Black Bile Theory
A plague laid siege to the land, and I moved into a castle. What was old is new again.
Mask use is intermittent at best in The Castle. It’s easy to get paranoid standing in a slow elevator with a few maskless people, or even touching door handles in the complex. People post on the Facebook group about being quarantined in The Castle with the virus. I take the concrete stairs almost all the time, and I never strike up conversations with my neighbors.
Plague life in The Castle isn’t that different from anywhere else, I suppose. I feel the same isolation, fatigue, anxiety, and boredom as anyone. I’ve been lucky that nobody close to me has gotten seriously sick. But between my dystopian domicile, the gloomy West Michigan winter, political strife, and the pandemic, it can feel like a dark time.
I first sought treatment for depression when I was 19. I’ve struggled with that darkness — not just to overcome it but even to comprehend it. Depression has dominated different chapters of my adulthood in different ways, and it’s something I fear that I’ll always have to cope with. I try not to define myself as a depressive, but it’s hard sometimes.
Last winter was dark for me too. In that darkness, I discovered black bile theory.
Back in the original era of castles and plague, people understood the body and the mind a lot differently. Their knowledge was shaped by the works of the ancient philosophers Hippocrates and Galen, who believed that four fluid elements — called humors — control the physiology of the human body. Those four elements are blood, phlegm, yellow bile, and black bile. They align with the four seasons and the four elements: air, water, fire, and earth. Humoral levels fluctuate constantly, changing with environmental circumstances, different stages of life, and even a person’s diet.
For centuries, Western medicine was premised on humoralism. People believed that diseases were borne of a surplus / deficiency of a particular humor, and that they could be cured by purging / restoring that humor, thus bringing balance back to the humoral ecosystem. Medieval medicine is remembered as crude, often vile, and ridiculously ill-conceived because of practices like leeching — an attempt to rid patients of an excess of blood. Though some medieval physicians began to doubt the credibility of humoralism, that framework persisted well into the 19th Century.
During those days when black bile theory was the basis of knowledge, people didn’t believe that they were healthier without their black bile; they maintained that equilibrium, balance, and stability between the four humors brought harmony to the body and the mind. For while an excess of black bile was indeed calamitous, a lack of it was as well.
Humoral theory went beyond disease and medicine. Humors also determined a person’s temperament: their disposition, their moods, their personality. Blood was associated with cheerfulness and passion; phlegm was associated with calmness and rationality; yellow bile was associated with anger and ambition.
Black bile was associated with depression, or to be more specific, melancholy.
Humoralism is absurd for many reasons. Black bile doesn’t even exist. The other three humors are at least compatible with our modern understanding of the human body: blood, phlegm, and bile (which is more of a yellowish color than black). Some theorists linked each humor with a specific organ. The spleen was thought to store black bile, but eventually humanity discovered that spleens filter blood cells and trigger immune responses instead. Various theories have been proposed as to what “black bile” could have actually been: clotted blood, perhaps, or maybe the dark liquid that seeps from the adrenal glands after death. Nobody really knows.
Therefore, black bile is fictive, abstract, metaphorical.
Ancient physicians believed it to be cold and dry — the opposite of blood, hot and wet. I imagine it to be sticky and a little tarlike, but quicker and more viscous, like a polar vortex wind to the touch, staining everything in an inky smudge, jet black but with the swirling rainbow sheen of gasoline spilled on dark water, carrying the faintly sweet scent of rotting meat.
When I first realized that I’d been suffering from depression, it was an epiphany. I felt a sense of exhilaration. I was walking from a friend’s apartment to a calc midterm; it was a beautiful, sunny Ann Arbor afternoon, brilliant yellows splayed through the trees on campus. I couldn’t focus on the test. After what had been a few inexplicably bleak, miserable months, I felt some hope. I could finally articulate what I was feeling.
That hope didn’t last long. On my next visit home, I told my mom that I felt depressed and wanted to seek treatment. I didn’t like the first counselor I saw, because I felt they didn’t seem to understand the severity of what I was going through. It took a while before I vented my frustrations and told them that their suggestions seemed woefully inadequate; they referred me to a psychiatrist who could prescribe medication, something I thought I needed.
I connected with that psychiatrist, but the pill regimens proved ineffective. For the rest of my time in undergrad, I went up to my psychiatrist’s office once or twice a week, a retrofitted one-bedroom apartment in an old tower near campus. The view was beautiful. I respected their intellect, held them in high esteem, and eventually felt comfortable sharing almost everything with them: my deepest fears and insecurities, sources of shame and regret, how I distracted myself with idle vices, and the depths of the pain I felt.
My college years were really difficult. I gained a lot of weight and hated the body I’d grown into. I was shy and withdrawn. The certitude of my religious upbringing was replaced by a grim nihilism. My academic performance suffered, and I didn’t prepare for what would come after graduation. During my junior year, I dropped out of school for a few months, returned home, and picked up a job shoveling snow and cleaning carpets.
Over those years, I tried so many different kinds of medication, and most of them just locked up my guts for some added misery. I dutifully went to my therapy sessions and talked through things with my psychiatrist, but the depression persisted. I was drowning in black bile. Whenever I return to Ann Arbor, I feel traces of it seeping into my consciousness, a shadow of the suffering I felt there, a reminder of the darkness that’s never too far away.
Depression was a mystery. It’s already been almost a decade since my sophomore year at U of M. Since college, I’ve grown to understand my mental illness better, but it’s been an arduous process. I kept in touch with my psychiatrist for a while over the phone after I left Ann Arbor; I started going to counseling again in Grand Rapids a few years ago. The conversations I’ve had in therapy sessions have helped immensely. In the early days of the pandemic, I sought additional treatment from a psychiatric facility in GR and tried a different kind of medication, which helped.
All things considered, I’m doing well right now, but depression has been a complex experience. Even though I have a much better grasp of how it works than I did when I was 19, it still can be mysterious sometimes.
Black bile theory became a breakthrough. What was old is new again.
I found the temperamental angle to humoralism fascinating. Even now, humankind strives to find essential qualities in the self. There are plenty of modern equivalents: Myers-Briggs tests and enneagrams, countless online quizzes determining personality types. Some people have attempted to retrofit more positive traits for the four humoral types, which is how melancholy can be reframed as introspectiveness.
I saw myself in the melancholic type, of course. I began to contemplate the meaning of melancholy, especially in relation to our modern understanding of depression.
When I started seeing my current counselor, I took a standard questionnaire. There were a lot of questions regarding symptoms associated with depression: sadness, anhedonia, hopelessness, abnormalities in appetite or sleep, thoughts of suicide, and so on. When you’re done rating each of them on a 1-to-5 scale, you add up the points to measure your suffering. A certain threshold determines whether you’re depressed or not, or how depressed you may be. At that time, my suffering was moderate.
It wasn’t until the 20th Century that the term depression came into use. At first, a tension arose between competing theories of depression: whether the disorder was due to biological predisposition or a form of stress reaction (my experience suggests the answer is both). Some psychiatrists at the height of existentialism believed it to be rooted in the intrinsic struggle of the human condition (a view I’m inclined to agree with). The classification of major depressive disorder wasn’t actually added to the DSM until the third edition was released in the eighties. By then, mood disorders had been associated with chemical imbalances in the brain, and patients had started taking early antidepressants to treat their depression. Eventually classifications grew to be more precise. It’s a common diagnosis these days.
People often say that mental illness, and depression in particular, is a disease like any other, no different than cancer or a broken leg. Usually those statements are meant to validate the significance of a person’s experience, but I’ve found depression to be more complicated than broken bones or gallstones. Modern psychiatry posits that depression is correlated with excessive / insufficient brain humors, and that pills stabilize them. At first, I thought medicine would fix me, but it didn’t. Eventually, I found that medicine could help me, even if it didn’t fix me. I struggled with depression all the while.
But when I became familiar with black bile theory, I found that there may be a different frame for my experience than understanding it as a struggle with depression. Instead, I felt as if I were afflicted with melancholy — a word that derives from the ancient Greek terms for black and bile.
Humanity grappled with melancholy far longer than it has dealt with depression. Aristotle posited that melancholics, though beset with a wide variety of ghastly physical ailments, were prone to brilliance — that their suffering could beget greatness. The author of the ur-text of Persian medicine, Al-Akhawyni Bukhari, included delusions and hallucinations as effects of black bile on the brain. Ancient Christians believed that melancholy and its related malady, acedia (a term that denotes apathy and inertia), were caused by demons. In the 17th Century, an Englishman named Robert Burton compiled an exhaustive encyclopedia of illness and madness under the umbrella of melancholia.
Melancholy was a broad concept, but virtually all definitions tended to emphasize the same symptoms found on modern depression questionnaires.
The terms melancholy and depression could be considered roughly synonymous. Indeed, depression has usurped melancholia as the label for that malady. There is a difference though. Melancholy encompasses the symptoms of depression but goes beyond that: it’s considered a persistent, existential despair, deep and severe, fraught with wondering and rumination. It’s an indulgent sadness, especially lonely and pensive, associated with idleness and excessive leisure. It also carries the tinge of tragic glory that elevates the melancholic into the protagonist of an epic battle against the self — the demons, the black bile, the depression, the darkness.
When your black bile levels rise high enough, black bile becomes all that you can see. It consumes everything.
It’s a dull, colorless existence. The depths of significant depressive episodes are sometimes accompanied with an acute, almost physical heartache. Sadness and melancholy are universal feelings; nobody passes through life without experiencing some tragedy, emotional or otherwise. Drowning in that feeling is different. Depression is all the melancholic can feel. Their entire life becomes filtered through the black bile.
I’ve spent so many mornings and nights lying fitfully in bed with the shades drawn, trapped in the liminal space between asleep and awake, marinating in black bile, afraid of the demons. It feels inescapable. Weeks, months, even years of my life have been lost to that darkness — the pain of living in a broken world, feeling nothing but the magnetism of the void, knowing that joy, the heat of life, has fled and not knowing when it would come back. Melancholy days don’t feel meaningful. They’re just cold and empty.
That loneliness is existential, whether you’re actually alone or not. I’ve been fortunate to have some wonderful people in my life. My family’s always been there for me, I had close friends by my side in college, I have a good social circle in Grand Rapids, and I’ve made meaningful connections in online communities. Still, I’ve felt as alone among loved ones as I did when I moved across the country to a city where I knew nobody and worked in an empty office building. Depression separates you from everyone. It creates a divide between you and the world.
Depression also traps the mind. Over the last decade, I’ve thought so much about my various melancholies: feeling sad and lonely, but always interrogating that sadness and loneliness, always wondering about the darkness, always sensing my idle thoughts drawing me towards whatever I was depressed about. Melancholics are brooding. I’ve found depression impossible to ignore when black bile levels are high; I become obsessed with my problems, whether existential (like mortality, decay, self-hatred, alienation, ennui, things of that nature) or more circumstantial (like a heartbreak or difficult financial situation). I’m always aware of my melancholy, always reckoning with it. Often the thought patterns feel the same — repetitive and tedious — but sometimes revelations can be found by exploring the depths.
There’s no inherent valor or righteousness in suffering like that. It doesn’t necessarily breed strength nor wisdom. When depression was still mostly mysterious to me, I sometimes wondered if the struggle lent gravity or depth to my life. Depression often felt meaningless and inexplicable, but not always. I felt that if I could articulate what I was experiencing, I might be able to conquer it. I hoped that I was slogging through a labyrinth to find some sort of treasure — a higher degree of enlightenment forged by black bile.
I learned a lot from 19 to 26, when I was introduced to the concept of black bile. By then, I’d come to grasp sources of it in my life. I’d started to identify my depression and deconstruct it; I understood how aspects of my life intersected with negative feelings, whether physical or emotional, and how I could let some of them pass. I came to realize how sleep, exercise, diet, drinking, smoking, and other habits influenced my mood. I was developing some discipline. Candid therapy sessions helped me dissect certain negative, deeply held beliefs about my life. I was far from conquering my depression, but I became better at managing it — or at least understanding it.
Not long after I learned about black bile, I started referencing it as a half-ironic bit, a little joke, a way to discuss depression while stripping it of its exhausting grandiosity. I did sincerely view myself in the glum, brooding melancholic, and black bile jokes helped reinforce that dynamic. For while I did unseriously champion the ancient theory of humoralism, I also found melancholy to be a more productive framework to understand my malady.
Plus I enjoyed the joking tone of black bile, as if I was sarcastically discussing an ailment: rating today’s black bile on a scale around the water cooler at work, predicting the week’s black bile forecast in counseling sessions, finding a few drops of it at the bottom of my fourth beer with the boys at the bar. I’d always been open about my feelings, but black bile reduced them to something else, more sardonic and unserious, maybe more manageable. Black bile theory can subvert depression. Humoralism can’t be much more irrational than the relentless, poisonous negativity that torments the depressed anyways.
And yet, that winter — our last time before the pandemic — was a very melancholy winter. A few weeks before the shutdown, I visited a good friend from college in Los Angeles. It was rainy there that weekend. I was mired in toxic circumstances back home. I felt like I needed to escape the black bile and wanted to flee Grand Rapids. Things changed for the worse from there, of course. It became a cold, clear spring of intensely painful personal growth for me. The black bile flooded my system. Once I felt it exhorting me to succumb, I knew I needed more help. I considered checking myself in for in-patient treatment, but instead decided to give medication another chance.
Those new pills helped drain some of the black bile and loosened its power over me. I enjoyed the summer — time with family, the beauty of Michigan. I started to develop some confidence and self-love. In the fall, I moved into The Castle and began writing. I found a girlfriend. About a year ago, my life fell apart. What’s been rebuilt in its place has been so much better, despite the darkness of the pandemic.
Learning to manage or even harness black bile is difficult, but can bring some form of transcendence, even if it’s only a temporary transcendence over the darkness. Throughout my experience with depression, I held onto the hope of that transcendence — an enduring, if not unwavering hope. That hope is vital.