Barry Blackwell’s Response to Gregory de Moore’s Response
Gregory de Moore and Ann Westmore: Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder
First, thank you Greg for the considerate and calm manner in which our exchange of opinions about John Cade and his discovery of lithium is unfolding. Clearly, we view the matter through different prisms. My own is attributable to Aubrey Lewis’s and the Maudsley emphasis on epistemology and the rigorous evaluation of validity and reliability for therapeutic claims. While yours are shaped by personal knowledge of the man in an environment in which he is understandably regraded as an Australian folk hero.
We both agree that there are issues that lack facts which inevitably invite interpretations and speculation. The best we can do is openly exchange our differing viewpoints and leave it to our readers to adjudicate and decide for themselves.
My own position may become clearer when my just completed review of Johan Schioldann’s epic volume, History of the Introduction of Lithium into Medicine and Psychiatry, is posted on INHN. It was published by Adelaide Academic Press in 2009 and I feel sure you are familiar with its scope - 1,245 references! What particularly impressed me was the Preface by German Barrios, Professor of the Epistemology of Psychiatry at Cambridge University UK. In it he states, “All nations need heroes and figures to look up to and … the Lange brothers and Schou fill the same social function as Cade does in Australia. All that a good historian can (and should do) is to try and understand why it is important for countries to have heroes, and why some official stories, however mythological they might be, cannot be changed or replaced.” In approaching this intractable problem together I feel conscious of the fact you come more from the heart and I from the head.
Was John Cade curious and biochemically minded?
Undoubtedly. This is well documented and explains the zeal and persistence with which he attacked his hypothesis that mania and melancholia might be biochemically akin to thyrotoxicosis and myxedema. But these were not his only character traits. He displayed obsessional behaviors, observed in youth and reflected in the daily habits and repetitive routines of his adult life, with an unflinching commitment to the Catholic faith. At times, he could be stubborn, proud, rigid and opinionated. He was observed to be modest and self-effacing in assessing his own limited scientific talents, but resolute in an opinion about his clinical skills.
Less clear is the cognitive set with which he approached his experimental tasks and etiological theories. I have suggested this was primarily deductive rather than inductive, consequently prone to error (Schizophrenia and Mongolism). It is also curious that he knew Feud’s theories well, but rejected them without realizing that Sherlock Holmes was equally at risk of error – but not to either his author or readers!
POW experiences and theories of psychiatric illness.
I am in complete agreement that Changi was the seed bed of Cade’s biological beliefs and am admiring of his talent both as an officer and leader of men, but also as a skilled medical practitioner willing to perform autopsies on his failures.
Where did he find Lithium?
This seems a curious diversion. Lithium was a prominent ingredient in the Australian Materia Medica and probably widely dispensed for various aliments around the turn of the century. Only by a leap of logic, abetted by missing data, can one construe that this implies its use in the early treatment of mental illness or that Cade knew or deduced this possibility.
Bill Brand’s death due to lithium toxicity
That Cade recognized his role in this tragic outcome and admitted it to the coroner some month’s later is congruent with his scrupulous honesty. Why he failed to acknowledge that outcome later in life is speculative. Once Schou entered the picture, prophylaxis was confirmed and blood monitoring was established as routine; why rock the boat? One swallow doesn’t make a summer and since Bill Brand’s death thousands of patients had been successfully treated. That Cade felt it would be ethical to remain silent is likely, although the fact this preserved his reputation and his self-image as a clinician might be a subsidiary consideration.
Cade and Trautner
I am sure you are right in observing these two men lived in different worlds. Not only in University versus mental hospital, but they were utterly incompatible as human beings. Trautner was a flamboyant free thinker, womanizer, libertine and atheist while Cade was a button-downed believer with fixed ideas and morals. The fact that Cade felt that good clinicians didn’t need laboratory findings to guide them was a not uncommon viewpoint in mid-nineteenth century thinking, on the cusp between bedside and laboratory driven practice and teaching.
Why Cade clung to an inability to even mention Trautner, let alone acknowledge his contribution to safe practice, is indeed a mystery. For me, it suggests a deeper antipathy, perhaps based on Cade’s POW feelings about wartime barbarity and a belief that Trautner, an incorrectly labeled enemy alien, had been shipped by Churchill to Australia, a reminder of colonial times past.
Who deserves priority?
This question is the most difficult to parse, Cade, Trautner or Schou? I believe Cade discovered the use of lithium for manic excitement, but not for bipolar disorder. That far wider indication belongs to Schou. In addition, Cade’s inability to see the significance of blood monitoring and his false dependence on clinical judgment (which failed him in Bill Brand’s case) led to his ban on lithium’s use that might have brought about an end to the lithium story if Schou had not entered the scene, paradoxically because of Cade’s discovery to which he gave full credit, rather than his Danish ancestors.
Ultimately, how one tilts in appointing credit is likely determined by the prism through which the conundrum is viewed. The mythical ending put forward in my review reveals my own biases, but does it matter if we accept Berrios’s view that once myths develop they become impenetrable to latter day reasoning?
October 5, 2017