Universite de Nantes, Orvault, Pays de la Loire, France
Received date: Aprl 23, 2015; Accepted date: May 20, 2015; Published date: May 27, 2015
Citation: Jackie P (2015) The Triumph of Dualism in Ancient Psychopathology . J Psychol Psychother 5:184. doi:10.4172/2161-0487.1000184
Copyright: ©2015 Jackie Pigeaud. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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What we need, to carry out a History of psychopathology, is not philosophy. We need ideas, clear, simple, regulating ideas, not a patchwork or a mere succession of events. I think that the history of psychopathology is determined by its subject. It cannot be elaborated after the same pattern as that of a History of Economy, or Politics, or Mathematics. We can define Economy, Politics, and Mathematics. But the subject of a History of Psychopathology, I mean psychopathology (a very bad term, of course), always raises the question of 'what is psychopathology?' So we have to try to find what we may call regulating or conditioning ideas or operative concepts. We have to show how problematic the constitution of psychopathology is, and try to integrate this problem into the History of psychopathology itself. We can offer the requisite of such an idea. It must be relevant to the genesis of man as a historical being and to the definition of man, given in the succession of centuries. It must also account for the different conceptions of psychopathology, as far as the definition of man has been a preoccupation of psychopathology itself.
This is the reason why I propose to consider, in such a prospect, the notions of monism or dualism, involving in themselves nothing more than this:
• The feeling of someone, being one or two;
• The decision, of any instance, that man is one or two.
If we look at the medical texts, from Hippocrates to Galen for instance, we can detect an evolution, or may be a revolution. It could be obvious that medicine improved. But I am not speaking of progress. I just try to show that certain events happened, some of which are essential to psychopathology. And the history of medicine alone cannot justify this evolution. I mean that a history of medicine, which looks only into the medical literature, cannot account by itself for this evolution. I would only try to determine this evolution, and to show the apparatus of events necessary, in my opinion, to make it understandable. There is a break between Hippocrates (4th century B.C.) and the texts of Aretaeus, Galen, Soranus, Caelius Aurelianus and even Rufus. It is true that we are speaking now of physicians who lived in the 1st/2nd century A.D. and even later. And that we have only fragments of physicians between the 4th century B.C. and these last ones. But anyway, except for Galen, medicine does not think anymore about itself, about its finality, its meaning and its concepts. Even when Galen tries to do so, he cannot help but think in a new structure so that Hippocrates seems difficult to understand and needs explanation. I think the question of dualism and its consequences is involved in this story, as I'll now try to show.
So let us begin with the physician's point of view; and, as rapidly as possible, retain the original Hippocratic features that would disappear from the medical treatises.
If we read, for instance, Sacred Disease of Hippocrates, we can't restrict the treatise to the mere description of epilepsy. We have no right to neglect, as odd as it may seem to us, what we could call the problematics of consciousness. The brain is a sort of container which receives air; this air goes to all parts of the body. In this air is synesis, that is to say consciousness. The quality of this consciousness depends upon the capacity of our brain and our veins to admit air into our body. Air is also the origin of motion. Sacred Disease makes choices of monism; I mean a monism of thought, or consciousness, feeling and motion. Anyone can see that the doctor is here assuming problems that we could call philosophical. And we shall see that later those problems become the philosopher's property.
If we consider, too, that in this Hippocratic text we find the problem of integration of man into the world, the problem of normality, the question of the responsibility of the doctor ; the question of the meaning of illness ; the question of the capacity of the doctor and the limits of the capacity, the question of the responsibility of the patient, we can see how broad the field of a doctor, at the end of the 5th century or the beginning of the 4th century B.C., was allowed to be. It is obvious that something happened, some centuries later, that me may call a partition.
I think that the responsibility of the partition between the desease of the soul and other diseases, that is to say diseases of the body, belongs to philosophy. But medicine has accepted this partition. Why? This is a difficult question. Perhaps medicine followed another way and did not want to be philosophical anymore. If we believe Celsus, it was, - I am quoting Celsus - "Hippocrates of Cos, man first and for more worthy to be remembered, notable both for professional skill and for eloquence, who separated this branch (that is to say medicine), from the study of philosophy" . And of course, we must think that Celsus is considering Ancient Medicine, this very old Hippocratic text.
But this is a wrong opinion. For it is true that Ancient Medicine, for instance, was broken away from philosophy, in as much as this implied adherence to Empedocles or to other philosophers ; as we are told in the beginning of the treatise. But the author of Ancient Medicine, in his text, developed a philosophy of medicine as a specific philosophy, determining the meaning of the dialogue between the patient and the doctor, the signification of pain, and all sorts of reflexions that later disappeared from medicine. The tabu of philosophy prevented medicine from reflecting on itself and on the exactitude of its concepts. This is particularly important as far as psychopathology was concerned.
With philosophy, we cannot say that all contacts were lost. But they are episodic or very technical. By the term 'technical', I mean, for instance, the discussion on causality distinguishing proximae causae (causa proxima aition prokatarktikon), that is to say the external antecedent cause ; the proegomenon which is an internal disposition ; the synektikon. Some of these terms, as Galen tells us, have been introduced by Stoïcism. This is the case of synektikon aition, which is the cause of the being of something. This aspect of logic in medicine interests some very good scholars of our day, as Michael Frede or Jonathan Barnes. By the term episodic, I mean, for instance, the echo of philosophical discussions about the truth of our perceptions. This is a fundamental debate of Hellenistic philosophy. We may recall, for instance, the distinction between phantasia and phantasma of Chrysippus, and the distinction formulated several centuries later by Esquirol, though discovered by the Stoïcs, between what Esquirol called illusion and hallucination. I have pointed out on several occasions this distinction in Celsus, or Aretaeus the Cappadocian, or Asclepiades of Bithynia, in cases of phrenitis or mania . Unfortunately, it never became operative.
In fact - and it may at first appear as a paradox - the most important part of the dialogue between philosophy and medicine is silent. It is present in the tacit recognition of a state; the soul belongs to philosophy and the body to medicine. Of course, this partition is not based on deliberately concealed agreements or contracts. But it is a fact, and the only explanation we can give to it, is the triumph of dualism.
Of course, there is a terrible lack of texts. But we know enough about this period of medicine to conceive that its main orientation was towards the description of the parts of the body, discovering anatomy. Nevertheless, we may perhaps notice something interesting. We know that Herophilos of Chalcedonia proposed a theory of dreams, and, more interesting for our purpose, that discovering the pulse, after Praxagoras, he produced a theory of pulsation, giving definite measures according to age, and congruent with the metrical laws of poetics. Perhaps there was here something incisive, which would help to define the unity of man.
Very interesting as well, are what we may call the semantic problems.
The terms Hippocrates uses to describe behaviour (it was also true for other signs, but behaviour is particularly difficult) are most often drawn from Greek common language, but they are images and metaphors. There is a genuine invention in these descriptions that fascinated centuries.
But at this point we must pay attention to a very interesting problem which belongs to something what we may call rhetoric, medical rhetoric. Galen is very aware of this question. To him Hippocrates is a great writer. To him, Hippocrates' language is good common Greek, he never writes too much, and what he writes is for the best. But Galen cannot always understand Hippocrates. There are problems, and especially in description of behaviour, of delirium, or madness. First of all he thinks that Hippocrates' terms are very precise ones; and that we must try to find their exact meanings. He tries to organize a terminology of madness that Hippocrates is supposed to use.
The words: lèrèsai, paralèrèsai, paraphronèsai, paranechthènai, parakopha, akstènai, manènai, ekmanènai  would correspond to different states of madness. Galen gives to Hippocrates' terminology something like a juridical value. And sometimes he has to justify Hippocrates himself, from what he thinks a natural point of view. For instance, Hippocrates speaking about phrenitis in Epidemics III, 6, says that "among the phrenitics no case showed the mad delirium (oud'eksemanè) that attacks generally phrenitics, but they passed away overpowered by a dull oppression of stupor" .
To us, the hippocratic description is very clear. The physician means that in this constitution the phrenitics were not excited, did not know the usual delirium, but were only torpid. But for Galen, there is a very hard problem. He is puzzled about the verb Hippocrates uses: eksemanè, the verb which denotes mania, in a case of phrenitis. Now, to him as to all physicians of his time, phrenitis and mania are two forms absolutely not homogeneous, unassimilable, of so-called madness. Phrenitis is an acute disease, mania is a chronic disease; phrenitis is delirium with acute fever, crocydismos and carphology (these gestures belonging only to phrenitis as diacritical signs; the patient seems to pick up wisps of straw or plies of wool). Mania is a delirium with change in usual behaviour, without fever . It is possible, as we tried to prove elsewhere, that mania was defined by opposition and symmetry with phrenitis, whose concept is already well-defined in the Hippocratic Collection, while mania is, to Hippocrates, a very general term. But in Galen's time, the opposition between acute and chronic diseases and the definition of phrenitis and mania being so strong, Galen must justify Hippocrates. He recalls the fundamental criterion which distinguishes mania from phrenitis : the lack of fever. He says that if Hippocrates had not used this word of eksemanè one could have thought that it was a slip from phrenitis to lethargy and so on .
The example is very instructive. It shows the formalism of the definitions, their juridical character. Of course, no physician was as rigorous as Galen, and it happens that Aretaeus says that phrenitis becomes delirious with noise. But neither Araeteus nor any other physician of this time, would substitute the term of phrenitis to that of mania. Galen is perfectly right about the concept and its definition with which all physicians of his time agree. But he asks Hippocrates something which is post-hippocratic. The definition of mania, which has, in Hippocrates' texts, a very general sense of madness, is posthippocratic. The classification of diseases is post-hippocratic. The clear and simple partition between acute and chronic diseases is, as Caelius Aurelianus notices, the invention of Themison, the first methodical physician, in the middle of the first century B.C. The definitions of phrenitis and mania are then definitely accepted by all physicians.
¨And there is something like a screen between the language of Hippocrates and that of Galen. It does not depend upon a mere evolution of language. Philologists would be, as Galen is, very perplexed. It belongs to the history of ideas, not to the history of words.
If we consider what we called the semantic way, we can see that first, in Hippocrates' texts; this was not linked to a coherent plan of describing madness, whose phenomena are signs to be balanced with other signs. But there was an invention and a liberty concerning vocabulary as well. But when the preoccupation about madness was more urgent, for several reasons that we could give, the Hippocratic point of view, the clinical point of view could we say, following Pliny: instituisse medicinam hanc quam clinice vocatur , has disappeared. The aim of the physicians is no more description but definition, classification, reflection on causality, nature of the locus affected. I already quite often pointed out that the physicians disagree about the last subjects. But that they are in complete agreement about definition and classification.
The consequences were very pregnant for the development of psychopathology. Celsus tried to delimit all the general madness (dementia) in three diseases: phrenitis, mania and melancholy. Though the name of melancholy is not given, things are clear. Of course the definitions of phrenitis and mania are those we described. But this, to my opinion, is the only attempt to unify all the phenomena of madness under a general concept of dementia. Elsewhere, it is not easy to give an account on all the diseases where madness or delirium can appear: chronical headache, lethargy, hydrophobia, satyriasis, and so on, have to do with psychopathology in some aspects. But it is true that phrenitis, mania and melancholy are the main forms of a so-called dementia. I shall come back to melancholy. But anyway, an important conclusion can already be drawn: all these diseases are diseases of the body.
¨We must not forget either one of the finest discoveries of the Hippocratic Collection, I mean the description of patients, especially in Epidemics I and III; that is to say the selection of events referring to an individual whose name and address are known, given in a chronological order, evoking causality only as prophasis, the evident cause, never as aitios, general and fundamental cause, and, with some very rare exceptions, proposing no diagnosis.
This is no more the story of Philiscos as a drama, but the history of the illness of Philiscos, or rather of Philiscos being ill. This is the main point. The disease in itself is far from being so important as the succession of events, becoming, for the only reason that they are selected, signs which must be balanced as favourable or not favourable, in order to make a prognostic. These signs are note essentially signs of something specific; but they are signs of the whole. This is the patient himself, considered as a whole. Taking the example of the bad colours of the urine, the author of Prognostic, perhaps Hippocrates himself, writes: "But be not deceived if the urine has these bad characters because the bladder itself is diseased; for this will not be a sign of the whole body, but only of the bladder in itself" (Progn. 13). We can extend this remark to the patient as a whole; I mean not only the body. Indeed we can immediately notice that signs that we could say somatic or psychological, in our dualistic language, are considered as equal. The bad colour of urine for instance, must be balanced with the fact that the patient is delirious or not, and all the other signs. If we study psychological signs, in Epidemics I-III, we must not forget that we are making a choice in some artificial way. But if we do that, in another way, we are right. Because the words of Hippocrates describing behaviour will provide the terms of psychopathology
I shall try, in a few words, to give an account of what may be one of the essential phenomena in the history of ancient psychopathology, I mean the Stoïc definitions of passions. Of course, it would demand a very long discussion. It is in the abodes of Stoïcism that passion was defined as a disease of the soul. The expression 'disease of the soul' is Plato's. But what is new, is the definition of passion as a disease of the soul.
We know, thanks to Art itself, sculpture or what we know about painting, how passion was a preoccupation of the Hellenistic period. Zeno, and then Chrysippus, defined passion as judgement and, so to speak, organic phenomena, as systoles, spasms, bites, swellings, all of them carefully selected by Zenon. For instance, we can say that sorrow is judgement, that is to say the recent opinion of a present trouble (opinio recens mali praesentis - Tusc. VI,VII,14), and systole retraction. But the difficulty begins with the relation between judgements and their organic manifestations.
Chrysipppus tried to establish that there is a same origin for thought and passions, lying in the abodes of kardia, indeed the heart itself, but also the mouth to the stomach. Anyway, this kardia is not important as a place, but as the origin of a spring. It means that if I don't want to separate a place of will from a place of affectivity, I must think passion jointly as judgement and organic phenomenon. Jointly, in a juridical sense, judgement and organic phenomenon must be thought as so inseparable as the recto-verso of a page.
This definition has some evident consequences. The first concerns morality. It had been conceived (and it will be again) in terms of conflict between two parts in man. This is the sense of "se vincere", to surpass oneself. It supposed that man is two, and finally that the soul must surpass the body. It is not fortuity if the tradition shows Chrysippus meditating on the lines of the Medea of Euripides. 'I understand that I do wrong things, but my thymos is stronger than my bouleumata". And of course, the senses of thymos and bouleumata are difficult. One can understand them as the topos of the morality: video melioro proboque deteriora sequor, as did Ovidius. But Chrysippus doesn't see between thymos, that is to say a sort of natural will, and bouleumata, a sort of intellectual impulse, any essential difference. Morality, for Chrysippus, must not be understood as a conflict; but passion is something which has a birth, a growth, something which becomes, at some moment, irrepressible, so that we can't help but succumb.
This is what we may call the monism of Chrysippus. If we want to gloss a bit, we can say that passion as a disease of the soul was a difficult expression for Chrysippus. He speaks of the same act; passion is made of judgement and contraction, dilatation, and so on. One does not belong to the soul, nor the other to the body; it is all one. This is the great originality of Chrysippus, but it is difficult to think and to maintain. In fact there were great reactions. As for philosophers, reactions came from Posidonius, a great Stoïc, and Cicero; as for physicians, from Galen of course. Posidonius (end of the 2nd century - beginning of the 1st century B.C.) tried to reinsert the Platonic dualism in the Stoïc theory of passion. But Cicero is certainly more important. We must never forget that his Tusculae Disputationes were the vehicle in occidental knowledge of Chrysippus' theory of passion. It is one of the main books on moral for centuries, and scholars and students, for centuries, adopted this theory of passion. I am thinking, particularly, of French doctors as Pinel, who clearly writes that he adopts the Stoïc theory of passions. I don't know whether Cicero was a diabolic reader. I believe he wasn't. But what is sure, is that he disliked monism. He is fundamentally a disciple of Plato and further of Pythagoras. He adopts what he calls the ancient discourse on man, and so will do Galen who speaks of palaios logos, that is to say veterem illam ... descriptionem ('this famous old partition'). So Cicero, this dualist, has chosen, as the more simple and the more efficious theory of passions that of Chrysippus. And this is a good paradox. The theory of the monist was very easy to read from a dualist point of view.
¨Remember: passions are judgements and organic phenomena together. To Chrysippus, it is the same act. If you say that organic phenomena are, in any way, the consequences of the judgement, if you introduce a slight delay in time, you make of the organic sensations mere epiphenomena of judgement. Then you have a dualist theory. And you can say, as Cicero did, that sorrow, for instance, is a recent opinion of a present trouble, having for consequence a retraction. So passion can be admitted as a disease which belongs essentially to the soul. The mind/body problem which was inscribed in the definition of passion itself by Chrysippus has disappeared
And it is in the discussion about passion that dualism was at stake. We can see that in Galen's major work on the doctrines of Hippocrates and Plato. Philosophy was directly engaged in the process of a discussion with medicine. This was possible because of the development of medicine itself, which would offer models and concepts for analogy. We can realize that when we hear Galen criticizing Chrysippus. The Stoïc had proposed a strict analogy between what he calls the disease of the soul and the disease of the body. He wanted to go as far as possible in the analogy between philosophy and medicine. Chrysippus writes:- I am quoting Galen - "that we must suppose that the disease of the soul is most similar to a feverish physical state in which fevers and chills do not occur at regular intervals, but irregularly and at random from the constitution (of the man) and at the incidence of small causes" . We can notice that Chrysippus passes, in his analogy, over all diseases, such as phrenitis and mania, which involve delirium. He chooses fever, which is a disease in itself; fevers, as Pseudo-Galen says, which have no regularity and no specific state. I will not insist here on this analogy. We shall just retain the conclusion of Galen.
"It is clear that Chrysippus' purpose is to explain and preserve the entire analogy...". But he failed because he is unable to give the names of the elements of the soul in order to define them and give their number. Galen is in fact fighting against the monism of Chrysippus. "My purpose", he writes, "is to show that it is not in a single part of the soul, nor by virtue of a single power of it that both judgement and affections occur, as Chrysippus claimed, but that the soul has both a plurality of power of different kinds, and a plurality of parts. Posidonius and Aristotle grant that the powers of the soul are three in number, and that by them, we desire, feel anger, and reason; but that they are also spatially separated from each other, and that one soul, not only contains many powers, but is composed of parts that differ in kind and in substance; this is the doctrine of Hippocrates and Plato" . This is true for Plato, but not for Hippocrates.
Galen cannot admit that Chrysippus may put judgements and passions or affections together in what he calls the soul and localizes this soul in one part of the body, that is to say the kardia.
There would be much to say about Galen, of course. But from the point of view of dualism we can say that to him, as to the other physicians, madness may be phrenitis, morosis, epilepsy, melancholy and so on. He seems to reduce the importance of mania, perhaps because it is too general. All of them are diseases, are lesions of the function of the soul. This soul, whatever it can be, is localized in the brain. Phantasia has got its origin in the forebrain; dianoia in the middle brain; and memory in the hindbrain. Of course, the anatomy of brain owes very much to Galen. So we can say that madness generally speaking, is a disease which affects the brain, which is a part of the body. The impediments of the brain come from humours. Passion has nothing to do directly with that. We can see that madness is naturally the field of the physicians. On the other side, of course, passions exist; but they are consequences of the state of the body. What seems very important is that we cannot retain one factor. To explain this triumph of dualism, we require many factors. All of them are important; I mean that the evolution from description to classification in medicine, the division of diseases into acute and chronic, is as necessary as the philosophical meditation on passions. As for psychè, the nature of the soul, Galen keeps at an epoché, a suspension of judgement. No more than other physicians, did Galen build a psychopathology which could have been a medicine of its own. But he insisted on the somatic origin of madness, and of course, as we saw too quickly, he maintained a militant dualism.
Galen is a great thinker. He worked hard to destroy monism. Other physicians don't show the same exigencies as Galen. So a dualist can perfectly admit that there are diseases primarily of the soul with consequences on the body; and diseases primarily of the body which affect the soul. It is a very clear situation which has consequences on the partition of the fields of diseases. It seems to be a comfortable situation for anybody. This way madness will be divided into disease of the soul which is the field of the philosopher, and disease of the body, the specialist of which is the physician. As we can see, it is not a mere intellectual discussion. It has cultural and social consequences. The philosopher and the physician both deal with madness, but certainly not the same madness.
We spoke of phrenitis, mania. Nowadays nobody would think of phrenitis as a mental illness. To modern readers it would have little to do with psychopathology. The delirium of phrenitis, most often an attack of toxic-infectious origin, if we dare to suggest a diagnosis takes place in a violent fever.
There was a chance, anyway, to reserve the problem of monism and dualism with the case of a disease to which we have only alluded: I mean melancholy. This is a very strange disease, and you know how immense the literature is about it. This is the disease which in itself raises the problem of monism and dualism; I mean the feeling of being one or two.
A melancholic is a sick person; but who is suffering an illness single in its essence. This illness puts together, as a problem, a pain of the body and the suspicion that this pain signifies more than itself and has something to say, indeed, on the sense of human being and self knowledge. We cannot explain otherwise why melancholy has exploded, at a first glance, into different fields, different ways, covering creation and creativity as in Pseudo-Aristotle's Problem XXX, as well as the relation between the philosopher and the melancholic in the pseudo-hippocratic Letters. I agree, that nowadays melancholy is not considered as a disease « sensu strictu », but rather as a symptom of different psychopathological conditions. But there is no doubt that in our Occident, melancholy revealed man as a complex being, soul and body, if we want to speak in these dualistic terms, suffering of this connection. In this way, melancholy has something to do with culture. Of course, this too is a Greek legacy. It would be a very long story. I shall just retain some aspects of the question, from a medical point of view.
We all know the Hippocratic Aphorism VI, 23: Fear (phobos) or depression (dysthymia) that is prolonged, means melancholia .
The term depression is bad enough, because too modern. Dysthymia in fact denotes bad thymos; something like prostration; and phobos is retreat, or recess, rather than fear. The worse is to understand these terms, as usual, as psychological terms and translate: Fear and sorrow that is prolonged... (The Latin translation is tristitia). As to the expression of Jones "means melancholia", perhaps could we rather translate: Retreat or prostration that is prolonged has something to do with a black state of the bile.
No psychology, but attitude, behaviour in relation to a physiological state. Hippocrates does not say that black bile would be the reason for such behaviour, nor the contrary. This is what we may call a paratactic definition of melancholia. Melancholia supposed the simultaneous presence of a particular behaviour and a particular state of the bile. So this Aphorism is fundamental for the medical tradition. There is no causality in the Aphorism. Galen will later elucidate it in terms of causality, in his Commentaries. To him, black bile is the cause of this particular behaviour.
To come back to dysthymia, what Adams  translates "lowness of spirits", we can find in Hippocratic texts some definitions of thymos. So in Epidemics VI, 5,5. Hippocrates writes: "As for the things which come from thymos, it is so: oxythymia which retracts heart and lungs and draws to the heart wet and hot. Euthymia, on the contrary, loosens heart." We must not give to these words a psychological sense. They are not passions, although a very early Latin translation gives tristitia for dysthymia. We must try to think thymos as, roughly speaking, selffeeling. Dysthymia is a discomfort, oxythymia an anguish, euthymia a calmness, which have nothing to do with passion, but with what we might call self-awareness, on condition that we do not give this expression an intellectual meaning. If I dare use a word which is Hübner's, at the end of the XVIIIth century, and in a sense which is not Hübner's, I should speak of caenesthesis . I may quote another text of Hippocrates: Epidemics III, case N° 6, case of a woman: "She was silent and did not converse at all; dysthymia, the patient despairing of herself". Things are of course very complex. But what I try to say is that there was in Hippocrates' Medicine something special, something before the event of the dualist situation.
The philosophical tradition took possession and developed the meditation on euthymia. This phenomenon began with Democritus; but we know very little about this. The Stoïc philosopher of the Middle Stoa, Panetius, wrote a Peri euthymias, of which nothing subsists; but we know enough of that by Seneca's De tranquillitate animi. The title, in itself, shows that euthymia is on the side of animus, psychè, the soul. Tranquillitas of course is a concession to no wise men; the wise man's aim being the vita beata based on principles. The discourse on tranquillitas is ad imperfectos et mediocres et male sanos ... non ad sapientes . We wrote that this literature was the philosophical attempt to lull the difficulty that anybody has to live, Seneca's De tranquillitate animi shows that he makes a difference between aegritudo, that is to say a sorrow that circumstances have provoked, and taedium vitae, this undetermined pain, very near of nausea, and which makes man despair of himself. Mutatis mutandis Freud's distinction between mourning and melancholy . And I think, this is the more advanced bastion of philosophy towards medicine; as the melancholy of physicians is the more advanced bastion of medicine towards philosophy
For instance, we see in Aretaeus the Cappadocian, that the melancholics "flee to the desert from misanthropy, turn superstitious, or contract a hatred of life" . And if the philosopher does not contempt drug, as wine, the physician uses exhortation. But nevertheless, the topography is spared; the margin is preserved. The name of the disease will not be the same. If philosophers use of the term of taedium vitae they never use melancholy, which is a medical concept. This tradition has been fixed by Cicero in the Tusculae Disputationes.
From our point of view, melancholy, that is to say melancholy of the physicians, is a disease of the body, with the presence of black bile, which can be the cause, if the physician believes in humours. In the beginning of the first century, something new will be added to Hippocrates' definition: Aretaeus writes: « phobos è dysthymiè epi miè phantasiè: It is a lowness of spirits from a single phantasy ». Phantasy, that is to say a picture without any reality; in anachronic terms, a simple illusion. But that is another story.
As far as Antiquity is concerned, I tried to show how complex the emergency of the so-called psychopathology was . I am sure an apparatus of events is necessary to explain the evolution of medicine about madness. I tried to show some of them that I shall recall in conclusion:
• The elaboration and the definition of diseases like mania, phrenitis, melancholy, is not something simple but implies some cultural facts.
• The simplification in the classification of diseases between acute and chronic diseases is certainly a factor of classification.
• The partition between diseases of the soul and diseases of the body, the triumph of dualism, the emergence of the Stoïc theory of passions as diseases of the soul are, as we tried to show, major events. These last three elements are linked.
We can say that what Greek-Roman medicine has given to posterity is in no case a natural or spontaneous form of madness. It is the result of facts, events, thoughts, which constitute for us a very heavy legacy.
In other terms, we can say that the discourse of medicine and the discourse of philosophy on madness are different. We can speak of a tacit dialogue.
Medicine deliberately kept its distance with philosophy. Physicians gave up to philosophers the part of the passions, defined as diseases of the soul. They gave up to philosophers the thought on passion. And, on the other side, philosophy gave up to medicine the somatic aspect of madness. The physiology of the passion does not seem to interest philosophers. We speak as if a partition existed de facto.
History of Ancient Psychopathology would be interesting by itself. But it is more interesting when we think that modern physicians, at the end of the XVIIIth century went back to ancient texts, with something like a "Renaissance", but in some disorder. I am thinking particularly of Pinel, and this comeback of the ancient discourse on madness has something to do, directly, with the beginning of modern psychiatry.
The partition between medicine and philosophy, especially about passion seems to be a preoccupation of many physicians, at the end of the XVIIIth century. But I would like to give some attention to the other side, I mean the philosopher, taking as a very enlightening example, in my opinion, a treatise that Kant devotes to an odd subject for a philosopher, "the diseases of the head" (Versuch über die Krankheiten des Kopfes). From the proper point of view of the history of psychiatry, this treatise is very interesting .
Kant begins with a semantic problem or what he calls onomastic of the diseases; from what we may call, in Greek terms, morôsis to mania. This onomastic is not new. We can see physicians of the XVIIIth century doing the same work (I think of the Exegesis nominum graecorum quae morbos definiunt by D.J.E. Hebenstreit ). Thus Kant proposes a classification according to a method that owes more to Sydenham than to Linné. This classification follows the gravity of the diseases, but there is a dividing line between diseases that Society can allow and those which demand authority and ask for legal measures. All those diseases are troubles of the head, and can be reduced to as many main kinds of diseases as there are faculties of the soul. Of course, this is not new, but we are not looking for novelty.
The madman is a waking dreamer (Der Verrückte ist also ein Träumer im Wachen). And here begins a digression on phantasm with the example of a special disease: hypochondria. Phantasm, Kant says, is never so common as in hypochondria. And really, if we look at Van Swieten (B 180-181), we may read a very clear excursus, based on Aretaeus the Cappadocian, which has been edited in 1735 by Boerhaave, and on Sydenham. We may read that hypochondria is a proteiform disease, cause of phantasms. In the treatise, this is the first fundamental reference to medicine. And then Kant tells us that the expression "diseases of the head" is metaphorical for "affections of the faculties of knowledge". As well the expression "diseases of the heart" is metaphorical for "alteration of the will". But, he says, the roots of the so-called diseases of the head, that is to say diseases of the soul (Gemüt) are in the body and their main seat is the organ of digestion "as tells us" - I am quoting Kant - "with verisimilitude, our dear weekly publication, known to everybody, I mean « Der Arzt » (the 'Physician') in N° 150, 151, 152". This publication is indeed well-known. It is Unzer's, a well learned physician. We must trust Kant, and follow the track he himself gives; a proceeding that people who generally propose commentaries, being philosophers, have omitted. Unzer is important; he is very much influenced by Boerhaave, Van Swieten, whom he is always quoting; and his preoccupation is to establish links between thought and digestion. "Gemütskrankheiten" (diseases of the soul), "Unsinn", "Schwermuth" or "Melancholy", "Wahnwitz", "Tollheit", have their cause in the abdomen, which he calls "the workshop of ideas". So we must attack all these diseases with medicaments, and specially purgatives. But, Unzer says, objections may be given. It is well known and proved that people may become melancholic or mad by the affect of quick and violent passions (Gemütsbewegungen). As they are moral causes, they cannot have their seat in the abdomen; nor can the physician take as a purpose of his cure the "workshop of ideas". In fact, Unzer says, this is a major error. The sick people have already in themselves the germ of madness, that is to say black bile accumulated in their abdomen ; and passions only make this germ grow and burst. The very seat of madness is the abdomen.
If all diseases of the soul are not madness, there is no disease of the soul where a digestion failure may not be suspected. So, back to Kant. To him, as to Unzer, the fundamental seat of madness is in the digestive functions. So, naturally, he observes that only medicament, not dialogue can work. This is, to a philosopher, an aporie ; and all the tension of the text is here. If we take way of medicine, if we trust in medicine, we can't get further. So we shall agree that we must not be, for humanist reasons, too hard with mad people. But then, where are the passions? Kant in his treatise links them to physiology. They are not the essential causes of madness. The troubles of the mind, as love or any other passion, may exist just before madness bursts. But the body is primarly affected; the germ grows ; one can feel an ambiguous disturbance ; and when madness explodes, it manifests itself in the situation of the mind which precedes immediately, love, or anger, or anything else. This is exactly Unzer's position. So we must not send for the philosopher, but for the doctor. So, there is no other solution for Kant to end his treatise but humor. He quotes Swift first; and then tells us that, if a bad poem is a purge for the brain, perhaps he would better evacuate silently the disease and not bother his readers. The last French commentator thinks that he is thinking of suicide . He is just thinking of purge.
So now, back to our problem of dualism. I think Kant's work is most interesting. He tries to go as far as possible, for the problem of madness, in the way of the physicians. His medical references are those of a good learned physician, who was, life long, preoccupied with hypochondria. He is not, of course, a great physician, but he is representative of his colleagues. And medicine cannot integrate the passions into the causality of madness. They can only be immediate causes (prophasis), or rather they are immediately present when the very cause of madness works. This cause is in the body. So madness is the field of the physicians.
Kant's treatise gives us the test of the division, the partition between the philosopher and the physician, all the more interesting as the philosopher here, plays the part of the physician (This tradition is, by the way, that of Plato's Timaeus). Kant cannot go further. And the aporie that he turns into a pirouette is an important test of the triumph, in facts, of dualism. Naturally, this is not the most important text among Kant's, and Kritik der praktischen Vernunft will think the problem of how the soul can act upon the body. But this treatise is very significant and allows to take the measure of the "coup de force" of a Pinel, for instance.
At the end of the XVIIIth century, many physicians had a great interest for the passions; and in terms which are very interesting for us. I quote J. Fr. Dufour. In the preface to his Essai sur les opérations de l'Entendement humain et sur les maladies qui les dérangent , Dufour writes: "I did not undertake this essay to establish a new system, nor to balance other ones; my purpose was only to put together the most interesting things that philosophers on one side, physicians on the other side, have told on their topics and to build a sort of pathologic physiology of human understanding, of which medicine seems to be in want" .
I told that the partition between medicine and philosophy, about passion, seems to preoccupy many physicians in this time. I can quote Crichton. "Moralists and metaphysicians have written copiously on the subject, but they have confined themselves solely to the views of moralists and metaphysicians ... The passions have to be considered in a medical point of view, as a part of our constitution, which is to be examined with the eyes of a natural historian, and the spirit and impartiality of a philosopher. It is of no concern in the work, whether passions be esteemed natural ou unnatural, or moral or immoral affections... they are mere phenomena" .
In a memoir on "periodic mania", Pinel is asking for a "medical history of the passions". In the Traité de l'Aliénation mentale  Pinel writes that he wants "to analyse the passions, their nuances, their different degrees, their violent explosion, their different combination, without any idea of morality and only as a simple phenomenon of human life". I could give many examples of the interest in passions by physicians of this period
But is it possible to speak of the passions as mere natural phenomena, and what does it mean? And what idea, or rather what theory of passion can the physician propose? Obviously, for instance, Chrichton and Pinel are not interested in the same conceptions of passions. Crichton wants to show how passions act upon the body, whatever they are. We assist to a florescence of books, of this "medico- philosophical" tradition, that Daremberg hated. He writes: "Even the too famous Marat... wrote about the influence of the soul over the body and the body over the soul (1775) ... This same year, P. Roussel published his Système physique et moral de la femme... which begins this empty literature which has found in France too many authors at the end of the XVIIIth century and the beginning of the XIXth" .
The originality of Pinel was to see the passions as the origin of madness and to announce that he had chosen a philosophical view of the passions, more precisely the Stoïc theory of passions. There were advantages and disadvantages.
Disadvantages first. Picking up this theory without any justification, Pinel introduced a historical problem, and he was not able to get rid of it. It is not a legacy of ideas; it is a legacy of problems. The Stoïc theory of passions is not a solution, because it poses, in itself, the mind-body problem. Or, in other terms, it is a reduplication of the mind-body problem. Pinel thought that he did not have to answer the question: do the passions belong to the body or to the mind? He avoided the problem of monism and dualism, the question of the mind-body reciprocal influence. Cabanis wrote very keenly: "The strong influence of ideas and passions over all the functions of the organs ... is always mysterious ... We should have been grateful to Pinel ... if he had made researches into this field" . Another question remains without any clear answer: if we speak of the passions, immediately the problem of morals and responsibility looms. Shall we say that the madman is responsible for his madness?
On the other hand, the passions are certainly a way for the physician to legitimate dialogue. But in fact, we can see that to annex philosophy to medicine is not sufficient to solve the problem of dualism. I shall quote Broussais. In his book De l'irritation et de la folie , he writes: "The modern psychologists have strongly criticized Cabanis because he put the passions in viscera; and some of them have put the passions, arbitrarily, in this famous soul to which they have never succeeded in giving a seat, the others in the flesh, but so vaguely conceived that nobody knows what they are speaking of; for it seems that the passions, for them, are some undefined and undefinable entities... What a beautiful psychology, and how beautiful should the morals be it could beget! But in their opinion, passions are either in flesh, blood, nerves, or they are not. If they are, our philosophers are immediately on the side of Cabanis; because the soul must be in the head with the intellect, as he put it, after some years; if they are not, if they flutter from place to place, till the soul gives them a home, why do they use this silly language, speaking, as they do, of heart? Yes, but it is a figurative heart. But what does that mean; a figurative heart?" I am not very fond of Broussais; but I think he hits the right point.