Thomas A. Ban
Neuropsychopharmacology in Historical Perspective.
Lehmann Collection 11
Neuropsychopharmacology in Historical Perspective.
A Tribute to Heinz Edgar Lehmann by Hector Warnes*
My congratulations for the overview of Heinz Lehmann’s outstanding achievements as portrayed by Barry Blackwell.
Allow me to dissent on the state of psychiatric wards prior to the introduction of chlorpromazine in 1953. Long before, we had achieved considerable improvement in the treatment of severe depression and psychomotor excitement with the use of electroconvulsive therapy (ECT), as well as in the treatment of schizophrenia and anxiety states with insulin therapy. In fact, today most studies have shown that ECT is more effective than anti-depressants in the treatment of selected cases of major depression.
Most of Barry's description of the state of the psychiatric wards was limited to those of chronic schizophrenics or patients with dementia of different etiologies and, perhaps, other neurological diseases, including neurosyphyllis and Korsakoff’s disease. The description of the psychiatric wards prior to and after the introduction of chlorpromazine, to a great extent, reflected the quality of nursing care and/or tender loving care (TLC). I would like to point out that preceeding this "miracle" of the introduction of chlorpromazine in 1952, and of imipramine in 1957, there were significant advances (“revolutions”) in changing the conditions of the mentally ill in the so-called "total institutions." I would agree that in the decade of the ‘50s there was a breakthrough in neuropsychopharmacology which must include the use of reserpine (isolated from the dried root of Rauwolfia serpentina). Lobotomies and sleep therapy (or Dauerschlaf, much inspired by Pavlov reflexology) were also used in severe cases refractory to other current therapies. Prior to chlorpromazine we had few choices of therapy for psychomotor excitement and uncontrolled aggression (pethidine, bromides, amytal sodium, reserpine and antihistaminic agents such as promethazine -- which later became the molecule that became chlorpromazine discovered by the chemist Paul Charpentier).
The first revolution was brought about by Pinel and Dorothea Dix. The "moral treatment" or humanizing of the patient’s condition was pivotal; the Asylum had a superintendent who knew each patient and often had dinner with them. The second revolution came about with the mental hygiene movement, particularly instigated by Clifford Beers and pioneered by Adolf Meyer and William James.
The third revolution was aimed at treating the patient in the community and half-way houses, even though frequent relapses led to "the revolving door syndrome" which was still seen after the introduction of anti-psychotics. The fourth revolution came about with the rapproachment between medicine, neurology and psychiatry; it led to the concept of "Biological Psychiatry." This view was upheld by the neurosciences and underlined the fact that mental illness be investigated employing empirical findings and rigourous scientific methods, notwithstanding that familiar, interpersonal and social factors continued to be paramount, as Lehmann himself stressed. Now, nobody can dispute the fact that epigenetic factors are just as important as genetic polymorphism in mental illness, with some exceptions (e.g., Huntington’s Chorea).
I would also like to point out that Henri Laborit, a surgeon and physiologist of the French army, was the first to use chlorpromazine in anesthesia in 1952 (artificial hibernation) and encouraged Deniker to test it in psychiatric patients. David Healy and Thomas Ban published a meticulous historical study of these earliest developments.
Since Wilhelm Griesinger at the end of the 19th century, most neurologists were psychiatrists and vice versa, up to the decade of the 1930s. We are rediscovering, through the monumental progress of the neurosciences, that the divorce from neurology, and to an extent from mainstream medicine, was ill-advised.
I have come across an excellent paper by Shiv Gautam (2010) who stresses the need for psychiatrists to be physicians first, since the issue of co-morbidity is on the rise.
Barry mentioned that one of the people who knew Lehmann well considered him to be "a humble and affable man." I could not agree more, but I would further add that although he was not dogmatic or inflexible, his scientific conclusions were tentative. He had an unusual and tactful respect for different opinions; in a word, he was eclectic and, at times, a skeptic. He was forever exploring new areas of knowledge, to the point that he became a classical and wise scholar -- I would say a polymath and polyglot, a superb clinician and a world-recognized researcher. In my interactions with him I never noticed authoritarianism or defensiveness. Being a caring pragmatist and rationalist, he also relied heavily on intuition and empathy. He had admirable bed-side manners and was indeed a humanist who had a vocacional devotion to help his fellow beings.
Since I first met him during my training at the Verdun Protestant Hospital (VPH) and a decade later when I met him for the last time at the home of a colleage, Dr. Minna Deutsch, he was as ever warm, kind and attentive. I dared to tell him that his teaching and example as a psychiatrist gave me inspiration and that he was my hero in this field. He smiled and was very pleased. (Dr. Deutsch’s daughter is Eva Anderman, wife of Fred Anderman, a neurologist and epileptologist of international repute and a friend of mine. Minna was a friend since we worked together at the VPH with her husband Leon Deutsch. The Eva Anderman syndrome is the agenesis of the corpus callosum linked to a genetic disorder in chromosome 15q.)
I recall that Lehmann once told me that chlorpromazine is more a psychotostatic than antipsychotic agent. Later he changed his mind. This raises the point that since the era of psychopharmacology the incidence and prevalence of psychiatric disorders have not decreased nor have the incidence or prevalence of suicide (just the opposite). We are now able to help at least 50 if not 60% of cases, but at least one third become chronic patients and have to take medication for the rest of their life, just like a diabetic insulin-dependent.
Are the anti-psychotics and anti-depressants etiological or are they symptomatic treatments or are they both? I would said that penicillin is an etiological treatment, but I cannot say the same of the anti-psychotics, in spite of the fact that their site of action is on neuronal circuits, altering neurochemical and neuroanatomical areas of the brain, but not curing the disease per se.
Some critics have written about the side effects or the lethalities of psychotropic drugs withhout comparing their adverse effects with the long list of adverse effects of pharmacological agents prescribed in the general medical practice as a whole. We are quite aware that most pharmacological agents have adverse effects -- some are mild, others moderate or severe. Lethal effects have even been encountered with antibiotics, acetylsalicilic acid (aspirin) and peanuts, which may cause an anaphylactic shock in a susceptible patient.
Lehmann was a very ethical person who promptly reported side effects and risks (e.g., EKG and EEG tracings, agranulocitosis paralytic ileus, photosensitivity, etc.). Every drug used in our medical field, with some exceptions, is likely to have side effects, some more severe than others, but they usually affect less than 10% of patients and, in most cases, around 1%. As we discovered, patients who are given placebo may have adverse side effects. We should expect and be prepared to see severe side effects when oncological chemotherapy or interferon are given. The dilema of risks versus benefits is forever dividing the good physician. The delay in reporting a potentially harmful side effect (e.g., thalidomide) or not closely monitoring the side effects of clozapine or lithium, may be dangerous. Most doctors in all specialties are likely to report their successes in treating cases and not their failures or a deadly end. I encountered many, many cases that were not reported, or the family dared not to report except to their priest, psychotherapist or family doctor -- that was the end.
Seeman’s comments on Lehmann’s versatility in teaching psychodynamics (Freudian slips) is most welcome and points to his acknowledgment of unconscious factors in lapsus (errors in speech) or parapraxis, as was the case described. Parapraxis or faulty actions are symptomatic (Fehlleitungens) reveal an unconscious or hidden meaning in some faulty actions that could be analysed as the Lehmann’s pupils attempted to do from different perspectives, though one or two interpretations would be the closest to the patient’s inner psychodynamics. For further clarification read Mary and Philip Seeman’s comment on Blackwell Lehmann collated papers on screen page 73 (of 96).
Edward Spranger (1914) wrote on the taxonomy of persons, or better yet, of their character: the theoretical, who search for truth. The utilitarian or economic, who is interested in what is useful. The aesthetic, who seeks form and harmony, grace and symmetry; for him truth is beauty. The social, who is altruistic, helpful, philanthropic, unselfish and loving. The political, who is interested in power, competition and struggle (Machtmensch). The religious, whose highest value is unity, an embracing totality, a higher reality; he is ascetic, reflective and practices self-denial.
These profiles are not sharply distinguished and may overlap. It is obvious that, although Lehmann called himself agnostic (though he had the characteristics of a religious and aesthetic man), above all he was forever searching for truth, just like the word "theoretical" implies (epistemophylia). He was also a man who was sociable with countless friends and admirers. He certainly was not an utilitarian nor a politician. With nostalgia of those pioneer times and grieving the loss of a great mentor, I would like to thank Tom Ban, his best friend and long-time collaborator in the most important researches carried out at VPH.
Alfred AL (editor). The common-sense Psychiatry of Adolf Meyer: fifty two selected papers. McGraw-Hill, New York, 1948.
Ban TA. Fifty years of Chlorpromazine: A historical perspective. Neuropsychiatric Disease and Treatment 2007; 3: 495-500.
Beers C. A mind that found itself: an autobiography. Publisher: Createspace, Scotts Valley, CA 2012, USA.
Gollaher D. Voice for the Mad: The life of Dorothea Dix. Free Press, New York, 1995.
Healey D. The creation of Psychopharmacology. Harvard University Press, Boston, Mass., 2002.
James W. The Principles of Psychology-Cambridge, MA, Harvard University Press, Boston, Mass. (with introduction of George A. Miller), 1890.
Laborit H, Huguenard P. Practique de l’Hibernotherapie en chirurgie et en Médicine. Masson et Cie Paris, 1954.
Pinel P. Traité medico-philosophique sur l’aliénation mentale ou la manie- Richard, Caille et Ravier, Paris 1801.
Shiv G. Fourth revolution in psychiatry: addressing comorbidity with chronic physical disorders. Indian J. Psychiatry 2010; 52(3):213-19.
Spranger E. Types of Men (Lebensformen; Halle (Saale): Niemeyer, 1914.
*Adopted from inhn.org.collated. September 7, 2017.
November 5, 2020