Finding Sanity

by Greg de Moore

  Jean starts, seeming to know the outcome of the year already:

  How do I write about this terrible year, yet I must keep the dates, as I am so forgetful of dates—and these are so important to me. John said, ‘1980 is not my year.’ How right he was and so very, very brave. So we start with Sunday March 23rd admittance to Eye and Ear Hospital for removal of cataract from left eye.

  What presentiment of disaster he sensed we will never know. At least at the start all went well and the eye operation was a success. But soon afterwards John had a fever that drenched him wet and shook his bed. These violent rigors returned later in the week. Something unexplained was going on. On 30 March he was admitted to St Vincent’s Private Hospital with a perforated appendix and remained in intensive care for two weeks. Jean, a nurse to the end, fondly inscribed in her diary ‘such a good patient’, from which we know John was not a man to complain. When his appendix was removed, unexpectedly a small tumour was found in his large bowel.

  Just over two weeks later, half of his large bowel was removed. As John recuperated, his quirkiness came to the fore, even in the most dire of contexts. Jean wrote:

  Three days after having a bowel resection operation my dear John told his nurse that he had said this little ditty and ‘it had worked’.

  I sang a hymn to Cloacina,

  Soft but cohesive let my offerings flow,

  Not harshly swift or impudently slow.

  It is quite possible that John’s nurse thought these lines the delirious drivel of a desperately ill man. It was, in fact, of all things a homage to Cloacina, the Roman goddess of sewers. For a man who observed and made jokes about animals and their various droppings, he couldn’t resist, in his time of sickness, to concoct a ditty about his own. To the end he enjoyed a riddle, a joke, even in the face of cancer.

  Jean optimistically charted his slow progression from bed to chair. She wrote of his discharge home: ‘Now to get strong.’

  While back in his Toorak home, news came through that the last of John’s original ten manic patients, whom he had treated with lithium from 1948 on, had just died. John made a note that this final patient had been on lithium for over 30 years. When first seen, this patient had been wild and lusty, his inflamed words poured out undiluted, outrageous and sexual, manic gusts hitting hard. He bellowed continuously and strode about the grounds of Bundoora with the bravado of madness. He eventually recovered fully with lithium. According to his death certificate he held the most settled of occupations, a clerk, and, succumbed at the ripe age of 76 from natural causes—a heart attack.

  At this point there is a long gap in Jean’s diary, until we read the ominous words ‘Now the terror starts.’ In early September, John noticed some difficulties in swallowing. By the end of the week Jean scribbled ‘Results bad’, and we learn that John had been diagnosed with cancer of the oesophagus. The cancer was almost certainly a result of John’s obsession with cigarette smoking, and although his sons had exhorted their father for decades to stop smoking, he never could resist fine Virginian tobacco. Further rounds of X-rays, biopsies and blood tests followed; on 16 September he was back home awaiting an operation on his oesophagus. He headed back to St Vincent’s for his operation, due on the afternoon of 24 September. When his surgeon, Dr John Clarebrough, opened him up, John was riddled with cancer. The operation was cancelled.

  Jean simply wrote: ‘Findings—terrible.’

  Oesophageal cancer was a death sentence in 1980; John knew it from the moment it was diagnosed. But his boys remember him being as selfless as ever, wanting to spare their mother and themselves. Even when experimental chemotherapy—primitive and brutal—poisoned his body, he never complained. The most anyone could extract from him was the fatalistic cricket phrase that was a marker of his generation’s stoicism: ‘Well, dears, I’ve had a good innings.’ He dutifully attended all doctors’ appointments; Jack, devotedly, drove him everywhere.

  John rarely talked about his religious faith at this time, but those who knew him are convinced that it offered him the solace of certainty. In dying, his attendance at church never waned, attending every Sunday at St Peter’s, Toorak. Undaunted by mortality, John set about the task of dying as he had lived: organised and not fussing, tidying up what needed tidying. With Christian self-examination he prepared to leave one life, and enter another. He called his son Jack over: ‘Look when I go, I’d like you to organise the simplest pine box . . . and I’d like to be buried in Yan Yean where my parents are.’ And then, closing his mind on that topic he ended with, ‘Now, we’ve discussed that. It’s done’, as if he’d just casually decided what he might have for dinner that evening. And so with a clang of the lid, discussion on death was over.

  Enfeebled by chemotherapy, John sat in bed, unmoving, shoulders bent forward, his bony scaffold visible. He hadn’t looked like this since 1945. His mouth filled rapidly with stinging, bleeding ulcers; swallowing was almost impossible, so Jean lovingly cradled cups of water to his lips. John refused to be fussed over; Jean fussed over him all the same.

  On the afternoon of Saturday, 15 November, his son, Peter, visited:

  We were sitting together on the verandah at Mum and Dad’s Orrong Road home. It overlooked a lovely garden. I spotted a bird in the garden that I didn’t recognise. I went inside to get Dad’s bird field guide. It was a White-Plumed Honeyeater, relatively common in Melbourne gardens. I kneeled down beside Dad and showed him the picture in the guide. His response was ‘Oh yes’ and he said no more. I thought the response was out of character . . . I now realise how very sick he was when he was so uninterested that day.

  The following day, as death tugged at John, and knowing his fate, he asked his son Jack to drive him to St Vincent’s Hospital. Shortly afterwards, settled into bed in the hospital’s intensive care unit, John closed his eyes to rest. Jack left and John was alone. Into the Melbourne evening John’s dependable wristwatch marked time, and for a man who had lived his life by the most exacting of measures, he expected nothing less of himself now. Never late for anything in his life, John Cade kept his rendezvous with death, going out with the tide just before the appointed hour, a few minutes before midnight.

  Epilogue

  In the weeks and months after John’s death, condolence letters poured in. Many now lie on Jean’s old roll-top desk, yellowed and stale with the aroma of time. Some are from men and women with bipolar disorder; most of them had never met John Cade. People unknown to him mourned his death—patients whose lives were resurrected because of lithium. They wrote to offer thanks. This is one of them:

  Thirteen years ago, I suffered an illness which placed me in and out of . . . hospital for almost 6 years where, each time, I received ECT treatment . . . Each admission proved a longer stay due, no doubt, to my having developed suicidal tendencies when, on two occasions, I almost ended my life. I didn’t want to live, but was petrified of dying. I had a loving husband and five beautiful, healthy children, but no feeling of love for anyone and nothing but hatred for myself . . . on my last admission, the psychiatrist felt I was manic-depressive and recommended I take lithium . . . I often wonder where I’d be but for lithium carbonate and continually give thanks to God for Dr Cade and his wonderful discovery.

  Next to the pile of letters is an assortment of items from John’s life—his dog tags from Changi, his well-worn rosary beads, his copy of the New Testament—spread out across the desk, entrails of a man’s life. Lifting each item, turning them over, trying to fathom John’s thoughts, inevitably there are questions. Some answers come from perusing his private letters; others come to us from the recollections of friends and family and (importantly) of those less well disposed towards him. All the letters—from friend or foe—point to a gentle, modest man.

  Regardless of which letter or item is picked over and examined, thoughts and questions always return to the Bundoora Asylum in 1948, when John first used lithium, when he crossed the Rubicon and stirred a solution and handed it to his first patient, Bill Brand. Bi
ll was always a bit of a mystery. No one really knew what he looked like; no photographs had ever been located. Indistinct and ghostly, he was defined by his medical records and the memories of John’s two older boys. Finding a photograph of Bill, to give him an identity—denied him during much of his life—became somewhat of an obsession.

  As the writing of this book came to a close, a photograph of Bill emerged. It came about by following the trail of Pearl Patten.

  Pearl and Bill, we know, married in 1923; unable to tolerate Bill’s illness, she left him. Pearl fled about as far away as she could from Melbourne without leaving the state, escaping to Underbool, a tiny town 470 kilometres northwest of Melbourne.

  Underbool is a town in the Mallee district of Victoria, not too far from the South Australian border. Driving in to town you pass through vast wheat fields and plenty of red dirt and twisted eucalyptus scrub. There’s not much to see in the way of buildings; there’s a parched oval where the town’s Aussie Rules team plays footy, although the local league folded in 2015—players were hard to come by. The 2006 Census recorded 217 inhabitants in Underbool.

  Pearl lived in Underbool for the rest of her life. She first worked as a housemaid, eventually meeting a new man and starting a new family. When she died in 1994, well into her 90s, her small and exquisitely cared-for fibro and timber house—where she had lived her final years—remained untouched. Years afterwards, as her children prepared the house for sale, they rummaged through Pearl’s belongings and came across a large, framed, oval photograph, in excellent condition, tucked away in her bedroom wardrobe. It was an unexpected find. The family had no idea of the photo’s existence; it was a photo of Bill and Pearl on their wedding day in 1923.

  When you examine Bill’s face, it is not the smudged, damaged face one conjures up when reading his medical history. His face is like that of a Grade 2 schoolboy’s: fresh, soft, as though his mother should be nearby to pack him off to school, or hold a hanky to his nose, or just be there for something, because you know that he will need it. Because he has the look of a boy, not of a man; his clothes are a smidgeon too big and slip skewiff from one of his shoulders. He has not worn these clothes before and he is unlikely to wear them again. It is a deceptive photo; he appears so uncorrupted by life, so unblemished, a sweet and beautiful boy. This is what Pearl saw before mental illness took Bill apart. It remains the only known photograph of Bill Brand.

  No patient was more important to John Cade, or perhaps more vital to the history of psychiatry, than Bill Brand, the first patient treated with lithium. In the decades after lithium was found to work, out tumbled other medications to treat the mentally ill: antipsychotics to quell delusions and hallucinations; antidepressants for the morbidly depressed; anti-anxiety pills for the fearful. Modern pharmacies bulge with medicines for different mental illnesses—but the first medicine ever to specifically treat a mental illness was lithium.

  If the story of lithium (and the countless lives it has saved) belongs to anyone, it perhaps belongs most of all to Bill and the other nine manic patients first offered treatment by John Cade. That’s the way John may have wanted it, for John knew a doctor was nothing without his patients.

  Lithium hasn’t changed since 1948, nor has its value, though we still don’t have a clear understanding of how it soothes the brain. Not every patient responds to it, and its dose still needs close monitoring. Although lithium itself hasn’t changed, the way we understand bipolar disorder has. When John experimented with lithium, manic depression, as he knew it, was a uniformly appalling condition in which sufferers might remain in hospital for weeks, months and sometimes years. Over the 70 years since John started his experiments, the concept of bipolar disorder has expanded. We now include many milder cases where the highs and lows are not as devastating. Lithium remains at its most effective for severe cases of bipolar disorder.

  John Cade—a true blue-blood of world medicine—occupies a rare perch. By showing that a simple chemical could help tame bipolar disorder, in a stroke, he turned our understanding of mental illness on its head. John’s enduring legacy, lithium—a chemical born at the start of the universe—is found all around us, in the crust of the earth upon which we live. His discovery of lithium treatment stands as a matchless accomplishment in the history of Australian psychiatry, an imperishable moment in medical history.

  When lithium was first stirred by John Cade, alone in the backroom of a mental hospital, in circumstances barely credible, a revolution in the care of the mentally ill flickered into life. At last we had something that worked, something almost beyond belief: a simple salt of the earth that was a balm for a troubled spirit.

  John Cade (left) with brothers David (centre) and Frank, and mother Ellen, c. 1916. (Image courtesy of Cade family)

  Jean Charles (right) during midwifery training, probably at Women’s Hospital, Melbourne, mid-1930s. (Image courtesy of Cade family)

  John and Jean Cade in front of Mont Park Mental Hospital on their wedding day, 1 November 1937. Their reception was held in the hospital. (Image courtesy of Cade family)

  The medical officer’s house, Beechworth Mental Hospital, where John Cade lived as a young doctor early in his psychiatric career. (Image courtesy of Greg de Moore)

  John Cade (left) and fellow soldier R.M.W. Webster, Malaya, 1941. (Image courtesy of Cade family)

  Australian soldiers in Malaya, c. 1941. John Cade (left) watching John Park, who is brandishing a bayonet (right). (Image courtesy of Owen Jenkin)

  ‘Changi Memory’, drawn by Australian POW Walter Andrew Sarkies, dated September 1944. John Cade was involved in the development of nutritional supplements for the prisoners held in Changi. (W.A. Sarkies collection, State Library of Victoria)

  Jack (left) and David with their mother Jean, probably in the back garden of their wartime home in Eaglemont, Melbourne, 1942. (Image courtesy of Cade family)

  The Cade family in the mid-1950s. Back (left to right): David, Jean, John and Jack. Front (left to right): Peter and Richard. (Image courtesy of Cade family)

  A typical ward in Bundoora Repatriation Mental Hospital, c. 1940s. (National Archives of Australia)

  The grim reality of life in a Victorian mental hospital in the early 1950s. (State of Victoria)

  ‘The shed’—John Cade started his experiments with lithium in the kitchen of an unused ward at Bundoora Repatriation Mental Hospital in the late 1940s. (Image courtesy of Jack Cade)

  John Cade began to treat Bill Brand with lithium in 1948. This card records his first few observations. (Image courtesy of University of Melbourne Medical History Museum)

  John Cade (centre) and other staff members discuss patient care at a staff conference at Royal Park Mental Hospital, undated. (Photographer unknown)

  Jean and John Cade, c. 1960s. (Image courtesy of Cade family)

  Acknowledgements

  My interest in the John Cade story was first aroused while a medical student at the Royal Melbourne Hospital. As a fifth-year student, and lost for something to do, I sat down in the hospital library and read through Dr Cade’s slim but remarkable book, Mending the Mind. It was a moment I have never forgotten. In 2010 I was fortunate to meet Ann Westmore, who had completed an exceptional PhD looking at aspects of the John Cade story. From that point on we resolved to continue the research and complete a biography.

  The interest and energies of so many in the Cade family over many years allowed much material to be recorded and used. Warm invitations were received from all the four Cade boys and I spent considerable time chatting and recording their memories over coffee and perusing the extensive collection of memorabilia and letters they had kept.

  Jack Cade was always welcoming, urbane and charming. His stupendous memory, like that of his brother David, was a storehouse for a biographer. David Cade wrote some superb memories of his father, and they were of a great assistance in drawing out the life of his father. Likewise, the two younger sons, Peter and Richard Cade, were unstintingly helpful. Peter’s daughter
s—Mindy and Anita—were also most hospitable, offering childhood recollections of their grandfather.

  Locating the Wandel family, with their memories and memorabilia, was a wonderful moment and filled numerous gaps in the story.

  The bibliography in this book includes a list of people we interviewed at different times over a span of nearly twenty years. To everyone we spoke to, your memories were crucial in piecing together this wonderful Australian story. Of this interview list, we would particularly like to mention Professor Barry Blackwell and Professor Sam Gershon; both live overseas, and took the time to speak openly and honestly about their experiences. Both are impressive individuals and we are deeply indebted to them.

  We also had the good fortune to hear the memories of Professor Russell Meares and the recollections of his father, Ainslie, which took us back to the key period of the 1950s and 1960s.

  Doug Craig, a former administrator at Beechworth, kindly took me on tours about the old Beechworth Asylum, and his wife, Val, was most hospitable during my stay.

  Professional genealogist Peter Gill, as on many occasions before for my research, sourced many important documents. This would not be the book it is without his expertise.

  In terms of written material, there was much to examine. Some of this we have outlined in the bibliography. Mention must be made of Professor Johan Schioldann’s masterly work on the history of lithium—a must-read for any student in this area.

  We would like to thank the staff at Allen & Unwin, especially Sue Hines, Angela Handley and Patrick Gallagher, who have supported this book from the start.