Really the Blues

“Moody, muddy, Moorditch melancholy”

If Shakespeare was correct, the web of our life is of a mingled yarn, good and ill. Like physical pain, sadness is something that enters the experience of each one of us at some time or other. Small wonder that mental distress should have attracted the notice of medical philosophers for over two thousand years. The humoral conception of disease propounded by Galen coupled low spirits with a surfeit of black bile; hence the term “melancholia.” Over the centuries came a series of dissertations by writers such as Rufus of Ephesus, Aretaeus of Cappadocia, Galen, Alexander of Tralles, Paul of Aegina, and the Persian Avicenna. The catalog of contributors extends throughout the Middle Ages. In 1621, Robert Burton published his Anatomy of Melancholy, which has been described as the most sententious book ever written; yet it can be read as a fascinating imaginative work.

Now we meet a worthy addition to the notable company of humanists in Professor Stanley Jackson, whose amplitudinous volume has been issued by the Yale University Press. The author is well qualified to undertake such a stupendous task on three counts: first, he occupies the chair of psychiatry at Yale, secondly, he is a medical historian, and thirdly he is a writer of distinction.

Professor Jackson carefully guides us through the wilderness of medical thinking since classical times. In ancient Greece mental illness was recognized, and physicians in their wisdom identified three categories, namely phrenitis (i.e., delirium), mania, and melancholia. However odd their ideas about causation, however bizarre their therapies, the physicians of that time were sound clinical observers. Rufus, for example, in the first century AD, recognized that melancholics were gloomy and filled with fears and doubts. Some were intolerant of loud noises. Others longed to die. A few were perpetually washing their hands, an eccentricity accepted nowadays as a compulsion. He also specified as symptoms an aversion to food and drink; alarm at the presence of animals; and a tormenting conviction that serpents were lodged within the belly.

Other bizarre delusions were reported by Rufus. One victim imagined that he had been transformed into an earthenware jar. Another thought his skin had become parchment. Yet another that he had no head. A few melancholics were endowed with the gift of divination. Among somatic symptoms, flatulent indigestion was a common complaint. Even the physical appearance might alter, with bulging eyes and eyelids blinking, the lips thickened, the skin dusky and hirsute. Rufus noted that melancholia was commoner in men, but when women were afflicted, the sorrow went deeper. Depression was especially frequent in the elderly. It was realized that in some instances the misery was due to a recent calamity, whereas in others no obvious cause could be found.

Perhaps it was the profundity of the depression in women that induced Dürer in 1514 to portray Melencolia as a female. Admirers of Anita Brookner will recall what she recently had to say upon this topic:

Melancholy is usually portrayed as a woman, dishevelled, deranged, surrounded by broken pitchers, leaning casks, torn books. She may be sunk in unpeaceful sleep, heavy limbed, overpowered by her inability to take the world’s measure, her compass and book laid aside. She is very frightening, but the person she frightens most is herself. She is her own disease. Dürer shows her wearing a large ungainly dress, winged, a garland in her tangled hair. She has a fierce frown and so great is her disarray that she is closed in by emblems of study, duty, and suffering: a bell, an hourglass, a pair of scales, a globe, a compass, a ladder, nails. Sometimes this woman is shown surrounded by encroaching weeds, a cobweb undisturbed above her head. Sometimes she gazes out of the window at a full moon, for she is moonstruck.¹

As Professor Jackson points out, the writings of Rufus influenced the thinking of such teachers as Galen, Constantinus the African (whose De Melancholia did not appear until nine hundred years later), and, in Baghdad, Ishaq ibn Imran. Even more: “He led the way with regard to the medical conception of melancholy for more than fifteen hundred years.”²

We are then introduced to another important figure, namely Aretaeus of Capadocia (to whom, incidentally, we owe the first adequate descriptions of migraine and of diabetes). In his monograph On the Causes and Symptoms of Chronic Disease, Aretaeus devoted a chapter to melancholia. Professor Jackson reproduces some of his observations:

The patients [with melancholia] are dull or stern, dejected or unreasonably torpid, without any manifest cause: such is the commencement of melancholy. And they also become peevish, dispirited, sleepless, and start up from a disturbed sleep.

Unreasonable fear also seizes them, if the disease tend to increase, when their dreams are true, terrifying, and clear: for whatever, when awake, they have an aversion to, as being an evil, rushes upon their visions in sleep. They are prone to change their mind readily; to become base, mean-spirited, illiberal, and in a little time, perhaps, simple, extravagant, munificent, not from any virtue of the soul, but from the changeableness of the disease. But if the illness become more urgent, hatred, avoidance of the haunts of men, vain lamentations; they complain of life, and desire to die. In many, the understanding so leads to insensibility and fatuousness, that they become ignorant of all things, or forgetful of themselves, and live the life of the inferior animals.

The last paragraph suggests intellectual deterioration, something which is not typical of a simple depressive disorder. Professor Jackson finishes his account of Aretaeus by quoting his views on treatment. “It is impossible, indeed, to make all the sick well, for a physician would thus be superior to a god; but the physician can produce respite from pain, intervals in diseases, and render them latent.” Verbum sat sapienti.

The tenth-century thesis on melancholy by Ishaq ibn Imran is interesting when it deals with etiology. Depression, we read, might afflict one whose mother’s womb had been “in bad condition.” We are warned against undue brain fatigue. “If doctors, mathematicians, or astronomers meditate, brood, memorize and investigate too much, they can fall prey to melancholy.” Another cause was grave misfortune, as from “the loss of a beloved child, or of an irreplaceable library.”

Interest in melancholia continued throughout the Middle Ages, and the influence of Galen is very obvious in the writings of such physicians as Alexander of Tralles, Paul of Aegina, and Constantinus Africanus. At this point, Professor Jackson interrupts his chronology and interpolates a discussion of the rather tortuous topic of acedia (or accidie). This term was first applied in the fourth century to a vague condition of mental and physical weariness, lassitude, or torpor. It was originally observed in anchorites and members of monastic communities in the Egyptian desert near Alexandria. From Cassian’s Twelve Books we learn that the affected cenobite would grow restless and anxious to escape, deploring his spiritual barrenness, his apathy and loneliness. Evil spirits and demons were tempting him with libidinous thoughts. Acedia was originally equated with hebetude, a state of sinful lethargy. Over the centuries, however, a gradual change in opinion came about with a growing uncertainly whether acedia was a sin or merely a symptom of a disorder more emotional than moral. The possibility was mooted of an underlying depression of a nondelusional type. Ivor Brown, one-time editor of the Observer, confessed that he always linked the word “accidie” with the wretched listlessness and sloth of the month of February.

Eventually the term “acedia” lost favor and no longer found a place within the vocabularies of either medicine or theology. Although the word is used by Chaucer to describe “roten-hearted sinne,” I note that Dr. Johnson did not include either “acedia” or “accidie” within his dictionary. Its status has never been firm or the subject matter clear. After much deliberation, Professor Jackson adopts a some-what equivocal attitude. In his own words: “To my already stated views that acedia was not merely melancholy, I would add only that acedia was not merely lethargy.”

Back on course again, he conducts us through the Renaissance. Prominent in the sixteenth century were Timothie Bright (1550?–1615), author of A Treatise on Melancholie; André Du Laurens (1560?–1609), who wrote A Discourse…of Melancholike Diseases; and Felix Platter (1536–1614). The famed Robert Burton was, of course, in holy orders and no medical man. His magnum opus stands apart, not least for its discussion of love melancholy. This was the tome that so delighted Arthur Ransome, who spent three of his happiest hours slitting its uncut pages, leaf by leaf.³

Another literary intercalation appears at this point, and one of unusual interest. Journalists sometimes adopt a snappy phrase to describe a particular decade, highlighting its specific attributes. Witness the Naughty Nineties, the Swinging Sixties, the Unheroic Seventies. Professor Jackson has endowed an even longer period of time with its own Zeitgeist by speaking of “the melancholic seventeenth century.” What is he trying to say? In his own words,

Melancholy was much in the popular mind in Western Europe by this time [the seventeenth century], and its less severe forms were considered by many to be a mark of distinction—a sign of intellectual and moral superiority, if not genius. Some of the moderately melancholic found comfort in the label, and many merely added the label to enhance themselves.

Two books have obviously interested Professor Jackson. One was Lawrence Babb’s Elizabethan Malady: A Study of Melancholia in English Literature from 1580 to 1642.⁴ (I wonder whether Babb reminded Professor Jackson of Taylor’s “Lamentation” of 1618: “my mind attired in moody, muddy, Moorditch melancholy”?) The other book Jackson draws on is Michael MacDonald’s Mystical Bedlam: Madness, Anxiety, and Healing in Seventeenth-Century England.⁵ This was an analysis of the sixty volumes of case notes written by the Reverend Doctor Richard Napier who ran a rural medical practice between 1597 and 1634. At the time he was also responsible for the medical care of over two thousand patients who were mentally disturbed. Dr. Napier was impressed by the high incidence of depression within the community and also its sociological implications. He observed that clinical distinctions occurred according to social class. Idle gentlefolk displayed a conventional type of melancholia, whereas artisans and husbandmen showed a “pale kind of melancholy, with sullen inactivity and mopishness.”

That there was something anomalous about the Zeitgeist of seventeenth-century England had, of course, long been realized by social historians. The time was indeed out of joint. W.Y. Tindall (1964) spoke of an age “lighted by queer radiance of insanity.” The miraculous was taken for granted, and there were prophecies in abundance. It was commonly accepted that the end of the world was imminent. Still on the subject of the gloom of the time, the author might well have quoted the observations of Ivor Brown in his book Old and Young:⁶

Suddenly the sky darkened and the Jacobeans were seized by pessimism. The universe was thought to be heading for disaster. “The long day of mankind,” wrote Sir Walter Raleigh in his History of the World, “fast draweth to a close.” John Donne, the Dean of St. Paul’s, described in his sermons “A sensible decay in the whole frame of the world, the seasons of the year irregular and distempered; the sun fainter and languishing; man less in stature and shorter lived; every year new sorts of worms, flies and sicknesses.” It was general fear that the end was approaching and that everything was shrinking by gradual diminution. If there was no hope save in a life hereafter there was no sense in planning for the future…. The gloom of the Jacobean had evoked some of the best English prose ever written.

The Elizabethan and Restoration drama reflected the abundance of words employed to express low spirits. In the theater were various stock characters to which the adjective “melancholic” readily became attached, namely the villain, the cynic, the scholar, and the lover. “Malcontent” had been introduced into the language as long ago as 1581.

According to Professor Jackson, this era—and especially its extension into the nineteenth century—was particularly sensitized to and interested in melancholic themes. Two autobiographical accounts of mental illness appeared within this period, one by the Nonconformist minister Timothy Rogers in 1691, and the other by the poet William Cowper in 1816, and quite naturally Professor Jackson also refers to Dr. Samuel Johnson, with his lifelong preoccupation with ill health and his fears of madness. By now the humoral theory of Galen was rapidly losing ground. A fleeting “iatrochemical” attitude advanced in Oxford by Thomas Willis, who spoke of an “acetous disturbance of the animal spirits,” did not endure for long, despite his very great authority. The “philosophers of the furnace,” as Francis Bacon called them, gave way to mechanistic ideas, the product of the work of Herman Boerhaave, Albrecht von Haller, Richard Mead, and William Cullen. The last named confidently asserted,

The melancholic temperament of mind depends upon a drier and firmer texture in the medullary substance of the brain; and…this perhaps proceeds from a certain want of fluid in that substance, which appears from its being of a lesser specific gravity than usual.

According to Professor Jackson, it was in the eighteenth century that the word “depression” ousted “melancholia” as a term for the mood of dejection, sadness, and desolation. Other terms like “tristomania” and “lypemania” came into being but not for long. In 1899 the conception of a manic depressive psychosis was put forward by the prestigious German psychiatrist Emil Kraepelin, who also emphasized the specificity of an involutional depression. But Adolf Meyer of Baltimore preferred to look upon mental disorders as faults in adaptation, finding them to be “reactive patterns” that depended upon constitution and life experience. During the first quarter of the twentieth century Meyer’s influence upon psychiatry was considerable, not only in the United States but also in Great Britain. His ideas persisted but the elaborate nomenclature that he employed was soon forgotten. Kraepelin’s involutional depression was not accepted by Meyer and his followers as an entity sui generis, and even now its status is a matter of debate.

Yet another question arose about this time, namely whether distinct clinical types of depression are recognizable, each with its own specific causation and outlook. A dichotomy became popular between “endogenous” as opposed to “exogenous” types, or perhaps “autonomous” as opposed to “reactive,” though many psychiatrists of repute remained skeptical, favoring a more holistic attitude. Incidentally, it is of interest that a similar discrimination between “splitters” and “lumpers” continues to pervade medical philosophy even today.

At this point, Jackson discusses the place of psychoanalysis in the history of melancholia. Karl Abraham’s seminal paper on depression (1911) was followed by Freud’s “Mourning and Melancholia” (written in 1914, revised in 1915, and published in 1917), with its emphasis on melancholia as being distinguished by a “lowering of the self-regarding feelings,” or “self esteem,” a theme that became the subject of an extensive psychoanalytic literature. Professor Jackson becomes here unexpectedly lengthy, calling attention to the subsequent views of psychoanalysts who have taken account of “constitutional or hereditary factors and somatic factors in etiology”; some of his nonanalytical colleagues may well comment, with the Comte de Rivarol, “c’est bien, mais il y a des longeurs.”

More recent psychological approaches toward depression include certain innovational studies. For example, in Philadelphia, Aaron T. Beck (1967) regarded depression as primarily a cognitive disorder, a failure of the patient to perceive his condition accurately, the abnormal mood and behavior being secondary. Characteristic of melancholic patients are such sentiments as poor self-esteem, feelings of loss, critical introspection, over-estimation of difficulties, and an urge to escape. Beck went on to develop what he called cognitive psychotherapy, a form of treatment based upon these premises. Then comes an account of Martin E.P. Seligman’s ideas on “learned helplessness,” a theory evolved from animal studies which held that “early experience with uncontrollable events may predispose a person to depression while early experience with mastery may immunize him.”

In contrast to these essentially psychological conceptions, important biologically based data have been accumulating. These attach importance to genetic and endocrine factors, and lay emphasis upon suggestive chemical anomalies involving electrolytes and neurotransmitters. So far the evidence, though exciting, has been inconclusive. But, as Professor Jackson admits, many neuroscientists seem convinced that some version of a biogenic hypothesis will prevail.

Several essays follow, each dealing with a selected aspect of melancholia. Some of the subjects have already been touched upon earlier in the book, but the author now goes deeper. One chapter examines in detail the links between mania and melancholia. Another scrutinizes the subject of hypochondriasis; and a third examines closely the problems of grief and mourning. Repetitious, but rewarding. Under “Religion, the Supernatural, and Melancholia” we find the “divine madness” of Plato, the gift of prophecy, divinatory dreams, ergumens, witchcraft, demonology, and much besides. Finally three intriguing articles come as a surprise. One deals with lycanthropy, better known as wolf-madness; another contends with the fanfaronade of love-sickness. The third and last of these essays is devoted to la douce amère of nostalgia and homesickness.

The final chapter is entitled “Overview and Afterthoughts” and summarizes lucidly all that has been deliberated before. It is disappointing, however, to find that we have been given merely a brief mention of two or three topics that are of great importance today. The first concerns the status of drug therapy. How and when did the current antidepressants appear on the scene? Precisely how valuable are they in clinical practice? How much have we learned about the ways by which they act? Have they replaced psychotherapy, either wholly or in part? There are, of course, pressing considerations in the way of side effects, addiction hazards, withdrawal symptoms, all of which are questions that deserve discussion, even in a historical monograph. As John Shaw Billings declared, “We are a bitters-and-pill-taking people” and we demand enlightenment.

Then there is the ambiguous story of convulsive therapy. Will we ever see the end of this dark interlude? The ethical problems alone which are involved in such invasive and inexplicable procedures demand searching inquiry. What will be the judgment of the medical historians of tomorrow? Yet a third issue arises. Today we have scarcely recovered from the era of psychosurgical permissiveness. Does anyone anywhere carry out lobotomy today? And what of the recent practice of minimal or precision attacks upon the brain in psychotic patients including depressives? We would have welcomed the views of Professor Jackson in his twofold capacity as a historian and a psychiatrist. We would also have liked to know his attitude toward the disturbing question of the sheer seemliness of such procedures.

Other than to bemoan such omissions, there is very little that even the most captious, carping critic can muster. He might complain, perhaps, that there is a good deal of repetition, especially of proper names, places, even textual matters. Because of the way in which the author has planned this book, tautology is difficult to avoid. This is a pity because l’art d’ennuyer c’est de tout dire. The result? A magnificent monograph; a masterpiece of erudition. Nay, more. The book is beautifully written, in the rare prose of a gentleman who is also a scholar. The reader, should he be skeptical, should consult the very last paragraph of the book, which glitters as an example of fine writing and sound thinking.

However objective we may become about depression or about a particular depressed person, however carefully we may manage to identify neurophysiological and neurochemical factors in clinical depressions, someone else’s depression, defined as clinical or otherwise, is ultimately going to come home to us as a fellow human being who also has needs, who also knows something about personal losses, disappointments, and failures, who also knows something about being sad and dejected, and who has some capacity for distressed response to such a distressing state. With such distress, we are at the very heart of being human.