Читать книгу Schizophrenia - Orna Ophir - Страница 17

I am about to discuss the disease called “sacred.” It is not, in my opinion, any more divine or more sacred than other diseases, but has a natural cause, and its supposed divine origin is due to men’s inexperience, and to their wonder at its peculiar character. (Hippocrates, The Sacred Disease)

While madness continued to be depicted as in the biblical sources as a supernaturally caused, categorically different, and “strange” phenomenon, the Greco-Roman tradition began to differentiate between madness as a form of possession, and madness as a natural affliction.

Caelius Aurelianus, a fifth century CE doctor, writes: “Plato, in the Phaedrus, declares that madness is twofold: one comes from a tension of the mind, having a cause in the body, the other is divine or sent down, and is inspired by Apollo; now we call this divination.”³⁰ As discussed in the Introduction, in the Phaedrus, Plato’s two types of madness correspond to the duality we now understand to be at the core of the human species, namely that of body and mind (or soul), of the physical and the metaphysical, the material and the spiritual.

As we saw previously, in explaining madness as inspiration by the gods, Plato suggests that prophetic madness is inspired by Apollo, as the gift of divination; mystic madness caused by Dionysus initiates one into mysteries; poetic madness is inspired by the Muses; and, finally, the madness of love is given to humans by Aphrodite and Eros.³¹ Yet when madness, by contrast, is seen not as divine inspiration but as a bodily ailment, mad people are viewed as bad or shameful.³² They are kept at home, out of view of wider society, and sometimes stoned to death.³³

With the differentiation between divine, meaningful, or “good madness,” on the one hand, and “bad madness” as a pathology of the mind and the body, on the other, Greco-Roman doctors parted from philosophers, marking an epistemological juncture where madness entered the history of medicine and its changing definitions of illnesses.

As Chiara Thumiger, a classicist and historian of ancient medicine and mental diseases, has argued, in Greco-Roman traditions, madness found a clear, albeit nuanced and differentiated, physiological explanation.³⁴ Indeed, a series of important innovations occurred during this period. First, a radically somatic interpretation of madness was offered. Second, madness became categorized as a bodily disease that is part of a more general classification of natural phenomena. And, finally, an approach to madness appeared that was both physiological and ethical. Indeed, according to the dominant view in this period of late Antiquity, mental health and soundness were thought to be achieved by maintaining a modicum of spiritual and ethical integrity.

In the medical corpus of Hippocratic texts from the fifth to fourth centuries BCE, madness is clearly framed not in divine or sacred but in naturalistic terms, as a manifestation of bodily dysfunction. At the time, the body’s functions were believed to rely on the four so-called humors or fluids, and their associated qualities: blood (which is hot and wet), yellow bile or choler (which is hot and dry), black bile (which is cold and dry) and, finally, phlegm (which is cold and wet). The condition of the humors and their overall corporeal balance were thought to relate both to macrocosmic factors (such as the seasons or the position of the celestial bodies) and to microcosmic elements in each individual. According to this model, when the humors or fluids are in a good temperament, good mixture, or balance (eukrasia), this is conducive to good health. An imbalance (dyskrasia) or bad mixture of the humors, on the other hand, harms the wellbeing of humans and causes disease.

Health and illness were thus seen not as categorically distinct or different in kind, but as existing on a spectrum. They were understood as a function of relative states of greater or lesser equilibrium of the different building blocks that constituted not only the human organism, but also the whole universe. These extended beyond the humors, to the four elements (earth, air, fire, and water); the four seasons (summer, fall, winter, and spring); the four qualities (hot, cold, wet, and dry); and the four temperaments, or mental states (sanguine, choleric, melancholic, and phlegmatic). Since the body was deemed to be subject to numerous influences, it was thought to oscillate constantly between health and illness. This rationale for understanding human beings set sickness and health on a continuous scale, ranging between imbalance and balance, too much or too little, of the quantity of a substance and its power, rather than opposing them as two distinct categories. Maintaining the body’s dynamic equilibrium (between extremes), keeping its internal substances in well-proportioned mixture, was considered an important part of people’s daily routine. More specifically, while the management of health involved a constant recalibration of an ideal state of humoral balance, the treatment of disease was directed at restoring it.

Furthermore, as Roy Porter observed, Greek medicine postulated that health and illness were “organic” or “constitutional,” deriving not from an external pathogen, but from inner processes. The inside of the body and the mind were seen as interconnected, so that the body affected the mind (e.g., fever causes delirium) and the mind affected the body. Intense emotions, for example, were thought to be responsible for a myriad of physical disorders, ranging from respiratory diseases to rheumatism, even death. A broken heart or a great fright, in this context, was seen as lethal.

Madness was thus seen as rooted in the individual, in the person’s body and mind. For example, in Hysteria in Virgins, Hippocrates observes a young female patient and writes: “When these places are filled with blood, shivering sets in with fever … when this is the state of affairs, the girl goes crazy because of the violent inflammation.”³⁵

In this case, the afflicted girl is understood to have become murderous, fearful, distraught, and anxious because of the bad condition of her blood. She says dreadful things and has visions that tell her to kill herself, she has a desire for death “as if it was a form of good.”³⁶ According to the Hippocratic texts, the abundance of blood, when it rushes up to the heart and to the lungs, is understood to create insanity in women. In this case, unlike other parts of the body (where the veins are straight and the blood flows quickly), the veins in the heart and the phrenes are slanted, and thus form “a critical place for insanity and suited for madness.”³⁷

The Hippocratic text The Sacred Disease also identifies the source of madness in the brain, mocking the idea that some forms of madness are divine.³⁸ Here, the brain is seen as responsible for emotions such as joy, delight, sorrow, grief, and despondency. It is also considered as the seat of intellect, wisdom, and knowledge. When the brain, which is dry and cold while healthy, becomes moist, it makes us “mad and delirious.” In this case, it can inspire fear, sleeplessness, aimless anxieties, absentmindedness, and “acts that are contrary to habit.”³⁹

The Hippocratic Corpus thus offers a coherent representation of mental disorders.⁴⁰ According to the Hippocratic doctors, mental disturbances are embodied and visible. Madness can be seen on patients’ faces, in their movements, their postures and gestures, their eating behaviors, sleep, and sexuality. Madness is also diagnosed based on patients’ reports about their disturbed sensations and perceptions. Finally, mental disturbance can be seen in the emotional responses of the patient, their ability to reason, and their – at times extraordinary – behavior.⁴¹

Although these early Hippocratic texts understand the differences between mental health and illness in terms of a humoral spectrum, they also contain attempts to categorize and differentiate the respective states of balance and imbalance. For example, The Sacred Disease offers the following differentiation between various kinds of madness: “Those who are mad through phlegm are quiet, and neither shout nor make a disturbance; those maddened through bile are noisy, evil-doers and restless, always doing something inopportune.”⁴² If the brain is chilled, “the patient suffers from causeless distress and anguish,” but when the brain is suddenly heated, the patient “shouts and cries at night.”⁴³

While it differentiates these types of madness based on the various humors, the Sacred Disease suggests that these states could also be part of normal occurrences such as dreams. Like these nightly visions, they too are reversible. As the Hippocratic author explains, the heating of the brain (which is caused by an abundance of blood that rushes into it, and boils it) can also follow a fearful dream. When the person wakes up and regains his consciousness, the blood is dispersed into the veins once more, and the “mad” manifestations cease. The text also argues that the same phenomenon can occur in the waking state, when “the face is flushed, and the eyes are red, mostly when a man is afraid and his mind contemplates some evil act.”⁴⁴

The Romans, for their part, also recorded a variety of types of madness. The first known psychiatric taxonomy of antiquity in the Western tradition, De Medicina, was written by Cornelius Celsus.⁴⁵ In this work, Celsus distinguishes between “three types of madness” (tria genera insaniae), which are classified according to their duration: madness that is similar to the Greek phrenitis is an acute, quick furor; mania is a longer insanity without fever; and, lastly, longissimum corresponds to melancholia.⁴⁶ Thumiger finds three elements in this Roman text that are relevant to later discussions of madness: first, the distinction between the acute and the chronic; second, the identification of somatic causes (e.g., fever); and, finally, the division of madness into three types (in this case, phrenitis, mania, and melancholia). Interestingly, Celsus further adds the original idea that insanity can be treated not only by balancing the body’s humors, but also by a form of psychotherapy, occupational therapy, cognitive exercises, and social activities.⁴⁷

The most famous Greek doctor, however, is Galen of Pergamon (130–210 CE), whose work remained deeply influential among medical professionals and other scholars, until late into the seventeenth century. Significantly, Galen did not pay much attention to the classification of disorders, or to discussions of diseases or syndromes.⁴⁸ Instead, as was the case in the Hebrew Bible and the tradition of commentary standing on its shoulders, in The Passions and Errors of the Soul, Galen sees madness as the absence of the single defining human characteristic, that is, “the special gift of reason.”⁴⁹

In Galen’s view, madness thus represents a lower kind of being (similar to that of a wild animal, a horse, or a dog, an “inferior man,” i.e., a slave or a child), driven by the irrational forces of the soul.⁵⁰ Mad behavior, such as kicking and screaming, biting, ripping off one’s clothes or hurting others, is more typical of a wild animal than a human being. However, Galen argues that this transformation into an inferior mode of being is not irreversible. In the spirit of Plato’s metaphor of the soul as a charioteer, Galen writes, “untamed horses are useless but horsemen can in a short time make them submissive and manageable.”⁵¹ These wild beasts, which symbolize untamed and unreasonable forces, are of two kinds. The irascible force located in the heart, which generates emotions such as courage, anger, and joy, is compared to animals that can be domesticated, like horses or dogs, which can be disciplined. But as regards the concupiscible force that seeks bodily pleasures (such as erotic desire, carnal lust, gluttony, or drunkenness), the comparison is to goats or boars, which cannot be domesticated, only weakened. Galen thus creates distinct categories, distinguishing between those who practice reason, and those who are unreasonable. But at the same time, he also offers a spectrum, placing the reasonable wise man at one end, inferior men (such as children and slaves) in the middle, wild animals that can be tamed lower, and untamable animals at the very bottom.

Galen is also known to have emphasized what later became known as the “non-naturals”; six factors that affect the body and mind, but are not innate or part of the body itself. These six hygienic elements are the ambient air, food and drink, exercise and rest, sleep and wakefulness, excretion and retention, and the passions of the soul.⁵² All of these, according to Galen, need to be regulated and regimented for one to attain, maintain, or restore mental health.

Just as he makes a distinction between animals that can be trained and those that cannot, Galen also differentiates between those whose madness is curable, and those that cannot be redeemed. As Thumiger shows, it is when Galen becomes “entirely materialistic and deterministic,” that he proposes the radical suggestion of killing those whose mental disturbance is due to such a severe damage to the body that it deems them “beyond redemption or cure.”⁵³

From this limited selection of Greco-Roman texts on madness, one can already clearly infer that when madness is regarded as part of a spectrum, on which it differs only quantitatively or relatively from sanity (i.e., as a result of having either too much or too little of the humors, in the biological interpretation, or too little reason and determination, insofar as the mental capacities are evaluated in their own right), the madman can be restored to health in body and mind. By contrast, the opposite conception of madness, as being caused by “severe damage to one’s bodily conditions” and affecting the very qualitative nature of one’s being, leads to the near-inevitable conclusion that madness, as such, is incurable. This is what, in turn, leads to the idea that the irredeemably mad person must be contained or set apart, cast out at best, or eliminated at worst.