The full temple experience also included other magical and practical amenities. There were rituals, prayers, incantations, and sacrifices intended to please the gods. The priest also specialized in psychotherapy, commonsensical advice, and medicinal plants. Surgeries were also performed as needed. On top of this there were gym and spa services, diet advice, opportunities for intellectual stimulation at the library, and entertainment at the theater. And there was wine. The high cure rates are not surprising. The patient would be expected to contribute a generous thank-offering to the god. A tablet documenting the miracle cure would be prepared and displayed prominently, among many others. Advertising was good for temple business and heightened the prestige of its healing powers.4 The healing temple survives today in three very different forms—sacred sites of modern pilgrimage for faith healing; secular spas that promote natural health by exposure to exercise, diet, and beauty; and the modern medical center.
Hippocrates: Father of Medicine (Circa 460 BCE to 370 BCE)
A religious understanding of the world has always been (and probably always will be) man’s greatest comfort in adapting to its uncertainties and hardships. Supernatural belief of one sort or another has dominated most times and most places. But the Greeks, beginning in the seventh century BCE, developed an alternative, secular model to explain how the world works and why people get sick. They called it natural philosophy; we call it science. This new method has great explanatory power and creates its own brand of awe and beauty. The worship of unseen supernatural forces was replaced by close observation of the natural world and careful reasoning about the underlying principles that govern its operation.
The Greeks were not working in a vacuum. They synthesized the considerable science base of the Babylonian, Persian, Egyptian, and Indian cultures and extended it on a grand intellectual tour that gave birth to the modern world. The progress was swift and enriched all of human learning. Pythagoras demonstrated that the language of mathematics could systematically describe the secrets of nature. Democritus intuited that the apparent complexity of the universe is reducible to simpler, irreducible atoms. The Greeks knew that Earth is round and revolves around the sun, and accurately calculated its circumference. They even speculated about “multiverses.” Euclid devised geometry, and Archimedes devised the beginnings of calculus.
And the Greeks invented modern medicine. Hippocrates introduced a fully biological understanding of mental and medical illness that required no gods, no priestly authority, no sacrifice, and no ritual incantation. “From nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations . . . and by the same organ, we become mad and delirious, and fears and terrors assail us . . . all these things we endure from the brain, when it is not healthy.” Psychiatric and medical problems came from an imbalance of the four basic “humors”: blood, yellow bile, black bile, and phlegm. Cures would come from natural (not supernatural) processes. The physician would necessarily be limited by the biological realities; he could assist but never guarantee cure. He would be better at predicting the prognosis than changing it. But he could always comfort, console, and advise—and these too are crucial to healing.
Medicine (and psychiatry) would take man as its measure and humane treatment as its goal. Healing became a secular profession based exclusively on scientific observation and practical knowledge. Studying his patients closely and taking careful notes, Hippocrates clustered symptoms into many new diseases, each with well-documented course, predictable prognosis, and particular epidemiology. He described mania, melancholia, phrenitis, and phobia. No mysticism of any sort intruded upon diagnosis and treatment. Illness was not a punishment or a visitation of the gods; it was part of nature. “Men regard the nature and cause of disease as divine from ignorance and wonder.”
Hippocrates was a genius at prognosis and saw it as the most essential skill in medical practice. He recognized the importance of sorting patients into three groups: those who get better on their own; those who need medical treatment; and those who will not respond to any intervention. This “rule of thirds,” the most robust finding in medical history, is still taught to medical students and holds today for many psychiatric disorders.
The treatment recommendation depends on the patient’s prognosis. For group one, don’t give treatments that may do harm, because they will get better with time and support; for group three, don’t give harmful treatments because they will add to the burden of illness without providing cure; instead, provide solace and comfort. Specific treatment should be pursued only for group two, balancing the risks of treatment with those posed by illness. Be sure that interventions are more likely to help than harm. Hippocrates favored cautious, mild, natural healing except when extreme circumstances required and justified a more aggressive approach. He would be puzzled and deeply saddened by the promiscuous use of harmful antipsychotic medicine that has become a dangerous part of current practice.
Hippocrates was a modest man, loving toward and beloved by his patients and students. Never doctrinaire or authoritarian, he took pleasure in learning from accumulated clinical experience, his own and others. He institutionalized the concept of secular medical education and practice—of learning at the bedside. His students further developed his methods and created a distinctive style of clear and objective medical writing.5 An interesting sidebar is that Thucydides borrowed from the Hippocratic style in his great clinical descriptions of the sickness that is our human history.
Galen: Father of Personality Theory (AD 130 to AD 200)
Galen was a man for all medical seasons—a healer of bodies and mender of minds. No doctor ever had a wider clinical experience, investigated such varied diseases, invented more treatments, or wrote so many words.6 When he wasn’t busy being team doctor for a stable of gladiators, inventing cataract surgery, and performing brain operations not repeated till modern times, Galen expanded the scope of humoral theory to explain human personality and its impact on illness. The humors explained not just what ails us but also who we are. Our fate is not determined by our stars or by the demons or the gods—instead it is based on the balance of our bodily chemistries. This biological model of temperament and its effect on behavior is not very different from modern theories, except that he got the specific chemistries wrong.
The Greeks did things in fours. There were four seasons, four ages of life, four planets, and there were four elements (air, fire, earth, and water) that in various combinations determined the physics of the world and the biology of body and mind. There were four humors (blood, yellow bile, black bile, and phlegm), each related to one of the elements. Hippocrates had noted that an imbalance of these causes illness. Galen added to the standard system that personality also comes from an imbalance of these same humors. Too much blood produced an excessively sanguine personality; too much yellow bile, the choleric; too much black bile, the melancholic; too much phlegm, the phlegmatic. Their harmonious balance led to normal mental functioning. There were all possible permutations of various mixes of humors that explained and gave color to the great variety of human behavior and tendencies. All this sounds “quackish” now, but it governed medicine for more than fifteen hundred years. For comparison, the half-life of many current theories is measured in decades, not centuries.
By temperament, Galen meant not only the behavioral aspects of personality but also its bodily manifestations. Mind and body were interacting; personality and health were inextricably linked. You could predict how a person of a given temperamental mix would behave, but you could also predict how his body would behave—which illnesses he was most likely to get and which treatments would work. Illnesses might come and go but your temperament was inborn and fairly stable. It could be influenced and brought into balance with appropriate interventions—diet, activity, herbs, bloodletting, cupping, purging. The treatment had to be very individualized, since there were so many permutations of imbalance among the four humors.
Galen understo
od that brain dysfunction and mental illness could have many causes (environmental or constitutional) other than an imbalance of the humors. Wine could drive man mad. His experience with the gladiators taught him the importance of head trauma, and the causative role of brain fevers was obvious. He also recognized that mental retardation was due to congenital problems in brain functioning. Equivalent to current practice, before making a diagnosis of personality disorder, one had to rule out the possibility that medical illnesses or substance use was responsible for the person’s behavior. Only when there was no more definite cause would temperament and humoral balance be considered primary.
Treating humoral imbalance was a balancing act that first required a careful diagnosis to determine which fluid was tipping the scales and then changing the patient’s life to even things out. Vomits, purges, sweats, and bleeding were obvious because of their direct impact on the fluids. Various herbs, spices, metals, hot and cold, dry and wet, were believed to have differential medicinal impacts that could titrate each humor. Curative manipulations included baths, climate change, and diet. There was also a philosophy-of-living component—each person has a very individualized temperament that will do best and be healthiest within a particular way of life. Once the temperament is diagnosed, a next step is to determine which aspects of the person’s life upset balance, which provide support. The prescription would be an adjustment in environment and daily habits (study, work, diet, sex, drinking, music, family relations) to correct the fluid imbalance and thereby improve personality, increase happiness, and prevent medical illness.
Galen dominated medicine for much longer than he should have or would have wanted to. Later generations accepted his writings as doctrine, honoring his authority but failing to honor his methods of independent observation and experiment. The humoral theory wasn’t conclusively overturned until the mid-1800s, when Virchow demonstrated the role played by the cell in disease. But Galen’s insight that inborn tendencies in personality affect mental and physical illness is as fresh as the day it was born.
The Dark Age of Demons
The treatment of the mentally ill in Europe went into the Dark Ages, which lasted from the fall of Rome (in the fifth century) to the rise of Philippe Pinel (in the late eighteenth). The dark ages were never nearly so benighted as we imagine (and there were always isolated bright spots), but for the mentally ill this was the worst of times, the worst of places. The Greek biological theories recognized the humanity of the mentally ill and regarded their strange behaviors as fully understandable within a medical model. The mentally ill were people like us who happened to have a biological imbalance. Not their fault and not scary, just unfortunate.
The Greek medical enlightenment was a victim of the Dark Ages. The doctor of medicine who diagnosed chemical imbalance was replaced by the doctor of the church who diagnosed demonic possession. Exorcism, inquisition, torture, and the stake replaced medical treatment. The mentally ill were inhabited by dangerously contagious, demonic forces that had to be destroyed as part of God’s struggle against the devil. Certainly there were exceptions (kindnesses extended and hospitals built by religious orders), but overall the treatment of the mentally ill was a holocaust and a shameful chapter in the history of the Church. Christian theology, mixed with pagan demonology, created a story line depicting mental illness as the devil’s handiwork. The moral neutrality of humoral theory was no match for a vivid religious drama portraying an eternal battle of God versus Devil, with madmen (and more often madwomen) as pawns on the losing side.
The Western world equated difference with evil and feared its contagion. Someone acting strange could be communing with the devil and threatening the welfare (and eternal salvation) of the entire community. In extreme cases, torture and execution were considered fully justifiable as part of God’s work. In milder cases, recovery was possible, but only after a confession of sin and a willingness to return to God and holiness. Greek scientific observation was replaced by a quaint system of spiritual diagnosis that matched the peculiarity of different mental states with a hierarchy of different devils. A pall of religious delusion had settled on Europe that sanctified a mean-spirited cruelty in the treatment of its most vulnerable citizens.7
Death did not protect the mentally ill from continued indignity. In canon law, attempting suicide was a crime instigated by the devil to spite God. The corpse was a fit candidate for extended punishment that might consist of some combination of hanging, torture, mutilation, and being dragged through the streets. Survivors of suicide attempts might expect to have their death wish fulfilled by superstitious neighbors, often in the cruelest way, to ensure that their devils were properly punished. The prohibition against burial in consecrated ground extended the punishment into eternity.
The Malleus Maleficarum, published in 1487, codified demonic doctrine and provided rationale and legal force for an inquisition of the mentally ill.8 They were weeded out with brutally efficient and inhumanly cruel bureaucratic methods. The mad were judged by God and man to be witches and demons, deserving no mercy and (with few exceptions) receiving none.
In more enlightened religious circles, sin gradually replaced possession as the diagnosis of choice and explanation of mental disorder. Disagreeable behaviors and manners were the outward symptoms of an unruly, uncivilized, greedy, and lascivious nature. The mentally ill had graduated from being demons to being sinners. Their behavior reflected not the direct intervention of the devil, but rather the immoral and ungoverned exercise of their own free will. In this they were not very different from the common criminals with whom they were often enough housed. Harsh treatment was recommended to redirect the mentally ill to the straight and narrow of passions governed and sins renounced. They needed to be taken in hand, tamed, and restrained. Sinful natures were stubborn and ingrained. Some of the treatment consisted of moral suasion; much of it was physical punishment. There were attempts to enhance the spiritual life of the mentally ill and to teach them habits of order, self-discipline, and restraint. This was intended to bring them closer to God and away from sin. But for the recalcitrant sinner who refused to get better under the direction of this light-handed approach, punishment had to be commensurately severe. Spare the rod and spoil the patient. The illness had to be quelled along with the sinful pride that caused it; morality was instilled with a strong hand that included all manner of physical restraint, whipping and other corporal punishments, spinning chairs, freezing baths, and other forms of exposure. Though punitive in the extreme by modern standards, such treatment was not as unrestrained in its cruelty or lethal in its effect as when it had been directed at the devil or his agent. No longer used were the torture tools of the inquisitorial trade or burning at the stake. The mad were seen as bad and treated as such, but at least they were not personifications of the devil.
Certainly there were important exceptions to Europe’s dark treatment of the mad. Many Christian charity hospitals were founded in the thirteenth century in monasteries and on the stops to the holy land or pilgrimage sites. The mad, the physically ill, lepers, orphans, and the poor were given room, board, prayers, and Christian understanding by monks and nuns. Therapy was minimal, scientific observation and clinical diagnosis nil. The goal was Christian care, not diagnosis or cure. But this was a huge step up from the stake.
But the more naturalistic, biological view was never completely suppressed. Humoral medicine had always kept a slender foothold in the monasteries and was greatly revived during the Crusades when rude Western invaders encountered the much more advanced medical civilization of the Muslim world. Galen’s treatises that had previously been translated from Greek to Arabic were now translated from Arabic to Latin. Town universities began to replace monasteries as centers of learning, and each established a medical faculty with a naturalistic worldview that to some degree balanced the demonology of its theology department. The professors of medicine taught that natural, humoral causes of madness should be considered exclusions before assuming demonic possess
ion. Unfortunately, the impact of the professors on practice was negligible. Medicine was taught as theory only, and its teachers were ivory tower types who spoke with Galen’s authority, but had no patients. Without close personal observation, it was impossible for them to have much influence or to advance the clinical science of understanding mental illness. Indeed, the naturalistic purpose of the medical professors was sometimes perverted to the cause of theorizing on the physiology of demonic possession and how it affected sanity. One interesting side effect of Galen’s renewed influence was a dramatic increase in the price of the treasured spices that had to be imported from the Orient; these were seen as particularly useful medicines in regulating the body humors.
Even in an age of superstition, common sense and humane attitudes never totally disappeared. Not every problem was demonized, not every patient subjected to torture. Other factors—overwork, overeating, too much sex, or excessive worry—were sometimes considered causative and called for reasonable treatment, behavioral changes, prayer, pilgrimages, rituals, and amulets. Many were cured through “miracles of faith.” And exorcisms did not all require trauma or death; sometimes they were symbolic—a model of the devil, not the person, would be beaten.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 6