 
Mending the Mind

A Short History of Twentieth Century Psychiatry

J. F. J Cade

A.O., M.D., F.R.A.N.Z.C.P., F.A.P.A.

Formerly Professorial Associate University of Melbourne,

Dean of the Clinical School and Psychiatrist Superintendent,

Royal Park Psychiatric Hospital, Melbourne.

Copyright 2015: The Trustees of the Estate of the late J. F. J. Cade

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Table of Contents:

Foreword

The Nature of Psychiatry

Mental Hospitals in 1900

What Causes Insanity? Masturbation Madness, Syphilis (GPI)

The First Milestone: Malarial Treatment of Syphilis

Schizophrenia: the Unsolved Riddle

Convulsive Therapy

Largactil for Psychotic Exhaustion

The Conquest of Epilepsy

Highly Controversial: FCI and Leucotomy

Depressive Illness

Out of the Ground: Lithium

Anxiety: the Universal Fate

Mental Deficiency

The Great Thinkers

Today and Tomorrow

Afterword

About the Author
Foreword

The author of this book is known to the international medical world as the man who introduced lithium into psychiatry. He discovered the beneficial effects of this compound on patients suffering from psychotic excitement, in particular those suffering from manic episodes of manic-depressive illness. That happened in 1948-49 and was the start of modern psychopharmacology, preceding by three to four years the introduction of the much more publicized tranquillizing drugs. For his distinguished contribution to psychiatric chemotherapy John Cade has received the Order of Australia and been given a number of coveted scientific prizes and awards.

In the present book Dr Cade speaks as the experienced physician rather than as a scientist. With broad strokes he paints a canvas which shows the advance of physical treatment in psychiatry during the twentieth century. His own work with lithium is mentioned in the context of the other major discoveries.

The book is packed with observations and information. It is also delightfully personal and entertaining, its lines being punctuated with illustrating and often humorous details. Compassion with the mentally ill is one of its guidelines. Another is fascination with the history of medical discovery. As one of those who became part of that history John Cade tells a tale that cannot but inform and engage.

Mogens Schou, M.D., F.R.C.Psych. (Hon.)

Professor of Biological Psychiatry and Research Director

The Psychopharmacology Research Unit, Aarhus University Institute of Psychiatry, Risskov, Denmark
The Nature of Psychiatry

In the most general terms, psychiatry is concerned with anyone who arrives on the psychiatrist's doormat. Psychiatry is about patients, people.

What sorts of problems do they present with? There are five categories of patients: those who suffer from defective cerebral development, the intellectually handicapped; those with demonstrable brain damage and its resulting behavioural deterioration; those with illnesses that are biochemically determined without demonstrable cerebral structural change – such as manic-depressive illness and perhaps more dubiously schizophrenia – but which are clearly illnesses in the traditional medical sense; those who react to environmental stress with either psychological symptoms – these suffer from so-called neurotic illness – or with bodily symptoms – the 'psychosomatics' (this is a purely theoretical distinction, a matter of emphasis, because it is in fact impossible to react mentally without reacting bodily and vice versa); and lastly a vast, ill-defined array of patients, almost always young, who are exhibiting socially maladaptive behaviour. It is this group particularly about which most modern controversy rages. Are they sick in the medical sense or are they maladapted in the sociological sense? The answer is that their condition reflects an element of both. Some are clearly victims of their inborn temperament ('cyclothymes', described later in depressive illness); their behaviour is largely symptomatic of their mood swings. Others are the product of their unfortunate environment and upbringing. While the psychiatrist is essential in the treatment of the former, he is no more successful than many other treating agencies in the management of the latter.

Next it might be useful to outline what psychiatric treatment really is. What goes on when a patient is admitted to an acute psychiatric ward, or seen as an out-patient?

Firstly, there may be general medical treatment, which is sometimes of an extremely urgent nature; this is frequently the case with in-patients, for it must be realized that a distinct proportion of such patients are seriously physically ill and that their mental aberration is secondary to their bodily infirmity. For this reason alone a psychiatrist must be medically trained. In such cases he is a physician first. Even amongst out-patients sent for consultation the occasional medicopsychiatric emergency arises. A middle-aged man, an orderly at a teaching hospital, was referred for treatment of his anxiety state. Certainly he was anxious and tremulous, and had lost a great deal of weight. But his pulse was irregular and too rapid to count, and he had a diffuse swelling in his neck. He was promptly referred back for urgent treatment of his thyrotoxic cardiac failure.

Many patients initially are very disturbed and require sedation, tranquillizers and not infrequently, even now, electroconvulsive therapy (ECT). This may be categorized as physical psychiatric treatment.

In others, psychotherapy is indicated. There is a vast range of theories and techniques in this area, whether the therapy be with or without the aid of drugs, individual, or in groups.

It may seem reactionary to refer to spiritual therapy, but occasionally the patient's distress is due to spiritual turmoil. Even the agnostic psychiatrist is lacking in sophistication if he fails to discern this. In these cases he should abdicate psychotherapeutic primacy in favour of the hospital chaplain. To tell of a rather extreme case: a poor woman was admitted to hospital in a state of despairing agitated depression. She was an obvious candidate for ECT and antidepressants. But when time was taken to listen to her story, it revealed a tragic, if faintly ludicrous situation... Two years previously her favourite brother lay dying, and the family invoked the aid of a spiritual healing group. The brother died but the family was converted to the extreme tenets of this faith. They were told, 'Down with the demon drink or you are damned to Hell fire'. The patient admitted that they enjoyed an occasional glass of celebratory wine, but this was an easy command to obey. Then they were told, 'Television is the work of the Devil'. They sold their set although this was rather a wrench. Then came the final command: 'Smoking is sinful. Smoke and you are damned'. With bitter tears of despair the poor woman sobbed, 'I can't give up smoking'.

The psychiatrist wisely thought that at this point he should opt out as primary therapist. In short the hospital chaplain did an expert job in restoring the poor soul's perspective, and rescued her from her anguish. It is well to ask what, in a case like this, ECT or anti-depressants would have achieved, although initial observation might have indicated their use.

Although such extreme examples are rare, spiritual problems of a lesser degree often trouble patients. The chaplain is thus an integral member of the therapeutic team.

The most important person in the patient's eyes and in reality is the nurse. She (references to 'he or 'she' are used for convenience and may be interchangeable) is, as it were, the final common path of all treatment, the adviser, the confidante and the support of the patient. She is the person who enjoys, or in troublesome cases endures, the most prolonged contact with the patient. Not only must she be a skilled observer, recorder and technician, but also trained and empathetic in human relationships. The doctor may enjoy more prestige in the patient's eyes, but he is more remote. The nurse is immediately accessible and available.

Devoted nursing – that is, the kind of loving care, not necessarily skilled, that a daughter might be expected to show towards her aged parent, or a mother her infant – is essential in the case of the totally dependent, whether they be the aged, the physically infirm or the profoundly mentally defective.

The psychiatric social worker may turn out to be the most important person therapeutically, especially with those patients who are the victims of environmental adversity that can only be rectified by knowledgeable intervention before, during or after hospitalization. Who is to care for children whilst their mother is in hospital for much-needed treatment or rest? What are the family dynamics? What about unemployment or sickness benefits? What are the retraining and re-employment possibilities and practicalities?

Then again a patient may be successfully treated for his illness but suffer the demoralizing effects that hospitalization, especially when it is involuntary, tends to have. As a result of this he may be socially incapacitated and require the skills of the occupational therapist in training or re-training in social competence and confidence.

Lastly, the young mentally handicapped must be trained to make maximum use of their limited capabilities. This is the task of special remedial teachers and trade instructors.

That, in summary, is the totality of psychiatric diagnosis and treatment.

This is, for the most part, the story of end-of-the-road psychiatry, of mental hospitals and the rejected ones detained therein: the chronically insane, the grossly defective and the irreparably brain-damaged. In this field there have been greater advances in my own professional lifetime than in all the previous ages of mankind. This book is an attempt to document concisely and accurately these milestones, these discoveries – who made them, how they came about and what effects they have had on this branch of medicine and the patients who have requested or been committed to our care. The expression 'branch of medicine' is used advisedly and with emphasis: psychiatry is not psychology, whatever use may be made of psychological theory and practice as aids to therapy.

My emphasis will be on the prevention and treatment of psychiatric disorders which are very much illnesses in the traditional medical sense, whether they are due (like general paralysis) to a demonstrable brain pathology or whether they are not (as in the case of manic-depressive illness).

The conquest of both types of disorder has been purely a triumph of medicine. From a position of almost complete therapeutic impotence at the beginning of the century, psychiatry has leapt forward. Of course there are problems, and massive ones, still to be solved. It would be stupid to even hint otherwise. There remains the great riddle of schizophrenia. Certainly major advances have been made in treatment which, strangely, is far in advance of a real understanding of its essential nature, or of even whether it is a single disease process or a series. The position is analogous to the use of quinine in the treatment of fevers before the discovery of the malarial parasite and the realization that it is specific for the fever of malaria alone.

The history of discovery in whatever field is always exciting, whether it be that of Columbus and the New World, or of Leeuwenhoek and his microcosmic 'new world'. Discovery is usually compounded of 10 per cent inspiration and 90 per cent perspiration. When Edward Jenner consulted the great John Hunter about his idea that vaccination would protect against smallpox, Hunter simply replied: 'Don't think. Try.'

Having lived through this era of fundamental advances, been enthralled by them both as a spectator and a participant, it is my ambition to convey to others something of that joy, excitement and satisfaction.

Advances have come from many lands. Wagner von Jauregg was an Austrian, Meduna a Hungarian, Deniker French, Putnam American, Moniz Portuguese and Gregg Australian. It would be impossible to predict from whence or from whom the next leap forward will come.

There must be many and regrettable omissions, conscious or otherwise, which will no doubt bring rebuke. I have said nothing about psychotherapeutic theory and practice, and for a very simple reason. This book is the story of the advance of knowledge in one particular area. It does not pretend to be a treatise on human wisdom, in which field the last significant advance, many would say, took place nearly 2000 years ago. Quite bluntly, I do not think we as psychiatrists are any better at helping people solve purely human problems of the heart than man has ever been. I have also made but passing mention of the great psychiatric systematists and theoreticians, being concerned with the story of discovery rather than with speculation.

This is not a treatise of psychopharmacology, although various major drugs are frequently mentioned, along with something of their actions, uses and effects upon psychiatric practice.

No apologies are made for the frequent references to the practice and state of psychiatry in mental hospitals in Victoria, and especially at Royal Park, a principal admission centre for adult psychiatric patients from the city of Melbourne since 1907 and a special teaching hospital affiliated to both Melbourne and Monash universities. These have been the venues of the whole of the author's professional life, places with which he can claim a very intimate knowledge. I believe they accurately reflect the changes, both good and bad, which have taken place in the theory and practice of psychiatry throughout the western world in this century.
Mental Hospitals in 1900

At the turn of the century patients with mental illness were stigmatized, confined and institutionalized. The stigma of insanity was a very real, widespread and dreadful concept in the minds of most men. It conjured up visions of violent and dangerous lunatics to be locked away for life (for the safety of the community) in institutions preferably decently removed from centres of habitation. Maximum security was deemed necessary: the hospital to be surrounded by a ditch and a high wall, the gates locked and guarded, the windows barred, and peep holes in cell doors so that attendants could see that patients were up to no mischief.

Staff naturally were more enlightened than the public. They knew that there were 'good' patients as well as 'bad'. It was necessary at each change of shift to list the 'bad' ones for the benefit of oncoming staff. The violent, dangerous, destructive, epileptic, suicidal and incontinent all received honourable mention. There was also the persistent absconder, for what patient, with an ounce of initiative, would not attempt to escape? Stories are told of an attractive young woman who used to take off over the ward fence, first stripping naked, especially when handsome young medical students were doing ward rounds. She recovered from her psychosis, only to relapse several years later. However, this time there was no challenge: the fence had been removed from the ward garden. The incentive to such exuberance had disappeared. She remained quietly until once again she had recovered.

In those days there was a ward at Sunbury Mental Hospital with the formidable and fearsome name of the 'Female Refractory', housing the most difficult and violent psychotic women in the whole of Victoria. The worst was an awesomely strong young woman who, every time the garden gate was unlocked, would make a frantic dash for freedom, staff tackling her from all directions. A new superintendent of the hospital arrived, a progressive man, who believed in the Open Door policy insofar as it was practicable at the time. On his first morning round he witnessed this remarkable phenomenon and pondered it. The next morning he unlocked the gate and motioned the staff aside. The distraught one bolted through and disappeared over the horizon. He remained phlegmatic and calmed the staff. Ten minutes later the poor soul wandered sheepishly back. She really did not know where she wanted to go, nor what she wanted to do. There were no problems thereafter.

There were also the rubbish hoarders; understandable in that most patients in chronic wards (and most wards were chronic) were permitted little or nothing in the way of personal possessions.

'Good' patients were encouraged to assist in the wards by polishing and scrubbing floors, making beds, washing foul clothes and bed linen, and helping in the kitchen and dining room. The really trusted were given the freedom of the grounds and would often work in the hospital artisans' shops (the bootmaker's, tailor's, carpenter's or painter's), the gardens or the farm. In the larger institutions there was nearly always a 'Farm Workers Block' for the men and a 'Laundry Workers Block' for the women.

This organizational pattern led to the expression 'asylum sane'. Such patients were employed in a variety of useful roles which they enjoyed. Some were quite erratic in behaviour or dress, many highly delusional, but all harmless and most amiable, although some were solitary and irritated by intrusion into their self-imposed isolation. When monarchy was a romantic institution, there were always a few kings and queens among the patients, rightful heirs to this or that throne and deprived of their birthright only by the machinations of their enemies. These grandiose ideas did not prevent them from cheerfully accepting the most humble tasks. All were respected and understood within the sheltered environment of the asylum. They could not possibly have survived in the harsh, demanding and critical world beyond its walls. And that, of course, is what asylum originally meant, a place of refuge and succour, however debased the word has now become.

From time to time, it has been ignorantly and maliciously claimed that such patients were used as a 'slave labour' force. Certainly they were unpaid and usually received only token material recompense, such as an issue of tobacco or cosmetics; but the fact is that no patients are really contented unless they have some useful role in life. These patients contributed substantially to the welfare of their sheltered home and were happy to do so. It was always a therapeutic role, occasionally brilliantly so. At the very least it contributed to a patient's contentment and usually to a vast improvement in behaviour. At the best, the patient recovered sufficiently to leave hospital. John was one such case. He was a useless encumbrance in a chronic ward, constantly moaning about the mythical murder of which he imagined he stood accused. One day the patient who usually polished the floors fell sick and the nurse in charge, whether in desperation or with a stroke of inspiration, asked John if he would fill in. John not only did so, but continued his help on a regular basis. Soon he became less preoccupied with his delusional ideas and no longer buttonholed the medical officer on his daily round. Not long after, he asked if he could take a part-time job with a local farmer. As he became more immersed in positive roles, so his delusional ideas steadily receded and eventually vanished. He was eventually able to leave hospital never to return.

In another hospital, a mental deficiency institution, a thirteen-year-old epileptic girl was growing into adolescence and her behaviour was becoming impossible. It was seriously mooted whether she would have to be committed to an adult mental hospital despite her tender age.' Then came an epidemic of influenza which laid low many staff. They were desperately short of staff in the totally dependent patients ward. The matron asked the difficult teenager whether she would look after a bed-ridden idiot girl of seven. The thirteen-year-old did a magnificent job in nursing this child. But the miracle lay in the change in her own behaviour. She had achieved the ultimate in womanly dignity as a mother surrogate, and as a result, changed into a sweet and loving girl. So much for slave labour.

The stigma of insanity was compounded of a number of factors: the aura of incurability, which had more substance than shadow in those days; the deprivation – sometimes temporary, often permanent – of fundamental human liberties; incapacity to make a contract or a will; inability to manage one's own affairs; ineligibility to vote; no freedom of movement except within the limits mentioned and only with the consent and goodwill of others, and no say in whether treatment, such as it was, could be accepted or rejected. There was also the relative or absolute absence of personal possessions and the wearing of drab, shabby and ill-fitting hospital clothing day and night. Women wore tough blue-and-white striped galatea dresses, men moleskin trousers for routine occasions, often hitched up with string or a bit of rope. Braces or a real belt were sometimes hard to come by. Besides, you could hang yourself with them. At night women went to bed in a coarse shift and men usually in a shirt. What was the sense of pyjamas on an incontinent patient? The trousers would be only another unnecessary item of clothing to wash.

The usual sleeping accommodation was a main barrack-type dormitory with an iron-grill-protected fireplace at each end; there were three rows of beds, one down each side and a row in the middle – in over-crowded wards, beds overflowed into corridors and on to verandahs. Over-crowding in some wards has been a problem until relatively recently: at one mental hospital in Melbourne, not twenty years ago, the beds in a geriatric ward were so closely packed that it was impossible to move between them and patients had to clamber in over the foot of the bed. Off the main dormitory there opened a series of single rooms for the nocturnally noisy and restless. Much thought was given to the provision of night toilet facilities for these patients. They could not be allowed to go to the ward toilet block each time they hammered on the door in the small hours: there were too few night staff and they were probably only making a nuisance of themselves anyway. They could not be given a china chamber pot: it was too easily broken and used as a weapon of offence or for self-mutilation. On the other hand, it was undesirable to have them urinating or defecating on the floor, so pots there had to be. The two favourite models were one of light metal, either tin or aluminium, and the other of rubber. The first was not altogether suitable because with a little ingenuity the handle could be wrenched off and used as a screw-driver to force a door or window; besides, the container was quickly dinted into the most unfunctional shapes. Rubber was a distinct advance. You couldn't dint it and you couldn't brain anybody with it. The worst you could do with it was to empty the contents over the head of some unsuspecting nurse. But after a while and some ageing, these utensils developed a most fearsome stench of stale urine almost impossible to eradicate.

There were no seats on the toilets. This made them much easier to clean but was hardly an invitation to regular bowel habits on cold winter mornings. Then again, toilet paper dispensers were unknown. So was toilet paper. A torn page of newspaper had to suffice, if it was even thought worthwhile bothering to observe such gentility.

Ward bathrooms were models of austerity and efficiency. They were very large, usually with lead-lined floors; situated somewhere off-centre, standing on claw legs, would be an old-fashioned, enamelled, cast-iron bath, usually badly worn and chipped; there would also be one or two unenclosed corner showers. A horrible sight was the bathing parade usually held twice a week and compulsory of course. The whole long queue stripped, assisted or unassisted, and – generally in a well-lit area – were carefully examined in their state of utter nudity by the ward staff. They were inspected for bruises or other injuries, rashes, ectodermal parasites especially head, body and pubic lice, bed bugs in some wards, hernias and other external evidence of disease. Such would be brought to the attention of the medical staff for appropriate treatment. There was as much privacy as running cattle through a dip, but everybody took it for granted. Then they were paraded along to the clean clothing line. It was a case of first bathed, best dressed, but the staff used to make valiant efforts to achieve an approximate fit. There were so many variables, the very tall and the very small, the very fat and the very thin, the disturbed, the destructive and the incontinent. Little wonder that in spite of their best endeavours with what was available, some trousers ended up half-mast, some crumpling over patients' boots.

Usually the twice weekly purge was then administered – a cupful of 'white house', an Anglicized corruption of Haust. Alba. This was a nauseating preparation of Epsom salts flavoured with peppermint but with a taste impossible to disguise. It was made literally by the barrel-full in the hospital dispensary and issued to the wards in huge glass bottles.

Regular purging was considered necessary to avoid constipation, believed to be the root of all evil. All those horrid organisms multiplying in the large bowel and poisoning the system had to be eliminated or dire consequences would result. Medical opinion of the time – including that of the eminent English surgeon, Arbuthnot Lane (1856-1943) – was doubtless strongly influenced by Metchnikoff's theories of auto-intoxication from the products of the flora of the colon and partial and total colectomy for a variety of conditions was often advocated and performed.

There was, however, an even more rugged trial by purgation given to the really disturbed patient. This was two drops of croton oil on a lump of sugar. It was calculated to so preoccupy such a patient and flush out his system that he had no time to indulge in any other activities. It did and he couldn't. In the mid-twenties, an older colleague of mine – more enlightened than some – decided to test his suspicion that this procedure might be regarded as punitive rather than therapeutic. He tried it on himself. He was so prostrated for twenty-four hours that his suspicions were confirmed. He forthwith forbade its use in his hospital, a small but humanely significant advance.

A major cause of lay suspicion and repugnance was the common knowledge that physical restraint was practised in mental hospitals. Although abhorrent, this was absolutely necessary at the time. Straitjackets or camisoles were in routine use – certainly their use had to be medically prescribed, justified and recorded – for how else could you prevent a continuously and determinedly self-mutilative patient from harming himself? The sedatives at the time were only transiently effective, working only so long as they kept the patient asleep. He was incorrigible and incurable with the means available, and so had to be strapped into his straitjacket. Some even managed to outwit this preventive manoeuvre. The arms were sewn rigidly to the body of this stout canvas and leather jacket. One such patient sawed with his thumb-nail through the stitching and proceeded to enucleate his testis. Another loosened the jacket in the same way and, twisting and bending, managed to wrench off a big toe-nail to use as a gouge. With this he proceeded to lay bare his internal jugular vein until discovered in the nick of time. If you have a restless self-punitive patient whom you cannot prevent banging his head against a wall and injuring himself, what do you do about it? You put him in a locked padded helmet. And the constant picker at himself? Locked gloves. And the athletic absconder rushing for the fence each time your back is turned? Webbed trousers, which force him into a Parkinsonian gait and trip him if he moves too fast.

But of all the means of restraint and seclusion the padded room, always referred to by the press as a padded cell, has attracted most notoriety and is most commonly associated in the lay mind with asylums and lunatics. It has been used till quite recent times. It is even whispered that some enlightened hospitals, including university departments of psychiatry, still have them.

The padded room was, in its time, an inevitable invention. The floor and the walls (as far up as a man could leap) were padded with leather cushions, and if the room had an external wall, there would be a small barred window high in one corner. Confined therein, it was almost impossible to injure yourself or others. The only entry was by a horizontally divided, horse-stall-type door, the upper half of which had a small plate-glass observation window in it; both halves were secured by stout bolt locks. Who was confined in such a room? The dangerous, the violent, the destructive, the incessantly restless who were rapidly exhausting themselves. As it was hazardous for a staff member to enter one of these rooms alone to care for the disturbed one – whether it be for feeding, personal care or treatment, or to clean up the end results of incontinence – the usual team was two or three, and in extreme cases five or six, to give a much resented and resisted injection or tube-feed.

However necessary and humane padded rooms were, they were psychologically highly undesirable. This was least so for the poor distraught, oblivious person confined therein; but others, (that is: other patients, their relatives and visitors, and the general public) thought of them with awe and abhorrence. They saw them as the very symbol of all that was impotent and repressive in psychiatry. Their abolition was an important land-mark in the march to modernity, the occasion of much relief on the part of the public, but initially regarded with much dismay by the staff.

In mid-1953 it was announced that Royal Park (which, built in 1907-8 could only be described accommodation-wise as third-class Victorian boarding-house standard) was to be completely remodelled to bring it up to the very latest standards of hospital design. A vast new occupational, recreational and entertainment centre was built, and pathology laboratories, a modern school of nursing and nurses' homes were added later.

Simultaneously, it was decreed that the padded rooms, one for each male and female admission ward, were to be closed and never to be reopened. The reaction of the nursing staff was one of profound dismay. How could they possibly cope with grossly disturbed behaviour, they asked, without this essential therapeutic weapon? Without exception they signed a petition to the superintendent imploring him to reconsider his decision. He, however, convinced of the tremendous psychological advantages of abolishing them, stood firm: he was quite sure that the staff, a very competent team, could manage, especially if prompt ECT was prescribed for very disturbed behaviour. He, in turn, called upon the Chairman of the Mental Health Authority to support him. This was promptly given in a very positive directive. The result was interesting. Within a few months the staff were taking a new-found pride in their ability to manage the disturbed behaviour of their patients without recourse to what had been regarded as an essential management resource. Paradoxically enough this direction was not followed by all. At about that time a new ward being built in an institution in Melbourne outside the jurisdiction of the Mental Health Authority, was incorporating the very latest refinements in the construction of padded rooms!

Straitjackets quietly departed from the psychiatric scene at the same time. A few years later an extremely distraught lady was brought to Royal Park for admission, escorted by several rather dishevelled policewomen. The senior of these inquired with interest of the very calm sister in charge of the ward about what model of straitjacket was used at the hospital. The composed and attractive sister opened her wide blue eyes and asked innocently 'What are they?', unshackled the poor woman, talked to her confidently and quietly, then led her to bed for a much-needed rest.

And so physical restraint steadily disappeared from the scene.

The typical asylum smell would assail the nostrils of visitors to chronic wards. It was a complex sensation, a strange compound of many ingredients. The principal were chronic urinary and faecal incontinence – unbearable in their own right during an epidemic of dysentery – sweaty, unwashed humanity, stale cabbage and tomcat. It took many years to identify all the ingredients of this olfactory smorgasbord. Faeces smeared into keyholes posed a singular aesthetic problem, insoluble except by drowning it with Phenyle or replacing the lock. The latter was impracticable as the price was prohibitive and funds limited. Besides, it was only a twenty-four-hour solution.

Walls of corridors and all living areas, dining rooms, lounges and dormitories were almost invariably painted a deep shade of brown. It is unknown now whether this evinced a singular lack of imagination on the part of the Public Works Department, an oversupply of brown paint, or an ingenious attempt to minimize the more obvious visual effects of faecal smearing. Inevitably it became known as 'asylum brown'.

'Difficult' patients were common and, as already indicated, a tremendous management problem. Not only were there those with the heavy nursing problems of physical enfeeblement and incontinence (requiring constant prevention of pressure sores and urinary infection) but also the 'characters'. One such insisted on smoking in his single room at night to the peril of himself and the ward. There were always several cigarette butts on the floor in the morning despite the fact that he was meticulously searched each night. He defied the best endeavours of the nursing staff for many moons until finally one observant nurse solved the mystery. He surreptitiously watched the patient enter the toilet block late one afternoon, carefully pack the 'makings' into a finger stall and insert it into his rectum for nocturnal retrieval!

Another had a rectal prolapse of impressive proportions which she could protrude at will. This manoeuvre she used with maximum effect to bring the most hard-bitten nurse to heel, for it was an alarming sight, enough to provoke an urgent call for medical attention although, in fact, it was perfectly easily reduced. There was little elective surgery available in those days although some of the medical staff, especially those who had some background of single-handed country general practice, used to operate very successfully in the hospital operating theatre. They were excellent all-round doctors, not the super-specialists of the present era, some of whom even relatively fresh out of medical school are afraid to give a simple anaesthetic.

In the 'male refractory ward' of a country hospital there was a patient who suffered intermittently from severe bloody diarrhoea. It was at first thought to be acute bacillary dysentery. He was always promptly hospitalized, which was what he wanted, intensely investigated and tenderly treated. No offending organisms could ever be found and he would be returned, quite recovered, to the ward whence he came. Once again the correct diagnosis was arrived at by an observant nurse. The ward garden was surrounded by a cypress hedge and the nurse saw him nibbling considerable quantities of this immediately prior to his next attack. It contains a powerful bowel irritant. This was a more important observation than it might seem because there was in those days a high incidence of serious, indeed malignant infective enteric disease, the so-called asylum dysentery, especially in wards which housed dirty, incontinent, debilitated, disturbed, demented or mentally defective patients. As late as the 1930s it was still a major health problem. Clive Farran-Ridge who was the departmental pathologist and headquartered at the major Victorian mental hospital, Mont Park, at that time, has given in his annual reports (1) vivid if taciturn descriptions of these scourges and his valiant if unsuccessful attempts to combat them. In 1931 he referred to an outbreak of typhoid fever at that hospital and reported that 'acute colitis or asylum dysentery is still a very serious disease in the mental hospitals. During the year it was the cause of 12 deaths at Kew and 14 at Mont Park'. Two years later the death rate was twenty-six at Mont Park and thirty-three at Kew. He made huge quantities of anti-dysentery vaccine and practically all the patients were inoculated, but without success. Amoebic dysentery was also endemic at Mont Park in those years and deaths from tuberculosis were not uncommon.

So infectious disease was rife and a major cause of death. It was not until the sulphonamides became available in the late 1930s that asylum dysentery ceased to be the scourge it had been for generations.

Deaths from psychotic exhaustion were also common. Often the patients were initially strong young people, but so uncontrollable, sleepless and impossible to nurse that they would drift steadily into increasing exhaustion, inanition and dehydration, ending inevitably with death from terminal bronchopneumonia. With central heating unknown, these deaths were always higher in the winter. More will be said of this in a later chapter.

Dietary deficiencies were manifold. At Beechworth Mental Hospital, as late as the 1930s, ascorbic acid (vitamin C) deficiency, causing latent or overt scurvy amongst patients, was almost universal.

It was only in early 1938 that this was discovered. A new young medical officer was disturbed by the number of cases of extensive bruising he saw. He could not reconcile this with the story of nil or minimal trauma and became suspicious that unnecessary force was being inflicted by staff, or that they were concealing assaults by other patients. Not being naturally paranoid, he decided to seek explanations in other directions and quickly came up with the answer. He tested these patients for vitamin C levels and found they were grossly deficient. Even the men who harvested the hospital garden crops were as bad. Asked if they ever ate any of the fresh fruit or vegetables they picked, most replied in the negative. All the produce was taken to the hospital kitchen and thrown into the huge copper cauldrons where every thermolabile vitamin, and especially ascorbic acid, was very thoroughly exterminated. His alarming report resulted in the early appointment of a departmental dietitian and the virtual disappearance of vitamin deficiencies within Victorian mental hospitals ever after.

The only subsequent case (apart from acute thiamine deficiency amongst newly admitted severely alcoholic patients) that comes to the mind of the author occurred some years ago when a young man was admitted to Royal Park with a strangely distributed redness on both hands, the backs deeply red, the palms pale, with a strict equatorial line between the two zones. He had obviously also lost a great deal of weight. Questioned, he explained that his food was being poisoned and so he had drastically reduced his food intake and restricted his items of diet. As a result, he developed pellagra or vitamin B2 (niacin) deficiency, an almost unknown disease in Australia. He recovered rapidly with appropriate vitamin supplementation, but it regrettably had no effect upon his psychosis.

This, then, was the grim picture of hospital psychiatry at the turn of the century and well into the lifetime and memory of many still living. Mental illness has always been regarded by the public and politicians as a millstone around the neck of the community and has been treated as such.

Long periods of political apathy have been punctuated by episodes of press indignation and demands for Royal Commissions, but the net result over many years has been that programs and institutions have been starved of funds much of the time. Advances have come only as a result of the initiative of dedicated individuals, working within the general social context of abhorrence, distrust or indifference.

1. J. F. J. Cade, 'Clive Farran-Ridge, a Man Who Missed Fame by a Whisker', Medical Journal of Australia, 1 (1973), p. 1057
What Causes Insanity? Masturbation Madness, Syphilis (GPI)

In 1900 theories about the causes of insanity were many and various. Most appear ludicrous now, but perhaps, in time to come, our grandchildren will in their turn burst into peals of ribald laughter at our quaint ideas.

Masturbation was believed to be a prime cause. (1) Theologians and psychiatrists joined forces in inveighing against this 'evil and perversity'. It was regarded as a dangerous, degrading and debilitating vice. The admission register of the Royal Park Receiving House reveals that, among the first full year's admissions, masturbation was considered solely or materially responsible for just over 5 per cent of insanity in males and slightly over 2.5 per cent in females. It could apparently cause or contribute to almost any form of mental illness.

Clouston (2), an eminent physician and author of a well-known and widely read textbook of mental diseases, is well worth quoting as typifying attitudes at this time. He devoted a whole chapter to 'Insanity of Masturbation' and amongst other remarks made the following sage observations:

The causes of this are either an innate morbid strength of the reproductive instinct, or much more frequently an innate weakness of the controlling faculties, or a lack of inherent brain stability, or an incapacity of organic repugnance to what is unnatural.

The weaker and more nervous he gets, the more he indulges his evil habit, till the point of absolute breakdown of body and mind is reached. [Although masturbation is] lamentably common as a complication of almost every form of existing insanity... tending to aggravate mental exaltation, to intensify depression, to produce stupor, to lead directly towards mental enfeeblement, to make impulsive tendencies more violent... induces relapses and in some cases prevents the recovery of otherwise curable cases, there is a special form of mental disease in which masturbation is the chief cause ... it begins by an exaggerated and morbid self-feeling... Then comes a melancholic stage of solitary habits... hypochondriacal brooding, vacillation and perversion of feeling towards near relatives. Suicide is often thought of and often talked of, but masturbation makes most of its victims too cowardly to kill themselves. Then an acute attack follows, usually of a maniacal kind. This may end in recovery, or may run quickly into a dementia that is masturbational in character, being solitary, unsocial and subject to impulses, sometimes homicidal – a sort of masturbational hyperkinesia. With these mental symptoms there are usually well marked bodily signs of the disease. The patient is thin, pale and pasty, with a cold clammy skin, a haggard face, and an eye that never looks straight at you.

Describing a typical case history, Clouston refers again to this important diagnostic sign: He never could look one in the face. Masturbators seldom can'.

As for treatment of this diabolical disease: 'The general principles of treatment of masturbational insanity unquestionably are to brace up the youth bodily, mentally and morally'. He was a strong advocate of 'cold baths, tonics, games, family life and a course of bromide of potassium'.

He diagnosed and treated forty-six cases of masturbational insanity sent to the Royal Edinburgh Asylum over a period of nine years. Oddly enough, there has not been one such case admitted to Royal Park in over twenty-five years. Perhaps the disease has ceased to exist or the Australian population possesses greater virtue and self-control than the young male Scot; or is it faintly possible that it never existed at all except as the fantasy of a tyrannical and fanatically Puritan mind?

The possible evil consequences of sexual activity, whether 'normal' or 'perverse', seemed to weigh heavily on our Victorian forebears. An earlier author, Mickle (3) (1886), quoting a famous psychiatrist of the time in his chapter on the causes of general paralysis of the insane, writes: 'Dr. Maudsley lays stress on sexual excess as a fertile cause of G.P. [general paralysis] and chiefly that carried on by faithful married persons: that quiet steady continuance of excess for months or years by married people, which was apt to be thought no vice or harm at all.'

It is relevant to quote Mickle's views on possible causes of general paralysis. (There were no developments of any consequence in the twenty years between Mickle's and Clouston's publications – in fact the views expressed by Clouston in 1904 reflect precisely those of Mickle in 1886.) Mickle noted the 4:1 preponderance of male to female cases and added that in France 'the proportion of female to male cases is very much higher in the lower than in the upper social classes'. He quoted several explanations of the sex difference in incidence, a popular one being 'a prophylactic influence of the menstrual discharge in women'. The learned author's own opinion was that 'probably the cause...lies mainly in the greater moral shocks and mental strain to which the male is subjected, as well as the greater frequency with which he indulged in excess, especially alcohol'.

His second epidemiological fact was as follows:

I found the regiments of the Guards, the flower of the army, yield the highest ratio of G.P. In soldiers there are several factors: amongst the officers, the tension of anxious responsibility; amongst all grades, the violent emotions and privations of warfare: the shock of artillery discharge, of bursting shells, but especially alcohol and sexual and venereal disease.

His third fact: 'It is an old observation that G.P. is rare in gentlewomen.'

His own view was that 'alcohol, though perhaps rarely acting alone, has appeared to be by far the most frequent and efficacious cause of G.P.'. He did, however, regard prepsychotic character or predisposition as important, it being the soil in which the seed was sown; he observed that the character of those suffering the disease has, on the one hand, 'often been fiery, choleric, intolerant of opposition; or on the other, douce, genial and evidencing much bonhomie: or sometimes proud, haughty, selfish, ambitious'.

Concerning syphilis he has to say: 'It has been a much contested point whether syphilis can and does produce G.P.' He quotes two extreme points of view, the first being that 'Most striking of all is the experience of Lewin – 20,000 cases of syphilis – one per cent becoming insane – not a single G.P.'; and the second that 'G. Kjelberg held G.P. to be a form of cerebral syphilis and never occurring in an organism free from both congenital and acquired syphilis'. Evidently another prophet crying in the wilderness.

Clouston's own views are: 'There is one cause above all others, predisposing or exciting – viz., the syphilitic poison, and two exciting causes, sexual excess, especially if indulged in at or after middle life and alcoholic intemperance, especially if impure or bad drinks are used ... I cannot agree that syphilis is the sole cause always, because I have had many cases in which the existence of personal syphilis was excluded by every sort of reliable evidence. [Remember this was written immediately prior to the introduction of the Bordet-Wasserman serological test for the diagnosis of syphilis.] Mental shocks and strains of all sorts will of themselves cause the disease.'

He believes there is a certain temperament that predisposes to general paralysis – the intensely sanguine, characterized by 'ambition and energy, sociability and a large capacity for enjoyment, a firm belief in oneself, and a preference for handsome women'. He quotes the case of the disease in twin brothers as showing conclusively that heredity may predispose to the disease.

In the Royal Park admission register for 1907-8 already referred to, amongst the women admitted with general paralysis – alternatively known as paralytic dementia – one case was attributed to masturbation, one to insomnia and three to change of life; in two the cause was unknown. Amongst the twenty-three male cases admitted, ten were without known cause, seven thought to involve syphilis; in addition there were the following rather less common causes: 'hit from cricket ball and fall from horse', 'injury from a fall down a shaft' and 'heat and bad food in Western Australia'.

Such was the state of ignorance concerning the cause of general paralysis of the insane at that time.

As for other forms of insanity, it was customary then, as now, to divide causative factors into the two categories of 'predisposing' and 'exciting', except that now the terms 'constitutional' and 'environmental' are used. Great stress was laid on a psychopathic or neuropathic heredity or the insane diathesis or constitution. Such an approach, along with the multiple superadded anxieties, excesses and privations of living, so debilitated the psychic and physical powers of patients that eventually mental illness of almost any type was precipitated. Hence, it gradually became realized that, if treatment was to be successful, these non-specific stresses had to be eliminated, and patients' psychic and physical strength improved by the judicious prescription of a variety of treatments.

Turning again to the Royal Park register to illustrate this philosophical straitjacket, it will be found that in sixty cases of melancholia, only six were of unknown cause. By far the commonest cause was worry, usually financial, often domestic. Six were the result of drinking, usually in combination with other causes. In four women it was attributed to change of life (no doubt now they would have attracted the dubious diagnosis of involutional melancholia, no great advance in itself). Six others were generously attributed to overwork. One unfortunate woman developed the illness because of 'shock from being rushed by a cow and from a fire', a man through 'overwork during the very hot days in January 1908'. It was added as an afterthought that he also had a 'sarcoma of the brain'.

Mania showed similar but wider multicausality. Amongst fifty or so cases, eight were due to drink and one each to syphilis, bodily disease and depressed fracture of the skull. There was also a great variety of less common causes. It seems the Sunshine (western suburb of Melbourne) suburban railway disaster was responsible for more indirect suffering in the community than was occasioned by actual injury: one woman had developed mania through 'fright and shock from reading of [Sunshine] railway disaster'. Other cases were a result of 'bad sea voyage and shock', 'shock from buggy accident' and, a magnificent example of multicausality, 'fright from bolting horse and insomnia, bodily illness and heredity'. In eleven of the fifty cases, the cause was unknown.

Similar causes were listed for delusional insanity – now known as paraphrenia or chronic paranoid schizophrenia – along with some less common ones: heatstroke, 'too close study of religion', cigarette smoking, consanguinity and 'fright from attack by dog'.

So it all boiled down to excessive environmental stress of one kind or another in predisposed individuals. It really did not seem to matter what caused the stress. If intense enough it produced a 'mental breakdown'.

Sunstroke seems to have been far commoner in those days. The annual report of the Inspector-General of the Insane for Victoria (1907) lists thirteen admissions to various mental hospitals resulting from sunstroke. It was a predisposing cause in three and an exciting cause in the remainder. One may conjecture why this no longer happens. Is it possible that urban smog dims the pristine brilliance of the solar rays sufficiently to avert this former cause of mental morbidity? If this is so, smog must be regarded as primarily preventive and therefore to be praised and encouraged, quite contrary to contemporary opinion.

Theories of focal sepsis as a cause of insanity enjoyed considerable popularity. This was understandable in view of the triumph of bacteriologists, notably Pasteur and Koch, in the latter half of the nineteenth century in elucidating the specific micro-organismal causes of many major infectious diseases. Arbuthnot Lane and his penchant for colectomies has already been mentioned, but the archpriest of focal sepsis was Cotton (4), who flourished in the early 1920s. He believed that the most important cause of the functional psychoses, manic-depressive illness and schizophrenia, was toxaemia coming from chronic foci of infection, situated anywhere in the body but originating in the teeth. He regarded oral sepsis as the most constant focus in psychotic patients. No mere theoretician, he ruthlessly extracted suspect teeth, especially impacted wisdom teeth which he regarded as always infected. He also found it necessary to remove tonsils in over 90 per cent of his patients. From the fact that the elimination of infected teeth and tonsils failed in some instances to improve the mental state of the patient, Cotton concluded that the original infection had spread to other parts of the body. Consequently secondary foci of infection were sought in the stomach, duodenum, small intestine, gall bladder, appendix and colon and the cervix of the uterus. Successive surgical assaults were made on these various organs until finally total colectomies were being done on an impressive scale. In a series of 133 cases, there were allegedly thirty-three recoveries, but also forty-four deaths. Partial removal of the right half of the colon was done in another series of 148 cases with forty-four claimed recoveries and fifty-nine deaths.

It is hardly necessary to say that the appalling mortality figures for those undergoing this systematic evisceration deterred most others from following Cotton's enthusiastic example, but theories of focal sepsis still flourished.

From the time of Hippocrates physicians have noted that the insane sometimes improved as a result of feverish illness. It was natural, therefore, that attempts should be made to harness this observation to therapeutic use (the most brilliantly successful of these will be described in the next chapter). Various fever-inducing substances were injected into psychotic patients with variable and not very spectacular results. Contradictorily enough, in view of concurrent theories of focal sepsis, fixation abscesses were sometimes induced to stimulate the immune responses of the body. A fixation abscess is a collection of pus produced by the injection of turpentine, a powerful tissue irritant, into the muscles of the lower back. One writer claimed that he had found the treatment beneficial particularly in post-puerperal conditions! It appears as logical as venesection for anaemia. Two other enthusiasts claimed that a fixation abscess exerted a remarkable effect on all vital functions, improved appetite, stimulated ovarian function and often cured intractable amenorrhoea. They claimed that all mental disorders, however caused, were influenced for the better.

These, then, were the most notable of theories concerning the causes of insanity at the turn of the century. They were vastly important because they dictated the direction of therapeutic practices at the time and thus had a profound effect on the treatment and management of the insane.

1. J. F. J. Cade, 'Masturbational Madness: An Historical Annotation', Australian & New Zealand Journal of Psychiatry (1973), p. 1.

2. T. S. Clouston, 'Clinical Lectures on Mental Diseases' (6th edition, Churchill, London, 1904).

3. W. J. Mickle, 'General Paralysis of the Insane' (Lewis, London, 1886).

4. Cotton, 'The Relation of Chronic Sepsis to Functional Psychoses', Journal of Mental Science, LX1X (1923), p.434. Also quoted in H. Devine, Recent Advances in Psychiatry (Churchill, London, 1929), p.131
The First Milestone: Malarial Treatment of Syphili **s**

It would be true to say that in A.D. 1916 physicians were just as impotent in treating major mental illness as were their predecessors of 1916 B.C. In both eras treatment was non-specific and only fortuitously effective. It masqueraded under such terms as supportive, stimulant or sedative, and was administered by a variety of ingenious techniques. Hydrotherapy was a favourite from ancient times – warm baths, cold douches, jets both fine and coarse, low and high pressure, and blanket baths both hot and cold. In addition, throughout the ages, mineral waters from famous spas had been used internally and externally for most of the ills of mind and body. There were drugs in great variety. The popularity of this one or that waxed and waned in successive eras. It was the strange convention in my grand-father's day for the physician to 'exhibit' a drug, not 'give' it. In most cases it might just as well have been exhibited for all the good it did.

In 1917 the first great milestone was reached when the first specific and effective treatment for any form of mental illness was introduced. On 17 June of that year, Julius Wagner von Jauregg (1857-1940), an elderly Viennese psychiatrist, withdrew some blood from a shell-shocked patient with malaria and injected it into two patients suffering from syphilitic general paralysis.

General paralysis of the insane (G.P. or G.P.I.) was a fearful scourge, extremely common and up to that time absolutely incurable. It can be described shortly as a chronic syphilitic disease of the brain substance. The infecting organism continuously and relentlessly destroys brain cells so that the affected person, unless treated, is steadily dragged from normal mental health to dementia and death often within one to two years from the time that the deteriorating mental state is first recognized. It usually occurred a number of years (five to twenty) after the original infection had been acquired. The unfortunate victim might have long since forgotten or might even have been unaware of having been infected. It would attack strong and capable men in the prime of life and reduce them to vacuous, slobbering, tremulous imbecility. Some would develop the most extravagant delusional ideas of untold wealth and power, others would become profoundly depressed, but most just unobtrusively deteriorated mentally and physically. All were quite unaware that they were in the grip of a mortal illness and all except the depressed ones were sublimely unconcerned. It was the relatives who suffered acute distress as they witnessed the steady disintegration of a loved one's mind and behaviour. A person's judgement and commonsense was first to be affected and if he were a man of some substance, he frequently indulged in senseless extravagance and speculation, rapidly dissipating his fortune before it was realized that he was in fact a sick man. He himself would be quite insightless regarding his need for hospitalization, and treatment was naturally often strenuously resisted. This was especially so with the grandiose or expansive type: for such a person would have never felt better or more capable in his whole life. How could he possibly be sick?

Many and bizarre were the theories of causation. (These have already been described in the last chapter.) It is understandable that excessive indulgence in alcohol should have been regarded as a potent cause because it can produce mental and nervous deterioration which mimics G.P.I. very closely. The diagnosis of the disease was placed on a firm basis only after the discovery of the very tenuous, pale and elusive germ of syphilis (a corkscrew-shaped organism named Spirochaeta pallida, later to be renamed Treponema pallidum), by the German proto-zoologist Fritz Schaudinn (1871-1905) in 1905 only a few months before his untimely death, and the introduction of the Bordet-Wasserman serological test for syphilis the following year. Finally, Noguchi (1) in 1913 demonstrated the organism in the brains of paretic patients and placed the cause of general paralysis beyond doubt.

So G.P.I. was caused by syphilis. Why, therefore, could it not be cured by anti-syphilitic drugs? The famous renaissance physician, Girolamo Fracastoro, had treated syphilis with mercury as long ago as the early sixteenth century. The great German doctor and chemist, Paul Ehrlich (1854-1915), and his team, searching relentlessly, had discovered powerful organic arsenical anti-syphilitic drugs in the first decade of the century – salvarsan or '606' (meaning that it was the six hundred and sixth compound of that series to be tested) in 1909 and neosalvarsan ('914') not long after. These were extremely effective in the earlier stages of syphilis but useless in G.P.I. Why? A fashionable explanation was that the drugs were unable to pass the 'blood-brain barrier' to attack the entrenched organisms.

On the face of it, it seems a crazy idea of von Jauregg's that he should have tried to fight one disease with another, but as with so many other startling discoveries, when the rationale is known, the seeming irrationality appears rather a stroke of genius. In fact, it was based on acute clinical observation and deduction. He, like everyone else, had treated G.P.I. unsuccessfully, but every so often he observed that nature produced a remarkable improvement, if not actual arrest, of the disease where he had been unable to do so. Further, and this is the key observation, he noted correctly the exact circumstances in which this seeming therapeutic miracle occurred. It happened when a patient with G.P.I. had had a fever, however caused. It may have been typhoid or pneumonia or erysipelas. He concluded that it was the fever, the high temperature itself, which was therapeutic. This was subsequently proved correct when fever produced by induced electrical currents, in the absence of any infection whatever, effected equally beneficial results.

Von Jauregg had been interested in the effects of fever on mental illness for thirty years. As far back as 1887 he had published a paper seriously proposing to infect crazy people with erysipelas or malaria. The suggestion was ignored by others, but he himself in 1890 started to induce fever with increasing doses of tuberculin in patients with miscellaneous psychiatric diagnosis. After ten years of mostly failures and a few successes, he decided in 1901 to concentrate on G.P.I. By 1909 his results with tuberculin were negligible. Von Jauregg had been quick off the mark to use Wasserman's newly-introduced serological test and in 1906 he discovered that ninety-nine out of a hundred specimens of cerebro-spinal fluid from paretics yielded a positive result. In 1911 he was trying the new hope, '606'. Failure again. Then he started combining mercury with tuberculin early in the illness with some modest success. Pursuing this will-o'-the-wisp of fever therapy with extra-ordinary persistence, he finally came to the decision to use malaria. It can hardly be said that it was the fortuitous discovery of an unprepared mind. At this time he must have been aware of, and fortified by, Landsteiner's demonstration of the extraordinary sensitivity of the spirochaete to heat. Even a few degrees above normal body temperature would kill it.

Von Jauregg's first two patients were infected with malarial blood in 1917; within the next two months he had inoculated seven more. Ten years later three were still completely well: formerly all nine would have been long-since dead.

There are several varieties of malarial parasite, one particularly deadly; the one von Jauregg chose for inoculation was that which produces benign tertian malaria. The object was to induce from ten to twelve bouts of fever and then to terminate the malaria with a short course of quinine. Various modifications of this treatment followed. Von Jauregg's disciple Kyrle combined precedent and subsequent courses of the latest and most effective anti-syphilitic drug, neosalvarsan, with malaria. Then treatment was given before symptoms appeared in those with serological evidence of early paresis, with singularly gratifying results. Lastly, he proceeded to treat early syphilis. In a series of 250 cases, there were only three relapses and all three had refused malaria after treatment with '914'.

Malarial treatment was introduced into Australia in 1926 by J. K. Adey when he was superintendent of the Sunbury Mental Hospital, and his medical officer, Reg Ellery. The malarial clinic was soon moved to Mont Park where there were adequate laboratory facilities to monitor malarial blood, and from then on all paretics within the Victorian mental hospitals were treated there. The original case register was still extant in 1946. Recoveries were entered in blue ink, deaths in red. Ominously the first six entries were in red ink. Then there was a gap of many months. After that, blue ink entries predominated with only an occasional death. It must be remembered that a number of these patients were physically very sick with other syphilitic lesions, including disease of the heart and aorta.

The reason for the inauspicious start was that the blood originally used came from a patient with a mixed malarial infection. Not only were there organisms of the benign tertian strain present, but also those of the malignant variety. These soon overgrew the benign, and patients were dying of cerebral malaria. It was only after the initial deaths that this was discovered. There was an anxious wait of months before a guaranteed pure strain of benign tertian blood could be obtained. This was passaged from patient to patient over twenty years until 1946 when, after World War II, penicillin became readily available for civilian use. It soon became evident that penicillin was equally therapeutic and imposed much less strain on the patient than a number of bouts of malarial fever. Also, quite a number of patients had proved relatively or absolutely immune to infection with malaria and thus, perforce, were denied the benefits of treatment.

This is not the whole story of the conquest of general paralysis. The fact was that treatment was only really effective in about 15 per cent of cases. In the majority, irreparable harm of greater or lesser degree had already been inflicted on the brain before the diagnosis was made and treatment commenced. Certainly the treatment killed the organisms and arrested the disease in these cases, but only to leave the wreck of a man to live out his days in a chronic mental hospital. In the late 1930s a considerable percentage of the chronic male patients at Mont Park were arrested G.P.I.s in various degrees of decrepitude.

The greatest advance lay in prevention rather than cure. With the advent of penicillin and subsequent antibiotics, the rapid and successful treatment of syphilis at all stages became practicable. The period of infectivity was also dramatically shortened, thereby sharply reducing the incidence of infection of others. This triumph of preventive medicine is reflected in the mortality statistics of Royal Park Hospital, taken out for the three five-year periods, 1946-50, 1956-60 and 1966-70.

In the first quinquennium there were fourteen deaths from G.P.I.; none in the later years. Penicillin literally killed G.P.I. as a cause of mental morbidity and death.

1. Noguchi & Moore, 'Demonstrations of Spirochaeta Pallida in Brain in Cases of General Paralysis', Journal of Experimental Medicine, XV11 (1913), p.232
Schizophrenia: the Unsolved Riddle

'Antiplegia is a man's complaint but I have it in a female sense' said a young lady, and immediately the diagnosis was obvious. Nobody but a schizophrenic or a goon could invent such an absurd but superficially plausible statement. Worse, she was quite unable to explain what she meant. The more she was pressed to elucidate the more addled and delusional she became.

A man wrote: 'Sir, because I am an atheist, democratic members of Victoria Police, mentally sick in obsessed thoughts concerning my mental state, as one permanently in need of psychiatric treatments they themselves urgently need. Their treatment is to cunningly transmit sounds into vibrative waves in lengths short, into the nervous system in alternating oscillations. At first I theoried 'twas electric light rays from heated globe source. But the Almighty Powers [note he has already described himself as an atheist] ever the Forces each of us secretly nature greatly assists me to detect this source of energy I receive.'

These two statements are a synopsis of a great deal of what is meant by 'schizophrenic thought disorder'. The subject has been dealt with by multitudes of psychiatrists and the number of descriptive adjectives would fill a large page. But although description has been exhaustive and theorizing profuse, understanding of the phenomenon is nil. Why do some people's minds become disordered in this particular way? Such a person may be able to give a perfectly coherent account of events external to himself, for example the date, his whereabouts, factual details of his childhood and schooling, but be quite unable to describe clearly his innermost thoughts, feelings and motives except in this bizarre and disordered fashion which none but he can understand. The whole essence of the disorder is a failure of meaningful communication.

It is a crippling disability. The patient himself may or may not be aware of it. If he is, he may complain that his thoughts are all mixed up, that they are echoing back to him, or that his mind is being influenced by some external agency.

Schizophrenics, in addition to their thought disorder, often have profound changes for the worse in their emotional life. They may become anxious and excited by what they perceive is happening or being done to them, or aggrieved by and aggressive towards their imagined persecutors. A famous example of this last behaviour resulted in the well-known and controversial 'clarification' of the English law in relation to homicide and insanity known as the 'McNaghten rules'.

The 'McNaghten rules' were not named after some learned judge who framed them, but after the accused whose trial prompted the formulation. The name is spelt variously – McNaghten, McNaughton, M'Naghten, etc. – and for a very good reason. The man himself could not spell his surname consistently.

The rules were formulated in 1843 as a sequel to his trial. Suffering from long-standing delusions of persecution (he was a chronic paranoid schizophrenic) he had made many complaints to various public authorities without result. He became increasingly embittered and decided to avenge his wrongs by killing the Prime Minister. Watching the house he thought he saw the Prime Minister emerge. In fact it was the P.M.'s private secretary, Edward Drummond, who bore some resemblance to the P.M. in rear silhouette. McNaghten followed and fatally shot him, in that mistaken belief. He was tried, found of unsound mind (much, it is said, to the annoyance of the young Queen Victoria), and committed to a criminal lunatic asylum.

The case aroused a furore. The result was that a Committee of Law Lords was formed to clarify the law relating to insanity and criminal responsibility. Their lengthy disputations crystallized in the so-called McNaghten rules. Briefly they are that to establish a defence on the grounds of insanity it must be clearly proved that at the time the act was committed the accused laboured under such a defect of reason from disease of the mind as 'not to know the nature and quality of his act or did not know that it was wrong'.

However, these rules are never invoked except in capital cases. The urgency is in direct relation to the existence of capital punishment in the community. There has been tremendous medico-legal controversy over the years about the adequacy of these rules as an exclusive criterion of the right-wrong test in assessing criminal responsibility, but as this is not a textbook of forensic psychiatry, the matter can be pursued no further here.

Perhaps even more often, however, schizophrenics become apathetic and indifferent. Their work or study record steadily deteriorates and they drift into increasing social isolation. Motivational drive may so atrophy that some – only rarely these days because the disorder is almost always checked before it reaches this profound and life-threatening stage – end up leading a vegetative existence known as catatonic stupor. Mute, motionless, unresponsive and oblivious to the world around them, they suffer from such a volitional palsy that they can do nothing. If they are stood up they stand; if they are laid down they lie; if they are sat they sit. Place an arm of such a patient in what would be for normal people an awkward, uncomfortable and constrained position and it remains thus until someone moves it. They behave as passively as a plastic doll. Some are not even able to initiate bladder and bowel activity, still less feed themselves. They have to be fed with a spoon or stomach-tube and toileted like babes.

One young man was admitted thus to the observation ward at Royal Park. He neither spoke nor moved. His bladder was grossly distended up to his umbilicus, the size of a six-month pregnancy. An acute distension of this dimension should cause agony in any normal person, but he was oblivious. It was not that there was any obstruction to urinary flow. He simply could not summon up the volition to void it.

Such patients do not have symptoms; that is, they never complain, in spite of near-mortal illness. The doctor and nurse can only rely on signs of physical abnormality and illness, very much as in veterinary practice, in idiocy, or with the unconscious patient.

At Mont Park in the 1930s there was the inevitable 'Farm Workers' Block' where 'good' chronically psychotic patients, almost always chronic schizophrenics, and patients with milder degrees of mental deficiency lived; their daily task, year in and year out, was the milking of the dairy herd and tending of the hospital farm..

One day the nurse in charge brought a middle-aged man to the attention of the medical officer as he made his daily round. The man had no complaints. The observant nurse had simply seen that the patient, although he had risen and made his bed as usual, had eaten very little breakfast and seemed a little unsteady on his feet. Examination revealed that he had a double lobar pneumonia and was in extremis. He died the same morning. This was just before the antibiotic era.

Another patient vomited, something he had never done before to anybody's recollection. Again no complaints. But the muscles on the lower right side of his abdomen were rigid and failed to move either when he breathed or when they were pushed. Immediate operation revealed, as was expected, an acutely inflamed appendix on the verge of bursting.

Such was the state of medicine and the art of diagnosis in those days. Medicine may have been in poor shape, but diagnosis was of a high order. There was a premium on acute observation by nurses and doctors.

It rarely happens, because it is very difficult to do convincingly, that a patient simulates a stupor. One day, however, there was a notation in the hospital daily report book that a young woman had become drowsy, stuporose, and seemed to have neck stiffness, a most ominous collection of symptoms. She was very properly transferred to a general hospital for neurological assessment but promptly returned the same day 'NAD' (nothing abnormal detected).

The following day there was an almost identical notation in the book. The superintendent thought it was time to thoroughly investigate. The patient was lying rigidly in bed, eyes closed, facing the window, the light on her eyes, quite unresponsive to any stimuli. Her neck was stiff. She could only be raised to the sitting position 'en block'; but strangely her neck was quite flaccid when her head was moved from side to side. A routine examination of her nervous system revealed nothing abnormal. Then she gave the game away. As the sun shone in the window her closed eyes started to blink, which can only happen in a conscious patient. The doctor, wondering how to rouse her, noticed she had rosary beads round her neck, so decided to press the God button: 'Does God command you not to open your eyes or talk?' he asked. In a few moments her eyes opened, she leapt up on the bed, then on to the floor and screamed, 'I'm not going to eat until they send me back to Transylvania'. The stupor miraculously terminated, but not the psychosis. That responded to later treatment.

Schizophrenia is one of the most malignant diseases to afflict mankind. It is the greatest unsolved problem in contemporary psychiatry. Theories of causation have been legion and, like the content of patients' delusional ideas, change from generation to generation in accordance with the cultural beliefs of a particular society. When witchcraft was fashionable, the afflicted were burnt as witches. When man was becoming victorious over infectious disease, there were vain searches for the schizophrenic germ or toxin, and patients were purged and fevered. Today, in a society claimed to exert many psycho-social pressures, the schizophrenic is seen by some as the unhappy victim of society's relentless demands for social conformity, driven into a blind alley where he is forced to react with the symptoms of schizophrenia to survive. The psychiatrist is seen as society's policeman. (Unhappily this pattern, with an insidious twist, appears to be only too true in the Soviet Union, where political deviance is viewed as mental aberration.) Treatment, particularly psychotropic drugs and above all, ECT, is viewed with repugnance as being simply society's coercive tools with which to shackle the unfortunate one into the straitjacket of conformity. It seems a bizarre and topsy-turvy point of view to anyone who has had the privilege of rescuing sick people from the turmoil and anguish of a psychosis. But, regrettably, it is a prevalent and influential school of thought in some parts of the world at present and is responsible, in some cases, for effective treatment being withheld or refused.

In spite of the absence of a real understanding of the disease process itself, the treatment of early, acute, recurrent and even chronic schizophrenia has become vastly more effective. This has been entirely due to the advent of modem drugs. Whatever the cause of schizophrenia, only physical methods of treatment are effective in producing remissions. Up till 1933 nothing really worked consistently. Fever-inducing drugs and vaccines seemed to produce improvement in some patients but in a quite unpredictable and inconsistent way. Nobody knew whether they worked or whether it was just coincidence. After all, some patients do recover in the absence of any treatment at all – there is a low spontaneous remission rate. One popular treatment was dosing patients with huge amounts of thyroid. It was based on Gjessing's work in the mid-twenties on the protein metabolism of schizophrenics: he observed that in a small group suffering from a form of the illness known as periodic catatonia, there were fluctuations in protein metabolism paralleling changes in their mental stage. Large doses of thyroid did seem, like so many other treatments, to produce modest temporary improvement in a few, but it was not impressive.

Such was the highly unsatisfactory and frustrating situation in the treatment of schizophrenia until the great leap forward from 1933 onwards. Up to that time all forms of psychotherapy had proven futile and various methods of physical treatment little, if any, better.

The following chapters describe the successive therapeutic triumphs that have been achieved since then.
Convulsive Therapy

The man who in 1933 introduced the greatest advance up to that time in the treatment of that large and malignant family, the functional psychoses (schizophrenia and manic- depressive illness), cannot even be named by today's vast majority of senior medical students. This was the man whose discovery, more than any other, got people out of mental hospitals and transformed the lives of the craziest of humanity, returning them to normality. It is not overstating the case to acclaim it as the greatest therapeutic miracle of its time, a treatment which is still used when all else fails. It is convulsive therapy, the favourite target of the anti-psychiatry movement.

Ladislaus von Meduna was born on 27 March 1896 in Budapest, to a family which had its origin in Papal nobility. He graduated from medical school in Budapest in 1921. As his experience in psychiatry increased Meduna steadily became possessed by a clinical impression which became an overriding thought. Was there a real antagonism between epilepsy and schizophrenia? Some investigations at the time suggested that they rarely occurred in the same patient. (This suggestion would, however, be strenuously and correctly denied today.) Therefore the thought arose – might they not eliminate each other? Theories of biological antagonisms were prevalent and of course there was von Jauregg's wonderful example of only a few years before. Would the induction of epilepsy benefit schizophrenics? Once again someone, this time Meduna, was inspired to obey the famous Hunterian dictum, 'Don't think. Try'.

At first he injected schizophrenic patients intramuscularly with a preparation of camphor in oil, which has convulsant properties. Soon he replaced this somewhat unreliable method with a much more certain and easily-measured intravenous injection of the soluble synthetic camphor derivative, pentamethylenetetrazol or 'Cardiazol' (marketed in the U.S.A. as 'Metrazol'). This had been discovered by Professor K. F. Schmidt of Heidelberg in 1925, although elaborated at that time purely as a general stimulant of circulation and respiration. The immediate results were so astounding that there was no turning back. In those days catatonic stupor was relatively common in mental hospitals. Meduna found that with a few Cardiazol convulsions a miracle happened: the patients spoke, they ate, they moved. It was like viewing a performance of Coppelia. If not completely recovered from their psychosis, they had at least been transformed from puppets into human beings again.

Meduna started to induce epileptic convulsions in man for therapeutic purposes in 1933, the same year in which insulin coma treatment, to be described later, was introduced, and two years before that now most controversial of all treatments, prefrontal leucotomy or lobotomy, was initiated.

There is a somewhat sad ending to the Meduna story. He emigrated to the United States in 1939 and began work at Loyola University in Chicago. Later he experimented with the inhalation of carbon dioxide in the treatment of psychoneuroses but without any real success. He died in 1964, a man rather embittered by the relative lack of recognition of the fundamental nature of his discovery. If von Jauregg and Moniz had been awarded Nobel Prizes, why was he not for his much more significant advance?

More clinical implications of convulsive therapy quickly became evident. Within a few years it was realized that Cardiazol had even greater value in the treatment of severe melancholia. Strangely enough the opposite condition, acute mania, responded equally effectively, if indeed only temporarily in many cases.

And so convulsive therapy came to stay. It was frantically strenuous treatment. The convulsion was appalling to watch and placed extreme stresses on the cardiovascular and musculoskeletal systems. Initially the therapist wondered if his patient would ever breathe again as respiration was choked off by the fit and he became more and more cyanosed. After what seemed an eternity he relaxed, gave first a deep gasp, then a series of gasps and his colour reverted rapidly from puce to pink. There could be the most alarming cardiac irregularities, but they always reverted to normal within twenty-four hours. Physical injuries were also possible: dislocation of the lower jaw was easily corrected; dislocation of the head of the humerus, not infrequent, was quickly reduced by the Kocher manoeuvre; but least easy to accept, as a result of the frightful exertions of the muscles of the back, vertebral cracks in the lower chest region were fairly common. Not that they were really serious, strange to say – it was a purely radiological diagnosis. A patient would complain of back pain. An X-ray would show a hair-line fracture of a lower thoracic vertebra, sometimes two or three; but there was no displacement. Splinting was not required. A week or two of minor analgesic drugs and all would be well.

A technical difficulty was that Cardiazol had to be given rapidly into a vein. Not infrequently it was a problem to find a superficial vein of sufficient size in a rather overweight, middle-aged woman suffering from depression.

Perhaps the greatest drawback to its use was that horrible latent period of thirty to forty seconds, terrifying to the patient and repugnant to the doctor, between the injection and the onset of the convulsion and oblivion. Patients suffered the pangs of imminently-anticipated death. One patient who had not uttered a word for eighteen months gasped 'Ta Ta' as he lapsed into unconsciousness, a brief desperate acknowledgement of this terror. Certainly he recovered from his long-standing depressive stupor in a few days, but the ordeal must have been worse than prolonged, recurrent immersion on a ducking stool.

Cardiazol could only be given to those patients whose disease was judged to be more painful than the therapeutic ordeal, but there were many of them. It was so extraordinarily effective that it had to be used, and with what brilliant and unprecedented success!

There is an addendum to this story. Was it possible to induce curative convulsions by other than chemical means? It was. Ugo Cerletti (1877-1963) and his assistant Lucio Bini (1908-1964) showed how in Rome in 1938.

Cerletti was the first to express the idea of using electricity to bring about unconsciousness and, hopefully, to obtain therapeutic results similar to those obtained with Cardiazol and insulin shock. (Electricity had been used extensively in medicine in the nineteenth century. It had not, however, been used to cause general shock, i.e. a convulsion; mainly it had been used locally, as both direct and alternating currents, for a variety of conditions but especially those of an hysterical nature. It is not therefore strictly relevant to the present account.) Kalinowsky, a major figure in biological psychiatry in the U.S.A., claims: 'In November 1937 the first patient was treated with ECT [electroconvulsive therapy] at the Psychiatric University Hospital in Rome, where I happened to work at the time.' Another account gives the date of this event as April 1938.

ECT was a major technological advance, but only that. It was simply another way of inducing a convulsion. The recognition of the therapeutic value of the convulsion itself, however induced, must remain eternally with Meduna.

ECT had several advantages over Cardiazol. It could be administered to any patient irrespective of the paucity of superficial veins for injection, but most importantly, the patient lost consciousness the moment the button was pressed and the current passed. No longer was there that agonizing half-minute wait. When he awoke he had no memory of the event, a merciful amnesia. If he was spoken to half an hour afterwards, as he was resting quietly in bed, and asked how he had spent the morning, he would reply that he had had a good night's sleep and had just woken.

But the physical effects of an unmodified electrically-induced fit were just as drastic as with Cardiazol. Over the following years increasingly successful efforts were made to eliminate these with the injection of more and more effective, and briefly acting, muscle relaxant drugs, and finally with concurrent routine intravenous anaesthesia. These days it is an extraordinarily gentle, safe and painless treatment – the muscle contractions virtually abolished by drugs – but equally effective. So slight is the muscle spasm that it can be difficult to know whether the patient has had a convulsion unless a close watch is kept for the tiny telltale twitching of the bared big toes.

Convulsive therapy, now always modified ECT, is used far less today than it once was because in so many cases drugs are equally effective. But there are still extremely distressed patients for whom it offers the quickest relief until the rather longer-acting drugs take over.

In its day the greatest advance, convulsive therapy still is important – although on a greatly reduced scale – in the treatment of the major psychoses.

1. L. Kalinowsky in Ayd and Blackwell (eds) Discoveries in biological Psychiatry (Lippincott, Philadelphia, 1970, pp. 59-67
Largactil for Psychotic Exhaustion

One day in late July 1954 a wildly restless young man was admitted to the receiving ward at Royal Park. Big and strong, he was an impossible nursing problem, actively resisting any attempts to nurse him, striking out blindly at all who came near him and shouting senseless obscenities. He was suffering from acute catatonic (schizophrenic) excitement and was likely to die of exhaustion and dehydration as so many had done before him.

This was the most tragic of all the modes of death associated with mental illness. It was certain that if he could be nursed through this excited phase he would either recover his sanity, or at least be settled enough to live with any psychotic symptoms which might remain. But he could not be nursed adequately. Treatment usually amounted to placing him on a floor-mattress in a single room so that there was less chance of him injuring himself; he would be force-fed, held by a team of nurses whilst the doctor inserted a naso-gastric tube and poured in a couple of pints of milk and eggs, fortified with malt, vitamins and probably sedative. Although many patients were treated in this way, it was actually only a holding operation destined eventually to fail. Often in spite of the most devoted and strenuous nursing care, the patients became progressively weaker, their shouting muting into mumbling incoherence, their lips and tongues becoming drier and drier and coated with yellowish-brown dried mucus, their eyes more sunken and wilder, their kidneys with no fluid to excrete. Finally their breathing rate would increase and their temperature start to rise. Death from psychotic exhaustion and terminal bronchopneumonia was not far away.

On this day in July the young man was given an injection of a new drug. Wondrous tales had been circulating about it for almost a year and it had just arrived. Within ten minutes he had been transformed from an impossible into a perfectly practicable nursing proposition. He became calm, drowsy and co-operative, able to take nourishment without demur as he lay quietly in bed. This seemed the ultimate in therapeutic miracles. He was destined to survive and recover.

No longer would such patients die. Until that time many deaths had been inevitable: after that, the number steadily declined, soon to disappear altogether. This fact is illustrated very vividly by the mortality statistics for Royal Park. Until then seventeen to eighteen such patients had died each year in that hospital in spite of the devoted efforts of the nursing staff. It is worth remembering that they endured a very great deal of frustration as well as mindless and unpredictable assault from such patients. It is extremely difficult to endure without reflex retaliation a painful kick in the testes or a bash on the breast, yet the nurses did so to their eternal credit with no harm to their patients. They knew that retaliation was both useless and brutal. The patient did not know what he was doing. Later when he recovered he would be the first to apologize if he could remember.

From 1954 onward the nursing task was much easier. Staff were able to nurse effectively such patients instead of being forever assaulted by them. Effective nursing in turn ensured survival and often recovery.

The reason for the disappearance of psychotic exhaustion as a cause of death can be summed up in one word, 'Largactil' (chlorpromazine). This was the miracle drug that was destined to change the whole practice of hospital psychiatry.

It was introduced in 1952 by Deniker (1) and Delay, in Paris. Pierre Deniker told the story in 1970 on behalf of himself and his colleagues Jean Delay and Laborit. The use in psychiatry of chlorpromazine, which was first synthesized by Charpentier in 1950, was stimulated by attempts to induce 'artificial hibernation' as an aid in anaesthesia. The 'lytic cocktail' developed by Laborit combined three drugs: pethidine (a morphine-like derivative), promethazine (an anti-histamine) and chlorpromazine. Psychiatrists knew the first two. Therefore interest centred on the last. It was Laborit who predicted that it might have some use in psychiatry. Deniker and Delay decided to use it without the other two agents in doses thought to be considerably high in those days. It was tried in cases resistant to all existing therapies. From May to July 1952 they treated thirty-eight cases of manic excitement and psychotic agitation which were resistant to shock or sleep therapy. The results were dramatic. The agitation, aggression and delusions of schizophrenics improved. Contact with patients could be re-established. It was not like former sedatives which promptly put patients to sleep when given in sufficient dosage. Certainly patients were drowsy, but they were calm, co-operative and rousable rather than confused. It had, however, no effect in alleviating depression – the development of drugs for that purpose took several more years.

Mortality statistics at Royal Park Hospital show that during the five years 1946-50 there were 86 deaths from psychotic exhaustion. By 1956-60 this had fallen to 8 deaths and by 1966-70 to zero.

There have been numerous phenothiazine derivatives developed since 1952, each with slightly different mental actions and miscellaneous side-effects or relative freedom therefrom, but none has superseded Largactil as the drug of first choice for acute psychotic excitement.

So far the emphasis has been on the tranquillizing effects of phenothiazines on disturbed patients, but phenothiazines also have an important long-range effect. In the long term they are actively anti-schizophrenic in a large percentage of patients.

Trifluoperazine ('Stelazine') is one such potent phenothiazine drug. It seems almost specific in banishing schizophrenic hallucinosis or 'voices'. This is specially found in out-patients who have been cured of an acute schizophrenic episode that demanded massive in-patient treatment, and who require indefinite follow-up medication to keep their distressing symptoms at bay. Minimal doses keep them completely well. An inadvertent omission of dosage for a day or two and the voices return. Double the dose for a short while and they disappear. It is almost mathematical.

Thus phenothiazines came to change the whole face of psychiatry. Till then padded rooms and straitjackets had been mandatory. After that they ceased to exist except as exhibits in historical museums.

A later advance was the development of the longer-acting drugs of this group. Many patients throughout the whole range of medicine when faced with maintenance medication of life-long conditions become careless with dosage. Feeling well, they become over-confident or absent- minded about it. As a result they relapse and have to be rehospitalized to be stabilized once again. In such patients, schizophrenics in this instance, treatment is best given by injection of long-acting preparations, requiring a brief out-patient attendance and assessment at intervals of one to two months. In this way multitudes of chronic schizophrenics are now being maintained in the community, at home and working, in a satisfactory state of health, whereas once they would have been foredoomed to spend the rest of their days as chronic mental hospital patients.

1. P. Deniker in Ayd and Blackwell (eds) Discoveries in Biological Psychiatry (Lippincott, Philadelphia, 1970, pp. 155-164
The Conquest of Epilepsy

The 'Falling Sickness' or 'holy disease' has been known since antiquity. Many remedies had been prescribed over the centuries but by the beginning of the twentieth century only one drug was actually of the slightest value and this was bromide, that is, one or other salt of bromine. There was considerable controversy amongst physicians about which was the more effective – sodium, potassium, lithium or ammonium bromide. By some the lithium salt was favoured, but others vigorously promoted the potassium salt as equal or superior. Others again sat on the fence and prescribed a mixture of bromides.

Bromides were introduced by the English physician Locock in 1857 for the treatment of epilepsy, and for a rather curious reason. They had been found to depress sexual activity and the idea had long been prevalent that masturbation was an important cause of epilepsy – after all, a major convulsion could be viewed as the very caricature of an orgasm. (As late as 1880 a paper was read at the annual meeting of the British Medical Association on the treatment of epilepsy by castration.)

It certainly was the first effective treatment, but only modestly so. For some reason borate was regarded as mildly enhancing its effectiveness and was often added to bromide mixtures. This treatment remained unchallenged for over fifty years, but has long since been discarded for more effective remedies.

In 1912 Hauptmann introduced phenobarbitone which was a considerably more potent anti-convulsant, but like all barbiturates it was hypnotic. Thereafter the standard treatment was a combination of bromides and phenobarbitone until the next advance in 1937.

In 1937 an American, Tracy Putnam (1), discovered the most potent anti-convulsant up to that time which, better still, was completely non-hypnotic. This was sodium diphenyl hydantoinate, known commonly as 'Dilantin'. He did not discover nor make the drug. It had already been synthesized in the Parke Davis Laboratories.

At a noteworthy symposium on biological psychiatry in Baltimore in 1970 Putnam, then a courtly old gentleman of seventy-seven, told the story of his discovery. It was a charming tale and told extempore which added to its charm. As with so many important discoveries, powerful personal factors were involved. In 1937 he had a cousin of whom he was very fond and she, an epileptic, was only partially controlled by existing medication. This fired his ambition to discover a more powerful and, if possible, non-hypnotic remedy. He began by asking himself why phenobarbitone was the only effective anti-convulsant amongst the barbiturates, and argued that it was the only one which had a phenyl ring attached to the barbiturate molecule. He then said to himself: 'If one phenyl ring is good for you, why should not two phenyl rings be twice as good?'

In the laboratories of the pharmaceutical industry there are, on the shelves, a vast array of bottles containing man-made molecules, each built in pursuit of a particular line of research, but most not fulfilling the hopes of the investigator and therefore labelled and relegated for storage and possible future exploitation.

Putnam therefore approached various pharmaceutical firms with a request for any such chemicals which conformed to his general prescription of a non-hypnotic barbiturate-like molecule with two phenyl rings attached to it. He received a large number of samples. He then built himself some quite simple apparatus to test the convulsant threshold in animals and set to work, testing them seriatim until he came to sodium diphenyl hydantoinate and discovered how magnificently it raised the convulsant threshold. He asked his colleague, Merritt, to confirm its value in human epilepsy. Their most optimistic hopes were fulfilled.

This may not seem to be a major advance in psychiatry but it was for those who were working in the field at the time. Until the last three or four decades there were considerable numbers of patients in chronic mental hospital wards suffering from what was called 'insanity with epilepsy' and 'epileptic dementia'. As Dilantin became quickly available throughout the world, its value was confirmed for these patients.

In 1938 there was one such patient, a young man in his early twenties, in a chronic ward at Mont Park. His epilepsy was incompletely controlled by maximum doses of pre-existing anti-convulsant medication. He had been there some years and the odds were that he would remain there for the rest of his days, confused and irritable much of the time and convulsing periodically.

It was decided to try the new drug, slowly increasing the dosage as that of his previous medication was steadily reduced and finally discontinued. The results were remarkable. His fits were completely controlled but better still, his so-called insanity disappeared as the accumulated bromides and barbiturate were eliminated from his system.

It was not sufficiently realized at the time that both these drugs were cumulative, and even many years later bromide intoxication was commonly caused by unwitting self-medication. Being retrospectively percipient, it is clear that many if not all of these so-called cases of insanity with epilepsy and epileptic dementia were, in fact, the result of chronic intoxication caused by these drugs used in recommended maximum doses. In many cases such large doses had to be used because of the difficulty in achieving control with incompletely effective drugs.

The young man left hospital completely well, never to return. This therapeutic miracle must have been multiplied a myriad times since. It is difficult for young people coming into this field to appreciate the significance of this advance.

There have been other significant advances in the treatment of epilepsy since, but perhaps none to equal it.

Troxidone ('Tridione') was introduced by Richards and Everett in 1944. It was, and is, an extraordinarily effective drug in the treatment of petit mal, brief attacks of unconsciousness without spasm. When this takes place, sometimes the patient's head nods, but oftentimes there is merely a transient blankness, a vacant look in the eyes and loss of the thread of a conversation. One such afflicted girl was in an institution for the mentally retarded. Although she was apparently retarded, it was simply because she was suffering literally hundreds of these episodes a day, each of which disrupted her awareness and concentration. Tridione abolished all this and established her as a perfectly normal girl.

Thus, step by step, epilepsy is being mastered, although not as yet completely. There are still a few recalcitrant cases, but new and more effective drugs are steadily being developed.

1. T. Putnam in Ayd and Blackwell (eds), Discoveries in Biological Psychiatry (Lippincott, Philadelphia, 1970), pp. 85-90
Highly Controversial: FCI and Leucotomy

There are two advances which, because they were major ones, must be recorded. They are now only of historical interest because more effective and less drastic treatments have replaced them. The first is full coma insulin treatment, the second prefrontal leucotomy.

The use of full coma insulin treatment (F.C.I.) was introduced by Manfred Sakel (1900-1957) in 1933 for the treatment of schizophrenia. Sakel was born into the Jewish community of Nadworna, Poland, then part of the Austro-Hungarian Empire. He studied medicine in Vienna until 1927, then became chief physician in a private psychiatric institution, the Lichterfelde Hospital in Berlin, a position he held until 1933. Here abstinence cures for morphinism were frequently administered. Struck by the resemblance between the stormy withdrawal symptoms of narcotic addicts and the clinical features of hyperthyroidism, he began using insulin as a thyroid antagonist in the abstinence cures, finding to his surprise that hypoglycaemic insulin shock was especially helpful to his patients.

Sakel became convinced that it could be a valuable tool in the treatment of states of excitement, and proceeded to employ it systematically in the management of other types of psychotic excitement, including schizophrenia, with good results. He returned to Vienna to work as a voluntary assistant in the Psychiatric University Hospital to develop his work under von Jauregg's successor, Poetzl. The latter, at first sceptical as was his wont, soon enthusiastically promoted it and had a great influence on Sakel's introduction of F.C.I.

It took four years before the treatment arrived in Australia, but once introduced there was no doubt about its value, especially amongst those who had till then vainly treated schizophrenia with the methods available. It was at last possible to induce remissions in those who previously had been absolutely recalcitrant. The last case of treatment with F.C.I. at Royal Park was in 1958. Why was it discarded twenty-one years after its introduction? There were several reasons.

First, it was a very arduous treatment for the patient. Five days a week for weeks on end, he was put into coma with an early morning injection of insulin, having fasted from the evening before. The process was reversed late each morning by giving either intra-gastric or intravenous glucose. It was arduous for the nursing team too, for the patient had to be watched as a cat watches a mouse, the depth of coma measured and recorded so that glucose could be given at the appropriate minute. If there was more than the slightest delay the patient sometimes drifted into irreversible coma ending either in death or, if the patient was finally resuscitated, in permanent brain damage. There was a small but appreciable death rate.

The second reason was that nobody knew and will never know precisely how effective it was because the treatment was contaminated from the start by concurrent convulsive therapy. It happened this way. A patient after a number of comas might remain as psychotic as ever. Then one day he would have a spontaneous hypoglycaemic convulsion after which improvement commenced. The lesson was soon learned. Cardiazol treatment had arrived at practically the same time as F.C.I.; if a patient on F.C.I. was not responding reasonably promptly and had not had a spontaneous seizure, he was given Cardiazol whilst unconscious from insulin. In these days of careful clinical trials in which a new treatment is scientifically compared with a well-established previous one, this would never have been permitted to happen, but neither perhaps would the use of C.I. have been permitted at all and many a patient who could have been rescued by this treatment would have been condemned to life-long insanity.

The third compelling reason for discarding F.C.I. treatment was that by the mid-1950s the phenothiazines had arrived, and six-month remission studies had shown that they were superior to F.C.I. – they were so much easier, safer and simpler to give.

The second advance, in recent years regarded as the most controversial of all time, was the introduction of prefrontal leucotomy or lobotomy by Egaz Moniz (1874-1955) and Lima in Lisbon in 1935.

It is not generally known that an Australian doctor, in a sense, discovered leucotomy twenty years previously, although he was not at the time in a position to appreciate its significance or explore its possibilities. In 1915 he was a medical officer to a battalion on Gallipoli early in World War I. A melancholic major decided to end it all and put a neat through-and-through bullet hole through the frontal lobes of his brain with his service revolver. He was promptly evacuated to the regimental aid post, where the doctor was struck by and remembered for many years the patient's amazing composure, indeed contentment and complacence. He had blown his melancholia clean out of his head. The observance of such personality changes after damage to the frontal lobes of the brain was the basis of the leucotomy theory. It was the reason behind Moniz's decision to produce deliberate but limited damage to this area of the brain.

Leucotomy was always a treatment of last resort. One does not undertake mutilative operations on the brain except when all else fails and the patient is in desperate straits. The prime indication state was described as being 'tortured self-concern'. The patient was in most cases a chronic melancholic who had had a vast amount of treatment – including, maybe, many courses of convulsive therapy – but with only temporary relief, and who had made at least one and usually several suicide attempts and was destined to succeed in this sooner or later. Others were obsessive-compulsives so preoccupied with their painful perfectionistic rituals that they had no time nor interest for anything else, and lastly some schizophrenics with a good pre-psychotic personality but now disturbed and distressed by their hallucinatory and delusional experiences.

The results were in general highly satisfactory for the patient. In at least two-thirds of the melancholics anguish and tension would disappear immediately as the leucotome severed the nerve fibres; the results with obsessive-compulsives and schizophrenics were less substantial but still considerable.

However, there was frequent personality deterioration, particularly with the earlier more extensive operations. Patients became disinhibited and could behave in socially embarrassing ways, that is, embarrassing to their relatives and friends. They themselves were unconcerned. The operation lessened or abolished feelings of guilt or remorse as markedly as it did anxiety and depression. A leading article in a prominent medical journal seriously suggested that the soul might have been destroyed. Post-operative epileptic fits also were not uncommon.

In spite of all this it became extensively used immediately prior to, during, and after World War II, simply because it rescued so many agonized patients from their exquisite distress. It was even used to assuage the frightful pains in some cases of terminal cancer.

In the Victorian Mental Hygiene Department operations were done only at the Neurosurgical Unit at Mont Park by a highly skilled neurosurgeon. All patients were referred there for treatment.

By 1958 leucotomy had become such a widely used procedure that one hundred and two leucotomies were done there. In 1959 the bottom fell out of the leucotomy market and by 1961 there were only a veritable handful of operations. It has ceased to be used as a therapeutic procedure in most places for a number of years.

The reason for the operation being consigned to oblivion from 1959 onwards was a simple one. In that year the first of the powerful modem anti-depressant drugs, imipramine, marketed exclusively at that time as 'Tofranil', became available in Australia, followed two years later by amitryptyline or 'Tryptanol', which was equally anti-depressant but rather more sedative.
Depressive Illness

Depressive illness is one of the commonest ills of mankind and in its milder forms one of the most unrecognized, undiagnosed and therefore untreated. It can present in a multitude of guises. Masked depression can mimic almost any form of organic illness, as the Serry brothers pointed out in a magnificent paper written in 1969 when they were in general practice in a suburb of Melbourne. (1) In this paper they pointed out that lengthy special investigations of various parts of the body in such patients revealed no satisfactory organic explanation of their symptoms. Given a course of one of the new anti-depressant drugs, their symptoms disappeared and they felt happy and contented again, maybe for the first time in many months.

When depressive illness is severe it is termed melancholia, a slightly old-fashioned term these days, although most apt. It is the most painful illness known to man, equalling or exceeding even the most exquisite physical agony. The patient is unconsolably despairing, often guilt-ridden – having committed, she imagines, the unforgivable sin – and completely immersed in her internal world of misery and utter loneliness. (The female pronoun has been used because depressive states are several times more common in women than in men.) There is no pleasure in living, no energy or interest in doing anything except agitatedly bewail or silently brood upon her unhappy fate; no hope for the future, abandoned by God and man. Suicide seems the only escape from her misery. These patients pose such a suicide risk that they must be hospitalized, compulsorily if necessary, and be kept under constant observation until their agony can be assuaged with treatment and they return to contented normality.

The only drug that seemed to give relief in some cases prior to the modern era was opium, but it was only palliative and carried the obvious risk of addiction. The majority of patients would have to remain in hospital until there was a natural remission of the illness. No one could predict how long this would take. Some recovered quite quickly, in weeks or months. In others relief never seemed to come and they spent the rest of their days in a mental hospital, quiet, withdrawn bundles of misery or agitatedly marching to and fro, wringing their hands and muttering their despair.

In Australia between 1937 and 1959 the only really effective relief was given by convulsive therapy, but unfortunately in many cases its effects were only temporary. Some patients would require maintenance treatment every week or two to keep them in remission.

In 1957 in Switzerland the whole outlook changed dramatically for the better. In that year the gentle existentialist Roland Kuhn discovered the powerful antidepressant action of imipramine. He described (2) the steps which led to the discovery and it is obvious from the account that no one else anywhere in the world at any time could have evolved such a concatenation of circumstances.

About 1950 the pharmaceutical firm of J. R. Geigy approached Kuhn and his team with a request to test one of their antihistamines to determine whether it could be used as a hypnotic drug. They did so, but although the results were largely negative they discovered that the substance had some anti-psychotic effects, although no effect on depression.

Soon afterwards they heard of the effects of chlorpromazine and got the impression that these effects bore some resemblance to those they had observed whilst testing the Geigy drug (code named G. 22150). In conjunction with Geigy they decided that the next substance of the group to be tested would have the same core structure as the previous drug, but the same side chain as chlorpromazine.

This substance (G. 22355) they tested for about a year in various mental disorders. To reach a final verdict they decided early in 1956 to test it on a number of patients suffering from depressive illness, as they had done with the previous preparation. It was not only thoroughness which prompted this decision, but their conviction that it must be possible to find a drug that was effective for such patients. Convulsive therapy had already proven effective, if temporary, in many cases.

It was clear to Kuhn's team after treating only three such cases that they had an effective anti-depressant in their hands and they energetically pursued their clinical studies.

On 6 September 1957 the paper announcing this momentous discovery was read to an audience of barely a dozen sceptical people at the Second International Congress of Psychiatry in Zurich. It would be wrong to say that it immediately electrified the world. To quote Kuhn: 'This was not surprising in view of the almost completely negative history of the drug treatment of depression to that time...We have achieved a specific treatment of depressive states, not ideal but going far in that direction.'

Within two years it had, however, swept the world. A measure of its fundamental importance is the immediate effect it had on the practice of prefrontal leucotomy, as has been described.

Subsequently other drugs in this family, the tricyclic antidepressants, were synthesized. Perhaps the best known of these is amitryptyline, first marketed for many years under its original trade name 'Tryptanol' and still widely known by that name. As an anti-depressant it is as effective as 'Tofranil' but is more tranquillizing and sedative. These additional effects may be an advantage in treating middle-aged, depressed women especially if they are anxious, agitated and insomnic; but for younger people this may not be necessary and, indeed, the day-time drowsiness may be complained of – for this reason they generally prefer Tofranil.

From the neurosurgeon working within the austere and sterile atmosphere of an operating theatre, it is a long step to the family physician treating the symptoms of a harassed, depressed, non-coping mother in her own home. Yet the tricyclics have revolutionized treatment in both areas. If they have taken the bread out of the neurosurgeon's mouth, they have permitted the family doctor to recognize and treat the common, mild to moderate depressive eminently successfully, combatting these symptoms in the patient's own home, thus avoiding further distress and what would have formerly been inevitable hospitalization. The change has been quite as remarkable as the conquest of infectious disease with antibiotics.

Another quite different series of anti-depressant drugs – mono-amine oxidase inhibitors (M.A.O.I.s) – may be dealt with briefly and in a minor key. In a minor key because not only are they less effective than the tricyclics in combatting most cases of depression, but because they have more undesirable and occasionally disastrous side-effects. Perhaps their greatest importance lies in their mode of action and theoretical interest in understanding the fundamental biochemical reactions that are the basis of affective illness.

It is a rather confused story when it comes to allotting priorities in the development of these drugs, because it seems that a lot of people leapt on to this particular band-wagon. As a result there has been much contention as to who contributed what in their original psychiatric usage.

The story starts, however, in 1951 when iproniazide was introduced for the treatment of tuberculosis. It soon became evident that however useful it might be as an antibiotic, it certainly had a marked effect on mental state. By 1957 an American, Dr George Crane, was reporting the success of iproniazide in the treatment of chronically fatigued tuberculous patients with a variety of psychiatric disorders. At that time there was great debate as to whether the anti-depressant action of iproniazide was due to the fact that it was a hydrazine derivative (also used in rocket fuel at that time!) or because it was an M.A.O.I.

This was resolved when, later, other drugs of the same anti-depressant effect were developed with quite different molecular structures, the only feature they shared being the fact that all were M.A.O.I.s.

1. D. & M. Serry, 'Masked depression and the Use of Antidepressants in General Practice', Medical Journal of Australia, 1 (1969) pp. 334-8

2. R. Kuhn in Ayd and Blackwell (eds) Discoveries in Biological Psychiatry (Lippincott, Philadelphia, 1970), pp. 205-17
Out of the Ground: Lithium

The fact that lithium, a simple inorganic substance, can reverse, neutralize and prevent a malignant psychotic illness, namely manic-depressive disease, has been of fundamental importance not only in treating but also in understanding the nature of this as well as other related processes. It is usually prescribed as lithium carbonate, a substance no more complex chemically than table salt or washing soda.

How it came into medicine, at first unsuccessfully, later disastrously, and finally triumphantly into psychiatry, is a long story but well worth the telling because it exemplifies in so many ways the devious paths and pitfalls that lie between initial discovery and final successful application.

The metal itself, the lightest of all and never found in its elemental state because, like the closely related metals sodium and potassium, it tarnishes or oxidizes so rapidly on exposure to air or water, was first isolated by the Scandinavian Arfwedson in 1817 whilst analysing the mineral petalite.

It was introduced into medicine by the English physician A. B. Garrod (1) in 1859 for the treatment of gout, following the demonstration that lithium urate was the most soluble of the urates. Urates are salts of uric acid which accumulate in the body in gout and the theory was that if lithium were given, it would dissolve these accumulations out of the system. In this it failed, but various lithium salts were subsequently introduced into medicine for a variety of other purposes. A salt may be thought of as a conjugation of a male and female partner in holy matrimony. Lithium is the midget amongst males so that in any marriage its partner is the disproportionately heavy one, which may thus be expected to do whatever medical work is required of it that much more effectively since it is relatively unhampered by the presence of its smaller spouse. It was for this reason that lithium bromide was esteemed by many physicians to be the most effective of the bromides when these were the only available drugs for the treatment of epilepsy.

However, lithium salts did not appear to be significantly more effective than other salts and because undesirable side-effects had been noted from time to time they became less and less popular. But the death blow came in the 1940s, when lithium chloride was increasingly used as a taste substitute for sodium chloride (common salt) in the salt-free diet used in the management of patients suffering from dropsy due to congestive cardiac failure. This was done quite uncritically and patients could freely use the substitute. As a salt-free diet is most unappetizing, the substitute was naturally used freely with the result that patients started to die of lithium intoxication from excessive self-administration. It was being given to quite the last kind of patient to whom it should have been given, and in quite the wrong way.

In mid-1949, following American medical press reports on the effects of lithium chloride, its medical use was prohibited by the Food and Drug Administration of that country. In that very same year its reprieve and rehabilitation was commenced on the other side of the world, but before that story is told something must be said of manic-depressive illness, its symptoms, course and treatment up to that time.

Straight depressive illness has already been described and its frequency, especially in its milder forms, has been emphasized. Manic-depressive illness, which when severe enough to warrant hospitalization is termed manic-depressive psychosis (M.D.P.), is almost equally frequent, again especially in its milder forms.

In such people there are alternations in mood; they are at times depressed, at others elated, in quite unpredictable fashion both in chronology and severity. When mood swings are within socially acceptable limits, the so-called normal range of mood fluctuation, they are described as 'cyclothymes'. They are likely to swing from being withdrawn, pessimistic and unproductive, immersed in anxious rumination, devoid of confidence and the ability to make decisions, from derogating themselves and performing poorly and with weary effort the daily tasks of life, to being bounding with energy and confidence, full of plans for the future, untiring, productive and socially exuberant – in fact, to being extroverted leaders. They will be the life of the party and to many a pain in the neck. An excellent and highly informative account of these people has recently been given by Fieve (2).

But so far they are controlled. They cannot be regarded as abnormal or sick people in any sense. They are the people of a mercurial temperament, interesting people, creative people. They contrast strongly with the phlegmatics, the stolidly steadfast, the always-reliable and predictable.

However, there are some who swing more widely, either into profound depression with suicidal despair (melancholia) or into the wildest euphoria. During the latter they are restless, excited, grandiose, talkative, sleepless, completely disinhibited and behaving for all the world like a riotous drunk on a spree. This is mania. Either state may be acute (occurring rapidly and subsiding fast), recurrent, or lasting months, years or indefinitely. One state may alternate with the other. Those cases in whom the alternation is regular are suffering from what used to be termed 'cyclical insanity'. Far more often it is irregular in a quite unpredictable way. There may be many 'downs' succeeded by a 'high' or vice versa. This is M.D.P. Extremes are seen far less frequently these days because treatment and prevention have become so effective.

It is perhaps imperfectly appreciated just how much manic-depressive swings in key leaders have altered the course of history, although Fieve's charming book touches on this. It is certainly not appreciated that it was an important contributing factor in the Protestant Reformation, but that this was so becomes quite clear to any psychiatrist who reads the history of the Church (2). It is worth describing briefly.

The great Schism of 1378-1418, when there were two rival lines of popes, and for a brief while a third, fatally diminished the power and prestige of the Papacy. Had this not occurred, had the Papacy been strong, united and not impoverished by the resulting contending factions' internecine wars and subsequent supine and corrupt popes, it is doubtful whether the Reformation would ever have been precipitated, still less been successful.

Soon after the death of Gregory XI in 1378 the assembled cardinals, under intolerable pressure from the Roman mob to elect a Roman or at least an Italian pope, by a handsome consensus elected Bartholomew Prignani, the Archbishop of Bari. He accepted and assumed the name of Urban VI. Close on sixty years old, he was an estimable and distinguished gentleman in every way. He is described as learned, modest and devout and enjoyed the deserved reputation of being an extremely competent and serviceable official. For fourteen months preceding the election he had been the principal personage in the curia after the pope himself. With his election, however, came drastic alteration: What does seem certain is that from the very first day after his coronation he began to act so wildly, to show himself so extravagant in speech, that historians of all schools have seriously maintained that the unexpected promotion had disturbed the balance of his mind.

He berated the cardinals individually and collectively, told one he was a liar, another a fool, bade others hold their tongue when they offered an opinion.

When the Cardinal of Limoges appeared, the pope had to be held down or he would have done him violence, and the noise of the brawl when the Cardinal of Amiens came to pay his first homage filled the palace.

Urban boasted that he could now depose kings and emperors

This Pope whom the cardinals beheld, daily 'breathing out threats and slaughter' was not the same man at all as the peaceable Archbishop of Bari.

The cardinals were astounded at this turn of events and quickly began to have second thoughts. Quietly, one by one, they began to slip out of Rome. Banding together at Anangni they decided that the election they had so shortly before proclaimed as valid, was invalid by reason of the pressures exerted upon them, demanded that Urban recognize the fact and proceeded to elect Robert of Geneva, who called himself Clement VII.

Naturally Urban, in his hypomanic exuberance, overconfidence and arrogance, disclaimed the invitation to resign and so the whole sorry fratricidal struggle commenced.

If only a psychiatrist with a knowledge of the anti-manic properties of lithium had been on the scene it might have all been averted. And then it might not. For it is highly unlikely that Urban would have consented to 'take the cure', short of compulsion. And who could have compelled him? If you are feeling on top of the world, better than you have ever felt in your life, who can possibly convince you that you are unwell?

What caused M.D.P. was anybody's guess up to the mid-1930s. Was it 'all in the mind'? That is, was the relevant model in understanding and management a psychopathological one? Or was the condition more fruitfully understood in medical terms? By that time there was a certain amount of presumptive evidence favouring a pathophysiological or medical rather than a psychopathological explanation. The moderately beneficial effect of tincture of opium in some cases of depression, the often-times dramatic recovery, or at least temporary remission, induced by Cardiazol and later electro-convulsive therapy, all pointed towards a physical or physiological basis. The psychopathologist remained unconvinced in spite of the absolute failure of psychotherapy of any variety to influence the course of the condition. The real clincher came in 1948 when it was shown that a simple inorganic substance, of whose nature the patient could know nothing, neutralized psychosis, releasing the patient from the constraints of mental hospital confinement. This simple and singular remedy was lithium. People inevitably ask, 'Why try lithium?' a perfectly valid question. After all, why not try potable pearl, unicorn horn or crocodile dung, all esteemed remedies for various ailments in their day? It would remain a profound mystery unless one became aware of the initial and intermediate steps that led to its discovery as a potent anti-psychotic agent. Then it can be seen, with hindsight, to have been the almost inevitable result of experimental work based on an hypothesis regarding the nature of manic-depressive illness. (4)

In view of the utter uselessness of psychotherapy based on psychopathological theories in either treatment or prevention, and for the reasons just stated, a medical model seemed more attractive as an explanatory hypothesis. After all, manic and melancholic patients appeared to be truly sick in the medical sense. Were there, however, any medical conditions that would provide some sort of analogy?

There was a persuasive parallel in thyroid disease. When the thyroid gland is overactive, the patient behaves in many ways as if intoxicated, as do manics. When it is under-functioning, the patient behaves in many ways as a deprived individual, as do melancholics. Was it possible, therefore, that mania was due to some metabolic substance circulating in excess and could melancholia be explained as the corresponding deprivative condition?

But even so, how to demonstrate it, knowing nothing whatever of its properties? An obvious thought was that if mania were due to the circulation of some substance in excess, some might be excreted in the urine and demonstrable therein. The best initial approach seemed to be to use an extraordinarily crude differential toxicity test to discover whether any differences could be detected between urine samples from manics and depressives. And crude the experiment was. It involved the injection into the abdominal cavity of guinea-pigs of samples of concentrated urine, in varying amounts, from manic, melancholic and schizophrenic patients; 'normal' controls were also involved. Although the mode of death of the animals was the same in all cases, suggesting the presence of the same toxic agent, the urine from some manic patients had a far more toxic effect than that from any other group. Urea proved to be the guilty substance, but why was it so much more toxic in these manic cases? Of the other products of protein metabolism, creatinine was powerfully protective when injected together with urea. Uric acid, if anything, mildly enhanced the toxic effect but the problem was its relative insolubility in water. For this reason the most soluble of its salts, lithium urate, was substituted. Surprisingly the toxicity was far less than anticipated. Contrary to expectations it, like creatinine, was protective. So it became important to determine the effects of lithium salts by themselves. It was quickly evident that they had a powerful calming effect on the guinea-pigs. The animals remained fully awake but after about two hours they became so calm that they lost their 'startle-reaction' and frantic righting-reflex when placed on their backs. It was this observation which prompted the trial of lithium salts in that over-excitable state of mania.

The very first patient ever deliberately and successfully treated with lithium salts was a little wizened man of fifty-one who was suffering from chronic mania. He had been in a chronic ward at the Repatriation Mental Hospital, Bundoora, Victoria, for five years and the odds were heavily in favour of his having to spend the remainder of his years therein. He was amiably restless and talkative, dirty, mischievously destructive and interfering. He was started on lithium treatment on 29 March 1948. On the fourth day he seemed to be a little calmer, but by the next day there was no doubt that he was rapidly settling down. Within three weeks he was enjoying the unaccustomed amenities and liberty of a convalescent ward. As this was a first case he was kept under observation and treatment for a further two months then, remaining perfectly well, was discharged from hospital on small maintenance doses of lithium to return to home and work.

And so lithium, after its dubious beginning in medicine and its disastrous apparent finale, was launched again – precariously it is true – as a powerful psychotropic drug in the control and prevention of affective or emotional illness. Originally it was thought to be effective only in combating and preventing manic episodes but the Danish workers, Schou and Baastrup (5), have subsequently found that it is extremely effective in preventing depressive swings as well; the 'lows' as well as the 'highs'.

Unfortunately one of the major problems about schizophrenia and M.D.P. is that not infrequently they mimic each other closely. Worse, there is no specific diagnostic test. Diagnosis must be made on purely clinical grounds, that is, the symptoms and behaviour of the patient. If the doctor makes the wrong diagnosis the result is disastrous, for what is effective treatment for the one is quite ineffective for the other.

Diagnostic criteria vary from one part of the world to another. Recently an Australian psychiatrist, trained in Western methods and familiar with the use of lithium, was conducted through a mental hospital in Jakarta. In one chronic ward an attractive young female patient accosted him and said, 'I can see you are a wonderful doctor. When can I go home?' He asked, 'How do you feel?' to which she replied, 'One hundred and fifty percent', a typically manic response. Soon after he asked the doctor in charge about the patient's diagnosis and was astonished to be told that it was 'chronic paranoid schizophrenia'. She had been in the ward for a long time and was going to remain there a long time. The visitor diffidently suggested that in his country her illness would have been called chronic mania, treated with lithium, and that she would have been home within three weeks, completely recovered. He pursued the matter of diagnosis in such cases further with another Indonesian colleague. His friend agreed that it was indeed so – M.D.P. was hardly ever diagnosed. The trouble was that in the early years of this century the great German psychiatrist Kraepelin, on a brief visit to the country, when quickly shown the large mental hospital at Bogor just south of Jakarta had announced, 'All your patients are chronic schizophrenics. You have no manic-depressives'. Ever since, the Indonesian doctor said, the Dutch psychiatrists in the country had re-echoed that dictum. Not that it mattered very much from the patients' point of view as lithium was not available anyhow.

By contrast the same Australian psychiatrist visited New York later that year and was introduced to the best-known lithium clinic in that city and country. There he spied an elderly lady patient in the waiting room. She was abstractedly and persistently plucking at her cheek. The chief of clinic spoke to her but she failed to respond, immersed completely in her useless repetitive activity.

It would have been obvious to any beginner who had seen the inside of a long-term mental hospital that she was exhibiting the symptom of 'stereotopy of movement', so characteristic of some regressed schizophrenics. The chief admitted rather wistfully that this was the case, but that she had been almost literally plucked off the street as apparently suffering from agitated depression and therefore a possible candidate for lithium treatment. He confessed that they had been so successful in their treatment of affective illness (M.D.P.) that there was now a tendency to over-diagnose the condition, whereas up till relatively recently – according to British diagnostic criteria – schizophrenia had been over-diagnosed in the U.S. and M.D.P. under-diagnosed. It seems in short that if treatment for a specific condition is dramatically successful there is a marked tendency to over-diagnose it, whereas if the treatment is not available, diagnosis of the condition is less likely – after all, what difference does it make.

At the present day there are, throughout the world, lithium clinics where millions of manic-depressives are being maintained in normal health on the basis of a periodic brief out-patient visit, when lithium blood levels are monitored and dosage schedules reviewed. Formerly these victims of the illness would have had to endure, throughout their lives, the agonies and frustrations of repeated admissions, often compulsory, to mental hospitals.

1. A. B. Garrod, Gout and Rheumatic Gout (Walton & Maberley, London, 1859), p. 438.

2. R. R. Fieve, Mood Swing (Wm. Morrow, New York, 1975).

3. Philip Hughes, A History of the Church (Sheed and Ward, London, 1955), vol. 3, pp. 233-6.

4. J. F. J. Cade, 'Lithium Salts in the Treatment of Psychotic Excitement', Medical Journal of Australia, I (1949), p. 195.

5. P. C. Baastrup, J. C. Poulsen, M. Schou, K. Thomsen, & A. Amidsen, 'Prophylactic Lithium. Double Blind Discontinuation in Manic-Depressive and Recurrent Depressive Disorders', Lancet 2 (1970), p. 326.
Anxiety: the Universal Fate

Anxiety has been variously dubbed a state, a syndrome, a neurosis, an illness. It is none of these.

No man except a profound idiot, a chronic psychotic, or a badly brain-damaged individual has ever been totally and permanently free from anxiety. It is an inseparable part of human existence and man since the beginning of time has always sought means to assuage it. He has propitiated the gods, he has ingested tranquillizers. No one knows when the first and still most popular drug, alcohol, was first discovered – it was almost certainly, however, an accidental discovery, perhaps initially arising from the drinking of juices of fermenting fruits, fluids, or moistened grain. He has found marvellous herbs and potions including fungi, roots, leaves, flowers, fruits and gases: for example reserpine, opium, cannabis, peyote, coca and nitrous oxide. He has sought the support of his fellows, individually and collectively. He has hastened for counsel and support from wise men, sages, yogis, prophets. He has looked to the interpretation of his dreams. He has been persuaded to be relieved of his anxiety on the instalment plan or by deconditioning, in which he starts by facing a little fear and works up to confront a big one.

How can he be rid of this unease? It is a normal physiological response to awareness of a threat to one's integrity, physical, moral, intellectual or social. The threat is often imaginary but the symptoms are only too real and uncomfortable, unbearable if intense. Anxiety frequently results in lapses of concentration and apparent failing memory with the inevitable self-question, 'Am I going mad?' Worse, the bodily symptoms of anxiety – namely tension, tremor, fatigue, palpitations – in turn breed fresh anxiety and intensification of the symptoms.

This sequence of events leads people to seek help from whatever available source. If the distress is perceived as purely mental, the nearest help is often a trusted friend or spiritual adviser, or the sympathetic country sergeant of police. But if the perceived symptoms are the bodily reverberations of anxiety, it is usually, in Western society, the hard-pressed family doctor.

A patient becomes aware for the first time in his life, let us say, of palpitations. Naturally his fear is that he has heart disease. He is given a quick examination and a hearty reassurance that it is 'only nerves'. He accepts this superficially and temporarily, but then comes the further gnawing fear. Did the doctor miss something in his brief examination or, having found something, did he hesitate to tell him. So he seeks further examinations and reassurances. He 'does the rounds' always with the same result and the same response until finally in desperation he turns to, or is referred to, the psychiatrist.

If the psychiatrist has wisdom, he will give the patient ample time to detail his symptoms and fears, at least an hour on initial interview. At the end of that time the patient may well say, 'I feel better already. You are the first doctor who has really listened to what is worrying me.' But much more is required. It may be that the cause of the anxiety is real and irremovable. However, the patient can be immeasurably helped if he is given a lay explanation of the physiology of anxiety and its bodily and mental reverberations, so that he can recognize his symptoms for what they really are and know that they are not due to serious undetected organic disease. Secondly, he can be given, as a temporary measure, a tranquillizer to dampen down his symptoms to manageable proportions and help him to face up to any stress-provoking situation which he cannot avoid.

It is in this second area that such great advances have been made. A patient has always had support, explanation and reassurance. Now he has, in addition, the highly effective pharmacological support he so frequently and desperately needs.

A new class of drugs, the benzodiazepines – 'Librium' initially, later 'Valium' and subsequent related drugs – have been of incredible value to those under stress: not because they solve their problems, but because they help people to endure them. In that indirect way they often assist in their solution because so frequently a situation endured is a problem solved. All that is called for may simply be a greater ability to suppress an angry or anxious rejoinder – so often anguish is the result of strained interpersonal relationships. In a sense it is equanimity bought on prescription, which is an extraordinarily attractive proposition.

Librium, or to give it its correct chemical name, chlordiazepoxide, was first introduced into general medical use in the U.S.A., in 1960, and Valium or diazepam less than four years later. The discovery of the tranquillizing effects of these drugs has never been identified with specific persons in the historical sense. It was, rather, the end result of a long series of chemical manipulations extending over a number of years. For those who would wish to pursue the topic in more detail, the story as told by Cohen, who played a significant part in their introduction, cannot be bettered.

Anxiety states are, in the great majority of cases, successfully treated by the family physician or in a psychiatric out-patient clinic. It is only in a small minority, where symptoms reach crippling proportions, that hospitalization becomes necessary; but even in these cases, it is usually only for short periods. As an example, one such young man was admitted to Royal Park some years ago in an acute anxiety state with a unique skin condition which defied diagnosis: it was a series of several hundred little drying scabs, each about the size of a match-head, spread liberally from below his right shoulder blade down to his right hip; some had scaled off leaving normal pink new' skin. It certainly was not herpes zoster (shingles). Although resembling the healing stage it had quite the wrong distribution. He also had three tiny, stony-hard nodules under the skin of his right forearm. Personal details: occupation, farm labourer; psychiatric diagnosis, acute anxiety state; dermatological diagnosis, unknown. Unknown that is, until he supplied the explanation: two shot-gun blasts at twenty-five yards two weeks previously from a crazed fellow worker, before he had had time to take shelter behind a water-tank on a country farm. Most of the pellets had been winkled out of his skin during first-aid but the ones in his forearm had been overlooked. To conclude his record: Hospital stay – short. Progress – rapid and uneventful.

It is appropriate at this point to describe how a small but significant cause of mental morbidity was abolished by, of all things, sensible legislative action. It is unusual, to say the least, to expect that government might abolish mental illness by decree.

The use of bromides in medicine has already been described. Initially they were used in the form of the simple inorganic salts, but later the bromine atom was incorporated into more complex organic molecules. For years these 'bromureides' enjoyed a thoroughly deserved reputation as effective minor tranquillizers. So safe were they considered that they were available over the counter without prescription. Unfortunately it was insufficiently recognized by the medical profession and, of course, quite unknown to the public that bromide, whether in organic or inorganic form, when taken into the body tends to accumulate faster than it is excreted. The result is bromide intoxication. If it is severe, the patient becomes drowsy, confused and unsteady, with a muddy appearance, dry tongue, slurred speech and drunken gravity: a state familiarly known as the 'stunned goose psychosis'. A similar state can be produced by chronic overdosage with a variety of sedative drugs, of which the commonest for many years were the barbiturates. They had high habituation potential – that is, increasingly heavy doses were steadily required to produce the same effect, whether it was sleep or tranquillity. Overdosage was, in parts of the world where they were readily available, one of the commonest methods of attempted and successful suicide. Fortunately, as equally effective and far less dangerous drugs have become available, 'barbiturate' has become a dirty word amongst many doctors and, in recent years, the quantities prescribed have sharply decreased.

Unwitting excessive self-medication with the popular, over-the-counter bromureides became so common in the 1950s and 1960s in Victoria that routine screening tests of urine for bromide were done on all women admitted to Royal Park. Women were far more frequently addicted to this hazard than men, who have always relied much more heavily on alcohol. If this test was positive, a blood bromide estimation was then done. By 1970 there were approximately twelve women each month with positive blood bromides, and of these, about a quarter were in the toxic range. This meant that such patients' admission to a psychiatric hospital was directly due to the symptoms of bromide intoxication.

By August 1971 this cause of mental illness quite suddenly began to disappear. Two months previously, on 23 June precisely, the Victorian State Government enacted, and not before time (indeed they were very laggardly about it compared with other States), legislation banning the sale of bromureides freely over the counter from chemists' shops. From then on they became available only on a doctor's prescription. As other equally or more effective, non-cumulative tranquillizers, notably the benzodiazepines, were now readily available, this practically meant the end of bromides in medicine. So much so that routine screening of patients for bromides became unnecessary and was discontinued at Royal Park within a year or two. It would surely be almost unique that a form of mental illness could be successfully banned by law.

It must be devoutly wished that similar effective legislation could banish the most common and malignant addiction, especially amongst men – alcoholism. Unfortunately it seems well-nigh impossible. The prohibition era in the U.S.A. in the 1920s was a disastrous failure. It led to an astronomical rise in the boot-legging of illicit liquor and associated organized crime.

However, on the bright side, there have been solid advances in the treatment of some of the more serious consequences of massive over-indulgence in alcohol. One remarkable success has meant the practical disappearance of death from that frightful acute illness, appropriately named delirium tremens. Formerly it carried a massive mortality risk. Roughly one in every seven patients died of it. Often they died suddenly and unexpectedly on the night following admission to hospital, especially the more restless ones. Till that moment they had given no real cause for alarm concerning their physical condition. They were just found dead in bed, as in the case of cot deaths in infancy. At autopsy the only consistent positive finding was a large yellow liver, the liver of so-called acute nutritional hepatitis, nothing else.

Prisoners-of-war in the Far East in World War II suffering from beri-beri due to acute vitamin (thiamine) deficiency used to die in exactly the same way. Once this parallel was recognized, and medical instructions given that every sick alcoholic, with or without delirium tremens, must be given prompt and massive doses of thiamine intravenously, this cause of death disappeared in those hospitals which practised this (first and foremost throughout the world at Royal Park).(2)

This is well illustrated in the mortality statistics for alcoholism at Royal Park for this disease, collected over three five-year periods: 1946-50: 72 deaths; 1956-60: 20 deaths; and 1966-70: 9 deaths There have been no further deaths since 1970.

Fashions in prescribing habits as in dress design come and go. The important duty of the medical profession is to recognize any inherent dangers in popularly prescribed drugs and perhaps more especially, those that are freely available without prescription. That miserable condition of infants, pink disease, disappeared when it was finally recognized that it was due to poisoning from teething powders containing mercury. There remains, however, the problem of kidney degeneration arising from the chronic over-usage of certain popular minor pain-relieving drugs.

1. Irvin M. Cohen in Ayd & Blackwell (eds), Discoveries in Biological Psychiatry (Lippincott, Philadelphia, 1970), pp. 130-41.

2. J. F. J. Cade, 'Massive Thiamine Dosage in the Treatment of Acute Alcoholic Psychoses', Australia & New Zealand Journal of Psychiatry, 6 (1972), p. 225.
Mental Deficiency

It would be needless, indeed futile, to enter into an academic discussion as to what mental deficiency really means. All normal people can recognize the dullards and the imbeciles in their midst, as do they their very bright fellows. For practical purposes the mentally retarded can be classified in terms of severity: the mildly retarded – the dullards and feeble-minded – who need some degree of continuing social support and are teachable to some extent in the formal sense although necessarily in special schools; the moderately retarded or imbeciles, who are not so teachable but are trainable in simple tasks and personal hygiene; and the grossly retarded, the idiots who are not trainable and require total and permanent care, since they are, as it were, in a mental state of perpetual infancy.

What has happened to the hospitalized seriously defective children in Victoria since the early years of this century? The statistics for the earlier years are as defective as their subjects, but some overall figures are available, and they are staggering.

The Report of the Inspector-General of the Insane for 1905 (1) states that at the Idiot Asylum at Kew (later more kindly renamed the Children's Cottages), there were twenty-nine deaths during the year. This figure, out of a total of 308 idiot-children inmates, represents an annual mortality rate of just under 10 per cent, which is about the same as that of pneumonia before the advent of the antibiotic era. Tuberculosis was rife, and small and large epidemics of respiratory and bowel infections almost the rule. The report for 1914 gives a slight increase in the average number of patients in that institution and a modest drop in annual mortality rate to 7.4 per cent.

By contrast, the present Victorian Mental Health Authority in its report for 1972 gives an enormously increased figure of 4312 patients under care in intellectual deficiency training centres, which is simply a reflection of the vastly expanded facilities by then available. That year there were seventy-one deaths: this represents an annual death rate of just over 1.6 per cent.

One must avoid the temptation to be harshly critical of our forebears. In those years tuberculosis was rampant in the community at large and so were the other infectious diseases. It has always been an impossible task to keep severely defective children, most of them incontinent of bladder and bowel, clean the whole of the time, especially with the concomitant universality of flies, faecal smearing and relatively defective sanitation. Bowel infections were inevitable in spite of the most devoted nursing care.

Additionally, the severely handicapped are often frail and have multiple handicaps. They have therefore a diminished resistance as well as a greater exposure and susceptibility to infectious disease. Mongols are, or were, notorious in this respect.

It is instructive to examine some of the differences between then and now, as these vividly illuminate the advances that have been made in this field.

Congenital syphilis, which was a relatively common cause of mental deficiency in those earlier years, has almost completely disappeared, a major victory in itself. The reasons for this disappearance have already been described. There is little to add. Syphilis is now far less common, and is easily tested for if there is the least suspicion of its presence; it can be diagnosed with certainty in pregnant women and rapidly and successfully treated.

Not many years ago candidates for the diploma in psychological medicine were sometimes failed because their much-older examiners would ask them about the signs of congenital syphilis in a child. The examiners knew a great deal, the candidates nothing; most of them had never seen a case. It really was not very fair.

On the other hand, new or rather newly-identified causes and conditions had appeared – infective, metabolic, chromosomal and teratogenic.

Since better methods of visualizing human chromosomes became available in 1956, a whole series of gross abnormalities of chromosome number and shape has been recognized. This has led to the recognition of a new category of causes and clinical forms of congenital malformation.

Mongolism has always been with us and is a personal tragedy for the parents, especially if the mother is young and the child her first-born. The first description of the condition is usually ascribed to Langdon Down (1866) and it is now usually referred to as 'Down's syndrome'. In 1959 Lejuene (2) and his colleagues cultured skin and bone-marrow cells from these patients and reported the presence of an extra chromosome. This was the first report of a chromosomal abnormality associated with a disease entity. Since then reports of more and more abnormalities (in structure and number of chromosomes) associated with congenital defects have appeared. There are two types of chromosomal abnormality associated with Down's syndrome. The more common is more frequent with increasing maternal age, but the other can occur in mothers of any age and is the usual explanation in the case of affected children of young mothers.

Various anomalies of the sex chromosomes have now been identified. One of the commonest is 'Klinefelter's syndrome', causing genital underdevelopment; it is often associated with mental retardation, usually mild. This malformation occurs in about one in every 400 males.

Unfortunately this new knowledge has not yet been translated into effective preventive measures. There has been no diminution in the incidence of such diseases. The great problem is that it is impossible to do anything about it if the foetus or the infant is discovered to have received a poor hand when the genetic cards were dealt, short of the Herodian or Hitlerian solution.

On a more cheerful note there are three success stories, one of treatment, another of prevention and the third in training.

Phenylketonuria, a disorder in which there is an inability to properly metabolize one of the essential amino-acids, phenylalanine, is the cause of the biggest clearly-defined group of cases of low-grade mental deficiency after Down's syndrome. It was first described by A. Falling in Norway in 1934. It is a recessive characteristic, as shown by the fact that it occurs much more frequently in the offspring of first cousins (about one in 800 births), as compared with one in 20000 of the general population. If the condition is promptly diagnosed in the babe, a diet low in phenylalanine started early enough gives a fair chance of avoiding mental retardation. Thus every undiagnosed case is a tragedy and a lost opportunity.

Therefore routine testing of the blood and/or urine of new-born infants has now become normal practice in various parts of the world, including Victoria. It is so vitally important to identify not only individuals but families at risk. If one child is affected, there is one chance in four that any other child of that union will also be.

It is intrinsically unlikely that an eye specialist should make a fundamental discovery in the field of foetal malformation, and yet it was so.

Rubella or German measles is generally regarded as one of the minor infectious illnesses of childhood with few, if any, serious aftermaths. Some children escape it only to contract it in early adult life, when some of the young women may be pregnant. No one suspected that this minor illness, minor that is for the mother, could have any deleterious effect on the early developing foetus. In 1941 a Sydney ophthalmologist, Sir Norman Gregg (3), with peculiar percipience, finding that he was confronted with almost a small epidemic of childhood cataracts, went meticulously into the history of the pregnancy of the mother of each affected child and was astonished to find that the single common pathological episode was that each had contracted rubella early in pregnancy. Since then rubella has been linked to various other congenital defects, particularly deafness and heart abnormalities, and, in some, mental retardation; this last is not usually severe and perhaps at least partially attributable to sensory deprivation of varying degrees of sight and hearing in these children.

And so Gregg opened a new and fascinating chapter in the history of foetal abnormality and, therefore, of mental deficiency. The beauty of the discovery is that it has led directly to a simple means of prevention. Older girls and young women who have not already had an attack of the naturally occurring disease are vaccinated with rubella vaccine before the likelihood of pregnancy.

Lastly, there has been an increasing recognition this century that even the moderately severely mentally retarded are far more trainable than was once thought. It is amazing what tasks even imbeciles can tackle successfully given systematic job analysis and work lay-out, and simple assembly techniques. It is even more amazing what a transformation in morale and behaviour is wrought in those children who are given the opportunity to participate in these special sheltered workshop conditions, as they realize that they, too, can really work just like their better endowed brothers and sisters; that they, too, can enjoy the dignity of contributing to their own support and the general welfare.

1. 'Report of the Inspector-General of the Insane' (tabled annually in the Victorian Parliament).

2. J. I.ejuene, M. Gautier, & R. Turpin, C.R. Academy of Science (Paris, 1959), pp. 248, 602.

3. N. McA. Gregg, Transactions of the Ophthalmological Society of Australia, 3 (19-11), p. 35
The Great Thinkers

In the preceding chapters the great discoveries have been described, and mention made of those happy discoverers who were fortunate enough to have contributed directly to the mental health of millions; but these miracles of medicine could not have been achieved had it not been for the existence of the infra-structure, the support system of evolving psychiatric knowledge.

Progress in any field is the fruit of many hands and many minds. Behind the discoverers are the observers, the thinkers, the experimenters and the pragmatists, who translate observation, theory and discovery into practical patient care.

The observers and recorders are the gatherers of facts, or as far as medicine is concerned, the shrewd and patient clinicians, the front-line troops in the never ceasing battle for mental health. They look at their patients long and closely, document in meticulous detail their observations, and record symptoms and outcome, i.e. prognosis. They refine and define what they see. Such are the great systematists of whom Kraepelin and Bleuler are supreme. Their work is essential, though they may make no discovery of any note. Neither Kraepelin nor Bleuler did. But they defined categories of illness, and prepared the way for more detailed investigations of those they described and isolated.

Emil Kraepelin (1856-1926), the great German psychiatrist, was almost an exact contemporary of Freud. Probably his greatest contribution was to sharply separate the two major constitutional illnesses, manic depressive or affective disorders, and what he called 'dementia praecox' and its sub-types. How important this was only became apparent many years later when it was shown that what was specific treatment in the one was quite ineffective in the other.

The Swiss, Eugene Bleuler (1857-1939), further revised the whole concept of dementia praecox and was responsible for renaming the condition schizophrenia or 'split mind'. But more importantly he seriously and correctly contested the Kraepelinian implication of incurability and gave real hope to thousands.

From the clinical observer and recorder has evolved the non-clinical recorder of systematically collected data, who patiently sorts, counts, measures and compares the facts fed to him. He may never see a patient in the flesh. He probably would not even know how to interview and examine one, still less attempt a diagnosis. He does not need to be trained in psychiatry but he must be an expert in the field of public health and statistical method. This is the epidemiologist, who measures the incidence of various illnesses (in this case mental illness) and the differential increases or decreases in various samples of the population. He both measures current trends and attempts to predict future ones. He is an essential right-hand man to the administrator planning the development of mental health services to meet present and future community needs.

This activity has been especially important since the huge migration waves thrown up by the fearsome cataclysm of World War II have swept many to foreign lands. Different populations have a different spectrum of mental ill-health. On the Australian scene, it has been shown that migrants from certain European countries have an extraordinarily low incidence of mental illness due to alcoholism, and that alcoholically speaking, they are vastly healthier than the Australian-born. By contrast the incidence of schizophrenia is much higher in some migrant groups than in those born in Australia.

The epidemiologist may not discover causes but he uncovers relationships. He signposts the direction in which causes must be sought. For example, any theory purporting to explain the cause or causes of schizophrenia must explain why such differences in incidence exist amongst various population groups when divided into the sub-categories of sex, age and socio-economic status.

Then there come the thinkers, the theoreticians, the philosophers. That colossus, Sigmund Freud (1856-1939), bestrode more than the psychiatric world for over half a century and bedazzled the eyes and minds of lesser men, including not only psychiatrists but psychologists, anthropologists and even novelists. It is only in the latter half of this century that some have dared to question his dogmatic genius and have wondered indeed whether the idol had feet of clay. His theory of psycho-sexual development particularly has come under attack. For a long time many paediatricians found themselves unable to discern the stages he described in the child, and as a result became afflicted with acute inferiority feelings. Then someone dared to ask whether it was really as described by the master and the flood-gates of scepticism were unlocked.

As far as real mental illness – as described in these pages – is concerned, Freudian theory and practice has been completely irrelevant. It has prevented no victim of such from entering a mental hospital nor has it rescued any from one. Many may violently disagree with this bald statement but it is the simple truth.

In spite of this stricture Freud has made a major contribution to the care of troubled minds, if not sick ones in the medical sense. He has shown how necessary it is to spend endless hours painstakingly attempting to discover how the personality evolves, the need for the therapist to unravel the complex strands of his patient's psycho-social development: to reveal what are the dynamics, the moulding influences, and how the person was shaped by them and is still reacting to them – how indeed he is reacting to the therapist just as the therapist is reacting to him. If the great systematists were the anatomists of mental illness, Freud was the embryologist of the mind in health and disease. It is interesting that Freud, Kraepelin and Bleuler were all born within a year of each other.

Freud's two erstwhile disciples, Carl G. Jung and Alfred Adler, who, deserting the parental fold, were more or less disowned by the father figure, still have their followers, if rather less numerous. Jung's free-association technique, his classification of mankind into introverts and extroverts, and his theory of archetypes and the collective unconscious of the human race still have a great attraction for some, particularly perhaps amongst the ranks of the social anthropologists. Adler believed that the will to power was the most fundamental and potent element in our nature (no doubt Hitler, Mussolini and Stalin would have agreed), and was the apostle of the inferiority complex.

In the United States one of the really great figures was the Swiss-born Adolf Meyer (1866-1950), who was professor of psychiatry at Johns Hopkins in Baltimore for many years. He had a profound influence on psychiatric thought, teaching and practice. He taught the psychobiological approach, which meant the detailed study of the individual personality of each patient in the context of his total social environment. In this respect he resembled Freud but, unlike him, he avoided the temptation to invent his own abstruse technical jargon.

The teaching of both Freud and Meyer was vastly important in patient care. Both insisted on a careful and time-consuming assessment of the patient's psychosocial development. This may be relatively unimportant in the treatment of psychoses or major mental disorders where constitutional predisposition is often overriding, or toxic or infective factors are paramount; where treatment is simply a matter of correcting abnormal body chemistry or combatting the physical illness which is causing the patient's mental symptoms. It is, however, an essential approach when it comes to the successful treatment of so-called neurotic illness and especially character or personality disorders.

Karl Jaspers was Meyer's German counterpart and had a powerful influence on European psychiatric thought. Unfortunately, his writings are so convoluted and obscure that it is extremely difficult for the ordinary doctor and student to follow them.

Amongst the thinkers must be included the typologists, those who attempt to group mankind into categories on the basis of either mental or bodily characteristics. Jung was one such with his division of people into introverts and extroverts, but this is merely to say that some people are more sociable than others. Another, who enjoyed enormous vogue in the 1920s and 1930s, was Kretschmer, with his famous book Physique and Character. (2) Briefly, he classified people into certain physical types and attempted to relate these types to predisposition to particular forms of mental illness. On the one hand there were the 'pyknics', with short, thick-set body build and a tendency to obesity and high blood pressure in later life. They allegedly were more likely to be predisposed to develop a manic-depressive illness if they ever became psychotic. On the other hand, there were the athletic, asthenic and 'dysplastic' types, whose predisposition was towards schizophrenia.

But an Englishman, Sheldon, capped this. On the basis of careful anthropological measurement, he divided mankind into three physical and temperamental types according to the apparent preponderance of one of the three primary embryonic layers from which all animals develop. He labelled them endomorphs, mesomorphs and ectomorphs. He correlated these with three corresponding physiological types – the viscerotonics, the somatotonics and the cerebrotonics. Now this may seem profound. But would it be unkind to suggest that if these esoteric terms are translated into the Anglo-Saxon vernacular, and we find that the human race has been divided into jelly-bellies, muscle men and egg heads, the apparent profundity wanes somewhat?

The whole fallacy about typological characterization is that it is a veritable Procrustean bed. Having constructed your bed you trim your victim to fit. The fact is that mentally sick patients, whatever their illness may be, come in all shapes and sizes. Typological research is not a very rewarding occupation, at least as far as psychiatry is concerned.

Next come the scientists. The huge figure of the Russian bear overshadows all. Ivan P. Pavlov (1849-1936) has had a more profound influence on thought manipulation or mind-bending than any other man in the history of the human race. He of course did not intend it so. He was essentially a physiologist who attempted initially to carefully measure the conditions that determined secretion in certain glands of the digestive tract. From this he was led to the study of conditioned reflexes, i.e. those signals that enhanced and those that blocked natural reflex secretion. From this work on animals (and in this field man is only another animal) stemmed all the techniques of behaviour and aversion therapy, conditioning and deconditioning. At first only of interest to physiologists, it later began to concern physicians, then psychiatrists, and last and tragically it has finally become a powerful weapon in the hands of totalitarian regimes and their secret police as a technique for political conversion or 'rehabilitation'. William Sargant has given a vivid account of all this in his well-known book Battle for the Mind. (2)

Cardinal Mindzenty, when he was arrested by the communist regime in Hungary, recognized, aware as he was of these sophisticated techniques of brain-washing, the inevitability of his own 'conversion' and warned his flock that any of his pronouncements from then on simply could not be believed. He knew that he must bow to this sort of duress. Practically no one but a completely psychotic or demented person can withstand it.

Parallel to this but in many ways different is the now nearly passé fashion of using 'truth drugs'. This technique was enormously popular for some years during and after World War II as 'a short cut to the unconscious', the lancing, as it were, of the psychological abscess and the freeing of the patient from all the inhibitions, conflicts, anxieties and traumas that presumably had produced his current symptoms.

It seemed to work in battle neurosis. Soldiers would relive traumatic episodes and the associated emotional agony, and be vastly relieved. It did not seem to be realized that the real therapeutic results were just as likely to be due to the soldier's removal to a rest area, the consequent relief from battle stress, and a convenient hook to hang his symptoms on. The procedure spread to civilian practice and was regarded as some sort of panacea. At least it gave an aura of respectability and drama to the therapeutic situation. However, it slowly dawned on more sceptical psychiatrists that they had been deceiving themselves. The use of such a technique, which involved giving either a sedative or stimulant drug into a vein, was really a confession by the psychiatrist of his inability to communicate meaningfully with the patient at a fully conscious level. It was on this point that Carl Rogers' teaching was so important. In brief, he claimed that if the patient perceived his doctor as an empathetic and informed individual genuinely interested in helping him in his distress, he would freely and thankfully give all the relevant information. If the patient did not so perceive his doctor, he would tell him only as much as he thought it good for him to know. And this was irrespective of the doctor's theoretical framework of psychopathology.

That this was indeed so was demonstrated to their own satisfaction by a group of psychiatrists. Each concocted a fictitious autobiography and the challenge was to maintain this lie whilst a 'truth drug' was administered by a colleague. None had any difficulty in doing so with one notable exception. He was such a completely truthful person that, like George Washington, he could never tell a lie. He spilled the beans immediately. One of the group had at the time a patient who was a pathological liar. She was given the stimulant drug Methedrine intravenously, a standard technique. Certainly her thinking and talking were accelerated and she produced reminiscences and secrets at an enormous rate but when they were checked, it was simply found that she was lying faster than she did without the drug!

Amongst the scientists the German, Hans Berger, must rate highly. He was the first, in 1928, to record 'brain waves', the electrical patterns that the brain emits in its manifold activities, awake or asleep, in sickness or in health, at any time short of death – namely, the electroencephalogram (E.E.G.). It has proved a most useful diagnostic tool in the hands of neurologists and psychiatrists, particularly in various forms of organic nervous disease. Years later it was Dement who used this tool to look at the physiology of sleep and dreaming, and came up with the beginnings of the exciting new knowledge of the various depths of sleep and how they are reflected in the differing electrical patterns emanating from the brain. Dreaming and its association with rapid-eye-movement (REM) sleep has now been extensively investigated, and much valuable work done on the importance of the dream state for normal mental function. How all this translates into improved patient care is still not clear but important clues are emerging.

Child psychiatry has been a fruitful and burgeoning field. Advances in the study of mental retardation have already been described. Detailed observation of child development has been extensively documented and is now perhaps far better understood. But in spite of this recognition, are we any more effective in helping the autistic child, the child-battering parent, or the child with school phobia than our great-grandparents of a hundred years ago? Certainly we can identify problems more readily and measure them more accurately but are we any more effective except in the prevention and treatment of organic diseases of childhood and their psychiatric sequelae? At least we can help the bed welters simply because an effective drug has become available, and we can most times prevent mental deficiency in, let us say, phenylketonuria (PKU) or cretinism by early recognition and treatment. We can measure reasonably accurately how bright kids are, or how dull, and assist them accordingly. We know the problems of the .hyperkinetic child and may help a bit because some drugs are moderately useful. But given all this, there is no evidence to show that the offspring of psychiatrists and psychologists are any better adjusted now than the children of lesser men, in spite of the spate of theoretical knowledge that has accumulated. The big advances, it seems, can largely be attributed to physical rather than psychological medicine.

There have been major studies in social anthropology and in transcultural psychiatry. Such culture-bound syndromes as latah, amok and koro have been brought by our Asian colleagues to the attention and understanding of Western-trained psychiatrists. Margaret Mead's studies on child-rearing practices in different cultures and their influence on subsequent personality development are well known, if open to various criticisms. There have been many sophisticated studies of the tribalized Australian Aboriginal and other indigenous populations, but all these have yet to bear fruit in the form of improved mental health programs. Yet they do repeatedly emphasize the need of knowledge as the basis for effective preventive, diagnostic and therapeutic work in these fields.

Ethology, or the study of animal behaviour, is a fascinating subject in its own right. Anyone who has the least interest should read Konrad Lorenz's book 'On Aggression'.(3) No doubt the aggressive behaviour of the brightly-coloured coral fish in defending its territorial rights is highly relevant to the ardent human nationalist and xenophobe. Certainly knowledge of the critical and transient 'imprinting' phase in very young animals is relevant to learning theory in the human species. Lorenz had first-hand experience of this phenomenon: he became the adoptive mother of a graylag goose which he personally reared as a gosling fresh from the egg. As he put it, it 'transferred to me, by that remarkable process called imprinting, all the behaviour patterns that she would normally have shown to her parents'. It is alleged, whether with malice or not, or correctly or not, that the Jesuits used to boast 'give me a child till he is seven and he is mine for life'. This is merely a restatement of the ancient aphorism 'as the twig is bent so the tree shall grow'.

It is a sad commentary on the theory and practice of psychiatry that there has arisen relatively recently a virulent and powerful school of anti-psychiatry. The reasons are multiple and complex. One is undoubtedly the conscious or unconscious resentment generated by the cloak of infallibility; this has been partly self-generated by psychiatrists and is partly the result of the uncritical acceptance of their more exuberantly optimistic therapeutic claims in the law courts, many of which have subsequently been proved to be disastrously untrue, especially as far as relapse in cases of serious anti-social behaviour is concerned. But most of all the reaction has been due to the influence of various civil liberty movements in protest, amongst other things, against involuntary committal procedures and involuntary treatment of the mentally ill. Unfortunately it is only too true that committal or 'certification' does deprive such people of fundamental freedoms (as has already been mentioned), temporarily in most cases, permanently in a small minority. Additionally there may be a life-long stigma, even for those who recover. Their friends and families thereafter tend to regard their behaviour with suspicion. In many countries they have to declare the fact of previous mental illness in any application for public employment, to their own prejudice.

The Scottish heresiarch, psychiatrist R. D. Laing, and his American counterpart, Thomas Szasz, have added fuel to the flames by their various controversial and inflammatory books on the general theme of the myth of mental illness. They claim that 'mental illness' is a social artefact and convention; that victims of such have been trapped by others for their own social and political purposes; that social pressures attack and confine them and that their 'illness' is an understandable reaction to such intolerable pressures. This all has a certain plausibility especially in view of the use that some totalitarian regimes make of psychiatric techniques in the disposal of dissidents. The concept of schizophrenia has been most under attack from this direction but, as Seymour Kety has pointed out in rebuttal, it is a strange sort of social disease that has a well-defined genetic component. ECT as a method of treatment has also come in for particularly virulent criticism. It is exceeded only by the vehemence of the opposition to any sort of psychosurgery, which is understandable enough, especially if there is any hint that it is being carried out in a confined population as a condition of release.

The really sad result of this point of view is that sick people are being persuaded or coerced into refusing treatment which, if given, would have cured their illness in a short time, and that the privacy of patients in hospitals is being intruded upon. However, all this criticism and opposition does serve a useful function. It forces psychiatrists to define and defend their diagnoses, their judgements, their actions. There could be no better health-promoting exercise for psychiatry.

1. Kretschmer, Physique and Character (tr. Sprott) (Kegan Paul, Tench, Trubner, 1925).

2. W. Sargant, Battle for the Mind (Heinemann, London, 1957).

3. K. Lorenz, On Aggression (Methuen, London, 1967).
Today and Tomorrow

The advances that have been achieved in psychiatry since 1900 have been quite remarkable, indeed almost unbelievable. Despair and public repugnance have given way to hope – hope that is well founded on the increasingly successful methods of combatting and understanding many of the great variety of disorders commonly grouped under the unwieldy and meaningless term, mental illness.

This is manifest in the steadily increasing proportion of people who voluntarily seek psychiatric treatment either as an in-patient or out-patient, or on a consultative basis. The great majority of patients are now admitted to Royal Park voluntarily. A quarter of a century ago, only about one-fifth of the total admissions were voluntary.

It is difficult to see how some patients can ever be admitted except on a compulsory basis, now or in the future. The very nature of some major psychiatric illnesses precludes insight. Although the person may be disturbed, erratic and to others obviously in need of care and treatment – either in his own interests or for the protection of others – he may be completely unaware of this. He is sick but does not realize it. To use an old-fashioned term, he is 'alienated'. His reason and judgement have departed to a greater or lesser extent. He is quite incapable of giving informed consent either to hospitalization or treatment.

It cannot be pointed out more strongly that under these circumstances, where a doctor is unable to establish communication with his patient (whether for reasons of the patient's infancy, idiocy, unconsciousness or mental illness), the doctor has a common law obligation to act in what he believes to be the best interests of his patient, and to act with reasonable care. This may well involve certification and compulsory detention of the patient in a psychiatric hospital for observation and treatment.

It is hard to see why having to enter a psychiatric institution should stigmatize a person. It is something that could happen to anybody. A question that is sometimes asked of medical students during psychiatry tutorials is the provocative one: 'Have any of you ever been psychotic (that is "insane")?' The answer is almost always a universal negative. Rephrase the question thus: 'Have any of you ever been delirious as a child?', and a number of hands are raised.

So it all boils down to an understanding of what the stigma of insanity really involves. Delirium is just as real and alienating as schizophrenia. It is all a question of durability and curability. If schizophrenia were as evanescent as the common cold or the delirium of fever it would carry no stigma.

Fortunately schizophrenia is now far more curable, or at least containable, than it used to be. Early in the century it used to be stated that roughly 23 per cent of patients diagnosed as suffering from schizophrenia would spontaneously recover. Today, with modern treatment, recovery or remission would be estimated at 85-90 per cent. Many require long-term or indefinite medication, it is true, as do diabetics, but they remain well, their only constraint being an occasional out-patient visit for review and adjustment of medication. Admission to hospital is now largely a measure of last resort, and very temporary at that, for more intensive restabilization. As a result, the stigma attached to schizophrenia has been largely dissipated.

What changes have these advances in treatment wrought? Consider Royal Park as late as 1952, still a grimly custodial institution with keys jangling in every lock, padded rooms for the acutely disturbed, the standard mass bathrooms and dormitories, and high, guardian, hair-pin-steel fences around the 'airing courts' or ward exercise gardens. Most patients were admitted routinely to a closed acute observation ward to be stripped, searched, inspected and bathed. It just did not seem to occur to anybody that people were being subjected to almost the ultimate affront to human dignity. It all seemed so necessary at the time.

By contrast, the admission procedure in a psychiatric hospital is now a very civilized process, with an informed but informal and friendly welcome, reception and assessment. The vast majority of patients are now admitted directly to a completely open ward and are never under lock and key. It is still true and doubtless always will remain so, that a small minority of acutely disturbed, aggressive or suicidal patients have to be admitted to a closed, constant-observation ward for a short while until their turmoil subsides. It would be criminally remiss not to afford them this protection.

But hospitalization, it must be repeated, is now regarded as simply an interim and emergency measure. Unless patients are permanently brain-damaged or belong to the small minority of therapeutically resistant schizophrenics requiring long-term care, they return to the community and their families in a very short time.

The modern psychiatric hospital is a pleasant place, usually situated in spacious grounds. Daily therapeutic programs – occupational and recreational – are carefully organized. Not only is treatment, medical care and accommodation completely free, but patients receive sickness benefits during the time of their illness. It is hardly to be wondered at that some people are attracted to this life of relative ease and freedom from responsibility, and are resistant to the thought of discharge from such an environment, reluctant to face the responsibilities of an independent life in the community again. Herein there is a trap for conscientious and tender-hearted staff. Some tend to foster dependency reactions in their patients, quite unwittingly, and fail to encourage positive roles and independence.

There has been a dramatic change in the constitution of the mental hospital population since the beginning of the century. Then well over half the total number were chronic schizophrenics destined to be life-long residents; there were also considerable numbers of chronically depressed and manic patients, and many G.P.I.s, descending rapidly into dementia and death. The senile infirm represented a relative minority of the population, because they did not live long – infectious illness, nearly always respiratory or gastro-intestinal, carried them off quickly. There was almost always a 'refractory ward' for the chronically disturbed. In various wards it was common for mental defectives of varying grades of severity to be mixed in with the psychotics and demented. The less retarded, however, were usually regarded highly by the staff because they were such reliable ward workers. It is true that in many hospitals there were special 'idiot wards' for the severely retarded, but apart from the Children's Cottages at Kew, there were no separate institutions to cater for the special needs of the intellectually handicapped.

Today general paralysis has, for all practical purposes, disappeared. There are few manics and depressives who are not maintained in normal health on a domiciliary or out-patient basis; far more schizophrenics can be satisfactorily stabilized in good health and prevented from drifting into a chronic condition and long-term hospitalization; and there are completely separate hospitals for the care of those more seriously retarded who require continuing institutional care. But there has been a vast proportional increase in the percentage of patients suffering from senile and arteriopathic dementia, for the twin reasons that far more people are growing into old age and that there is a much lower death rate from infection amongst the aged infirm. As a result of this some mental hospitals have been converted entirely to geriatric use and, in others, increasing numbers of wards are being converted for this purpose.

The vast therapeutic advances that have occurred have been responsible for equally revolutionary changes in psychiatric hospital design and function, and in psychiatrist and psychiatric-nurse training. Numerous university departments of psychiatry have been founded with an emphasis on teaching and research. Psychiatric-nurse training schools have multiplied. In the first instance these were always entirely within the psychiatric hospitals themselves, but recently they have started to move at least partially to colleges of tertiary education, a far cry from the time only forty years ago when the total training of the psychiatric nurse was twelve lectures annually for three years!

The century has seen the rise of the paramedical professions – occupational and speech therapy, physiotherapy, social work, clinical psychology, remedial teaching – of interpreter and full-time chaplaincy services and of various specialized medical, neurological, dental and laboratory departments.

Most importantly it has been possible to achieve what was formerly impossible, to decentralize and regionalize mental health and mental deficiency services. Out-patient departments were developed initially within the psychiatric hospitals themselves, largely to follow-up former in-patients of that hospital, but increasingly to assess and treat new referrals. Later, out-patient clinics were evolved for either general or specialized psychiatric services, including emergency advice, and were quite divorced from hospitals. Recent years have seen the evolution of community mental health clinics, strategically situated to give direct and immediate consultative care to the local population, liaising closely with other social and helping agencies in the community. Both in-patient and out-patient departments of psychiatry within general hospitals (which are quite independent of government-controlled mental health services), have become increasingly numerous and more functionally important in making a major contribution to the general as well as the mental health of the community.

Lastly, many patients are, with the powerful psychotropic drugs now available, treated eminently successfully by their family doctor when formerly they would have drifted deeper and deeper into mental ill-health to the extent that they had to be hospitalized.

It is much easier to document the past and present than to predict the future. All one can usefully do is point to the current unsolved problems and major causes of mental morbidity and ask, 'From what directions are solutions likely to come?' The answer of course is that they can come in the most unexpected ways as they have always done, and also, in some cases, by sensible social action within the framework of existing knowledge.

Schizophrenia remains only peripherally solved. The great advances in empirical treatment have not been matched by an understanding of its essential cause or causes. Almost certainly, current argument and sometimes bitter debate will not be resolved until someone comes up with a simple and specific solution. There is certainly a genetic factor involved, but there is little doubt that there are environmental causes also and it is anybody's guess as to the direction in which to search. My own view is that in most cases schizophrenia is truly a medical illness, and that the answer will come somewhere from research in the fields of medicine, physiology or neuropharmacology.

If one were asked to nominate the four major unsolved problems in contemporary Western medicine, few would quarrel with the quartet, schizophrenia, malignant neoplasia, atherosclerosis (with its disastrous effects on brain and heart), and senile cell atrophy.

It may well be that the answer to the prevention of senile deterioration will come from the field of general biological or immunological research, just as the prevention of atherosclerosis is, on the face of it, most likely to come from a pathologist, biochemist, haematologist or dietician. But they could conceivably both come from an herbalist or native healer. Let us not forget that digitalis came into medicine in the eighteenth century for the treatment of heart conditions simply because a wise English physician, William Withering, was humble enough to accept the fact that an old woman of Shropshire, a skilled herbalist, was more successful than he in the treatment of dropsy – examining with great care her herbal preparation, he came to the correct conclusion that it was the infusion of foxglove which contained the active ingredient. Or, for that matter, that quinine came into medicine from the herbal lore of the Peruvian Indians and was transmitted to Europe by the Spanish Jesuits who accompanied the conquistadors of that country. An infusion of the bark of the cinchona tree, so-named in honour of the Countess of Chinchon, wife of the Spanish viceroy, was esteemed a sovereign remedy for fever. Indeed it was, but only for a certain type of fever, that caused by malaria. This was only discovered three centuries later, in the nineteenth century, when the malarial parasite was first identified in the blood.

There are two further major current causes of psychiatric disability still to be overcome. Both are good examples of the sort of problem which must be solved by the application of existing knowledge and enlightened legislation rather than by new discoveries. The first is the fluctuating problem of addiction to various drugs whether socially sanctioned (such as alcohol or tobacco) or socially frowned upon (either the widely used marihuana or the less-often-used but more pernicious major addictive drugs: morphine and its derivatives; cocaine; and the hallucinogenic drugs, natural or synthetic).

The other is the tragic consequence of brain damage due to motor vehicle accidents, most likely to occur in young people often on the threshold of careers of great promise.

And so the world goes on: as old evils are conquered new ones appear. There will always be challenges to man's mental integrity to observe, identify, overcome and prevent. It is doubtful that psychiatrists will ever be unemployed.
Afterword

Here is a fascinating perspective of psychiatric illness as it was in the 20th century. It is written by the psychiatrist Dr J. F. J. Cade who is world famous for his discovery of the lithium treatment of manic depression – now known as bipolar disorder. He also discusses schizophrenia, anxiety, epilepsy, melancholia, masturbational madness, ECT and leucotomy, and describes the evolution of mental asylums.

When this book was originally published in 1979, mental illness was a closed book to the general public. It is not surprising that in that climate of widespread ignorance, mental illness was a taboo subject. It was rarely mentioned in the media, useful information and professional help was hard to find and so it was not a topic for open discussion.

Dr. Cade gives a lucid account of the false theories and beliefs, mistaken practices, the many discoveries and the advances in the field of mental illness up to that time. He presents an account of the first specific psychiatric treatment for bipolar disorder (at that time called manic depression), namely lithium salts but he refrains from mentioning that he made this discovery himself.

There has been much progress in the 36 years since then. These days we are all aware of the frequency and significance of mental illnesses which have at last, well and truly, come out into the open.

Various aspects of mental illness are now drawn to our attention every day. Everyone has some familiarity and empathy with bipolar disorder and with schizophrenia. Information about these and other mental disorders is readily available and easily found in printed texts and on the internet. There are contact persons and focus groups within the community who are willing and able to help sufferers of mental illnesses and their families to recognize the nature of their problem and to assist them in finding professional help.

Psychiatry has indeed come a long way in the 36 years since this book was first published and it is interesting to be told by this psychiatric pioneer where it has come from.
About the Author

The late Dr John F. J. Cade wrote this book in 1979. It is now out of print and his four sons (Jack, David, Peter and Richard) are re-publishing it here, with the added 'Afterword' and 'About the Author', as an eBook. Many people with an interest in mental illness may not have had the opportunity to read this book when it was available in print form.

The following references will take you to sites where there is considerable further information about Dr Cade.

https://en.wikipedia.org/wiki/John_Cade – this is an extensive Wikipedia entry and photo of the Cade Wing at Royal Park

http://adb.anu.edu.au/biography/cade-john-frederick-joseph-9657 – bio. of J. F. J. Cade in Australian Dictionary of Biography with above photo

http://www.eoas.info/biogs/P004692b.htm – this is a Biography of Dr Cade

http://www.onlymelbourne.com.au/john-cade-dr#.VbmZN5Uw-ig – this has other links e.g. to bipolar lives.com

www.bipolar-lives.com

https://www.ranzcp.org/About-us/About-the-College/Our-history/Presidents-of-the-College/John-Cade.aspx – this has a different photo of John Cade on a sofa at home (taken by DCC)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560740/ John Cade's 1949 MA Li article – this is the original article of 'Lithium salts in the treatment of psychotic excitement'. 1949

Journal of Mental Science, LXIX (1923), p. 434. Also quoted in H. Devine, Recent Advances in Psychiatry (Churchill, London, 1929), p. 31

Mending The Mind was first Published 1979 by Sun Books Pty Ltd

South Melbourne, Victoria 3205, Australia

Copyright © J. F. J Cade 1979 National Library of Australia cataloguing in publication data

Cade, John F. J.

Mending the mind.

Index.

ISBN 0 7251 0329 9

1. Psychiatry – History – 20th century.

I. Title.

616. 89' 00904

This book is sold subject to the condition that it shall not, by way of trade, be lent, re-sold, hired out, or otherwise circulated without the publisher's prior consent, in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser.

Typeset in 'Monotype' Baskerville, Series 169 by

Dudley E. King, Melbourne

Printed in Australia at Griffin Press Limited
