Posts Tagged ‘melancholia’

Melancholia and Depression: From Hippocratic Times to Modern Times

Melancholia and Depression: From Hippocratic Times to Modern Times

Stanley W. Jackson

New Haven, CT: Yale University Press, 441 pp., 1990

“Melancholia is one of the great words of psychiatry. Suffering many mutations, at one time the tenacious guardian of outworn schemes or errant theories; presently misused, cavilled at, dispossessed, it has endured into our own times, a part of medical terminology no less than of common speech.” With such magisterial prose did Sir Aubrey Lewis start his historical review of the subject. Now, over half a century later, Dr. Jackson gives us a splendid volume to flesh out the skeleton which Sir Aubrey provided. And one of the excellent features of this book is the ample use of quotations from the various authors thus enabling the reader to form his or her own opinion on the clinical entity being described.

In his first chapter Jackson makes it clear that he is concerned with the disease or syndrome, not the symptom. But equally, consideration of the developing concepts of disease, knowledge of “the passions,” explanatory systems in medicine and, at times, the relevance of contemporary “belief-action systems other than medicine” receive attention to elucidate the main subject.

Greeks, Arabs and Others

Like Sir Aubrey, Jackson begins with Hippocrates and Greek medicine. This is of necessity as ‘melancholia‘ is formed from the Greek words for black bile an excess of which was supposed to account for the condition. This is not to say that earlier peoples had no notion of this enduring aberration of the human condition. The skulls of many neolithic men showed trephine holes made, it is conjectured, to let out spirits supposedly inserted to cause disease. (As Ackerknecht points out thought insertion may be a legitimate explanation of disease in some primitives and not a sign of illness.) Nonetheless, there is little recognizable reference to affective disorders in either primitive medicine or the ancient civilizations of Egypt, Sumeria, Mexico or Peru. The concept of disease as retribution for offending the gods, however, was prevalent in all cultures and the equating of disease with sin was particularly characteristic of the Babylonians.

But it is entirely appropriate for Jackson to start with Greek medicine because, in the words of Ackernecht, it “is incomparably closer to modern medicine than any other historical form of medicine.” “Disease was no longer regarded as a supernatural phenomenon; it was approached from a rational, naturalistic and scientific point of view” and he wonders why “a small group of people in the eastern Mediterranean took this important and radical step in human thought.”

As Jackson recounts, the Hippocratic writings of the fifth century B.C. describe melancholia as an “aversion to food, despondency, sleeplessness, irritability, restlessness” and “fear or depression that is prolonged.” The cause was located squarely in the body due to an excess of black bile. (The latter, together with yellow bile, blood and phlegm, formed the explanatory system of four humors which was to last for another two millennia. Had the subject started in our present day one wonders if ‘indolia’ or ‘catecholia’ would be equally durable). Subsequently Aristotle speculated why those who became “eminent in philosophy or politics or poetry or the arts” were apparently prone. The disease was distinguished from both the temperament and the despondency “which occurs in everyday life.” Yet supernatural or dualist views still persisted in that some forms of melancholia were believed to be a “divine madness” associated with gifts of prophecy. Aristotle also noted sexual intercourse as a cause. Subsequent writers elaborating on these ideas included Celsus, Soranus and Rufus of Ephesus who, in contrast to Aristotle, regarded coitus as “the most helpful remedy of all against melancholia.” These views were later extended by Aretaeus, (c. 150 A.D.) and in particular by Galen (A.D. 131-201).

This teaching was preserved and nurtured in translation during the “Golden Age” of Arabic medicine and the names of Constantine, Oribasus, Alexander of Tralle and Paul of Aegina deserve honor. Throughout the clinical descriptions remained remarkably consistent from Soranus’ account at the beginning of the second century A.D. to that of Bartholomaeus Anglicus in the thirteenth century (summarizing Greco-Arabic views) and which, hardly changed, persisted to the seventeenth century.

The Early Church

Powerful religious views, on the other hand, took a different direction. Whilst the humoral theory obviously anchored symptoms to changes in the body, many were of a dualist persuasion (from Plato to Descartes), and the spiritual side was emphasized by the early Christian church through the notion of “acedia.” This condition was first described in Egyptian desert monks near Alexandria in the fourth century A.D., and the symptoms included dejection, sorrow, lassitude, weariness, carelessness and neglect. This result of cenobitic life was considered a sin and hence the cure lay in religion. An important part of Jackson’s work is the separation of the concept of acedia (which was blameworthy) from melancholia (for which the sufferer was to be pitied). It is one of the banes of sufferers from depressive illness that the milder manifestations are often categorized as sloth, a fate which those suffering from many mild forms of physical illness escape. (If one has a mild rash one simply has fewer or less ostentatious spots). In contemporary terms, it is illustrated by the debate about the “chronic fatigue syndrome.” But certainly the idea of “accidie” as a cardinal sin had great influence and, together with the often proffered guilt of the sufferers themselves and theological notions of demonic possession, not infrequently led to burning of many depressed women as witches. It is to Dr. Jackson’s great credit that he teases out from the very confusing and conflicting notions of medieval writers these two concepts of sin and illness.

Renaissance to the Eighteenth Century

The early years of the Renaissance saw little change in the humoral theories of Hippocrates and Galen. There were, however, comprehensive accounts including Burton’s well-known “Anatomy of Melancholy” and also, as Jackson points out, the lesser-known but equally deserving notebooks of Richard Napier, which contained records of more than 2000 mentally disturbed patients and which have been analyzed by MacDonald. An exception was the fiery Paracelsus. He objected to the system of Galen but had to replace it with an equally speculative “chymistrie.” (He also disagreed with the clergy who espoused supernatural causes.) And Thomas Willis in the later seventeenth century tried to shift explanatory schemes for the first time in two thousand years from humors to chemistry. For Willis, melancholia was “a complicated Distemper of the Brain and Heart: for as Melancholick people talk idly, it proceeds from the vice or fault of the Brain, and the inordination of the Animal Spirits dwelling in it.” The latter, which were normally transparent, became thick and dark, “Acetous and Corrosive, like those liquors drawn out of Vinegar,” and were instilled into the brain. Iatro-chemistry, however, was short-lived and replaced by iatro-mechanics, reflecting both the advances in physics pioneered by Newton and in physiology by Harvey. Thus melancholia for Pitcairn was due to a defect of the normal “vivid motions” of the blood, part of which became sluggish. Similar views were espoused by Hoffman and Boerhaave, the black bile being transmuted into a sort of dark sludge from the blood. In turn, mechanistic views were criticized or often held pari passu with electrical and vitalist theories.

More important, Jackson suggests, was the clinical separation of hypochondriasis from depression, the former consisting of “a syndrome of physical complaints and a non-psychotic depressed state…. It seems likely that the logic of separating nonmad dejected states from mad dejected states was more compelling to clinical observers than any effect of mechanical explanations.” The notion of melancholia had also penetrated the literary world and was ascribed to Addison, Thomas Gray and Cowper. Jackson considers in detail the autobiographical accounts of two other supposed sufferers, namely Timothy Rogers and Samuel Johnson. The latter defined Melancholy in his dictionary as “a kind of madness, in which the mind is always fixed on one object.” (Shakespeare, incidentally, was also considered afflicted by the careful and critical Sir Aubrey Lewis on the basis of the sonnets. A “heartfelt utterance of shame and self-disgust” was thought to be expressed in sonnets 110 and 111 to be distinguished from the “contrived woe” of sonnet 66).

The Nineteenth Century to the Present

In the nineteenth and twentieth centuries we reach more familiar ground. The fresh insights which Jackson’s work provides show that Rush departed from his contemporaries in both terminology and concepts. He advocated a theory of an excited cardiovascular system which he derived from Cullen who had previously abandoned it. Jackson reaffirms the central place of Pinel, whose 1801 scheme of mental disorders comprised the quartet of mania, melancholia, dementia and idiotism. Pinel’s use of the term “mania” reflected the understood meaning of his time but must not obscure the fact that he obviously recognized the manic component (in present-day terminology) commenting: “sometimes it is distinguished by an exulted sentiment of self-importance, associated with chimerical pretensions to unbounded power or inexhaustible riches.” Esquirol, the pupil of Pinel, introduced the term monomania to denote any form of insanity “in which the delirium is partial, permanent, gay or sad.” It is to Griesinger that we owe both the use of the word depression in a technical psychiatric sense and the concept of the unitary psychosis (Einheitspsychose) currently being resuscitated by British workers. His views on an organic pathology were far more sophisticated and less dogmatic than many think. Others receiving mention include Tuke, Bucknill, Maudsley, Krafft-Ebing, Mercier and Savage.

Kraepelin’s name is given primacy at the start of the chapter on the twentieth century which is just since his views have continued to hold influence to the present day. Adolf Meyer, Freud and others take us up to DSM-III and our current preoccupations.

The book’s concluding sections comprise a thoughtful discussion of the relationships of melancholia to mania, hypochondriasis, grief and religion; accounts of three variants of the syndrome, namely, lycanthropy, love and nostalgia, (none of which have yet appeared in DSM formulations); and an overview and afterthoughts.

The Value of History

Many, preoccupied with the minutiae of advancing technology, will be impatient with an exploration of the ideas of bygone years; some may even be suspicious — remarking that whilst God cannot change the past historians can. But this book clearly exemplifies the values of an historical approach.

First, the volume shows, through quotations of the various authors across two millennia, that melancholia or depression is an enduring and recognizable clinical entity surviving all translations and known as far back as recorded history will take us. It is a biological phenomenon capable of description, and remarkably consistent in its main features. To regard it as a professional construct or a mode of behavior imposed by society or physicians, as some of the more outre* and otiose sociological and Marxist theories profess, is to adopt a viewpoint of marginal and tangential significance.

Second, not only has the notion survived down the centuries but it is equally evident that it has occurred in all cultures where there are adequate records. It has affected ancient Greeks, monks in Egyptian monasteries, medieval Englishmen and modern Americans.

A third value of chronicling the past is, one hopes, the encouragement of humility in those who espouse particular causes and/or treatments.

Fourth, the story of melancholia displays beautifully the four perspectives of psychiatry enunciated by McHugh and Slavney. It can be a disease, a temperament, a learned form of behavior, and, in all cases, an individual’s life story.

Fifth, it directs us to look carefully at our current approach to nosology. The strength of the Kraepelinian view was to base disease distinctions on carefully observed natural histories. The psychoanalytical approach on the other hand introduced interpretation which influenced DSM-I and -II to be replaced by the operational criteria provided in DSM-III. Now that we have improved reliability surely the next step in nosology is empirical biological validation rather than committee reviews of the literature. Science should proceed from individual studies which can be replicated rather than consensus and democratic opinion. One has a rising anxiety, not yet of DSM-III proportions, that we are currently in danger of allotting vast amounts of money and human effort to an enterprise where the shifting sands of categorization are determined by political process (cf. the pre-menstmal syndrome) and not by scientific method. Further whilst DSM-III and III-R gave us a more reliable vocabulary, frequent repetition of the undertaking may be self-defeating. The case has been well argued by Zimmerman. In fact committee confusion and conflation of conflicting concepts are evident in the DSM-IH-R definition of delusions — the veritable keystone of psychopathology — a matter lucidly exposed by Manfred Spitzer. It would logically follow, as cogently argued by Costello, that such careful examination of symptoms may be more fruitful than constantly changing the syndromes.

At the end, an exemplary volume such as Jackson’s reminds all of us engaged in day-to-day practice or research that from time to time it is imperative to stand back and look at the subject from afar. This is the final message of the historical approach. It should ensure that our broader objectives are sensible and worthwhile, and that our energies are channelled in the most appropriate way to the elucidation and alleviation of suffering in our patients. Dr. Jackson’s excellent exegesis provides a scholarly and even-tempered survey for our future guidance.

Modern Perspectives in the Psychiatry of the Affective Disorders

Modern Perspectives in the Psychiatry of the Affective Disorders

John G. Howells

New York, NY: Brunner/Mazel Publishers, 440 pp., 1989

This multi-authored book is the thirteenth in the modern perspectives series. The purpose of this series is to bring up-to-date information to the clinician and psychiatry resident about developments in particular areas, in this case affective disorders. The book comprises 23 chapters on various aspects of the epidemiology, clinical presentation and treatment of affective illness. Its aim is not to be comprehensive but rather to highlight particularly important aspects of the field.

This book is very uneven in its presentation and in fulfilling its purpose. Most authors have been given the impossible task of trying to summarize a vast literature and a huge amount of information in just a few pages. The result is that many of the general chapters on biology, phenomenology and treatment are cursory in nature and offer little more information than can be obtained in a standard textbook. Furthermore, in some chapters, the information presented is so basic and the concepts so simple that the book appears to be more directed to medical students rather than psychiatrists and residents.

There are some delightful exceptions to the above mentioned criticisms. Dr. Calloway presents some fascinating data on abnormalities of thyroid function tests in depressed patients. Dr. Golden and coauthors have written a lively discussion on the concept of involutional melancholia, and Drs. Williams and McGlashan have written a succinct and critical review of the concept of schizoaffective disorder. There is also an excellent chapter on drug therapy and depression in children and an interesting discussion on the relationship between tardive dyskinesia and affective illness.

Other than the few interesting and well-written chapters mentioned above, this book adds little to the vast number of multi-authored texts written on the affective disorders. In most cases, the discussion is limited and lacks both critical appraisal or comprehensive assessment of the literature. It certainly would not be useful to psychiatrists who are primarily interested in clinical or research aspects of affective illness. I think that it would, with the exceptions noted above, have limited value either for general psychiatrists or residents in training. It may be of some use to medical students and housestaff, although it is likely that it would not be preferred to standard general textbooks of psychiatry.