The doctor should make intolerable memories tolerable, Rivers told his colleagues. He should assist his patients in replacing horror with the more bearable emotion of grief. Between them, doctor and patient, they should find a balance between dwelling on the traumatic experience of war and “banishing such experiences from their minds altogether.” The problem, Rivers said, “was to find some aspect of the painful experience which would allow the patient to dwell upon it in such a way as to relieve its horrible and terrifying character.” “It’s bad to think of war,” wrote Sassoon in a poem named for Rivers’s lecture “Repression of War Experience”: “When thoughts you’ve gagged all day come back to scare you; / And it’s been proved that soldiers don’t go mad / Unless they lose control of ugly thoughts / That drive them out to jabber among the trees.”
Madness and the memories of war go, return, stay:
You’re quiet and peaceful, summering safe at home;
You’d never think there was a bloody war on!…
O yes, you would…why, you can hear the guns.
Hark! Thud, thud, thud,—quite soft…they never cease—
Those whispering guns—O Christ, I want to go out
And screech at them to stop—I’m going crazy;
I’m going stark, staring mad because of the guns.
T. E. Lawrence, who knew the horror of war well and had been instructed in the ancient Arab remedies for healing through recollection, sometimes in hard memory, wrote in Seven Pillars of Wisdom about Arab reckoning of their animals:
I was on my Ghazala, the old grandmother camel, now again magnificently fit. Her foal had lately died, and Abdulla, who rode next me, had skinned the little carcase, and carried the dry pelt behind his saddle, like a crupper piece. We started well, thanks to the Zaagi’s chanting, but after an hour Ghazala lifted her head high, and began to pace uneasily, picking up her feet like a sword-dancer.
I tried to urge her; but Abdulla dashed alongside me, swept his cloak about him, and sprang from his saddle, calf’s skin in hand. He lighted with a splash of gravel in front of Ghazala, who had come to a standstill, gently moaning. On the ground before her he spread the little hide, and drew her head down to it. She stopped crying, shuffled its dryness thrice with her lips; then again lifted her head and, with a whimper, strode forward. Several times in the day this happened; but afterwards she seemed to forget.
A healing forgetfulness could follow sharp remembrance, but not by averting or tamping down pain and loss.
For a poet such as Lowell, who did much of his healing through his writing, and who by character returned to, rather than retreated from, the front lines of life, Rivers’s psychotherapeutic philosophy would have been compassionate and practical. Standing back from or skirting the trauma of madness would not work. Repression would not work. “If imagination is active and powerful,” Rivers insisted, “it is probably far better to allow it to play around the trials and dangers of warfare than to carry out a prolonged system of repression.” This encouragement of limited but direct engagement, although it carried risk, suited Lowell’s character and temperament. The human part of war, wrote Lowell, may help the poet through “war’s sordor, heroism, the death and adventures of friends, the blow brought home to one’s whole being.” So too the human part of madness.
Rivers repeatedly made the point that men of courage could and did fall to madness. Siegfried Sassoon, whose courage in battle was renowned throughout the British Army and who had received the Military Cross for “conspicuous valour,” gave to Rivers, as did his fellow poets Wilfred Owen and Robert Graves, who knew but were not treated by him, the kind of respect that makes healing possible. Rivers, by all accounts tough, sympathetic, and deeply intelligent, saw a significant part of his role as a doctor, as a healer, as someone who could accompany his patients through their terrors.
“My definite approach to mental maturity began with my contact with the mind of Rivers,” wrote Sassoon. “He exists [now] only in vigilant and undiminished memories, continuously surviving in what he taught me. It is that intense survival of his human integrity.” When everything had “fallen to pieces and one’s mind was in a muddle and one’s nerves were all on edge…,” said Sassoon, “unexpected and unannounced, Rivers came in and closed the door behind him. Quiet and alert, purposeful and unhesitating, he seemed to empty the room of everything that had needed exorcising.”
It was the kind of healing, of exorcising, that seems to have eluded Lowell, perhaps because such doctors are impossibly rare or perhaps because the ravages of Lowell’s illness did not allow it. It is a pity. The laying on of hands and binding up of wounds is ancient, biblical, and continues still. “I undo the clotted lint, remove the slough, wash off the matter and blood,” wrote Walt Whitman, who nursed dying soldiers during the Civil War. “I thread my way through the hospitals, / The hurt and wounded I pacify with soothing hand, / I sit by the restless all the dark night.”
Lithium curbed the relentlessness of Lowell’s manic attacks until, toward the end of his life, when he took it only erratically, and sometimes not at all, his mania came back. His anxiety in the wake of recurrence was palpable. In February 1976, a year and a half before he died, Lowell wrote to Frank Bidart, “I am weighed down by the new frequency of attacks. How can one function, if one is regularly sick. Shades of the future prison.” He made the point again to Blair Clark the following month. “I can’t really function against two manic attacks in one year,” he said. It was untenable. He expressed the same fear to Elizabeth Bishop: “I had a longish though not violently troubled stay in the hospital, and have been out a month—mildly depressed as the cheerful doctors insist. Mildly is bad enough. Though I can’t make too much of it. I fear the frequency of these things, fear becoming something that must be categorized as a burden.”
Lowell’s third wife, Caroline Blackwood, reiterated Lowell’s fear of becoming manic again. He was “terrified of being mad alone,” she said. “I don’t think people generally realized the terror he was in that he might lose his mind minute by minute. In fact, his last lines were about that: ‘Christ, may I die at night with a semblance of my senses.’ ” The regret for lost time, the grinding cycle of hope and despair, the dread of madness find their way into Lowell’s last book, Day by Day, which was published just months before he died; hope is shown to be fool’s gold: “if we see a light at the end of the tunnel, / it’s the light of an oncoming train.”
In 1949, the same year that Lowell was first admitted to a hospital for mania, John Cade, an Australian psychiatrist, published in the Medical Journal of Australia an article titled “Lithium Salts in the Treatment of Psychotic Excitement.” The impact of Cade’s discovery—or, more accurately, rediscovery; it had been used briefly by Danish physicians in the 1890s to treat depressive illnesses—is difficult to overstate. Lithium was the first drug that not only treated but prevented mania and depression. His work, often described as serendipitous because it took a rather higgledy-piggledy path of scientific reasoning, was intuitive, odd, risky, and utterly changed clinical practice and research in psychiatric medicine.
G. P. Hartigan, an English psychiatrist who did early clinical work with lithium, and whose paper “Experiences of Treatment with Lithium Salts” I occasionally give to residents as an example of excellent clinical writing, put Cade’s work, which spanned a line of reasoning from speculation about toxins in the urine of manic patients to lethargy in excitable guinea pigs, thus: “Some Australian physiologists, working on some recondite project whose exact nature I regret I am unable to recall, found it expedient to introduce a lithium salt into the peritoneal cavities of guinea-pigs. It was observed that for some hours after this outrage the animals became thoughtful and preoccupied.”
Cade’s guinea pigs, thoughtful and preoccupied though they may have seemed, more likely were acutely ill from the lithium, which at too high a dose can be toxic. Cade made excellent use of his observation of passivity in his experimental animals and speculated that
the effect might be transferable to the very sick manic patients he was treating on the wards. He gave lithium to ten severely ill patients with mania and in all of them there was a significant reduction in psychotic excitement. When the lithium was discontinued, the psychosis returned. There were problems: the first patient who received lithium stopped taking it after having become “overcome with confidence” at being well. When he restarted his lithium, however, he again showed a dramatic recovery. He later died of lithium toxicity, an outcome far more common in the early days of treatment and research than it is now.
Cade, in his landmark paper, speculated that lithium might be an essential trace element. “It is widely distributed,” he wrote, and “has been detected in sea-water and in many spring and river waters, in the ash of many plants, and in animal ash.” Soranus of Ephesus in the second century, and physicians long before him, had recommended the use of mineral well waters, some of which had high concentrations of lithium, for patients who were manic. The concentration of lithium in these waters doesn’t approach the level necessary for a clinical response, but speculation about lithium concentrations in ancient wells and modern water supplies remains a part of the drug’s lore.
Lithium spewed out in the first minutes of the creation of the universe. Fifteen billion years later it was discovered by a chemist analyzing minerals in an island cave off the coast of Sweden. The element, which exists in mineral springs and igneous rocks, was named lithos, the Greek word for stone. In the two decades after Cade’s clinical findings were published in 1949, Danish researchers demonstrated that lithium was effective in preventing both mania and depression. They also worked out the dosages and preparations of lithium that were effective and safe. The drug was then used in Britain and continental Europe and eventually found its way over the Atlantic into American medical practice.
Lithium salt reserves
“All I’ve suffered, and all the suffering I’ve caused, might have arisen from the lack of a little salt in my brain.” Credit 23
Lithium is light—only hydrogen and helium are more so—flammable, and as ancient as is possible. Better than anything we know, it treats and prevents mania and depression; better than anything we have, it acts to prevent suicide. It also appears to protect and heal the brain from the damaging effects of repeated attacks of mania and depression. Recent studies suggest that lithium prescribed to bipolar patients increases gray matter volume and density, increases cortical thickness and hippocampal volume, and may reduce the risk of dementia. There are other drugs now available to treat manic-depressive illness, primarily anticonvulsant medications used for seizure disorders and antipsychotic drugs, but lithium remains the gold standard for treatment. Lithium, as Hartigan wrote, possesses “certain modest magical qualities.”
Lowell was first given lithium in 1967 and, early in his treatment, he felt Cade’s wonder toward the drug. In February 1967 he wrote to Elizabeth Bishop, “Nothing new worth writing about, except that I have another doctor now, and there seems to be real hope that my manic seizures can be handled by a new drug, Lithium, and that all my giddy reelings come from a kind of periodic salt deficiency in some lower part of the brain. At least, this drug is now working with many.”
That June he wrote to another friend, “I’m in terrific shape! I even have pills that are supposed to prevent manic attacks…which supplies some salt lack in some obscure part of the brain.” A year after first taking lithium he wrote to Bishop again: “Yes, I’m well. The pills I am taking really seem to prevent mania. Two or three years will be necessary, but already critical months have passed. Ordinarily I would certainly have been in a hospital by now. The great thing is that even my well life is much changed, as tho I’d once been in danger of falling with every step I took. All the psychiatry and therapy I’ve had, almost 19 years, was as irrelevant as it would have been for a broken leg. Well, some of it was interesting, tho most was jargon.”
Lowell made the same point again in May 1968: “These pills for my manic seizures seem to have made a cure, tho I will take them to my dying. This has changed my life, not only no attacks, no hospitals, but even, and perhaps most, health itself is different, freer and out of the shadow.” For many years lithium, though an imperfect drug, gave him relative health and stability; it untied him from the killing cycle of manic-depressive illness to which he had been bound.
Robert Lowell: Hospitalizations and lithium treatment
“No attacks, no hospitalizations, but even, and perhaps most, health itself is different, freer and out of the shadow.” Credit 24
Some of Lowell’s friends found lithium to be a problematic treatment, in part because of its side effects—he was kept at a higher dosage than he would be now, which appears to have somewhat flattened his moods (clinical practice has changed significantly in this regard)—and in part because his illness still was not entirely under control. Although Lowell fit the clinical profile of someone likely to respond to lithium—his manias were “classic,” that is, characterized by elation, flight of ideas, and grandiosity; he had a family history of mood disorders; and his attacks of mania preceded his depressions, rather than the other way around—he was put on lithium late in his illness, and stability is harder to achieve after repeated episodes of mania. Lowell also drank heavily at times, most notably when he was manic, which almost certainly affected his response to lithium as well as disrupting his sleep. Other medications that he took for his heart disease, including methyldopa and digitalis, may have had an impact on his moods as well.
Mary McCarthy, in a letter to Hannah Arendt in the fall of 1967, gave her usual unvarnished opinion of Lowell and his treatment:
He is taking some new drug, a kind of salt [lithium carbonate], that is supposed to guarantee that he’ll never have another manic seizure. But what it has disclosed, by keeping him “normal,” is how mad he is all the time, even when on his good behavior. It is as we said last December. And this, we hear from Lizzie, is the view of the new doctor, who is more a physiologist than a psychiatrist: “The salts,” he told her, “will prevent manic outbreaks, but they can’t change the fact that he is crazy.” He’s very tense and, when he’s drinking, quite grandiose; he oughtn’t to drink and has stopped for the moment, but I don’t think he can keep it up. It’s as though the drug were depriving him of his annual spree and he compensates for the deprivation rather cunningly by using the license given to drunkards. My opinion is that it would be better to let him be crazy once a year, be locked up, then emerge penitent, etc.
Jonathan Miller, who trained as a physician before his work in the theater, observed that Lowell “became much more frazzled. I’ve got a feeling that the episodes of lunacy, instead of being concentrated in acute, easily manageable episodes at the beginning or the end of the year—the drugs had somehow squashed it out and spread it evenly throughout the year.”
Grey Gowrie described the advantage and cost to Lowell of taking lithium. “Lithium had made a terrible difference to him. I don’t think it was very good for him physically, but he seemed to be on a much more even keel. He was unhealthy, Cal. He smoked all the time and he liked to drink, and this drug was blowing him up a bit. And he was puffier. He’d lost his fitness in a way.” Another friend, Esther Brooks, stated that she thought lithium worked for a while and that “he appeared to be released from the terrible ordeal of more and more frequent breakdowns.” As the years passed, however, “he became more and more careless about its use and the consequent effects were subtly noticeable to those who knew him well. The well person and the unwell person seemed to rub together in a strange kind of muted euphoria. One no longer feared that he would go mad but one kept waiting for the delicate and exquisite side of his mind to assert itself once again.”
It is difficult to gauge the effect of lithium on Lowell’s work. There is little available about his blood levels, which are critical in any discussion of the drug’s effects on thinking and writing. His stepdaughter Ivana states that Lowell felt lithium flattened
him out and had a negative effect on his creativity; his friend the poet Kathleen Spivack agreed, and said he complained that lithium “flattened him out, all his moods; there was a creative price to be paid for medicine.” The painter Sidney Nolan said that lithium stopped him going to the hospital but “I think it was a dampener at both ends. It stopped the mania and it stopped the depression and left him somewhere in between. From the point of view of the artist, I don’t know that it was necessarily a good thing. I think he sometimes realized this and didn’t take it.”
Lithium appears to have checked the extremes of Lowell’s mania, but his mind continued to create at a fast, submanic pace. He was first prescribed lithium in March or April 1967 and began writing the Notebook 1967–68 poems in July 1967. “I never wrote more,” Lowell said about his productivity during this time. By Christmas of that year he had written more than seventy sonnets. He told Elizabeth Bishop in July 1968, “I guess the summer goes, because I write so much. I must average six days a week nine to three-thirty….19 new sections added. It must end, but impulse keeps pushing up something new.” “This beautiful summer,” he wrote to Adrienne Rich, was “the best, the most productive I’ve had.” Later he commented, “Words came rapidly, almost four hundred sonnets in four years….I did nothing but write.”
Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character Page 21