Abstract
The clinical description that follows was included by Dr Robert James (1703-76) in his magnificent three-volume Medicinal Dictionary (see Corley, 2004). James’s reputation as a larger-than-life eighteenth-century doctor has outlived him (O’Malley, 1972), but in spite of many criticisms (Stine, 1941) his Dictionary remains a monument to medical scholarship. Dr Johnson, a school and lifelong friend of James, is said to have helped with some entries; James, in turn, reciprocated in Johnson’s Dictionary (Brack and Kaminski, 1984).
As source for the case reported in the excerpt below, James quoted a Jacobus Janus (sic). I have been unable to identify this author or indeed any reference to the case in Sennert (Kangro, 1975; Newman, 2008). Be that as it may, the case illustrates well the polysemy of the term ‘Melancholia’ and highlights the difficulties confronting retrospective diagnosticians. Indeed, what James called ‘Apoplectic Melancholy’ may be fitted into clinical categories such as melancholia attonita, catatonic stupor, melancholic stupor, benign stupor, akinetic cycloid psychosis, etc., etc. (Berrios, 1981a, 1981b, 2008).
The problem is which one to choose given that: (a) the categories in question cannot be lined up in a progressive series of ‘validity’; and (b) it would be unlikely that having the actual patient available for further examination (in this case the poor clergyman) would provide any additional information. Retrospective diagnosticians (as shown by the frequent pathographic papers submitted to historical journals) are likely to choose as the ‘true’ diagnosis the one appearing in the latest diagnostic list, e.g. DSM-IV-R. It should be obvious that: (a) this adds little to clinical or historical knowledge; and (b) it remains as ‘valid’ to state that our clergyman suffered from apoplectic melancholy as from any of the other candidate categories listed above.
James R (1745) Melancholia. In: Medicinal Dictionary, Vol 2. London: T Osborne, 1099–1100
“Erratic melancholy is that species of the disorder, which most generally seizes patients in the month of February. It is so called, because those who labour under it, cannot remain for an hour in one place; but continually wander about, without knowing where they go. It is by the Arabians call’d Kutubuth, from an animal, which, as they inform us, perpetually moves up and down on the surface of stagnant waters.
Under erratic melancholy, the patients, as we have already observ’d, are in continual motion, shun company, love solitary places, and know not whither to wander. The colour of the body is yellowish; the tongue dry, like that of a person scorch’d with thirst; the eyes dry, hollow, and never discharging any tears; the whole body dry and parched; and the countenance overcast with gloom, horror, and sadness. Such melancholy patients are more timorous than others; for which reason they love solitude, wander in the night, and seek for concealment about the sepulchres of the dead, and other solitary places. They endeavour not to meet human creatures, and, if they should unexpectedly do so, they do not look at them, nor see them; which is undoubtedly owing to their unaccountable dread and fear, in consequence of which they suspect and shun every thing; or because they do not advert to external objects, since their fancies are always employ’d, and their thoughts continually dwelling on the representations of their fancies. They seek after solitary places, that they may not be disturb’d in those speculations, on which their exorbitant fancies brood; just as the studious in their senses shun company, and all those other objects, which are capable of drawing their minds off their favourite subject. Their legs are generally full of ulcers, which cannot be consolidated, since by the continual motion the peccant humour is solicited to the legs.
The cure is almost the same with that of common Melancholy, since it proceeds from the same cause, and only differs in degree, and the commixture of the humours. For this reason, the melancholic humour, which affects the spirits in the head, and disposes the brain to the generation of the like spirits, is to be corrected and evacuated. Then the head is to be corroborated, and its intemperature reduc’d to a due state, by moistening and moderately heating, or rather temperate cephalics. In this disease copious venesection is useful, either at one time, or repeated intervals, as the condition of the patient requires. But, above all things, sleep is to be carefully procur’d, since nothing contributes more to the removal of this disorder. Purgative medicines are;[sic] also, to be frequently repeated. Some physicians, when other measures prove ineffectual, order the patients to be lash’d, till they forsake their wild fancies, resume their reason, and become obedient. But I doubt whether this practice is safe, since the dread with which this species of melancholy is attended, may by this means be increas’d, and the patient more exposed to danger.
The opposite of this erratic melancholy is the apoplectic melancholy; for as in the former the patients are restless and wander about from one place to another, so in the latter every circumstance is revers’d; for the patients appear stupid, and, being apparently destitute of a locomotive faculty, seem to be fix’d to a particular place. When they lie, they care not for erecting themselves; when they sit, they care not for rising; and when they stand, they will not walk, except forc’d to it by their friends, or by the by-standers. They do not shun men; but tho’ they seem attentive to what is said to them, yet they make no answer to it; and being pensive, and wrapt up in their contemplation of other things, they do not attend to the objects of sight and touch. They sleep and watch by intervals, eat their aliments when held to their mouths, drink like other people, and in these and the like things are pretty tractable, and easily manag’d.
Tho’ this disorder is pretty rare, yet Jacobus Janus furnishes us with a remarkable instance of it in a clergyman of about thirty years of age, who, having a larger fund of superstition than sense, falsly imagined that almighty God could never be reconcil’d to him, on account of the trifling miscarriages of his youth; for which reason, he thought himself unworthy of the sacred function he bore. In consequence of this foolish notion he labour’d so much under the fatal consequences of despair for a whole Spring and Summer, that he frequently attempted to lay violent hands, both on himself, and on this wife, at which times he seemed to act in consequence of a certain paroxysm. But in the Autumn, the violence of his disorder being allay’d, he remain’d preternaturally melancholy, and could not be induc’d to speak, tho’ he uttered frequent and deep sighs. Tho’ he seem’d chearfully to listen to the consolatory discourses of his friends and acquaintances, endeavouring to remove his grief, and sooth his anxious thoughts; yet he could never be prevail’d upon to make any answers to their questions; tho’ he was frequently heard to invoke God in a manner which testified despair and horror. For some weeks after not a word could be extorted from him; tho’ he was often solicited to speak. He slept well in the night; and in the morning, when he wak’d, appear’d pensive, and, as it were, immoveable in his bed. When rais’d out of bed, and his clothes put on, he stood like a statue, only with this difference, that he put his hand on his head and temples spontaneously. He fetch’d deep sighs, as melancholy people do; when push’d forwards, and led by the hand, he walk’d; when brought to a chair, or seat, he sat down; when forc’d to sit at table, he took the aliments given him by his wife, and drank as other persons do, when advis’d to it. His disorder lasted during the whole Autumn, but began to be diminish’d about the middle of the Winter; so that at last he became capable of exercising his function; tho’ he remain’d dejected for a long time, because he was naturally of a melancholic habit.
The diagnostic signs of this disorder are sufficiently obvious from what has been said. There is a great difference between a catoche, and apoplectic melancholy; since the former generally seizes the patient suddenly, whilst the latter invades slowly. In the former, the patient is depriv’d of sensation and motion; whereas in apoplectic melancholy, both these are retain’d, tho’ the patient cannot use his senses so quickly as sound persons do; because their fancy, being employ’d on certain objects, cannot advert to others. In a catoche, the patients sometimes neither see, hear nor feel; whereas in apoplectic melancholy they do all these, tho’ they do not testify in words, that they do so. In a catoche, the patients generally have their members retain’d in the state and position they are plac’d by the by-standers; whereas, in apoplectic melancholy, the patient is capable of moving his members. Those, also who labour under a catoche, have their eyes open, and cannot speak, which symptom is not observ’d in apoplectic melancholy. Sennert. Oper. Lib. I. Part 2. Cap. 14.”