Tuesday, 21.09.2021

Carl Lange: On periodical depressions and their pathogenesis. Speech delivered to the Medical Society of Copenhagen January 19, 1886. Translated from Danish into English by Johan Schioldann
Samuel Gershon’s comment

 

            I was invited to comment on Johan Schioldann’s translation of Carl Lange’s speech On Periodical Depressions and Their Pathogenesis posted to INHN’s website (INHN 2018). At the outset, I must thank Johann for undertaking this special task of translation and congratulate him for making this special piece of history available to us in such an elegant form.

            Also, I need to stress that this speech by Carl Lange was presented in Danish in 1886, 132 years ago and I want to apologize in advance for my many uses of direct quotations from his text. My reason for doing this is because many of these same points are still unresolved and are with us still today.

            The introduction of Schioldann’s translation opens with an apology “… for some of the statements, short comings and weaknesses presented herein.” He goes on to state that some of Lange’s findings “… are lacking in no small degree the scientific exactitude and precision that nowadays are mandatory … even within the clinical field.” I wish such views were truly followed by the authors of the many presentations that come before us today and, also on this score, that these same authors adhere to the careful, thoughtful and scientific attitude Lange applied to his own work.

            Lange expressed the qualifications at a time when psychiatric forms and diagnoses were very much in a critical state. He further qualified his findings by stating that his observations were derived from patients he had actually seen in his private practice. He stressed that the nature of the subject and thestart of development of the field at that time contributed to his findings. He presents some summaries of his direct clinical observation from his clinical notes by saying “… that in general, the symptoms were very serious and extremely painful, both for the patient himself and for those around him.” He proceeds to add that “... despite remissions even for major periods … it often destroys or drastically reduces the happiness or capacity for work of its victims” and ends by stating that “… the patient feels he is wasting his life.” (Through out this detailed discussion and description of the depressive illness, however, Lange does not raise the question of suicide.)

            He then goes on to face the critical issue of the need “to make a diagnosis.” He starts his discussion on this point by saying “... in other words give the illness a label … it is then usually placed under one or other of the common illness concepts; many of which are sufficiently vague to allow of the inclusion of quite a number of heterogeneous features.” I feel that this observation of 132 years ago is still dangling before us and has not been satisfactorily or scientifically resolved.

            He does, however, continue to attempt to present a brief description of his typical clinical picture of the condition, “… melancholy … depression,” bringing to mind a justifiable clinical picture. The marked periods are of longer duration and, commonly, there is a constant fluctuation in the patient state with weeks or months of profound illness alternating between periods of wellbeing. Yet, his description of the “fluctuations” in mood does not seem to provide a very clear picture of what he may actually have observed. He goes on to state “… that as far as my experience goes between the periods of depression there never develops states of morbid elevation.” That could place the whole illness under the sphere of cyclical forms of insanity. His description continues:“… under such constant swings between suffering and wellbeing these miserable people drag on often for a large part of their lives.” Thus, his presentation on remissions, their quality and degree are perhaps too vague to clearly state that he is describing cases of bipolarity.

            His speech goes on to discuss etiology and therapy for this disorder. He presents a description of the “uric acid diathesis” which was the then predominant theory covering the etiology and treatment for excreting these toxins. However, Lange is very careful in concluding: “… no meaningful evidence is available to support these proposals.”

            We have seen from his speech that he was a careful and reserved person and avoided the limelight; he even declined a royal recognition for his work.

            However, it is important to remember to give the Lange’s (Carl and Fritz) full recognition for being the first psychiatrists to treat patients with lithium for a current episode of depression. That Carl went on to record that he proposed that lithium treatment should be continued in these patients with recurrent depression to provide prophylaxis against recurrence of these episodes should also be recognized.

            As a sort of reverse picture of scientific discovery, William Hammond of Bellevue Hospital, New York University, presented in his textbook (Hammond 1871) the first proposal for the use of lithium to treat mania and maniacal excitement. Also, it is important to add that both these scientists published in their early writings the actual prescription of the medication for the individual patient. Hammond raised an important question about possible variation of dosage that might be needed to treat mania by suggesting that higher doses may be needed for more severe cases. This was the first occasion that dosage range became a question for debate.

            On the other hand, Hammond, never seems to have mentioned any observations on depression which we presume he must have seen and had to treat in some way or another.

            There is some minor oddity in this dichotomy in the work of these two pioneers on their thinking and usage of lithium and the clinical entities with which they were dealing.

 

Reference:

 

Carl Lange: On Periodical Depressions and their pathogenesis. Speech delivered to the Medical Society of Copenhagen, January 19, 1886. Translated from the Original Danish into English by Johan Schioldann. INHN.org August 16, 2018; Archives.

Hammond WA. Treatise on diseases of the nervous system. New York: Appleton, 1871:358-366 (‘Mania’), 380-381 (‘Treatment’).

 

January 31, 2019