Wednesday, 28.10.2020

Barry Blackwell’s review
Gregory de Moore and Ann Westmore: Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder.

Gregory De Moore’s commentary

 

            Thank you for asking me to make a few comments about Barry Blackwell’s review of the book: "Finding Sanity: John Cade, lithium and the taming of bipolar disorder."

            I suppose one of my aims is to bring this lithium story into the lives of medical and nursing students around the world. Not just those students intent upon studying psychiatry, but all students. This is a remarkable and idiosyncratic story that occurred in circumstances barely believable. It was a narrative written up by John Cade, an ex-POW, and published in the Medical Journal of Australia in 1949. It is that journal’s most cited article. And I love the fact that there is not a complex statistical reference in sight. Just a series of short stories about what he did, why he did it, and how men walked out of the asylum unburdened by their illness. When I read Cade’s article for the first time, I thought of the wonderful book by Oliver Sacks, Awakenings. Robin Williams played the lead in the film version. Well, in my mind, the dispensing of lithium to patients in the 1940s is the Australian equivalent. Imagine that very first patient – Bill Brand – walking out of the asylum gates. As I write this I can imagine that there might be some academic psychiatrists, bristling. That they see this more as story-telling than factual history. But I disagree. Ann and I were at pains to make this book factually correct. We had access to material that no one had previously sought and interviews with people long since dead. That this discovery of lithium for bipolar disorder also happens to be a ripping yarn, fit for a film, is a bonus we should all enjoy. After all, anything that brings psychiatry to the forefront of the public mind is something we should encourage.

            I hope this will be an ongoing dialogue that will see this story take its place as a cornerstone in the history of psychiatry.

            Today I wanted to cover a little of the background that led to me write the book (along with my co-author Ann Westmore) and also my initial engagement with Barry Blackwell. Ann will make further comments on Barry’s review in due course, and she will, no doubt, have her own perspective on the story.

            The driving force for this book, at least for me, goes back to my years as a medical student at Royal Melbourne Hospital. I first came across the name John Cade when I was a fifth year medical student at Royal Melbourne Hospital. Our psychiatry term was eight weeks long and, like many students, I blithely floated along, avoided tutorials, until I found myself one week before exams. It was only then I thought I should learn something about this thing called psychiatry. When I turned up to my first tutorial, the tutor (noticing me for the first time) brushed aside my excuses and ordered that I stay back that evening to admit my first psychiatric patient. It was a moment that changed my life. That evening I saw a young man with his first episode of illness – early schizophrenia. He was 22 years of age. That was also my age. Picture two young men – in opposite corners of a stark white room anxiously eyeing each other – on a winter’s night in a psychiatry unit in Melbourne. That evening, as I made my way home I realised psychiatry was the only thing in medicine I really wanted to do. The following day I went to the hospital library and ferreted out books on psychiatry. Amongst them was a slim volume – "Mending the Mind," John Cade’s brief history of psychiatry. I remember holding that book and thinking that surely Cade’s discovery of lithium for the treatment of mania must be one of the great moments in medical history and certainly Australia’s greatest moment in the history of psychiatry. I have never forgotten that thought.

            Years later I had the opportunity to live and work for one year in New York City, during the mid-1990s. I was based at Cornell University Medical Centre/The New York Hospital. I could not help but be impressed by how so much was going on in medicine in that city and around the United States. It was almost overwhelming. Indeed so much was going on that at times I wondered how a small country like Australia could compete. Americans seemed inordinately proud of what their own country had achieved, though interestingly seemed amazingly ignorant of matters beyond their own shores.  Australians on the other hand continually downplayed their own country’s achievements and seemed far more interested in lauding other countries. While I was in New York the story about lithium and John Cade bubbled its way to the surface of my thinking. Here was an Australian story that more than matched anything I saw in the U.S. Yet no one, either in Australia or just about anywhere else, seemed to know much about it. It was one of the things I wanted to rectify.

            Throughout "Finding Sanity" an American or British reader might sense a subtext of Australian nationalism. You are not imagining things, it is meant to be this way. Barry Blackwell certainly did notice this when he alluded to our comments about the Maudsley’s attitude to lithium in the 1960s and 1970s. You will also find in it the section on Changi, the Prisoner of War Camp, during WWII. Though the motivation for me, as an author, was actually directed at Australians to understand and take more pride in their own history.

            So back to Barry.

            Barry Blackwell was at the centre of my thoughts almost from the outset of my research and writing. My initial feeling (when I read the critiques on lithium by Michael Shepherd and Barry Blackwell from the 1960s and 1970s) was one of quizzical curiosity, amazement and intrigued voyeurism. I wanted to know why lithium and the recent work by Schou and others provoked such hostility from these English psychiatrists. I understood some of this. There had been so much in psychiatry that was dubious, so much that had been adopted without evidence. And psychiatry is ever desperate to prove its worth. I was sure that the insulin coma epidemic was a driving force in the Maudsley’s critique. But still I was not satisfied. I couldn’t quite understand the hostility in some of the articles directed towards the use of lithium and how it might impact lithium researchers at the time. Michael Shepherd had since passed away and so I set about trying to find Barry Blackwell. I asked numerous Australian psychiatrists, all of whom had known Barry decades before, as to his whereabouts. One after one they scratched their heads and said Barry had been living in the U.S., had been in academia and then was in industry. But to a person no one I spoke to in Australia had heard of him for some time. So, in the early years of research I scoured the internet, but found no current address. I made some hopeful phones calls to a few US Medical Departments. But nothing. So I stopped searching and moved on to other areas of the book. Matters would have probably remained there, but in the final year of writing the book, I searched for Barry again and through the glory of the internet (and its endless growth) found his name, where once I had found nothing. One e-mail later the expanse of the Pacific Ocean evaporated and Barry and I were in e-mail communication.   

 

            Now, I have to tell you I was a bit nervous when I made the decision to ring and tape an interview with Barry. I was not sure if he would be hostile to my interest in the early lithium history. What did he now think about lithium? How would he regard John Cade? How would he regard me? This person from Australia prodding and poking about in history. As an author I know that people do not always wish the past to be stirred up, examined and fossicked through. But I also knew that there nothing like speaking to individuals who were there at the time. The one thing the Australian psychiatrists who recalled Barry, from their time at the Maudsley, told me was that he was a warm and friendly man. So I rang. It turned out that my phone call with Barry was a gem. At least for me. His memory of events from the 1960s was sharp and his manner charming. Barry is a polymath: an accomplished author, historian, medical doctor and raconteur. And probably more.

            Barry Blackwell’s polymath expertise is now recorded on tape, and I loved especially his whimsical memories of his role in uncovering the side effects of MAOIs.

            When it came to his articles on lithium and his time at the Maudsley he gently defended the British context in which those articles were written, but more importantly, acknowledged that his understanding of, and attitude to lithium had changed over the decades. He explained how he now acknowledges the critical role of the work of Cade and others in the evolution of psychopharmacology. I make a point of this because it is rare in my experience for an individual to be so candid about a matter where he/she had once taken a very different view. I finished that first phone interview with Barry liking him and with a slightly different mindset as to what I should write about lithium in the 1960s. I found my initial draft about lithium in the 1960s and realised it was too harsh. I changed it. That’s what a personal interview can do. 

            I thank Barry for taking the time to write such a detailed and generous review of our book. This is not a gratuitous comment. Over the years, as an author, you never take a positive review for granted.

            While writing this book I was very aware of sensitivities around the work on lithium from the 1940s to 1960s. Mysteries abound, not the least John Cade’s changing attitude towards lithium. I can’t believe that no one took the time to interview John Cade in detail about his discovery. This was an oversight that left me guessing at motives and cryptic steps in his experiments. Perhaps I will discuss this another time.

            Before I leave today I must mention Professor Sam Gershon. My interviews with Sam were a highlight of a decade of research. Sam, even more than Barry, was right there at the forefront of research. He is a kind of living treasure and storehouse of knowledge. I am eternally gratefully to both of these men. 

Gregory De Moore

May 11, 2017