Gregory de Moore’s response to Barry Blackwell’s reply

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

These are some further comments to continue the conversation regarding lithium therapy and how it began in Australia. Ann will have her own perspectives on these issues. I have put my thoughts in response to a series of questions.

Was John Cade always someone curious about the natural world, and was he biochemically-minded?

John Cade, from a very young age, was recognised as being exceptionally curious about the world. He was a great lover of nature and spent inordinate time observing botany and local wildlife. Partly this was a function of his upbringing which, for lengthy periods, was in a rural or semi-rural setting.

John Cade was descended from a long line of medical doctors and chemists. So, in one sense, his destiny was set. It was a family background of which John Cade was very familiar and proud. One memory of him, as a University student, was that of a young man very experimentally-minded. Having said this, it might be tempting to say that he was always biochemically oriented in his thinking about psychiatry, and that he always spurned the psychotherapies. This assessment would be incorrect. Indeed, when I spoke to Ed Darby (a retired psychiatrist) who was taught by Cade, one of Ed’s enduring memories is of a teacher who knew and understood a lot about psychotherapy. Ed Darby can remember Cade quoting slabs of Freud during tutorials. Now, I am not saying that Cade agreed with Freud. Patently he did not. I only raise this because at some point in his training John Cade took the time to read Freud deeply. As a biographer of Cade, one of the treats was to find Cade’s textbooks and notes where he had underlined things that intrigued him. When it came to Freud, the theories at first intrigued him, but he came to violently disagree with a Freudian view of psychopathology.

How did his experiences as a POW in Changi affect John Cade’s view of psychiatric illness?

There is no doubt in my mind that Cade’s time as a POW was the turning point of both his professional and personal lives. I am sure this could be said also for the many thousands of allied soldiers and civilians captured by the Japanese in Singapore. During his three and-a-half years of captivity, Cade, along with other medical staff, became the linchpin for the survival of the men. With normal army duties largely suspended, it was the doctors and their helpers who assumed positions of great respect and authority. John Cade was remembered well by the men whom he served.

Although the British and Australians established separate hospitals to care for the wounded and the ill, they managed somehow to establish a joint mental health unit. This in itself seems staggering to me: that a psychiatry unit in a POW camp in the middle of a hot, stinking jungle was set up. As far as I know, John Cade was the only psychiatrist involved in the care of these psychologically-wounded men. We had limited notes from the time of WWII, but many years afterwards John Cade did record his memories of some psychiatric patients. While he noted that there were patients with mental illnesses one might see in any asylum, such as depression, he recalled that suicide was relatively uncommon. We get a sense of how his thinking about psychiatry shifted during his time in Changi. Remember, everything was about survival, nutrition and the closest of clinical observations. Like all doctors, when a patient died Cade undertook an autopsy, something that most psychiatrists these days would struggle to contemplate let alone undertake. But Cade saw himself first and foremost as a general doctor and psychiatry was its offshoot. So physical care for him was always as important as psychological care.

In his memoirs, he describes cases which clearly impacted upon his psychiatric thinking. One was a young man who presented to all the world as if he was manic. Suddenly he dropped dead and Cade sought to find out why. At autopsy he found a massive subdural haematoma. Although he does not quite articulate it, the manner in which it is described suggests to me that he started to think about physical causes for apparent psychiatric illnesses. And for someone who liked and was good at physical medicine, it was not a big step to think of psychiatric illnesses in the same way as physical illnesses. That is, to see them as having an underlying biochemical, or physical cause. There was another case where a young soldier presented with what seemed like hysteria. Again, after unexpectedly dropping dead, John Cade found that the soldier had an undiagnosed demyelinating illness. After the war, those who knew and worked with Cade remembered this last case (and others like it) as having had a decided affect upon him. Thus, in the decades after WWII, he would rail against the diagnosis of hysteria, often claiming that if a doctor looked hard enough a physical cause would be found. Whatever the rights or wrongs of his thinking, when the Americans dropped two atomic bombs – Hiroshima on 6 August, and Nagasaki on 9 August in 1945 – and the war came to an end, John Cade’s thinking about psychiatry had altered. He later claimed that no specific hypothesis formed in his mind about the aetiology of psychiatric illness during Changi, but rather it was a time when ideas were tossed about in his creative mind, marinating over three and half years, until the return home to Australia.

On his way home from war he wrote a letter to his wife including what must be one of the most prescient paragraphs in the history of psychiatry:

"Then to work – as you guessed in one of your early letters the old brain box is simmering with ideas. I believe this long period of waiting has allowed many of my notions in psychiatry to crystallise, and I’m just bursting to put them to the test. If they work out, they would represent a great advance in the knowledge of ‘manic-depressive’ insanity and primary dementia – sounds like my usual over-optimism, doesn’t it?! Well, there is only one way to find out – test it and see."

Where did John Cade find the lithium which he used in his guinea pig experiments?

We are not certain of this answer. Indeed, when his results became more widely known a psychiatrist in Sydney wrote to Cade asking him this very question because the Sydney psychiatrist was unable to source lithium. It is quite possible that there were lithium preparations in the mental hospital pharmacy. We are all aware that lithium was used for a variety of ailments (e.g., gout) from the late nineteenth century onwards. So lithium in different forms was available for much of the first half of the twentieth century. John Cade would undoubtedly have been aware of the use of lithium for these illnesses.

Although John Cade called himself a ‘lone wolf’ when it came to research and that he was wary of telling too many people about his work, he did have people upon whom he relied. Most importantly, he relied on Dr Catarinich, a long time friend and mentor. Dr Catarinich was head of Victoria’s mental health service. Dr Catarinich assisted Cade with chemicals and equipment. So it is quite possible that this was his source of lithium. But exactly in what form John Cade found his lithium is unknown.

What was John Cade’s reaction towards lithium therapy after the death of his first patient?

This, of course, was a terribly important area to cover when we wrote the biography. While researching the book, I was struck by Cade’s reaction to his first patient (Bill Brand) during lithium therapy. Although lithium was given to 10 bipolar patients, Bill Brand was the first and clearly the most important for John Cade. So when Bill recovered from mania, John Cade was ecstatic. He knew he hovered on the edge of a remarkable discovery. But when Bill stopped his lithium and relapsed, I sensed urgency in John’s description of how to get Bill well again. Partly this would have been to help his patient, but, undoubtedly, partly to prove again the value of lithium. And while Bill did improve, there was a long period of waxing and waning. Cade increased lithium to toxic levels (unbeknownst to him) and then reduced them, only to increase them again trying to improve his patient’s mental state.

When Bill dies it is a tremendous blow to Cade. It was at this point I wished that John had kept a personal diary into which he could spill his soul. But no. So we relied on Cade’s clinical notes, his manner and his behaviour afterwards. When John Cade fronted the coroner, he was scrupulously honest about the cause of death. I was most curious about this aspect because there is always a tendency to shape the evidence to put oneself in the best light. Rather, John Cade told it as it happened. I thought this pretty courageous.

My own view is that John Cade for a period of time did shy away from lithium. In fact I think this is clear. Unfortunately, we don’t have Cade’s own views of this period, so we are left to speculate. But those who knew him at the time, including Sam Gershon, John Cawte and others, record John Cade’s reluctance to use lithium. It is true that John Cade went on to further clinical and administrative duties, and had little time for research, but I don’t think that fully explains why he never did more experiments with lithium. I never saw John Cade’s early reluctance to continue to use lithium as a criticism, but rather as an understandable reaction from a man, a doctor, to the death of a patient for whom he had known closely over years.

This brings in the other key people in Melbourne. When I think of lithium therapy, while I have the John Cade story at the helm, it is clearly a discovery that can and should be attributed to multiple people. Melbourne post-WWII was an interesting place in many ways, although as Lisl Gershon (the wife of Sam) said in one of the most wonderful interviews I did, back then Melbourne was overly British and very WASPish. In other words, it could be a tad boring. No doubt. But refugees and migrants had been pouring into Melbourne from before, during, and now after the war. And it is the next phase of discovery – with Edward Trautner and Sam Gershon – that starts to mark out a modern Australia.

‘Blind spots’ for John Cade?

Barry you suggest that one of Cade’s blind spots was his attitude to the work of Edward Trautner? This was only one of several ‘blind spots’ where we struggle to know what John Cade thought.

One of the most mysterious for me was the death of his first patient. When John Cade starts to gain publicity for his work with lithium, the recovery of his first patient – Bill – becomes the flagship of the discussion. Interestingly, Cade did not mention that this patient, while making a stunning recovery, also died afterwards as a result of lithium toxicity.

So what was going on? All the evidence I found was that John Cade was an upright man. Indeed, when his first patient – Bill Brand – died, he was compelled to present his clinical treatment before a coroner. If you have even been witness to this type of grilling, then you might appreciate that he may have attempted to present his work in a manner that absolved him of any guilt. Instead he presented his clinical care with a remarkable clarity and did not flinch from the truth. So I think it is unlikely that in later life, decades after Bill Brand’s death, that John Cade would in any way try to obscure or hide this death. For me, it may be simply that newspapers and magazines of the day thought it wise not to delve into this death in case it detracted from an otherwise stunning accomplishment. Perhaps Cade did mention it to some journalists, but it was not included in the published accounts. It is hard to know for sure. I also wonder if, having taken so long for lithium to gain acceptance, that John Cade was disinclined to resurrect something that might (in the popular press) be unduly criticised.

John Cade’s attitude to Edward Trautner?

As a biographer, historian and psychiatrist, my discovery of Trautner was one of the most revealing moments of the research. He should be known by all Australian psychiatrists (and beyond) but is not. Indeed, recently I spoke to a well-known expert in bipolar disorder and we chatted about the book Finding Sanity and the role of John Cade and lithium. Almost nonchalantly I dropped in: "And of course there was the marvellous work of Edward Trautner." I knew immediately by the nonplussed look of the professor in front of me that he had never heard of Trautner. So I told him about this remarkable refugee to whom Australia owes a great deal. Trautner is every bit a part of the lithium story as is John Cade. Indeed, in my mind, I immediately think of "Trautie" when I think of lithium. Sam Gershon and his wife Lisl have the most affectionate memories of ‘"Trautie." Lisl’s description of Trautner as kind of bohemian version of the Star Wars character Yoda has me laughing and thinking of Yoda leaning back, blowing clouds of cigar smoke and reminiscing about the early days of lithium. But what of Cade’s relationship with Trautner? Well, there is clear evidence that John Cade was aware of Trautner’s early lithium experiments. And we know that he had some direct communication with Trautner. But equally John Cade did not work with Trautner. Cade was in the mental hospital system, and rapidly consumed by administrative and clinical work in the early 1950s, while Trautner was at Melbourne University working on lithium and developing a close working relationship with Sam Gershon.

My interviews with Sam Gershon underscored the disconnection between the world of John Cade in the mental hospital and that of Trautner’s university world. Whether Trautner courted John Cade to work with him is unlikely; as it seems just as unlikely that Cade courted Trautner. Was there professional jealously in either direction? Not that I found in the archives. Rather the two men seemed in different worlds. But surely Cade was curious about Trautner’s work. Yes, we have evidence that Cade was curious. And Cade must have felt pleased that lithium was being vindicated.

The final point you ask me, Barry, is why did John Cade laud Schou but seemingly ignore the work of Trautner and Gershon. The simple answer is I don’t know. Sam mentioned to me (and I am sure he is more than able and willing to expand on this) that the relationship he had with John Cade was not a close one. Perhaps personal enmity was at play. Sam is best placed to speak to such matters. Interestingly, in the early days John Cade was not convinced about the need for serum levels of lithium. This may seem odd and, we now know, misplaced. But you have to understand that John Cade was a brilliant clinician. Everyone who knew him considered him a sublime bedside doctor. I imagine (as is often the case with first-rate clinicians) that he placed too much emphasis on his clinical skills as against the need for biochemical monitoring. In the end, Trautner's and Gershon’s contribution to the story of lithium was and is a lasting one.

I don’t know why John Cade never alluded to Trautner in his interviews. As I have mentioned earlier, the interviews were usually for newspapers and magazines, and it is possible that these areas were skipped over. But John Cade did, himself, write about lithium in the last decade or so of his life. And one might have thought Trautner and the Melbourne University work would have figured prominently. Generally speaking, John Cade was a remarkably down-to-earth, practical man, and he gave credit where it was due. I do not think John Cade was one to artificially elevate himself if he felt it was not justified. So we have a mystery. Why didn’t he more openly acknowledge or talk about the work of Trautner? As a writer and historian, I can only bemoan that a historian did not sit down and go over this remarkable story of discovery with John Cade before he died, and do so with the kind of care and scrutiny it deserves.

Who deserves priority in the discovery of lithium for bipolar disorder?

The most important thing to say is that numerous figures were of great importance. But I know that you will press me on this so I will continue.

For me this is pretty easy. Of all the key figures in the story of lithium’s discovery, John Cade stands in clear relief. Not because he did everything. Clearly he didn’t. Not because everything he did and claimed was correct. It wasn’t. For me he stands in clear relief because he came back as a POW after nearly four wretched years at the hands of his Japanese captors. Somehow in that crucible of despair he hit upon an idea that later led to an unlikely trial of lithium. And he chose a man, Bill Brand, another ex-soldier, cast aside by the doctors of the time as beyond help. The discovery of lithium is a timeless story. Its appeal is way beyond anything to do with science, though science is at its heart. It is a story that should be known by every person who professes an interest in medicine. It should appeal to anyone interested in stories of hope and resurrection of the human spirit. Lithium may not have lasted as a therapy without the important contributions of many other people, but just as assuredly, without John Cade the names of those other people would not be on our lips.

June 1, 2017