Melancholia, on the other hand, was a burnt-out state, one that looked much like our modern concept of depressive illness. Its sufferers, then as now, were without hope, despondent, sleepless, anxious, irritable, and confused. They ruminated ceaselessly, asked to die, and sought to be alone. Mania was a soaring of the vital senses, melancholia a sinking, a great tiredness.
Five hundred years after Hippocrates, another Greek physician, Aretaeus of Cappadocia, wrote that “the modes of mania are infinite in species, but one alone in genus,” an observation that anticipated by two thousand years the clinical observations of modern psychiatry. The manifestations of manic insanity varied, Aretaeus observed, but they were kin. Some patients had a madness dominated by joy. They, Aretaeus said, “laugh, play, dance night and day, and sometimes go openly to the market crowned, as if victors in some contest of skill; this form is inoffensive to those around.” Others, more susceptible to rage, “have madness attended with anger; and these sometimes rend their clothes and kill their keepers, and lay violent hands upon themselves.” Yet both types of madness were manifestations of mania, a derangement of the mind that occurred in the absence of fever, one that was “hot and dry in cause, and tumultuous in its acts.” Those prone to mania tended to be “naturally passionate, irritable, of active habits, of an easy disposition, joyous.”
Although mania was attended by danger, Aretaeus noted that some of his patients displayed a mental edge during their excited states. They learned astronomy and philosophy and created poetry that was “truly from the muses”; their senses were peculiarly astute. His observation that mania might confer advantage even in the midst of its perniciousness was one that had been made centuries earlier by Greek philosophers; it would be repeated time and again in the centuries to follow. The mind could benefit from some mania, but risk was there. The mind needed protecting if it was not to burn. (Marsilio Ficino, writing thirteen hundred years after Aretaeus about the causes of frenzied mental states in scholars, concurred. Madness and perturbed minds in scholars were due to negligence, he argued. “The painter keeps his brushes clean, the smith will look to his hammer, anvil and forge…the falconer or huntsman will have a special care of his hawks, hounds, horses.” Scholars, on the other hand, “neglect that instrument—their brain and spirits—which they daily use.”) Mania might inspire the scholar and poet, but too much inspiration fuels the mania.
Aretaeus made the essential observation that mania and depression are lashed together. “Melancholia is the commencement and a part of mania,” he said. Mania reflected a worsening of illness, “rather than a change into another disease.” “Dull or stern, dejected or unreasonably torpid,” depressed patients were seized by unreasonable fear and the desire to die. Sleep “does not brace their limbs,” noted Aretaeus, and “watchfulness diffuses and determines them outwardly.” Mania and melancholia did not keep separate company so much as they moved into and out of each other. He intuited then what clinical science has since established: manic-depressive illness is at its heart a cyclic disease of fluctuating moods, energy, sleep, and thinking. Mania and depression, Ovid-like, constitute an illness of mutability, of changing form; they are plaited together in action and fate.
The centuries that followed Aretaeus’s clinical studies saw considerable clinical and academic interest in mania and melancholia. Many dissertations in European medical schools, more than sixty before 1750, described the defining features of mania—excandescentia, a burning passion or fury; audacity; ferocity; absence of fever—as well as its clinical course and treatment. Similar symptoms, but accompanied by fever or another underlying medical cause, would today be considered a manifestation of delirium or infection.
“These Distempers often change, and pass from one into the other,” the English physician and anatomist Thomas Willis wrote in 1683. “For the Melancholick disposition growing worse, brings on Fury; and Fury or Madness growing less hot, oftentimes ends in a Melancholick disposition. These two, like smoke and flame, mutually receive and give place one to another.” In mania, the brain was “an open burning or flame.” In melancholia, the brain darkened over with fumes, covered with “a thick obscurity.” The manic-depressive mind burned and then grew dark, revived, lightened, articulated. The mind was hostage to a cycle of dark and light, formlessness and then form.
The observation that manic-depressive illness was a single disease was most clearly set forth in the mid-nineteenth century by the French alienists Jean-Pierre Falret and Jules Baillarger. They introduced the concepts of “circular insanity,” la folie circulaire, and “double insanity,” la folie à double forme. Cyclicity, with or without remission, was integral to their and to all subsequent conceptualizations of manic-depressive illness.
Falret, like Aretaeus and Willis, was an astute clinical observer. He vividly described the progression of manic illness from its mild beginnings of high spirits to acute mania: “The profusion of ideas is prodigious, the feelings are exalted,” he wrote. “Great affection is expressed for people toward whom the patient had previously felt indifferent, and hatred flows against those persons who had before been loved the most.” Activity is electric, seemingly without stop. Manic patients create art, they create chaos. They “turn over their furniture, change apartments, dig up their garden, become mischievous, malicious.” They carry out impulsively generated plans, they “compose and write prose and verse; and this prodigious activity, flowing forth in all directions, is present at night as well as during the daytime….The senses acquire considerable acuity.” Mania is active, alert, and destructive. It is, in the words of the doctors of old, an open burning, a fury.
For most of us who study mania and depression it is to the German psychiatrist Emil Kraepelin (1856–1926) that we owe our deepest clinical and intellectual debt. His 1921 monograph Manic-Depressive Insanity and Paranoia remains the clinical cornerstone for understanding the illness. Kraepelin, like Hippocrates more than two thousand years before him, based his notion of psychiatric disease on the patterning of symptoms and the natural course of the illness (that is, the circumstances of its onset, how it progresses, and its outcome). He divided psychosis into two major forms, manic-depressive insanity and dementia praecox (now known as schizophrenia). In distinguishing them he emphasized the periodic course of manic-depressive insanity, as well as its strong genetic component and relatively more benign outcome. Manic-depressive insanity was a broadly conceptualized illness, according to Kraepelin; it included not only the periodic and circular insanities but recurrent depression as well. He and his students further described mixed forms of the illness in which symptoms of mania and depression combined in important and potentially dangerous and perturbing states, including agitated depression, manic stupor, and depressive mania.
In the first half of the twentieth century, European and American psychiatrists formulated more specific diagnostic criteria for mental illness. In 1949, the year Robert Lowell was first hospitalized for mania, his diagnosis, manic-depressive reaction, was defined in very much the same way as it would be three years later in the first edition of the Diagnostic and Statistical Manual for Mental Disorders, the DSM-I, as a psychotic condition “marked by severe mood swings and a tendency to remission and recurrence.” The symptoms for mania included elation or irritability, overtalkativeness, flight of ideas, and increased activity. Accessory symptoms included delusions and hallucinations. The diagnostic criteria were succinct, if broadly interpretable.
“Manic-depressive illness” was the diagnostic term used throughout Robert Lowell’s lifetime, and it is the one that appears in his medical records. It is the term used by Lowell and his doctors, as well as by his friends and family. Today he would be diagnosed as having bipolar I disorder, terminology first formally incorporated into the DSM-III in 1980, three years after Lowell’s death. The current diagnostic criteria for mania and depression are discussed in Appendix 2.
Treatments for mania and depression are as ancient as their first description. Hippocrate
s stressed the natural cures for madness—time and rest, bathing in spring or mineral waters, diet, exercise—but he and his followers also dispensed a wide variety of natural balms and excitants such as myrtle, laurel, incense and myrrh, lotus and hellebore. That doctors and priests would turn to roots and flowers to calm their patients’ nerves, to sedate the frenzied and vitalize the dulled, was not new. The Chinese and Egyptian healers used herbs and other plants long before the Greeks. Herodotus, in his travels to Babylon in 300 BC, wrote that the local treatments for madness and sleeplessness included mulberry, iris rubbed into the head, poppy, mandrake, apples, and saffron. Pliny the Elder recorded in his Naturalis Historia, published circa AD 77, that there were thirty-two medicinal uses for the rose, including as a treatment for the mentally ill.
Caelius Aurelianus described the treatment of mania in fifth-century Rome: “The patient should be kept in bed (tied up, if necessary for safety reasons), in a warm and peaceful room….He is massaged, fomented, phlebotomized, cupped and medicated (helleborized, if need be); he is prescribed fasting, then light food, physical exercise.” Words, said Aurelianus, could help in treating the mentally distraught as well, since they “alleviate fear, sorrow, and anger.” The Roman physicians emphasized that manic patients should not be beaten, forced to listen to music, kept in the dark, or permanently tied up. Nor should their delusions be encouraged. Sea voyages and baths were recommended.
Paul of Aegina (c. 625–c. 690), a Greek physician and the author of an important compendium of Western medicine, argued that mania could best be treated by leeches, fennel, and applying oil of roses to the head. Manic patients were to be secured in their beds to keep from hurting themselves or others, or they were to swing in a wicker basket hanging from the ceiling. The Anglo-Saxons, a few centuries later, were not inclined to rose and fennel. They advised whipping. But treatment of the insane in Saxon times was complicated. According to Daniel Hack Tuke, it was a “curious compound of pharmacy, superstition, and castigation.” Herbs and ale were “to be drunk out of a church-bell, while seven masses were to be sung over the herbs, and the lunatic was to sing psalms, the priest saying over him the Domine, sancte pater omnipotens.” Peony and periwinkle were prescribed in early Britain, and wolf flesh given for hallucinations. There were wells and pools in Scotland to heal the insane.
Medieval Persian treatments for mania were gentle, until they were not: damask rose, lavender, cinnamon, white lily, balsam apple, and pomegranate. The Persian doctors also recommended milk and honey—centuries later Lowell was to consume these in legendary quantities—and for depression, clove and cinnamon. Ibn Síná, the great eleventh-century Persian physician and philosopher, wrote that when the north wind blew, those inclined to mania got restless and perturbed. He prescribed bloodletting and bathing in water in which poppies had brewed; advised the use of pomegranate and pear juice, barley water, and lavender and honey. If these did not work, the manic patient was to be tied and put into a cage suspended from the ceiling.
Priest and remedy were inseparable from cure. Faith in the healer transformed herbs and the laying on of hands into relief from suffering. John Guy, in Thomas Becket, describes the murder of Becket at Canterbury in 1170 and how the blood that flowed from his death became a balm to pilgrims who streamed to the archbishop’s tomb in search of cure. After the coup de grâce, Becket’s brains had been scraped out from his skull and smeared together with his blood and bone. Many of the pilgrims who were treated with the “water of Canterbury,” the potion made from Becket’s blood and brain diluted in water, were the insane and the melancholic. One of the “miracle windows” at Canterbury Cathedral portrays an insane man, beaten with sticks and tied with ropes by his caretakers, dragged to the tomb of Becket. Cured overnight, he is shown in the stained-glass window together with the ropes that had bound him and the sticks that had beat him, left in faith at the base of Becket’s tomb. Together, saint and potion effected the impossible.
Robert Burton, in his 1621 Anatomy of Melancholy, described remedies from the natural world: marigold is “much approved against melancholy,” he wrote, as was “a ram’s head that never meddled with a ewe.” The brain of the unsullied ram once removed from the skull and spiced with cinnamon, ginger, nutmeg, and cloves would act powerfully against depression, Burton wrote. Many of the flowers and plants thought by the ancients to be effective against mania and melancholia were still of use: dandelion, ash, willow, tamarisk, roses, violets, sweet apples, syrup of poppy, and sassafras. More lyrical than effective perhaps.
The New England Puritans also turned to powders and elixirs to treat madness. Mania could be cured by an “elixir made of dew,” John Winthrop the Younger, son of the founding governor of Massachusetts Bay Colony and a physician as well as governor of Connecticut Colony, was advised in 1656. The elixir was to be purified until it became a powder “black as ink, then green, then gray.” After two years, when it was “white & lustrous as any oriental pearl,” it was guaranteed to “cure mania at 15 months end.” This was a guarantee with little risk; mania left to run its own course resolves more quickly. Time alone will cure many who are ill in mind or body, Sir William Osler taught his medical students and house staff at Johns Hopkins 250 years later. Prescribe time, he said. Time in divided doses.
The nineteenth-century asylum physicians treated manic patients with enforced quiet, darkened rooms, and sedating medicines such as digitalis, camphor, rhubarb, tincture of ginger, salts of morphia, and other preparations of opium. Patients soaked in hot baths, water mixed with hemlock and cherry laurel leaves, for hours at a time and were fed diets of milk, peaches, and lemonade to further calm them. Melancholic patients were treated with stimulants—iron bitters, quinine, malt liquors—as well as long baths, and tinctures of camphor or opium for sleeplessness, agitation, and suicidal depression.
Remedies that were uncertain in their effects were common in times when the causes of insanity were uncertain. In the nineteenth-century asylums little was known about the etiology of mental disease, although heredity and dissipation were not uncommonly cited. Indeed, Dr. Rufus Wyman, the physician who first treated Harriet Brackett Spence Lowell, wrote that the most prominent causes of insanity in the patients admitted to the McLean Asylum were intemperance, insane ancestors, and madness associated with pregnancy. “Unknown” was often listed as the cause of insanity in the asylum ledgers, as was “insane ancestry.” Insanity, said Wyman in 1835, was transmitted from generation to generation, “a medical fact everywhere admitted.”
At the time that Robert Lowell was first hospitalized in 1949, the primary treatments for mania were hospital care, sedative medications, hydrotherapy, and electroconvulsive therapy. The hospital was meant itself to be therapeutic, designed as a safer, quieter, less stressful place than life outside its walls. Lowell generally found that being in a hospital, however demoralizing, was a respite and protection. His expectations of what he would get done while he was in hospital were often unrealistic: “I went off to the hospital armed with a suitcase of classics,” Lowell wrote to Adrienne Rich in 1964. “Freud, the complete Aristotle, Dante, etc. and then spent most of my time looking at popular television, even waiting breathlessly for the next Thursday’s Dr. Kildare.” Later came the poignant aftermath. “Then at last the books were brought back home,” said Elizabeth Hardwick. “The socks, with their name-tapes as if for a summer camp, were gathered up. And there it was, with only the sadness, actually the unfairness of the fate, remaining.”
Causes of insanity, patient ledger, McLean Asylum, 1845 Credit 22
Hospitals by their nature sap dignity. Privacy, privilege, and freedom are in short supply. Doctors and nurses determine the flow of hours and activity. Writing to Hardwick from the Institute of Living in Hartford in 1965, Lowell said, “I won’t go into the boredom of ‘leather appreciation’ and ceramics appreciation, of watching basketball games for an hour without smoking, or of trying to converse with the oldster reading Francis Bacon sentence by sentence.” I
n “Near the Unbalanced Aquarium,” he drew a particular arrow against the lost cause and embarrassment of occupational therapy: “It was a sunny, improving world; and here, unable to ‘think’ with my hands, I spent a daily hour of embarrassed anguish. Here for weeks I saw my abandoned pine-cone basket lying on the pile for waste materials. And as it sank under sawdust and shavings, it seemed to protest the pains Mr. Kemper, our instructor, had once taken to warp, to soak, to reweave, to rescue it.” Reweaving was the difficult thing. Many who knew Lowell agreed that despite his dread and shame of having to be in a hospital, he was relieved once admitted. It shielded his mania from the eyes of others and limited the damage he could inflict.
Lowell received electroconvulsive therapy for mania in 1949, 1952, and 1954. It worked quickly and well, but it did not prevent him from getting sick again. In May 1954, while hospitalized at Payne Whitney, he was given the antipsychotic chlorpromazine for the first time; he was prescribed it during several subsequent hospital stays and, on occasion, when he felt himself speeding up, he took it when he was out of the hospital as well. It was an effective drug against acute illness but, like electroconvulsive therapy, it did not successfully prevent recurrence of his mania.
It was inevitable that Lowell, introspective and beholden to words, would want to understand what he had been through. “All the late froth and delirium have blown away,” he wrote to Elizabeth Bishop. “One is left strangely dumb, and talking about the past is like a cat’s trying to explain climbing down a ladder. One would like to look at it all without moodiness or bravado.” Consistent with the era, Lowell was in and out of psychotherapy, starting with his first hospital stay in 1949. His therapy was often with psychoanalysts, although he was not in formal psychoanalysis. At times he was enthusiastic about what he was learning from therapy. He wrote to Elizabeth Bishop in 1949, early in the long years of his illness: “Psycho-therapy is rather amazing—something like stirring up the bottom of an aquarium—chunks of the past coming up at unfamiliar angles, distinct and then indistinct.” In early 1950 he wrote to his parents, “I have been seeing a psychiatrist here about once a week, and we agree that I am well out of my extreme troubles. There is a stiffness, many old scars, the toil of building up new habits.”