Medical Psychology

Medieval and early modern medicine inherits from Galenism a certain indifference toward psychology. This indifference persists also after the fall of Galenic humoralism, until the end of the eighteenth century, so that the mainstream approach to mental disorders remained for a long time a predominantly somatic one, from both an etiological and a therapeutic point of view.

Psychopathological nosology continued for a long time to be viewed in ancient terms, focusing on traditional areas such as mania and melancholy, with the addition of some ‘‘diseases’’ entrusted to medical competence during late antiquity and the Middle Ages. Such ‘‘diseases’’ include lycanthropy (the supposed transformation of a human being into a wolf, considered by physicians of this time as a form of melancholia) and amor hereos (passionate love), the ancient love sickness that in the anecdote quoted above was considered a disease of the soul but was included by Arnald ofVillanova (ca. 1240-1311), for example, among the physical disorders.

Besides Galen, the only ancient physician with whom the Middle Ages were acquainted and who was interested in mental pathology is Rufos of Ephesos (first to second century bc), a supporter of humoralism as well and the author of a treatise on melancholia that was appreciated by Galen himself. There are also ancient physicians, like Cornelius Celsus, Aretaeus of Cappadocia, and Caelius Aurelianus, who followed other medical theories. They give detailed accounts of mental disorders with both pharmaceutical and relational therapeutic prescriptions, but their works were rediscovered only in the Renaissance and influenced only a few authors, whereas the cultural context was still dominated by Galenism. Among the authors of the early modern age interested in the psychological dimension of mental disorders, we should mention, for example, Paolo Zacchia (1584-1659), from Rome, physician of popes and founder of legal medicine, who made use of Celsus and the ancient moral philosophers in the psychopathological part of his Quaestiones medico-legales (Medical-legal questions; see Stok 2006).

This situation changed in the Enlightenment, when the French physician Philippe Pinel (1745-1826) elaborated a medical psychology that had great relevance in the history of psychiatry and psychiatric care (he also reformed the Parisian asylums of Bicetre and Salpetriere, as illustrated by Michel Foucault in his History of Insanity in the Age of Reason). In his Medico-Philosophical Treatise on Mental Alienation (1801), Pinel pushed aside the somatic approach hitherto prevailing and highlighted the importance of the passions as causes for mental disorders. From a therapeutical point of view, he elaborated the so-called ‘‘moral treatment’’ - a relational treatment aimed at controlling the behavior, the way of thinking, and the emotions of the patients. As the title of his work suggests, Pinel attempts in this way to give a philosophical foundation to medical discourse. He is obviously thinking of contemporary philosophy (Locke, Condillac, the Ideologues, and others), which was characterized by an approach to psychology that was detached from the problems of the soul.

But Pinel’s ideas are also influenced by his classical background (Pigeaud 1994): his theory of the passions as causes of mental disorders comes partially from the Stoic theory of the passions discussed in Cicero’s Tusculan Disputations, and his moral therapy is like the ancient ‘‘medicine of the soul.’’ According to Stoic doctrine, however, philosophy must eradicate the passions; not so for Pinel, who believes that they are to be controlled and disciplined by medicine through application of the moral treatment. Pinel’s classicism is also remarkable in his attitude toward the ancient physicians. He is resolutely hostile to Galen, to whose influence he ascribes the difficulties hitherto encountered by medicine in the psychopathological field. On the other hand, he thinks highly of Celsus, Aretaeus, and Caelius Aurelianus.

The second great exponent of French psychiatry was Jean-Etienne-Dominique Esquirol (1772-1840): he, too, used ancient authors, both medical and philosophical. In the essay entitled The Passions Considered as Causes, Symptoms, and Means of Cure in Cases of Insanity (1805), he affirms an approach to anger and madness evidently suggested to him by Seneca (On Anger 1.2). Like Pinel he praises Celsus, Aretaeus, and Caelius, along with Erasistratos, evidently for his treatment of love sickness. In the anecdote mentioned above, however, Erasistratos recognized the boundary between the medicine of the body and that of the soul, whereas Esquirol enlarged the field of medicine to include love sickness.

Hippocratic aphorism 6.23, on melancholia, is also discussed by Esquirol in his proposal for a new psychopathological denomination, that of lypemania (in an essay contained in his On Mental Disease Considered in Medical, Hygienic, and MedicoLegal Terms, 1838). This was a clinical condition that foreshadows today’s pathologic depression (Jackson 1986: 152-3) and which has provided the term that has been used by psychiatrists for some decades. Unlike melancholia, use of the term ‘‘lypemania,’’ for Esquirol, had the advantage of avoiding the obsolete reference to humoralism (for him this disease was mainly caused by ‘‘moral affections’’), along with the ambiguity connected with the humoral typology.

Ancient authors probably also influenced the important distinction theorized by Esquirol in 1817 between hallucination (the perception of an object when no object is present) and illusion (the deceptive perception of reality), a distinction already suggested by ancient philosophy and medicine (Cicero Academics 1.88-9; Aretaeus 3.6; Caelius Aurelianus On Acute Diseases 1.118-19).

In the second half of the nineteenth century, an approach based on the organic and neurological aspects of mental disorders again prevailed in psychiatry. The German psychiatrist Wilhelm Griesinger (1817-68) programmatically declared that ‘‘mental diseases are diseases of the brain,’’ a declaration reminiscent of the one we found in the Hippocratic De morbo sacro. Psychiatric research, consequently, was giving priority to anatomy and neurophysiology. In Vienna the most influential exponents of this approach were, in the seventies and eighties, the psychiatrist Thedor Meynert (1833-92) and the neuropathologist Ernst von Brucke (1819-92). It was with these teachers that Sigmund Freud (1856-1939) began his scientific career.