Wednesday, 25 June 2014

Melancholy: the English Disease

The history of psychiatry and mental health – not surgery – was my first real introduction to “doing” not only early modern English history, but the history of medicine as well.  The fascination with historical understandings of mental health never quite disappeared and I hope to return to it for a post-doctoral project.

For England, the 17th century was a time of extraordinary upheaval.  Recent religious reformation and the growth of sectarian Protestantism sparked heated debates about spirituality, the senses, and emotional experience.  Political instability and ubiquitous warfare, especially the English Civil War, meant uncertainty and threats to life and lifestyle.  The Little Ice Age, frequent and devastating epidemics, coupled with an already low life expectancy meant a compromised physical state.  Increasing urbanization, crowded conditions, and widespread poverty meant a stressful existence. 

As Michael MacDonald observed, the period was marked by an increasing awareness of madness, melancholy, and suicide. 

Indeed, this is an era where great literary figures like Spenser, Shakespeare, and Milton wrote of the passions and madness and the people flocked to Bedlam to observe the mad. 

Melancholy became known as the English disease. 

But what is melancholy?  And how did early modern medical practitioners define and treat it?

Diagnoses and understandings of disease categories – then as now – are created in specific times and places. 

18thC portrait of a "typical" melancholy face.
One needs only to look at the firestorm over the DSM for illustration.  The manual’s first edition (DSM-1) was published in 1952 with newer editions published each decade to revise both disease definitions and the criteria used to diagnose specific ailments.  Controversial revisions include the removal of homosexuality as an expression of a sociopathic personality type.  Under the DSM-5, grief, happiness, worry, and even behaviours like forgetfulness or absentmindedness have become symptomatic of mental disorders. 

Revisions to diagnostic definitions and disease categories reflect both newly discovered pathophysiological explanations of psychiatric disorders and changes in social and cultural values.

For early modern Britons, melancholia was a very real and severe affliction.  Like hypochondria it “attacked the sedentary and those who had too much time to think,”[1] a fact which gave rise to the stereotype of the melancholy gentleman.  Though not exclusively an affliction of the élite, melancholy affected an inordinate number of the upper classes.

The Galenic humoural explanation of disease dominated early modern medical practice; mental illness, more specifically melancholy, was not exempt.  Galen’s humoural explanation for disease was based upon the theory that there were four main bodily fluids – namely black and yellow bile, phlegm, and blood – and that all illnesses stemmed from an imbalance of these humours. 

In the case of melancholy, it was assumed that it was caused by an excessive of the black bile, or the melancholic humour.

Simon Forman ((31 December 1552 -5 or 12 September 1611) 

Simon Forman was an astrological physicians who generally subscribed to a Galenic theory of illness.  Despite his leanings toward to the occult, he never made pure use of astrology to diagnose a disease, nor did he use the supernatural or preternatural to explain illnesses wherever possible. 

In fact, there were cases in which Forman rejected the notion that witchcraft was to blame for an illness, and instead favoured a physical cause.  As he stated, “Many…persuade themselfes to [be] bewitched or forspoken or possesset with spirits, and…many…thinke themselues to be this or that through much melancholy oppressing the braine and hearte.” 

Forman associated depression with melancholy, and believed that grief could also trigger the illness. 

As Forman noted during his diagnosis of Robert Burton, he found “heaviness, wind in the bowels and belly (flatulence), unlustiness (lack of sexual desire), [and] stopping of the veins (lethargy).” 

Interestingly, Forman also denoted various types of melancholy, whose nature was dependent upon with which humor black bile mixed.

John Hall (1575-25 November 1635)

John Hall, Shakespeare’s son-in-law, was a general practitioner, who treated everything from “asthma, dropsy, sterility, cancer…emphysema, worms and jaundice.” 

Select Observations was printed posthumously
Throughout his Select Observations on English Bodies there are eight diagnosed cases of melancholy: two cases recorded simply as “melancholy,” five as “melancholia hypochondriaca,” with the last cross-listed with stupidness. 

Hall, like many of the physicians under consideration, recorded cases of both melancholy and hypochondriac melancholy without distinguishing between the two illnesses, and thus gives the impression that the two terms were interchangeable, referring to the same disease.  Those that were diagnosed as simply melancholic, however, were also recorded as suffering from “fits of the mother.” 

Hall noted the many symptoms of melancholy for each patient, and it is evident that while the recorded diagnoses differed nominally, there was a clear understanding not only of what melancholy consisted, but also of how it could be contracted. 

Pains of the head, as in the cases of Captain Basset and Mrs. Wagstaff of Warwick, or spleen, as found in most recorded cases of melancholy were noted.  Although dedicated to humouralism, Hall also noted the commonly thought cause of melancholy in the case of Mr. John Trap.  Trap was a minister who had a naturally melancholy temper; this was only exacerbated by “much study [and he] fell into Hypochondriac Melancholy, and pain of the spleen.”

Thomas Willis (27 January 1621-11 November 1675):

Thomas Willis’s account of melancholy is quite similar to that of John Hall.  Like Hall, he regarded splenetic people as being melancholic:

they tended to expectorate frequently and complained of vague left-sided pains as a consequence of the defective organ.  In those predisposed to melancholia the spleen failed to ferment the ‘more early and melancholic parts of the blood’ which degenerated into ‘an acid or vitriotic diathesis’ causing melancholy as he believed that ‘there is a great sympathy and relationship between the brain and the spleen.’

Instead of hypochondriac melancholy, however, we find cases diagnosed as depression.  These cases were nevertheless clearly recognized by Willis as forms of melancholy, as he stated in both cases that they were “of melancholic temperment [sic]” and “liable to hypochondriacal states” or “hypochondriasis” respectively. 

Willis included one particularly peculiar case which demonstrates his faith in humoural theory.  The case was that of a woman named F. Bodily who was excessively melancholy.  Bodily had recently given birth and was in the process of breastfeeding her child when, as Willis stated, “the milk taken by the infant was infected with a melancholy juice or black bile,” and as a result, the child contracted melancholy from its mother.

Sir Hans Sloane (16 April 1660-11 January 1753):
Hans Sloane, like the other general practitioners of the day, treated cases of mental illness.  Of these, there was one case diagnosed as hypochondriac melancholy.  The patient, a man by the name of Barrett, is an anomaly in the study of melancholy. 

Sloane himself notes this, stating that “it is not very ordinary (though it sometimes happens) to find labouring  Men troubled with this Distemper as this Patient was, who was very diligent, and wrought land about a Pen of Cattle, and small Plantation he had some few Miles out of Town.”

Though Sloane did not explicitly state his adherence to Galenism, it is clear that humoural theory has a profound effect upon his practice as his first inclination, similar to that of his contemporaries, was to simply purge the patient.

Treating Melancholy

As these physicians generally attributed melancholy to an imbalance of the humours, they unsurprisingly prescribed similar herbal or chemical concoctions with the addition of a variety of dietary restrictions, exercises and leisurely pursuits. 

Yes, *that* Richard Burton
Herbs such as sarsafras, sarsaparilla, aloes, wormwood and calomel were designed to purge the patient; hartshorn, ammonia, saffron, garlic, soap (probably black soap), and horseradish were used to promote sweating; aromatics such as wormwood and cinnamon were used to restore elastic and tone.  

Barbara Traister notes two melancholic cases in which Forman recommended purges – one of which was the case of Richard Burton, while Sloane recorded that he also recommended purges in his only case of melancholy. 

John Hall also recommended these medicines, while adding no small number of his own.  These included mallows, beets, violets, borage, and fennel.

Other than herbs and chemicals, physicians advised patients in matters of diet and leisure in order to cure melancholy.  As Forman, in his treatment of Richard Burton, stated: “the sufferer should be surrounded with pastimes and mirth, eat fat and sweet meats, and get lots of sleep,” and that “poultry, herbs, and young white wine are to be consumed.”

Let me know what you think here or on Twitter – I’m @medhistorian.

Works Cited:

Jones, Harriet.  Shakespeare’s son-in-law, John Hall, man and physician.  Hamden,
Conn.: Archon Books, 1964.

Sloane, Hans. 1707. A voyage to the islands Madera, Barbados, Nieves, S. Christophers and Jamaica, with the natural history ... of the last of those islands; to which is prefix'd an introduction, wherein is an account of the inhabitants, air, waters, diseases, trade, &c. ... Illustrated with the figures of the things describ'd, ... In two volumes. London: printed by B. M. for the author. 

Willis, Thomas, and Kenneth Dewhurst. Willis's Oxford Casebook (1650-52). Oxford:
Sandford Publications, 1981.

Willis, Thomas, and Eugenius Philiatros. The London Practice of Physick. Boston:
Milford House, 1973. 

Traister, Barbara.  The Notorious Astrological Physician of London: works and days of
Simon Forman.  Chicago: University of Chicago Press, 2001.

Turner, E.S. Call the Doctor: A Social History of Medicinal Men.  New York: St.
            Martin’s Press Inc., 195                          

[1] E.S. Turner, Call the Doctor: A Social History of Medicinal Men (New York: St. Martin’s Press Inc., 1959), 71.


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