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How did pre-twentieth century theories of the aetiology of depression develop?

By Mead Mathews

“And yet in certain of these cases there is mere anger and grief and sad dejection of mind………those affected with melancholy are not every one of them affected according to one particular form but they are suspicious of poisoning or flee to the desert from misanthropy or turn superstitious or contract a hatred of life. Or if at any time a relaxation takes place, in most cases hilarity supervenes. The patients are dull or stern, dejected or unreasonably torpid……they also become peevish, dispirited and start up from a disturbed sleep.”

Arateus (AD 150)

“We can chart our future clearly and wisely only when we know the path which has led to the present”

Adlai Stevenson

How did pre-twentieth theories of the aetiology of depression develop?

Depression has always existed. King Saul is described as experiencing depression and committing suicide because of it in the Old Testament. Even before this theories on mental illness and depression existed. However, it has not always been seen as separate from other types of mental illness. Therefore, it is not possible to look at the aetiology of depression without paying some attention to the development of psychiatry as a whole. This, in turn, is not an isolated event. Advancement of scientific knowledge occurs in spurts that are greatly influenced by the attitudes of time, particularly ideas abut human behaviour which are not just directly connected with science. I have tried to create a flavour of the periods the theories developed in, in order to understand better the background and consequences of them in society as a whole.

It is thought that ancient man saw mental illness as possession by supernatural forces. Ancient human skulls have been found with large holes in them, a process that has become known as trepanning.¹ The accepted theory is that it was an attempt to let evil spirits out. We cannot be certain of this, but we do know that again and again human kind has returned to the idea of mental illness being caused by “evil forces”.

The great cultures of old, such as those of Egypt and Mesopotamia, fluctuated between naturalistic and supernatural explanations of diseases.² In the classical Greek era attempts were made to explain physical and psychological phenomenon with more scientific approaches. Empedocles (490-430 BC) developed the humoral theory, based on what he regarded as the four basic elements, each was characterised by a quality and a corresponding body humor:

Element	Quality	Humor
Fire	Heat	Blood (in the heart)
Earth	Dryness	Phlegm (in the brain)
Water	Moisture	Yellow bile (in the liver)
Air	Cold	Black bile (in the spleen)

Disease was said to be caused by imbalance among these humors and the cure was to administer a drug with an opposite quality to the one out of balance.³

Hippocrates (460-377 BC) lived at the time of Hellenic enlightenment, when great advances were made in all areas of knowledge. He applied Empedocles’ theory to mental illness and was insistent that all illness or mental disorder must be explained on the basis of natural causes. Unpleasant dreams and anxiety were seen as being caused by a sudden flow of bile to the brain, melancholia was thought to be brought on by an excess of black bile⁴, and exaltation by a predominance of warmth and dampness in the brain. Temperament was thought to be choleric, phlegmatic, sanguine or melancholic depending on the dominating humor.

Plato (427-347 BC) had a retrograde influence on psychology in that he reintroduced a mystical element.⁵ He believed in two types of madness, the first was divinely inspired and gave the recipient prophetic powers, the second was caused by disease.² He conceived of two souls:

Soul	Mortality	Location
Rational	Immortal	In the brain
Irrational	Mortal	Emotions located in various parts of the body e.g. anger and audacity in the heart.

The second type of mental disorder resulted when the irrational soul severed its connection with the rational, resulting in an excess of happiness, sadness, pleasure seeking or pain avoidance. The reason for the abandonment of reason was due to the imbalances explained in Hippocrates’ humoral theory.

Aristotle (384-322 BC), Plato’s pupil, believed in the two parts of man’s soul. However, he said because reason was immortal it must be immune to illness, so all illness, mental or otherwise, must be rooted in man’s physical structure.¹

Through the Punic wars (264-146 BC) Rome came to dominate much of the civilised world. The Romans produced few notable physicians and instead imported Greek ones for the treatment of injured Roman soldiers. These physicians eventually began to practice in Rome itself. Therefore, many of the advances in Roman thinking about mental disorder came from physicians steeped in Greek tradition.

Asclepiades (dates unknown) was one such physician. He regarded mental disorders as stemming from emotional disturbances, in his terms “passions of sensations”.⁵

Cicero (106-43 BC) was a philosopher, not a healer. He went further than Asclepiades and rejected Hippocrates’ bile theory, stating that emotional factors could cause physical illness, “What we call furor they call melancholia, as if the reason were affected by only a black bile, and not disturbed often by a violent rage, or fear, or grief”. The difference between physical and mental disorders was that the former might be caused by purely extraneous factors, but “perburtations of the mind may proceed from a neglect of reason”. Man could help with his own cure through “philosophy”, which would nowadays be known as psychotherapy.⁵

Arateus (ca AD 30-90) was the first to suggest that the origin of mental disorder might not be specifically localised. It could originate from the head or abdomen and the other could be affected as a secondary consequence. He had begun to see that an individual functions as a unitary system. He also worked on ideas about premorbid personalities and discovered that individuals who became manic were characteristically labile in nature, easily irritable, angry or happy. Those who developed melancholia tended to depression in their premorbid state.¹ Emotional disorders were merely an extension or exaggeration of existing character traits, a very original idea for the time. He also observed that mania and depression could occur in the same individual, thereby anticipating Kraeplins’ work on mania and melancholia being part of one disorder by many centuries.

Galen (AD 30-90) did not so much develop highly original ideas as sum up the thinking of the Greco-Roman era. He again divided the soul into two areas:

Souls	Location	Function
Rational	Brain	Controls internal and external functions. Internal = imagination, judgement, memory, apperception, movement. External = the five senses.
Irrational	Heart and liver	Control all emotions

He suggested again that infection of one area could be secondary to something else. He stated that food passed from the stomach to the liver where it was transformed into chlye and permeated by natural spirits (which exist in every living substance). The veins carried the material to the heart. Air, which held the vital principle, combined with the natural spirits, thereby producing the vital spirits. These rose into the brain and were converted into the animal spirits. Mental disease/disturbance of animal spirits arose because either because the brain was directly afflicted (mania and melancholia) or because it was affected by disorder in another organ.³ These theories by Galen contrasted greatly with the period of thought that was about to begin.

Christianity had grown from a persecuted minority into the official religion by the fourth century AD With the fall of the Roman empire there was much insecurity amongst people and the Christian Church played an important role in bringing consolation to the masses. People were again more willing to trust in supernatural explanations of phenomena that could not be explained at the time with rational thought. Some believe that Christianity ensured the continuation of civilisation and prevented a further retrogression. The price paid was probably the loss of the scientific thinking of the Greco-Roman era.

The Church of the early middle ages was concerned very much with life in the hereafter and not on earth. It also stressed greatly the healing powers of religious symbols. This probably explains the decline in the healing arts in particular.

Much superstition and belief in the supernatural abounded amongst lay people. The Church did not deny the existence of the supernatural, but saw magic as evidence of communion with devils.⁵ The early rationalism abated. The learning of the Greco-Roman era were only accessible in places such as monasteries where learned men read and compiled them, but added little that was new.

The nunneries were more creative places of learning, centred around the arts and nature. They probably used many herb and plant remedies to heal the sick², as did the lay people of that time. Nature was again seen as a healer. This is reminiscent of pagan beliefs. However, unlike the Pagan’s who worshipped the femininity and healing powers of women and held them in esteem, the Christian authorities begun to see women as inferior and dirty. Even so, the Abbesses held much power for women at that time.

The phenomenon of mental disturbance troubled the early Christian authorities. The Devil could not always be blamed because the content of the madness seemed to have religious significance, it was undecided as to whether the mad were communicating with the devil or were saints. However, in the early seventh century the Devil was accepted as a culprit for all types of deviant behaviour and Demonology became the “psychiatry” of the day. Symptoms looked for were marks on the skin that the Devil might have left and cures involved placing holy relics on the afflicted.

In the sixth century the Bedouins experienced a religious transformation at the hands of their prophet Mohammed. A century later the Arabs had conquered Babylonia, Persia, Syria, Egypt and had penetrated into Europe as far as Spain. They were not interested in changing the cultural habitat and so provided an intellectual oasis. Their culture was highly civilised and medicine reached heights not seen since Greek times within a few centuries. Hospitals for the insane were built.² However, little original work was produced because the Koran was seen as the authority for all knowledge, therefore no schools for higher learning existed unless they taught the Koran. The theories of Hippocrates and Galen still abounded and therapies such as the administration of purgatives were traditional. They also believed in provoking argument with the patient seen as “the stirring of the dead fire to make it burn afresh”.

This reawakening in the Arab world had little effect on western Europe where medicine was restricted to the body and the mentally ill were seen as the responsibility of the clerics. Despite the theories of devil-possession the mentally ill were not treated harshly. Saints were appealed to and religious pictures of the eleventh and twelfth centuries depict the holy figures in the process of casting out the devils.¹ Torture and execution of the witch and sorcerer flourished much later.

The appearance of the witch-hunt coincided with the beginnings of the Renaissance spirit in Europe. During this era (the thirteenth to sixteenth centuries) the Church was under attack and tried to impede the Reformation. There was also threat within church ranks due to disrespect for the vows of celibacy. The status quo had been rocked and their needed to be something around which the forces of orthodoxy could rally, this was the witch hunt.

It was assumed that woman stimulated man’s licentiousness, so the blame for sinful erotic behaviour was laid here; women tempted man so they must be the Devil’s agents. Psychotic women who openly acted erotically were easy targets.³

By the end of the fifteenth century psychological problems were greatly entwined with legal and religious issues and were not seen alone. The devil was seen as the cause of all ills (even Galen’s humoral theory was rejected). Mental disorder was equated with sin. The devils greatest preoccupation was sex. The Malleus Maleficarum, the authority on witches at the time, stated that “all witchcraft comes from carnal lust which is in women insatiable”. They also stated that where doctors could find no cause for a disease and where the disease did not respond to traditional treatment it was caused by the devil.⁶ A witch was stripped and her pubic hair was shaved before presentation to judges, so that the devil would have nowhere to hide.¹ On being found guilty a witch would be burnt at the stake. Literally hundreds of thousands of women and children suffered this fate and probably many of the mentally ill.⁴ In this climate nearly all natural thinking about mental illness was swept away.

Johan Weyer (1515-1588) was the private physician of William, Duke of Cleves (who suffered from depression). The Duke protected him and enabled Weyer to speak out and reject the doctrine of witchcraft. He stated that natural causes of illness should be looked for in the mentally ill.²

The early questioning of the established order, that had been crushed by the backlash represented by the witch-hunt, re-emerged. This may have been due to the rise in trading amongst Mediterranean countries or the reintroduction of Hellenic learning by the Arabs. Machiavelli described the world of political reality, renaissance painters depicted the human form realistically, Calvin, Knox and Luther even looked closely at the church. The well-accepted theories of the Greeks were rejected, Leonardo da Vinci wrote (1425-1519) “those who study old authors and not the works of nature are stepsons of nature, who is the mother of all good authors”.

Juan Luis Vives (1492-1540) was a social philosopher and humanist whose interests ranged from education, through social welfare to mental illness. He helped to establish hospitals for treatment of the mentally ill and stressed that “The mentally ill are, first and last, men, human beings, individuals to be saved and to be treated with utmost humaneness”.¹ He described a process whereby events register in our minds outside of our conscious awareness and later recall took place through a chain of associations, this advanced thinking foreshadowed the idea of the unconsciousness. He also recognised that emotions were often a mixture of one type of feeling and its opposite, anticipating Freud and Bleuler’s formulation of “ambivalence”.

It would be misleading to suggest that the sixteenth century was completely analytical. It also saw a large growth in the interest in astrology, palm reading (which dates back to ancient China) and other methods of fortune telling. Some of these methods were even used by specialists of the day to foretell personality configurations.¹ This belief that celestial bodies controlled events on earth reflects back to the thirteenth century. The observation that man is often most disturbed at night, when the moon is present, had led to the development of the term “lunatic” (one who is deranged by the presence of the moon).⁷

The seventeenth century has been termed “The Era of Reason and Observation”¹. There was a general and literal expansion of man’s horizons. Great seafarers such as Walter Raleigh and Francis Drake discovered new lands and brought back reports, which changed attitudes about the social order. Many important ideas about mental functioning were developed by philosophers and literary figures.

Robert Burton’s anatomy of melancholy appeared for the first time in 1621.²He described in detail the psychological and social causes (such as poverty, fear and solitude) that were associated with melancholia and seemed to cause it.²

The emotions were studied and their impact on the physical organs, particularly the heart, recognised. The philosopher Spinoza (1632-1677) wrote of the inseparability of the mind and body, that they were identical and that physical processes are experienced psychologically as emotions, thoughts and desires. In his advancement of the views that psychological events had causes the same as physical events, he rejected the idea that man possessed an absolutely free will. In implication this was the beginning of the psychodynamic approach.¹ Spinoza regarded self-preservation as the cause behind all psychic processes; man loves whatever enhances survival and hates whatever threatens it. We retain consciously only the experiences that positively enhance the body’s power; this notion anticipated Freud’s idea of repression.⁵

Others, who contributed to man’s understanding of his psychological processes, but in an unsystematic way, were the great literary figures of the time. Particularly William Shakespeare (1564-1616) and Miguel de Cervantes (1547-1616). Shakespeare produced masterful descriptions of the unconsciousness conflicts in man. The two heroes in Cervantes’ “Don Quixote”, Don Quixote and Sancho Panza, personify two aspects of the same personality – wishful fantasising and stabilising reality. One of the great significances of these works, as well as accurate descriptions of human behaviour, was the suggestion that special psychology is not necessarily needed to understand the mentally disturbed. The thought processes of “the Mad” could just be extensions of the “normal”; they may just be more vulnerable and less able to control processes that typify us all.

In the eighteenth and early nineteenth centuries many of the mental hospitals that had appeared in early medieval times and had become prominent by the sixteenth and seventeenth centuries were reformed. They had started life as a dumping ground for all of society’s undesirables.⁷ The mentally ill were exhibited to the public in the same spirit as animals in a zoo. They were restrained by chains in dirty and damp rat infested cells. It was to such settings that Phillipe Pinel in France, Chiarugi and Pisani in Italy, and Tuke in England brought reforms.⁶ These hospital reformers were not men of genius, but dedicated humanitarians. Most of these men provided few new ideas to enrich our understanding of the causes of mental illness, but much to improve the treatment of the individual.

Pinel did develop theories. He points out that the patient’s emotional life is often disturbed before the onset of the attack and emphasises the importance of psychological factors in the development of insanity. He suggested a series of causes²:

1.)heredity

1.) Harmful factors in the social environment e.g. a faulty education.

3.) an irregular way of life

4.) spasmodic passions (rage, fright)

5.) enervating or opposite passions (grief, hate, fear, remorse)

6.) the gay passions

7.) a melancholic constitution

8.) physical factors (he includes alcoholism, amenorrhoea, non-bleeding haemorrhoids, fever , the puerperium and head injury)

Pinel still believed that abnormalities are often found in the abdomen. Franz Joesph Gall believed that specific brain areas control specific body functions⁴ and even character traits are related to the structure of certain localised areas within the brain. Gall’s further assumption was that skull shape, particularly protuberances accurately reflected brain shape and with it under or over development of particular character traits, thus the direct method of character reading, “phrenology” was conceived.¹ Although the later steps in Gall’s argument are false, the ideas of cerebral localisation were to develop further. An increased interest in brain pathology led to theories that different forms of mental disorder were associated with lesions in different parts of the brain.²

Esquirol was a student of Pinel, he freed himself from Pinel’s theory of gastrointestinal localisation and adopted Gall’s theory of cerebral localisation.² He is credited with recognising the force of emotional and moral factors in an individual’s life and also distinguishing between predisposing and precipitating causes.⁴ He understood more clearly the roles of social upheaval and isolation in mental illness.² He also stressed that predisposition was acted on by social and psychological causes. For example, domestic troubles, “disappointed love” and reverses of fortune.

Early nineteenth century psychiatry largely consisted of the romanticists of whom Johann Christian Heinroth was the most prominent representative. Heinroth believed that sin was the causal factor in mental illness.¹ Not sin in the theological sense, (there is a general tendency to discard him as a religious healer), but the offending of an individual’s morals by their own thoughts.⁵ He was referring to an internal conflict between acceptable impulses and conscience. He developed a theory of psychological processes stressing three levels of functioning:

Level	Name	Function	Development
Lowest	Instinctual forces	Seek pleasure
Second	Ich (ego)	Facilitate security in the external world and enhance the enjoyment of life.	From lowest level through recognition of differences between the self and the world around it.
Highest	Gewissen (the conscience)	First experienced as an alien force opposing self –centred ego strivings.	From the ego.

Mental illness resulted from conflict with one’s conscience. These views about personality certainly herald those of Freud.

For J. Moreau de Tours, a disciple of Esquirol, understanding could only come from introspection and experience.³ Dreams were similar to hallucinations and were therefore the link between the ill and the healthy; they were a transient form of psychopathology.⁵ He postulated that man exists in two worlds, one from communion with the outside world and the other from contact with his own internal sources.³ The dream was a bridge between these two realms. The insane can be seen to dream whilst awake (the inner world had impinging on the outer). Because dreams normally occurred when there was an absence of external stimuli and the internal stirrings are allowed to dominate; Moreau concluded that the insane person must have an excessive preoccupation with the internal world and an alienation from external affairs. These views, like Heinroth’s, sound surprisingly similar to Freud’s.

In the mid-nineteenth century theoreticians turned towards organic causes as the basis of mental illness and the pioneering ideas described above were eclipsed. Heinroth and his contemporaries were rejected as romanticists and philosophers. At the end of the century when Freud’s theories arrived on the scene they were seen as completely novel. However, we should not overlook the inherent weaknesses of the romantic approach. These theories were not the result of careful observations, but of visionary speculations. Therefore a scientific reaction was inevitable.

The man who exemplified the hard-nosed scientific feel of this era was the German psychiatrist Wilhelm Griesinger (1817-1868). For him mental diseases were somatic diseases⁶, and the cause of mental illness was always to be found in the brain.³ This oversimplifies him in some ways, because he did deal with a concept of the ego and refer to the role of repression in mental illness. He firmly believed that psychiatry and neuropathology were one.³ Understanding of the psychological origin of our psychological attributes was not necessary, only their anatomical and psychological ones.

Whilst the lab worker was concentrating on the organic cause of illness the clinical worker was particularly interested with the course an illness took. Karl Ludwig Kahlbaum (1843-1899) set out to observe the forms taken by abnormal behaviours. He wrote about a “cyclic insanity” characterised by alternation of mood from mild depression to mild euphoria and termed it “cyclothymia”.⁸ After Kahlbaum there was a relatively quiet period in German psychiatry.⁵

The work of Emil Kraeplin (1855-1926) began in the last twenty years of the nineteenth century. He was a faithful follower of the tradition fostered by Griesinger. At first he leaned strongly to regarding heredity factors as the cause of mental illness; later he shifted toward a belief in the importance of metabolic factors.¹

Kraeplin’s work can be seen as culmination of the neurophysiological approach which began with Griesinger and continued to dominate the scene until Freud’s dynamic motivational approach revived interest in the patient as a unique individual with a unique history. What Freud successfully realised was that neurophysiological and psychological knowledge need not be contradictory.

Psychoanalysis predominated until the 1970s, which was followed by renewed interest in genetic, biochemical and neuropathological causes of mental disorder which came to be known as biological psychiatry.

Understanding of the tortuous development of ideas about depression and an awareness of the common obstacles in the past, gives us a greater understanding of the difficulties we could encounter when attempting to make progress in our own time. From looking at the history of ideas on the causation of mental disorder it becomes very apparent that each generation bases its theories of aetiology on the scientific approaches most active at the time. Sometimes psychological ideas prevail, sometimes neuropathological and sometimes genetic. Scientific approaches are also influenced by the wider attitudes of the time, the social, political and cultural climate. I, myself, have been educated with much emphasis placed on the scientific and logical approach and this has probably affected the slant I have taken when writing this essay. Who is to say the mysticism scientists so easily discard is wrong? Eastern philosophy still places much emphasis on these rejected “hidden powers” and in this sense my essay is limited in that most of the literature available only considers Western psychiatry. The ideal would be for psychiatrists, psychologists, neurologists and whoever else is involved in the suggestion of theories to keep as wide a viewpoint as possible.

References

1.) Zax M, Cowen E L. Abnormal psychology - Changing Conceptions, 2nd rev ed. USA: Holt, Rhinehart and Winston, 1976.

2.) Ackerknecht E H. A short history of psychiatry. New York: Hafner, 1959.

3.)Alexander F G, Selesnick S T. The history of psychiatry. USA: Harper and Row, 1966.

4.)Gelder M, Gath D, Mayou R, Cowen P. Oxford textbook of psychiatry, 3rd rev ed. New York: Oxford University Press Inc, 1998.

5.)Zilboorg G, Henry G W. A history of medical psychology. New York: W. W. Norton and Company, 1941.

6.) Johnstone E C, Freeman C P L, Zealey A K. Companion to psychiatric studies, 6th rev ed. Edinburgh: Churchil livigstone, 1998.

7.) Wing JK. Reasoning about madness. Great Britain: Oxford university press, 1978.

8.) Berrios GE. Melancholia and depression during the 19^th century: a conceptual History. British Journal of Psychiatry 1998 Sep, 153: 298-304.