Melancholy’s Whole Physician

The mental illness called depression is far more savage than its name suggests. The word’s economic meaning has become more fearsome than its medical one, whose force has been eroded by common usage: we say, “I’ve been depressed,” when we’ve been a little glum, down in the mouth, under the weather — a minor disturbance, equilibrium soon restored. And anyway, the term was never appropriately ferocious to begin with, suggesting a mere dip in the road rather than the sulfurous sinkhole that engulfs you and all you love and sends you into infernal freefall like the host of wicked angels, plummeting in terror with no end in sight, no hope of seeing the beautiful face of God again. The illness requires a word that renders this sense of bottomless horror, inescapable pain, irreparable loss — even though the horror, pain, and loss are, in most cases, treatable. “O the mind, mind has mountains; cliffs of fall/Frightful, sheer, no-man-fathomed,” the manic-depressive Gerard Manley Hopkins wrote in one of his Sonnets of Desolation in 1885. Desolation sounds more precise and evocative than depression, though it is hard to imagine it in a clinician’s mouth. Our language reserves such emotional exorbitance for artist-types, expecting doctors to be more sober and carefully euphemistic. And this cautious medical language does possess a pedestrian good sense: a doctor’s saying “I’m prescribing some Prozac and cognitive behavior therapy for your desolation” would seem more than a touch grotesque, like lipstick on a death’s head. The preferred treatment these days, which does tend to work, somehow fits the euphemism.

There was a word for this awful scorching anguish that enjoyed medical currency for millennia but has since become a dusty curio: melancholy. Melancholy is now mostly a literary word, and in the pejorative sense which hard scientists and medical men assign to the merely literary. Indeed, Peter D. Kramer, a clinical professor of psychiatry at Brown University, writes in his 2005 book Against Depression that the literary tradition of “heroic melancholy” needs to be severely re-evaluated, so that it will not stand in the way of the project to eradicate the medical illness depression as we have eradicated smallpox. The Problems, believed to have been written by followers of Aristotle, inaugurated this literary tradition, asking why remarkable men — Heracles, Ajax, Bellerophon, Socrates, Plato, the Spartan general Lysander — are so often melancholic, in some cases given to raging madness. Renaissance scholars rediscovered the Problems, and the Florentine humanist Marsilio Ficino identified melancholy as a hallmark of the intellectual vocation; his acolytes exalted melancholy in order to prove their vocational aptitude. Shakespeare canonized the melancholy Hamlet, whose tragedy Kramer calls “arguably the seminal text of our modern culture.” With the feckless lover and suicide Werther, Goethe completed the triumph of melancholy. Kierkegaard described creative genius as the wailing of a soul in torment. Baudelaire and Dostoevsky sorrowfully measured the fevered modern soul’s distance from salvation. In the twentieth century, hangdog French philosophers in seedy raincoats allured those nauseated by life as the Pied Piper did unwitting schoolchildren. Innumerable depressive stars shine blackly in the modern artistic and philosophic heavens. Heroic melancholy continues to have a forceful grip — Kramer might say a death grip — on our culture.

Medical science, on the other hand, has taken off in an entirely different direction, exploring the neurochemical basis of depression since the development of the first anti-depressants, the monoamine-oxidase inhibitors (MAOIs) in the 1950s. The neurotransmitters serotonin and norepinephrine, which facilitate the movement of impulses across the synapse between one nerve ending and the next, are known to affect mood profoundly; although the complex whys and wherefores remain mysterious, low serotonin levels are connected with depression, high levels with elevated mood. A more recent generation of medications known as selective serotonin reuptake inhibitors (SSRIs) sharpened and subtilized the action of the MAOIs, without the earlier drugs’ perilous side effects. Prozac, Paxil, and Zoloft are among the best known SSRIs — and some of the most widely prescribed drugs in America.

Research has followed the lead of this therapeutic success and produced further proof that depression is a medical illness affecting neurophysiology. Depression has been shown to cause the brain actual physical injury, which then contributes to further depression. In 1999 the anatomist Grazyna Rajkowska demonstrated with computer-aided mapping that, in certain regions of the prefrontal cortex of depressed patients, cells known as glia, which protect and support the neurons, were vitiated, disordered: the longer the depression, the worse the brain damage. Later that year, a psychiatrist expert in radiology, Yvette Sheline, revealed the correlation between the duration of depression and the degree of atrophy of the hippocampus and amygdala, parts of the brain associated with emotion. The brain damage was significant, and persisted even when the illness was in remission. The physiological research of Robert Sapolsky further suggested the intimate relation of stress, depression, and cell death. Stress can trigger depression, and depression in turn becomes a chronic stressor, which damages the hippocampus and other brain cells; the switch in the hippocampus that normally signals the adrenal glands to stop producing stress hormones gets stuck, so that even minor adversity causes those hormones to run amok; they suppress the brain cells’ capacity to repair and regenerate themselves, resulting in lasting injury.

All this makes talk of suffering poets and falls from grace sound literary and overheated where cool scientific rationality is called for, but literary men down the ages have understood what modern doctors increasingly fail to grasp: that depression is an affliction demanding spiritual as well as physical healing. Robert Burton, an Anglican vicar and a fellow of Christ Church, Oxford, presses the point with eloquent urgency in his 1,500-page masterpiece, still vital after nearly four centuries, although not often read, The Anatomy of Melancholy (1621):

It is a disease of the soul on which I am to treat, and as much appertaining to a divine as to a physician, and who knows not what an agreement there is betwixt these two professions? A good divine either is or ought to be a good physician, a spiritual physician at least, as Our Saviour calls Himself, and was indeed (Matt. iv, 23; Luke v, 18; Luke vii, 21). They differ but in object, the one of the body, the other of the soul, and use divers medicines to cure: one amends animam per corpus [the soul through the body], the other corpus per animam [the body through the soul] as our Regius Professor of Physic well informed us in a learned lecture of his not long since…. Now [melancholy] being a common infirmity of body and soul, and such a one that hath as much need of a spiritual as a corporal cure, I could not find a fitter task to busy myself about, a more apposite theme, so necessary, so commodious, and generally concerning all sorts of men, that should so equally participate of both, and require a whole physician. A divine in this compound mixed malady can do little alone, a physician in some kinds of melancholy much less, both make an absolute cure.

Melancholy as Burton describes it, and prescribes for its treatment, is in crucial respects a richer moral phenomenon than depression as it is treated today. Burton is writing in the nascent days of the modern scientific project for the conquest of nature and “the relief of man’s estate,” in the words of his contemporary Francis Bacon, but he is somewhat behind the times: with a staggering breadth of learning, he invokes repeatedly, indeed literally a thousandfold, the wisdom of the ancients, both classical and Biblical, whom Bacon and his successors leave bobbing fecklessly in the wake of their inexorable advance upon the radiant future. The Baconian project has of course triumphed, and it would be insane to want to undo some of its most spectacular successes: psychiatric medications developed during the last fifty years have made it possible for persons who in Burton’s day — and indeed in far more recent days — would have been chained in phrenic dungeons to live relatively normal lives. However, marvelous technical sophistication has come at a serious moral price. Psychiatrists now tend increasingly to treat the condition rather than the patient. Intense mental and spiritual pain is offered a purely physical fix. The full human implications of mental illness are worn away as pills are becoming ever more effective and insurance companies are becoming ever less inclined to cover the costs of psychotherapy. To recover the sense of what such suffering means to the sufferer, one might do well to look at a classic text from a time when the neurochemistry of mental illness was not even a glimmer in the Baconian eye and moral tribulation was the essence of melancholy.

Robert Burton knows melancholy from the inside; prolonged combat at close quarters has familiarized him with the adversary. “Concerning myself, I can peradventure affirm with Marius in Sallust, ‘That which others hear or read of, I felt and practised myself; they get their knowledge by books, I mine by melancholizing.’” Like the virtuous lady who was a leper and gave all she had to build a hospital for lepers, he goes on, “I will spend my time and knowledge, which are my greatest fortunes, for the common good of all.” Although divinity is his calling and the highest activity there is, he turns to melancholy as a subject because it sorely needs elucidating and he is just the man for the job. Melancholy has chosen him — “I was fatally driven upon this rock” — perhaps more than he has chosen melancholy.

He begins by examining the subject from a philosopher’s point of view, adopting the moniker Democritus Junior, after the thinker who was stricken with hilarity at the spectacle of human folly and the misery it causes. The people of Democritus’ native city, Abdera, believed him mad, and called in the nonpareil physician Hippocrates to confirm their opinion. The great men found themselves at odds: Democritus flayed humanity for its ridiculous longings and bestial appetites, while the gentler Hippocrates held that men cannot help their wants and so should be forgiven. In the end, however, Hippocrates told the startled Abderans that although Democritus certainly ought to dress and eat better, “the world had not a wiser, a more learned, a more honest man, and they were much deceived to say he was mad.”

For that which is but a flea-biting to one, causeth insufferable torment to another; and which one by his singular moderation and well-composed carriage can happily overcome, a second is no whit able to sustain, but upon every small occasion of misconceived abuse, injury, grief, disgrace, loss, cross, rumour, etc. (if solitary or idle), yields so far to passion, that his complexion is altered, his digestion hindered, his sleep gone, his spirits obscured, and his heart heavy, his hypochondries misaffected; wind, crudity on a sudden overtake him, and he himself overcome with melancholy.

Overwhelming melancholy as Burton describes it begins with the emotions but proceeds to undermine various organs and cause systemic distress. It is a physical illness with a mental and emotional aetiology. One man’s “singular moderation and well-composed carriage” may safeguard him from sorrow, but Burton does not cast moral aspersions on the sufferer whose immoderate response to similar events cuts him down; inborn temperament is a mystery, and Burton devotes himself to helping the afflicted find their way out of misery rather than fault them for its advent. That is, in this passage at least, he regards melancholy principally as a medical illness rather than a moral failing.

The word melancholy is derived from the Greek for black choler: one of the four humours, or bodily fluids, it is associated with the spleen, predominates in men of saturnine temperament, and predisposes them to seriousness and heaviness, but it can also make them uncommonly brilliant and witty and perspicacious. Classical authoritative medical opinion is divided on the very existence of the humours: Galen supports the notion, while Paracelsus is dead set against it. For true believers, melancholy matter is implicated in the origin of various physical ailments as well: black jaundice, quartan ague, leprosy, scurvy.

Burton’s description of melancholy distinguishes it from madness and frenzy, both more severely deranging conditions, but it sometimes comprises mania and even persistent florid psychosis as in schizophrenia. “Fear and sorrow are the true characters and inseparable companions of most melancholy, not all…; for to some it is most pleasant, as to such as laugh most part; some are bold again, and free from all manner of fear and grief.” Burton recounts the cases of melancholy persons who thought they were giants or dwarves, or bears or dogs, or shellfish, or that they were made entirely of glass and dared not sit down for fear of shattering. Although for the most part he maintains an imperturbable medical demeanor in discussing such fantasticos, he can get carried away with the comedy of it all. His personal favorite among preposterous melancholics is the man who held his water because he feared that it would flood the entire town. When he could hold back no longer, to his amazement the town was spared, and he was cured.

On the dispute between those who believe the organ most affected by melancholy to be the heart, as the seat of the emotions, and those who favor the brain, the home of reason and imagination, Burton sides with the shrewder interpreters who argue that the affliction begins in the brain and moves to the heart and other organs. The true origin of the disease is hard to track, however. Astrological, climatic, hereditary, anatomical, and characterological factors all figure prominently in case histories. Isolating melancholy in its pure form is a virtual impossibility: it takes as many forms as there are patients. On this point Burton is in fundamental agreement with modern medicine, which identifies nine symptoms of major depression — in the summary of Peter D. Kramer, “depressed mood, problems experiencing pleasure, low energy, disrupted sleep, diminished or increased appetite, mental or physical agitation or slowing, feeling of worthlessness or guilt, difficulty concentrating, and suicidality.” These symptoms appear in different permutations from patient to patient, and in the same patient different symptoms may present at different times. The sheer variety of symptomatology makes the treatment of depression far from a simple matter, and, of course, with its men of glass and magic bladders, Burton’s melancholy is more complicated still. “The Tower of Babel never yielded such confusion of tongues, as the chaos of melancholy doth variety of symptoms.”

On the hereditary contribution to melancholy, as set forth in the subsection “Parents a Cause by Propagation,” Burton is centuries ahead of his time. A man’s “temperature” is part of his parental endowment, and thus no man can be morally liable for his predisposition to mental illness: “I need not therefore make any doubt of melancholy, but that it is an hereditary disease.” Contemporary geneticists measure the genetic factor in severe or recurrent depression at some fifty percent, higher than that in such well-known heritable conditions as hypertension, high serum cholesterol, or diabetes. Burton’s hereditary speculations, however, would not all pass rigorous scientific muster. One of his sources cites the case of a man who “went reeling and staggering all the days of his life” because his pregnant mother had seen a drunkard wobbling around in the street.

The line of inquiry into physical causes for melancholy leads Burton to identify some likely culprits: diet, retention, evacuation, air, exercise, sleeping, waking, and perturbations of the mind. He dispenses advice on how not to eat your way into melancholy, giving various meats the going-over of a moralizing dietitian, as in this description of why “fenny fowl” like ducks and geese are bad for you: “Though these be fair in feathers, pleasant in taste, and have a good outside, like hypocrites, white in plumes, and soft, their flesh is hard, black, unwholesome, dangerous, melancholy meat.” You are what you eat or drink, and what goes for your body goes for your mind. Too little can be as bad as too much: monks’ fasting has been known to drive them around the bend. When it comes to exercise, overtaxing the body and inclining to lassitude are equally pernicious. And proper sleep is essential to warding off or recovering from melancholy: “Nothing better than moderate sleep, nothing worse than if it be in extremes or unseasonably used.” Diet, exercise, and sound sleep are integral parts of the modern regimen against depression, and Burton’s prescription for moderation in these combines the physician’s wisdom about the body with a moralist’s sense of propriety.

Burton parts ways with the moderns, however, in expanding the range of causative agents for melancholy beyond the bounds acknowledged by science: “General causes are either supernatural or natural.” The enterprising inquirer may ascertain divine, angelic, and diabolical origins of the illness; for plenteous examples, he need look no further than the Bible. “And this disease is peculiarly specified (Ps. cvii, 12), ‘He brought down their heart through heaviness’; (Deut. xxviii, 28), ‘He struck them with madness, blindness, and astonishment of heart’; ‘An evil spirit was sent by the Lord upon Saul, to vex him’; Nebuchadnezzar did eat grass like an ox, and his ‘heart was made like the beasts of the field.’” Hellacious sin is a surefire begetter of melancholy, so that Hippocrates himself takes pains to distinguish divine punishment from more mundane causes. And what the hand of God inflicts only the hand of God may remove. There are cases beyond the help of human medicine, for which divine mercy is the sole remedy. Often God does not intervene directly, but lets His minions or even His adversaries do His work for Him. The Lord permits diabolical forces to loose themselves upon men for the chastisement of our failings and the trying of our mettle. Devils are adept in the ways of nature, and can cause or cure most diseases. The melancholy humour is catnip to fiends, which insinuate themselves into susceptible bodies, there wreaking mental havoc.

So Burton presents himself on the one hand as a physician after the modern manner, compassionate yet morally disinterested, healing his patients without passing judgment, searching out the natural causes and cures of a terrible illness, and on the other hand as an old-fashioned moralizer and even a metaphysician, appalled by the raging appetites of mankind, offering spiritual counsel to troubled souls, reiterating the primordial teaching about the human creature as he stands before his Creator, explaining the universe from a religious point of view. This apparently divided figure in fact attacks this baffling illness from both directions, attempting to join modern knowledge to ancient wisdom, to be the “whole physician” who combines physic and divinity and who thereby cures an affliction resistant to either medical or moral treatment on its own.

Burton understands the subtle action of body on mind, and that of mind — or soul — on body. Writing of the deleterious effects of passion, “this thunder and lightning of perturbation,” he nears the heart of his analysis:

For as the body works upon the mind by his bad humours, troubling the spirits, sending gross fumes into the brain, and so per consequens [consequently] disturbing the soul, and all the faculties of it … with fear, sorrow, etc., which are ordinary symptoms of this disease: so, on the other side, the mind most effectually works upon the body, producing by his passions and perturbations miraculous alterations, as melancholy, despair, cruel diseases, and sometimes death itself; insomuch that it is most true which Plato saith in his Charmides, omnia corporis mala ab anima procedere, all the mischiefs of the body proceed from the soul.

There is a profound connection between thought and passion, brain and heart, and Burton even divines some secret physical passages between them. A storm-ravaged imagination provokes sympathetic disorder in the heart and other organs, causing “all these distemperatures, alteration and confusion of spirits and humours…. [G]reat is the force of imagination, and much more ought the cause of melancholy to be ascribed to this alone, than to the distemperature of the body.”

There follows a disquisition of more than one hundred pages on the pervasive human enslavement to violent passions and the mental defect that allows imagination to overpower reason. Burton writes here of the incomparable searing pain of grief — both a cause and a symptom of melancholy; the seeking after honor that is a golden virtue in moderation but becomes a destructive rage in excess; the vanity of those scholars and would-be philosophers who profess to have overcome it; the supreme folly of those out to astound the world; the futility of theological speculation; and the greatest sorrow of all — losing your money. To escape completely the common lot of ruinous passion requires superhuman reasonableness, but men can school themselves in right living little by little, and thereby acquire the virtues of true philosophers.

Then Burton reverses his previous contention, and attributes the soul’s distress to the body’s failure: the body is imperious, and there is no escaping it in this lifetime, however the soul might try. He turns to the somatic explanation for melancholy, but the somatic explanation doesn’t get far beyond the surmise that there must be such an explanation: the malfunction of just about any organ can be implicated in the aetiology of melancholy. The tempest of mental illness, then, can blow out of anywhere at any time; vigilance is everything, and even that might ultimately fail. “Now go and brag of thy present happiness, whosoever thou art, brag of thy temperature, of thy good parts, insult, triumph, and boast; thou seest in what a brittle state thou art, how soon thou mayest be dejected, how many several ways, by bad diet, bad air, a small loss, a little sorrow or discontent, an ague, etc.; how many sudden accidents may procure thy ruin, what a small tenure of happiness thou hast in this life, how weak and silly a creature thou art.” Rashness and intemperance grease the skids to self-destruction, and the watchful Lord pays attention, rewarding his creatures’ admirable striving, and flogging them for their prodigal excess: “Remember our miseries and vanities, examine and humiliate ourselves, seek to God, and call to him for mercy; that needs not look for any rods to scourge ourselves, since we carry them in our bowels, and that our souls are in a miserable captivity, if the light of grace and heavenly truth doth not shine continually upon us: and by our discretion to moderate ourselves, to be more circumspect and wary in the midst of these dangers.”

Moderation is ever the wisest course. Miracle cures are not to be trusted. While cures by diabolism or wizardry have been known to work, no decent Christian will dare consider them. The saints, whom Burton associates with a sulfurous Romish smell, offer the same specious aid as the pagan gods or devils. The forces of divinity and physic must be joined to effect the surest cure. Prayer alone is ineffectual; reasoned action — medical treatment — is also required. As Lord of spirit and body, God’s help is indispensable, to be found both in Scripture and in physic, divine gifts to be judiciously applied. A good doctor may be the Lord’s agent, but some purely practical considerations are essential to successful treatment: the patient must be completely forthcoming to his doctor about his illness, he must be confident in the doctor’s ability to help him, and he must be willing to pay.

What kind of treatment does he pay for? When it comes to medicines for melancholy, almost everything — vegetable, animal, and mineral — has at some time been tried. Gargarisms, apophlegmatisms, masticatories, suffumigations, and clysters all have their medical champions. The plant black hellebore earns Burton’s most lavish encomium; it is the Prozac of its era, which extends back to Hippocrates’ time. Some cures smack of witchery, and are so disgusting they are likely to induce mental illness in persons of any refinement: “to anoint the soles of the feet with the fat of a dormouse, the teeth with ear-wax of a dog, swine’s gall, hare’s ears.” Blood-letting is advocated for far-gone patients, “where the melancholy blood possesseth the whole body with the brain.” Finger of birth-strangled babe is contraindicated for melancholy, though it is recommended in other cases. Reading Burton on the materia medica makes the SSRIs look like blazing salvation. Whatever Burton might offer of philosophical or religious solace, the therapeutic drugs and procedures he prescribes seem at least as noxious as the illness they purport to cure.

Other curatives are much more sensible. To moderate diet, exercise, and sleep, Burton adds sex in prudent doses as a restorative: “Immoderate Venus in excess, as it is a cause, or in defect; so, moderately used, to some parties an only help, a present remedy.” The quiet pleasures of an afternoon fishing on the river or of a refreshing stroll through the countryside in the company of friends come highly recommended. Indeed, Burton advocates the appreciation of all the world holds of delight, which can soothe a troubled soul, from extravagant glories to trifling diversions. “Domitian, the emperor, was much delighted with catching flies, Augustus to play with nuts amongst children; Alexander Severus was often pleased to play with whelps and young pigs; Hadrian was so wholly enamoured with dogs and horses that he bestowed monuments and tombs on them, and buried them in graves.” Of course you needn’t imitate emperors at play; rather, if you are of sufficiently sound mind, you can throw yourself into more worthy activity: “Whoever he is, therefore, that is overrun with solitariness, or carried away with pleasing melancholy and vain conceits, and for want of employment knows not how to spend his time, or crucified with worldly care, I can prescribe him no better remedy than this of study, to compose himself to the learning of some art or science.”

The healthy mind demands activity and repose in due measure, and well-ordered thinking relieves all distress: “All things then being rightly examined and duly considered as they ought, there is no such cause of so general discontent, ’tis not in the matter itself, but in our mind, as we moderate our passions and esteem of things.” The mind can walk confidently along the most precipitous paths, if it is fortified with philosophy, or better yet, divinity; if the pagan Cicero could console himself for his daughter’s death with the thought that she was in heaven, a Christian ought to be all the more secure in mind and heart when faced with terrible loss. What is weak or unseemly in your nature can be overcome: moral strenuousness is the very stuff of a well-lived life. “Thou art malicious, envious, covetous, impatient, no doubt, and lascivious, yet, as thou art a Christian, correct and moderate thyself.” However grave your failings, earthly redemption by your own merits is always possible. If only men would live otherwise than they do, the awful reign of relentless agony could be overthrown, and sweet reason rule in its stead.

Burton’s own comprehensive course sometimes does not moderate so much as envelop both extremes. Thus to those who smell brimstone and believe themselves plagued by demons, he offers the comfort of a reasoned physiological explanation, designed to calm such sufferers’ throbbing minds. On the other hand, though, into the midst of a scientific discussion of visual hallucinations, he introduces the devil’s power to beguile men with evil visions. Neither the spiritual aspect of the case nor the scientific is ever definitively excluded. What some say can be cured only by exorcism, others declare to be curable by purging. Burton takes both camps seriously, though in this case he comes down on the side of those who see devilment at work.

Even with the most thorough and advanced care, not every melancholic gets better. For such unrelenting anguish, suicide sometimes seems the only answer. Not even the threat of damnation may stop someone from killing himself who feels damned while still alive: “If there be a hell on earth, it is to be found in a melancholy man’s heart.” There are no diseases more grievous than those of the mind; no one can fault the melancholy suicide for lack of fortitude in bearing pain: “I say of our melancholy man, he is the cream of human adversity, the quintessence, and upshot; all other diseases whatsoever are but flea-bitings to melancholy in extent: ’tis the pith of them all.” Several pages of philosophical testimony condone suicide in dire extremity, but after the pagans have had their say, a Christian warning overrides it: “God and all good men are against it. He that stabs another can kill his body; but he that stabs himself kills his own soul.” Yet when the Christian divine has spoken, the non-judgmental physician breaks in, pleading clemency: “This only let me add, that in some cases those hard censures of such as offer violence to their own persons, or in some desperate fit to others, which sometimes they do, by stabbing, slashing, etc., are to be mitigated, as in such as are mad, beside themselves for the time, or found to have been long melancholy, and that in extremity; they know not what they do, deprived of reason, judgment, all, as a ship that is void of a pilot must needs impinge upon the next rock or sands, and suffer shipwreck.” God alone knows men’s hearts and minds and the limits of their endurance, and we can only hope that He will show mercy to those moved by mental illness to cast away their lives.

Nothing drives a man or woman to desperation more surely than love-melancholy, unless it is religious melancholy — the two conditions to which Burton devotes The Third Partition of his book, a closing section of more than four hundred pages. If wanting the right object in the right way leads toward happiness, then wanting the wrong object in the wrong way is the path to earthly doom, and perhaps to everlasting perdition. Intellectual and moral beauty can shine through a plain or even an ugly face and body, and moral hideousness can make physical beauty repellent. Physical beauty alone, however, especially when it conceals a defective moral nature, poses a fatal danger to the soul. “I come at last to that heroical love, which is proper to men and women, is a frequent cause of melancholy, and deserves much rather to be called burning lust, than by such an honourable title.” This is the love that allows of no limits, that overturns all decency and good sense, that cannot be tamed. “It will not contain itself within the union of marriage, or apply to one object, but is a wandering, extravagant, a domineering, a boundless, an irrefragable, a destructive passion: sometimes this burning lust rageth after marriage, and then it is properly called jealousy; sometimes before, and then it is called heroical melancholy; it extends sometimes to corrivals, etc., begets rapes, incests, murders.” Lust flames out fast and leaves a foul-smelling ash. Its power is that of the most ravaging mental illness, which leaves reason gasping in the dust. The tortures of the Spanish Inquisition do not compare to the pangs of love-melancholy. The poor lovelorn sap becomes fairly rabid with desire, “as he that is bitten with a mad dog thinks all he sees dogs, dogs in his meat, dogs in his dish, dogs in his drink, his mistress is in his eyes, ears, heart, in all his senses.” No matter how repulsive the mistress is in fact, to the lover she is a peerless wonder. Such yearning is degrading servitude.

Yet love can make a man far better than his usual self. Every lover is a poet; what else indeed do poets write of but love? Love spurred the gods to invent the arts. The attempt to deny love’s power, the life of enforced chastity, produces a riot of perversions. Burton, the confirmed bachelor, firmly exhorts his readers to take a chance at “incomparable happiness” and get married. Of course, a lengthy treatment follows of jealousy, which makes ordinary melancholy seem like a piece of cake. The man who marries had better do so for the right reasons, and loving his bride solely for her looks is not a good reason. “He that marries a wife that is snout-fair alone, let him look, saith Barbarus, for no better success than Vulcan had with Venus, or Claudius with Messalina.” Impotence, sterility, and December-May romances lead all but unstoppably to jealousy, and for good cause; where a wife is sexually dissatisfied, she is more than likely to stray. But then a wife may rove even if her husband is all that one man can be, young, handsome, virile, passionate: “she is as well pleased with one eye as one man.” The torments of jealousy infect every aspect of man’s life: “‘Tis a more vehement passion, a more furious perturbation, a bitter pain, a fire, a pernicious curiosity, a gall corrupting the honey of our life, madness, vertigo, plague, hell, they are more than ordinarily disquieted, they lose bonum pacis [the boon of peace], as Chrysostom observes; and though they be rich, keep sumptuous tables, be nobly allied, yet miserrimi omnium sunt, they are most miserable, they are more than ordinarily discontent, more sad, nihil tristius, more than ordinarily suspicious.” And all that Burton says about jealous men goes double for women, “by reason of the weakness of their sex.”

Even the hottest torments of love-melancholy are trifling, however, beside those of religious melancholy, whose soul-crushing nadir is despair. Burton heads into uncharted territory by making religious melancholy a distinct diagnostic category, but he is convinced of his rightness and the significance of his claim: “[religious melancholy] more besots and infatuates men than any other [melancholy] above named whatsoever, doth more harm, works more disquietness to mankind, and hath more crucified the souls of mortal men (such hath been the devil’s craft) than wars, plagues, sicknesses, dearth, famine, and all the rest.” Here moral philosophy and Protestant theology are the diagnostic instruments and the therapeutic ministrations: this sickness represents the soul’s profound failure to recognize the love of the One True God and to live contentedly in His favor.

The deluded comprise the fatuously sanctimonious or superstitious and the flagrantly unholy. Numberless species of idolaters account for most of the world’s population, and most Christians besides are unworthy of the name. Burton writes in a spirit anything but ecumenical, harrowing every faith or sect but his own. His diatribes get mighty ugly. The Pope is the supreme Christian menace, snaring the credulous with a false god and demonic saints and empty ritual. Burton loathes the unprecedented earthly rule of this spiritual potentate, who wields power with the utmost cynicism, while the blind multitudes swallow whatever swill their master dishes out. Ecclesiastical grandees secretly sneer at the pious fools, and enjoy the full measure of worldly gratification without a care for their own souls or those of their flocks.

Superstition is the chief cause of bloodshed. There is, Burton warns, a superabundance of doctrinal inanity, with vicious consequences: theologians split hairs, and their worldly champions split skulls. The time calls for a hero or god to cleanse the earth of superstition and the murderous faction it breeds. “To purge the world of idolatry and superstition will require some monster-taming Hercules, a divine Aesculapius, or Christ Himself to come in His own person, to reign a thousand years on earth before the end, as the millenaries will have Him. They are generally so refractory, self-conceited, obstinate, so firmly addicted to that religion in which they have been bred and brought up, that no persuasion, no terror, no persecution can divert them.” This recalcitrance of the faithful in their warring faiths has brought many nations around to the practice of religious toleration, although Burton is not nearly so tolerant himself: he is all for the excommunication of heretics. As for deluded would-be prophets and visionaries, deranged perhaps by melancholy, combining medical treatment with reasoned persuasion and coercion if necessary is the preferred course. “We have frequently such prophets and dreamers amongst us, whom we persecute with fire and fagot; I think the most compendious cure, for some of them at least, had been in Bedlam.” The madhouse certainly seems the humane alternative to immolation.

At the opposite extreme from the superstitious are the “atheists, epicures, infidels,” whose “grand sin” has been called “monstrous melancholy,” or “poisoned melancholy.” Their willful mockery of the pious of all faiths is not to be borne:

When those bloody wars in France for matters of religion … were so violently pursued between Huguenots and papists, there was a company of good fellows laughed them all to scorn for being such superstitious fools to lose their wives and fortunes, accounting faith, religion, immortality of the soul, mere fopperies and illusions. Such loose atheistical spirits are too predominant in all kingdoms…. Satan is their guide, the flesh is their instructor, hypocrisy their counselor, vanity their fellow-soldier, their will their law, ambition their captain, custom their rule; temerity, boldness, impudence their art, toys their trading, damnation their end.

Reasonable and philosophical faith is demanded to subdue the despair unto death, which makes the loss of life seem preferable to the soul’s continued earthly suffering. Despair is the hardest melancholy to bear, penning up innocent men and women in the mind’s inferno. Too much of the wrong kind of faith can bring it on. Hellfire preachers, lacking in mercy, torment timorous and credulous souls with fears of their own unworthiness and the agonies of hell; the papists and the Calvinists are most toxic in their scare-mongering. Spending too much time desperately on your knees can be more spiritually destructive than roistering. To be temperate in your self-examination, not to flagellate yourself for minor transgressions, and above all to believe in God’s mercy: this is how best to avoid an overwrought conscience. Divine forgiveness is always available to the soul that seeks it, even one that falls again and again and again. Religious melancholy even in its most severe forms is a purifying ordeal whose successful passage brings the sufferer nearer to salvation, “So that affliction is a school or academy, wherein the best scholars are prepared to the commencements of the Deity.” What Burton offers in the end is conventional religious balm and succor, the soothing ointment of the Judeo-Christian tradition: “But the best remedy [against demons] is to fly to God, to call on Him, hope, pray, trust, rely on Him, to commit ourselves wholly to Him.” Burton’s penchant for practical advice and his fondness for the most solemn spiritual counsel are joined in the book’s closing words: “Give not way to solitariness and idleness,” he recommends, and in the words of St. Augustine, “Be penitent while of sound mind.”

Some modern doctors would not find such consuming mention of penitence and fighting off devils to be at all conducive to soundness of mind. In their view, Burton does not have much to teach the up-to-date clinician, except as an object lesson in what to avoid. All this soul-talk sounds obsessive, perhaps symptomatic of Burton’s own religious mania. Salvation may be incompatible with mental health. It might be wiser to lay off the preaching and stick to psychopharmacology.

Those modern doctors would be wrong, and would miss out on profitable instruction. Although no reasonable person today would take seriously Burton’s diagnoses of godly chastisement and demonic possession, Burton nevertheless understands the spiritual component of mental illness to a profound degree. The Lord may not smite the contemporary depressive as He did Nebuchadnezzar, but the modern sufferer often knows his mental illness to be a spiritual crisis as well as a neurochemical meltdown. Depression often emerges from the feeling that one has been living a mistaken life, getting the essentials hopelessly fouled — lacking or losing a sense of vocation, not loving the right people enough, loving the wrong people too much or entirely inappropriately, failing to understand why the choices one makes seem invariably to lead to suffering. Sometimes, on the other hand, depression strikes from out of nowhere, in the midst of contentment, and then one must face the questions that all affliction brings: Why this, and why me?

What Burton preaches as prevention and restorative is above all moderation, in one’s physical as in one’s spiritual regimen. Suitable diet, sleep, exercise, recreation all contribute to mental health, and so do a just conviction of one’s own rectitude and decency, a confidence that one is living the life he is meant for in love and work, whether or not that entails a religious judgment. The divine in Burton might well insist on the religious judgment, but the religion is not onerous or doctrinaire; its God is merciful, and its moral precepts are readily accessible to reason — indeed shared down the centuries by the many philosophers Burton adduces. For all Burton’s passionate faith, the comfort he offers melancholics is almost as much philosophical as religious.

To heal himself was a powerful impetus to write this book, and according to some, not even the writing could save him from his own mind’s darkness. Oxford students spread the rumor at the time of Burton’s death in 1640 that he had “sent up his soul to heaven thro’ a slip about his neck,” and the epitaph he composed for his gravestone certainly did not squelch the rumors: “To whom Melancholy gave life and death.” Perhaps Burton could not find sufficient comfort in his own best thoughts, or in the immemorial wisdom he had gathered. That does not mean, however, that he has not offered sweet comfort to other sufferers.

Writing just as scientific modernity is getting underway, Burton stands athwart two epochs. Sometimes to modern eyes he seems like a comic figure who has one foot on a dock and the other on a boat that is moving inexorably away from shore: outworn therapeutics and old-style moralizing cannot hope to produce the benefits of the coming medical advances, and this wise man who was simply born at the wrong time to be an effective healer is bound to do a header into the drink. And yet he does do a healer’s work, and does it remarkably well: he practices psychiatry in its original meaning, as the cure of souls. And the wisdom he represents is far more than some agglomeration of quaint lore: it is a still-living tradition that points the way to the physician of the twenty-first century who wants to unite the latest neurochemical refinement to the moral sagacity that has stood for ages. Robert Burton is the exemplar of a whole physician, and his wonderful book indicates the direction toward an absolute cure of this desolating illness.