GREG DE MOORE AND ANN WESTMORE Finding Sanity: John Cade, lithium and the taming of bipolar disorder. Reviewed by Bernard Whimpress
Let’s start with a statistic. The year 1948 marked a peak for deaths in Melbourne asylums, 183 at the Royal Park Mental Hospital alone, and John Cade kept a tally – three and a half a week, two out of every 15 admissions. A high proportion of those patients would have suffered from bipolar disorder, then known as manic depression. The figures were astonishing.
John Frederick Joseph Cade was the son of a doctor, and doctors and chemists represented an unbroken line among his ancestors for nearly a century and a half. His father was a medical officer and then superintendent of mental asylums at Beechworth, Mont Park and Sunbury after the First World War, so the son was exposed to life in these institutions as a child and a young man. After graduating in medicine in 1934 he served briefly at the St Vincent’s and Royal Children’s hospitals before joining the mental hygiene department of the Chief Secretary and returning to his old stamping grounds as medical officer at Beechworth and Mont Park while undertaking an MD degree in psychiatry in 1938. During the Second World War he served with the 2nd/9th Field Ambulance and following the fall of Singapore in February 1942 spent the remainder of the war as a prisoner in Changi camp.
He was dubbed the ‘Mad Major’ during his POW days, but the term was most likely a form of endearment because Cade was above all a physician first, a psychiatrist second, and very much a practical man, as is evident in the following passage from his unpublished memoir. Survival meant eating and gaining nutrition, no matter the source:
I was asked by the cook to condemn a batch of rotten fish. I said ‘You stupid bastards. We won’t get any replacement. It’s rich in protein and maggots. Thrash it within an inch of its long departed life, sieve out the bones and maggots and serve it as fish soup. It won’t kill you but it will nourish you.’
Another source was a local grass – lalang – which was bundled in armfuls and churned into a foul-tasting liquid known as ‘Tiger’s piss’, which many soldiers refused to drink but was rich in riboflavin.
On his demobilisation in 1946 Cade returned to the mental hygiene department as medical superintendent and psychiatrist at the Repatriation Mental Hospital, Bundoora, and began a lone research project injecting urine into guinea pigs. Although his first hypothesis that urine from a manic patient was more toxic than regular urine proved false, he found that adding lithium to uric acid to make lithium urate had a calming effect on the animals.
Now comes a moment of high drama, as co-authors Sydney psychiatrist Greg de Moore and Melbourne medical historian Ann Westmore report:
John Cade in 1948 was a blend of the military and the medical: it was never likely that he would inflict an untried potion on an innocent man until he had weathered its effects himself. For a man who had survived three and half years’ incarceration as a POW, the act of self-experimentation and a preparedness to take chances had become a way of life …
All John knew was that lithium had led his guinea pigs to lie vacant-eyed and dreamily insensitive to the prodding of human fingers.
As John prepared to take lithium, the spirit of the alchemist stirred within, knowing he was doing what many would regard as against the natural order. He emptied the lithium powder into a test tube, stirred a solution and raised the transparent fluid to his lips. Whatever the nature of the force that guided his hand, it was deep-rooted and arcane.
He held the elixir to his lips: his nostrils sensed no odour, and, with the courage and recklessness anything truly original must embrace, he opened his mouth.
Eyes closed, he drank.
Having experienced lithium with no ill effects, he decided it was now time to test it on Bundoora patient Bill Brand, who had been in a state of mania for five years. Brand had been misdiagnosed and shamefully treated by the army and various medical practitioners over a period of 25 years. Two years before, Cade had given him nine treatments of electroconvulsive therapy – then a violent and gruesome process – but while each treatment had calmed him for several months, the mania had always returned: ‘The remnant of a near-demolished human being, Bill was a wreck by the time John Cade resorted to giving him lithium.’
Within days the potion began to work and after a few weeks Cade began to use it more widely. In September 1949 when causes of mental illness – psychological, biochemical, social – were being debated, he published a historic paper in the Medical Journal of Australia on his treatment of 10 manic patients. De Moore and Westmore enthuse:
The paper is a masterpiece, his magnum opus. It is everything a scientific paper should be, and so different from just about every modern scientific paper you will ever read. It is a four-page wonder, a manifesto on the treatment of mania; its scope – of life and death – is operatic. It was published without fanfare – just another article in the midst of hundreds – but it would, in due course, be celebrated as the journal’s most cited paper, and for changing the way we think about mental illness.
A year later at least 100 patients around the country were receiving lithium.
Lithium treatment of mania, however, now struck a few reverses. It could cure but it could also kill. Bill Brand died of lithium toxicity in 1950; two manic female patients treated by the same doctor at the Ballarat and Ararat mental hospitals also succumbed over the next two years, and another male patient died in Perth. Lithium was also banned in the United States. Three people had died from the use of lithium chloride in place of table salt and as a result an effective treatment of mania was delayed for a generation. In 1952, after Cade was appointed superintendent of the Royal Park Mental Hospital, the most important psychiatric institution in Melbourne, he had less time for medical research and his belief in lithium seemed to waver. Fortunately it was kept alive by others – Edward Trautner and Sam Gershon in Australia in the 1950s, and then by Mogens Schou in Denmark in the early 1960s. It was not until 1970 that Cade gained full international recognition for his work.
Beneath the main narrative of the doctor and medical researcher is the very human story of how the boy became the man:
In 1920, a typical eight-year-old boy played cricket with his mates on the streets of suburban Melbourne; John played games with disturbed men in a lunatic asylum who thought they were Jesus. There can be little doubt that in these germinal years John’s affection for the mentally ill stirred and took root.
The narrative is also extended by Cade’s choice of secondary education at Scotch College. He had been raised a Catholic, following the religion of his mother, and his father’s old school was Melbourne Grammar (Anglican), yet he opted for the Presbyterian school his grandfather Joseph had attended. That made him an outsider, and he remained something of an outsider in the psychiatric profession, initially by turning his back on private practice, then as a medical researcher, and particularly through his criticism of Freudian psychoanalysis.
A decent man who lived an ordered life, Cade is humanised by his routines, even if they seem exaggerated: grace before meals; mass every Sunday; bedside prayers with his sons; ‘seven cigarettes daily, but they were strategic’; ten cups of tea daily at five set intervals – breakfast, morning tea, lunch, afternoon tea, night; a double glass of sherry in a favourite oak chair. He could be reserved and his emotions were described as ‘clipped hard’ in dealing with the death of an infant daughter, as they had been in Changi.
At other times he could enjoy life, as he did with his elder sons shooting rabbits at Bundoora at the end of a working day, and body-surfing at Kennett Beach on holidays with his family on the Victorian south-west coast. With patients he was warm and thought of many as members of an extended family, while medical students who attended his Royal Park lectures regarded them as legendary:
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 … They relished his Sherlockian deductions in deciphering the meaning of self-cutting on different parts of the body, and poured in through the doors on Saturday mornings to hear lectures they would remember for the rest of their professional lives.
I received an inscribed copy of Finding Sanity from one of the authors, who is a friend, with a supplementary remark – ‘A Great Australian Story’.
Indeed, it is.
Greg de Moore and Ann Westmore Finding Sanity: John Cade, lithium and the taming of bipolar disorder Allen and Unwin 2016 PB 336pp $32.99
Bernard Whimpress is a historian who usually writes on sport but once took a psychology major in his undergraduate degree. He most recently edited a cricket anthology, Baggy Green: A selection 1998-2010.