Authors: Andrew Solomon
Within seventy years of the death of Hippocrates, the School of Aristotle began to exert powerful influence on how we think about thinking. Aristotle accepted neither Hippocrates’ diminution of the importance of the soul and its philosophers, nor Plato’s dismissal of the doctor as a mere artisan. Aristotle proposed instead a theory of a united self in which “a disturbance of the body affects the soul; the diseases of the soul come from the body, except those that are born in the soul itself. Passion changes the body.” His wisdom on human nature is not matched by any particular knack for anatomy. Saying that “the brain is a residue lacking any sensitive faculty,” Aristotle proposed that the heart had a regulatory mechanism that controlled the balance of the four humors, and that either heat or cold could disrupt this balance. Aristotle’s view of depression, unlike that of Hippocrates, was not entirely negative. Aristotle took from Plato the notion of divine madness and medicalized it by associating it with melancholia. Though Aristotle sought ways to understand and alleviate the ailment, he also felt that a certain amount of cold black bile was necessary to genius: “All those who have attained excellence in philosophy, in poetry, in art, and in politics, even Socrates and Plato, had a melancholic habitus; indeed some suffered even from melancholic disease.” Aristotle wrote, “We are often in the condition of feeling grief without being able to ascribe any cause to it; such feelings occur to a slight degree in everyone, but those who are thoroughly possessed by them acquire them as a permanent part of their nature. Those who possess an atrabilious temperament in slight degree are ordinary, but those who have much of it are quite unlike the majority of people. For, if their condition is quite complete, they are very depressed; but if they possess a mixed temperament, they are men of genius.” Heracles was the most famous of the classical geniuses afflicted with the black bile complaints,
and they also touched Ajax (“the flashing eyes of Ajax raging, and his mind weighted down,” as it is written in
The Sack of Troy
). This notion of inspired melancholia was carried forward by Seneca, who said that “there has never been great talent without some touch of madness”; it resurfaced in the Renaissance and has reared up regularly ever since.
In the fourth to first centuries
B.C.
, medical science and philosophy developed along closely associated lines, describing psychiatry in an increasingly unified way. Melancholy was seen in this period to be a universal destiny in one form or another; the fourth-century poet Menander wrote, “I am a man, and that is reason enough for being miserable.” The Skeptics believed that it was important to study the visible world and therefore looked to symptoms without theorizing about the origins of those symptoms or their deep meaning. Uninterested in the big, difficult questions of the nature of the physical and cerebral self that had preoccupied Hippocrates and Aristotle, they tried to categorize symptoms to delineate disease.
In the third century
B.C.,
Erasistratus of Juli separated the brain and the cerebellum, determining that intelligence resided in the brain and that motor ability was based in the cerebellum; and Herophilus of Calcedonius then determined that from the brain “motive power goes toward the nerves,” so establishing the idea of a controlling organ supervising a nervous system. Menodotus of Nicomedia, who lived in the first century
A.D.
, combined all previous wisdom, incorporating the thoughts of the symptom-oriented empiricists with those of the grand philosophers and the early doctors. He recommended for depression the same hellebores that Hippocrates had discovered, and the same self-examination that had come from Aristotle, and introduced also the use of gymnastics, travel, massage, and mineral water to help the depressive. Such a total program is just what we strive for today.
Rufus of Ephesus, Menodotus’ contemporary, isolated melancholy delusion from the rest of the mind and spoke of melancholy as a discrete aberration that occurred in otherwise stalwart minds. He cataloged the delusions of some depressive patients: Rufus treated at various stages a man who believed himself to be an earthenware pot; another who believed that his skin had desiccated and was peeling off his body; and one who thought that he had no head. Rufus noted the physical symptoms of what we now recognize to be hypothyroidism, a hormonal imbalance whose symptoms are similar to depression’s. He believed that the primary causes of melancholy were heavy meats, inadequate exercise, too much red wine, and inordinate intellectual toil, and he noted that a genius might be particularly prone to the complaint. Some melancholiacs “are that way by nature, by virtue of their congenital temperament,” while others
“become that way.” He also spoke of degrees and types of melancholy: one in which black bile infected all the blood, one in which it affected only the head, and one in which it affected “the hypochondria.” Rufus found that his melancholy patients also suffered the buildup of unreleased sexual fluids, whose putrefaction infected the brain.
Rufus was in favor of routing out depressive illness before it became ingrained. He proposed bloodletting, and a “purge with dodder of thyme and aloe, because these two substances, taken daily in a small dose, bring about a moderate and soothing opening of the bowels.” This might be supplemented with black hellebore. Regular walking was suggested, and so was travel, and so was washing before meals. Rufus also formulated his “sacred remedy,” the Prozac of its day, which remained widely popular at least through the Renaissance and was used on occasion even later. This was a liquid compounded of colocynth, yellow bugle, germander, cassia, agaric, asafetida, wild parsley, aristolochia, white pepper, cinnamon, spikenard, saffron, and myrrh, mixed all with honey and given in four-dram doses in hydromel and salt water. Other physicians of the time proposed everything from chains and punishments, to placing a dripping water pipe near the melancholic to lure him to sleep, to putting him in a hammock, to giving him a diet of light-colored, moist foods such as fish, poultry, diluted wine, and human breast milk.
The late Roman period was a time of considerable learning on these matters. Aretaeus of Capidoccia studied mania and depression, as associated and as separate complaints, during the second century
A.D.
He believed in a physical soul that traveled around in the body, bursting forth in heat among angry men (whose faces therefore turned red) and withdrawing in fearful ones (whose faces therefore went pale). He proposed that among melancholiacs the level of black bile “may be stirred by dismay and immoderate anger,” and that the humors had a circular relationship with the emotions, so that a cooling of the soul’s vital energy might lead to severe depression, while depression served to cool the bile. Aretaeus was the first to give a convincing portrait of what we now call agitated depression—a complaint for which recent popular philosophy misguidedly tends to blame postindustrial life. It is as organic and eternal as sadness. Aretaeus wrote, “The melancholic isolates himself; he is afraid of being persecuted and imprisoned; he torments himself with superstitious ideas; he is terror-stricken; he mistakes his fantasies for the truth; he complains of imaginary diseases; he curses life and wishes for death. He wakes up suddenly and is seized by a great tiredness. In certain cases, depression seems to be a sort of demi-mania: the patients are always obsessed with the same idea and can be depressed and energetic at the same time.” Aretaeus emphasized that severe depression
often occurred in people already inclined toward sadness, especially those who were old, obese, weak, or alone; and he suggested that “the physician Love” was the most powerful in curing the complaint. His oral remedy of choice was the regular consumption of blackberries and leeks; he also encouraged the psychodynamic practice of articulating symptoms and claimed he could help patients to release fears by describing them.
Claudius Galen, born in the second century
A.D.
, personal physician to Marcus Aurelius, likely the most important doctor after Hippocrates, tried to arrive at a neurological and psychological synthesis of the work of all his forebears. He described melancholic delusions—one of his patients believed that Atlas would get tired and drop the world, while another thought he was a fragile-shelled snail—and identified beneath them a mixture of fear and despondency. He saw “tremors in the hearts of healthy young people and adolescents weak and thin from anxiety and depression.” Galen’s patients experienced “scarce, turbulent, and interrupted sleep, palpitations, vertigo . . . sadness, anxiety, diffidence, and the belief of being persecuted, of being possessed by a demon, hated by the gods.” Galen also shared Rufus’ belief in the disastrous consequences of deficient sexual release. He treated one of his female patients, whose brain, he believed, was troubled by the noxious fumes of her rotting unreleased sexual fluids, “with a manual stimulation of the vagina and of the clitoris and the patient took great pleasure from this, much liquid came out, and she was cured.” Galen also had his own patent recipes, many of which included Rufus’ ingredients, though he recommended an antidote made of plantains, mandrake, linden flowers, opium, and arugula for the treatment of combined anxiety and depression. Interestingly, while Galen was formulating his cordial, a continent away the Aztecs began the use of strong hallucinogenic drugs to prevent depression among prisoners, which they believed was a bad omen. Captives who were to be sacrificed were given a special brew to keep them from despairing so that they would not offend the gods.
Galen believed in a physical soul, what we might call a psyche, located in the brain; this soul was subject to the rule of a self as masterful in the body as God is in the world. Mixing the idea of the four humors with notions about temperature and moisture, Galen formulated the idea of nine temperaments, each a type of soul. One was dominated by a melancholia conceived not as pathology but as part of the self: “There are people who are by nature anxious, depressed, anguished, always pensive; for them the doctor can do but little.” Galen noted that melancholia could be the result of a lesion to the brain; or it could follow on external elements that altered the functioning of an intact brain. In the event of humoral imbalance, black bile could go to the brain, drying it; and this would
damage the self. “The humor, like a darkness, invades the seat of the soul, where reason is situated. As children who fear the darkness, so adults become when they are the prey of the black bile, which supports fear; they have in their brain a continual night, are in uncessant fear. For this reason the melancholiacs are afraid of death and wish for it at the same time. They avoid light and love darkness.” The soul could in effect be dimmed. “The black bile envelops reason as the crystalline lens of the eye, if it is limpid, allows a clear view, but if it becomes ill and opaque, does not allow a distinct view. In the same way the qualities of animal spirits may become heavy and opaque.” Galen, preferring psychobiology to philosophy, was sharply critical of those who attributed melancholy to emotional, abstract factors; but he believed such factors could exacerbate symptomatology of a mind already skewed by humoral imbalance.
The next stage of medical history traces its roots back to the Stoic philosophers. Their belief that external agency caused mental illness was dominant in the Dark Ages that followed the fall of Rome. The rise of Christianity was highly disadvantageous for depressives. Though Galen was the medical authority of the Middle Ages, his notion of psychopharmaceutical treatments conflicted with the paradigm of the Church. His treatments, in philosophical exile, were used less and less.
Saint Augustine had declared that what separated men from beasts was the gift of reason; and so the loss of reason reduced man to a beast. From this position, it was easy to conclude that the loss of reason was a mark of God’s disfavor, His punishment for a sinning soul. Melancholy was a particularly noxious complaint, since the melancholic’s despair suggested that he was not suffused with joy at the certain knowledge of God’s divine love and mercy. Melancholia was, in this view, a turning away from all that was holy. Furthermore, deep depression was often evidence of possession; a miserable fool contained within himself a devil, and if that devil could not be exorcised from him, why then he himself must go. Clerics soon found support for this idea in the Bible. Judas had committed suicide, and so, the reasoning ran, he must have been melancholic; and so all melancholiacs must be Judas-like in their carnality. The description of Nebuchadnezzar in Daniel 4:33 was taken to demonstrate that God sent insanity to punish the sinful. In the fifth century, Cassian writes of the “sixth combat” with “weariness and distress of the heart,” saying that “this is ‘the noonday demon’ spoken of in the Ninetieth Psalm,” which “produces dislike of the place where one is, disgust, disdain, and contempt for other men, and sluggishness.” The section in question occurs in Psalms and would be literally translated from the Vulgate: “His truth shall compass thee with a shield: thou shalt not be afraid of the terror of the
night. / Of the arrow that flieth in the day, of the business that walketh about in the dark: of invasion, or of the noonday demon”—
“ab incrusus, et daemonio meridiano.”
Cassian presumed that “the terror of the night” refers to evil; “the arrow that flies in the day” to the onslaught of human enemies; “the business that walketh in the dark” to fiends that come in sleep; “invasion” to possession; and “the noonday demon” to melancholia, the thing that you can see clearly in the brightest part of the day but that nonetheless comes to wrench your soul away from God.
Other sins might waste the night, but this bold one consumes day and night. What can one say in favor of a man unprotected by the shield of God’s truth? Punishment might be effective in redeeming such a hopeless case: Cassian insisted that the melancholy man be set to manual labor, and that all his brethren should withdraw from and abandon him. Evagrius, using the same phrase, said that melancholic dejection was a “noonday demon” that attacked and tempted the ascetic; he listed it as one of the eight main temptations we must resist on earth. I have taken the phrase as the title of this book because it describes so exactly what one experiences in depression. The image serves to conjure the terrible feeling of invasion that attends the depressive’s plight. There is something brazen about depression. Most demons—most forms of anguish—rely on the cover of night; to see them clearly is to defeat them. Depression stands in the full glare of the sun, unchallenged by recognition. You can know all the why and the wherefore and suffer just as much as if you were shrouded by ignorance. There is almost no other mental state of which the same can be said.