Finding Sanity

by Greg de Moore

  This time the criticism came not from the United States but from England, indeed from the well-respected Maudsley Hospital in London. The English critique was launched like a series of missiles. Indeed, Sir Aubrey Lewis, the Adelaide-educated head of the Maudsley, it was said, unflinchingly labelled lithium as ‘dangerous nonsense’. So the tone was set.

  The Maudsley critique rejected the Scandinavian evidence that lithium prevented future episodes of depression and mania in bipolar disorder. The authors of the articles on lithium regarded the promotion of lithium as a misplaced infatuation with an unproven and dangerous treatment. In one paper, it was implied that doctors who promoted lithium were the modern-day equivalent of those who once treated the mentally ill by blood-letting. Scientific civility, always a slender thread in the world of research, was now worn thin.

  To understand where this criticism came from and how it was shaped, you have to first understand something of the Maudsley Hospital in the 1960s. Russell Meares, Emeritus Professor of Psychiatry at the University of Sydney, who trained at the Maudsley during the 1960s, has some distinct recollections:

  I went to the Maudsley in 1964 . . . and for the most part I enjoyed it. But it had a curious atmosphere; it was very, very critical; and they were very good at ripping people to shreds . . . they were very afraid of doing things that were psychologically minded because Aubrey Lewis, the head of the Maudsley, might ridicule them; so they didn’t go near that sort of stuff . . .

  I remember the junior common room, and you were very much reminded of being the ‘colonial’ from Australia . . . I remember the fear of not sitting correctly, or of not speaking correctly. People were very careful not to say anything that could be criticised. There was a kind of game they played, of scoring points, an intellectual game. There was a lot of sparkling talent but it was a tightly controlled atmosphere. Aubrey Lewis, of course, was very clever. He’d start asking questions to expose the first deceit if you were presenting to him; it brought some trainees to tears. We were all lined up like ducklings: from Aubrey Lewis downwards. It was a strangled rigidity and the atmosphere could be one of cruel humiliation. Fortunately it never happened to me and I seemed to get on well with Aubrey Lewis, and, indeed, most people at the Maudsley.

  The early Scandinavian studies did have some methodological weaknesses and, after all, nothing published as medical research should be beyond scrutiny. But the criticism from England went further than this.

  Barry Blackwell, a young doctor at the time, was in the thick of things at the Maudsley. He is affectionately remembered by everyone who knew him as a likeable man with a warm handshake and convivial manner. He boxed in the army, and was once slated to take on Henry Cooper, who, of course, went on to challenge for the world heavyweight title. Fortunately Blackwell side-stepped this but was, in his pugilistic career, twice knocked out. His other pursuit was rugby and when he arrived as a medical student, ‘had such bad cauliflower ears I couldn’t get a stethoscope in them. A plastic surgeon operated on them . . . so I could hear with a stethoscope.’ An impressive man with a broad range of interests, Blackwell recalls his early medical career vividly. Everyone liked and likes, it seems, Barry Blackwell.

  Blackwell very openly admits that he didn’t actually use lithium and observe its effect on patients; he and his colleagues were critiquing the methodology. But in the midst of all the verbal cleverness and the preoccupation with numbers, the most important thing got lost—the patients themselves. Blackwell is now happy to say: ‘It turned out that we were wrong. Lithium was really the start of a revolution in psychiatry.’

  Welsh-born Brian Davies, the first professor of psychiatry appointed at the University of Melbourne—a Maudsley trainee from the Aubrey Lewis era—summed it up pithily: ‘I’ll tell you, they [the Maudsley critics] never used it on a patient and followed through and saw the family. They didn’t have any clinical experience with lithium. You only have to do it to one patient and family and it [bipolar disorder] stops. You don’t need any bloody clinical trials.’

  John Cade watched this all unfold during the late 1960s. To John it was all bluster and bulldust; he never had much time for British condescension. We imagine that he saw this as Changi all over again; the Brits wanted to take charge and bulldoze lithium. John simply ignored them and their criticisms. His son Jack, by then a doctor himself, recalls that his father was little affected by this debate: ‘I think he was pretty set in the way he thought about lithium by that stage. He knew that it worked. He had his patients in front of him. That’s what mattered. He was not the sort of man who let those kinds of harsh words from other psychiatrists ever bother him.’ John just waited for it to end.

  Further research vindicated lithium’s role in preventing episodes of mania and depression in bipolar disorder. And when lithium’s opponents were finally routed, John, with the killer instinct of a prize-fighter observing his opponent sink to his knees, wrote to his friend Mogens Schou in Denmark: ‘K-Oed . . . in the final round! Your contention has been proven so convincingly that the whole world must be persuaded.’

  And it was. The Food and Drug Administration (FDA) in the United States prepared to lift its twenty-year ban on lithium for use in mania. Lithium clinics, like fresh shoots in spring, germinated around the world. Research and publications on lithium rocketed—at last lithium had found its rightful and lasting place in treating bipolar disorder. Over twenty years had passed since John took those remarkable, almost unbelievable steps with guinea pigs near his home in Bundoora, and now the United States was finally listening to the evidence. With the United States moving towards widespread use of lithium, it was inevitable the world would follow.

  There are many endearing memories about John’s love for his patients. How he would brook no stupid administrative directives when it came to their care. If there was any doubt about John’s affection for his patients, and his bulldoggish protection of them from mindless medical administrators, there is one letter about a Royal Park patient that dispels all doubt. It is a letter that makes you wish for a psychiatrist like John Cade on every street corner and, in all its fighting glory, reveals John’s disdain for unthinking authority.

  To the Public Trust Officer

  Re: Doreen

  I understand you would be happier if Doreen were to submit dockets documenting her various purchases. Forget it. There will be none forthcoming. Doreen’s accountant is God. Unlike you and me, she has a hot line to Heaven which she uses very audibly many times a day and she has been advised from on high regarding accountability. True, at times she makes unnecessary, ill-chosen and expensive purchases. This however is an index of femininity rather than psychosis. She buys quite a lot of food too as her own purchases always taste better to her than the hospital menu and she has the appetite of an elephant.

  She is also a chronic giver of cards—birthday cards, Christmas cards, Easter cards, new baby cards, wedding cards, engagement cards—to name a few of the occasions which she documents in this fashion.

  This must run away with a good few dollars a year.

  We do our collective best to see that she keeps her purchasing within reasonable bounds, especially in relation to clothing, but Doreen is an exceptional case and must be treated as an exception.

  For example, she is the one patient in the hospital whom I have exempted from the annual chest X-ray survey for many years. No man is going to invade the privacy of her body. God will strike them dead if they attempt any such violation. This prediction is made with considerable vehemence and gesticulation.

  In short, as I said at the start, you won’t be getting any dockets.

  J.F.J. Cade

  Psychiatrist Superintendent, Royal Park Mental Hospital

  The public trustee must have also considered John and his letter exceptional. And so, rather than anonymously file the letter into oblivion, he kept it, like a secret treasure. Years later the daughter of the Public Trust Officer dug it out from her father’s belongings and (to the delight of the
Cade family) returned it.

  Of course, Doreen was held in special regard by the Cade family: she was their housekeeper and favoured companion. The Cade boys still recall her coming to the house, striding up the hill, in a ‘Mother Hubbard dress and an apron’ even on the most oppressive summer’s day, donning a heavy overcoat and lugging a bulky suitcase to ‘The doctor’s place’. She always addressed John courteously as ‘The Doctor’ and Jean as ‘The Missus’. She’d poke about in the scullery, polish the cutlery and take an interest in all the Cade brood’s doings. She was exquisitely modest, refusing to disrobe for anyone. And in the bizarre way of the deluded, this prohibition included herself. For when Doreen bathed she did so in the dark. John knew his patients well, and he knew when and how to protect them.

  During the late 1960s, John frequently travelled around rural Victoria, visiting country GPs and offering advice on care for their psychiatric patients. John loved these jaunts up-country; they were a liberating time to loosen the coat collar and sniff the air. His peregrinations took him to Ballarat, Echuca and to his old haunt of Beechworth. Best of all he loved staying in the old pubs and having a counter tea.

  Often he’d take along a younger psychiatrist on these country sojourns—Russell Meares was one of them. Russell remembers John well from these trips, and, in particular, one memorable conversation they had over dinner in a pub:

  We travelled around Victoria quite a bit. We’d meet as much as possible in older hotels; it was something John really liked, the old hotels. He did like to see himself as a doctor, and, I think, he carried a stethoscope, which was pretty unusual for a psychiatrist. We did chat a bit about Changi, which, in a way, was unusual for war veterans because my experience was that they didn’t talk about it. He talked about how they even contemplated cannibalism to survive. I’m not sure if the POWs as a body contemplated it but it must have been he and several associates who wondered whether this was ethical or plausible to survive. It was a passing comment, just a few minutes; it was just a calling to mind something that occurred to him in Changi and he didn’t linger over it. So in a sense it kind of fitted in with him being a very practical man and it also . . . implied a moral dilemma.

  Russell Meares was right. It was unusual for John to bring up Changi, on any occasion; Jean could barely wring a sentence out of him about the war. So what prompted this momentary rush of self-reflection on events 30 years earlier, we’ll never know. And why on such a provocative topic as cannibalism, even if it was in the form of a moral dilemma? It might seem strange that a man could, matter-of-factly over a roast dinner, have a dead-eyed discussion on cannibalism, to reflect rationally on what he might have had to do to survive as a POW. But should anyone think John was a cold man, all it needed was just the right ingredients to reveal his deep humanity. And sometimes the right ingredients came at the most unexpected of times. Like the time he had to kill his dog.

  For most of his life John had dogs, and held them in high affection. His favourite dogs were dachshunds. Several years before his chat about Changi in that Victorian pub, John’s beloved dog Sossie, a light tan dachshund, nosed about the Royal Park backyard. In the disused stables Sossie found and chewed on a cardboard packet filled with green pellets—rat poison. Within minutes, Sossie staggered and fell, lime foam clogging his mouth. As the dying dog twisted on the ground, John ordered his wife and children into the house. With no antidote for strychnine, the lethal agent in rat poison, John calmly found his Winchester rifle and shot Sossie in the back of the head—then broke into inconsolable weeping.

  By the end of the 1960s John was living a comfortable middle-class life. He had his family and his well-worn routine at the hospital and was respected within and outside psychiatry. Lithium was increasingly accepted around the world and was helping to revolutionise mental health care. John expected, indeed wanted, little else. That’s when he received an invitation to meet the President of the United States.

  PART 5

  Even the dogs were

  barking lithium

  LITHIUM: Tales from a bipolar patient

  After a few months off lithium, I felt energetic, engaged, even electric . . . I turned down jobs and burned all professional bridges with sharp and illogical emails . . . I painted my face with spectacular green-and-gold eye shadow . . . I stood on my head every morning; my apartment burned down; I served as the sole witness to a stranger’s wedding on top of the World Trade Centre; I wore 800 necklaces . . . I preached about Jesus wherever I went, which for a Jew is unusual . . .

  For two decades . . . I have been taking lithium almost continuously. It has curbed my mania, my depression and, most significant, the wild delusional cycles that have taken me from obsessing over the value of zero to creating a hippie cult . . . As long as I take those three pink lithium-carbonate capsules every day, I can function. If I don’t, I will be riding on top of subway cars measuring speed and looking for light in elevated realms.

  Jaime Lowe, ‘I don’t believe in God, but I believe in lithium’, The New York Times Magazine, 25 June 2015

  30

  On 4 July 1969, John Cade sat at his kitchen table having breakfast opposite his youngest son, Richard. An overseas letter, just arrived, lay unopened on the tablecloth—probably another enquiry about lithium. As John opened and read the letter, a deep smile split his face. Then, with the slightest of affectations, he nonchalantly turned to his son: ‘I say, old boy, I’ve been invited to the States to receive an award and meet the President.’

  Once the hullaballoo settled in the Cade household, it emerged that John had been awarded a prestigious medical prize—The Taylor Manor Hospital Psychiatric Award—for his 1949 lithium discovery. It was to be bestowed at a Baltimore symposium in April the following year, with President Richard Nixon in attendance. The meeting would be ground-breaking, bringing together for the first time in the history of medicine, the discoverers of major therapies within the discipline of psychiatry. More than a dozen eminent scientists and clinicians, including John, would have the opportunity of telling their stories of discovery in their own words. Travelling expenses would not be a problem; the Americans were footing the expensive bill with an around-the-world ticket. If there was a single moment when John Cade was catapulted from obscure doctor, who looked like a suburban bank manager, to worldwide medical fame, this was that moment.

  Up until now, his family had known of John’s work with lithium but perhaps not appreciated its full significance. That was to change after a deluge of phone calls and requests to speak to the media. Never ambitious for fame, John was, nonetheless, ripped out of his burrow like a bunny and into the glare of daylight. Discombobulated, he found himself in a celestial swirl of intense media fascination. And when John was elevated to the feature pages of The Australian Women’s Weekly, he knew that he’d become, albeit reluctantly, the rock star of Australian medicine.

  The reporter for the Women’s Weekly, Roslyn Ross, visited John and Jean at their Park Street home, and immediately sensed that this was a man whose bearing and manner belonged to a different era. Slim in build, John moved and talked with due consideration, framed by an unassuming formality. Ross insightfully wrote ‘there was something of the past about him. The “family doctor” of a century ago must surely have looked like Dr Cade. Tall and imposing in stature, with a friendly but distinguished face and a manner both gentle and sure, he looked out of time.’ Those who regarded John as something of an anachronism in the changing world of psychiatry were now confronted with the reality that he was a spectacularly successful world figure. Because of him, patients with bipolar disorder were less likely to be hospitalised, and, if they were, recovery and discharge were earlier.

  The Women’s Weekly article exposed John and his work on lithium to the public in a manner that propelled him to centre stage, and he was asked to pontificate on all manner of issues. Encouraged to speak his mind about the future treatment of psychiatric illness, he boldly stated his views: ‘We believe that many more mental con
ditions have physical or organic causes—not psychological ones—and therefore can be successfully treated with drugs.’

  There was one oddity about this Women’s Weekly article. When it came to how lithium was introduced, John related the story of Bill Brand; it was something he’d do hundreds of times in the future. The Women’s Weekly stated that his first patient, Bill Brand, ‘remained normal for the rest of his life’. This, of course, was not true. We all know that Bill suffered numerous relapses before dying from too much lithium. Perhaps this wasn’t the place to tarnish an otherwise glowing story, or to detract from John’s newly acquired American award. Or, perhaps, John was never asked what happened to Bill Brand, and the journalist simply glossed over his fate. We don’t know. Maybe John felt that with the evidence now so overwhelmingly in favour of lithium it might do more harm than good to elaborate. So, as had happened before, and would do so in the future, the fate of John’s first patient was never revealed in public interviews.

  And as for Jean—after all this was to a readership of women—she appears in the photograph next to her husband, both of them bespectacled in thick dark-rimmed glasses. Her eyes are lit up, her smile spontaneous; John’s smile is thin-lipped and calibrated. Jean is described as ‘a petite woman with a bright personality’ who it seems manages her husband’s workaholic personality well. ‘They are a perfect match. Even when Dr Cade looks serious she can make him laugh.’

  When Jean was asked about their upcoming trip to the United States, she shrugged with more than a note of resignation and sighed: