Mental Illness in Post-Hippocratic Medicine (1st – 7th centuries A.D.)

The earlier Hippocratic medicine was credited with: the rational understanding of the mind and its disorders, the setting of the foundations of the clinical observation, the importance given to the biological substratum of mental illness, the attempt to treat illnesses empirically, the setting a code of ethics for the physician in his practice.

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However it was post-Hippocratic medicine that, building on earlier progress, developed a comprehensive nosology and treatment of mental illnesses for which it has been credited. Medical writers, early in the era* between the 1st to the 7th century A.D., provided descriptions of the illnesses of the mind and recommended therapies, however only two among them, Aretaeus and to a lesser degree Soranus (as reported by Caelius Aurelianus), presented these illnesses systematically.

*[A number of important physicians-writers flourished in this six century period. Among those who lived in the earlier centuries, Aretaeus the Cappadocian (c. 50 A.D.), Soranus of Ephesus (c. 78-117 A.D.), and Rufus of Ephesus, probably contemporary of Soranus, have dealt with mental illness extensively. Galen of Pergamum (131-201 A.D.) presented his views on mental illness less systematically. Among his several treatises none is dealing exclusively with them. At a later date other medical writers such as Oribasius of Pergamum (c.325-400), Aetius of Amida (6th century A.D., Alexander of Tralles (525-605 A.D.) and Paulus of Aegina (609-690 A.D.) gave considerable attention in their treatises to mental illness. Most of these physicians came from Ionia and some lived and practiced medicine in Rome. Oribasius and Aetius were encyclopedic writers reporting in their textbooks postulations of earlier physicians whose works are not in existence. Soranus’ major clinical work on Acute and Chronic Diseases has been preserved to posterity in a Latin treatise by Caelius Aurelianus]

Pathology

For an overview of nosology it is necessary to turn the attention first to Aretaeus’ work. In brief illnesses of the mind were distinguished in acute and chronic. Acute illnesses were epilepsy, ‘phrenitis’ [φρενίτις] and ‘hysterical suffocation’ [υστερική πνίξ]. Epilepsy represents the concept that has existed till modern times. Phrenitis which was considered to occur always with fever corresponds evidently to modern delirium associated with infectious diseases. Delirium was obviously common in an era infectious diseases were rampant. Aretaeus attributed delirium to overheating of the head and to alteration of the spirit [πνεύμα] as well as to infection affecting the body in general [φλεγμονή]. Caelius Aurelianus attributed phrenitis to a generalized condition with specific effect on the head. Later authors, e.g. Aetius and Paulus wrote about infection of the meninges and/or of the brain. Hysterical suffocation, the third acute disease was evidently an attempt to conceptualize anxiety disorders. Some authors considered this illness to be associated with a disturbance affecting the uterus, particularly with movements of this organ in the abdomen.

The chronic mental illnesses were two and were considered to be related to one another; they were ‘mania’ and ‘melancholia’. According to Aretaeus and Themison and ‘others’ as reported by Caelius Aurelianus, ‘mania’ and ‘melancholia were different expressions of the same disease. Alexander also expressed the same view. Aetius , Paulus, and Oribasius included ‘lycanthropy’ in the same group of diseases. Those suffering from lycanthropy wonder around graveyards in the night during February howling like wolfs or dogs. In a study on Aretaeus’ nosology it was suggested that ‘mania’ and ‘melancholia’ covered the whole spectrum of functional psychoses that is schizophrenia and manic-depressive illness of modern medicine. ‘Mania’ in fact appears to subsume what in modern psychiatry is mania and schizophrenic states of excitement and agitation.

‘Melancholia’ on the other hand subsumes modern depression and schizophrenic states of withdrawal and chronic deterioration. Mania and melancholia were considered the result of imbalance of body fluids or humours [κακοχυμίη], as Aretaeus put it when black bile concentrated in large quantities in the head and other parts of the body [δυσκρασία]. Caelius Aurelianus did not share the same views about the disturbance of the humours in the pathology of the illness. Instead he adopted the theory of Asclepiades of Bythinia  who suggested that the pathology of the disorders depended on the condition of the passages [πόροι] that exist between the molecules [άναρμοι όγκοι] which form the organs including the brain. Disease depended on the closing or relaxing of the passages. This appears to be an early anticipation of cells and their pathology.

Rufus of Ephesus, who had become known in late antiquity for his treatise on melancholia, appears to have included it in ‘madness’ in general dealing with the illness purely from the biological point of view specifically with regard to treatment. Rufus’ book has not survived to posterity. We have only excerpts of this work which survived as quotations in the works of other Greek, Latin and Arabic authors.

Besides ‘mania’ and ‘melancholia’ some writers, including Aretaeus described other chronic psychiatric conditions such as psychiatric disorders associated with epilepsy, senile dementia [λήρησις, μώρωσις], catalepsy, lethargy, sleep disturbance. Caelius Aurelianus included homosexuality. Galen (c. 131-200 A.D.) dealt also with personality characteristics called ‘passions of the soul’ and their treatment.

Treatment

Consistent with their views that the background of mental illness was biological or physical, the ancient physicians attempted to treat the illness primarily with biological or physical means. Environmental arrangements and psychological treatments were in general considered as adjunct or supplementary therapies. Caelius Aurelianus probably answering arguments suggesting that mental illness might be treated with psychological means that is by listening or talking with philosophers commented: ”Those who imagine that the disease is chiefly an affection of the soul and only secondarily of the body, are mistaken. For no philosopher has ever set forth a successful treatment for this disease”. However, if the patient has improved a lot and presents “no new symptoms” and “is willing to hear discussions of philosophers he should be afforded the opportunity. For by their words philosophers help to banish fear, sorrow, and wrath and in so doing make no small contribution to the health of the body”. If the author had to use words of current usage he would probably have spoken about psychotherapists than about philosophers.

The limits of the treatment of the mental illness were stated eloquently by Aretaeus. He recommended that the physician cannot cure every patient, since he is not superior to God, but he could “produce respite from pain, intervals in diseases and render diseases latent”. Objective of the physician, Aretaeus says should be the strengthening of nature since “the nature without instruction and learning does what is proper. A similar in content comment was made by Rufus of Ephesus who said: “It often happens that we cause additional problems with too active treatments…Time should be given to nature”. He was referring to the practice of prescribing in excess emetic drugs (epithymum and aloe).

Fasting and dieting were of special concern to most physicians. Both were of help in restoring balance of the humors [ευκρασία] in the body.

Music therapy was recommended by others, probably older tunes, such as the phrygian mode for depression and the dorian mode for mania. These were referred to by Caelius Aurelianus. The environment where the patient is kept and his diet are also of special concern to Alexander of Tralles.

The number of drugs in use was substantial towards the end of the 6th century. Most drugs were extracts of pharmaceutical plants many of which were originally presented by Dioscoridis (1st century A.D.). A concise account of the treatment of mania and melancholia was provided by Paulus of Aegina. Similar in nature was the treatment of mania and melancholia recommended by Archigenes, Poseidonius, Galen and Rufus as reported by Aetius.

Galen described certain personality characteristics, such as explosive tempers, envy, and other which he named “passions of the soul”. For the treatment of passions Galen recommended a purely psychological type of treatment which was to be administered by a wise man, a teacher, a philosopher who could teach and train the person to self-understanding and to new modes of self- expression. Galen’s treatment appears to resemble the modern cognitive behavior therapies.

(Source: “Treatment of Mental Illness in Post-Hippocratic Ancient Medicine”, by S. Kotsopoulos)

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Research-Selection for NovoScriptorium: Maximus E. Niles

 

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