Abstract

Thesis statement: The work of ancient, Roman physicians added to the mainstream of psychiatric evolution that paved the way for the development of the specialty of psychiatry.

Methodology: This article employed historiography and conceptual analysis of the writings of three leading Roman physicians: Soranus of Ephesus, Aulus Celsus, and Claudius Galen.

Results: Roman physicians (medici) provided a simple protocol for the diagnosis of mental illness, and early models for the treatment of psychiatric disorders. The results demonstrate the importance of the rationalistic approach to mental illness used by the ancient Romans.

Conclusion: The work of Roman physicians added to the mainstream of psychiatric evolution that paved the way for the development of the specialty of psychiatry.

Keywords

Psychiatry; Psychotherapy; Pharmacotherapy; Roman progenitors

Introduction

Psychiatry is the branch of medicine that deals with the diagnosis, treatment, and prevention of mental illness [1]. It did not become a medical specialty until the late 18^th and early 19^th century. Ancient Roman physicians (medici) had no specialty in this area. Still, some physicians recognized the correlation between the state of mind and adverse medical conditions. An important consideration was anger management. Widespread anger was a danger to society and the state that could lead to political violence. The Romans believed that managing anger was one factor in maintaining law and order.

Caelius Aurelianus of Sicca in Numidia was a Greco-Roman physician and writer on medical topics. He is best known for his translation from Greek to Latin of a work by Soranus of Ephesus titled: On Acute and Chronic Diseases. Soranus flourished in the 5^th century [2]. Aurelianus provided one of the earliest texts on mental illness. He described events which affect the brain, and three kinds of psychiatric disorder: phrenetis, mania and melancholy. Phrenetis, a form of organic delirium resulting from fever, causes fluctuating pulse rates and spastic movements. Mania denoted chaotic thoughts, frenzy, anger, and delirium. Melancholy correlated with depression, including sadness, fear, and despondency. In its severe form it produced paranoia, catatonic stupor, and schizophrenia. Melancholy could lead to withdrawal from external reality into an inner world [3].

We have written about the Roman treatment of Traumatic Brain injuries and Post Traumatic Stress Disorder in other journals [4,5]. Conditions which require a neurosurgeon, to diagnoses and treat conditions that affect the central nervous system, including the brain and spinal cord, will not be included in this study. The focus in on Roman medici who used counseling, drugs, and other forms of noninvasive procedures to address psychiatric disorders.

Scope and Methods

Roman physicians used a variety of methods to treat psychiatric disorders. The thesis of this paper is that the protocol for diagnosis and treatment of psychiatric disorders established a prototype used by some psychiatrists today. These prototypes incorporated and advanced Egyptian and Greek techniques for dealing with mental illness. This is especially true after Greece became a province of the Roman Republic in 146 BCE and Egypt became a province of the Roman Empire in 30 BCE. This study relies on the conceptual analysis of the writings of Roman physicians and historians. Roman physicians used forms of Cognitive Behavior Therapy, A version Therapy, and psychoactive herbs to address psychiatric disorders. Some modern psychiatrists still adhere to these ideas, although modern technology and techniques have made dramatic advances in the treatment of mental illnesses.

Primary sources

Aulus Cornelius Celsus (first century CE). Celsus was an advocate of Aversion Therapy. A version Therapy is a method in which the physician applies a form of punishment to the patient to discourage an undesirable behavior. The goal is to have the patient associate the undesirable behavior with punishment to replace an undesirable behavior with a desirable behavior [6]. The Greek physician Pedanius Dioscorides (AD 40-80) compiled an extensive list of drugs and other materials used in medicine, including psychoactive medicines. Claudius Galen, (CE 129-205) developed an empirical approach to medical procedures. He based his diagnoses and treatments on experiences, observations, and experiments. Galen collected and analyzed data and used statistical techniques to classify and treat mental illnesses. Caelius Aurelianus and Soranus (2^nd century CE) employed Behavior Therapy to treat patients with mental disorders.

Behavior Therapy employs various methods to change maladaptive behaviors, based on principles of learning theory. This therapy may include the use of positive and negative reinforcement. Aurelianus used standardized, brief sessions with his patients that fostered conversations as specific, learning experiences [7]. The Greek physician Paulus A Egineta (625-690) wrote a medical encyclopedia, a Medical Compendium in Seven Books, which include some mental disorders. Quintus Martialis 1893. (3^rd century) specialized in dietetics. His work emphasizes the role of nutrition in the treatment of mental disease. A contemporary book, by Alexander and Selesnick explores Greek and Roman medical techniques to treat mental illness [8].

Galen developed a seven-step protocol for the diagnosis of psychiatric disorders. These seven steps include:

1. Subjective information from the patient if the patient was awake and coherent.

2. Objective findings of the physician upon examination of the patient.

3. Diagnosis by the primary care physician in consultation with other healthcare professionals.

4. Formulation of a treatment plan.

5. Implementation of the treatment plan.

6. Monitor and evaluate the effects of the treatment plan, including efficacy and safety.

7. Alter the treatment plan with a follow-up plan as necessary [9].

Roman techniques in the treatment of mental disorders

Celsus used Aversion Therapy to treat alcoholism, binge-eating disorder, sexual deviance, and psychotic behavior. This therapy involved modifying undesirable behavior by punishment and fear in long-term mental illness. This form of operant conditioning was a method of learning that used punishment to modify behavior. Celsus believed that consistently punished behavior will rarely reoccur after treatment. His method included subjecting the patient to: hunger, chains, flagellation, and memorization of long passages, immersion in water and oil, and violent exercises until the patient became rational [10]. Scribonius L argus (1^st century CE) experimented electric physiotherapy. He treated Emperor Claudius’ (41-54 CE) headaches with electric rays (torpedoes) [11]. Each ray generates 8-220 volts. As the patient’s behavior became more compliant, Celsus began to reward him/her with pleasurable experiences. These rewards included: food preferences, pleasurable reading (if literate), baths and massages, pleasant and moderate exercises, soothing music and eventually freedom [12].

Aurelianus used Behavior Therapy to treat mentally ill patients. He spent considerable time and writings on Phrenitis (encephalitis). In contrast to Celsus he stressed kindness, gentleness, and hope in his relationship with patients. Encephalitis is usually caused by a virus that produces inflammation of the brain. Roman physicians (medici) had no empirical knowledge about microbiology. However, they knew through deductive reasoning that pathological microorganisms existed. Roman scholar, Marcus Terentius Varro (116-27 BCE) wrote; “the pathogen is alive, too small to be seen; it enters the body though the mouth and nose, propagates, and produces many diseases resistant to treatment” [13]. Aurelianus observed the symptoms of Phrenitis include headache, cerebral edema, fever, seizures, vomiting, movement disorders, sensitivity to light and sound, neck stiffness, convulsions, and loss of consciousness.

Aurelianus believed the patient should be made comfortable and lodged in lighted rooms with high windows and a pleasant temperature. Lights were dimmed to promote relaxation. If the patient required restraints, he advised wool or clothing to protect the restrained areas. He stressed psychotherapy, the importance of the relationship between the physician and the patient, and he minimized the use of drugs [14]. The patient should receive adequate fluid intake to prevent dehydration, eat small, frequent meals, and receive regular oral hygiene. To reduce cerebral edema Aurelianus recommended dietetics in the form of foods with anti-inflammatory properties [15,16]. Examples are grapes, grape juice, mulberries, raspberries, garlic and ginger [17].

Aurelianus’ Convalescent staff, under the command of an optioconvalescentium (Physician’s Assistant) controlled fever in several ways. Using lukewarm water and acetum (vinegar), they sponged the patient and gave them a drink containing the powdered bark of the willow tree (Salix Alba). If the fever was high, the staff kept the head of the patient cool with ice or cold compresses, and the body warm with blankets. If ananalgesic was necessary for moderate pain [18], they used a draught of mandrake (Mandragora officinarium). Valerian (Valeriana officinalis) [19] could help with the patient’s seizures. Behavior therapists used a range of methods to help convalescent mental patients recover. They employed Physical Therapy in the form of specific exercises, hot and cold baths, and massage. Medical staff repositioned patients frequently to prevent neck discomfort and joint pain. They also used Music Therapy [20] in the form of soothing, string instruments to reduce stress and anxiety. Hospital staff gave words of assurance to the patient and the patient’s family that harmful behavioral changes are sometimes transitory.

Claudius Galen employed Empirical based therapy on patients. Empirical Therapy is based on learning skills through experience, rather than theory, as a basis of treatment [21]. Galen studied the techniques of physicians from Hippocrates (460-370 BCE) through his own era. He attended the medical school at Alexandria, Egypt. In 157 CE Galen traveled to Pergamum and from 157 to 161 he becomes a physician to treat the gladiators at the ludus (Gladiatorial school) of that city. He acquired valuable medical experience and knowledge at the ludus. After brief service as a medicus in the Roman Army Galen returned to Rome to practice medicine and became an imperial physician. He treated Emperor Marcus Aurelius and his son Commodus [3,22,].

Galen took careful notes on his patients and classified several mental disorders in patients with similar symptoms. He observed that severe emotional disturbance might indicate a lesion in the brain. The mental disorders he classified were mania (anxiety disorders), melancholy (depression), mood disorders, neurological disorders, cognitive disorders, post-traumatic stress disorders, substance abuse disorders, and schizophrenia. Anxiety is a vague feeling of apprehension, worry, uneasiness, or dread, the source of which is often nonspecific or unknown to an individual [23]. Galen explained: “To those who are sleepless, grieving or overanxious, give something that induces sleep” [24]. Galen used Behavioral Therapy and Pharmacotherapy to treat anxiety disorders. He presented a calm, caring demeanor in a quiet, controlled environment to reduce the patient’s anxiety, feelings of isolation and instability. He prescribed a mixture of valerian and hops as a sedative, and in larger doses, as a somnifacient. He also prescribed a mixture of wine and water, and recommended warm baths, massage, and food with sweet juices for patients with anxiety [3].

Melancholy (depression) is a state of lowered mood, often accompanied by disturbances of sleep, energy, appetite, concentration, interests, and sexual drive [25]. During sessions with depressive patients. He wrote: “The consequences of which are depression of the spirits and sadness” [26]. Galen used Behavior Therapy and pharmacotherapy. He recommended adequate nutrition and fluids, abstinence from alcohol, and physical activity. He also felt a structured routine, and noncompetitive activities, could help build self-confidence and encourage interactions during sessions with the physician and with other patients. Galen demonstrated warmth and interest in depressive patients and presented an optimistic attitude. He prescribed St. John’s Wart [27] as a stimulant to help the patient recover.

Bipolar disorder is marked by manic or manic and depressive episodes. This condition may include the risk of violence against oneself and others, irritability, impulsive behavior, delusional thinking, hostility, aggressive acts, inadequate intake of food, sleep pattern disturbances, sensory and perceptual alterations and altered family relationships [28]. Galen wrote: “When two or three conditions are intermingled and when they require opposite remedies to each other, it is necessary to know the substance of each of the conditions” [29]. Galen employed Cognitive Behavioral therapy and other talking therapies to confront the seeming duality of manic-depressive disorders. He helped the patient explore how feelings, thoughts, and behaviors influenced each other, and how the patient could change behavioral patterns. The goal was to change negative, self-defeating patterns to positive and rational ones. Galen prescribed lithium carbonate to treat bipolar disorders.

Schizophrenia is a disorder that alters perception, inferential thinking, language and communication, behavior, affect, volition, drive, social functioning, and attention [30]. Galen wrote of the “damage to reasoning and excessive movement” [31] associated with this disorder. He employed Cognitive Behavioral therapy and other talking therapies for patients with Schizophrenia. Galen prescribed Indian snakeroot (Rauvolfia sepentina) to treat patients with this condition. Unfortunately, this plant was native to the Indian subcontinent, and had to be imported by Rome via the Silk Road. The Silk Road was a network of Eurasian trade routes active from the second century BCE until the mid-15^th century CE. Rome and Indian leaders forged a Treaty of Friendship circa 20 BCE that included trade between the two nations [32].

Substance Use Disorders were uncommon in ancient Rome, but alcoholism was an exception. Alcoholism is a chronic progressive, sometimes fatal disease marked by chronic excessive intake of and dependence on alcoholic drinks [33]. Wine was the beverage that caused the problem. Galen wrote about men “drunk around dawn, and some of them smell so clearly of wine. As a result, they become sick” [34]. Galen employed Cognitive-Behavioral Therapy in treating alcoholics. He recommended relaxation, deep breathing, nutritious meals, moderate exercise, and the gradual reduction of alcohol intake through increasingly diluted wine with water. Pharmacotherapy consisted of a mixture of valerian and hops as a sedative, Saint John’s Wart for depression and Milk Thistle (Silybum marianum) [35] to protect the liver.

Binge-eating disorder was common among wealthy Romans who attended eloquent banquets which contained many delicious, gourmet foods. Binge eating is marked by rapid consumption of large amounts of food in a short period of time [36]. Galen wrote: “Whenever the body turns to obesity, and is not able to breathe freely, the diet should be constructed to melt this away and get rid of it” [37]. Galen recommended brisk exercise, a thinning diet, running, swimming and other forms of exercise. The diet should consist of plant foods, such as vegetables, fruits, nuts, beans, and whole grains. A little fish or poultry also could be consumed. He prescribed herbs such as St John’s Wart, as an antidepressant, and Willow Bark, as an anti-inflammatory [38].

Discussion and Conclusion

The work of ancient, Roman physicians (medici) added to the mainstream of psychiatric evolution that paved the way for the development of the specialty of psychiatry. The main goal of these medici was to replace torpid minds with legerity. This article employed historiography and conceptual analysis of the writings of three leading Roman physicians: Soranus of Ephesus, Aulus Celsus, and Claudius Galen. The education, training, and abilities of modern psychiatrists to diagnose and treat psychiatric disorders extend far beyond the crude techniques of the ancient Romans. The Romans knew nothing about neuroimaging, the mental status exam, Folstein test, and other modern, diagnostic aids. The advanced psychotherapeutic techniques and targeted medications in use today were beyond their knowledge. Today there are many classifications of medications for psychiatric disorders, including antidepressants, antipsychotics, benzodiazepines, barbiturates, stimulants, and others. There were no mental hospitals during the Western Roman Empire (31 BCE-476 CE). During the Eastern Roman Empire (395-1453) (Byzantine Empire) there were more than 100 hospitals. Some of them had neurological and mental units, and, eventually, mental hospitals [39]. Roman physicians (medici) provided a simple protocol for the diagnosis of mental illness, and early models for the treatment of psychiatric disorders. The results show the historical importance of the rationalistic approach to mental illness employed by the ancient Romans.

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Article Information

Article Type: REVIEW ARTICLE

Citation: Belfiglio VJ (2024) Psychiatric Practices in Ancent Rome: 27 BCE-476 CE. J Psychiatry Ment Health 9(1): dx.doi.org/10.16966/2474- 7769.156

Copyright: © 2024 Belfiglio VJ. 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.

Publication history: 

Received date: 04 Mar, 2024

Accepted date: 21 Mar, 2024

Published date: 27 Mar, 2024