I turn a few pages on. There is a photograph of a serene, patrician-looking man, with thin lips and slick, greased hair. The caption says, ‘Egas Moniz’. A Portuguese neurosurgeon and diplomat, António Egas Moniz was shot the year of my grandfather’s breakdown by one of his patients. I find this funny for some reason. In 1949, I read, having recovered from his gunshot wound, he was awarded the Nobel Prize for having developed a new method of curing severe depression: prefrontal lobotomy. This involved hacking out portions of the front part of the brain, or injecting alcohol into the cortex to kill off brain cells. I begin to see that this history is not so distant after all, and that it presses distinctly on to the fates of my family.
It just so happens that about the time my grandfather suffered his mental collapse a great wave of new ‘scientific’ ideas was sweeping away what had previously been characterized as primitive, semi-religious approaches to mental illness. Apart from lobotomy, already being practised by Egas Moniz and other doctors, there was electro-convulsive therapy, pioneered by Ugo Cerletti after experiments on pigs, which sent patients into fits so violent they often fractured bones. There were drug treatments, many of them addictive. Some of them, like insulin shock, were capable of putting the patient into a permanent coma, while others, like cardiazol injections, could give the patient an awful terror of impending death – which was not always misguided, as cardiazol could lead to thrombosis. There was psychoanalysis, pioneered by Freud and now becoming famous, which analysed dreams, mesmerized patients and which in some versions forbade masturbation. There was electric sleep, in which a charge of electricity to the head rendered the patient unconscious.
If Art had decided to visit a doctor who had ‘modern’ ideas, these represented the menu of ostensibly new but in character rather medieval, magical treatments that could have been tried out to solve the ‘problem’ of his intractable grief. But my grandfather, so far as I know, did not visit a doctor during his collapse. Quite apart from the expense, to do so would have been the final abandonment of his pride and strength, of what he was meant, by culture, to be: self-reliant, enduring, independent.
Had he overcome those barriers, he would as likely as not have simply been told to go to bed, or to take a warm bath and then ‘pull his socks up’. Many doctors, like many laymen, were not sympathetic to what was perceived as weakness or self-pity. Yet if what Art was suffering from could be described as simple grief, his practically comatose state, and its duration, suggest something more.
‘Nervous breakdown’ is a vague, rather innocent-sounding phrase that suggests a physical failure of the ‘nerves’, the central nervous system. And in the 1930s that was, despite the vogue for psychoanalysis, how it was largely seen – as a physical complaint. People had ‘bad nerves’ or ‘suffered nerves’. Art’s (hypothetical) doctor, if sophisticated enough to be sceptical of the efficacy of baths and the hoisting of socks, may well have prescribed either drugs – amphetamines, barbiturates, both highly addictive – or a period in a mental hospital, for this was the most common form of treatment. And admittance to the hospital was the treatment. Patients were just left to lie there, in the hope that the depression would lift, as most depressions do, spontaneously, in six to nine months. The prospect of such a hospitalization would have terrified Art, since it conjured up – as it does now – images of drooling idiots, strait-jackets and padded cells. These images, in 1939, were as often as not perfectly accurate.
All these approaches, despite the avowed modernity, had deep roots. They were developments in many ways of ancient, equally blatant witch-doctoring. Depression – from the French déprimer, to push down – was not used as a medical term until the end of the nineteenth century, but the condition has been recognized throughout history. The treatments always came down to a few basic approaches. There was shock, what you might call the ‘kicking the TV’ approach. There was radical surgery. There were narcotics of one kind or other. And there were the ‘talking cures’, which predated Freud by about 5,000 years. Then there were other, in many ways less bizarre, treatments which had only relatively recently been abandoned by the time of Art’s breakdown, such as blood-letting and hydrotherapy.
To read about the history of this particular strain of madness, depression, is to be struck by how little ideas and even cures changed from ancient times to the middle of the twentieth century. Even in its earliest manifestations, ancestors of organic and psychoanalytic treatments were clearly discernible. The ancient Egyptians, like the doctors of the 1930s, prescribed sleep as a cure. Under Imhotep, vizier to the Pharaoh’s temple in 2900 BC, patients were washed and purified, then made to sleep overnight at the temple. Their dreams would be interpreted by priests, and those eruptions from the subconscious ‘talked through’.
At the temples of Asclepius, the ancient Greek god of healing, snakes were supposed to lick the eyelids of patients sleeping there and induce healing dreams. Priests would interpret the dreams and this would lead to a resolution of conflicts. In The Odyssey Homer suggested narcotic treatments for melancholy, particularly the root nepenthes, believed to be borage.
Imhotep, Homer and the Greek temple doctors believed that melancholy, in ancient Greece recognized as one of the four kinds of madness, had mainly physical causes. The Hippocratic doctors believed it was due to an imbalance of humours, in this case an excess of black bile, stored in the spleen. The cure was purging or blood-letting, a method that would be used up until the end of the nineteenth century, as would the belief in the ‘black juice’.
It was the Greek dramatists who identified despair and suicide as products not of some bodily malfunction but of inner conflicts between love, desire, revenge and duty – as well as defiance of the gods. Ever since this distinction was made, so far as I can tell, a dirty war has been going on over the real meaning of depression, with the battlefield divided between these two camps. On the one hand, there are mind ‘doctors’, who tend to concern themselves with medical treatments and the activities of the brain. Nowadays, we call them psychiatrists. On the other, there are mind ‘experts’, who, although not trained medically, attempt to treat psychological dysfunction. We now call them clinical psychologists or psychotherapists, or, if they are followers of Freud or Jung, psychoanalysts. Each view contains momentous, quite different implications. Each view claims a level of objectivity, but both are soaked with judgements and values.
The Romans, being Romans, followed the lead of the Greeks. They characterized melancholia as being ‘larvatum plenum’, ‘filled with phantoms’. This is, I know from experience, a frighteningly accurate description of the condition. In AD 14 the Roman writer Celsus suggested curing the malady by frightening the patient, or by stopping his heartbeat momentarily with drugs or by swinging the patient around in circles by his feet. This was the beginning of ‘kicking the TV’ cures.
The Cappadocian physician Aretaeus, in the second century AD, was the first to describe melancholy in a way that I can recognize:
[Sufferers] flee to the desert from misanthropy… they are suspicious of poisoning, and turn superstitious… they contract a hatred of life. The patients are dull or stern, dejected or unreasonably torpid without any manifest cause. They become peevish, dispirited, sleepless, and start up from disturbed sleep. Unreasonable fear seizes them. They complain of life and desire to die.
As Christianity began to spread, the thinking on depression gradually took on religious and moral aspects. St Augustine and Thomas Aquinas stigmatized suicide as cowardly and an offence against God, for which there was no chance of repentance. This thinking informed the Church and law up to the 1960s in England. If Art had made an attempt on his life, he could have been put in prison for two years. In the ten years after the Second World War, nearly 6,000 people were prosecuted for attempting suicide.
In the Middle Ages, the Arabs attached leeches to the anus to cure persistent sadness. The Incas anticipated Egas Moniz by drilling holes in the skull to let out evil spirits. But by the sixteenth century,
melancholia had begun to lose some of its bad reputation, and take on some of the glamour it would later hold for twentieth-century nihilists and rock stars. It was seen as a mark of depth and contemplation. The greatest of all tragic heroes, Hamlet, is in fact the first dramatic depiction of someone suffering from a depressive psychosis.
When I was suppurating in my bed, six months before my mother’s death, I became obsessed with Hamlet. In him I saw clearly a reflection of what I imagined to be my own struggle. For Hamlet is clearly undergoing a nervous breakdown. He is obsessive and misanthropic; he cannot sleep properly, or make up his mind about anything; he drifts in and out of reason; he wishes above all to die, but the fear of death prevents him; he feels in the grip of an immutable destiny which he knows will destroy him; he is full of disgust for himself and for everything else. Hamlet is tortured and elemental – someone who cuts through all the crap and just finds more crap. He is the patron saint for depressives, at least male depressives. Perhaps Sylvia Plath serves that role for women.
Intriguingly, Hamlet, along with a number of other ‘Shakespeare’ plays, was, according to some sources, written by Robert Burton, author of The Anatomy of Melancholy, the key seventeenth-century text on depression. Burton, himself crippled by melancholy, had the insight that his state of mind was a veiled hostility and resentment towards the world in general, a sort of self-hatred in disguise. Illuminatingly, in Old English, the word anger meant sorrow as much as rage.
Burton also recognized that emotional pain could be a product of past experience: ‘A man,’ he wrote, ‘may be undone by an evil bringing up.’ So here the idea of childhood trauma enters the picture, the power of the personal, distant past to act ruinously on the present. But all Burton had to offer as a remedy was talking to a friend, listening to soothing music or the consumption of a variety of exotic herbs – eglantine, sweet briar or, poetically, the scent of dried roses.
Later in the seventeenth century, the treatments, like society, became more Baroque. Jean-Baptiste Denis, physician to Louis XIV, drew out blood and replaced it with calves’ blood for two days. This apparently worked. However, the results were unpredictable. One patient died after receiving lambs’ blood. Transfusions of one kind or another to treat depression continued until the end of the nineteenth century.
At around the same time, more shock treatments were being developed. At the Salpêtrière asylum in Paris, jets of freezing water were shot up the anus, taking the sitter by surprise. Others were immersed under the sea for as long as possible.
These desperate, in themselves practically psychotic, attempts to cure persistent dolour continued. The French doctor Théophile Bonet bled a young girl thirty times to cure her depression. He was disappointed, but can hardly have been astonished, when she died as a result. In England, patients from Bedlam were sent to the Fens to contract malaria, what was known as ‘fever shock’. This had predictable, if terminal, results. More successfully, in 1792 two cases of melancholy were cured by applications of electricity to the head by John Birch at St Thomas’s Hospital in London.
The nineteenth century was a watershed for the treatment of mental illness, partly because the widespread establishment of asylums made the study of symptoms possible for the first time. Hanwell Asylum in Southall, where my mother was sent for consultation – known locally, to me as a child, as the bin – was established in 1831. Even then it was criticized for its prison-like atmosphere, gloomy corridors and warders dressed like gaolers. Hospitals such as Hanwell marked the wholesale introduction of padded cells and strait-jackets.
The brain doctors were entirely dominant through this materialist century, the age that christened the ‘nervous breakdown’ and saw suicide rates begin to push upwards at an alarming rate. Their typically materialist view was well put by the modern medical historian Dr W L. Parry-Jones, when summarizing the conclusions of the eminent psychiatrist Dr Henry Maudsley’s 1883 book Body and Will: ‘[Maudsley believed that] mind and all its products are a function of matter, an outcome of interacting and combined atomic forces, not essentially different in kind from the effervescence that follows a chemical combination or the explosion of a fulminate.’ Melancholics, as they were still called, were not suffering from life problems or inner struggles. They were simply suffering from a disease, like TB or gout. You had a ‘broken brain’. The prejudice with which the common public viewed the mentally ill, seeing sin, evil and failure there, was irrational; you might as well hate and shun someone because they suffer from persistent migraine.
This physical perspective was underlined by the discovery of the first proof of organic madness in syphilis early in the century. German psychiatrists went on to discover the physical basis of what Emil Kräplin divided into two kinds of madness, schizophrenia and manic depression. Schizophrenia, or dementia praecox, is the classic, full-blown barking madness, of Napoleonic delusions and God complexes. Manic depressive psychoses manifest themselves in alternating mania and depression, and most doctors have little doubt that they, like schizophrenia, are seated in brain malfunction.
But there were those even in that famously empirical age who thought that a physical glitch was not enough of an explanation for many kinds of melancholia. Sir Andrew Halliday, who campaigned for the reform of asylums in India, in 1828 asserted that serious mental illness was due to excessive use of mental powers, a by-product of Western civilization. The nineteenth-century writer and doctor Oliver Wendell Holmes asserted that mental illness was ‘often the logic of an accurate mind overtaxed’.
Towards the end of the century, the sociologist Emile Durkheim similarly claimed that suicide was a result of changes in society, that depression – as it was then starting to be called – was a cultural product. He noted that the populations of Protestant countries were much more inclined towards suicide than their equivalents in those countries dominated by Catholicism. This he attributed to the spirit of free inquiry implicit in Protestantism. Depression was, as Halliday suggested, the result of thinking too much. He also noted that more ‘civilized’ countries, like Germany, had much higher suicide rates than less developed countries like Portugal or Spain. A sort of collective unhinging took place as societies became more complex and therefore more atomized and less integrated. Suicides kill themselves because their accustomed world has been destroyed or lost and they cannot make sense of what replaces it.
Suicide, for Durkheim, was all about a sense of place, of identity. For instance, he noted that for all the problems and responsibilities associated with a large family, it was demonstrably true that members of such families were far less inclined to suicide than the unmarried. What was more, suicide of the Western, self-hating variety was virtually unknown in traditional societies, which were intimately interconnected. It wasn’t personal circumstance that set people on the path to self-destruction, it was the stress of adaptation and change. People who became wealthy too quickly were observably more likely to kill themselves than those who remained poor. Being stable and integrated was the great inoculation against despair. To lose your fixed point of reference, at whatever level, was to be in danger of losing your mind.
If I was looking for some intellectual justification for imagining that the collapse of both my mother and myself may have been partly rooted in a wider crisis in England, Durkheim was a touchstone. One phrase in particular struck chords, at least as regards my own breakdown: ‘The lower classes have their horizons limited by those above them, and because of that their desires are more restrained. But those who have only empty space above them are almost inevitably lost in it.’
At the other end of the telescope – looking from mass to individual – was Sigmund Freud. Freud, although he accepted that some depressions could be organic, believed that in many cases there was a deeper, as yet unplumbed explanation.
Freud studied at the Salpêtrière in Paris under the neurologist Jean Martin Charcot, who followed on from the work of Franz Mesmer. It was Mesmer who had developed a method of hand passes and eye
fixations to lull anxious patients into a trance. To help the process, the patient was connected to a covered tub filled with ‘magnetic fluid’ by cords and rods. The hint of voodoo around mesmerism was less obvious with Charcot, a brilliant neurologist, although there was still a certain end-of-the-pier value in his ‘three stages of hypnosis’ – lethargy, catalepsy and somnambulism – and he entertained audiences throughout Europe with demonstrations.
Freud was impressed by these demonstrations, which were crucial to his formulation of the idea of the unconscious mind, that in depressives – more likely to be described as ‘neurotics’ or ‘hysterics’ at that time – there was a mass of disassociated, unintegrated mental material that distorted the proper operations of the mind.
It was Freud who formulated the idea that within the unconscious mind there was a death instinct (Thanatos) which vied with the life instinct (libido, or Eros) for dominance. Thanatos was present from the beginning of life and worked continually to unbind connections, to destroy, to return what is living to a null but peaceful inorganic state. Eros, the pleasure principle, was continually seeking to unite, to renew, to preserve.
In Freud’s model of the mind, there was a three-way split: ego, the sense of self, of very identity; superego, a sort of inner policeman that makes judgements on the self; and id, the vast hidden glacier of the subconscious and unconscious, a theatre in which secret conflicts and ancient desires and instincts compete. For the depressive, the superego turns savagely on the ego and becomes an avenger, punishing the perceived failings of the self. This is manifested in crippling guilt and self-hatred. In the worst cases, Thanatos, the instinct to death, infects the superego and drives the ego towards destruction, either of self or of others.
The source of this guilt – a sort of terrible, unacknowledged displaced anger, turned inward – was, for Freud, lodged in childhood experience. Here the immature perceptions of the child attempting to make sense of some trauma – perhaps physical or sexual abuse – become lodged as part of that individual’s way of making sense of the world, a distorted lens through which the whole of experience and the world are interpreted.