Madness: A Brief History (5 page)

6
Melencolia
by A. Dürer, 1514. A despondent winged female figure holding a geometrical instrument surrounded by attributes associated with knowledge. The sands of time are running out; nature too is in decay.

As noted, Greek medicine, with its routine binary 
thinking, singled out two main manifestations of mood and behavioural disturbance, mania and melancholia. The fullest early clinical descriptions of these were advanced by a contemporary of the great Galen, Are-taeus of Cappadocia (ad c. 150-200), in his
On the Causes and Signs of Diseases.
He observed of one case of melancholy:

Sufferers 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 fears also seize them. ... 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 are seen: 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 and forgetful of themselves and live the life of inferior animals.

Melancholia, as is evident from this clinical account, was not, as it would later be for Keats and other Romantic poets, a fashionably dreamy sadness. For Aretaeus and for Classical medicine in general, it was a severe mental disturbance. Anguish and dejection were its essential elements, but also involved were powerful emotions springing from hallucinations and sensations of suspicion, mistrust, anxiety, and trepidation. ‘The patient may imagine he has taken another form than his own,’ Aretaeus commented on the delusions of the depressed:

one believes himself a sparrow; a cock or an earthen vase; another a God, orator or actor, carrying gravely a stalk of straw and imagining himself holding a sceptre of the World; some utter cries of an infant and demand to be carried in arms, or they believe themselves a grain of mustard, and tremble continuously for fear of being eaten by a hen.

Similar tropes—one man too terrified to urinate in case he drowned the whole world, another sure he was made of glass and about to shatter at any moment—were recycled right through to Robert Burton’s
Anatomy of Melancholy
(1621) and beyond.

For Aretaeus, depression was a grave condition, its delusions, obsessions, and
idées fixes
highly destructive. ‘The melancholic isolates himself, he is afraid of being persecuted and imprisoned, he torments himself with superstitious ideas, he hates life ... he is terror-stricken, he mistakes his fantasies for the truth ... he complains of imaginary diseases, he curses life and wishes for death. ’

At the opposite pole lay mania. A condition marked by excess and uncontrollability, it found vent, for Aretaeus, in ‘fury, excitement and cheerfulness’. In acute forms, the sick person ‘sometimes slaughters the servants’; or he might become grandiose: ‘without being cultivated he says he is a philosopher.’ Mania often included euphoria: the sufferer ‘has deliriums, he studies astronomy, philosophy ... he feels great and inspired’.

Displaying the rationalist temper of Classical medicine, Aretaeus deplored those collective outbursts of frenzied cultic Dionysian activity which, to his mind, had disgraced Greek civilization and were still all too present in the Roman Empire, diagnosing these religious outbursts medically. He pinpointed the kinds of superstitious mania which involved possession by a god (divine
furor),
especially amongst those following the cult of Cybele (Juno). In ‘enthusiastic and ecstatic states’, devotees would stage wild processions, and, as with the Corybantics, believers ‘would castrate themselves and then offer their penis to the goddess’. Zealots fell into trances supposedly derived from divine inspiration, feeling deliriously euphoric and worshipping the gods of ecstasy and the dance. All this, in his view, betrayed ‘insanity ... in an ill, drunken and confused soul’.

Aretaeus has been credited with identifying what were much later to be called bipolar disorders. ‘Some patients after being melancholic have fits of mania’, he observed, ‘so that mania is like a variety of melancholy.’ A person previously euphoric suddenly ‘has a tendency to melancholy; he becomes, at the end of the attack, languid, sad, taciturn, he complains that he is worried about his future, he feels ashamed.’ After the down phase, they might swing back to hyperactivity: ‘they show off in public with crowned heads as if they were returning victorious from the games; sometimes they laugh and dance all day and all night.’

Aretaeus’ very recognizable picture of wild mood-swings would have seemed perfectly familiar to the nineteenth-century French psychiatrists, Jean-Pierre Falret and Jules Baillarger, whose work on circular or double insanity pointed towards the modern category of manic-depressive psychosis (see Chapter 6). Yet we must beware the temptations of hindsight.

Graeco-Roman medicine offered a welter of therapies for the mad, sometimes at odds with each other. The physician Soranus recommended talking to the deranged; Celsus by contrast believed in shock treatment, suggesting isolating patients in total darkness and administering cathartics in hopes of frightening them back into health.

A continuing tradition

Medieval Islamic and Christian medicine honoured and followed the medical traditions begun by Hippocrates and systematized by Galen, Aretaeus, and others, and the accounts of madness advanced by medieval learned doctors essentially repeated them. In the herbals and leechbooks produced by early medieval monks, simplified Classical learning was intermingled with folk beliefs and magical remedies. Melancholia and mania dominated the diagnoses. Among the medi-evals, Bartholomaeus Anglicus, who taught in thirteenth-century Paris, in the Aretaean manner included under ‘melancholia’ such states as anxiety, hypochondriasis, depression, and delusion.

Greek-derived thinking retained its validity and vitality in the Renaissance. Denis Fontanon, a mid-sixteenth-century professor at Montpellier, then a major medical university, stated, apropos mania, that it ‘occurs sometimes solely from the warmer temper of the brain without a harmful humour, and this is like what happens in drunkenness. It occasionally arises from stinging and warm humours, such as yellow bile, attacking the brain and stimulating it along with its membranes.’ Addressing its varieties, he explained their distinct features and causes. It was a good sign if mania involved laughter; whereas when the mixture of blood and choler (yellow bile) was ‘burned’—that is, appeared especially heavy and thickened—there would be ‘brutal madness and this is the most dangerous mania of all’.

Fontanon’s younger contemporary at Montpellier, Felix Platter (1536-1614), similarly identified mania with excess. As in melancholia, its victims would ‘imagine, judge and remember things falsely’. The maniac would also ‘do everything unreasonably’:

Sometimes they are the authors of relatively modest words and deeds which are not accompanied by raving; but more frequently, changed into rage, they express their mental impulse in a wild expression and in word and deed. Then they come out with false, obscene and horrible things, exclaim, swear, and with a certain brutal appetite, undertake different things, some of them very unheard of for men under any circumstances, even to the point of bestiality, behaving like animals. Some of them seek sexual satisfaction particularly intensely. I saw this happen to a certain noble matron, who was in every other way most honorable, but who invited by the 
basest words and gestures men and dogs to have sex with her.

7
The sixteenth-century Swiss physician, Felix Platter, is shown seated, with two companions, at a table covered with surgical instruments and books. Below are the figures of Hippocrates and Galen, on either side of flayed human skin.

In his portrait of melancholia, Platter foregrounded anxiety and delusion. Echoing Aretaeus, he cast it as a ‘kind of mental alienation, in which imagination and judgement are so perverted that without any cause the victims become very sad and fearful’. The disorder thus involved a crazy gothic castle of delusion founded upon false images.

Another contemporary, Timothie Bright, published the first English treatise on melancholia in 1586— Shakespeare’s familiarity with psychiatric writings probably came through reading Bright. The climax of the humoral approach to mental disorder lies, however, in the encyclopaedic
Anatomy of Melancholy
(1621) by Robert Burton, an Oxford don who spent his entire life researching, writing, and revising his
magnum opus.
In creating a gloomy portrait-gallery of taciturn, solitary, deluded, and often dangerous melancholics, Burton, in addition to the classic distemperature of the spleen, brain, and blood, included the following possible causes or precipitants of the condition: ‘idleness, solitariness, overmuch study, passions, perturbations, discontents, cares, miseries, vehement desires, ambitions, etc.’. His encyclopaedic curative recommendations similarly ran the gamut of remedies suggested ever since the Ancients: diet, exercise, distraction, travel, purgatives, bloodletting, and so on, including literally hundreds of herbal remedies. Marriage was the best cure for melancholy maids, wrote the bachelor Burton, and he also urged music therapy, which went back at least to Old Testament times:

And it came to pass, when the evil spirit from God was upon Saul, that David took the harp, and played with his hand: so Saul was refreshed, and was well, and the evil spirit departed from him. (1 Sam. 16: 23)

Like many other writers on the subject, Burton was himself a sufferer: ‘I write of melancholy by being busy to avoid melancholy.’ And with an eye to fellow sufferers, his mammoth work concluded with the admonition, ‘Be not solitary, be not idle’, advice the author himself had evidently but half-followed. Burton’s great work conveys the melancholy impression that there are as many theories of insanity as there are mad people, and that they all contradict each other: Polonius vindicated once more! The Renaissance thus brought no Copernican revolution in psychiatry, which would finally lay bare the secret motions beneath the skull. It was rather the culmination, and the conclusion, of the Classical tradition. In the century after Burton, the new 
anatomy and physiology associated with Andreas Vesalius and William Harvey was to usher in new organic theories of insanity to replace the humours, as will be shown in Chapter 6. Meanwhile developments in philosophy would open up new psychological approaches.

8
The Stone of Folly
by Teniers, seventeenth-century engraving. An itinerant surgeon extracting stones from a grimacing patient’s head symbolizes the extraction of ‘folly’ (insanity).