Gregory de Moore and Ann Westmore: Finding Sanity: John Cade, Lithium and the Taming of Bipolar Disorder
Heart or Head
Our book is written from the viewpoint of John Cade and his personal and professional life, and is done so unashamedly. Part of our motivation for tackling this subject was that his life was largely unappreciated in Australia, and, for the most part, unknown overseas. This does not mean it was written more from the heart than the head. Indeed, our research comes to well over 20 years of combined detailed archival research and interviews with dozens of individuals including some who worked and lived closely with Cade, and who no longer are alive. We uncovered archives previously unknown, which shed light on his thinking about patients and their care and provide important context for his evolution as a research-oriented psychiatrist. The results of this work, apart from our book, include a PhD thesis (Ann Westmore, ‘Mind, Mania and Science: Psychiatry and the Culture of Experiment in Mid-Twentieth Century Victoria’, University of Melbourne, 2002) as well as numerous academic articles and presentations. So, no, this work sprang as much from the head as from the heart. But the heart was and is important.
For me (Greg), as an Australian writer, this drive partly comes from the year I spent as a psychiatrist in New York City during the mid-1990s. In 1995-96 I worked at Cornell University Medical Centre in Manhattan. During that time, I had the opportunity to attend many of that hospital's functions including its psychiatry Grand Rounds. On one of those occasions I attended a lecture given by Kay Jamison. Two things struck me while she spoke. The first was her conclusion that writing a book for a general audience was perhaps more satisfying and more interesting than writing/reading a technical academic paper. The second was something she didn't say: in the ensuing discussion about lithium, John Cade’s name never came up. As l looked around the large auditorium, filled to the brim that day, I wondered if I was the only Australian in the audience. I also wondered how many of the Americans around me knew the story of John Cade and how he used lithium to treat mania. During the lunch afterwards, I raised this subject with my American colleagues. It was pretty clear that John Cade was an unknown.
For me (Ann), as a writer and historian of medicine, and as the daughter of a General Medical Practitioner whose mentally disturbed patients sometimes sought help at our door at all hours, the search by mental health practitioners for the principal causes of mental illness has long held intrigue. The feasibility of accessing a rich archive of locally- and internationally-sourced materials, including interviews with confidants of John Cade’s family, even some former patients, was an unrivalled opportunity to explore this subject. Heart and head came together when this body of evidence was subjected to rigorous historical evaluation of validity and reliability.
The source of lithium
Where John Cade sourced his lithium is still a bit of a conundrum. Just in last few months Greg received a short note from one of John Cade's sons that helped solve part of this puzzle.
I found this interesting letter over the weekend. My father had been using as a bookmark in his favourite mathematics book (Hogben's "Mathematics for the Million").
Charles Brothers was a distinguished psychiatrist, at the time the Director of Mental Hygiene in Tasmania. He later came to work in Melbourne.
It seems that the clinical results of lithium in manic patients in Tasmania had been impressing the medical officers there in 1950 & they wanted to source some more reliable supplies.
The letter referred to was written in June 1950 by an Australian psychiatrist, Dr Charles Brothers, to John Cade. Attached is this 1950 letter:
If you read the letter carefully, John Cade has scribbled (after the typed section) the names of three pharmaceutical companies from which he most likely obtained lithium. At least this tells us that the drug was available commercially in Melbourne. From John Cade’s seminal 1949 article announcing his treatment of psychotic excitement with lithium salts we know that he was aware of the 19th century use of lithium for gout and gouty manifestations, and of the early 20th century use of lithium bromide for epilepsy. He also referred in this article to Henderson and Gillespie’s 1944 remark that the waters from certain wells in Britain were regarded as having virtue in the treatment of mental illness. In no way does this knowledge account for John Cade’s discovery that lithium salts could rapidly calm manic excitement in patients with intractable mania, a finding that built on more than a decade of self-education as a research psychiatrist.
Regarding John Cade's silence over the death of his first patient from lithium toxicity: for us the most important moment was how he coped when he fronted up to the coroner. It was an undeviating and honest approach. He was prepared to accept the consequences. This was impressive in 1950; it impresses us now. We don’t know why, in newspaper reports or academic papers, he did not refer to this death. Maybe he wasn't asked. Perhaps he didn't want to raise uncertainties once lithium therapy had gained therapeutic acceptance after two decades of knock-backs and refinements. We have no reason to doubt that had he been asked about this death, he would have answered the question directly.
Eduard Trautner (and Mogens Schou)
With our backgrounds in psychiatry (Greg), history of medicine (Ann) and writing (both of us) we would have liked to know John Cade’s assessment of Eduard Trautner. Trautner, for us, has been a largely overlooked contributor to the lithium story. And when we talk of our admiration for John Cade, it is equalled by our admiration for Eduard Trautner. Partly this admiration is for his medical research, but it is also because he encapsulates so much about modern Australia. Apart from our aboriginal population, this is a land of immigrants who stepped onto Antipodean shores only in the last 200 years. Their varied contributions and, at times, their sufferings are all reflected in the life of Eduard Trautner. In particular, Greg’s own parents came to Australia from Sri Lanka after the Second World War and much of their experiences informed our book’s descriptions of post-war Australian life.
Cade’s attitude to his war-time enemies
Dr. Ed Chiu, a psychiatrist who knew John Cade very well in Melbourne, regarded his depiction of Changi and the treatment meted out by the Japanese and Korean guards as uncompromisingly honest. Nonetheless, Ed Chiu also made it clear that John Cade's moral compass was a deeply Christian one and that he held no bitter enmity towards the Japanese, or anyone else, despite this treatment. We believe that at times John Cade struggled with this, as any good man might do. Remember that in his early days as a POW, John Cade discovered that his best friend had been beheaded during the Japanese invasion of Singapore. It was a scar from which he never fully recovered, whatever the word “recover” might mean in that context. Who are we, or anyone else to say, what that experience might do to a man? Later in life John Cade travelled widely throughout Asia and saw himself as an envoy to improve medical dialogue between Australia and these countries. He also kept to certain strict routines that were likely fostered and found valuable during his years in captivity.
The question of priority
And the question of priority? We have no doubt that John Cade was proud of his achievement in introducing lithium therapy. It would be an unusual man who was not. But all the men Barry Blackwell cites – John Cade, Eduard Trautner and Mogens Schou - deserve accolades. We consider John Cade would think so as well. But for us, there is always that first moment when something undeniable shifts: that was Cade's lithium moment - when he opened the door for others to follow.
January 18, 2018