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 Handbook of
Depression
and Anxiety
Second Edition, Revised
and Expanded

edited by

Siegfried Kasper
University of Vienna
Vienna, Austria

Johan A. den Boer

Academic Hospital Groningen
Groningen, The Netherlands

J. M. Ad Sitsen
Academic Hospital Utrecht
Utrecht, The Netherlands

MARCEL

MARCEL DEKKER, INC. NEW YORK • BASEL

D E K K ER
The first edition was published as Handbook of Depression and Anxiety: A Biological
Approach, edited by Johan A. den Boer and J. M. Ad Sitsen (Marcel Dekker, 1994).

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress.

ISBN: 0-8247-0872-5

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Neither this book nor any part may be reproduced or transmitted in any form or by any
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or by any information storage and retrieval system, without permission in writing from
the publisher.

Current printing (last digit):

10 9 8 7 6 5 4 3 2 1

PRINTED IN THE UNITED STATES OF AMERICA

 Medical Psychiatry
Series Editor Emeritus
William A. Frosch, M.D.
Weill Medical College of Cornell University
New York, New York, USA

Advisory Board

Jonathan E. Alpert, M.D., Ph.D. Siegfried Kasper, M.D.

Massachusetts General Hospital and University Hospital for Psychiatry
Harvard University School of Medicine and University of Vienna
Boston Massachusetts, U S A Vienna, Austria

Bennett Leventhal, M.D. Mark H. Rapaport, M.D.

University of Chicago School of Medicine Cedars-Sinai Medical Center
Chicago Illinois, USA Los Angeles California, USA

1 Handbook of Depression and Anxiety A Biological Approach, edi-

ted by Johan A. den Boer and J M Ad Sitsen
2 Anticonvulsants in Mood Disorders, edited by Russell T Joffe and
Joseph R Calabrese
3 Serotonin in Antipsychotic Treatment Mechanisms and Clinical
Practice, edited by John M Kane, H -J Moller, and Frans Awou-
ters
4 Handbook of Functional Gastrointestinal Disorders, edited by Kevin
W Olden
5 Clinical Management of Anxiety, edited by Johan A den Boer
6 Obsessive-Compulsive Disorders Diagnosis • Etiology • Treat-
ment, edited by Eric Hollander and Dan J Stem
7 Bipolar Disorder Biological Models and Their Clinical Application,
edited by L Trevor Young and Russell T Joffe
8 Dual Diagnosis and Treatment Substance Abuse and Comorbid
Medical and Psychiatric Disorders, edited by Henry R Kranzlerand
Bruce J Rounsaville
9 Geriatric Psychopharmacology, edited by J Craig Nelson
10 Panic Disorder and Its Treatment, edited by Jerrold F Rosenbaum
and Mark H Pollack
11 Comorbidity in Affective Disorders, edited by Mauncio Tohen
12 Practical Management of the Side Effects of Psychotropic Drugs,
edited by Richard Baton
13. Psychiatric Treatment of the Medically Hi, edited by Robert G.
Robinson and William R. Yates
14. Medical Management of the Violent Patient' Clinical Assessment
and Therapy, edited by Kenneth Tardiff
15 Bipolar Disorders. Basic Mechanisms and Therapeutic Implica-
tions, edited by Jair C. Scares and Samuel Gershon
16 Schizophrenia A New Guide for Clinicians, edited by John G.
Csernansky
17 Polypharmacy in Psychiatry, edited by S. Nassir Ghaemi
18 Pharmacotherapy for Child and Adolescent Psychiatric Disorders-
Second Edition, Revised and Expanded, David R. Rosenberg,
Pablo A Davanzo, and Samuel Gershon
19 Brain Imaging In Affective Disorders, edited by Jair C. Scares
20 Handbook of Medical Psychiatry, edited by Jair C. Soares and
Samuel Gershon
21 Handbook of Depression and Anxiety: Second Edition, Revised
and Expanded, edited by Siegfried Kasper, Johan A. den Boer, and
J. M. Ad Sitsen

ADDITIONAL VOLUMES IN PREPARATION

Aggression- Psychiatric Assessment and Treatment, edited by Emil

F. Coccaro

Autism Spectrum Disorders, edited by Eric Hollander

Depression in Later Life: A Multidisciplinary Approach, edited by

James Ellison and Sumer Verma

Handbook of Chronic Depression: Diagnosis and Therapeutic Man-

agement, edited by Maurizio Fava and Jonathan Alpert
Series Introduction

Depression and anxiety, both externally experienced and internally perceived, are part of
the normal human repertoire of response to stress. In my opinion, those who never experi-
ence such feelings are seriously ill, unable to recognize or respond appropriately to the
importance of danger and loss. On the other hand, the capacity to tolerate a “normal
expectable” level of each is a sign of mental health. Unfortunately, however, many of us
are unable to withstand the impact of the usual vicissitudes of life and are overwhelmed
by excessive stress or chronic strain. The stressors may be as sudden as the events of
9/11, the diagnosis of a life-threatening disease, or the loss of someone we love, or they
may be an accumulation of the ordinary stresses of life at work and at home, with family
and friends. Symptoms of depression and/or anxiety may develop, sometimes assorted
into identifiable syndromes and, at times, representing specific disease states.
The chapters of this volume provide us with background information, such as the
conceptual history of our understanding of anxiety and depression, their epidemiology
and genetics. They also provide insight into our current knowledge of the physiology and
pathology of both anxiety and depression, and information about up-to-date treatment
approaches for both acute and chronic presentations.
This volume should be kept on our desks, readily accessible for consultation when
we need help with understanding the difficult issues that bring people to us in search of
relief. It is a “vade-mecum”—a useful manual of what we now know about the biological
and pharmacological treatments of depression and anxiety, and an invaluable resource for
all who care for the afflicted, important for general practitioners as well as for psychiatrists
and others in the mental health fields. The internationally renowned group of contributors
illustrate a growing consensus that anxiety and depression are both symptom and syn-
drome, and, in some instances, disease. It is time to apply this understanding to the practice
of medicine.

William A. Frosch, M.D.

Weill Medical College of Cornell University
New York, New York

iii
Preface

Anxiety and depression are complex emotional states in which cognitive evaluations and
affective and physiological responses are involved. Considering the complexity of these
emotions, which can be described in several scientific languages at different levels of
analysis, there is no doubt that multiple neuronal systems in the brain are implicated in
the pathophysiology of these closely related disorders.
On a phenomenological level, there is a high degree of overlap between symptoms
of anxiety and depression as well as a high degree of comorbidity. This does not imply,
however, that both syndromes are merely different phenotypical expressions of a geneti-
cally based constitution sharing similar biological underpinnings. The question of whether
anxiety and depression result from similar or different biological abnormalities cannot be
answered using one research strategy. On the one hand, psychophysiological research
provides evidence suggesting that anxiety and depression are clearly distinct disorders;
on the other hand, some anxiety disorders and depressive syndromes respond to similar
pharmacological interventions. Thus, these conflicting findings from different biomedical
fields of research present a challenge to all of us involved in the study of these very
common and often debilitating psychiatric illnesses.
Some investigators argue that distinguishing different subtypes among depressive
syndromes and anxiety disorders is a somewhat artificial practice. They reason that a
syndrome exists based upon a common underlying propensity toward ‘‘nervousness.’’
This (dimensional) viewpoint implies that the different diagnostic categories could be
merely phenotypical manifestations of an underlying vulnerability to anxiety or depres-
sion.
Over the last decade, our knowledge about the biological underpinnings of depres-
sion and anxiety disorders has increased substantially, particularly for anxiety disorders,
and new insights are continually emerging from widely disparate fields, such as epidemiol-
ogy, genetics, immunology, psychophysiology, and psychopharmacology. This volume
brings together these different disciplines and reviews the state of the art in research on
anxiety and depression and their interrelatedness.
We consider ourselves fortunate to have succeeded in getting so many internation-
ally renowned contributors, who lend to this volume their knowledge and expertise in

v
vi Preface

these disciplines. We hope that scientists and clinicians from many fields will be inspired
by the exciting findings presented in this book.

Siegfried Kasper
Johan A. den Boer
J. M. Ad Sitsen
Contents

Preface iii
Contributors xi

1. A Conceptual History of Anxiety and Depression 1

Gerrit Glas

2. Epidemiology of Depression and Anxiety 49

Borwin Bandelow

3. Comorbidity of Depression and Anxiety 69

Giovanni B. Cassano, Nicolò B. Rossi, and Stefano Pini

4. Anxiety, Depression, and Personality 91

Harald N. Aschauer and Monika Schlögelhofer

5. Is There a Common Etiology for Depression and Anxiety? 111

Dean F. MacKinnon and Rudolf Hoehn-Saric

6. Measurements of Depression and Anxiety Disorders 127

Saena Arbabzadeh-Bouchez and Jean-Pierre Lépine

7. Combining Psychotherapy and Pharmacotherapy for Depression and

Anxiety 151
Robert H. Howland and Michael E. Thase

8. Genetics of Depression 165

Wolfgang Maier and Kathleen R. Merikangas

vii
viii Contents

9. Genetics of Anxiety 189

Wolfgang Maier

10. Stress-Responsive Neurohormones in Depression and Anxiety 207

Andreas Ströhle and Florian Holsboer

11. Neuropeptide Alterations in Depression and Anxiety Disorders 229

David A. Gutman, Dominique L. Musselman, and Charles B. Nemeroff

12. Immunology in Anxiety and Depression 267

Norbert Müller and Markus J. Schwarz

13. Brain Imaging in Depression and Anxiety 289

Peter S. Talbot, Sanjay J. Mathew, and Marc Laruelle

14. Neurobiology of Anxiety and Depression 331

Philip T. Ninan and Thomas K Cummins

15. Intracellular Signaling Transduction Dysregulation in Depression and

Possible Future Targets for Antidepressant Therapy: Beyond the
Serotonin Hypothesis 349
Andrea Trentani, S. Kuipers, G. J. Ter Horst, and Johan A. den Boer

16. Norepinephrine in Depression and Anxiety 387

Pedro L. Delgado

17. Benzodiazepines, Benzodiazepine Receptors, and Endogenous Ligands 415

Werner Sieghart

18. Antidepressants for the Treatment of Depression and Anxiety Disorders:

Same Mechanism of Action? 443
R. Hamish McAllister-Williams and Stephen P. Tyrer

19. Studies on the Neurobiology of Depression 457

Carlos A. Zarate, Jr. and Dennis S. Charney

20. Animal Models of Subtypes of Depression 505

Paul Willner and Paul J. Mitchell

21. Pathogenesis of Depression: Reconsideration of Neurotransmitter Data

by Depletion Paradigms 545
Alexander Neumeister and Anastasios Konstantinidis

22. Effects of Antidepressants on Specific Neurotransmitters: Are Such

Effects Relevant to Therapeutic Actions? 561
Brian Leonard
Contents ix

23. Pharmacotherapy of Depression: The Acute and Long-Term Perspective 583

Robert J. Boland and Martin B. Keller

24. Pharmacotherapy of Bipolar Disorder 599

Kenneth Thau and Anna Maria Streeruwitz

25. Development of New Treatment Options for Depression 615

Siegfried Kasper and Alan F. Schatzberg

26. The Depressed Patient: From Nonresponse to Complete Remission 629

Koen Demyttenaere and Jürgen DeFruyt

27. Pharmacogenetics of Mood Disorders: Is There a Future? 641

Bernard Lerer, Ofer Agid, and Fabio Macciardi

28. Theories of the Etiology of Anxiety 657

Trevor R. Norman, Graham D. Burrows, and James S. Olver

29. Animal Models of Anxiety and Anxiolytic Drug Action 681

Dallas Treit, Aldemar Degroot, and Akeel Shah

30. Provocation of Anxiety States in Humans and Its Possible Significance

for the Pathogenesis of These Disorders 703
Richard Balon, Robert Pohl, Vikram K. Yeragani, and Ravi K.
Singareddy

31. Pharmacotherapy of Anxiety Disorders 733

David S. Baldwin, David Bridle, and Anders Ekelund

32. Pharmacotherapy of Mixed Anxiety/Depression Disorders 757

A. Carlo Altamura, Roberta Bassetti, Sara Fumagalli, Donato Madaro,
Daniele Salvadori, and Emanuela Mundo

33. New and Emerging Therapies for Anxiety 779

David J. Nutt and Spilios V. Argyropoulos

34. Scales Used in Depression and Anxiety Research 789

Hans-Jürgen Möller

Index 809
Contributors

Ofer Agid, M.D. Department of Psychiatry, Hadassah-Hebrew University Medical Cen-

ter, Jerusalem, Israel

A. Carlo Altamura, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Saena Arbabzadeh-Bouchez, M.D. Department of Psychiatry, Hôpital Fernand Widal,

Paris, France

Spilios V. Argyropoulos, M.B.Ch.B., M.R.C.Psych Department of Psychiatry, Univer-

sity of Bristol, Bristol, England

Harald N. Aschauer, M.D. Department of General Psychiatry, University of Vienna,

Vienna, Austria

David S. Baldwin, M.B.B.S., F.R.Psych. University Department of Mental Health,

Royal South Hants Hospital, and University of Southampton, Southampton, England

Richard Balon, M.D. Department of Psychiatry and Behavioral Neurosciences, Univer-

sity Psychiatric Center, Wayne State University School of Medicine, Detroit, Michigan,
U.S.A.

Borwin Bandelow, M.D., Ph.D. Department of Psychiatry and Psychotherapy, Univer-

sity of Göttingen, Göttingen, Germany

Roberta Bassetti, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Robert J. Boland, M.D. Department of Psychiatry and Human Behavior, Brown Uni-

xi
xii Contributors

versity, and Medical Director, Center for Behavioral and Preventive Medicine, Miriam
Hospital/LifeSpan, Providence, Rhode Island, U.S.A.

David Bridle, M.B., B.S., M.R.Psych. Department of Psychiatry, Royal South Hants
Hospital, Southampton, England

Graham D. Burrows, M.D., Ch.B., B.Sc., FRANZCP Department of Psychiatry, Aus-

tin and Repatriation Medical Centre, University of Melbourne, Heidelberg, Victoria,
Australia

Giovanni B. Cassano, M.D. Department of Psychiatry, University of Pisa, Pisa, Italy

Dennis S. Charney, M.D. National Institute of Mental Health, National Institutes of

Health, Bethesda, Maryland, U.S.A.

Thomas K Cummins, M.D. Department of Psychiatry and Behavioral Sciences, Emory

University School of Medicine, Atlanta, Georgia, U.S.A.

Jürgen DeFruyt, M.D. University Hospital Gasthuisberg, Leuven, Belgium

Aldemar Degroot Department of Psychology, University of Alberta, Edmonton, Al-

berta, Canada

Pedro L. Delgado, M.D. University Hospitals of Cleveland and Case Western Reserve
University School of Medicine, Cleveland, Ohio, U.S.A.

Koen Demyttenaere, M.D., Ph.D. Department of Psychiatry, University Hospital

Gasthuisberg, Leuven, Belgium

Johan A. den Boer, M.D., Ph.D. Division of Biological Psychiatry, Department of

Psychiatry, Academic Hospital Groningen, Groningen, The Netherlands

Anders Ekelund, M.B.Ch.B., Ph.D. Department of Psychiatry, Royal South Hants Hos-
pital, Southampton, England

Sara Fumagalli, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Gerrit Glas, M.D., Ph.D. University of Leiden, Leiden, The Netherlands

David A. Gutman Department of Psychiatry and Behavioral Sciences, Emory Univer-

sity School of Medicine, Atlanta, Georgia, U.S.A.

Rudolf Hoehn-Saric, M.D. Department of Psychiatry and Behavioral Sciences, Johns

Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Florian Holsboer, M.D., Ph.D. Max Planck Institute of Psychiatry, Munich, Germany
Contributors xiii

Robert H. Howland, M.D. Department of Psychiatry, University of Pittsburgh School

of Medicine, and Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania,
U.S.A.

Siegfried Kasper, M.D. Department of General Psychiatry, University of Vienna, Vi-

enna, Austria

Martin B. Keller, M.D. Department of Psychiatry and Human Behavior, Brown Univer-
sity, Providence, Rhode Island, U.S.A.

Anastasios Konstantinidis, M.D. Department of General Psychiatry, University of Vi-

enna, Vienna, Austria

S. Kuipers Division of Biological Psychiatry, Department of Psychiatry, Academic Hos-

pital Groningen, Groningen, The Netherlands

Marc Laruelle, M.D. Columbia University College of Physicians and Surgeons, and
New York State Psychiatric Institute, New York, New York, U.S.A.

Brian Leonard, Ph.D., D.Sc., M.R.I.A. Department of Pharmacology, National Univer-

sity of Ireland, Galway, Ireland

Jean-Pierre Lépine, M.D. Department of Psychiatry, Hôpital Fernand Widal, Paris,

France

Bernard Lerer, M.D. Department of Psychiatry, Hadassah-Hebrew University Medical

Center, Jerusalem, Israel

Fabio Macciardi, M.D., Ph.D. Center for Addiction and Mental Health, University of
Toronto, Toronto, Ontario, Canada

Dean F. MacKinnon, M.D. Department of Psychiatry and Behavioral Sciences, Johns

Hopkins University School of Medicine, Baltimore, Maryland, U.S.A.

Donato Madaro, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Wolfgang Maier, M.D. Department of Psychiatry, University of Bonn, Bonn, Germany

Sanjay J. Mathew, M.D. New York State Psychiatric Institute, New York, New York,
U.S.A.

R. Hamish McAllister-Williams, Ph.D., M.R.C.Psych. Department of Psychiatry,

University of Newcastle upon Tyne, Newcastle upon Tyne, England

Kathleen R. Merikangas, M.D. Department of Health and Human Services, National

Institutes of Health, Bethesda, Maryland, U.S.A.
xiv Contributors

Paul J. Mitchell, B.Sc., MIBiol, CIBiol, Ph.D. Department of Pharmacy and Pharma-
cology, University of Bath, Bath, England

Hans-Jürgen Möller, M.D. Department of Psychiatry, Ludwig Maximilian University,

Munich, Germany

Norbert Müller, M.D. Hospital for Psychiatry and Psychotherapy, Ludwig Maximilian
University, Munich, Germany

Emanuela Mundo, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Dominique L. Musselman, M.D. Department of Psychiatry and Behavioral Sciences,

Emory University School of Medicine, Atlanta, Georgia, U.S.A.

Charles B. Nemeroff, M.D., Ph.D. Department of Psychiatry and Behavioral Sciences,

Emory University School of Medicine, Atlanta, Georgia, U.S.A.

Alexander Neumeister, M.D. Mood and Anxiety Disorders Program, National Institute
of Mental Health, National Institutes of Health, Bethesda, Maryland, U.S.A.

Philip T. Ninan, M.D. Department of Psychiatry and Behavioral Sciences, Emory Uni-
versity School of Medicine, Atlanta, Georgia, U.S.A.

Trevor R. Norman, B.Sc., Ph.D. Department of Psychiatry, Austin and Repatriation

Medical Centre, University of Melbourne, Heidelberg, Victoria, Australia

David J. Nutt, M.D., Ph.D., F.R.C.Psych., F. Med. Sci. Psychopharmacology Unit,

University of Bristol, Bristol, England

James S. Olver, M.B.B.S., M.P.M., FRANZCP Department of Psychiatry, Austin and

Repatriation Medical Centre, University of Melbourne, Heidelberg, Victoria, Australia

Stefano Pini, M.D., Ph.D. Department of Psychiatry, University of Pisa, Pisa, Italy

Robert Pohl, M.D. Department of Psychiatry and Behavioral Neurosciences, University

Psychiatric Center, Wayne State University School of Medicine, Detroit, Michigan, U.S.A.

Nicolò B. Rossi, M.D. Department of Psychiatry, University of Pisa, Pisa, Italy

Daniele Salvadori, M.D. Psychiatry, Department of Clinical Sciences ‘‘Luigi Sacco,’’

University of Milan, Milan, Italy

Alan F. Schatzberg, M.D. Department of Psychiatry and Behavioral Sciences, Stanford

University School of Medicine, Stanford, California, U.S.A.

Monika Schlögelhofer, M.A. Department of General Psychiatry, University of Vienna,

Vienna, Austria
Contributors xv

Markus J. Schwarz, M.D. Hospital for Psychiatry and Psychotherapy, Ludwig Maxi-
milian University, Munich, Germany

Akeel Shah Department of Psychology, University of Alberta, Edmonton, Alberta,

Canada

Werner Sieghart, Ph.D. Brain Research Institute, University of Vienna, Vienna, Aus-
tria

Ravi K. Singareddy, M.D. Department of Psychiatry and Behavioral Neurosciences,

University Psychiatric Center, Wayne State University School of Medicine, Detroit, Mich-
igan, U.S.A.

Anna Maria Streeruwitz, M.D. Department of Social Psychiatry and Evaluation Re-
search, University of Vienna, Vienna, Austria

Andreas Ströhle, M.D. Max Planck Institute of Psychiatry, Munich, Germany

Peter S. Talbot, M.D., M.R.C.Psych. Division of Functional Brain Mapping, New

York State Psychiatric Institute, New York, New York, U.S.A.

G. J. Ter Horst, Ph.D. Division of Biological Psychiatry, Academic Hospital Gro-

ningen, Groningen, The Netherlands

Michael E. Thase, M.D. Department of Psychiatry, University of Pittsburgh School of

Medicine, and Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania, U.S.A.

Kenneth Thau, M.D. Department of Social Psychiatry and Evaluation Research, Uni-
versity of Vienna, Vienna, Austria

Dallas Treit, Ph.D. Department of Psychology, University of Alberta, Edmonton, Al-

berta, Canada

Andrea Trentani, Ph.D. Division of Biological Psychiatry, Department of Psychiatry,

Academic Hospital Groningen, Groningen, The Netherlands

Stephen P. Tyrer, M.B., B.Chir.DPM Division of Psychiatry, Royal Victoria Infir-

mary, University of Newcastle upon Tyne, Newcastle upon Tyne, England

Paul Willner, M.S., Ph.D. University of Wales Swansea, Swansea, Wales

Vikram K. Yeragani, M.D. Department of Psychiatry and Behavioral Neurosciences,

University Psychiatric Center, Wayne State University School of Medicine, Detroit, Mich-
igan, U.S.A.

Carlos A. Zarate, Jr., M.D. National Institute of Mental Health, National Institutes of
Health, Bethesda, Maryland, U.S.A.
1
A Conceptual History of Anxiety
and Depression

GERRIT GLAS
University of Leiden
Leiden, The Netherlands

I. INTRODUCTION
For more than 2500 years, physicians have distinguished the clinical conditions we call
affective or anxiety disorder from such everyday feelings as fear, restlessness, and despon-
dency. Contrary to what might be expected, case descriptions from the past often bear
remarkable resemblances to patients encountered in modern-day clinical practice. Whether
one consults Aristotle, Galen, Burton, or the 19th-century alienists, images of a suggestive
reality are evoked, images in which we can easily recognize the depressive, anxious, and
melancholic individual of our own era. These are similarities in symptomatology and
course, as well as in the distinction between normality and pathology.
On the other hand, there are also considerable disparities in language and frame of
reference, conceptualization, and interpretation. From the time of Hippocrates until well
into the 17th century, the description and interpretation of anxiety and depression were
dominated by the doctrine of bodily fluids (humors). And, until quite recently, all manner
of ideas involving neural energy overshadowed discussions of phenomena such as neuras-
thenia, inhibition, and motor agitation.
These disparities have traditionally been given particular emphasis. The undeniably
impressive growth of our knowledge is seen as evidence of the superiority of contemporary
explanatory models. Conversely, ideas that were current from antiquity until the 19th
century are considered to be of no more than historical interest—simply a fanciful mythol-
ogy for enthusiasts. The history of medicine has become a somewhat antiquated study,
pursued by a handful of specialists.

1
2 Glas

This may or may not be considered regrettable. However, these disparities once
again become relevant at a deeper level of discussion for clinicians as well as for scientific
investigators. I refer here to the level of medicine’s basic concepts and to the cultural and
ideological strata from which these concepts derive their meaning.
A consideration of the foundations of medicine helps, for example, to put into per-
spective the already overly strict separation of symptoms and explanatory models. Symp-
toms are not natural phenomena in that they are not the invariable expressions of an
unchanging biological substratum. Whatever one’s concept of disease, what the patient
says is always based upon interpretation, at least to a certain extent. That interpretation
can be colored by whatever is considered to be normal or abnormal in a particular culture.
Explanatory models, on the other hand, are not simply conjured up out of the blue. They
are neither arbitrary nor coincidental, but are instead closely linked to whatever paradigms
are currently fashionable in the various branches of science. Moreover, they are always
interpretations of a reality that is already interpreted by the afflicted person and those
around him.
Accordingly, we cannot pretend that depression and anxiety are natural phenomena
that have consistently been expressed and experienced in the same way down through the
centuries. The view according to which only the explanatory models have changed and
not the phenomena themselves should be rejected. Concentrating purely on differences at
the level of the explanatory models can easily turn the history of medicine into a study
of scientific folklore, as if, with the passage of time, only the explanatory models have
undergone change and not the signs and symptoms of the disorders. Notwithstanding the
above-mentioned similarities in clinical picture and course, the symptoms of anxiety and
depression also have changed (i.e., their relevance to what counts as disease and their
meaning as an expression of disease).
Seen from this point of view, the study of the history of medicine suddenly becomes
extremely relevant to a clear understanding of all sorts of current explanatory models.
The medical history of anxiety and depression is, therefore, not simply concerned with
internal scientific development. It also involves the interplay of cultural changes and psy-
chopathological phenomena, including the scientific interpretations of such phenomena.
In this chapter, several leading concepts in the history of anxiety and depression will be
summarized. Instead of delving into historical detail, the emphasis will be on concepts
and, particularly, on the paradigm shifts associated with the changes in conceptual content.
Anyone interested in the detail is referred to the existing literature on the history of medi-
cine, particularly to the outstanding studies of Jackson [1] and Klibansky et al. [2]. Also
of interest are the studies by Ackerknecht [3], Beek [4], Berrios [5,6], Flashar [7], Foucault
[8], Gardiner et al. [9], King [10], Leibbrand and Wettley [11], Lewis [12], Roccatagliata
[13], Rosen [14], Starobinski [15], and Zilboorg [16].

II. NOMENCLATURE
Before commencing with our historical review, a few comments about terminology. First
of all, it should be realized that the generally accepted distinction between anxiety and
depression is of comparatively recent vintage. The first nonphobic form of anxiety to take
its place in the description of disease did so as recently as the middle of the 19th cen-
tury. Flemming’s Über Praecordialangst, which dates from 1848, was cited by Schmidt-
Degenhard [17] as the first medico-psychiatric text exclusively devoted to a nonphobic
form of anxiety.
History of Anxiety and Depression 3

Of course, this does not mean that subtle variations in the spectrum of anxiety and
depressive disorders had not been observed and described prior to this. Evidently, how-
ever, there was no recognition of the need for a systematic distinction between anxiety
and depression. For a long time, both were encompassed by the broad concept of melan-
cholia. Since the Corpus Hippocraticum (5th-century b.c.), fear and despondency have
been referred to as the prominent characteristics of melancholia.
The terms melancholia (Greek: melaina cholè, black bile) and hypochondria (Greek:
hypochondrios, under the breastbone) are therefore of ancient vintage. The same applies
to the concept of mania. The word depression (Latin: deprimere, to press down) gradually
came into use during the 18th century [18].
Unlike the term phobia (Greek: phobos, fear), the term anxiety has neither Greek
nor Latin origins. The word anxiety (German: angst, worry) probably derives from the
Indo-Germanic root angh, which means to narrow, to constrict, or to strangulate [19–21].
This root reappears in the Greek word anchein, which means to strangle, to suffocate, or
to press shut. The root angh has also survived in Latin, for example, in angor (suffocation;
feeling of entrapment) and anxietas (shrink back fearfully; being overly concerned). Fear
derives from the German stem freisa or frasa. The term panic, on the other hand, has a
Greek background, namely, Pan or Panikos, the Greek god of the forest and of shepherds,
who was thought to have caused panic amongst the Persians at Marathon.
The boundaries of the different terms are rather vague. This is particularly true of
the term melancholia, which covers practically all forms of nonorganically determined
psychopathology. In summary, however, it can be stated that despondency is a central
element in numerous terms for depression, whereas in terms referring to anxiety the em-
phasis is often on sensations of tightness and constriction in the region of the chest and
throat.

III. A HISTORY OF THE CONCEPTS OF ANXIETY AND DEPRESSION

BASED UPON THE CONCEPT OF MELANCHOLIA
A. Ancient Greece and Rome
Western psychiatry, just like somatic medicine, has its roots in Greek natural philosophy.
In this philosophy, the traditional explanations of mental illness, based upon the supernatu-
ral, gradually diminish in significance. Clinical observation and reasoning become estab-
lished practice. Natural philosophers attempt to elucidate the universal principle behind
observed phenomena. They observe heaven and earth, the orbits of heavenly bodies, and
the course of the seasons, as well as the cycle of ascension, splendor, and decline in the
living and the nonliving worlds. They are dissatisfied with demonological explanations
of mental illness, such as those found in the works of Homer, for example.
This does not mean that moments of speculation become a thing of the past (let us
consider, for example, the Corpus Hippocraticum). This work consists of a series of 70
medical texts dating from the 5th century B.C., which are attributed to Hippocrates and
his pupils. The Corpus contains the earliest formulation of the theory of the four humors
or bodily fluids. This humoral theory was a modified version of the view first encountered
in the works of Empedocles that the universe is made up of a mixture of four elements:
earth, fire, air, and water. Empedocles himself was probably influenced by the Pythagorean
school’s doctrine of the “harmony of the spheres,” which placed strong emphasis on no-
tions such as tuning and equilibrium. According to the humoral theory, disease results
from a disturbance in the natural balance (dyscrasia) of the elements.
4 Glas

Blood, yellow bile, black bile, and phlegm are the four bodily fluids or humors
distinguished in the Hippocratic texts. These fluids were considered to be influenced by
the seasons. Accordingly, blood would increase in the spring, yellow bile in the summer,
black bile in the fall, and phlegm in the winter. In addition, each of the humors was
associated with a pair of primary qualities. Thus blood was associated with heat and wet-
ness, yellow bile with heat and dryness, black bile with dryness and cold, and phlegm
with cold and wetness (see Fig. 1).
To the Greek physician, disease was caused by a disturbance in the natural balance
of the bodily fluids. This balance was influenced by all sorts of factors, such as seasonal
changes, climate, geographical conditions, age, mental effort, as well as eating and drink-
ing habits. The Greeks were well aware, for example, of the link between depressive
phenomenon and the fall. In addition to these factors, certain people were temperamentally
predisposed to melancholia. The term temperament refers to a personal’s humoral constitu-
tion. Due to an excess of black bile, or to an increased susceptibility of the black bile to
heat or cold, some people could have a natural tendency toward melancholia.
This suggests that the balance between the humors reflects a much broader biopsy-
chological and ecological equilibrium. This is indeed the case. The ancient concept of
disease must be seen against the background of the then popular idea of a fundamental
likeliness of macrocosm and microcosm. Universe at large is a well-ordered macrocosm.
Its changes are reflected at the level of microcosm—the individual body, for instance.
This theme was to dominate the concept of disease for at least two millennia. It left no
room for the principle of linear (unidirectional) causality, which began to dominate medi-
cine in the middle of the 18th century, nor can it be equated with the late 19th-century
concept of homeostasis, since this concept presupposes the idea of internal feedback, a
notion that is quite foreign to the ancient Greeks. In antiquity, disease was seen as a
disorder reflected on all levels of existence, rather than as the consequence of an internal
disorder. The excess of black bile in melancholia was the analogue of changes in the
seasons, in dietary habits, and in psychological constitution [22,23]. The origins and con-
clusion of disease were not confined to the relative isolation of the body. Instead, disease
reflected changes on various levels within the macrocosm.

Figure 1 The four humors and their relation to the seasons, the elements, and the primary
qualities.
History of Anxiety and Depression 5

The first-century reader may suspect that there are conceptual problems here; how-
ever, none seemed to exist for the Greek physician-philosopher, who seemed quite uninter-
ested in the question of how all these different processes interacted with one another, and
chose instead to ignore the problem. Some have suggested, for example, that the Greek
outlook could not accommodate a psychogenic cause of mental illness. This is factually
incorrect, since the literature of that time includes many examples of scholars becoming
depressed through excessive study, and of melancholics consumed by feelings of guilt,
hatred, or grief over a lost love. In addition, there is also a conceptual misunderstanding
here, such as occurs whenever modern ways of thinking begin to dominate the interpreta-
tion of humoral pathology. The humors are then reduced to purely biological phenomena
(comparable to neurotransmitters) and the lovelorn state, or that of being overworked, to
mere matters of psychology. Greek physicians undeniably thought of the melainè cholè
as a substance that was both visible and tangible, even though they had never actually
seen it. Nevertheless, they persisted in associating this unseen substance with all kinds of
effects at the psychological and behavioral levels. From a first-century point of view, this
association could be seen as a metaphor. To the Greek physician, however, the notion of
atrabiliousness (black bitterness) was a condensation of all sorts of very real experiences
and perceptions. In short, even though the emphasis lay on what is now referred to as the
biological component, the psychological connotation still was implied by the terms for
the bodily fluids.1 According to Aretaeus, bile means anger and black, much or furious:
. . . in certain of these cases, there is neither flatulence nor black bile, but mere anger and
grief, and sad dejection of mind; and these were called melancholics, because the terms bile
and anger are synonymous in import, and likewise black with much and furious (Aretaeus;
via Jackson [24]).
For all that, black bile was the last substance to be ranked amongst the true bodily fluids.
Initially interpreted as a breakdown product of yellow bile, black bile was first described
as a natural constituent of the body in the Corpus Hippocraticum. Its change in status can
probably be attributed to the dark-colored urine and feces observed in malaria sufferers
and in patients with hepatic disease or gastric bleeding.
However, more than five centuries were to pass between this reference to black bile
in the Hippocratic texts and the first summarized description of its effects. This summary,
which can be found in the medical works of Galen (131–201 a.d.), was to serve as a
model for medical thinking for centuries to come.
Galen owed a great deal to the work of Rufus of Ephesus (circa 100 a.d.), who we
must thank for a description of various melancholic delusions, amongst other things. One
such delusion was that of being an earthen pot, another was that of lacking a head. Rufus
also influenced Arabic medicine and, through it, the medicine of the Middle Ages. It was
Rufus from whom the great Ishaq ibn Imran, of 10th-century Baghdad, reputedly derived
his ideas about melancholia. The latter’s work was to become the direct source for De
Melancholia by Constantinus Africanus (11th century), a text that enjoyed great authority
during the Middle Ages and the Renaissance [25]. The distinction between the three forms
of melancholia, which he may have derived from Rufus, was considered by Galen to be
of particular significance. He distinguished the following forms:
1. A generalized form of melancholia, with the blood being full of black bile
2. A cerebral form of melancholia, which only affected the brain
3. An hypochondrical form of melancholia involving the organs of the upper abdo-
men [26–28]
6 Glas

The first form, unlike the second, could be accompanied by other phenomena (e.g., discol-
oration of the skin, cirrhosis of the liver, and the accumulation of fluid). The mental mani-
festations of both the generalized and the cerebral forms were due to obstructed blood
vessels in the brain, as a result of a thickening of the blood. Galen suspected that this
obstruction led to a blockage of the channels through which the so-called pneuma animalis
flowed. This pneuma was an etherlike substance, made up of small, lightweight, highly
animated particles. From ancient times until well into the 17th century, it has been associ-
ated with all kinds of mental functions, including perception and imagination. In other
cases, according to Galen, black bile caused cerebral tissue damage, leading to the impair-
ment of intellectual functions in particular. In the third form of melancholia, disease symp-
toms were not interpreted as resulting from black bile as such. Instead they were caused
by a vapor emanating from this fluid, as a result of local warming in the hypochondrium.
This smoky vapor, according to Galen, rose up into the brain, obscuring thought. It was
this mental obscuration that explained the anxiety seen in melancholics. Galen compared
it to the darkness of night, which induces a causeless fear in many people:

As external darkness renders almost all persons fearful, with the exception of a few naturally
audacious ones or those who were specially trained, thus the color of the black bile induces
fear when its darkness throws a shadow over the area of thought [in the brain] [29].

Apart from generating this vapor, such local warming also converted one of the other
bodily fluids to black bile, thereby producing an excess. Under circumstances such as this,
melancholia would be characterized by heat rather than coldness. According to some later
writers of the Galenic school, this explained motor restlessness and behavioral disorders,
an interpretation with which Burton concurred in 1621.
In terms of treatment, it was the distinction between the three forms of melancholia
that became of primary importance. Phlebotomy, the preeminent therapy for the general-
ized form, was ineffective in the treatment of the other two forms of melancholia, which
required alternative measures. Mention is made of changes in eating and drinking habits,
the use of emetics and laxatives, and attaining a correct balance between rest and physical
exercise.
Galen was aware that, while the manifestations of anxiety and depression are tremen-
dously varied, the heart of melancholia consists of despondency and anxiety, especially
the fear of death:

Although each melancholic patient acts quite differently than the others, all of them exhibit
fear or despondency. They find fault with life and people; but not all want to die. For some
the fear of death is of principal concern during melancholy. Others again will appear to you
quite bizarre because they dread death and desire to die at the same time.
Therefore, it seems correct that Hippocrates classified all their symptoms into two
groups: fear and despondency. Because of this despondency patients hate everyone whom
they see, are constantly sullen and appear terrified, like children or uneducated adults in deep-
est darkness [30].

The link between melancholia and mania had already been established by Aretaeus of
Cappadocia, who lived around 150 a.d. [31]. However, in the work of Galen, this link is
conspicuous by its very absence. In the Hippocratic texts, the term mania was frequently
used when referring to mental illness in general, even though the link with the action of
black bile had already been established. In the centuries that followed, mania and melan-
cholia gradually became delineated as disorders having a certain periodicity, but with
History of Anxiety and Depression 7

contrasting outward expressions. Nevertheless, we must exercise caution, and not be over
hasty in identifying these ailments with the present-day, bipolar disorder. The term melan-
cholia still has very wide connotations, incorporating many different forms of psychosis
and all kinds of neurotic symptoms. Mania, on the other hand, specifically refers to the
various forms of emotional restlessness and motor excitation.
In fact, mania and melancholia together encompass virtually the entire field of pro-
longed psychopathology, that is, chronic diseases not associated with fever. The third form
of mental illness, phrenitis, is both acute and associated with fever. The obvious compari-
son here is with delirious visions and acute psychoses. Epilepsy had a place all its own.
Viewed by the Greco-Roman world as a “sacred disease,” it includes forms that are transi-
tional between classic epilepsy and melancholia.

B. The Middle Ages

During the Middle Ages, ideas about anxiety and depression actually changed very little.
Scholars continued to build upon the foundations created by the Hippocratic–Galenic
school. For many centuries, Alexandria, with its enormous library, was the center of re-
search and contemplation. One area of Byzantine medicine, as it is known, is particularly
worthy of mention, particularly with respect to the work of compilers such as Oribasius
of Pergamon (325–403), Alexander of Tralles (525–605) and Paul of Aegina (625–690).
These scholars classified existing ideas from many different sources, without adding any
significant contributions of their own.
At about the same time, the work of the Greek authors began to be translated into
the Semitic languages by Christians who had fled the Byzantine Empire, as well as by
Arab authors. In this way Arabic medicine came to assimilate its Byzantine inheritance,
in addition to influences from India and even China. By the end of the first millennium,
writers from the Eastern Caliphate (Baghdad), such as Rhazes (865–923) and Avicenna
(980–1037), had produced medical treatises of their own. Avicenna’s Canon of Medicine,
in particular, was to dominate medical ideas for centuries to come. From Persia came
another significant figure, Ishaq ibn Imran (early 10th century), who has been referred to
previously. His work on melancholia inspired the great and influential treatises on the
subject by the encyclopedist Constantinus Africanus (1020?–1087). Originally from North
Africa, Constantinus subsequently lived in Salerno and later moved to Monte Cassano.
His work reflects that of Ishaq, in that he also devoted an extraordinary amount of consider-
ation to psychogenic causes of melancholia. Later on, famous scholars from the Western
Caliphate (Spain), such as Averroes (1126–1198) and Maimonides (1135–1204), also
exerted an influence on medicine. In the late Middle Ages, however, authors dealing with
melancholia mainly referred to the works of Avicenna and Constantinus [32]. In the late
Middle Ages, medical knowledge was mainly concentrated in monasteries and in cathedral
schools. Moreover, various university medical schools were founded, the best known of
these being Montpellier, Bologna, and Padua. In addition to continued classification,
some scholars now began to apply morality to humoral pathology [33]. This led to melan-
cholics being described by some as degenerate, along with phlegmatics and cholerics.
Sanguinics, on the other hand, were considered to represent man, as God had intended
him to be, at the Creation. Melancholia was also associated with acedia, a type of list-
lessness and restless boredom, accompanied by a longing for change of environment. As
long ago as the 4th century, Cassianus described this condition in the monks of desert
monasteries not far from Alexandria. The afternoon demon would appear around the sixth
8 Glas

hour. It bred in the monks a loathing for their own cells, a disdain of the other brothers,
and a slothful unwillingness to take part in the routine activities of monastic life. Acedia,
in the guise of Sloth, was to become one of the Seven Deadly Sins of the Middle Ages
[34,35]. One particular development in the continuing systematization of humoral pathol-
ogy was an accentuation of the difference between two forms of melancholia. In additon
to melancholia as a result of an excess of natural black bile, a second form was discerned,
caused by an excess of unnatural black bile. Unnatural black bile was thought to be pro-
duced by the combustion, or degeneration, of one of the four bodily fluids.
In cases of an excess of natural black bile, the characteristics of the melancholic
temperament became more prominent. In such patients, mediation gave way to brooding.
Their previously sincere and caring attitude toward life plunged into one of anxiety and
gloom. Those afflicted would stare at a single point, be incommunicative, and avoid all
contact. Beek, whose Waanzin in de Middeleeuwen (Madness in the Middle Ages) is,
unfortunately, not available in an English translation, summarizes the writings of many
authors as follows:
An excess of melancholic humor, which is thick and sediment-like, imparts a red color to
the head. The patient also experiences a feeling of heavy-headedness. He tastes a bitter-sweet
taste, the sediment of the humor. The pulse is weak and the veins full. The urine is thick and
red-colored [36,37].
Although the combustion or degeneration of black bile presents a broadly similar picture,
there is the added element of preoccupation with death:
They become agitated about funerals. Believing that they are about to die, they lie on graves
and collect the bones of the dead. The pulse is hard and tense, the urine is lead-colored and
thin [38].

The picture that developed as a result of burned yellow bile was one of mania. Patients
ranted, raved, and screamed all day long. Referring, once again, to Beek:
They lie awake. They exhibit excessive movement, jumping and running around. They are
reckless and quarrelsome, wanting to beat those around them, preferably with an iron bar.
In the grip of the mania, they throw themselves through windows. The choleric temperament
is characterized by a lack of inhibition, wild behavior, recklessness, constant motion and rage.
Such patients have a lemon-colored complexion, their urine is thin and yellowish, the pulse
hard and rapid. It is thought that sufferers do not feel the cold because the combustion of
the bile keeps them warm [39].

Conversely, the combustion of blood produces feelings of happiness rather than of sadness:
They talk and laugh the whole time, wanting to dance and make merry all whole day long.
Their temperament type is one of happiness, laughter and loquacity. Their urine is thick and
reddish brown [40].

Degeneration of phlegm, on the other hand:

. . . induces apathy, inertia and absent-mindedness. Feeling heavy-headed, these patients nei-
ther move nor laugh, nor do they feel joy. In people with this type of temperament, inertia,
drowsiness and forgetfulness come to the fore. Characterized by a moist mouth and nostrils,
and a pale white complexion, they are referred to as lymphatics. Believing themselves to be
fish, they ask for water all day long and pine for river, or the sea. Their pulse is small and
weak, their urine pale, whitish and of medium thickness [41].
History of Anxiety and Depression 9

In tracing the origins of melancholia, factors other than the humors (combusted or other-
wise) must be taken into consideration. These were the complexio (the temperament and
primary qualities) of the brain and the condition of the rest of the body. A brain that is
overly dry, or excessively cold, has an increased susceptibility to disease. A weak heart
lowers the threshold against developing melancholia. Particular and frequent mention is
made of the relationship between heart and head. Heart palpitations, for example, are the
expression of an affection of the heart. Obviously, there is a relationship between the
malfunctioning of this organ and a person’s state of mind. After all, did not the spiritus
vitalis ascend from the heart to the brain, where it influenced the spiritus animalis?
In medieval medicine, the nature of these influences was connected to the localiza-
tion of functions in the different ventricles. The anterior (or lateral) ventricles were associ-
ated with imagination (imaginatio), the median (or third) ventricle with reasoning (ratio),
and the posterior (or fourth) ventricle with memory (memoria). Melancholia was usually
linked with a disorder of the middle ventricle. Conditions that involve hallucinations and
delusions, such as mania and psychotic depression, were based upon disturbances to the
equilibrium of the anterior ventricles.
Classification was extended to include therapeutic procedures. Polypharmacy had
been popular even in ancient times, with leading roles being played by black hellebore
and extracts of mandragora. In addition, regulation of the so-called non-naturalia (external
or environmental factors) remained an important part of the therapeutic arsenal. Tradition-
ally, six such factors were identified. These were:

Air: The patient should be kept in a warm, moist environment, the door of his house
should preferably face east.
Rest and exercise: The aim should be to reduce sensory excitation and to achieve
relaxation. The patient should preferably be nursed in a dark room. The walls
should be bare of pictures, since these might overstimulate his imagination. A
not overly arduous walk, when the time is ripe, is beneficial for the maintenance
of body temperature, as are massages and hot baths. An excess of body heat,
however, dries out the body and causes melancholia.
Waking and sleeping: The patient should sleep neither too little nor too much.
Food and drink: This sickness can result both from overeating and from excessive
fasting (as seen in the ascetics). Food must be easily digestible. Vegetables such
as lentils and beans give rise to flatulence and therefore cause melancholia. Pep-
pery spices, garlic, leeks, and onions must be avoided since they can burn the
humors. The same applies to both mature and salted meat, the meat of forest
animals, mature cheese, vinegar, and fish. A heavy wine, rich in sediment, causes
sickness, whereas a light, young wine can actually raise the spirits.
Retention and excretion: Melancholia can result from the accumulation of those
bodily fluids which are normally discharged, such as menstrual blood, sperm, or
hemorrhoidal blood. The same is true of feces. Evacuation sometimes requires
mechanical assistance, for example, in constipation, the nonappearance of men-
struation, or the nonbleeding of hemorrhoids. Coitus is generally to be recom-
mended, although men with low potency should avoid overindulgence. Bathing,
whether in a herbal bath or just with plain water, is an important therapeutic agent
that can also facilitate evacuation. However, excessively hot baths can induce
madness.
10 Glas

Passions of the soul: Excessive fear, hatred, and grief should be avoided. The same
applies to excessive study and to intense preoccupation with a particular task.
Nevertheless, anxious and inhibited melancholics can actually be cured by either
a fierce rage or a sudden shock. Generally speaking, however, these passions
should be kept under control. Discussion and philosophical reading can both be
useful in calming the patient.2

C. Intermezzo: Melancholia as a Characteristic of Genius

We have placed great emphasis on the continuity of the medical debates regarding melan-
cholia. This continuous dialogue spans the centuries, from ancient times until the Middle
Ages and, as we shall see, even beyond. There are, in all, three closely related concepts:
1. Natural black bile.
2. The disorder of melancholia, based on either an excess of natural black bile or
the combustion of one of the four body humors (melancholia adusta)
3. A chronic predominance of natural black bile in people with a melancholic-
type temperament.
In spite of the allegorizing and moralizing interpretations, the concept of melancholia
retained its link with humoral pathology. This doctrine, however, was not entirely undis-
puted in ancient times. The empirical school, for example, considered the theory of bodily
fluids to be too speculative. There was also the methodist school, which sought refuge in
a much simpler classification of disease (involving the status strictus versus status laxus
or, in other words, the respective contraction and relaxation of the so-called internal pores).
We also found that, with regard to the temperaments, there was some doubt about the
normalcy of the character variations (cf. Note 1).
There is another line that, in terms of the theme of this review, is even more impor-
tant. This proceeds from Plato and Aristotle, via the Florentine School of the Middle Ages
(Marsilio Ficino) and Robert Burton [42] in the Renaissance, to William James [43] in
the present. It is a line of thought that regards the melancholic as exhibiting certain traits of
genius. There is the famous opening line from the thirtieth book of Aristotle’s Problemata:
Why is it that all those who have become eminent in philosophy or politics or poetry or the
arts are so clearly of an atrabilious temperament, and some of them to such an extent as to
be affected by diseases caused by black bile, as is said to have happened to Heracles among
the heroes? [44]

Aristotle seeks a natural explanation for this “madness which comes from the gods.” This
is in contrast with Plato’s Phaedrus [45], which offers a mythological description.3 Aris-
totle suggests that the eminence of the poets, politicians, and philosophers in question
could be ascribed to an optimum warmth of the black bile. Black bile, by its very nature,
was thought to be sensitive to changes of temperature. When cooled, it brought about
“apoplexy or torpor or despondency or fear.” Heating induced “cheerfulness accompanied
by song and frenzy and the breaking forth of sores and the like” [46]. In the case of a
man of genius, black bile, which is as such a pathogenic fluid, is in an optimum state.
Such a person represents the normal within the abnormal or, in the words of Klibansky,
Panofsky, and Saxl, an “eucrasia within an anomaly” [47].
During the Renaissance, a time of revived interest in astrology, this association
History of Anxiety and Depression 11

between melancholia and genius acquired a special meaning. In antiquity, the planet Saturn
had been associated with Kronos, the son of Uranus (the god of Heaven) and Gaia (the
Earth goddess), who had been banished to the underworld after the castration of his father.
Now, Saturn gradually turned into a symbol of the ambivalence of intellectual and artistic
life. According to ancient astrology, Saturn was the planet of gloom, desolation, decline,
and old age. However, the Neo-Platonists claimed that Saturn, as the highest planet, was
the planet of the elevated, of ecstatic release from early things and happenings [48]. Mar-
silio Ficino (1433–1499), Neo-Platonist of the Florentine school as well as a priest and
physician, depicted Saturn at the heavenly body whose rays influenced the vital spirits of
the brain (spiritus animalis), which were thought to connect the physical to the spiritual.
This influence was described as a kind of saturation process, one to which those born
under the sign of Saturn were especially sensitive. Although enjoying intellectual powers
and creative talents far exceeding those of others, there was a tragic element to these
people. They spent their lives teetering on the very brink of catastrophe and they were
especially susceptible to melancholia. Black bile was identified with the earth, including
the very center of the planet itself, which meant that such people tended to have a deeply
penetrating understanding of existence. The association with Saturn, the highest of the
planets, meant that they aspired to higher planes of thought [49]. The novel element here
is the heightening of self-consciousness, the awareness of man’s vulnerability to catastro-
phe and decline. Their view of life took on a nostalgic and tragic tint. This outlook was
to recur in a variety of different forms in later periods, as, for example, in the Elizabethan
literature of the 16th and 17th centuries (Elizabethan Malady) [50].

D. The Renaissance, 17th, and 18th Centuries

The Renaissance was not only an age of heightened self-awareness and the era of Homo
literatus, with his knowledge of the classics, it was also the time of alchemy. This lent
impetus to the interpretation of disease in terms of chemical change, an approach that
texts on the history of medicine refer to as iatrochemistry. Substances such as salt, sulfur,
and silver became the focus of attention. Paracelsus (1493–1541) was one of the first to
apply the newly gathered knowledge to medicine in an attempt to break down the hegem-
ony of humoral pathology. He did not, however, renounce the doctrine of the temperaments
and the elements. Melancholia now became associated with the qualities of the chemical
elements, which are sharp and acidic. Thomas Willis (1621–1675), renowned for Two
Discourses Concerning the Soul of Brutes, expounded the theory that, in melancholia, the
blood became “salino-sulphureous,” causing the spiritus animalis to adopt a different pat-
tern of motion [51].
The high point of 17th century medical literature on melancholia, however, was
Robert Burton’s The Anatomy of Melancholy, published in 1621 [52]. This work, which
may seem somewhat bizarre to the modern reader, offered a compilation of all contempo-
rary knowledge on the subject of melancholia. Greatly indebted to ancient medicine and
philosophy, Burton punctuated his arguments with references from ancient times. He sub-
scribed to the dichotomy of the passions (derived from Thomas Aquinas), a doctrine that
was generally accepted at the time. Here, the passions that predisposed one toward desire
(passiones concupiscibiles) were distinguished from those which predisposed one toward
rage (passiones irascibiles). “Sorrow” and “fear,” emotions (perturbationes) belonging to
the latter category, were described by Burton as being directed at the evil that crossed
12 Glas

one’s path. Sorrow was related to disaster in the present, fear to disaster in the future.
Burton considered sorrow to be a major cause of melancholia, as well as one of its manifes-
tations. It was:
. . . an inseparable companion, the mother and daughter of melancholy, her epitome, symptom,
and chief cause [53].

The same was true of fear, the emotion most able to hold the imagination in thrall [54].
The imagination was:
. . . medium deferens of the passions, by whose means they work and produce many times
prodigious effects [55].

Burton went on to add, however, that the converse was also true, since imagination serves
to enhance the impact of emotions.
In discussing the symptoms of melancholia, Burton considered fear and sorrow to
be two of a whole list of phenomena affecting those suffering from this condition. How-
ever, although these emotions were relatively nonspecific, this did not mean that they
were unimportant. Burton was acquainted with many of the forms of anxiety known today.
He made reference to fear of death, fear of losing those who are most important to us,
and paranoid anxiety. He also cited anxiety based on ideas and delusions of reference,
fear associated with depersonalization, delusional depersonalization, and hypochondria.
Other forms that are mentioned include agoraphobia (!) and many other kinds of specific
phobias, such as fear of public speaking, fear of heights, claustrophobia, anticipatory fear,
and hyperventilation [56]. The physiology of emotions was strongly emphasized in René
Descartes’ Les Passions de l’Âme (The Passions of the Soul), which was published about
a quarter of a century later [57–59]. This emphasis on physiology had a distinctly mecha-
nistic flavor in keeping with the contemporary trend toward a general mechanization of
the world view—a trend in medicine that really only took off in the 18th century and is
known as iatromechanics [60]. According to Descartes, passions not only prepare the body
but also predispose the soul to desire that for which the body is being prepared. The
physical manifestations of emotion therefore provide some degree of insight into the func-
tion of emotions.
Fear and anxiety did not rank highly amongst the passions [61]. Descartes considered
the emotion of fear to be quite useless. Nevertheless, his descriptions of the processes
that give rise to fear are worthy of mention, since they are representative of the 17th- and
18th-century mechanistic view of disease. According to Descartes, the sight of a dangerous
animal caused certain particles (the “esprits animaux” or spiritus animalis referred to previ-
ously) to be released by the pineal gland. Although invisible, these rapidly moving parti-
cles were quite material in nature. They traversed the neural pathways to reach the heart,
the leg muscles, and the circulatory system, and gave rise to the physiological component
of the fight-or-flight response. The altered distribution of blood then caused a rush of these
esprits animaux (animal spirits) to the brain. Here, the pores associated with fear were
opened, directing the esprits onward, back toward the periphery. Mental influences were
not, therefore, presumed to be involved in the generation of fear. Instead, fear was seen
as a complex, but purely physiological, reflex.
Although emotional perception was secondary, consisting of the registration of pi-
neal gland movements, Descartes believed that such registration had a purpose, namely
evaluation. It facilitated the perception of objects in terms of their effects upon us, whether
beneficial or otherwise.4 Properly employed, passions predispose the soul to desire those
History of Anxiety and Depression 13

things which are naturally good for us. In this resigned adaptation to the eternal laws of
nature, one can detect the after-effects of the Stoa—after-effects that extend to the implicit
morality of certain modern-day forms of psychotherapy aiming at tolerance and cognitive
apprehension of the symptoms of anxiety and/or depression.
Descartes’ emphasis on mechanics was not accepted by the medical world until the
closing years of the 17th century. It enjoyed a brief flowering in the period around 1750
before giving way to other interpretations. Those associated with iatromechanics, as it
was called, included men such as Pitcairn, Hoffmann, and Boerhaave (whose work reveals
traces of a humoral pathology, interpreted from the point of view of fluid dynamics).
Boerhaave and Pitcairn favored a vasocentric approach seeking the origins of melancholia
in the modified flow patterns and viscosity changes of liquids in the blood channels. Hoff-
mann was one of the first to consider a neurocentric approach. He considered nerves to
be hollow tubes containing a flowing liquid. Under normal circumstances, this neural
fluid was thin and volatile; however, if it thickened to an earthy, slimy consistency, then
melancholia developed.
Under the influence of Isaac Newton, men such as Mead and Cullen (who was the
first to use the term neurosis) speculated that this neural fluid might also have electrical
properties. Cullen and others thought of this neural fluid as a tenuous, highly mobile
substance that was related to ether. This etherlike substance did not actually flow, but
transmitted motion to the various parts of the body by means of vibration. This caused
the fluid hydraulics model of mental illness to be discarded. At the time, there was only
a vague notion of electrical phenomena. These were linked to the vitalistic interpretation
of disease, the central concepts of which were tone and irritability. Cullen considered the
irritability of the nervous system to be responsible for tissue tone [62].
Meanwhile, the clinical description of melancholia remained virtually unchanged.
Some still cited the Galenic trio of generalized, cerebral, and hypochondriacal melancho-
lia. However, there were those (Boerhaave, for example) who interpreted this classical
triad merely as stages on a continuous scale of severity. Some authors were inclined to
uncouple hypochondria from melancholia (of which it was the least serious form) and
link it instead with hysteria. According to Sydenham and Lorry, for example, hysteria in
women was equivalent to hypochondria in men.
The 18th century was a time bursting with tensions and contrasts, shifts and changes.
Humoralism gave way to solidism (the explanation of disease based on the properties of
the organs and tissues). Iatrochemistry gave way to iatromechanics, which in turn was
replaced by concepts such as tone and irritability. Vasocentric views were replaced by
neurocentric views. Meanwhile, vitalistic views of disease blended with speculation on
the electrical properties of neural fluids. Each of these various approaches was considered
to be compatible, incompatible, or related to one another. The rational framework of the
early 18th century clearly offered medicine of that time the requisite intellectual freedom
with which to forge its principal concepts.
Toward the end of the century, this all began to change. Pathological anatomy had
expanded enormously, and greater emphasis was being given to clinical observation and
description. It was a time of sensualism and fascination with sensory perception. Notions
such as irritability bear witness to a preoccupation with the hypersensitivity of the nervous
system and of the senses. The end of the 18th century saw the final demise of humoralism.
During the same period, the notion that melancholia originated in the blood, or in the
functions of the liver or spleen, was also dismissed. The central nervous system replaced
blood and abdominal organs. Today, the idea of temperament is all that remains of hu-
14 Glas

moralism. Although it has no place in the scientific view of character and personality, it
still exists as a metaphorical expression for the experience of despondent people.

E. The 19th Century: Further Disintegration of the Concept

of Melancholia
The concept of partial insanity was popular in the nasographical schemes of the 18th
century and the first decades of the 19th century [63]. As has been noted, medical scholars
of the late 18th century were fascinated with the sensitivity and irritability of the nervous
system. This, together with the fast-growing influence of faculty psychology (which
sharply distinguished between intellect, will, and imagination), may have contributed to
the popularity of the concept of partial insanity. This was not particularly novel, it was
more the emphasis of an element of meaning found in descriptions of melancholia dating
from ancient times (e.g., those of Aretaeus and Galen). For centuries it had been observed
that the thoughts and ideas of the melancholic were confined to a single theme, often to
the extent that they became delusional. Melancholia was traditionally considered to be a
delirium without fever, accompanied by fear, despondency, and additional phenomena
such as restlessness, insomnia, weariness, and discomfort in many parts of the body. In
addition, however, frequent reference was made to the monothematic content of the melan-
cholia sufferer’s ideas and thoughts [64].
Late 18th-century medicine had a neurocentric orientation, one which tended to
focus upon sensitivity and cognitive capabilities. Perhaps this may have influenced the
classification of mental illness into disorders in which the powers of judgment were com-
pletely incapacitated, and those in which they were partially impaired (partial insanity).
Melancholia was considered to fall within the latter category, a view that can be found,
for example, in the Traité Médico-Philosophique sur l’Aliénation Mentale (Medical-Philo-
sophical Treatise on Mental Disorder) by Philippe Pinel (1745–1826) [65]. Pinel also
considered mania to belong to this “melancholia with delirium.”
This (temporary) identification of melancholia with partial insanity completed the
decline of a concept that for centuries had dominated the description of mental illness.
Melancholia was divided up and its various parts were classified under other disorders.
A number of things contributed to this redistribution, such as resistance to humoral pathol-
ogy, and its terminology; more detailed observation (as a side effect of growing institution-
alization); and rationally inspired expectations regarding psychology’s ability to influence
mental illness [66].
The first line of demarcation was the idea of partial insanity itself. Some melanchol-
ics exhibit no signs of insanity (delirium) whatsoever; thus none of their thoughts and
ideas would be regarded as psychotic in the modern sense. In the Manual of Psychological
Medicine, which he wrote in collaboration with Bucknill, D. Hack Tuke (1827–1895)
distinguished between simple melancholia, in which the intellectual powers were intact,
and complicated melancholia, in which they were not. The distinction applied by Henry
Maudsley (1835–1918) was essentially the same as Tuke’s, if somewhat wider in scope.
In addition to melancholia simplex (cf. Bucknill and Tuke’s simple melancholia), he dis-
tinguished not one, but two, forms of melancholia, both falling within the category of
ideational insanity. These were melancholia as a form of general insanity and melancholia
as a form of partial insanity. In the first case, intellectual derangement is complete, whereas
in the latter case it is only partial. There was also a parallel distinction in mania. However,
Maudsley went to great pains to emphasize the provisional nature of this theory [67].
History of Anxiety and Depression 15

Similarly, in France the significance of the term melancholia declined considerably

under the influence of a nomenclature introduced in 1838 by Jean-Etienne-Dominique
Esquirol (1772–1840) in Des Maladies Mentales [68]. Since ancient times, the meaning
of the term melancholia had encompassed both dejection and exultation. Finding this an
unsatisfactory state of affairs, Esquirol substituted the term monomania for melancholia.
Monomania, which became an equivalent of the term partial insanity, was subdivided as
follows:

1. monomania, properly so-called, which is indicated by a partial delirium and a gay or excit-
ing passion; this condition corresponded to maniacal melancholy, maniacal fury, or (. . .)
melancholia complicated with mania; in fine . . . (to) amenomania; and 2. monomania
coresponding to melancholy of the ancients, the tristimania of Rush and the delirium with
melancholy of Pinel [69].

Esquirol borrowed the terms amenomenia and tristimania from the work of Benjamin
Rush (1745–1813), the father of North American psychiatry. It was Rush who had linked
tristimania with hypochondria, alluding to the ancient hypochondriacal form of melancho-
lia rather than to the diluted, 18th-century meaning of the term. Confusingly, besides
employing monomania in the broad sense mentioned above, Esquirol also used the term
to denote the manialike form of partial delirium. In this way, monomania became the
equivalent of the first form of monomania, the partial delirium with the “gay or exciting
passion.” The second, melancholic form of monomania was denoted by the term lypema-
nia. In addition, Esquirol distinguished mania as a generalized insanity associated with
excitement and exultation. He occasionally tended to describe lypemania, monomania (in
the strict sense of the word), and mania as having progressive degrees of severity, the
greatest derangement occurring in mania and the least in lypemania.
Even in ancient times it was frequently pointed out that melancholia and mania
could occur in parallel, in sequence and in combination. However, it was not until 1854
that cyclical mood swings were specifically identified as the distinguishing criterion of a
subcategory of manic and depressive patients. In the same year, Jules Baillarger (1809–
1890) described la folie à double forme (the insanity with two forms), 10 days later fol-
lowed by a commentary of Jean-Pierre Falret (1794–1870), in which he also discussed a
folie circulaire (circular insanity). Some 40 years later, Kraepelin explicitly harked back
to the work of these two French clinicians when he distinguished dementia praecox from
manic-depressive psychosis. Nonetheless, even by the middle of the 19th century, the
terminological distinction between affective and schizophrenic psychopathology was by
no means a fait accompli. Accordingly, Richard von Kraft-Ebing (1840–1902) declared
that there were two forms of melancholia, namely simple melancholia and melancholia
with stupor. The latter form, also known as melancholia attonita or melancholia stupida,
was quite different from the partial delirium of French and English psychiatry. It was
related to a condition that, a few decades later, Kahlbaum was to call catatonia, which
could also be associated with reduced consciousness. With regard to simple melancholia,
von Kraft-Ebing distinguished between a mild form of melancholia that was not associated
with delusions, melancholia associated with precordial pain, and melancholia associated
with delusions and hallucinations. He placed strong emphasis on psychomotor inhibition
in all forms of melancholia, stating that in cases of melancholia attonita, this usually had
an organic cause, such as a blockage in the motor neuron pathways. Such inhibition could,
however, also be psychogenically induced. In practical terms, there were all kinds of
transitional states between the two major forms of melancholia. The difference between
16 Glas

these states lay in the relative degree to which mental and organic components were in-
volved in the origin of the inhibition.
This shows that the ups and downs of 19th-century melancholia, as a concept, were
determined by a variety of different factors. In addition to attempts to distinguish new
forms and the pursuit of ever-more precise classification, there were also advocates of
continuity, who searched for transitional forms between the diverse clinical pictures. An
extreme example of this is provided by Wilhelm Griesinger (1817–1868), who strongly
defended the concept of a unitary psychosis (Einheitspsychose) in his Die Pathologie
und Therapie der psychische Krankheiten für Ärtzte und Studierende (The Pathology and
Therapy of Mental Diseases for Physicians and Students). In this work, he cited both his
mentor, Zeller, and the Belgian alienist Guislain. According to Griesinger, the various
clinically defined forms of mental illness could be reduced to the different stages of one
and the same disease. The first of these successive states of mental depression was the
stadium melancholicum—that is, the deterioration of normal emotions such as grief and
jealousy. Next came hypochondria, the mildest form of insanity. This was followed by
melancholia in sensu stricto, which, although not necessarily associated with psychotic
phenomena, had a greater effect on the personality than did hypochondria. Finally, there
was mania, which caused the most pronounced mental derangement of any of the condi-
tions listed here.

F. Emil Kraepelin
The debate about the classification of mood disorders, which continued on into the 20th
century, centered around the question of whether or not this group of disorders could be
subdivided. However, after 1900, the matter of whether mood disorders constituted a sepa-
rate category of mental illness was hardly ever discussed.
This remarkable fact can be largely traced back to the work of one man, Emil
Kraepelin (1856–1926). It has often been pointed out that the term melancholia (along
with related terms such as mania, partial delirium, and monomania) certainly cannot be
identified with what we currently refer to as affective disorder. The clinical pictures were
always those incorporating a variety of phenomena that would currently be regarded as
expressions either of schizophrenia or of a schizophreniform disorder. It is remarkable,
to say the least, that this age-old intermingling of psychotic and affective symptomatology
should have come to an end at the beginning of this century.
In his early years, Kraepelin worked with the neuroanatomist Flechsig. For a lengthy
period, he was also a research worked in Wundt’s psychological laboratory. Kraepelin
cannot simply be portrayed as a materialist, or as a somatologist; his field of interest was
much too comprehensive for that [70]. Nevertheless, the idea that every psychiatric clinical
picture could ultimately be reduced to an organic substratum in the brain was kept alive
by Kraepelin and many of his contemporaries. They were motivated by the discovery of
the cause of dementia paralytica, the confrontation with many cases of alcohol dementia,
and the aftermath of the theory of degeneration, formulated by Morel in the middle of
the 19th century. Kraepelin accordingly established an anatomical laboratory in Heidel-
berg. He also brought in Nissl, a histopathologist, to assist him in the visualization of
the cerebral cortex. Their collaboration eventually bore fruit in the form of photographs
(measuring from 50 to 75 cm) showing general views of the cerebral cortex [71].5
However, it was not these efforts that ultimately contributed to the lasting topicality
of Kraepelin’s work. Possibly influenced by Kahlbaum, Kraepelin became persuaded
History of Anxiety and Depression 17

about the importance of systematic clinical observation and description. This conviction
inspired him to amass a database of all the patients registered in Heidelberg. This database
enabled him to follow the medical histories of his patients, in some cases for several
decades. It formed the basis for the separation of manic-depressive illness (‘das manisch-
depressive Irresein’) from schizophrenia (dementia praecox), which was first described in
the fifth (1896) and sixth (1899) editions of his famous textbook [72]–[74]. Although
there was always a bias toward neuroanatomy and localization, it gradually faded into the
background and made way for a more functional and strictly empirical approach in which
classfication had less to do with diagnosis (i.e., the cause) and more to do with prognosis
[75]. It was the course alone (rather than cause, symptoms, or periodicity) that proved
decisive in demarcating dementia praecox from manic-depressive illness. Dementia prae-
cox led, by definition, to personality decline (Verblödung; dementia), whereas manic-
depressive illness did not.
(. . .) the universal experience is striking, that the attacks of manic-depressive insanity within
the delimitation attempted here never lead to profound dementia (Verblödung, G.G.), not
even when they continue throughout life almost without interruption. Usually all morbid man-
ifestations completely disappear; but where that is exceptionally not the case, only a rather
slight, peculiar psychic weakness develops, which is just as common to the types here taken
together as it is different from dementias in diseases of other kinds [76].

At the onset of the illness, it can be extremely difficult to reach a correct diagnosis. Some
things to go by are age at onset (younger than 20 or beyond middle age) and a confirmed
family history. There is also the premorbid character that, in the case of manic-depressive
illness, is weak, susceptible, dejected, and lacking in self-confidence [77].
Meanwhile, the category of manic-depressive illness was very broad, encompassing
much more than the bipolar disorder, as it is called today:
Manic depressive insanity (. . .) includes on the one hand the whole domain of the so-called
periodic and circular insanity, on the other hand simple mania, the greater part of the morbid
states termed melancholia and also a not inconsiderable number of cases of amentia. Lastly,
we include here certain slight and slightest colorings of mood, some of them periodic, some
of them continuously morbid, which on the one hand are to be regarded as the rudiment of
more severe disorders, on the other hand pass over without sharp boundary into the domain
of personal predisposition. In the course of the years I have become more and more convinced
that all the above mentioned states only represent manifestations of a single morbid pro-
cess [78].

In this definition, the bipolar disorder of our time coincides with “periodic and circular
insanity.” Here, manic derangement is characterized by the triad of rapid association of
ideas, elated mood, and hyperactivity. Depression, on the other hand, is associated with
the triad of dejection or anxious moods, inhibition of thought, and reduced spontaneity.
In addition to the circular and simple disorders, amentia, and milder mood disorders,
Kraepelin also refers to mixed pictures. These cases exhibit characteristics resembling the
mixed episodes of contemporary bipolar disorder. He also refers to the so-called “ground
states” (Grundzustände; predisposing personality traits), which form the basis for the de-
velopment of mood disorders [79]. Kraepelin distinguished four ground states: depressive,
manic, irritable (erregbare), and cyclothymic. Finally, a distinction was made between
this group and the form of melancholia associated with a decline due to the effects of
aging (Rückbildungsalter; involution). In the latter case, inhibition was often absent while
anxiety and hypochondria were more prominent. Although Kraepelin was initially inclined
18 Glas

to keep this (involutional) melancholia separate from the others, he abandoned this idea
after the comprehensive study of this clinical picture by [80]. He subsequently included
this form of melancholia within manic-depressive psychosis (das manisch-depressive
Irresein). The debate about involutional melancholia was not finally settled until the 1970s
when this condition became just another form of depression.
Something that is common to all forms of manic-depressive illness is the absence
of an immediate cause, or at least a course that appears to be independent of possible
causes. A distinction should therefore be made between psychogenic depression and the
conditions referred to above [81]. The most fundamental cause of manic-depressive psy-
chosis is an hereditary, morbid predisposition. According to Kraepelin, of the 990 cases
that he studied in Heidelberg, he managed to establish that about 80% involved an heredi-
tary defect [82].
Despite opposition [83,84], Kraepelin’s interpretations nevertheless enjoyed great
authority in German-speaking regions. For example, this is demonstrated by Eugen
Bleuler’s textbook, which was published in 1916. In describing the manic-depressive ill-
ness as a distinct disorder, this work relies heavily on the questions that Kraepelin had
raised on the subject [85]. The 13th edition of this book, published in 1975, exhibits some
reservations about the heredity hypothesis and about the possibility of an airtight distinc-
tion between dementia praecox, on the one hand, and psychogenic disorders on the other.
Nevertheless, it still contains references to the old Kraepelinian classification [86].

G. Critique on Nosology: Reaction Type Versus Endogeny

The situation was different in the United States where, during the first decade of the 20th
century, Adolf Meyer (1866–1950) expressed doubts about the value of the course crite-
rion. He distinguished several forms of depression, such as constitutional depression, sim-
ple melancholia proper, other forms characterized by neurasthenic malaise or hypochon-
driacal complaints, depressive deliria, catatonic melancholia, and the so-called “delire de
negation,” in which the patient believes he is nothing [87]. This was more than just a
debate about classification. Meyer was particularly uneasy about the coupling of heredity
(endogeny) and manic-depressive psychosis, in the broad, Kraepelinian sense. He viewed
this link as nothing more than “neurologizing tautology,” which might easily give rise to
therapeutic nihilism. Moreover, it did not do justice to the fact that mental illness is an
attempt at adaptation, a reaction to the demands of a changing situation. Only when disease
is seen as an inadequate attempt at recovery, the search for what he called “modifiable
determining factors” could begin. We are then “in a live field, in harmony with our instincts
of action, of prevention, of modification and of an understanding doing justice to a desire
for directness” [88].
The question remains as to whether Meyer did justice to Kraepelin. In any event,
Kraepelin cannot be accused of therapeutic nihilism. Under his direction, the enlarged
baths at Heidelberg achieved international fame and were visited by many foreign guests.
Nothing was too much trouble for him when it came to experimenting with new methods
of treatment. Of greater importance is the conceptual point at issue here. According to
Meyer, the debate on classification should not be short-circuited by an appeal to such
ideas as endogeny and heredity, about which nothing was empirically established. He did
not presume that biological processes should enjoy a privileged position in the list of
determining factors for mental illness. For this reason, Meyer substituted the term manic-
depressive psychosis with the etiologically neutral term “affective reaction type.” Within
History of Anxiety and Depression 19

this reaction type, he distinguished a manic-depressive type, an anxious type, and simple
depressions [89].
Essentially the same view was held by Sir Aubrey Lewis who, in the 1930s, pub-
lished an authoritative study of 61 cases investigated at the Maudsley Hospital in London
[90–92]. According to Lewis, a total reaction of the organism is involved, even in cases
where the illness appears to be entirely without cause. Without doubt, there were

changes in the internal structure of the body, its chemical and vegetative regulation which
play a great part in determining its course. But these are only part of the total reaction of
the organism, and it is by no means in denial of their fundamental importance in the illness
that one refuses them independent and preponderant significance, either aetiological or as
part of the process of the illness [93].

According to Lewis, the more closely patients were studied, the less evidence there was for
a nosological distinction between autonomous (endogenous) and reactive (psychogenic;
situational) depressions. Incidentally, the very same view had already been expressed 8
years earlier by Mapother, Lewis’ predecessor, on the basis of impressions obtained in
clinical practice.
This established the scope of a debate which, since then, has been repeated with
endless variations and which, even now, continues to exert a hold on psychiatry [94,95].
Ironically enough, the seeds of controversy were sown by Kraepelin, the very person who
most wanted to distance himself from the speculative impetus within the debate. In spite
of his empirical bias, Kraepelin continued to link the clinically descriptive course criterion
with the etiological hypothesis of endogeny. Through this, the reference to heredity be-
came an established fact. In practical terms, Kraepelin’s coupling of the course criterion
with the idea of endogeny raised two mutually related issues, namely: (1) the role of
exogenic (biological and nonbiological) factors in the origin of depression and (2) the
demarcation of manic-depressive illness with respect to psychogenic depressions and
milder variants within the manic-depressive spectrum [96,97].
Both of these issues ultimately proved to be insoluble within the framework of the
endogeny/exogeny dichotomy. In practice, it was quite impossible to distinguish between
depressions that were psychogenically induced and those in which psychological and situa-
tional factors merely played an instigating role. The responsiveness of the illness proved
to be of only limited significance as a distinguishing criterion. Meanwhile, it should not
be forgotten that, in Kraepelin’s time, the term endogeny was also an expression of embar-
assment. At the end of the 19th century, Möbius introduced the twin concepts of endogeny
and exogeny. By about 1900, these concepts corresponded respectively to diseases whose
causes were still unknown and those whose causes had been well defined. Causes whose
existence were (still) uncertain were described as endogenous. These were attributed, more
or less out of embarrassment, to innate personal qualities [98]. Exogenous causes included
bacteria, toxins, and tissue injury resulting from brain trauma. In 1910, Bonhoeffer devoted
a monograph to these so-called exogenic reactive types, and his name has been linked to
them ever since [99].

H. The Influences of Psychology and Psychoanalysis

After 1920, mainly because of changes in the use of the adjective “exogenous,” this debate
became even more complex. Originally this term was used only in relation to biological
factors; now it was extended to include intrapsychic and situational factors as well, thus
20 Glas

highlighting the demarcation between depression and neurosis. New dichotomies conse-
quently arose, such as endogenous/reactive (Lange); autonomous/reactive (Gillespie);
endogenous/neurotic; psychotic/neurotic. After World War II, these were supplemented
by S (somatic) type/J ( justified) type (Pollitt); and vital depression/personal depression
(van Praag). Of course, this shift in the debate cannot be dissociated from the influence
of Sigmund Freud (1856–1939) and the psychoanalytic school. In one of his early works,
the so-called Draft G, Freud had already addressed the neurological explanation of melan-
cholia [100]. In 1917, he published an excellent, authoritative article on the link between
grief and melancholia [101]. In this article, he stated that, unlike grief, object loss in
melancholia was associated with unresolved feelings of ambivalence and regression of
the ego. Anger at being abandoned would then be directed toward the ego, which remained
narcissistically identified with the other. This internal “other” was then destroyed. Indeed,
Karl Abraham had already demonstrated self-destructive behavior and experiences in de-
pressive patients [102]. From here, a line can be drawn via the work of Melanie Klein to
authors such as Lindemann [103] and Bowlby [104–106]. Klein distinguished a depressive
position as a phase in early childhood development. Lindemann wrote an influential article
on reactions to grief. Bowlby, as is well-known, worked extensively on the relationship
between psychopathology and the processes of attachment and separation.
The influence of the theory of emotions, developed by the philosopher Max Scheler
(1874–1928) should also be mentioned. Scheler distinguished between four emotional
levels or strata: the level of sensory, physical (or vital), psychic, and spiritual feelings,
respectively [107]. This theory constitutes part of Scheler’s own moral philosophy with
emphasis on values as nonsubjective realities that are expressed in the interaction between
a person and the environment. Scheler’s theory had the advantage of accounting for the
fact that people are capable of experiencing more than one mood and/or emotion at a
time. A person can be in a dejected mood while at the same time being angry with his
neighbor. Kurt Schneider applied this feeling theory to depression by stating that depres-
sion is based on a disorder in the vital sphere. Psychic feelings, such as feelings of guilt
and inadequacy, whould then be an “understandable reaction” to this vital disorder. The
vital feeling of being depressed would co-occur with psychic feelings of guilt and worth-
lessness. This theory of feelings was held, albeit temporarily, in high esteem. The adjective
“vital” for endogenous depression, which until recently was in use in Europe, represents
the psychopathological remnant of this theory.

I. Toward the Twin Pillars of DSM-III

Psychoanalysis enjoyed considerable influence for several decades, to such a degree that
there was barely any perceptible movement in the classification debate. However, this
began to change with the discovery of the mechanisms of action of antidepressants, toward
the end of the 1950s. At that time, the effects of lithium had been known for 10 years
while ECT had been in use for more than 20 years. The advent of these new therapeutic
drugs raised the question of whether the biological active site of these drugs could be
linked with specific target symptoms of depression (or mania). Gradually, it was accepted
that this was indeed the case. Target symptoms, it was assumed, pointed to a given core
disorder in the spectrum of depressive symptomatology. The increasing use of advanced
statistical methods also had considerable impact on the debates. It enabled larger groups
of patients, taken from adjacent diagnostic categories, to be investigated for clustering of
History of Anxiety and Depression 21

symptoms (discriminant function analysis) and underlying factors or dimensions (factor

analysis).
The outcome of these developments was not immediately obvious [108]. In sum-
mary, the classification debate gradually split into two separate debates after 1960. These
concerned (1) the distinction between manic-depressive psychosis and other forms of de-
pression; and (2) the distinction between “endogenous” and neurotic depression.
The considerable overlap between these two debates served only to complicate mat-
ters, since the classificatory status of endogenous depression was central to both. When
highlighting some moments of this debate, mention should first be made of the clinical
and genetic studies of Perris [109] and Angst [110]. Both workers found that depressives
with a previous history of mania had different hereditary profiles from those with no such
previous history. On the basis of these findings, they concluded that the distinction between
unipolar and bipolar depressions, which was already defended on clinical grounds by
Leonhard in 1959, was valid. This distinction became one of the basic assumptions of
the classification of mood disorders in the DSM-III [111] and its subsequent editions
[112,113].
Kendell, meanwhile, carried out a retrospective investigation of 1080 patients who
had been admitted to Maudsley Hospital [114]. He could find no evidence of a bimodal
distribution in the symptom profiles of a heterogeneous group consisting of manic de-
pressive patients, patients with neurotic depression, and patients with involutional melan-
cholia. However, this kind of distribution was found in the Newcastle study. Something
common to both studies was the relatively high loading of a “bipolar” factor.
As Kendell himself observed, his investigation did not negate the distinction be-
tween psychotic and neurotic depression. These could represent two poles of a continuum,
with the psychotic pole displaying greater homogeneity than the neurotic pole. The simple
fact that the symptoms of the neurotic side are milder and fewer in number contributed
substantially to the reduced tendency toward clustering [115].
The lack of homogeneity at the neurotic depressive pole of the spectrum also found
expression in the tri- and tetra-partite divisions of Klein [116] and Paykel [117], respec-
tively. Klein distinguished an “endogenomorphic” depression, as well as a reactive and
a (chronic) neurotic form. Paykel distinguished psychotic depressives as well as three other
groups: anxious depressives, hostile depressives, and young depressives with personality
disorder. Again, remarkably, some degree of consensus existed with respect to the psy-
chotic or “endogenomorphic” end of the spectrum. The limited extent of this consensus
was due to the fact that, for the above-mentioned authors, the central issue was not bipolar-
ity (cf. Perris, Angst, and Kendell), but rather vital phenomena and psychotic symptoms.
For this reason, it is not surprising that some clinicians opted for a center-periphery instead
of a continuum model. Mendels and Cochrane, for example, observed that:
the so-called endogenous factor might represent the core of depressive symptomatology,
whereas the clinical features of the reactive factor may represent phenomenological manifes-
tations of psychiatric disorders other than depression which ‘contaminate’ the depression syn-
drome [118].

Ultimately, however, with the advent of DSM-III(R), neither the center-periphery nor the
continuum model was to gain the upper hand. Instead, the winner was a twin pillar model,
centering around the pillars of bipolar disorder and depressive disorder. In an article that
appeared in 1974, Klein articulated an important consideration regarding this shift [119].
22 Glas

He pointed out that endogenomorphic depressions (those which give the impression of
having arisen endogenously) occur particularly frequently in the group of neurotic de-
pressives. As a result of epidemiological studies, less emphasis was placed upon the het-
erogeneity of neurotic depressions. Conversely, greater attention was paid to the chronicity
and severity of the disease. Finally, in the 1980s, genetic investigations not only favored
the further demarcation of bipolar disorder—something which had already been advocated
on the basis of factorial analysis studies—but also the distinction of dysthymia (neurotic
depression) as a separate category.
In summary, it can be said that a consensus began to emerge in which the most
important demarcation line was drawn between bipolar disorder and unipolar depression.
In addition, within the group of unipolar depressive disorders, a subdivision was created,
roughly corresponding to the distinction between endogenomorphic and chronic neurotic
depression as described by Klein. Ironically enough, the old concept of melancholia was
once again called upon for assistance, namely, in the definition of the endogenomorphic
(vital) form of major depression.
It should be noted, however, that this consensus was by no means universal. For
example, it still has not been decided whether or not the categorical distinction between
cyclothymia and dysthymia, on the one hand, and personality disorders, on the other, is
an artifact. In addition, the debate about the demarcation between affective and anxiety
disorders has become of particular relevance in the past decade. Longitudinal, familiar,
and epidemiological studies have demonstrated that there is a high degree of comorbidity
between affective and anxiety disorders, both in the course of the illness and in relatives.
However, this discussion is beyond the scope of this chapter.
I switch now to a discussion of some highlights from the conceptual history of
anxiety and anxiety disorders.

IV. HIGHLIGHTS FORM THE CONCEPTUAL HISTORY OF ANXIETY

AND ANXIETY DISORDERS
A. The Demarcation of Agoraphobia
As mentioned in Sec. II, prior to about 1850, anxiety was not considered to be a distinct
form of psychopathology in the medical literature. This is of particular importance to the
recent debate on the demarcation between affective and anxiety disorders. For hundreds
of years, the symptoms of anxiety had simply been seen as part of melancholia. In the
course of the past century and the present one, the various forms of anxiety came to be
distinguished from depressive disorders, on a variety of grounds. In light of the century-
old merging of anxiety and depression, a reconsideration of these grounds is therefore a
matter of considerable topical interest. Why the urge to merge the independent status
of various forms of anxiety within the total spectrum of psychopathological symptoms?
Historically, attention focused initially on phobias. Phobic anxiety, like other symptoms of
anxiety, had been described in other terminology in the Hippocratic texts. Burton described
agoraphobia, claustrophobia, and fear of public speaking. Errera [120] cites le Camus’
Médecine de l’Esprit (Medicine of the Mind) from 1769 [121] and de Sauvages’ Nosologie
Méthodique (Methodical Nosology from 1770–1771 [122] as being the first medical stud-
ies in the field of phobia. The former includes a section on Des aversions (avoidance
behavior) while the latter lists many different types of phobias. The term phobia was
History of Anxiety and Depression 23

occasionally used in a diagnostic context even before 1850, as, for example, in the 1798
work of Benjamin Rush [123].
However, three publications that appeared around 1870 became particularly authori-
tative. The first of these was a short article by Benedikt entitled Über Platzschwindel (On
dizziness on squares) [124]. Here, the author focused on a form of dizziness that, because
of its characteristic symptomatology and treatability, in his opinion, merited a separate
classification among the various forms of giddiness. This article was to go down in medical
history as one of the first descriptions of agoraphobia. As just noted, this is in fact histori-
cally inaccurate. Furthermore, the term “Platzschwindel,” was invented by Griesinger, not
Benedikt. Nevertheless, by according a separate classification to the series of phenomena
currently referred to as agoraphobia, Benedikt’s article does mark a turning point.
Although Benedikt had observed anxiety in the patients he described, he believed
this to be secondary to the dizziness:

. . . however, as soon as they enter a wider street or (especially) a square, they are overcome
by dizziness. They either become terrified of collapsing mentally or else they are gripped by
such tremendous fear that they will never dare to pass through such a place again [125].

Two years later, Westphal challenged the view that dizziness was of primary importance
[126]. Westphal, who was the first to use the term agoraphobia in a technical sense, be-
lieved that anxiety, rather than dizziness, was at the root of this phobia. It was anxiety
that caused the dizziness, not the other way around. Westphal’s observation was the fore-
runner of a debate that went full swing more than a century later [127]. This debate centers
around the provocative role of bodily sensations and their interpretation in the origin of
panic attacks. Westphal based his hypothesis upon clinical observation, rather than on
theoretical considerations. He imputed Benedikt’s interpretation to the incompleteness of
his investigations [128].
Interestingly enough, Westphal himself was very much aware of the fact that the
three patients he described were certainly not afraid of streets or squares, as such. He
stressed the unfounded nature of their anxiety. Theirs was rather a fear of anxiety itself,
an anxiety that only much later is linked to particular situations. Modern-day authors who
point out that agoraphobic anxiety is not a fear of streets or squares and that it occurs
under all sorts of other circumstances find an ally in Westphal.

B. Anxiety Under Circumstances of War

During the same period, Da Costa published an article on cardiac symptoms in exhausted
infantry soldiers during the Civil War [129]. Da Costa, himself a cardiologist, spoke of
an “irritable heart.” Observations of more than 300 patients led him to believe that this
condition was caused by a heightened nervous irritability of the heart, which, in turn,
was caused by prior overactivity, such as long marches or physical illness, for example.
During auscultation of the heart, Da Costa heard a weak and sometimes split first sound,
a pronounced second sound, and sometimes a systolic murmur. This systolic murmur
has recently been related to the midsystolic click of mitral valve prolapse. Da Costa
spoke of a sound “like the sudden motion of an only slightly elastic or cartilaginous sub-
stance” [130].
This classic article by Da Costa continued to stir things up among cardiologists,
neurologists, and psychiatrists well into the middle of this century [131]. The debate be-
came particularly intense during and after both world wars when, once again, tens of
24 Glas

thousands of those departing for the front lines were afflicted with the syndrome described
by Da Costa. Thomas Lewis gave a figure of 70,000 such cases among British soldiers
during World War I, 44,000 of whom subsequently received a war pension [132]. In
addition to a report on this subject, which he drew up for the Medical Research Committee
in 1917, in 1940 Lewis also published a monograph on the same theme [133]. By that
time, many agreed with Lewis that the term “irritable heart” was incorrect, since this
placed a one-sided emphasis on heart palpitations and on pain in the region of the heart,
which wrongly suggested that the complaints were cardiac in origin. However, despite
this consensus, there was still no unanimity about what actually lay behind the syndrome.
This lack of unanimity was also reflected in the nomenclature. Lewis introduced
the term effort syndrome in order to emphasize both the intolerance to physical exertion
and the syndromal character of the picture described by Da Costa. While the clinical
picture was indeed determined by cardiac symptoms, he found that only one-sixth of the
patients actually suffered from heart disease. Other terms that came into use were soldier’s
heart [134], war neurosis [135], Da Costa syndrome [136], neurocirculatory asthenia, and
heart neurosis.
Following rejection of the cardiac hypothesis, the controversy over etiology mostly
centered on whether this picture was determined by psychic factors [137,138] or whether
it was a syndrome that could develop in more than one way [139–142].
Mackenzie, for example, blamed the confusion surrounding the condition (which
he termed soldier’s heart) on consideration of some individual symptoms to the exclusion
of all else, and on the fact that this disorder had been named after its most prominent
symptom (in this case, heart palpitations and pain in the region of the heart). Because
of this, less prominent symptomatology tended to be disregarded. Mackenzie states that,
according to the “law of associated phenomena,” local disorders are usually accompanied
by so-called reflex symptoms in other parts of the body (see Sec. IV. D). Moreover, long
before the formulation of the attribution theory, he already emphasized the influence of
medical terms on the way in which disease is perceived. By designating the systolic mur-
mur associated with effort syndrome as an aortic or mitral valve defect, physicians could
turn their patients into invalids. Intolerance to exertion would then wrongly be labeled as
heart disease.
The debate was settled provisionally by two collaborative studies by a number of
specialists from a section of the Maudsley Hospital, which was rehoused at Mill Hill
School during World War II. A special unit had been set up at the school for the purpose
of studying patients with effort syndrome. One of these studies was an award-winning
work by Maxwell Jones, who later achieved fame as a champion of the therapeutic commu-
nity [143]. In the other study, cardiologist Paul Wood concluded that the symptoms of
Da Costa syndrome were also prevalent in peace time and that they closely resembled the
symptoms of anxiety neurosis [144]. Although constitution, heavy exertion, and previous
infectious diseases could all be precipitating factors, effort syndrome was ultimately expli-
cable in terms of (and maintained by) a neurotic mechanism. It affects those who, in their
youth, “clung too long to their mothers’ skirts” [145] and who, either due to parental
overconcern or to comments by their physician, learned to interpret various (normal) phys-
iological changes as signs of physical impotence or even of danger.
Like Mackenzie, Wood placed great emphasis on the suggestibility of the patients,
particularly on their capacity to interpret, in a negative way, the normal physiological
changes that occur during physical exertion. Wood’s interpretation was partly based upon
physiological experiments that had demonstrated that peripheral sensation in effort syn-
History of Anxiety and Depression 25

drome was founded neither upon local abnormalities like hypersensitivity of the central
nervous system (such as in hyperadrenalism), nor hyperventilation. Therefore, in his opin-
ion, there was no specific pathophysiological mechanism that could be held responsible
for the physical symptoms. However, there did exist a specific psychological mechanism
that involved the association of exertion with all sorts of imaginary physical catastrophes.
Wood believed that this association was mediated by an emotion, usually anxiety, although
patients were generally not consciously aware of this. Therefore, the therapy consisted of
a form of psychoeducation in which people were informed of the physical manifestations
of emotions and of the fact that physical sensations were not, by definition, indicative of
a disorder in any particular organ.
Maxwell Jones concurred with this. He developed a form of group psychoeducation,
using groups of about 100 patients, which later evolved into the first therapeutic commu-
nity. The aim of therapy was to teach patients to adopt a different attitude toward their
symptoms. In addition, Jones stressed the reality of intolerance to exertion, for which
extensive physiological studies failed to provide an explanation. He therefore spoke of
an effort phobia. Jones’ investigations had demonstrated that effort phobic patients quit
exerting themselves long before they reach their physiological limit, as expressed by a
slightly smaller increase in the lactate level relative to a normal control group following
the subjective maximum of exertion.
The debate can be summarized by stating that the variation in nomenclature was
determined not only by all sorts of theoretical views concerning the causation of physical
sensations, but also by the immediate military importance of identifying and treating those
suffering from war neurosis. Wars have contributed greatly to our knowledge not only of
anxiety disorders but also, for example, of traumatic neuroses and terror psychoses
[146,147]. In addition, they have propelled this knowledge in a specific direction. Lewis’
choice of the term effort syndrome was significant, as was his involvement in the develop-
ment of exercise programs to increase the exertion tolerance of the soldiers he was treating.
Both can be seen as a direct reflection of the military importance of the capacity to deliver
physical effort [148]. Lewis’ effort syndrome is a splendid example of social influences
affecting psychiatric diagnosis. Regarding subsequent developments, it can be noted that
the special relationship between anxiety phenomena and the heart persisted even after
1950. While consideration was being given on the sidelines to the psychiatric mode of
interpretation, the somatic approach continued to play a dominant role. The 1960s saw
the development of somatic concepts such as hyperkinetic heart syndrome and hyper-
dynamic beta-adrenergic condition. In the 1980s and 1990s, the relationship between anxi-
ety disorders and mitral valve prolapse has been the subject of debate, as has the so-called
fatigue syndrome [149,150].

C. Anxiety Psychosis
The frequent occurrence of anxiety with psychotic symptoms did not, of course, go unno-
ticed by 19th-century psychiatry. Wernicke, however, was the first to use the term anxiety
psychosis. In Wernicke’s opinion, frightening cognitions, hallucinations, delusions, and
delusory ideas were the result, rather than the cause, of the emotion of anxiety. He ex-
plained the psychotic phenomena seen in anxiety psychosis by the intensity of the anxiety
itself. The reverse was true of alcohol hallucinosis, where anxiety was the result of the
hallucinations. Melancholia also differed from anxiety psychosis. So-called agitated mel-
ancholia, on the other hand, which was actually a variant of anxiety psychosis, was totally
26 Glas

unrelated to melancholia [151]. The motor expressions that appeared in anxiety psychosis
were interpreted by Wernicke as complications, rather than as direct consequences of
anxiety. In the ensuing debate, criticism was leveled at the term anxiety psychosis
[152,153]. Some questioned the worth of a classification that was based on the content
of cognitions. Anxiety-dominated cognitions were not restricted to anxiety psychosis; they
also occurred in a variety of other psychiatric disorders. Wernicke himself had already
made a distinction between anxiety psychosis, on the one hand, and anxiety in paranoid
delusions and in delusions of reference, on the other. The distinguishing criterion—
namely, that the cognition in anxiety psychosis must be a direct consequence of anxiety—
proved not to be unequivocally applicable in practice.
Meanwhile, Specht’s interpretation differed considerably from that of Forster.
Specht felt that anxiety psychosis was a mixed (Kraepelinian) form of manic depressive
psychosis in which motor agitation was an expression of the manic component. Like Wer-
nicke, he drew a sharp distinction between anxiety and agitation on the basis that the
former frequently occurred in depression, while the latter was commonly a feature of
mania. Specht’s view was that anxiety psychosis involved motor agitation as an expression
of the manic component, accompanied by the anxiety and inhibition of thought as a result
of the depressive component. For Wernicke, anxiety was the central characteristic of anxi-
ety psychosis; for Specht it was agitation.
Forster, on the other hand, felt that the symptoms of anxiety psychosis could best
be seen either as a variant of melancholia (melancholia agitata) or as the early stage of
another disorder. Not only did Forster not want to separate anxiety from agitation, he also
resisted Kraepelin’s separation of manic depressive psychosis from dementia praecox. In
his opinion, anxiety was not so much an emotion that was difficult to define, but more a
complex series of cognitions that cannot be expressed in words. This formal characteristic,
i.e., a special type of cognitive complexity, was determined by the “fundamental disorder”
that Forster placed at the level of the organic cerebral substratum [154].
In the ninth edition of Kraepelin’s textbook, anxiety psychosis was still included
under the Emotionelle Symptomenkomplexe (emotional symptom complexes). It was de-
fined as a dysphoric condition that cannot be sharply distinguished from depression. It
was associated with anxiety, motor restlessness, and psychotic symptoms [155]. As a
symptom complex, it could occur in all types of psychiatric disorders, including manic
depressive psychosis and dementia praecox. It could also be age-related, as in presenility
and senility.
Two questions dominated this somewhat confusing debate surrounding anxiety psy-
chosis. These concerned the relationships between emotions and cognition, and between
anxiety and (psycho)motor agitation. On the first point, Wernicke considered the anxiety
emotion to be dominant, whereas Forster placed the cognition in the leading role. Specht’s
reference to the Kraepelinian idea of the manic depressive mixed condition suggested a
preference for the view that the affective component was dominant. On the second point,
both Wernicke and Specht made a sharp distinction between anxiety and agitation. With
regard to a distinguishing criterion for anxiety psychosis, Wernicke emphasized the anxi-
ety, Specht the agitation. Forster allowed anxiety, agitation, and desperation to intermingle,
since he believed that there were insufficient empirical grounds for a sharp distinction
between anxiety disorders, manic depressive disorders, and psychotic disorders. Basically
Forster rejected the traditional classification (derived from faculty psychology) into think-
ing disorders, feeling disorders, and disorders affecting the function of the will [156].
History of Anxiety and Depression 27

In the post-1910 literature, two publications are worthy of mention: G.E. Störring’s
Zur Psychopathologie und Klinik der Angstzustände (On the psychopathology and treat-
ment of anxiety states) [157] and K. Conrad’s Die beginnende Schizophrenie (incipient
schizophrenia) [158]. Although neither work includes the term anxiety psychosis, both
point out the fundamental significance of anxiety in the origin of psychosis. Both go on
to describe a period of depersonalization, anxiety, and anxious moods which often pre-
cedes the onset of psychosis. Conrad used the term trema to denote this anxious delusory
mood. Störring described how this anxious delusory mood could lead to so-called objecti-
vation of anxiety, which nowadays is called projection. Feelings of anxiety are no longer
experienced internally, but transform into perceptions of a dreadful and mysteriously
changed world. In the case of psychosis, the background to this symptom is a disorder
that affects the sense of identity. Psychotics are no longer able to perceive themselves as
the source of meaningful experiences and activities. Feelings lose their natural bond
with the I. As a consequence, they take on an enigmatic and indeterminate character.
While the patient does not necessarily experience anxiety subjectively, the world neverthe-
less changes in an obscure way and appears to be terrifying, threatening, and gruesome.
Sometimes anxiety is experienced in flashes, in which case, according to Störring, it makes
sense to speak of a delusory affect rather than of a delusory mood.
Meanwhile, with the virtual disappearance of the term anxiety psychosis from clini-
cal usage, interest in anxiety symptoms in the context of psychosis had also faded [159].
However, studies pertaining to the occurrence of panic attacks in schizophrenia and in
schizophreniform disorders are still published from time to time.

D. Neurasthenia
In the second half of the 19th century a new concept, neurasthenia, gained ground. George
M. Beard, the American advocate of this idea, considered neurasthenia to be a functional
disorder characterized by a deficiency of “nervous force.” This deficiency could express
itself in a multitude of symptoms, particularly at the level of the central nervous system,
the digestive tract, and the reproductive tract [160,161]. Although not highly prominent
among these symptoms, morbid fear and phobia were nevertheless ranked among the most
difficult symptoms to cure [162,163]. Beard used analogies for nervous exhaustion such
as that of a furnace lacking in fuel and of a battery losing its charge [164]. Central to the
concept of neurasthenia was the lack of the strength and reserve to fight the disturbances
of nervous function caused by stress. Beard’s neurasthenia concept was closely linked
with his vision of American society, which supposedly caused much greater overexcitation
of the central nervous system than did European society. “American nervousness,” one
of Beard’s favorite synonyms for neurasthenia, was a typical product of an industrial
society in which the upper classes were doomed to a hectic lifestyle.
Beard experienced just as little difficulty with the conceptual difference between
the physical depletion of energy and the psychic feeling of exhaustion as did Freud a
decade later [165]. He had observed that not only did neurasthenia patients tend to survive
their own physicians, but also they were capable of considerable mental effort. However,
this did not cause him to reconsider the difference between subjective feelings of exhaus-
tion and an actual deterioration in achievements resulting from a lack of physical reserves.
On the contrary, he stressed that, in a functional sense, there was actually something amiss,
such as a hyperemia of the cerebrum, the stomach, or the prostate, for example.
28 Glas

Due to a lack of resistance, the functional disorder (which initially occurred locally)
became transmitted to other regions of the body (irradiation). It therefore had no opportu-
nity to develop into a permanent local abnormality. In Beard’s opinion, this was not the
case in healthy people where occasionally local overexcitation could even result in death.
In the case of neurasthenia, the local functional disorder never exceeded the threshold of
intensity beyond which permanent defects could develop. Irradiation not only explained
the variable and migratory course, but also the multiplicity of symptoms. Among the
symptoms included by Beard were the “irritable heart,” all kinds of phobias, compulsions,
impotence, hyperesthesia, and a huge range of physical sensations.
The irradiation of the local functional disorder occurred reflectively, and Beard
thought that the sympathetic nerve played an important role here. This hypothesis of re-
flective nerve impulse transport was one of the three basic assumptions in Beard’s concept
of neurasthenia. In addition to the reflex theory, there was the idea of the electrical nature
of nerve excitation and the law of conservation of energy [166].
Beard himself believed that it was open-minded observation that led him to the
discovery of neurasthenia, and his descriptions do indeed bear testimony to his extraordi-
nary attention to detail. He would take even the most idiosyncratic, subjective sensations
quite seriously. The fact that neurasthenia had not been previously described was, in his
opinion, due to the fact that neurasthenic patients are not found in hospitals or mental
institutions. They should instead be sought elsewhere, neurasthenia being a disease of the
street [167]. Nevertheless, Beard overestimated his inductive powers, as is demonstrated
by the above-mentioned three basic assumptions and the role they played in his work.
These assumptions constituted the guiding principle on which he based his attempts to
forge a whole out of the positively exorbitant diversity of observations. Moreover, it was
quite common in those days to think of psychic disorders in terms of an excess or a
deficiency of (nervous) energy. Furthermore, as we have previously seen, ideas such as
asthenia and irritability were already fashionable a century earlier [168,169]. In 1848,
W.B. Carpenter explicitly suggested the idea of a close relation between nervous energy
and electricity. Thinkers such as Spencer, Fechner, and Darwin subsequently elaborated
this idea still further. Meanwhile, in the therapeutic sphere, the process of electrification
became quite popular [170]. Nor was Beard the first to see a connection between lifestyle
and functional changes in the central nervous system. The previously mentioned theory
of degeneration, which was very popular on the European continent at the time, provides
still more far-reaching examples. It is true to say that the fascination with the relationship
between nervous energy and electrical phenomena was not unconnected with develop-
ments in the natural sciences. Its origin, however, lay in the romantic period. The intellec-
tuals of the romantic period are known to have been strongly captivated by the living
world’s organic urge to develop and evolve. Early in the 19th century, the concept of
natural force encompassed not only physical forces, such as motion and heat, but also
biotic and psychic forces, such as the life force, growth energy, and the urge toward further
development. It is therefore not the case that the concept of physical energy was initially
discovered by physicists and only later applied, in a metaphorical sense, to psychic symp-
toms. In the second half of the 19th century, the prevailing climate of thought, which
was still dominated by the influence of the romantic period, swung in a materialistic and
mechanistic direction. This transformation, which was associated with such names such
as H. Helmholtz, E. du Bois-Reymond, E.W. Brücke, and C. Ludwig, was triggered by
the discovery of the law of conservation of energy by Robert Mayer in 1842. It resulted
History of Anxiety and Depression 29

in a differentiation between physical and psychic force, which suddenly breathed new life
into the psychophysical problem. At the end of the 19th century, there was yet another
swing, this time back in a neoromantic direction, whereby all sorts of vitalistic concepts
gained new ground. Beard’s concept of nervous force seemed to fit in with this neoroman-
tic pattern of a vitalistic mixture of psychic and physical forces. In summary, it can be
said that both Beard’s description of neurasthenia, as well as the temporary popularity of
this concept, cannot be understood from a purely medical perspective. Instead, one must
consider the interaction between medical observations, theoretical opinions, philosophical
traditions of thinking, and various social changes. However, the fact that medicine con-
cerned itself with neurasthenic patients at all was, to a great extent, a social phenomenon.
When social pressure became too much for an individual’s resilience, neurasthenia offered
a medical excuse for taking it easy.

E. Psychasthenia
One of the most remarkable studies in the history of the classification of anxiety is Pierre
Janet’s Les obsessions et la psychasthénie (The obsessions and psychasthenia), dating
from 1903 [171]. This work, written in an elegant and still readable style, not only offers
an overview of all possible manifestations of pathological anxiety, it also contains numer-
ous vivid descriptions of conditions that are known today as depersonalization, somato-
form disorder, hypochondria, stereotyped movement disorder, and chronic fatigue syn-
drome.
Janet argues against the tendency of many of his colleagues to divide symptom
clusters into separate diagnostic entities. Indeed, he presents a classification of his own, by
making a distinction between three types of psychasthenia: obsessive thoughts, irresistable
movements (compulsions, tics, outbursts of temper as a result of the inability to complete
the compulsions), and visceral anxiety (generalized anxiety, panic, phobias, and even pain
syndromes). These types, in their turn, are subdivided into various clinical states. Janet
nevertheless emphasizes the close ties between these states. In the course of their illness,
many patients show symptoms of conditions belonging to different types. Moreover, sup-
pression of the target symptoms of one type often leads to the emergence of symptoms
belonging to another type of psychasthenia. Blocking of the obsessions, for instance,
heightens the anxiety and may induce compulsive behavior. Resisting one’s compulsions,
on the other hand, often leads to cardiac palpitations and the sensation of suffocation.
The real innovative element of Janet’s study, however, is his attempt to fit his numer-
ous observations in a general theory of psychological functioning. In his Introduction,
Janet declares his sympathy with the French psychologist Ribot, who was one of his intel-
lectual fathers and who had made a plea for the close collaboration between medicine
and psychology. Common to all patients, says Janet, is a disturbance in psychological
functioning, the so-called psychasthenic state or psychasthenia. This state is characterized
by three distinctive features, namely: (1) a sense of incompleteness (sentiment d’incom-
plétude); (2) a diminishing or loss of the sense (or function) of reality (la fonction du
reel); and (3) exhaustion [172].
It is not easy to perceive exactly what Janet meant with the first two of these features.
Roughly speaking, the sense of incompleteness refers to the subjective feeling that some-
thing is missing in one’s actions, feelings, or intellectual functioning. It is a sense of being
incapable and unsuccessful. Whatever one does, it seems useless and incomplete. Doubt,
30 Glas

hesitance, and endless rumination dominate one’s activities. Depersonalization, feelings

of doubleness and unreality, restlessness, apathy and disgust complete this list of manifes-
tations.
With regard to the second feature, the diminishing of the sense (or function) of
reality, it is at first sight even harder to imagine what Janet had in mind. Citing Spencer,
he defines it as “the coefficient of reality of a psychological fact” [173]. Rephrasing this
statement, one could say that certain classes of psychic functioning can be assessed with
respect to their degree of reality (i.e., to a certain quality of psychic functioning in relation
to actual tasks and circumstances). In sum, the function of reality refers to the capacity
to be present, spontaneous, and effective, particularly in the domain of voluntary action,
attention, and perception.
Janet, after all, discerns five hierarchical levels of psychological functioning: the
function of reality at the upper level; then indifferent activities (routine acts and vague
perceptions); the imagining function (memory, imagination, abstract reasoning, and day
dreaming) and visceral emotional reactions; and finally, at the lowest level, involuntary
muscular movements. The quality of psychological functioning is determined by the so-
called psychological tension, the psychic correlate of the nervous energy, to which Beard
and Freud had alluded to. Lowering of this tension initially leads to a lack of attention,
concentration, and other synthetic mental functions—in other words, to a loss of “la fonc-
tion du réel” and subsequently to a disruption of routine activities at the second level.
The psychasthenic state is the result of precisely this lowering of psychic tension (abaisse-
ment de la tension psychologique) [174].
From this, it will become clear that anxiety is by no means the central symptom in
Janet’s account of the psychasthenic state. Anxiety occurs when psychic functioning is
disturbed from the upper level down to the fourth level, that of the visceral emotional
reactions. Anxiety, consequently, belongs to the most elementary of the mental functions:
Underneath the anger, fear and love, there is an emotion, that is not specific any more, that
is a sum-total of vague respiratory and cardiac complaints, which don’t evoke in the mind
the idea of any inclination or any particular action. That emotion is called anxiety, the most
elementary of the mental functions (translation by the author) [175].

Clearly, psychasthenia encompasses a broad range of clinical phenomena, including

the anxiety disorders of our time. The psychasthenic state, however, is determined by a
breakdown of only the highest level of psychic functioning. This implies that even in the
case of phobias, obsessive-compulsive disorder, and panic attacks, a central role should
be assigned to feelings of unreality, incompleteness, ineffectiveness, and depersonaliza-
tion, and not to feelings of fear and anxiety. Emotions and emotion theory play only a
secondary role in Janet’s description and explanation of these disorders.
Janet does not deny the occurrence of panic attacks in some cases of psychasthenia
[176]. But these can only be accounted for by the assumption of a temporary and more
severe collapse of the psychological tension, leading to disturbances at the third and fourth
level. Fear, on the other hand, is a more complex and differentiated emotion, involving
psychic activity of the higher levels, such as imagination, perception and goal-directed
behavior. Fear as such, however, is the expression of activity at the fourth level of psychic
functioning.
From a psychological point of view, Janet was far ahead of his time, by pointing
to the importance of disturbances in the domain of attention and perception and their
History of Anxiety and Depression 31

relation to the sense of self. Psychology and psychiatry had to wait until the 80s before
attentional bias became a topic of some interest in empirical research of the anxiety disor-
ders.

F. Anxiety Neurosis
The history of the classification of anxiety disorders since the time of Beard can be seen
as a peeling away of layers of the concept of neurasthenia. Anxiety neurosis was the first
stratum to be laid bare under its surface. Next came all sorts of classificatory subdivisions
within anxiety neurosis [177].
Kahlbaum’s successor, Hecker, initiated the above-mentioned process in a classic
article on anxiety states in neurasthenia [178]. He had noticed that the anxiety attacks
experienced by many neurasthenia sufferers were not accompanied by any subjective feel-
ing of anxiety. There were also patients who did not show anything like the full range of
physical symptoms. Hecker used the term “larvirt” (larval; larvalike) to denote this absence
of a feeling of anxiety. The term “abortiv” was indicative of the interrupted, incomplete
nature of the attack in terms of the somatic symptomatology. The picture described by
Hecker bears a strong resemblance to the so-called limited symptom attacks in present-day
literature on panic disorder. Citing Lange, a Dane who had formulated an interpretation of
emotions that was practically identical to that of William James, Hecker stated that the
absence of subjective anxiety in the attack was based on a kind of misperception. The
physical symptoms were simply not recognized as expressions of anxiety. However, it
was also possible for an attack to commence with just one of the somantic symptoms
before radiating to other parts of the body. The way in which Hecker described this irradia-
tion betrays a relationship with Beard’s reflex theory.
In 1895, Sigmund Freud, with reference to Hecker, joined the critics of Beard’s
broad concept of neurasthenia. However, in being more explicit about pathogenesis, Freud
went a step further than Hecker [179,180]. He believed that demarcation of neurasthenia
was essential since anxiety neurosis, because of its different pathogenesis, required differ-
ent treatment. Neurasthenia was a disorder of the way in which the so-called somatic-
sexual excitation was released, whereas anxiety neurosis was primarily a disorder in the
psychic processing of such excitation. In the case of anxiety neurosis, Freud imagined
that there was a buildup of pressure on the walls of the male seminal vesicles. When this
pressure exceeded a given threshold, it was transformed into somatic energy and transmit-
ted, via neural pathways, to the cerebral cortex. Under normal conditions, sexual fantasy
groups became charged with this energy, leading to sexual excitement (libido) and the
pursuit of release. Anxiety neurosis involved a blockage in the psychic processing of this
somatic sexual tension. Such a blockage might arise through abstinence, for example, or
due to the use of coitus interruptus, or because sexual fantasies had simply failed to take
shape. Somatic sexual tension was thus deflected away from the psyche (the cortex) and
directed to subcortical paths, finally expressing itself as inadequate actions, which occurred
most characteristically during an anxiety attack.
The pioneering article in which Freud detached anxiety neurosis from neurasthenia
includes a description of the symptomatology of the various forms of anxiety that is still
valid today [181]. Freud cited anxious expectation as the core symptom of anxiety neuro-
sis. He also distinguished between specific phobias agoraphobia, free-floating anxiety, and
anxiety attacks. The latter were spontaneous in nature and were described as a purely
Another random document with
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The days passed on, and Christina never said a word to Nelly still.
And then, the very Sunday that she was expecting Heffernan to
come again to Greenan-more, wasn’t there a letter from Jim; and
most surprising news in it, this time.
It told that the uncle Jim had gone out to was after dying, very
suddenly, and had left all he had to Jim. This had happened some
time before, but Jim wouldn’t say anything about it, till he was sure.
But now the whole thing was settled up. He had the money; and he
was coming home at once.
Jim coming home! Jim coming home! Christina felt wild at the
thought! If he had the money, what delay would there be only to ask
Nelly, and she would have him, fast enough! The thing was as good
as done. Nelly was to the good yet, as long as there was nothing
settled with Heffernan. Oh, if only Jim’s uncle hadn’t died so smart!
If only.... But must she tell Nelly? Why need she tell her? Let her
alone! Sorra hair Nelly would care! Let her marry Heffernan! One
was as good to Nelly, Christina really believed, as another! She
would very soon content herself at the Furry Farm ... and then....
Oh, if only Heffernan would marry her at once, and end the thing! If
once Nelly was out of the way.
But Jim, Jim, that had trusted her with his secret! Christina began to
think of this now, and that Jim had told her everything, and as good
as asked her to look after Nelly for him! Would it be fair to Jim? How
could she play him such a dirty, mean trick, as to keep this news
from Nelly, knowing all it meant, knowing that Jim intended Nelly to
hear it?
She would tell Nelly. Of course she would! How could she do
anything else but tell her? But it appeared as if something always
came in the way that morning. She started off to find Nelly, and read
the letter with its wonderful news to her; and she couldn’t find her.
Christina had been to first Mass; and now Nelly was off to second
Mass, a bit late, as often happened her; and hurrying all she could,
hoping to get a lift on a neighbour’s car.... So she was a piece off,
down the hill, when Christina called to her; and not a foot she’d
come back!
And what was Christina to do? There was the letter, burning in her
pocket, and never a chance of telling about it to Nelly, the one that
was most concerned; because, when she got back from the chapel,
she had Heffernan with her, all dressed out in his best; and Christina
thought it would not answer to have any talk of Jim then; and of
course no more it would.
The same thing, while the dinner was going on; no opportunity for a
word with Nelly.
“It isn’t to be, now!” Christina said to herself; she might indeed have
spoken to Nelly, if she had really made up her mind to it, but the
minute they were done eating, Heffernan said, “I may’s well have a
look at that hay you were telling me about, now. And this little girl
will show me the way!” meaning Nelly.
“Very well!” said Christina, wondering in herself how cute old Mickey
was, to make a chance for himself!
So they got up from the table. Heffernan took his stick, that he
never could do without, since his accident at the fair of Balloch, and
there was Nelly all smiling, quite ready; and off they went together;
December and May.
Before they were farther than the yard, Christina called after them:
“Nelly! Nelly, come here a minute...!”
“Ah, for what?” cried Nelly.
“I ... I have something to say to ye!” said Christina; and she wished
she hadn’t.
“Oh, won’t it keep?” says Nelly, that had often been called back that
way, to be told how to behave, and to not be wild ... and she had no
edge on for being lectured then.
She thought it was bad enough, having to go off with Mickey by
herself....
“That’s all right! come along!” said Heffernan.
He was thinking, the poor old man, that it was what Nelly wanted to
be hurrying off with him.
“Mind, now! I told you to listen to me!” said Christina, very serious.
Yet she was relieved when Nelly just laughed and went on to the
hayfield. And Christina called out, “I’ll be after you, Mr. Heffernan, as
soon as ever I have the place readied up. And glad I’ll be of an
advice about that hay.”
“Och, sure there’s no occasion for you to be in too great a hurry!”
said Heffernan, quite talkative.
When they were started, “I could do no more!” said Christina to
herself, looking after them, Nelly like a child, frisking along beside
Heffernan and his limp, and she chattering away to him and amusing
him. There’s the sort Nelly Flanagan was; always ready to please
whoever was next to her.
Plenty there are like that; plenty of girls, pretty and pleasant and
smiling. But there’s nothing more! no more than if it was a picture
you had hanging by a nail from your wall. But God made them, and
the men like them.
As I was saying a while ago, it’s hard to know exactly what is in your
own mind, let alone in another’s. But it’s likely that what Christina
was really thinking now was this: if once Heffernan spoke to Nelly,
and got her to pass her word to him, the thing would be settled, for
good and all. Heffernan would get the marriage over at once. An old
man has no time to lose, courting. Not that Mickey was what people
in general would count as old; only that was how the girls always
talked about him, he being so very settled and quiet-going in every
way.
Along with that, she thought how that Nelly would be safe and
contented with him. He was good, and Nelly was easy-going and
hadn’t any one else in her mind. Christina was only too ready to
think that.
But the great thing was, that if Nelly was out of the way ... mightn’t
anything happen, as soon as not! Christina did not put that into
words, even in her own mind. There was one thing sure, however.
She wanted Jim for herself. But that, too, she had to put away from
her. The loneliness of her! She had not one, in this world wide, to
speak to. If she had had itself, how could she! how could she!
As soon as Christina had all done, the dishes washed up, and the
floor swept over, and a bit thrown to the hens, she went off after
Nelly and Heffernan. She thought she wouldn’t be in too big a hurry.
The day was hot and bright and she would take her time.
She did that. When she got to the gate of the Big Meadow, and
looked across it down to the lake that lay beyond, she perceived
Heffernan and Nelly, and they standing, talking, with their backs to
her, gazing out over the water that rippled and flashed under the
sunshine, just as it was when Jim had told her he was going away,
and for her to give him news of Nelly.
Christina stopped when she caught sight of them. The thing was
going on just as she would wish it should. She might as well give
Heffernan his time to say all he wanted. He was slow. It would take
him a good while to make Nelly understand. She laid out that she
would go across to join them, of course, as she had arranged, but
very nice and easy, taking her time. She began by being very
particular about hasping the gate; a thing, in troth, that you can
hardly be too careful about, on a farm.
It gave her some trouble, the gate being loose from the hinges, and
Christina remembered it was a job that Jim had meant to do for her,
to set that gate right, only he got such short notice about leaving for
America. When she had it secured again, she straightened herself
up, and turned round, so as to be facing the field she was going to
cross. What did she see, there half-way between herself at the gate,
and Nelly at the far end of the meadow, only Jim himself!
The sight left her eyes, near-hand, and small blame to her. She
rubbed them hard, and looked again. There he was, right enough.
He was laughing, as he had the fashion of doing, a quiet, half-shy
smile, but saying nothing. It was Jim all over. The field was so full of
light and heat that she felt dazzled. You could see little quivering
waves rising up into the air from the sun-cocks. Christina thought
everything was moving before her eyes. Except Jim. He stood there,
quite quiet, laughing still.
“Nelly doesn’t see him!” was the first thought that came into
Christina’s head; “Nelly doesn’t see him! and maybe he hasn’t seen
her! It’s not that side he’s looking, at all! It’s towards me he’s
turned.... Och, if only I can keep him that way...! till I’ll get down to
him ... and keep him in chat ... if only Heffernan had his say out with
Nelly, and gets her promise.... Oh, why did Jim come here, just this
minute! What at all brought him now! If only he’d have stayed away
another bit! Even an hour ... and not for he to be appearing, till it
would be settled.... An’ Nelly that doesn’t mind one, no more than
another ... what does Nelly care!”
With that word, in a clap, Christina begins to think of Jim! Jim, and
the look in his eyes, straight and full of longing and misery, while he
was beseeching of her to write him word of every one ... “and
Nelly!”
It takes a long time to tell a thing, but you’ll make up your mind
quick enough. Christina had hers determined, before she had made
her way across the warm, smiling aftermath to the first line of sun-
cocks.
Supposing Nelly didn’t care! Jim did. It was like a blow on a bruise
for Christina to have to feel that this was true. But when she did,
and saw what ought to be done, she lost no time.
“Jim!” she called out; and when he made no answer, “Jim!” again.
Still he said nothing; only stood there, laughing. So then she
shouted out, “Nelly! Nelly! look-at-here. See who’s in it!”
At the word, Nelly turned round, and in a second there she came,
flying like a bird up the field, the sun shining on her shining hair, and
her pink skirts floating this way and swelling that way, as she ran,
and kept calling out, “Jim! Jim! is it yourself that’s in it, at all at all?”
She was like a bird, as I said, but a bird that was taking wing from a
cage.
To tell the truth, she wasn’t caring so much about poor Mickey and
his way of courting. She was listening to him, because she was too
much surprised to do anything else, and besides she couldn’t really
imagine he was in earnest, and was just letting him go stuttering on,
and half inclined to laugh in his face, only she was too kind to do the
like.... But of course she’d far liefer have a boy more her own age
and gait of going to be looking out across the lake with, than
Heffernan, Furry Farm and all. So off she ran from him and towards
Jim.
There you have them all; Nelly running lightly from one end of the
hayfield, and Christina stepping quickly from the other end of it, and
they both making for Jim who was standing between them. Surely
either of them would reach him quickly ... and of course, poor
Christina was full sure he would go a piece of the way down to meet
Nelly! But instead of that, he kept backing, and backing away from
them; laughing always, but saying nothing.
“What are you at, Jim?” said Nelly, flushed and out of breath, but
radiant with smiles of welcome. “Can’t you stop, and not be going on
that-a-way?”
Still Jim kept moving, moving away from them; sliding across the
field, and not a word out of his head, in spite of all Nelly could say.
Then he got to the stone wall that ran round the Big Meadow; and
then over with him, and Nelly and Christina coming after him.
When they got to the wall, they looked over it into the next field; a
big, flat pasture-field it was; broad and open to the blazing sunshine.
You’d think a mouse couldn’t stir there, without being seen. But
sight nor light of Jim the sisters could not get there.
“Where is he, at all at all?” said Nelly, her cheeks as red as roses
between the heat and the excitement she was in; “some trick he’s
after playing off on us! We’ll find him above at the house, never
fear! And to say he lepped the wall, and never stirred a stone off it!”
The wall was just made of loose stones, laid one upon another
without mortar. Cattle or sheep could knock a gap through them,
ready.
The sisters looked at one another. Nelly turned white.
“Sure, Jim’s always souple,” said Christina, so quietly that you’d
never imagine she had a hair turned on her; “but now, let you make
no delay, only turn back to Mr. Heffernan, not to be leaving him
there with no one only himself ... sure that’s no right way to be
going on! Have manners, child dear!”
And to herself, Christina was saying, “To think she never took notice
of the breast-pin, and he with it in his tie!” for they were close
enough to see it; anyway, that pin sparkled in the sun. “I wonder
does she remember giving it to him, at all!”
“Let you come back with me, Chris!” said Nelly, coaxing her; as if
she was turning shy with Mickey, all of a sudden.
“What nonsense is this to be going on with?” said Christina a bit
short. But still in all, she went. She scarce ever could refuse Nelly
anything that she had the giving of.
And wasn’t it a small thing to do, to walk down a piece to meet old
Heffernan, compared to what Christina was after making up her
mind to?
She was going to give Jim up! I mean, to give up thinking about
him; for the bitterest part of the thing was, that she had nothing
else to give up! Why would she come between Jim and what he
wanted so much?
“... and Nelly!” he had said; “write me about everything that’s going
on about the place ... and Nelly!”
Something had died in Christina at these words.
To give up Jim! I won’t say it was like parting with a bit of herself;
for Christina had no such great liking for her own four bones, that
that would have troubled her much. And did anything trouble her
now? She felt all ice, as if she had no feeling left.
And what was she to do! What was she to do!
It seemed half her life, before they met Heffernan, coming puffing
and limping up the field. He hadn’t a word more out of him about
the business he had in hand, and seemed really vexed at the way
Nelly had run off from him.
“Cassidy? Jim Cassidy?” he said, when they went to explain the thing
to him; “why, what at all! there wasn’t a living soul in the meadow
nor isn’t now, only our three selves! Is it wanting to make me out a
fool, altogether, yous are? Maybe that’s not so easy done!”
He stopped at that, with his mouth open, as if he was surprised at
himself that he had said so much. He looked from one to another of
the two girls, as much as to say, “What excuses have yous to make
to me?” for he was quite offended. And when no one said anything,
he just turned off short, when they reached the gate leading out of
the meadow, and went home, as crabbed as you like.
But by that time Christina was past caring a pinch of snuff what he
did. She could think of nothing, only Jim. She thought she’d never
get back to the house quick enough, she was so full sure he would
be there waiting for them.
Leaning out over the half-door, she pictured him to herself, the way
he often was, before he went to America, laughing and kind. Her
face was white, and the two eyes burning, burning in it, as she went
hurrying on, across the yard, and into the house.
As for Nelly, she was all smiles and gaiety. Little she cared for
Heffernan, or what humour he was in, and he going off from that!
She was calling out, “Jim! Jim! where at all are you? what do you
mean...?” as she ran here and there looking for him, rosy and warm
again in the cheeks, as if they were playing a game of hide-and-
seek.
But the sorra Jim could they find! High, low, or holy, there wasn’t a
sight of him to be seen; though Nelly hunted and searched and
looked and called, all over the place; while Christina, white and hot-
eyed, went about her usual work.
“A body would think you didn’t care, Chrissy,” said Nelly indignantly.
Care! Did she care about her chance of heaven?
Later in the evening, Nelly went straying off through the neighbours,
telling her story, about Jim being in the Big Meadow, and then going
off from them. Did This or That body see him? Nelly would ask, with
wide, innocent eyes. She was only laughed at. Nobody saw Jim
Cassidy! Let her go home and make up some better story than that,
if she wanted to entertain people.
“But we did see him! the two of us saw him! and we even spoke to
him! And he made us no answer, only disappeared, the same as if
the ground had opened and swallowed him down!” Nelly insisted.
“Maybe so it did, but we’ll not swally your story!” was all the
satisfaction Nelly got.
So she went home to Christina and “Ah, Chrissy, do you think would
it be a warning, and that poor Jim just came back to tell us he’s
dead, there beyant in America?” said Nelly, beginning to cry down
tears like the rain.
But Christina never made her an answer. She couldn’t! What Nelly
was after saying, was what she had been thinking. But such
thoughts never seem so bad, till some one else puts them into
words.
To think of Jim, Jim Cassidy dead! She nearly hated Nelly for saying
the word that ends everything ... except Love.
She put her hand into her pocket, and pulled out Jim’s letter, and
gave it to Nelly.
“That came this morning, and I never got the chance of showing it
to you all day, till now,” she said. And she kept watching Nelly from
under her eyelashes, to see would she mind it much.
But Nelly was a real child. She never thought of anything, except
just what a body would put before her in words. She said nothing as
she took the letter and read it. There was nothing in it, only about
he coming home; and the money he was after getting by the uncle
that died.
Then: “Starting the day week this was wrote!” she said. “Well, well!
But sure he couldn’t be here yet, this len’th of time...! whether or
which....”
And then she gave a look at Christina, but she was as busy as a
nailer with one little thing or another about the kitchen, so that she
took no notice of the way that Nelly was staring her. And maybe it
was as well that Nelly got no encouragements to say, what was on
the tip of her tongue, how that Christina appeared noways glad or
interested at the thoughts of Jim coming home.
“And the luck that he’s after happening on! And they two that were
always the greatest of friends!”
That was what Nelly said to herself. But she never kept anything
long in mind, and so things went on at the Flanagans’. The sisters
were in a kind of bewilderment. Christina was going about, not
speaking only when she couldn’t help it, and she feeling as if she
was moving through a black fog, cold and dreadful, and Nelly upset,
because she wasn’t used to anything from Christina but petting.
She’d wonder for a minute or so what at all should be the matter
with Chrissy, and then she’d start her gay little lilt of a song again....
It appeared to Christina as if she had known all her life what was
going to happen, when, a few days later, as she was coming in with
the milk, what did she see, only Jim Cassidy, and he leaning over the
half-door, just as she had often fancied him. Leaning across it he
was, and Nelly standing just inside, and they two laughing and
chattering together and seeming as if they didn’t think there was
another soul in this living world, except their two selves.
Christina started back; and the can of milk dropped out of her hold.
“Oh, Chrissy! here’s Jim!” said Nelly, the words tumbling out over
one another and she between laughing and crying ... “and he only
just after landing....”
“What else, only just landed?” said Jim, looking from one to the
other, very puzzled; “what else would I do, only come on here
straight?”
“But sure, didn’t we see you...? Ora, Chriss, look at the milk...!”
“Never mind now! come and give a hand to wipe it up!” said
Christina, and they all were glad of an excuse for doing something,
Christina in particular. For she was all of a tremble, and didn’t want
that to be seen.
So by this, one thing and another was spoken of, till at last Jim got
telling them about a queer dream he had had, while he was on the
way home.
“I thought to see the two of you,” he said, “in the Big Meadow, and
yous coming towards me, through the sunshine ... it appeared as if
it was a Sunday, with yous, and so it was with us in the ship, too ... I
remember it well....”
“Sure, if you saw us, we saw you, too!” said Nelly; “Sunday ... sure
enough! it was the day old Mickey Heffernan was....”
She stopped herself, and grew very red.
“The day Mickey Heffernan ... what?” said Jim.
“Ah, nothing at all!” said Nelly; “men does be shocking foolish
betimes ... and quare conduction you got on with, that same day ...
backing away from us, as if you thought we had the scarleteen, or
something you’d take from us, that you wouldn’t let us within the
bawl of an ass of you...!”
“That was quare and very quare, too!” said Jim; “but I’ll see not to
let the like occur again, if I can prevent it!”
He and Nelly began to laugh again. And they two were so taken up
with one another, that they never heeded Christina. She slipped
away without their knowing.
They didn’t miss her for long enough. Maybe it was bad of them; Jim
that had trusted her, and Nelly that she had given up all for. But
there’s what happened. And it was only natural, after all. Jim had
Nelly; and Nelly couldn’t but be taken up with all he had to say....
And then, Christina was one that no one ever thought wanted
looking after. So it wasn’t till it had grown dusk, that they began to
wonder where she was, and why wasn’t she there, to be making
down the fire, and seeing everything ready, as she always did. They
waited a little bit longer, and then another little bit longer ... and the
time seemed short enough, to Jim, anyway; till at last they got
uneasy, and went looking for Christina.
But they never saw her again.
They searched high and they searched low. They went to the
neighbours, thinking to find her somewhere off among them;
though, as they well knew, it was the last thing she thought of
doing, idling and ceilidhing[10] away from home of an evening. The
neighbours came, and helped, and there wasn’t a spot about the
place but they searched, calling and whistling and shouting for her;
out all night with lanterns and candles. Every one had a great wish
for Christina. Why wouldn’t they! she that was so good and kind. But
she was not to be found.
They kept up the search, for days and days, thinking it might be that
some kind of weakness had come over the poor girl, and that they
would come on her somewhere, and she in a faint.
But not a sign of her ever they found.
Some thought it was what she might have slipped into the lake,
when she was turning out the cows after milking them, for it was
down towards the water they were driven of an evening. And that
lake, it was well known, had no bottom to it, in places; and it was
supposed that the water drained away through underground
channels ... and if any one chanced to get drawn into one of them ...
well, there was no more to be known of that person.
And more were of the opinion that she might have fallen into one of
the swallyin’-holes I mentioned. And anything that goes in there
never comes out any more.
It nearly killed Nelly, the fright and awfulness of losing Christina that
way. She fretted and pined, till the half of her wasn’t in it. And Jim
as bad, for he was as fond of Christina as Nelly was; just in the
same way, too; as if she was his sister.

For many a long day, after Jim and Nelly were married, and living on
there in the old home, they would talk of Christina, and think maybe
she’d be coming back to them, just walk in on the door.... For they
always thought it wasn’t dead she was at all, only “away” with the
Good People in the old rath, at the top of the hill behind Greenan-
more.
The door was always left open, and the fire strong, and food ready,
at night, and in particular on Hallow Eve, the way she could come in
there, if she had a mind to.
But she never did.
And so best. It’s a poor thing, to be looking at happiness through
another person’s eyes; even if you chance to be as fond of them as
Christina was of Nelly, let alone of Jim.
And it’s bad enough to fret for doing wrong. But isn’t it worse again
to have to feel yourself sorry, and you after doing what you knew
was right! as it was with Christina. But there’s many a thing that it’s
hard to explain, as well as what the Flanagans saw in the sunshine,
that day crossing the Big Meadow.
 CHAPTER V
MATCHMAKING IN ARDENOO

There was of course a good deal of talk among the neighbours about
all that took place at Greenan-more, just soon after old Flanagan
dying there. To say nothing of the queer way Jim Cassidy appeared
(as they said), to the two girls, that Sunday evening, when they
were out in the hayfield, with old Heffernan ... and anyway, nothing
was farther from Nelly’s thoughts then than the same Jim! whatever
poor Christina may have had in her mind!... To say nothing of this at
all, wasn’t it a shocking affair to see a fine, good girl like Christina,
going out of this world the way she did! no one to know what
became of her, no more than if she never had been there at all!
Still, the people didn’t speak so much over it as you might expect.
They felt Nelly and Jim wouldn’t like it. Besides, there was talk of
Christina’s being “away”; and as every one knows, it doesn’t answer
to be too free-spoken about the Good People.
Very little of the talk reached Mickey Heffernan, as usual. He lived
very backwards, as has been said; he heard little, and he said less.
It was the fashion he had, and it served him well. It did now, for it
helped him to believe that no one knew a word about his having
wanted little Nelly Flanagan for himself. In fact, very few did and
they soon forgot it, there was so much else to be talked about.
Mickey was very proud to think that the business with Nelly had
gone no further; any man would feel the same. But instead of this
taking the edge off him for getting married, it only made him the
more anxious to hear of some other girl that would come in upon
the floor of the Furry Farm. Julia was gone out of his way; so why
would he not strive to bring a wife in there?
Little Kitty Dempsey was the next he looked to get; and a very
curious way that came about. Not that any man was to be blamed
for fancying Kitty! She had every one’s good word, the same little
girl.
“A very nice little cut of a person,” it would be said of her, “agreeable
and pleasant-spoken in herself; noways uppish or short with any
one. And the darlint blue eyes of her, that she can say what she
chooses with! Sometimes they’ll laugh, like running water in
sunshine; and again, they’ll fill up, if she’s fretted, till they’d remind
you of nothing so much as a shower of an April day. And as straight
she is as a rush, and as light on her foot as a willy-wagtail; like a
young larch tree, slim and upright; and wouldn’t any one sooner be
looking at the like of that than at one that has been twisted and
bent by the wind on the side of a hill, or has had the half of it ett
away by a hungry colt? Oh, there’s some girls that there does be a
power of marrying on, before they can be settled! But troth! that’s
not so with Kitty Dempsey!”
In fact, at this time, though Kitty was young yet, it was the wonder
of Ardenoo that she wasn’t married long ago, for as they said, it
wasn’t her looks stood in her way; though she never got to be as
rosy in the face and flauhoolich[11] as her sisters all were. Many a
time they blamed Kitty for that, as if she could help how she looked!
But the father, old Dick Dempsey, would whisper to Kitty:
“Never mind, asthore! it isn’t always the big people that reaps the
harvest, Kitty!”
He was very nice and gay, the poor man, and always had a great
wish for Kitty, and stood up for her whenever he could. But Kitty was
the youngest of a long family; and as you may often notice in that
case, she seemed to come in for the fag-end of everything.
When she was no more than a child, she could see plain enough
that there wasn’t a dance or a fair, a wake or a wedding far or near,
but all the other girls would go off to, and have their fling of
whatever fun was to be had. And they would say to Kitty, “Better for
you stop at home and let your hair grow! you’ll have your turn by
and by!”
But there was not really much difference in age between Kitty and
the next sister; only one had to stop at home, and somehow, Kitty
was more agreeable to do that than any of the others. Though, as
she grew up more, she often had a wish to go about, like another,
and get her share of sport; and when they’d say, she’d have to wait
another little while, and then let her take her turn, “To-morrow’s a
long day!” Kitty would cry. But that never did her any good.
She would feel it lonely enough, of an evening, when the others
were away off sporting somewhere, and only the old father and
mother left about the place. The only consolation Kitty had those
times was when she’d go off to the well for the can of water. Dan
Grennan would be very apt to be there or somewhere about, and
then, of course, he’d get the water for her to carry it home, as far as
the back of the turf-clamp. Dan was a neighbour, a decent, quiet
boy, what we call a “lone bird,” for he had no one belonging to him
in the place.
Well and good; this got to be the habit most evenings, till Kitty’s
mother took notice that the water began to be very late coming in
for her cup of tea. So, out with her, one time, and she slipped along,
very quiet and easy, till she heard a laugh from behind the turf-
clamp. Round it she went; and there were Kitty and Dan, with the
can of water on the ground between them.
There’s where they were in error, not to have talked their fill below
at the well, and have done with the thing. But sure, young people
are all the same. When they begin to chatter and talk with one
another, they get it as hard to stop as if it was the sea they were
striving to empty out with a sieve.
It chanced that old Mrs. Dempsey was very thirsty at that present
time, which was what maybe had her so fractious. But indeed, at the
best of times, the turn of a straw would leave her as cross as an
armful of cats, she was so short in the temper.
“Well, Dan, me fine fellah!” she said; “and is it you that is in it?”
“It is, Mrs. Dempsey, mam,” answered Dan, quite civilly; and then he
added, “and no harm in that, I hope?”
He should not have said that; giving her an opening.
“Troth, I dunno about that!” said she, and was twice as vexed,
because poor Dan was so quiet-spoken with her; “that depends,” she
says, “but a boy that has nothing between him and the world only
his two hands has no call in life,” she says, “to be here,
colloguing[12] with my dauther!”
Mrs. Dempsey was a Cusack, and held herself very high. She turned
to Kitty, that was as red as roses by then.
“Off with ye, and bring in that water, that I’m sick and tired waiting
on!”
Kitty was ready enough to go. Ashamed she felt, to have that word
said to Dan, and she by. She went off, without giving him word or
look. How could she, with the mother stumping along behind her, as
big as a bush and as red as a turkey-cock!
“And she gobbling out of her, too!” said Dan to himself, as he
sneaked off, with a very sore heart. He was a fine, big, able boy, that
you would never think troubled his head about anything. But boys
like that have times that they want comforting, as well as another.
Dan was out of a job then, and he was intended to ask an advice of
Kitty, whether he ought to go to England for the harvest or not, only
when he saw her, he forgot everything else except little Kitty
Dempsey. He was not to be blamed for that. You would maybe have
done the same yourself.
But the very next day after Mrs. Dempsey giving him his walking-
papers, as I said, Dan got a job of driving a lot of cattle out to
Dublin market. And when he had that done, he bobbed up against a
comrade-boy of his own, and this boy was after taking his passage
to America. And he was so lonesome in himself, to be going away,
that he offered the lend of money to Dan, the way they could go
together. I needn’t say Dan jumped at the chance.
But he had to start off as he stood; and no one at Ardenoo knew a
word about his going, for long enough. So there was many a mile of
salt water between poor Dan and Kitty, and still Mrs. Dempsey would
be going to the well herself of an evening. It was the price of her, to
be putting such rounds upon herself, and for what? But as Dan said
long after, when he and Kitty would be talking over things, “Divil’s
cure to them that has a bad suspicion of others!”
Kitty used to fret a good deal, wondering how it was that she never
saw Dan nor heard anything about him, since the time her mother
caught her and him together behind the turf-clamp. But she passed
no remarks to man nor mortal. And one day that she and the mother
were at Melia’s shop, where the post-office is, a letter was slipped to
Kitty, that no one saw only herself. Mrs. Melia knew well the sort old
Mrs. Dempsey was, and so did every one else about Ardenoo.
Kitty had to keep that letter in her pocket, and it burning a hole
there, till she was going to bed that night before she had any
opportunity of opening it. What was there inside of it, only a picture
of Dan, all done out so grand and fine, that you would scarcely know
it to be Dan at all, only his name was written under it. And on the
back of the picture there was this verse:
When this you see,
Then think of me, D. G.
So Kitty was not much the wiser about what had happened, when
she got this from Dan. But not long afterwards, she got word that it
was in America he was, and had good pay there. And then no one
seemed to know much more about Dan.
It wasn’t too long after this, that old Dick Dempsey, himself, Kitty’s
father, took and died on them; “harished out of the world,” some
said, by the wife he had, that could never think anything right that
he did; or any one else, for that matter, except herself. There’s a
power of people like Mrs. Dempsey.
It was the woe day for poor Kitty, when her father was gone, and
she and the mother left to manage for themselves. By this time all
the others were married, or gone off to America. And of course they
all said among themselves, that the farm that had reared the whole
of them, and had given snug fortunes to every girl that married out
of it, ought to be able to keep Kitty and the mother in the greatest
of comfort.
So it should too; only there chanced to be a few bad seasons, when
the grass was short ... or the rain didn’t come till it wasn’t wanted,
and so the crops got spoilt in the saving. Every one else about
Ardenoo was in the same boat. Except for this: Mrs. Dempsey was of
the opinion that they were all fools but herself. That kept her down
worse. She would take no advice. She thought she knew better than
men that had been farming all their lives, while she had been rearing
chickens and making butter. Her great idea was, to spend nothing.
She grudged doing that, more than anything.
Now it is well known that the best fertiliser you can use on land is,
money. If you treat your land well, it will treat you well; a thing that
is true of more than farming.
But with Mrs. Dempsey it was take all and give nothing; above all,
for labour. She would keep no help for the house. So it was Kitty!
here; and Kitty! there, from dawn to dark. Kitty was never done. She
was the most willing little creature you could find in a day’s walk; as
good as ever was wet with water. But what avails all one girl can do
on a farm? with poultry and milk, turkeys and pigs, and then be
expected as well to do haymaking, or the thinning of turnips, or
dropping potatoes, and I don’t know what all besides. It was only
folly to think any one pair of hands could overtake all that.
And here again was another reason why poor Kitty was not to have
her chance of a bit of sport like another. At first, as I explained, she
had to step one side, in order that the sisters that were older, the
“ones that were next the door,” as they are called at Ardenoo, could
have their fling, there were so many of them there. And secondly
she had to stop at home now, because they were not there! no one
in the place, only the old mother and Kitty. So that is how she never
had any other “coort” except Dan; and of course then she thought
all the more of him; the same as a hen with only one chicken. She’ll
fuss and cluck as much for it as if she had the whole clutch.
Girls that are allowed a bit of liberty, the way they can be putting a
whole lot of boys through their hands, as some do, are better off in
a way than Kitty was with Dan.
“One thing moiders another!” as the man with the toothache said,
when he felt the pain going into his ear. And if a girl has Phil, and
Jack, Mike, and Pat as well as Art, it’s likely she’ll not fret too much
about any of them if they go off, as Dan did.
However, you never know what turn a young mind will take. People
differ, as well as the things they happen up against. Kitty wasn’t like
other girls; and those that knew her best never wished that she was.
All the same, good and contented as she strove to be, it was hard on
her! Year in, year out, going on the one old gait; her nose for ever to
the grindstone. And along with all, if anything went wrong, Mrs.
Dempsey would take and scold at Kitty, most bitterly, as if the girl
was to be blamed when the potatoes turned black, or the oats got
lodged, beaten into the ground with the heavy dreeps of rain.
As for the fow! That was what had the old woman more annoyed
than anything. The rage she got into, one season, when a lot of
young goslings died! She said it was what Kitty had neglected them,
and that she cared for nothing, only idling her time over her
geranium-pot. Now it was true that Kitty did think a lot of that
flower, and no one but herself knew, or cared, that it was Dan
Grennan that had brought it to her, and it only a little weeny bit of a
thing. Kitty had minded it so well, that it flourished up the finest ever
was seen. She was very fond of flowers, but any little bit of a garden
that ever she made, something happened it; either the pigs rooted
it, or the hens tore it about. So to keep her geranium-pot safe, it
was up on top of the pump she had it, the time the goslings died.
Mrs. Dempsey was making for it, to fling it pot and all out of that,
when, behold ye! she was took bad all of a sudden. Some kind of
Blessed Sickness it was; and in the clap of your hand, it left her
speechless, and with no power of herself from the waist down, ever
after. In fact she didn’t last too long after this happening. But, of
course, Kitty nor no one could know but she might live for years yet.
When she was laid up that way, it left Kitty there, nothing but a bird
alone, as you might say; the mother good for nothing, only having
to be fed and minded, the same as an infant child, and twice as hard
to please as any baby. Kitty was that tender-hearted, that she
fretted, night, noon, and morning, when the old woman wasn’t able
to speak; though what all the neighbours were saying was, “Won’t
poor Kitty have great ease, now that the mother’s tongue is stopped,
the ould torment!”
But to listen to Kitty, you would believe there never was another
mother so good on the face of the earth, as what she had herself.
Shortly after this taking place with the Dempseys, the fair-day of
Timahoe came round. Dark Moll Reilly was in it, of course, herself
and her fiddle. No wake nor wedding nor sport of any kind was right
about Ardenoo, without Moll.
There was people of the opinion that the dark woman could see
more than she let on to be able to; and that it was just a gait of
going she put on, the way she could get a better acquaintance with
things that were not meant for her. Certain it is that there wasn’t a
stir, far or near, or anything going on about Ardenoo, but what Moll
always had the first whimper of it. But no one ever heard a bad
word from her, about any son of men; nor she wouldn’t either. She
knew only too well, that she ought to be careful, and not have the
people afraid of her tongue. In that way, she had many a snug
stopping-place, where she was always made welcome, with her
fiddle and her chat about everything, because the people felt Moll
wasn’t one to carry stories. Besides, she was a knowledgeable
person, and very understanding, and had made up many a match
among the neighbours at Ardenoo.
Going away from the fair she was, this day, when Big Cusack, that
was a brother of Mrs. Dempsey’s, overtook her on the road, and
asked her would she sit up on the side-car with him, and he could
be giving her a lift as far as he was going her way.
“I’m thankful to ye, sir,” said Moll, “but I wouldn’t wish to be too
troublesome....”
“Not the least trouble in life!” he said, and gave her his hand across
the well of the car, to help her up. And then, when they were
jogging on again, they fell into chat and the whole topic between
them was, poor Kitty Dempsey and the way she was left with the
helpless old mother; and she with ne’er a one in it but herself.
“But sure, she needn’t be so!” said Moll. “There’s plenty of boys
would be glad enough to be sending in their papers there ... and she
your niece, too, Mr. Cusack!”
“Troth, I’m not so sure about the boys at all!” said Big Cusack; “the
most of them, they put a high figure on themselves now. They’re not
to be caught with chaff, these times. Kitty Dempsey, indeed, with no
stock to speak of on the farm! And it all racked out, the mother
taking in grazing cattle, and letting them eat the roots out of the
pasture ... and the ditches choked ... and fences wanting to be made
up ... let alone the two years’ rent that’s owing on the place this
minute....”
He had a sup taken at that time, or he wouldn’t have been so
talkative.
“Do you tell me that! Dear, dear!” said Moll; though well she knew it
all before he spoke. But there’s no way so good to flatter people up,
as to listen to them talking as if it was all new to you, although you
might have the thing twice as well off, as they would that were
telling it. Dark Moll was well aware of this. Besides, being old and
poor, as well as blind, the creature! of course she knew she ought to
be very humble in herself. So she had the habit, as I said before, of
being very careful and exact in what she would say, and in particular
to a man like Big Cusack, a strong farmer that had a right to every
respect.
“I do tell you that, and, moreover, I’m sure of it!” says he in answer.
“Troth, then, and I’m not one bit sure!” said Moll, “askin’ your
pardon and grantin’ your grace for the word, Mr. Cusack! But I think,
and not alone that, but it’s too sure I am that there’s plenty would
jump at little Kitty Dempsey, ould mother and all. Sure, she can’t last
for ever, God help her! and let her do her best. I know one, anyway,
that I’m too sure would take her,” says Moll, “this instant minute; a
qui’t, settled boy, wid money in the bank, as well as the snuggest
place you need ask to lay an eye upon! And he wanting a woman
there, this len’th of time! And well you know that I’m only saying
what’s the truth!”
“Who is it you’re speaking of?” asks Cusack.
“Why, who but Mickey Heffernan!” said Moll, “away off at the Furry
Farm; he’s after marrying the sister Julia to a boy from Clough-na-
Rinka ... one of the Caffreys ... but that’s no consarn of a man like
you, Mr. Cusack! But poor Mickey hasn’t one to do a hand’s turn for
him now, barring himself. Sure he had a right to have looked into the
thing before this, and not be leaving himself the way he is. And now
he’s driving about the country, I hear, looking for a wife; and his
spokesman with him....”
“I have no great acquaintance with the man,” said Cusack.
“No, nor couldn’t,” said Moll; “Mickey was like the rest of the
Heffernans, great always at keeping himself to himself. And the
lonesome place he has! But sure, if it was arranged, can’t he come
to live at Dempsey’s, and be seeing after the two places from there,
quite handy?”
“That might answer,” says Cusack. “Middling ould he is, I believe?”
“No more than sixty, if he’s that, itself,” said Moll; “and as sound as a
trout; ay, and maybe would be better to Kitty than one of them
young bloomin’ boys that’s going these times, the sorra much good
they are only spreeing and play-acting.... But Mickey is not that way
of thinking ... real sober and.... Let me down off o’ the car, Mr.
Cusack, sir, if you please.... It’s to Biddy Fay’s I’m going for the
night....”
“We’re past it,” said Cusack.
Moll knew that, as well as he did. But it came more natural to her to
tell a lie than the truth, even if it was to do her no good itself.
“Past the turn to Biddy’s are we? but sure we can’t be far,” said Moll;
“just stop if you please, sir, and let me down and give me a twist
round to set me going right, and may the Lord reward ye for helping
the poor dark ould woman!”
So Cusack did that; but it wasn’t to Biddy Fay’s Moll was steering;
no, but passed on, and made for the Furry Farm, as hard as she
could go. It was a long way, and she couldn’t make it that night at
all. But the next evening she got to Mickey Heffernan’s right enough.
There was no one within at that time, except the boy that was
spokesman to Mickey in looking for the wife. He was a neighbour’s
son, well known to Moll.
“So you haven’t Mickey marrit yet?” said Moll, when they had passed
one another the time of day.
“No, faith!” said the boy; “and sick and tired I am of the job! God
and the world wouldn’t plase Heffernan with a wife!”
“Och, wait till your own turn comes round, me hayro! maybe you’ll
have picking and choosing then....”
“When I want a wife, I’ll see to do the thing myself!” said the boy;
“I’ll have no interference, only go and kill a Hussian for meself! Why
can’t a man go and make it all right with the girl herself, and not to
be having all this ould botheration...?”
“Musha!” says Moll, “there’s a great deal to be looked into, besides
the girl!”
So then she went on to talk of Kitty, and they spoke about that over
and over and up and down; and at long last the spokesman agreed
to bring Heffernan across to Cusack’s the very next Sunday; and he
sent word by Moll.
That all came about; and very pleasant they were, all round.
Heffernan and a few more; tea they had and hot cake and punch
afterwards.
“I thought to have the girl herself here,” said Cusack, “but she’s not
willing to leave the mother, that’s ‘donny’ this len’th of time; and
besides she’s a bit timersome in herself....”
“She’s none the worse of that!” says the spokesman; “and anyway,
won’t it be time enough, when we have all settled ... we’ll see her
then....”
To make a long story short, they agreed about the whole thing, that
very evening; Cusack praising up the Dempseys’ farm, sure, and all
the fine grass it was able to grow; and the spokesman not one bit
behind in making much of the Furry Farm. Mickey himself said
nothing, only sat there smoking and looking into the fire.
And there’s the sort they were laying out for little Kitty Dempsey!
and he without a word to throw to a dog! But they never minded
him; only settled everything, even to having the wedding in a week
from then. Heffernan and the boy went off home, and Cusack went
to his bed, very satisfied with the work he was after putting over
him.
Away with him the very next day to Dempsey’s to tell Kitty. He found
her very lonesome and fretted.
“I miss me poor mother, every hand’s turn,” she said; “now that
she’s laid by in her bed. And I dunno at all how I’ll get to mind her,
the way she should be attended to. Och, but it’s lonesome the place
is, without her voice, even to be faulting me! And the doctor’s
bottles to be paid for...!”
So the uncle begins then to advise Kitty about this thing and that,
and how it was a thing impossible for her to be thinking of going on
the way she was; she could never manage to do all. And then he
worked it round that she ought to get married. And in the end he
spoke of the fine match he was after making up for her.
“What! It’s not ould Mickey Heffernan!” said Kitty. “I never seen the
man, but I remember to hear me father, the heavens be his bed!
speak of him as a settled man, since I was the height of a bee’s
knee! An old fellah ...” and then Kitty took to go cry the father, that
had always been so good to her.
“Hut, what at all!” said Cusack; and then he began to reason cases
with Kitty over the marriage, reminding her that the mother was
depending out of her then; and what a good thing it would be for
them both, for Kitty to get Heffernan that was able and willing to
pay up the rent that was due on the Dempseys’ farm; and how
would Kitty like for them to be thrown out on the roadside, instead
of being left in the old home in comfort, and having some one
sensible to do all for them?
Poor little Kitty! she cried down tears like the rain. For that was the
first that ever she heard of there being rent owing. It was the
mother that had managed badly to let that happen; she couldn’t
help it, maybe; and had never told Kitty a word about it.
Kitty said now, would the uncle wait a bit, till she could think it over?
But Cusack saw no sense in that; he being an experiented man in
business and money and all to that. He knew there might only be
unpleasantness, if there was any delay. And maybe Heffernan might
change his mind about paying up, and then wouldn’t he only have
had his trouble for nothing, and Kitty not settled, and where would
the rent come from? Cusack hadn’t it, nor wouldn’t know where to
look for it.
So he just told Kitty that the gale-day was coming round very
shortly, and what was she going to do, to make up the rent? And
that cowed her, the crature! and she was always biddable. Sure she
got the fashion of it, from the time she was able to walk. So she
gave in to what Big Cusack said.
In due course, the day for the wedding came round. There was a
great gathering of the neighbours and friends at Dempsey’s, and
everything done in the greatest of style, four bridesmaids for Kitty
no less. Cusack wanted to do the thing right, when he went about it,
and he took on the ordering of it all.
Up bowls Heffernan’s side-car, and himself and his friends; and he
with a sprig of spearmint in his coat for a buttonhole-bit; feeling as
fresh in himself as a rolled ass. But he was as white as the snow
about the head, and as lame as a duck, the poor man! And when
they saw him, spraddling up towards the house, “Sure, that can’t be
him that’s going to be marrit!” said one of the bridesmaids. Not one
of them ever laid eyes on Mickey before. He was never one for going
about, as I said, and in particular had given up the fashion of even
going to a wake, or any place of the kind, where the boys and girls
consort together, for years past.
“Is it a wife he wants, or a coffin?” says another girl; “bad scran to
him, what a thing he wants to go do, to get a girl to marry him!”
I needn’t say, Kitty wasn’t let hear these remarks. But of her own
accord, when Heffernan got up to the door, she makes one fly, out
of the kitchen, and into her own little room, and begins to cry. And
the bridesmaids went after her, and clapped the door to, and began
flinging up their hands, and crying “Och, wirra, wirra!” till you’d think
it was keening at a funeral they were, and not at a wedding, where
there should be nothing but rejoicement.
The noise they made vexed Cusack.
“What nonsense is this?” he said; “let me have no more of it! Go
after Kitty,” he said, “and tell her I order her to come out here, at
once! and not to be making a Paddy FitzSummons’s grandmother of
herself. Let alone of every one else!” he says.
“Och, give her her time!” said Heffernan. It was remembered to him
after, that the only word he said at that time was to try to pass
things off agreeably.
A comrade-girl of Kitty’s, that knew the ins and outs of the whole
affair, went up into the room after her.
“Come back into the kitchen, Kitty agra!” she said; “and give over
that work.... Put by that pickther of poor Dan ... that’s all done with
... and where’s the sense in heating up old broth...?”
But Kitty did nothing, only stand there with her face to the wall in a
corner, and she crying; while outside in the kitchen, Cusack was
raging like a lion.
“She should be made to come out here!” he said; “I seen girls before
now purshood through a bog, and had to be tied on the car, to get
them to the chapel, the way they could be married.... Well, Moll
Reilly, and is that yourself?”
“It is, it is, then! and God save all here!” said Dark Moll, very
breathless and hurried. “Where’s Kitty? Not that I could see her! but
sure I thought she would be coming to bid me the ceud mile
failte!”[13]
Cusack began to whisper to Moll, to explain what was going on. But
she seemed not to care to hear him, and only anxious to get into
where Kitty was.
“Let me at her; I’ll go talk to her!” said Moll, “and you’ll see I’ll soon
make her l’ave that, before I have done with her!”
And so she did, too. But it wasn’t exactly the way Cusack thought.
“Take care! Mind yourself!” said he to Moll, seeing her making a
drive for the door of Kitty’s room, the same as if she had the sight of
her eyes. But Moll was so taken up with what she had on her mind,
that for once she forgot she was blind.
“You’re wanting without there!” said Moll to the bridesmaids; and
when they were gone, said she, very quiet and easy, “Who do you
think I’m after seeing ... I mean, after meeting up with ... there, a
while ago?”
“I dunno,” said Kitty, giving a great sob.
“... and he looking into the well ... and talking of how he used to be
rising cans of water there with you ... and then carrying them as far
as the turf-clamp....”
“Not Dan!” said Kitty. And she turned first as white as paper and
then as red as roses.
“Faith, who else?” said Moll.
“Ora, what made he come now? and it too late!” And Kitty began to
cry again.
“Late? the sorra late!” said Moll.
“Why wouldn’t it be late, and the wedding all fixed up? ... let alone
the rent that’s owing....” Kitty was thinking that Dan had come home
as poor as he went.
“Och sure! ‘divil dance on the rint!’—there’s the very word Dan said!”
said Moll; “it’s churns and ass-loads of money he has with him, that
he’s after bringing out of America!”
That was only foolish talk of Moll’s. A few pounds was all Dan had
been able to gather up while he was away. But it was enough, for all
that. To start with, he had given Moll a half-sovereign out of his
purse, to let him have a word with Kitty. Ay, and had promised her
as much more, if he got her. And Moll had never owned that much
before in her life. Whereas, all old Heffernan would be good for
would be an odd copper or two, and maybe an apronful of potatoes,
whatever time they would be going to waste.
“Poor Dan, and he only landed home yesterday!” said Moll; “and the
fine figure of a man that he is!”
“Ora, what will I do, at all at all?” cried Kitty, with the tears pouring
down her face. They two were shut into Kitty’s room, while outside
the kitchen was full up of people, fidgeting about, waiting for the
bride to appear and passing the time by looking at every mortal
thing in the place.
The table was all laid out for the wedding dinner, the greatest you
could see. And when any of the Dempseys’ friends would pass
remarks, carelesslike, on the fine white table-cloth, or the china
teacups, or the silver forks and spoons; they well knowing that all
had been borrowed from Miss O’Farrell above at the Big House ... on
the minute, Heffernan’s spokesman would cry out: “We’ve bigger
and betther at home, in our place!”
But in Kitty’s room: “What will you do, is it?” Moll was saying: “well,
seeing the strong faction that Heffernan has with him, there would
be neither sense nor reason in Dan Grennan’s coming in for you
among them all, and he without one, only himself; barring that he
could r’ise a ruction, like Phaudrig Crohoore! But he never could;
and as he can’t come to you, you’ll have to go to him.”
“How so?” says Kitty; “they’re the full up of the kitchen, so that I
couldn’t pass them by; and as for the window, it’s that small I
needn’t try that way; so what am I to do, Moll?”
“Troth, it’s you has little wit! What’s to ail you, only to put on my
cloak, and the hankercher over your head, and draw it well down
over your eyes ... and who’s to know is it Dark Moll or Kitty
Dempsey?... I mean, Mrs. Dan Grennan, that is to be...!”
“And then ... what am I to do, after?” said Kitty, with a trembling in
her voice. But there was a kind of little smile in her eyes, too.
Moll explained the thing.
“You’ll meet Dan below, there at the well. Sure it’s you that mightn’t
be surprised to see him there, nor he to see you, faith! And
Heffernan’s car is at the corner below, just out of sight of this
house.”
“But ... but....”
“And why not? Isn’t that car nearly yours, this minute, and haven’t
you every right, so, to take the lend of it? And maybe you never
would have the chance again! Lepp up on it, yourself and Dan! and
off wid yiz to the chapel. Ould Father Brogan is laid up in his bed,