Depression In The Medical Casebook

 

This Week

We are going to take a look at Victorian psychiatry over the next couple of weeks. These were the hardest chapters of the book to write. Firstly it was challenging to choose which excerpts from the Sherlock Holmes stories to include. Secondly it was hard to find Victorian medical textbooks on this area of medicine, and the terminology at the time was very different to modern psychiatry terminology. Hopefully I have managed to produce interesting chapters despite these challenges.  

 

The Illustrator

Our page header this week is from the chapter on Insanity, and is a scene from “The Adventure Of The Beryl Coronet”. 

“The distressed Alexander Holder beats his head against the wall of 221B Baker Street” by Alex Holt

Alex Holt is an artist specialising in original ink illustrations. He has a special interest in Comic Art, single image illustrations and covers. Alex is a student of the Edinburgh Atelier of Fine Art. He works in private commissions and commercial projects. More of his work can be found in Instagram @alexholtart.

 

Depression

Depression + Sherlock

This has been another interesting and challenging chapter to write. Though there was no exact concept of “depression” as a disease in Victorian times, it was seen as a symptom of disease, and Conan Doyle uses the term [or “depressed”] widely in the stories. I have decided to include the references which I feel relate to a persisting problem, rather than just to a brief response to a difficult situation. I have also excluded a couple of references to “breakdown”, as this is neither a term we would use in modern medicine, nor could I find any clear reference to it in the Victorian medical texts. This still leaves us with 8 excerpts to look at.

We start with “The Sign Of Four”, where we get 2 excerpts which refer to Holmes having fits of deep depression.

It was half-past five before Holmes returned. He was bright, eager, and in excellent spirits, a mood which in his case alternated with fits of the blackest depression.

Our meal was a merry one. Holmes could talk exceedingly well when he chose, and that night he did choose. He appeared to be in a state of nervous exaltation. I have never known him so brilliant. He spoke on a quick succession of subjects – on miracle plays, on medieval pottery, on Stradivarius violins, on the Buddhism of Ceylon, and on the warships of the future – handling each as though he had made a special study of it. His bright humour marked the reaction from his black depression of the preceding days. Athelney Jones proved to be a sociable soul in his hours of relaxation, and faced his dinner with the air of a bon vivant. For myself, I felt elated at the thought that we were nearing the end of our task, and I caught something of Holmes’s gaiety. None of us alluded during dinner to the cause which had brought us together. 

The list of Holmes’s areas of expert knowledge is lovely. One suspects that, if alive today, he would have been diagnosed with bipolar disorder.

In “The Five Orange Pips” it is again Sherlock who is struggling with his mental health, on this occasion triggered by him failing to prevent the death of John Openshaw. It is hard to know if this is part of his chronic recurring depression, or just an acute reaction to bad news.

We sat in silence for some minutes, Holmes more depressed and shaken than I had ever seen him.

“That hurts my pride, Watson,” he said at last. “It is a petty feeling, no doubt, but it hurts my pride. It becomes a personal matter with me now, and, if God sends me health, I shall set my hand upon this gang. That he should come to me for help, and that I should send him away to his death—!” He sprang from his chair and paced about the room in uncontrollable agitation, with a flush upon his sallow cheeks and a nervous clasping and unclasping of his long thin hands.

Again it is Holmes suffering from depression at the start of “The Reigate Puzzle”.

On referring to my notes I see that it was upon the 14th of April that I received a telegram from Lyons which informed me that Holmes was lying ill in the Hotel Dulong. Within twenty-four hours I was in his sick-room, and was relieved to find that there was nothing formidable in his symptoms. Even his iron constitution, however, had broken down under the strain of an investigation which had extended over two months, during which period he had never worked less than fifteen hours a day, and had more than once, as he assured me, kept to his task for five days at a stretch. Even the triumphant issue of his labours could not save him from reaction after so terrible an exertion, and at a time when Europe was ringing with his name and when his room was literally ankle-deep with congratulatory telegrams I found him a prey to the blackest depression. Even the knowledge that he had succeeded where the police of three countries had failed, and that he had outmanoeuvred at every point the most accomplished swindler in Europe, was insufficient to rouse him from his nervous prostration.

This is our only visit to this short story, which is unusual as it went under three titles within its first year of publication. I have gone with “The Reigate Puzzle”, as this is used in my Penguin collected works edition, though oddly this was the name used in the initial US “Harper’s Weekly” publication. The initial British “The Strand” short story was called “The Reigate Squire”, which then became “The Reigate Squires” in the “The Memoirs of Sherlock Holmes”. 

In “The Crooked Man”, Holmes persuades Watson to accompany him to Aldershot as part of his investigation into the death of Colonel James Barclay, and provides background information on the deceased.

“Colonel Barclay himself seems to have had some singular traits in his character. He was a dashing, jovial old solder in his usual mood, but there were occasions on which he seemed to show himself capable of considerable violence and vindictiveness. This side of his nature, however, appears never to have been turned towards his wife. Another fact, which had struck Major Murphy and three out of five of the other officers with whom I conversed, was the singular sort of depression which came upon him at times. As the major expressed it, the smile had often been struck from his mouth, as if by some invisible hand, when he has been joining the gaieties and chaff of the mess-table. For days on end, when the mood was on him, he has been sunk in the deepest gloom. This and a certain tinge of superstition were the only unusual traits in his character which his brother officers had observed. The latter peculiarity took the form of a dislike to being left alone, especially after dark. This puerile feature in a nature which was conspicuously manly had often given rise to comment and conjecture.”

Next we head to “The Naval Treaty”, where it is the client, Percy Phelps, who is suffering from low mood. Holmes cures his depression by theatrically revealing he has recovered the document that Phelps has carelessly misplaced.

The table was all laid, and just as I was about to ring Mrs. Hudson entered with the tea and coffee. A few minutes later she brought in three covers, and we all drew up to the table, Holmes ravenous, I curious, and Phelps in the gloomiest state of depression.

“Mrs. Hudson has risen to the occasion,” said Holmes, uncovering a dish of curried chicken. “Her cuisine is a little limited, but she has as good an idea of breakfast as a Scotch-woman. What have you here, Watson?”

“Ham and eggs,” I answered.

“Good! What are you going to take, Mr. Phelps—curried fowl or eggs, or will you help yourself?”

“Thank you. I can eat nothing,” said Phelps.

“Oh, come! Try the dish before you.”

“Thank you, I would really rather not.”

“Well, then,” said Holmes, with a mischievous twinkle, “I suppose that you have no objection to helping me?”

Phelps raised the cover, and as he did so he uttered a scream, and sat there staring with a face as white as the plate upon which he looked. Across the centre of it was lying a little cylinder of blue-gray paper. He caught it up, devoured it with his eyes, and then danced madly about the room, pressing it to his bosom and shrieking out in his delight. Then he fell back into an arm-chair so limp and exhausted with his own emotions that we had to pour brandy down his throat to keep him from fainting. 

We are back to “The Adventure Of The Dancing Men”, which we looked at in our Anxiety chapter, for our next excerpt. Our sufferer on this occasion is Hilton Cubitt, whose wife, Elsie, is the recipient of the mysterious cipher.

We had not long to wait, for our Norfolk squire came straight from the station as fast as a hansom could bring him. He was looking worried and depressed, with tired eyes and a lined forehead.

“It’s getting on my nerves, this business, Mr. Holmes,” said he, as he sank, like a wearied man, into an arm-chair. “It’s bad enough to feel that you are surrounded by unseen, unknown folk, who have some kind of design upon you; but when, in addition to that, you know that it is just killing your wife by inches, then it becomes as much as flesh and blood can endure. She’s wearing away under it—just wearing away before my eyes.”

In “The Hound Of The Baskervilles”, in addition to suffering from heart disease, Charles Baskerville is also revealed to have depression [we still find that mental health problems are more common in patients with other chronic health issues].

“Their evidence, corroborated by that of several friends, tends to show that Sir Charles’s health has for some time been impaired, and points especially to some affliction of the heart, manifesting itself in changes of colour, breathlessness, and acute attacks of nervous depression.”

Our final excerpt is from “The Adventure Of The Blanched Soldier”, Colonel Emsworth is struggling with having to keep his son’s leprosy secret.

“It was a dull evening. We dined quietly, the three of us, in a gloomy, faded old room. The lady questioned me eagerly about her son, but the old man seemed morose and depressed. I was so bored by the whole proceeding that I made an excuse as soon as I decently could and retired to my bedroom.”

We will see below that Victorian physicians did not make a diagnosis of depression, and yet Conan Doyle used the term much as we would today. This might suggest he was ahead of his time in his understanding [and sympathy towards] psychiatric disease. It is of note that he gave his chief protagonist both psychiatric problems and addiction issues. This remains very common in modern detective fiction, and Conan Doyle can be seen as a trailblazer for this style of characterisation. 

  

Depression In Victorian Times

This has been a tricky section to write, as the diagnostic terminology in Victorian times is so different to our current concepts, and the medical literature of the time was limited with regards to psychiatric problems. As we have seen above, in Victorian times there was no such diagnosis as “depression”. Rather this was a term for a disease symptom. I feel the nearest diagnostic term at the time was “melancholia”, which was a subdivision of insanity, and I have thus based this section on the Victorian medical understanding of this condition.

Melancholia stands next in importance to mania as a leading form of insanity. It is often met with as Simple Melancholy, without delusion or distinct intellectual derangement of any kind. The patient is aware, and admits that there is no real cause for the mental depression, but is quite unable to shake it off. A sense of the ludicrous may exist along with this habitual state of feeling. A disposition to suicide is frequently present. It will usually be found that the general health is weak; and in women there is often anaemia and frequently also leucorrhoea. [5]

The descriptions of melancholia in the Victorian sources are very similar to what we would now call depression. I suspect readers who suffer from depression will be horrified to think that previously this was considered a form of insanity.

Leucorrhoea, incidentally, is an old-fashioned term for a vaginal discharge. Interestingly, unlike other psychiatric conditions we will cover, melancholia doesn’t seem to have been considered to be a condition that women were the main sufferers from. 

What is the pathological condition here? Beyond question there is a lack of nerve force, a failing genesis of nerve power which is unable to supply and permeate the centres and fibres of the brain. But although this failure of nerve force produces the feeling of depression and inadequate power in the higher centres, it may not do more than this. A man’s consciousness may at first be little affected. He is aware of the depressed feeling, but does not assign it to any cause beyond physical weakness or ill health. His judgement concerning things in general is unimpaired, and he is able to converse and argue rationally; nay, at certain times of the day, under influence of meat and drink, the stimulus of society, and pleasurable surrounding, his brain may be so permeated by the nervous fluid, and so incited into energy, that his gloom is thrown off and he is himself again; to relapse, probably, into great gloom afterwards. [35]

When depression, however, advances to the melancholia of insanity, delusions characterised by the prevailing feeling soon manifest themselves. The self-feeling of the individual is shown in fears for his eternal salvation, because this is one of the channels of constant thought which is easily permeated by the sluggish current of his nervous fluid; or he thinks he is ruined, reflections concerning his wealth and worldly position being his usual line of thought; or his relations to others make him think all are looking at or regarding him, or are conspiring to do him injury and hurt. [35]

On the other hand, he may have experienced some great loss or sorrow, or have been exposed to long harass and worry, and this has exhausted his nervous power either by its own depressing influence, or because his physical strength quickly fails, owing to some bodily condition or infirmity. Among the latter we may class such conditions as anaemia, various chronic or wasting diseases, lactation, the climacteric period of life, dyspepsia, or unhealthy work, and lack of hygiene. In the same way, the instability of the centres and increased arterial action may be due to an over-stimulation caused by external circumstances, as shock, protracted worry, or over-work, or to such causes as masturbation, alcohol, epilepsy, or sunstroke, or the brain-organisation may be specially unstable under the influences of puberty, pregnancy, or child-birth. [35]

This is the only section I could find looking at the aetiology of depression. The author clearly feels there is a gradation from lesser forms of depression to a point where the condition was classed as insanity.

Depression is the chief feature of mild or simple melancholia. The sufferer has no pleasure in life; life itself is one long pain, hence the wish to end it. After a short and restless night, with little and unrefreshing sleep, he wakes in the deepest gloom, with all his morbid thoughts intensified, without hope in this world. Bear in mind that the morning is the time when all melancholics are at their worse, and most likely to do themselves harm; you will see again and again accounts of suicides which have taken place at this time. [35]

When the disorder is fully developed the unhappy feeling may attain to one of despair. The wretched sufferer may utter loud lamentations, tear his hair, strike his breast, and even make desperate attempts at self-destruction. It is seldom, however, that the condition is as bad as this; but there are all degrees between simple melancholy and the state just described. The attitude and the expression betoken the mental frame. In some, the arms hang heavily by the side, the eyes are turned downwards towards one point, and are almost statue-like in the fixity of their gaze, and the angles of the mouth are depressed; or – the morbid feeling being more acute – the hands are clenched, the features are tense, and the sufferer moves about in restless agitation. The latter variety is less common than the former. Notwithstanding their misery, melancholics seldom shed tears; their sorrow is too deep for that. [5]

The disposition assumes an entirely negative character (that of abhorrence or repulsion). All impressions, even the slightest and formerly more agreeable, excite pain. The patient can no longer rejoice in anything, not even the most pleasing. Everything affects him uncomfortably, and in all that happens around him he finds new sources of pain. Everything has become repulsive to him; he has become irritable and angry. Every trifle puts him out of temper. The result is, either perpetual expressions of discontent, or – and this is more common – he endeavours to escape from all outward mental impressions, by withdrawing himself from the society of men, and, completely idle and unemployed, seeking solitude. [4]

The Victorian descriptions of melancholia are, I feel, consistent with a modern diagnosis of depression, albeit with the addition of the embellishment of Victorian medical writing.

We will return to the topic of Suicide in a separate chapter. 

I’m going to break down the treatment section more than in other chapters, to aid clarity of the interesting information in the Victorian texts.

A considerable number may be treated as out-patients, and recover without the restraint of an asylum. [14]

The first thing you are to remember is, that every patient of this kind is to be looked upon as suicidal. Where is the treatment of such a patient to be carried out? An asylum is not absolutely indispensable, if the patient’s means will afford him what he requires elsewhere. If a poor man, there is nothing for it but to send him to an asylum. For he must not be left for a moment where he can do himself harm, or make his escape. He requires the companionship of some person his equal in education, as well as of attendants; must be removed from home to a house, airy, light, and quiet, and should have facilities for taking exercise without going into crowded thoroughfares. All this implies some considerable expense. If, as I say, his means suffice, such a plan often works a cure more rapidly, in my opinion, then the asylum, with its depressing influences and lack of sane companions; but if funds are scanty, the latter is a necessity, for the other plan is impracticable unless carried out completely in all its details. [35]

So if your depression progresses to a level the Victorian doctor considered insanity, and you weren’t reasonably wealthy, or had wealthy relatives, then it was off to the asylum, quite possibly never to recover. 

The two things to be kept in view may be called, in concise terms, moral and medical treatment. We must inquire into, and if need be correct, the patient’s external surrounding, and, by diet and medicine, try to restore his physical health. In many cases, perhaps in most, it will be advisable to send him away from home – to produce an entire change of ideas and objects – to remove by this means painful subjects of thought constantly presented by the sight of home, or wife, or children, subjects already, it may be, distorted by fancies, and incapable of being regarded in their true aspect. [35]

One thing is certain – he should not go alone. Morbid fancies come thick and fast to a man who has no one with whom to interchange ideas.  The place to which invalid Londoners and many others are chiefly sent is to the seaside, but I do not find that sea air is beneficial to those threatened with insanity. I have seen too many get rapidly worse after a few days’ sojourn at Brighton, that I cannot help coming to the conclusion that there is something about the seaside which tends to convert the preliminary stage of confusion and depression into wild excitement; and for this reason I prefer to send patients for change to an inland place. [35]

Patients at this time are not capable of great fatigue, mental or bodily. If sent into the country, very hard exercise – as boating or very long walks – must be interdicted. I have known it to produce suddenly a very acute attack. Neither must they be exposed to great heat or sun. Amusement they require, not work, and this must be regulated by the companion, without whom, as I have said, they are not to be trusted, and who is to have supreme authority in everything. [35]

I had a good chuckle at the thought of Brighton being a terrible place to send a depressed patient.

I would be actively encouraging more exercise than advised here.

I can imagine that being put under the command of a very bossy relative or companion would not be greatly appreciated by a patient with depression.

This is the kind of diet which I have frequently given for the purpose. Before getting out of bed in the morning, rum and milk, or egg and milk; breakfast of meat, eggs, and café au lait, or cocoa; beef-tea, with a glass of port, at eleven o’clock; and a good dinner or lunch at two, with a couple of glasses of sherry; at four, some more beef-tea, or an equivalent; at seven, dinner or supper, with stout and port-wine; and at bedtime, stout or ale, with the chloral or morphia. [35]   

The ideal diet for the depressed patient is hilarious – you might improve the depression, but would likely cause them to become an alcoholic.

If sleep be insufficient and irregular – and you will rarely find it otherwise – are you to give medicine of any kind? At this time I think that we derive valuable assistance from the hydrate of chloral. Should this fail, you may try bromide of potassium alone or combined with chloral, or extract of henbane, or tincture of digitalis; but assuredly chloral should be given first, in doses of twenty to twenty-five grams. Tonics may be required – iron, quinine, arsenic, or strychnia. [35]

Chloral will produce sleep in these cases, as in others, but is better suited to the slight than the severer forms of melancholia. It is a sleep-compelling agent; beyond that its effect seems to little import. It does not appear to have such a healing influence as opium where the latter is beneficial. In sub-acute melancholia, the preparation of opium are of great service, whether given by mouth or subcutaneous injection. [35]

We are, unsurprisingly, many decades before the existence of antidepressants as a treatment option. Instead, Victorian doctors were using a fine range of addictive and poisonous drugs.

Of course in such cases moral treatment is not to be lost sight of; and although no precise rule can be laid down on this subject, yet the recovery of a patient may be greatly aided by the judicious care of those about him. Every one must be struck by the intense self-feeling of the melancholy man. His egotism exceeds even that of the paralytic or maniac. He thinks that everything is centred in him, that he has committed the greatest sins, or is to endure the greatest torments. His superlative misery is a theme on which he loves to descant as much as the paralytic loves to describe his wealth and greatness. His depression is great, but he magnifies it in the recital of his woes. Therefore it is necessary to lead him away from self-contemplation, and to awaken in him and interest in others; and it is curious and interesting to see the gradual improvement in this respect. [35]

Finally, this is the only [brief] discussion I can find on what today we would call counselling.

Patient photo:

“William Wilkinson, a patient at the West Riding Lunatic Asylum, Wakefield, Yorkshire.” [36]

 

Next Week

Next week we’ll venture into the subject of Hysteria – a fairly shocking chapter with some dreadful Victorian views.

 

Buying The Book

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.