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Guest Gallery I
The story of psychiatry (part II)
Uddip Talukdar, M.D.
Senior Resident of Psychiatry, Himalayan Institute of Medical Sciences, Jolly-Grant, Dehradun
We ended part I with Rene Descarte’s Mind-Dualism, and there I viewed that his Mind-Body Dualism actually regressed the study of mind and I expressed my doubts in my own view candidly, so that you can read further and make your own opinion. Throughout this series of articles, I am trying my best to remain unbiased and put forward only facts. But, psychiatry in its complexity and difference of opinions makes this a very challenging task and somewhere in the mind we tend to get biased to one theory, as I believe our minds hate confusion and always try to have one clear answer however silly it may be.
Descarte’s Mind-Body Dualism essentially states that Mind is non-entity (that it is not a structural organ and it does not follow laws of physics), while Body is an entity and it follows the laws of physics. The Mind resides in the Body, and controls it, very occasionally. Body can also influence the mind as in the acts of passion. This may seem easy for us to understand because the concept of ‘Atma’ and ‘Sarir’ is very much similar to this. When Krishna says that Atma is immortal and the Sarir is just robe for Atma. It echoes the Mind-Body Dualism. I point out to readers that though I draw a simile of Mind Body Dualism to Atma-Sarir concept, one should not confuse them. Because Atma is not Mind, as concepted by Descarte. But, our understanding of Atma being a non-physical identity makes us assimilate the notion of a non-entity easily, but to the thinkers of the West, of Descarte’s time, it was a ground-breaking concept.
Thus, Descarte influenced a new school of thinking for the study of mind, hitherto unconsidered. It was a good starting point for the study of the mind. Still, I find that it hampered the study of Psychiatry, and that I would like to state a bit in detail.
The biggest difficulty that aroused out of Mind-Body Dualism is that Mind is a non-entity and that it follows no physical law, made the prominent thinkers believe that mind cannot be studied by scientific procedures as they can detect merely the changes in the physical properties. Naturally, all great thinkers tended towards philosophical studies of the mind, and the observational approach, the fundamentals of a proper science, was ignored. The result, mind became more and more confusing to general public, a topic of elite discussion with no application. Volumes were written on the philosophy of mind with no practical use. One more aspect of this is as Mind was a non-physical entity the concept of a physical problem in the mind also became a non-entity. For these two reasons, I believe Descarte made a negative impact on the thoughts of people towards diseases of the mind. But, blaming him solely probably is not fair enough. Because Descarte was a man of many facets—He is called The Father of Modern Philosophy, he developed the Cartesian system of co-ordinate geometry, he is the person who could provide an answer to the biggest question of all time, the meaning of existence, in three words—Cogito ergo sum (I think, therefore I am).
The problem was in the near-sight of his followers, who always cling to the sayings of their masters without questioning and forget that that only by questioning the existing beliefs their masters got new answers. Same feat happened to Galileo, as followers of Aristotle refused to believe that Earth moves round the Sun.
Mind Body Dualism remained so prominent in the later years that only in the first half of twentieth century Mind again became an entity, which can be studied by scientific method. Still, there are people who refuse to give mind a physical shape and they even refuse to accept Psychiatry. But, that will come much later in this series of articles.
The next big event that took place in the time line of history of Psychiatry is the ‘Unchaining of the Inmates of Asylums’ by Philippe Pinel (1745-1826). Before turning to this truly great event of 1793, let us look back at the history of the Asylums.
A maristan (Persian word for hospital) devoted to treatment of mentally ill people is reported as early as 490 A.D. Travelers reporting back expressed wonder at the care and kindness showed to the patients there. Another well-known hospital was built in A.D. 872 in Cairo. In Europe there were varieties of small institutions to keep mentally ill patients in monasteries or town towers (Fool’s tower). The ancient Parisian Hospital Hotel-Dieu had separate cells for insane. When Christianity became widespread throughout Europe after Chirtian Reconquista, various hospitals were built to keep the insane for safe-keeping of the society; fee notable cities are Valencia (1407), Zaragoza (1425), Seville (1436), Barcelona (1481) and Toledo (1481). The priory of Saint Mary Bethlehem (Bedlam) was founded in 1247, which is recognised as the first psychiatric hospital.
Though called psychiatric hospitals, none of these had any proper means to treat psychiatric patients. Instead, they relied heavily on torture and cruelty to subdue the inmates, earning the notoriety the term ‘madhouse’ brings to a reader’s mind.
Pinel’s great contribution lies in understanding that not all patients require constant chaining and torture to be subdued and they need to be treated with care and humanity.
When he was appointed the director of Bicetre, Paris directed his attention to seventh ward where 200 mentally ill patients were kept chained. Pinel was greatly influenced by Jean-Baptiste Pussin (1745-1811), working in the same hospital who brought concept of humane touch to treatment. Pinel brought the concept of ‘moral treatment’ based on Pussin’s ideology and developed ‘moral treatment’, consisting of strict but non-violent management and careful observation and he unchained them. Legend has it that both political parties and general public opposed this move, and one of the unchained inmates of the hospital saved Pinel from a hurling mob. Pinel gave due credit to Pussin for the ‘moral treatment’, but somehow in public memory Pinel remained the sole person behind it.
Pinel also devoted time to careful observation of patient’s behaviour and classification of disorders. He was the first person to bring vaccination to Paris. Interestingly, he was devout follower of Hippocrates and followed his observational methods carefully, while giving away the inhumane treatment procedures like bleeding, purging, blistering etc.
William Tuke adopted the methods outlined by Pinel and opened the York Retreat in England. That institution became known as a model throughout the world for humane and moral treatment of patients suffering from mental disorders. It inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living).
The approach of Pinel’s careful observation to understand mental illness brought in the required methodological approach which was lacking in the study of mental illness. His methods gained acceptance and more and more people began to devote time to observation of the behavioural patterns of insane and the first truly scientific approach to mental illness grew up.
Noteworthy that this approach did not consider the mind as such and it neither concentrated on theoretical things like what is the shape of mind. It was neither for nor against Cartesian Dualism nor against any school of thought. This was a very simplistic approach which drew heavily from Hippocratean school of thorough observation and remedy based on the same. It was an age-old proven method all healing sciences like Ayurveda, where the main approach of diagnosis is to study the symptoms and signs, not the disease process itself. The modern medicine on the contrary deals with the causes and pathology in the organs while the interest in the patient’s symptoms and signs take a second tire. As a result, there is a possibility that patients who are more disturbed with the symptoms than the actual process of illness feel sidelined in the humdrum of the diagnosis and tests. The alternate therapies are thriving for their simple approach of caring the symptoms than the disease process. While none of the approach is better than the other, and the best healing science would care to maintain the right balance between the process and symptoms.
So, influenced by Pinel, studies were undertaken to understand the symptoms of psychiatric illness and as a result, various descriptions of mental illness and attempt to classify them based on the symptoms grew. Thus, we got a wonderful branch of Psychiatry called Phenomenology.
Johann Christian Reil (1759 – 1813) was a German physician, physiologist, anatomist and psychiatrist. He coined the term psychiatry or, in German, Psychiatrie in 1808. Thus began the study of mental illnesses mainly from their symptoms and analyzing them. Reil in 1808 coined for the first time the term Psychiatry.
In 1812, Benjamine Rush published his seminal work “Medial Inquiries and Observations upon diseases of the mind.” Same year, Jean-Étienne Dominique Esquirol (1772 - 1840), a favourite student of Philippe Pinel, lectured about mental illness to medical students.
The second half of the nineteenth century saw emergence of the first attempt at classifying mental disorders and there emerged some notable persons who changed the study of psychiatry forever. That story will come in the next part. Again, I would like to remind you, most of the comments here are my own and there may be differences in opinions about them. I urge the young students of psychiatry to go through the history part in their spare time and form their very own opinions about them.
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