Richard Mahony — the misfortunes of younger onset dementia

Ultima Thule, the third volume of the Australian trilogy The fortunes of Richard Mahony1 by Henry Handel Richardson (the pen name of Ethel Florence Richardson), was published in 1929 to critical acclaim. Although critics have long noted that Richard Mahony’s mental decline was modelled on the author’s father, Dr Walter Richardson, who died of general paresis of the insane (GPI),2 there has been little recognition of Richardson’s description of the evolution of dementia and the effects it had upon her family. It is timely to examine Richardson’s accomplishment in the context of renewed interest in younger onset dementia.3

The first two volumes of the trilogy, Australia Felix and The way home, are a fictionalised account of Dr Walter Richardson’s life as a general practitioner on the Ballarat goldfields and in Melbourne, his financial success and return to Europe, and his subsequent ruin. Mahony is portrayed as an eccentric character — temperamental, indecisive, and inclined to make decisions based on inadequate consideration of the issues involved and the effects on his family.

In Ultima Thule, Richardson focuses on Mahony’s psychological challenges — the difficulties in re-establishing his medical career back in Australia, the pressures of being a parent to young children in middle age, and the shame of financial embarrassment. In this context, his initial symptoms of dementia — subjective and objective memory changes, irritability, and coarsening of personality — could be understandable as a consequence of the strain that the 49-year-old Mahony was experiencing.

Mahony’s attempts to re-establish his medical practice, first in Melbourne and then in a declining mining town, are unsuccessful. His behaviour is often odd — he walks around, head bowed, talking to himself. He is emotionally labile — full of guilt over his debts, and mourning the death of one of his daughters (from dysentery) with nocturnal visual hallucinations. Cognitively, there are episodes of disorientation and aphasia over a period of several years.

Mahony finally becomes aware of the neurological nature of his disorder and consults a physician, who confirms his fears. He communicates the diagnosis only obliquely to his wife, Mary, who puts it all down to hypochondriasis. Eventually, Mary realises that Mahony’s increasing symptoms of depression, suicidal preoccupation, somatic complaints, insomnia and inappropriate social behaviour must have an underlying medical component. There are parallels here with the present-day challenges of diagnosing dementia in younger age groups, with the average time to diagnosis being 3.4 years.4

Mahony rapidly declines — disinhibited behaviour becomes prominent, his language skills deteriorate further, and he has difficulty in recalling autobiographical events. He experiences cutaneous anaesthesia in his legs and has an apoplectiform attack. After consulting his physician, it becomes clear to Mary that Mahony will be unable to work again. She finds a position as a postmistress and arranges for Mahony to be cared for in a private hospital, until financial constraints force her to transfer him to the public asylum.

The contrast is stark. All his possessions are returned, and Mary gets no reply to her enquiries from the asylum authorities. Her efforts to visit him are thwarted and, when she meets his warder, she is told that her husband is disobedient and disorderly at meal times. Mary realises the cause of this behaviour when she is told that Mahony is served his food on tin plates rather than crockery — that is not how gentlemen eat. Richardson clearly understood that behavioural change frequently reflects the way in which a cognitively impaired person is treated, and that being aware of his or her habits is crucial to providing quality care. This approach is now well recognised as person-centred care.5 Mahony is returned to his wife’s care for the final months of his life, with improved behaviour but rapidly deteriorating cognition, function and physical health.

In the narrative of Ultima Thule, Richardson closely follows the last 4 years of her father’s life, when she was between the ages of 5 and 9. Her own traumatic and unhappy experiences of living with a dementing father are expressed through Mahony’s son, Cuffy. Parts of Mahony’s last months of life are written from Cuffy’s perspective and appear to be Richardson’s recollections of incidents with her father and her reaction to them. Her mother’s experiences as a carer are expressed through Mary; the undoubted stresses of working full-time while caring for a severely demented husband and two children under the age of 10 obviously took their toll.

Although Mahony’s dementia is modelled on the GPI of Richardson’s father, there is no explicit mention of this disorder in the novel. GPI tended to occur in males aged 30–50 years and hence was a common cause of younger onset dementia.6 While the connection between syphilis and insanity had long been recognised, the syphilitic aetiology of GPI was controversial in the 19th century. However, when Richardson wrote Ultima Thule, the link between GPI and syphilis had been firmly established.6 Although neurosyphilis is now an uncommon cause of dementia, other younger onset dementias such as frontotemporal dementia have similar challenges.

In Ultima Thule, Richardson succeeds in providing a detailed account of the cognitive, emotional, behavioural and physical changes associated with younger onset dementia and the devastating effects it has upon a young family. These are still the major psychosocial challenges of younger onset dementia for health services in the 21st century. Considering Ultima Thule was published almost 80 years ago, Richardson’s accomplishment is immense.