Abstract
On 29 March 1948, at Bundoora Repatriation Hospital in Melbourne, a 54-year-old male patient, W.B., started to take lithium as a treatment for his chronic manic symptoms. On 1 May his treating doctor, John Cade, wrote: ‘there has been a remarkable improvement in the last few weeks. He now appears to be quite normal – a diffident, pleasant, energetic little man’. This improvement, in a man with a manic illness of at least five years’ duration, marked the beginning of present-day clinical psychopharmacology, lithium preceding the use of chlorpromazine by some four years.
This therapeutic milestone and the importance of lithium in current psychiatric practice makes it worth while reporting in more detail the case history of John Cade's first lithium patient. In his paper ‘Lithium Salts in the Treatment of Psychotic Excitement’ published in the
The first record of the chronic manic illness for which he received lithium in 1948 begins on 20 September 1943 when he was taken to a Repatriation Hospital by the police — ‘he is very restless, does not sleep, is loquacious, irrational and talks from one idea to another’. The next day he was transferred to the Bundoora Psychiatric Hospital at which he was to be a patient until his death in May 1950. His admission notes record ‘he is excited, restless and garrulous. He is oriented in all spheres. Shows flight of ideas and is irrational in speech. His memory for recent events appears to be defective, and though he remembers his regimental number, his rank and his battalion, he cannot give much of an account of his military career. No definite hallucinations or delusions, but he has some idea that birds, or beasts can bring messages and he says he sometimes hears the voice of his father (deceased) in imagination. Physically his health is below par. His pupils are equal, and react to light’.
Three days later the notes record ‘his behaviour is now definitely that of a case of mania. Though so far there are no physical signs of GPI, the possibility of this must not be lost sight of.
Three weeks later ‘his mental condition has shown no change for the better, it is perhaps more maniacal than on admission’. On this date a blood Wassermann was reported as negative.
The next note that refers to his mental state was made on 24 February 1946 by John Cade (as were all subsequent notes. ‘His mental state has remained unchanged over the last two years. He is chronically euphoric: excitable, restless and has no power of concentration whatever; so lacking even momentary attention that questions usually fail to interrupt his flight of ideas. He is dirty and destructive; noisy both day and night. A rubbish gatherer and petty pilferer. Frequently impulsive, occasionally his energy finds outlet in mowing the lawn in the airing court. On physical examination he is thin and edentulous but appears in good physical health.’ One month later ‘the mental state had not improved’.
On 29 April 1946, W.B. was given ECT. One month later Cade wrote that W.B. ‘has had nine ECT treatments. Remarkable improvement. He is now quiet, clean and tidy in his appearance, well behaved and an excellent and willing worker, contrasting strongly with his previous restless, destructive, interfering state a few weeks ago’.
He maintained this improvement for four months and was sent on leave to a holiday home. However, on 17 September he was described as being ‘euphoric, restless, destructible and flight of ideas. Has evidently been a great nuisance at home and in the neighbourhood for the last few days’.
Ten days later ECT was recommenced but a month later, and after five treatments, it was noted ‘he seems to have reached his mental optimum with this sort of treatment — but still rather uncertain and lacking in judgement’.
One month later it was recorded that ‘he has been slowly deteriorating, becoming more restless, untidy and erratic’. Two months later his mental state was no better. One year later in December 1947 the notes describe W.B. as being ‘in a state of chronic mania all this year’.
On 29 March 1948, lithium citrate was commenced gr. 10 t.d.s., then after a few days increased to gr. 20 t.d.s. and after a few more days to gr. 40 t.d.s. ‘He commenced to vomit with nocturnal enuresis but his mental state was improving. Dosage reduced and replaced with lithium carbonate gr. 5 b.d.’
On 1 May the notes read ‘remarkable improvement in the last four weeks. He now appears to be quite normal — a diffident, pleasant, energetic little man’.
On 9 July the improvement had been maintained and he was discharged on ‘indefinite trial leave’ and later that month he was reported to be back at work at his old firm taking lithium carbonate gr. 5 b.d. In September 1948 it was noted that he was ‘very well mentally and continues at work’. In November the notes state that ‘he was well and working but had stopped his lithium 6 weeks previously’. A few days later a letter from a son-in-law describes how W.B. had become excitable and argumentative after a trivial row. W.B. was written to and lithium restarted but he did not take this regularly and the notes state that ‘relatives say he has been irritable, sleepless and restless and they do not think he is taking his medication regularly, if at all. On examination he was not too bad. Rather garrulous, mild distractability and flight of ideas, consequently his account of himself is unreliable. He was restarted on lithium carbonate gr. 10 t.d.s.’. A week later the notes state ‘no improvement so far. Quite well behaved and not euphoric or restless, but erratic with flight of ideas’. Five days later ‘he appears considerably more settled but there was some retching. He is more settled and doing useful odd jobs’.
Four days later he was described as being ‘approximately normal and his lithium carbonate was reduced to gr. 5 t.d.s.’. Two days later he was considered ‘normal again’.
Over the next month he continued well with occasional biliousness. Then he became erratic and restless and the lithium was increased. A few months later he was allowed home and he remained well for a further three months.
On 25 August 1949 ‘he was mildly depressed and found work too hard. He looked thin and cold’. A month later vomiting was occurring regularly and the lithium was stopped for a few days.
In October the patient was sure the ‘medicine’ was disagreeing with him and took it only under protest, so it was discontinued. Eleven days later ‘flight of ideas became evident’ and three days later he was described as being ‘at his best manic manner, restless, euphoric, mischievous, erratic, his dyspepsia quite forgotten’. Lithium carbonate gr. 10 t.d.s. was recommenced. Five days later he had settled, so the lithium dosage was reduced. He became noisy, restless and euphoric so the dosage was increased with improvement over three days.
In November the notes state he was ‘very erratic and restless. Amount of salt in the food to be reduced — it may be interfering with the efficiency of lithium’.
Later that month W.B. was described as ‘noisy and mischievous as ever. It is probable that he is not taking his mixture’. Four days later the notes state that he was ‘saturated at last – mildly tremulous and ataxic this morning. Subdued and lachrymose occasionally. At other times very bright’.
In March 1950 it is stated that W.B. ‘still complains of dyspepsia, anorexia and vomiting. Still bradycardia’. The lithium was discontinued. ‘Under all circumstances it seems that he would be better off as a free restless case of mania rather than the dyspeptic, frail little man he looks on adequate lithium’. Two weeks later the notes state ‘he was rapidly reverting to his manic phase and forgetting his dyspepsia’.
On 3 May the following description occurs. ‘He has continued manic, restless, euphoric, noisy, dirty, mischievous, destructive, flight of ideas and thoroughly pleased with himself. His state seems as much a menace to life as any possible toxic effects of lithium. Therefore recommence lithium lithium citrate gr. 20 t.d.s.’. A note on 19 May states ‘quieter but miserable and asthenic. Put to bed and lithium discontinued. He became semicomatose and had two partial and one complete major fit’. He was treated with I.M. Iuminal and given nutrition by gastric tube. Two days later W.B. is described as ‘in extremis, skin breaking down, myoclonic twitching noted. Died that night’.
‘Causes of death (clinical):
toxaemia due to lithium salts, therapeutically administered inanition chronic mania’ No autopsy was performed.
Previous history
W.B. was born in 1895 and enlisted in the Australian Light Horse in July 1916. He went to England by troop ship but on arrival at Plymouth was transferred to an isolation hospital in Salisbury with a diagnosis of ‘cerebrospinal fever (mild case)’. He stayed in hospital for three months and returned to his depot. However, disturbances were reported. ‘He has periods of permanent excitement… He lacks comprehension… He does not remember much at all’ were three separate notes.
He was returned to Australia in July 1917 and a medical officer on the hospital ship noted: ‘This man is suffering from dementia and should be under control’. Later that year he was discharged from the army as medically unfit.
In August 1918 when aged 24 years ‘He took a motor from Melbourne to Bendigo, regardless of cost’, and a few days later he was admitted to a psychiatric hospital, where he stayed for five months. A diagnosis of ‘adolescent mania’ was made. He was seen regularly each year in order to assess any disability resulting from his army service.
For the next 10 years, though he made some complaints at these regular attendances, he remained at work and married (though his wife eventually left him because of his behaviour). In 1929 he was described as ‘rational and though mildly euphoric has no mental disorder’. In 1930 he complained of headaches and difficulty in sleeping. In 1931 he was admitted to hospital where he was described as ‘run down and sleepless and was kept in bed, but on Monday night he went to the picture show, and, clad only in his pyjamas, sang to the audience. He is loquacious and boastful’. He was not in hospital long and returned to work.
Two years later he tried to buy a car which ‘he couldn't pay for and is excitable’. One year later (in 1934) he was admitted to a psychiatric hospital for some months with a diagnosis of ‘melancholic depression with retardation of thought and cerebral inhibition’. This was his only hospital admission for depression. In 1936 he was ‘very erratic mentally’. Two years later he was described as ‘not well, worrying about his mother’. In 1939 he was described as ‘quiet and well behaved’, but in 1941 the note stated ‘He is cunning and loquacious. He says ‘life is sweet’. He is strange but not certifiable’.
Two years later he was admitted to hospital and, as described, remained there with chronic manic symptoms, relieved for a period with ECT and eventually responding in the way described with lithium but dying of presumed lithium toxicity.
Footnotes
Acknowledgements
I am grateful to Professor Harold Atwood, Curator of the Medical History Museum, University of Melbourne, for access to John Cade's original cards; to Dr Fiddler, Superintendent of Bundoora Repatriation Hospital for the case records of W.B.'s last five years of illness, and to the Repatriation Commission for providing access to his medical records from 1916.