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.
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
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.
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, centered around the arts and nature. They probably used many herb and plant remedies to heal the sick, 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.
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During the period of the writing of the New Testament Galen's theories about two souls and the natural and animal spirits would have been the prevailing belief of the civilized world. Well, I for one think that's better than the practice of the ancients to drill holes in the skull to let out the evil spirits.
