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.
By the time of the Inquisition, in the thirteenth century, some depressives were fined or imprisoned for their sin. In this period, Thomas Aquinas, whose theory of body and soul placed the soul hierarchically above the body, could conclude that the soul was not subject to bodily illness. Since the soul was, however, below the divine, it was subject to intervention by God or Satan. Within this context, an illness had to be of the body or the soul, and melancholia was assigned to the soul. The medieval Church defined nine deadly sins (they were subsequently compacted to seven). Among these was acedia (translated as “sloth” in the thirteenth century). The word seems to have been used almost as broadly as the word depression is in modern times, and it described symptoms familiar to anyone who has seen or felt depression—symptoms that had not previously been counted as vice. Chaucer’s Parson describes it as a thing that “deprives the sinner of the quest for all goodness. Acedia is man’s enemy because it is hostile to industry of any kind, and it is also a great enemy to the livelihood of the body, for it makes no provision for temporal necessities and even wastes, spoils, ruins, all earthly goods by negligence. It makes living men [be] like those who already suffer the pains of Hell. It makes a man peevish and encumbered.” The passage goes on and on, becoming more disagreeable and judgmental with each phrase. Acedia is a compound sin whose elements the Parson enumerates. “It is so tender and delicate, as Solomon says, that it will suffer no hardship or penance. The shirking makes man fear even to begin to perform any good work. Despair, loss of hope in the mercy of God, springs from unreasonable remorse and sometimes from excessive fear, which makes the sinner imagine that he has sinned so much that it will do him no good to repent. If it persists to a man’s last moment, it is numbered among the sins against the Holy Ghost. Then comes the sluggish sleepiness that makes a man dull and indolent of body and soul. Last comes the sin of World Weariness, called sadness, which produces the death of soul and body alike. Because of it, a man becomes annoyed with his own life. So the life of man is often ended before, by way of nature, his time has really come.”
Monks were particularly likely to develop acedia, which among them manifested itself in exhaustion, listlessness, sadness or dejection, restlessness, aversion to the cell and the ascetic life, and yearning for family and former life. Acedia was distinguished from the sadness (tristia) that leads a man back to God and to repentance. Medieval sources are not clear about the role volition plays in this. Was it a sin to let oneself develop acedia? Or was acedia a punishment meted out to those who had committed some other sin? Its most passionate opponents equate it with original sin; the eloquent nun Hildegard von Bingen wrote, “At the moment when Adam disobeyed the divine law, at that exact instant, melancholy coagulated in his blood.”
Order was somewhat precarious in the Middle Ages, and disorder of the mind was therefore particularly frightening to the medieval sensibility. Once reason was impaired, the whole of the human mechanism would fall apart; and then the social order would disintegrate. Folly was a sin; mental disease was a far more serious one. Reason is necessary to allow a man to choose virtue. Without it, he has not enough self-control for such a choice. The psyche, as understood by classical thinkers, could not be detached from the body; the soul, as understood by medieval Christians, was barely coincident with the body.
It is from this tradition that the stigma still attached to depression today has grown. The soul, being a divine gift, should be perfect; we should strive to sustain its perfection; and its imperfections are the primary source of shame in modern society. Dishonesty, cruelty, greed, egotism, and lapses of judgment are all shortcomings of the soul, and so we automatically attempt to suppress them. So long as depression is grouped with these “afflictions of the soul,” it seems to us to be abhorrent. There are many stories of how the association cast depression in the worst possible light. The fifteenth-century painter Hugo van der Goes, for example, entered a monastery in the 1480s, but continued, by virtue of great talent, to have regular interaction with the outer world. Returning one night from a journey, Hugo is recorded as having been “struck by a strange disorder of his imagination. He cried out incessantly that he was doomed and condemned to eternal damnation. He would even have injured himself, phantasmagorias clouding his diseased mind.” According to his fellow brothers, who attempted treatment with music therapy, “his condition did not improve; he continued to talk unreasonably, and to consider himself a child of perdition.” The monks considered whether Hugo had artistic frenzy or was possessed by an evil spirit, and decided that he had both complaints, perhaps exacerbated by consumption of red wine. Hugo was terrified of the work he had agreed to do and could not imagine that he could finish his commissions. With time, and with great rituals of religious repentance, he eventually recovered his equanimity for some time; but he had a subsequent relapse and died in a bad state.
If the Middle Ages moralized depression, the Renaissance glamorized it. Reaching back to classical philosophers (more than to classical doctors), Renaissance thinkers posited that depression indicated profundity. Humanist philosophy presented an increasingly strong challenge to Christian doctrine (though, in other cases, it strengthened Christian beliefs and tenets). The irrational pain that in the Middle Ages had been described as a sin and curse was now an illness (increasingly called melancholia) and the defining quality of a personality (increasingly called melancholy). Among all Renaissance writers who discussed depression—and they were legion—Marsilio Ficino was its greatest philosopher in the Renaissance. He believed that melancholy, present in every man, is the manifestation of our yearning for the great and the eternal. He wrote of those for whom melancholia is a default state: “It is astonishing that whenever we are at leisure, we fall into grief like exiles, though we do not know, or certainly do not think of, the cause of our grief . . . in the midst of the plays of pleasure we sigh at times, and when the plays are over, we depart even more sorrowful.” The melancholy here described is what is revealed beneath the busyness of daily life, a constant quality of the soul. Ficino reverts to the Aristotelian idea of divinely mad sadness and goes on to say that the philosopher, the deep thinker, or the artist will of necessity be more in touch with his melancholy than the common man, that the very profundity of his experience of melancholy will reflect his success in raising his mind above the distractions of ordinary life. For Ficino, the tortured mind is the more worthy, as it is catapulted up toward the melancholy inadequacy of its knowledge of God. This becomes a holy credo as he explains the nature of divine melancholy: “As long as we are representatives of God on earth, we are continually troubled by nostalgia for the celestial fatherland.” The state
of knowledge is dissatisfaction, and the consequence of dissatisfaction is melancholy. Melancholy divorces soul from world and so propels the soul toward purity. The mind “increases in perfection the more it goes away from the body, and so the mind will be most perfect at the time when it flies away entirely.” Ficino’s description of the divinity of melancholy acknowledges that the state is very near death.
Ficino subsequently proposed that artistic creation relied on a muse who descended during temporary insanity: melancholia was a prerequisite to inspiration. Nonetheless, Ficino recognized that depression was a terrible complaint and recommended treatments for it, including exercises, alterations of diet, and music. Ficino himself was a depressive, who, when feeling low, could not conjure all these attractive arguments in favor of depression; when his friends came to see him, they often had to make his own arguments to him. Ficino’s philosophy, like much post-Renaissance thought on the subject of melancholy, is autobiography—and so he speaks of steering the course between nonmelancholic phlegm on the one hand and desperate melancholic illness on the other, titling the sixth chapter of his first book “How Black Bile Makes People Intelligent.”
The Renaissance attempted to reconcile its understandings of classical thought with certain accepted “knowledge” that came from the Middle Ages. In bringing together the classical idea of the temperaments with the medieval fascination with horoscopes, Ficino described Saturn as the weighty, isolated, ambivalent planet that reigned over melancholy. Saturn is “himself the author of mysterious contemplation,” according to the alchemist and cabalist Agrippa, “not given to public dealing, the highest of the planets, who first recalls the soul from outer offices to its core, then has it ascend from lower matters, leading it to the highest, and granting it the sciences.” These views are borne out in the writings of Giorgio Vasari on the great artists of this time.
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