainment centre and laboratories in which to conduct research. Straitjackets were given short-shrift and disappeared into museums. Dr Dax had set ambitious rebuilding targets throughout the state of Victoria. Royal Park, the flagship mental hospital of the state, was undergoing massive changes; the vaunted half a million pounds of refurbishment was in full swing. Everywhere at Royal Park one could hear the thud and clang of machinery putting things together or pulling them apart. Almost as soon as John returned from England, his relationship with Dr Dax soured.

  As Dax recalled from this time:

  I have no doubt that [Cade] ran Royal Park in the same way that things were done in the Army. He’d come over at 8 am. I’m sure he expected everyone to stand to attention . . . Cade turned up at the right time. He was always at meetings. He had his notes and his reports . . . I’d put the buildings there and left him to manage them. I was overbearing perhaps; [Cade] had to fall in with it . . . Well, he was rather rigid . . . a person who had high standards and he was a very good Catholic and had high principles . . . he worked conscientiously around the day. He could always be relied on . . . he was a very good rigid administrator.

  Several photos of John at this time—thin-lipped and dour—conceal his lively humour; perhaps this is all Dax saw. John’s reserve confused some of the people he met, who came away finding him humourless; nothing could be further from the truth. If you listen carefully, there is a twinkle in almost everything John said and wrote. In the end it probably depended on whether John was among friends or foes; his admirers called him formal, his detractors rigid.

  Dax found John to be very stiff, and years later recalled a difference of opinion about the new Royal Park staff cafeteria as evidence of John’s neat institutionalised mind: ‘in a typical John Cade way he got all the tables up in line in a rigid sort of way . . . I moved around about half a dozen tables [into a more relaxed format]. I turned round and saw him raising his eyes to the ceiling. I had no doubt he’d put them back by the next day . . . Of course, next time I went they were all in straight lines.’

  Looking back, perhaps the tension between the two men was the inevitable heat of friction when two strong-minded men—both of whom had a deep love of the history and culture of psychiatry—collide.

  It is hard to fully recreate the tensions between the pair but the undertow of censure is apparent in this letter from Dr Dax to John in 1955:

  Dear Dr Cade,

  Following the last superintendents’ meeting I would like to stress the need for patients to be adequately occupied in a useful way. There seems to be a growing misconception that when people speak of social therapy this is a form of constant amusement for the patient which excuses them from following useful occupations in the hospital. Adequate occupation and a feeling of responsibility for the day-to-day work which is done in the hospital is in fact a part of social therapy. The privilege of attending the recreational activities and amusements should, subject to the superintendent’s discretion, be dependent upon the patient doing an adequate amount of work in hospital . . . It is hoped that much more of the minor maintenance and side-works of the hospital will be done by using patient labour. There is much useful work that needs to be done in the removal of unwanted walls, the cartage of bricks to close ward gardens, and their cleaning and stacking . . .

  And so this letter went on with Dax detailing how John should lift his game. Dax’s grandiloquence was not to John’s liking; over 60 years later, we can almost taste John’s fury as he read this dressing down. When this letter was read out to John’s widow in the year 2000, some 45 years after it was written, she remarked: ‘That sounds like Dax . . . I can hear the uproar when that was read.’

  John, for his part, had a rather broader idea of occupational therapy than Dax. He favoured the offbeat idea of giving the patients Australian Rules footballs to kick joyously around the hospital yards, without a neat stack of bricks in sight. Clearly John’s notion of therapy was a little too libertine for his more authoritarian boss, and a disputatious cloud settled over the two men. It never lifted.

  In the early 1950s, just before John travelled to England, a gentle wayfarer knocked on the Cade’s front door at Royal Park. The young man, having noticed the unused loft above the Cade’s garage, boldly asked whether they would consider turning it into an artist’s studio. That’s how Max Middleton, a young artist on the rise, came into the Cade family’s life. Max, as it turned out, had just returned from a rambling painting expedition that had taken in Spain, Italy, Bali and half-a-dozen other countries. With characteristic generosity, John not only allowed this young painter, then just over 30, to use the loft, but also refused any payment. In return, Max taught John and Jean the rudiments of painting, a task accomplished with some skill by Jean and none by John.

  With John’s name increasingly in the media it was not, perhaps, unexpected when Max Middleton, a specialist in oils and still life, entered a portrait of John for the 1955 Archibald Art Prize—Australia’s most-prestigious portrait competition—picking up a more-than-respectable finalist slot.

  Throughout the 1950s, while John was preoccupied with clinical and administrative work at Royal Park, research on lithium continued in Melbourne. Edward Trautner and Sam Gershon had confirmed John’s early work, that lithium curbed mania. But they also solved the huge problem that had stalled lithium’s continued acceptance. The problem had always been this: how did a doctor know how much lithium to prescribe for a patient? The right dose in the right person cured mania, but too much and the patient sometimes died from toxicity. Trautner’s work brilliantly solved this problem. Using a technique called flame spectrophotometry, they measured blood levels of lithium in patients. They carefully worked out what was a safe blood level and what was a worrying toxic range. Doctors could now give lithium with the assurance that by measuring the patient’s lithium level they could avoid toxic doses. It was the vital breakthrough lithium needed.

  Among the vast collections of the Museum of Victoria is a leather-bound prescription book from Royal Park for mid-1956 to late 1957. It shows beyond doubt that lithium was being prescribed, with eight different doctors writing 27 prescriptions for lithium carbonate over a six-month period. Lithium, it seems, was regaining favour under John’s watch at Royal Park. With lithium more safely dispensed, the rollcall of the dead was over; the last recorded lithium death in Victoria during this early period was in 1953.

  The enigmatic Trautner remained in Melbourne until the end of the decade, when, like some furtive bush marsupial, he slipped away into the night as mysteriously as he had arrived. He headed north to retirement and the amnesia of Queensland, a refugee again, of sorts. Colleagues fondly imagined him beachcombing on Heron Island, knee-deep in salty waves. When he left, he gave one of his colleagues a prized first-edition copy of Richard von Krafft-Ebing’s classic on human sexuality—in German, of course.

  The ambitious Sam Gershon, who had a close, almost filial relationship with Trautner, relinquished Australian citizenship and emigrated to the United States. He would have more to do with lithium there, and became its evangelist, preaching its virtues to the non-believers unt
il the Americans eventually re-entered the fray—like their entry into both world wars—late.

  28

  John’s reading habits were broad. He relished the works of Arthur Conan Doyle, who made just one visit to Australia, in 1920–21, recording his impressions of the Great South Land in his book The Wanderings of a Spiritualist. During that visit, one afternoon, early in October 1920, Conan Doyle, celebrated author and doctor, saw something he liked. He sat high up in the Members’ Pavilion at the Melbourne Cricket Ground, closely watching a game of Australian Rules football. His gaze scanned the arena, then settled upon the players. He observed their athletic stride with a keen mind and sharp eye, like the most famous of all his creations—Sherlock Holmes. Conan Doyle loved sport, once describing it as the ‘sometimes brutal, sometimes grotesque’ activity that lay ‘deeply in the springs of our nature’. And he loved the indigenous game of Australian football he watched that day in Melbourne, writing ‘I have played both Rugby and Soccer, and I have seen the American game at its best, but I consider that the Victorian [Australian] system has some points which make it the best of all . . .’

  It is quite possible that even as a youngster John Cade knew of Conan Doyle’s visit to the MCG, for John read just about everything that Conan Doyle ever wrote; later John, unashamedly, replicated the methods of Sherlock Holmes in his daily psychiatric work.

  Take for instance, ‘The Adventures of the Solitary Cyclist’, a classic Conan Doyle short story published in 1903. A Miss Violet Smith—modest, beautiful and accomplished—enters the famous rooms of 221b Baker Street late one evening to stand before Sherlock Holmes and Dr Watson. Holmes scrapes the laziest of eyes across her features. Dr Watson takes up the narrative and describes how Holmes picks apart his prospective client:

  ‘At least it cannot be your health,’ said he, as his keen eyes darted over her; ‘so ardent a bicyclist must be full of energy.’

  She glanced down in surprise at her own feet, and I observed the slight roughening of the side of the sole caused by the friction of the edge of the pedal.

  ‘Yes, I bicycle a good deal, Mr. Holmes, and that has something to do with my visit to you to-day.’

  My friend took the lady’s ungloved hand and examined it with as close an attention and as little sentiment as a scientist would show to a specimen.

  ‘You will excuse me, I am sure. It is my business,’ said he, as he dropped it. ‘I nearly fell into the error of supposing that you were typewriting. Of course, it is obvious that it is music. You observe the spatulate finger-end, Watson, which is common to both professions?’ There is a spirituality about the face, however’—he gently turned it towards the light—‘which the typewriter does not generate. This lady is a musician.’

  As usual, Holmes was right on the money. Now listen to John Cade writing about how he observes a new patient as they walk into his office:

  After the face, the hands reveal most. It would be true to say that at times it is possible to make a reasonably confident psychiatric diagnosis if one is permitted to inspect only the patient’s hands. They reveal infallibly the state of tension. One only has to see the agitated crumpling of a handkerchief to realise how distressed a woman really is . . .

  The cosmetic state of a woman’s hands and finger nails gives many clues to her mental condition, her occupations and her preoccupations. It is even possible at times literally to measure how long she has been mentally disturbed. Consider the woman who has previously taken great pains to care for her nails. There is lacquer on each nail, but it is in bad state of repair. Quite a lot has rubbed off, but she has neither taken the care to renew it nor had the interest to remove it. Knowing the growth rate of nails (approximately 1 mm every ten days) and measuring the fresh unlacquered growth at the base of the nails, one finds, say, a growth of 4 mm, since the nails were last attended to. It is hardly hazarding a guess to infer that she has been distressed for about six weeks. Right-handedness or left-handedness is sometimes obvious from the different rates of wearing off of lacquer.

  Ed Darby, a medical student in Melbourne in the 1960s, remembers John emphasising in lectures the necessity for scrupulous observation. Darby, though not a student of John’s, made a special one-off pilgrimage to listen to the well-known psychiatrist:

  I’d heard of Cade. I was a 5th year medical student. Cade was very keen on students and demonstrating things to students. That one day I went he talked about the importance of hands. How if you were a motor mechanic and had no grease on your hands you hadn’t been working for a while. He was an astute observer. He then showed us a patient, a man who was sitting in a chair, not apparently doing very much, just making funny movements with his lips and mouth and was totally unresponsive. I answered that he might be catatonic and John Cade was a bit surprised. But that’s what it was and he then picked up the chap’s arm and it stayed suspended for some time. It made quite an impression on me.

  John rather liked these dramatic flourishes when presenting patients to an audience. Sometimes it was a suspended arm, another time a wayward walk, and, at other times, it was a manic patient who proclaimed himself as the true medical superintendent of Royal Park and that Dr Cade was merely an imposter. But John was never careless in how he presented patients to his students, and was never anything but compassionate in the manner in which he interviewed them. He habitually warned medical students before his demonstration started to be respectful and ‘never, ever laugh at the patients. But you may laugh with them.’

  John Cade’s lectures, held on Saturday mornings at Royal Park, were legendary among medical students. At 9 am, 60–70 medical students, like a flock of sheep, assembled outside and then filed in to sit, cramming next to one another, in the small tutorial room. There was a great buzz of anticipation, for the word had got around that these were the best lectures on offer.

  His teaching was traditional, perhaps even old-fashioned. You rolled a patient out in front of your assembled students and took a history and tapped tendons, or in the case of psychiatry, asked more questions to reveal the mire of depression or exuberance of mania. And so the patients would enter, one at a time, and John would demonstrate, masterfully. He cast his eye over each component of the patient before him, totting up evidence for and against each possible diagnosis. In most cases he’d have this sorted before the patient opened his or her mouth.

  One medical student remembers one patient, who’d grown a little stout, squeezing into a Richmond football jumper that had not been worn by the patient for nearly twenty years. There was a tell-tale scar poking above the jumper’s neck line—a past suicide attempt—the story of which John gently fished out during the interview. Or there was the man who presented with the oddest of charcoal spots on his chest that confounded the assembled students. Guesses range from an exotic tropical skin disease to home-made tattoos. John revealed the patient was depressed and a smoker who habitually puffed away in bed. The patient was so depressed he barely felt the pain as the ash fell from his burning cigarette and ate into the flesh of his torso.

  John observed every patient intently until he had drained dry everything that could be offered. The face told him most: ‘Quite often one can make a spot diagnosis from an inspection of the patient’s face; but, short of this, one invariably obtains vital clues . . .’ He rattled off a list of what was front of mind when he greeted a new patient: who can forget ‘the clicking mouth-moistener is usually anxious’ or the ‘frozen’ face of depression. And then there was the ‘hand-clasping entry of the manic, whose hoarse garrulity detected from afar announces the diagnosis even before he himself arrives to confirm it’. As an aside he noted ‘invariably the insistent hand-shaker is manic’.

  John detailed his observations with a brutal economy of syllables and was impatient with the wordiness of those about him. Taut lines connected cause and effect. Dr Dax once gently deprecated John: ‘he taught things in black and white, the students liked that’. Well, black or white, the students devoured John’s jokes and clever as
ides and his commitment to high standards. They cherished his Sherlockian deductions in deciphering the meaning of self-cutting on different parts of the body, and poured in through the doors on a Saturday morning to hear lectures they would remember for the rest of their professional lives.

  Back in the hospital, John brought his theatrical bent to his daily rounds. On one occasion a group of junior doctors, waiting for John, noticed that he was peering out the window. Slowly they sauntered over, curious as to what was going on. John, now with his audience assembled, remarked: ‘Do you see that tree over there?’ Pointing to a tree in the courtyard he went on: ‘I bet you in about 5 seconds a magpie will land on the grass under it.’ The magpie duly arrived. Some of the doctors probably worked out that John had seen a magpie at the base of the tree tugging a worm, which it had dropped and flown away as John approached the window. John knew it must return for its fleshy food. Although generally an undemonstrative man, John was not beyond these touches of coup de théâtre to impress.

  Puzzles were not just for medical students. John, playfully, inflicted them on anyone. If you spent time with John Cade you were bound to be put on the spot. All his four boys remember the dinnertime conundrums around the Cade table. It might start with John listening to questions the two older boys had from their university lectures that day—both Jack and David became medical students—and offering the soundest of responses. Then John would smile, lean back and launch into a puzzle or two. The boys recall:

  He had a couple of favourites. ‘If a chook and a half lays an egg and a half in a day and a half, how many eggs does a chook lay in a day?’ or on another day we’d get ‘Brothers and sisters have I none but that man’s father is my father’s son. Who is that man?’ But he’d never tell us the answer. You had to work that out.