A HISTORY OF MEDICAL PSYCHOLOGY : A HISTORY OF MEDICAL PSYCHOLOGY Douglas Lehrer, M.D.
Director of Medical Education
Twin Valley Behavioral Healthcare
Why Study History? : Why Study History? “History is a set of lies agreed upon.”
Napolean Bonaparte
Slide4 : “Don’t forget your history, know your destiny, in the abundance of water the fool is thirsty.”
Bob Marley
Three basic trends : Three basic trends Magical
Organic
Psychological
Greece: Asklepios (Aesculapius) : Greece: Asklepios (Aesculapius) Asklepios: chieftain turned god
Mental illness resulted from mischief of the gods
Patients slept at the temple overnight
Treatment based on visions seen in sleep
Hippocrates (c.460-377 BCE) : Hippocrates (c.460-377 BCE)
Humoral theories : Humoral theories Blood
Phlegm
Black Bile
Yellow Bile
Sanguine: confident, optimistic
Phlegmatic: slow, stolid
Melancholic: sad
Choleric: irritable
Hippocratic Classification of Mental Disorders : Hippocratic Classification of Mental Disorders Epilepsy
Mania
Melancholia
Paranoia
Hysteria
Greek Philosophers : Greek Philosophers Plato: Madness derives from disease OR gift of the gods
rational soul: seated in brain: immortal, divine
Irrational soul: pleasure, pain, audacity, fear, love, hope, anger
Aristotle: naturalistic; emotions; faculties
The Romans : The Romans Embraced Greek culture, sciences, mathematics, etc.
Medicine amalgam of Greek & oriental, mixed with forms of charlatanism
Early post-Roman trends : Early post-Roman trends Rise of spiritualism
Decline of Greek tradition that every manifestation of human activity was worthy of scientific study
Center of attention: the soul and the beyond
Psychology moving from medicine to mystical philosophy & religion
Dark Ages: 2nd through 4th C’s : Dark Ages: 2nd through 4th C’s Spiritual/ demonological basis of human ailments and suffering, esp. re. to the soul (= mind)
Centers of learning became religious institutions
305: Practice of magic condemned in Spain
Late 4th cent: medicine to monasteries
Mental illness separated from medicine
Dark Ages: continued : Dark Ages: continued Early Christian DDx dilemma: Not all mental illness attributable to devil, given variable religious content
saint vs. devil’s work
By 7th century: active rejection of sectarian or classicist (ie, pagan) learning, reading…
Study of psychiatry was study of devil, his cohorts, means, etc.
The Muslim Empire : The Muslim Empire Muslim world followed Greco-Roman lineage; became the repository for that lineage during the dark ages in Europe
Tolerant of non-Muslims
Environment for learning and sharing of knowledge; Classics embraced
Strong pharmacological basis in Arab-Persian medicine
Medical Psychology in Europe: A Loss of Reason : Medical Psychology in Europe: A Loss of Reason
Slide17 : “A man or a woman who has a ghost or a familiar spirit shall be put to death; they shall be pelted with stones; their blood guilt shall be upon them.”
Leviticus 20:27
Slide18 : “If the work of G-d could be comprehended by reason, it would be no longer wonderful, and faith would have no merit if reason provided proof.”
Pope Gregory I (St. Gregory the Great, 540-604)
Heresy: Diagnostic Criteria : Heresy: Diagnostic Criteria Error in reasoning
Error must be in matters concerning faith
Accused must be of Catholic faith (R/O Jew, pagan)
Accused still professes some Christian belief (R/O apostate)
Accused obstinately holds to the error
Treatment of Heretics : Treatment of Heretics By 12th century, the practice of persecuting heretics was rampant throughout Europe. Vigilante burnings were widespread.
Why Now? (or then rather…) : Why Now? (or then rather…) Historical context:
Plague and other pandemics/epidemics
Steppe invasions
Growth of the Muslim world
Result?
Fear, confusion
Treatment of Heretics Early 13th Century: Frederick II : Treatment of Heretics Early 13th Century: Frederick II Emperor Frederick II outlawed heretics:
If they recanted: Imprisoned, property taken, home burned; children lost eligibility for positions unless they betrayed the heretic
If they did not recant: Burned
Treatment of Heretics Early 13th Century: Frederick II : Treatment of Heretics Early 13th Century: Frederick II Ironically, Frederick advanced general medical practices:
Established “modern” form of education, i.e., five years hospital-based study followed by one year “internship,” followed by an examination
Allowed dissection of a human cadaver every five years
Inquisition : Inquisition The Church sought to bring order and “due process” to the investigation and treatment of heretics.
1233: Pope Gregory IX inaugurated the inquisition, designating the Dominicans as the administrators of the formal investigation of heretics, a role formerly marginally held by the local Bishop.
Inquisition : Inquisition Cases of alleged heresy investigated by monastic authority
If the heretic was repentant, penance was determined by religious authority
Imprisonment in monastery, pilgrimage, loss of property; +/- death
If condemned (ie, not repentant), heretic turned over to secular authority: Burned
Medicine in the Inquisition : Medicine in the Inquisition By 14th-15th C, hard to consider any illness without considering soul, sin, etc
Non-psychiatric illness: visitation of sin on the body
Natural and religious responses required
Non-Psychiatric Disease: DDx : Non-Psychiatric Disease: DDx Extrinsic cause ID’d: Due principally to natural causes
Idiopathic, incurable, sudden: Witchcraft
Slide29 : Psychiatric illness: purely in the realm of the spiritual
Former pity (at best) for the mentally ill gave way to fear (of the devil vs. church authority)
Afflicted cast into streets by their own kin
The Witches’ Hammer : The Witches’ Hammer 1484: Pope Innocent VIII appointed Johann Sprenger and Heinrich Kraemer Inquisitors of Germany
1486: They co-authored the Malleus Maleficarum
Inquisitors’ “DSM” & practice guidelines
19 editions from 1486 - 1760
The Witches’ Hammer : The Witches’ Hammer Part I: Argument proving existence of witches, witchcraft
Part II: Methods to ID (“diagnose”) a witch; clinical vignettes
Pat III: Legal forms of examining and sentencing a witch
Inquisitorial Due Process: Questioning of accused and witnesses : Inquisitorial Due Process: Questioning of accused and witnesses
Slide33 : “…common justice demands that a witch should not be condemned to death unless she is convicted by her own confession.”
Slide34 : “…direct or indirect evidence of the fact, or the legitimate production of witnesses…she is to be exposed to questions and torture to extort a confession of her crimes.”
Slide35 : The Judge should “not be too quick” to examination, for the Devil will render the accused “so insensible to the pains of torture that she will sooner be torn limb from limb than confess any of the truth.”
Slide36 : If a confession is obtained under torture, the accused is “conducted to another place, that he may confirm it and certify that it was not due alone to the force of the torture.”
“…written with firm conviction and a fervent zeal which made the authors totally anesthetic to the smell of burning flesh.” : “…written with firm conviction and a fervent zeal which made the authors totally anesthetic to the smell of burning flesh.” Gregory Zilboorg
Slide38 : While not all accused of witchcraft were mentally ill, almost all mentally ill people were considered witches, sorcerers, or bewitched.
Slide39 : Rationale needed to give free reign to fear and hatred of MI
Man chooses to succumb to the Evil One. Hence, punishment is moral and just (and necessary)
Soul must be delivered (body burned) = Act of supreme purification and devout communion with the will of G-d
The Power of Devils “clinical manifestations” : The Power of Devils “clinical manifestations” induce an evil love in a man for a woman, or ...woman for a man
to plant hatred or jealously in anyone
bewitch them so that a man cannot perform the genital act with a woman, or conversely a woman with a man
The Power of Devils “clinical manifestations” : The Power of Devils “clinical manifestations” to procure an abortion
to cause some disease in any human organs
to take away life
to deprive them of reason
Slide42 : Demons and witches may do “injury to the use of reason, and...tormenting of the inner perceptions…”
“…they can see absent things as if they were present; they can turn the minds of men to inordinate love or hatred…”
Role of the Physician : Role of the Physician “As a physician, the medical man was considered of no consequence in these measures; he could only help as a citizen and as a Christian, since the problems involved were those of salvation, of suppressing sedition, of saving the faith, of the total destruction of the devil’s servants and their machinations.”
Gregory Zilboorg
Demographics of the Inquisition : Demographics of the Inquisition How many perished?
Estimates range from the tens of thousands to millions
Best estimate: 100,000-300,000
Female to male ratio: Reports from 1:1 to 50:1
70% of those tried were executed
Last witch killed in 1792 in Switzerland by decapitation
Related to long departure of women from medical practice?
The Early Flicker of Reason : The Early Flicker of Reason 16th Century: Age of Michelangelo, Leonardo, Machievelli, Copernicus
Renewed increasing interest in human impulses, emotions, motivation of behavior
Slide46 : “I do not feel obliged to believe that the same God who endowed us with sense, reason, and intellect had intended for us to forgo their use.”
Galileo Galilei
Juan Luis Vives (1492-1540) : Juan Luis Vives (1492-1540) Pious non-physician
Urged scholarly attention on common, poor people
Embraced intellectual potential of women
Community must act responsibly toward its unfortunate members, and show compassion for physically and mentally sick
Juan Luis Vives (1492-1540) : Juan Luis Vives (1492-1540) De Anima et Vita (1538)
Physician should know nature & mind
Criticized cruelty toward mentally ill
Advocated for MI, medical treatment, gentle and friendly tx, minimal use of force/chains, and, above all, tranquility
Juan Luis Vives (1492-1540) : Juan Luis Vives (1492-1540) De Anima et Vita (1538)
Described associations (fever/cherries)
Anticipated unconscious
Detailed attention to nature of emotions
Paracelsus Theophrastus Bombastus von Hohenheim (1493-1541) : Paracelsus Theophrastus Bombastus von Hohenheim (1493-1541) Physician; sought the open fight
Busy, energetic, iconoclastic clinician
Unequivocally denounced demonology and its dogmae re. MI
Paracelsus Theophrastus Bombastus von Hohenheim (1493-1541) : Paracelsus Theophrastus Bombastus von Hohenheim (1493-1541) Humoral ideas re. etiology of MI (heat/cold)
Writings more intuitive than rational, calculating
Johann Weyer (1515-1588) : Johann Weyer (1515-1588) Personal physician to Duke William
Busy clinician, in the Hippocratic-Galenic tradition
Highly critical of inquisition
Johann Weyer (1515-1588) : Johann Weyer (1515-1588) “It is highly unpleasant to see how people, in order to kill errors are busy killing human beings.”
Pled for right of medicine to care for poor (esp. women) called witches
Johann Weyer (1515-1588) : Johann Weyer (1515-1588) Of contemporary medicine: “Ignorant physicians and surgeons cover their stupidity and errors by referring to sorcery and the virtue of saints.”
Brought methodical, systematic curiosity and common sense to his practice of clinical medicine
Johann Weyer (1515-1588) : Johann Weyer (1515-1588) 1563: De Praestigiis Daemonium
Carefully, exhaustively, rationally attacked entire Malleus
Concluded “witches” are mentally sick
Monks who torture and torment the ill should be punished
Used scriptures to make argument
Johann Weyer (1515-1588) : Johann Weyer (1515-1588) Attempted to divorce mental illness from theology
De Praestigiis Daemonum was banned by the Catholic church until early 20th century
1st physician w/ major interest MI
“Founder of Modern Psychiatry”