Exhaustion

A History

Anna K. Schaffner

• Publisher: Columbia University Press
• Year: 2016
• Topic: Psychology
• eBook ISBN:
  9780231538855
• Subtopic: Alternative & Complementary Medicine
• Index: Psychology

Today our fatigue feels chronic; our anxieties, amplified. Proliferating technologies command our attention. Many people complain of burnout, and economic instability and the threat of ecological catastrophe fill us with dread. We look to the past, imagining life to have once been simpler and slower, but extreme mental and physical stress is not a modern syndrome. Beginning in classical antiquity, this book demonstrates how exhaustion has always been with us and helps us evaluate more critically the narratives we tell ourselves about the phenomenon.

Medical, cultural, literary, and biographical sources have cast exhaustion as a biochemical imbalance, a somatic ailment, a viral disease, and a spiritual failing. It has been linked to loss, the alignment of the planets, a perverse desire for death, and social and economic disruption. Pathologized, demonized, sexualized, and even weaponized, exhaustion unites the mind with the body and society in such a way that we attach larger questions of agency, willpower, and well-being to its symptoms. Mapping these political, ideological, and creative currents across centuries of human development, Exhaustion finds in our struggle to overcome weariness a more significant effort to master ourselves.

1

Humors

Recent biomedical theories of depression, and of the symptoms of physical and mental exhaustion that are associated with it, center primarily on chemical imbalances in the brain. They are based on the assumption that pathological low mood states are connected to neurotransmitter deficiencies. Since the 1980s, biomedical depression research has concentrated predominantly on the monoamines norepinephrine and serotonin, and the enhancement of selective serotonin reuptake inhibitors (SSRUI).¹ Serotonin is a molecule that transports signals between the synapses in the brain and that regulates emotions, reactions to external events, and physical drives. Low serotonin levels are generally seen as a symptom of depressive moods, but there is still considerable debate as to whether they are also their cause. SSRUIs were first sold under the trade name Prozac in 1987, and Prozac rapidly became a blockbuster prescription drug. It is still the most frequently prescribed antidepressant to date.

Yet the idea that an imbalance of specific substances in the body causes states of low mood–related exhaustion is not at all new. Indeed, it is to be found in ancient humoral theory. Hippocrates first introduced humor theory to medicine in the fifth century B.C.E., and the Greek physician Galen of Pergamum (129–ca. 216) further developed the idea. Galen’s version of humor theory was so influential that it remained the dominant medical paradigm until the advent of modern medicine in the nineteenth century.² One of the central tenets of this theory is the importance of a balance among the four bodily fluids, or humors: blood, yellow bile, black bile, and phlegm. Within this framework, all illnesses—be they chronic or acute, mental or physical—can be explained by the relative excess or insufficiency of one or more of the four humors. According to Galen, each humor is also associated with specific qualities and with one of the four elements: blood is aligned with warmth and moisture, and the element air; yellow bile with warmth, dryness, and fire; black bile with coldness, dryness, and earth; and phlegm with coldness, moisture, and water. Furthermore, each of the humors is also related to a particular temperament—blood is associated with the sanguine, yellow bile with the choleric, black bile with the melancholic, and phlegm with the placid temperament. Humor theory functions thus to explain not only acute and chronic physical and mental disturbances but also long-term character traits and psychological dispositions.

The balance among the humors was thought to be precarious—it could easily be upset by a surplus or deficit of particular fluids, which could be caused by infections, inflammations, unwise dietary choices, and intemperate lifestyles, as well as by grief and sleeplessness. Acute diseases were mainly associated with disturbances in the quantities of blood or yellow bile, while chronic diseases were generally related to a deficiency or an excess of phlegm or black bile. Consequently, the most common cures administered by physicians until the modern period entailed bloodletting, emetics, the application of leeches, blistering, and purging—all designed to evacuate the body of a humoral excess and thereby to reestablish an equilibrium among the bodily fluids.

In Galen’s writings, we encounter exhaustion primarily in the guise of lethargy, torpor, weariness, sluggishness, and lack of energy. Moreover, all these were thought to be typical symptoms of melancholia, which thus features some of the key symptoms of physical and mental exhaustion among its core indicators. Melancholia is a complicated disease entity, the exact definition and symptoms of which were subject to change through the centuries. For a long time, melancholia’s defining features were considered to be causeless sorrow and fear, but they were always accompanied by a range of other symptoms, among which the symptoms of physical and mental exhaustion feature prominently. Like neurasthenia, the diagnosis often encompasses a plethora of associated complaints, ranging from irritability, restlessness, mania, hallucinations, and paranoia to misanthropy and self-loathing.³

One of the most persistent myths surrounding the condition is the supposed link between a melancholic disposition and exceptionality, artistic inclinations, and “brain work.” It can be traced all the way back to Aristotle (or one of his followers), who wonders in Problemata 30 (ca. 350 B.C.E.): “Why is it that all men who have become outstanding in philosophy, statesmanship, poetry or the arts are melancholic, and some to such an extent that they are infected by the diseases arising from black bile, as the story of Heracles among the heroes tells?”⁴ Yet in the Middle Ages, melancholia was redefined in a theological context as acedia, with a particular focus on forms of lethargy, torpor, and lack of motivation, which were considered sinful diseases of the will and a sign of bad faith, as it was assumed to be within the power of the individual not to yield to these “demonic” temptations, which entailed contempt for the divine nature of God’s creation.⁵ In the early modern period, melancholia was revalorized and once again associated with creativity, genius, and scholarship, and it was celebrated as the natural inclination of sensitive and emotional men in the age of Romanticism.⁶ The nineteenth century saw the advent of biological medical models and psychiatric classificatory systems, and melancholia was explained in purely organic terms.⁷ In the twentieth century, Sigmund Freud introduced the idea that melancholic self-loathing is a reaction to the loss of a love object and a form of narcissistic aggression turned masochistically against the self.⁸ Currently, cognitive behavioral theorists understand some forms of depression, melancholia’s twentieth-century successor, as the result of distorted cognitive process and faulty reasoning.⁹ Yet in spite of the eclectic diversity of explanatory models of melancholia, almost all accounts mention the physical and mental symptoms of states of exhaustion as either associated or primary symptoms.

Aristotle’s and Galen’s highly influential descriptions of the causes and symptoms of melancholia were to shape substantially all that followed. Galen explicitly theorizes exhaustion symptoms as belonging to the melancholic symptom cluster. The most important physician of the Roman era, trained in Platonic, Aristotelian, Stoic, and Epicurean systems of thought, Galen became court physician to the emperor Marcus Aurelius in Rome. He was a prolific writer and added his own empirical findings to past writings on medical subjects, in particular to Hippocrates’s teachings.¹⁰ In On the Affected Parts (composed after 192 C.E.), one of his most important treatises and originally written in Greek, Galen argues that a surplus of black bile triggers melancholia. He distinguishes between two types of melancholia. In the first kind, the entire blood supply of an individual becomes atrabilious, the melancholic humor thickening and slowing the blood, rendering the patient lethargic, slow, and prone to stupor.¹¹ (Interestingly, a general slowing of the patient’s movement and speech and the impairment of cognitive faculties are still considered behavioral signs of depression.)¹² Galen proposes that as a result of the denser texture of the black-bile-infected blood, it either does not reach the brain at all, as it travels more slowly and is often obstructed on the way, or else damages the brain’s functions by clogging up its pathways. The cure for this kind of melancholia entails bloodletting, so as to purge the excess of bilious fluids from the body and to reinvigorate the sluggish bloodstream.

The second kind of melancholia Galen describes in On the Affected Parts originates in the stomach and can be caused by inflammation, indigestion, heartburn, and certain types of food. To fight these disturbances in the fluid economy, the body attempts to burn the excess of melancholic humors accumulating in the stomach. However, the ashes of the burned black bile rise to the brain in the form of a black vapor that subsequently clouds the sufferer’s judgment and feelings: “As some kind of sooty and smoke-like evaporation or some sort of heavy vapors are carried up from the stomach to the eyes, equally and for the same reason the symptoms of suffusion occur, when an atrabilious evaporation produces melancholic symptoms of the mind by ascending to the brain like a sooty substance or a smoky vapor.”¹³

Ostensibly figurative expressions still in use, such as “clouded judgment” and “black mood,” are thus rooted in what in ancient medical theory was actually thought to be the case: the assumption that the brain and its cognitive and affective functions were literally clouded and dulled by black vapors. (Interestingly, a strand in current depression research focuses on the role of negative attention and memory biases in the thought processes of the depressed, that is, the selective and often exclusive attention to and memory of negative information, which can be considered as forms of clouded judgment.) Galen emphasizes the literal link between darkness and melancholia elsewhere, too: not only is the color of the melancholic humor explicitly designated as black, but a certain type of person is more prone to becoming melancholic—that is, “lean persons with dark complexion, much hair and large veins.”¹⁴ (Other twenty-first-century avenues of depression research involve the search for defective genes that predispose certain individuals to depression and for other definitive biological markers of the condition.) Moreover, the inherent qualities of black bile, coldness and dryness, are of course primarily associated with dead matter, organic life being defined by warmth and moisture.

In addition to more or less predetermined temperamental and physiognomic qualities, external circumstances and lifestyle choices can trigger melancholia. Like many other theorists writing on exhaustion syndromes, Galen is keenly interested in diet and compiles a long list of forbidden foods that can bring about atrabilious reactions. Among the potentially melancholia-inducing and energy-draining fare he counts

meat of goats and oxen, and still more of he-goats and bulls; even worse is the meat of assess and camels, since quite a few people eat these as well as the meat of foxes and dogs. Above all, consumptions of hares creates the same kind of blood, and more so the flesh of wild boars. [Spiral] snails produce atrabilious blood in a person who indulges in them, and so do all kinds of pickled meat of terrestrial animals, and of the beasts living in water, it is the tuna fish, the whale, the seal (phoke), dolphins, the dog shark and all the cetaceous species [related to the whale].

He also warns against the consumption of cabbage, sprouts prepared in brine, lentils, and “wheatbreads made from bran.”¹⁵ Furthermore, he advises against the consumption of heavy and dark wine in large quantities, as well as aged cheeses. Other controllable lifestyle factors aggravating melancholic symptoms such as lethargy, weariness, and a dark mood can be lack of exercise and not enough sleep. (Again, physical exercise and a balanced diet are still thought to be important in the treatment of depression.)

While Galen emphasizes that every melancholic is unique, reacting differently to a surplus of black bile in the system, he agrees with Hippocrates’s basic definition of melancholia’s two key symptoms: “Fear or a depressive mood (dysthemia) which lasts for a long time render [patients] melancholic [that is, atrabilious].” All his melancholic patients, Galen writes, exhibit fear or despondency. One of them, for example, is afraid that “Atlas who supports the world will become tired and throw it away and he and all of us will be crushed and pushed together.”¹⁶ This is a particularly telling fantasy of catastrophe, which betrays a timeless fear about the calamitous consequences of the waning of engagement, the inevitable decline of our physical and mental powers, and the inescapability of death. Galen’s melancholic patients also generally “find fault with life and hate people,” many tiring of life altogether and wishing to die.

Galen believes in the Hippocratic and Platonic idea of the division of the soul into three faculties: the rational, the spiritual, and the desiderative. Unlike Plato, he also believes that each of these faculties is seated in a particular organ: the rational part is thought to be located in the brain, the spiritual in the heart, and the desiderative in the liver.¹⁷ Moreover, Galen proposes that the soul is embodied and that it is directly affected by bodily processes: “All of the best physicians and philosophers agree that the humors [krâseis] and actually the whole constitution of the body change the activity of the soul.”¹⁸ He does not conceive of the soul as an autonomous entity but repeatedly emphasizes that it is a “slave to the mixtures of the body” and that the body thus has the ability to deprive the soul of its energy:¹⁹ “So one is bound to admit, even if one wishes to posit a spare substance for the soul, at least that it is a slave to the mixtures of the body: these have the power to separate it, to make it lose its wits, to destroy its memory and understanding, to make it more timid, lacking in confidence and energy, as happens in cases of melancholy.”²⁰

The idea that physical processes essentially determine the soul, moods, and even specific behaviors starkly contrasts with later medical thinking, which frequently divides phenomena into those that pertain either to the mind or to the body, and which leaves little room for theorizing the complex interactions between the two entities. (There are parallels here to the arguments of researchers who believe in the purely biomedical origins of depression, that is, the idea that chemical processes in the brain, the “mixtures of the body,” are the exclusive determiners of our moods.) Galen draws on the authority of Plato to support further the idea that the bad humors of the body commonly cause diseases of the soul:²¹

When the humours of sharp and salty phlegm, or any other bitter and bilous humours, wander about the body without finding any path of exit, but are churned around and mix their spirit with the motions of the soul and are blended with it, they cause all kinds of diseases of the soul, great and small, few and many, in accordance with the three places of the soul to which they are brought, multiplying the kinds of ill-temper and low spirits, of bravery and cowardice, of forgetfulness and ignorance.²²

Irritability, low mood, difficulty concentrating, and cognitive impairments are symptoms of exhaustion that frequently appear in other syndrome-clusters, too—for example, in later discussions of acedia, neurasthenia, and depression.²³

According to Galen, melancholic exhaustion thus originates at a physical, almost proto-biochemical level and only in a second step proceeds to adversely affect the mind and the spirit by slowing or blocking the movement of the blood or by literally clouding the spirit. The causes of exhaustion symptoms such as weariness, lethargy, and torpor, as explained in the humoral framework, then, are essentially physiological in nature: it is the body that adversely affects the mind, and not, as twentieth-century psychosomatic theorists would argue, the other way around. Consequently, Galen also believes that doctors rather than philosophers should be charged with the improvement of the intellectual and moral qualities of the soul.²⁴

Yet curiously, there appears to be no room in Galen’s model for the notion that purely mental processes can influence bodily reactions and result in physical symptoms—for example, that faulty reasoning and irrationally pessimistic interpretations of phenomena and experiences may become manifest in a physical lack of energy. Although Galen very briefly mentions “excessive worrying” and grief as potentially melancholia-enhancing phenomena, he never theorizes further how these psychological factors might actually interact with and affect the physical body.

While the humoral model of melancholia offers a theory of the ways in which the body affects the spirit, it centers on the idea that the mind and soul are pure and pristine, and that it is the body that acts as the corrupting force. But might not the mind also affect the body in a comparable way? Galen does not comment on this possibility. In contrast, many twenty-first-century biomedical researchers investigating the chemical makeup of depressed brains admit that they are not at all certain whether reduced serotonin levels are a consequence of depression or its cause. This matter is still essentially considered an unresolved chicken-and-egg question.

Both during and since the age of classical antiquity, the exact nature of the interrelation between the mind and the body has been the subject of ongoing speculation, and it is very far from having been resolved by modern science. In the Hellenistic period, the ...

Table of contents

• Cover 
• Title Page
• Copyright
• Epigraph
• Contents 
• Acknowledgments
• Introduction
• 1. Humors
• 2. Sin
• 3. Saturn
• 4. Sexuality
• 5. Nerves
• 6. Capitalism
• 7. Rest
• 8. The Death Drive
• 9. Depression
• 10. Mystery Viruses
• 11. Burnout
• Epilogue: The Future
• Notes
• Bibliography
• Index