Bryn Mawr Classical Review

Chiara Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought. Cambridge; New York: Cambridge University Press, 2017. Pp. viii, 503. ISBN 9781107176010. $135.00.

Reviewed by Jessica Wright, University of Southern California (j.wright@usc.edu)

Version at BMCR home site

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This book argues that Hippocratic medicine presents mental disorders as bodily phenomena that manifest themselves in disturbance of physical features and gestures, vital functions, and sense perception. The aspects of mental life most prominent in Western psychiatry and in scholarship on the history of madness—the rational faculties, the emotions, and ethical responsibility—are de-emphasized in, if not entirely absent from, Hippocratic writings. The reason for this, Thumiger argues, is that Hippocratic authors sought to demarcate their professional territory by distancing themselves from contemporaneous philosophy and tragedy, where irrationality, emotions, and ethics are focalized. Taking the body as their lens, Hippocratic authors naturalized and neutralized mental disorder, and in so doing established a distinct professional identity. The incorporation of ethics and emotions into post-Hellenistic accounts of mental disorder, Thumiger suggests, might be explained by the more secure professional status of doctors at this later period.

Thumiger's approach draws on work in medical anthropology and cross-cultural psychiatry to challenge the hegemony of "current official Western psychiatric culture" as a source for understanding mental disorder. She suggests that the focus on bodily symptoms in Hippocratic medicine may reflect a clearer and more accurate conceptualization of mental disorder, a claim that she backs up through reference both to the prominence of the body in non-Western psychiatric cultures, and to the increasing attention to the body in current Western scholarship on cognition and mental life. Recognizing the centrality of the body in Hippocratic accounts of mental disorder contributes to a broader critique of Western psychiatric culture as unhelpfully fixated on the psyche. It also explains why Hippocratic accounts of mental disorder have seemed so impoverished and inconsistent to the modern Western reader: precise terms for irrational thoughts or depression, for example, are unnecessary within a framework that does not privilege "non-physical" experiences over bodily symptoms.

The introduction lays out a substantive historiography of mental disorder in classical antiquity, covering the past two hundred years but focusing especially on the most recent half-century. In order to cover the range of different approaches, Thumiger identifies eight categories: comprehensive cultural studies of mentalité addressing madness; the emotions; literary approaches; historical psychoanalysis; studies of insanity in ancient medical sources; disability studies; history of self and history of mind; cognitive studies. This introduction offers a valuable overview of the different fields and approaches that have contributed to the study of mental disorder in antiquity. It closes with the observation that the history of mental disorder and the history of mind "meet only later in Greek thought"; it is for this reason, she adds, that her analysis focuses on "embodied and externalised manifestations of the mental" (14). Chapter one turns, then, to the method that underlies this approach.

Chapter 1, titled "Mental Disorder and History: Methodological and General Issues," offers three central methodological insights. First, while the topos of insanity is well-developed in other classical genres (for example, comedy and tragedy), Hippocratic authors do not clearly conceptualize mental illness as a phenomenon separate from physical illness. This, Thumiger argues, must be interpreted as the intentional demarcation of professional territory.

Second, an approach to mental disorder in antiquity must find a middle path between biological, social, and psychological perspectives, a point that Thumiger draws from work in medical anthropology and cross-cultural psychiatry. Thumiger distinguishes four principles that support this middle path: (1) acknowledgement of "hard facts" about mental disorder that allow for some retrospective diagnosis, (2) prioritization of the visible body as the central focus in Hippocratic accounts of mental disorder, (3) contextualization in terms of generic conventions, literary traditions, expected audience, and social convention, and (4) recognition that the individual and subjective nature of human experience is cross-cultural.

Third, Thumiger distinguishes three aspects of the study of mental disorder: causation and prognosis (or, as she glosses it, theory of mind), notions of the good life, and manifestations of insanity. Only the last of these, Thumiger argues, appears in Hippocratic texts, which exclude even aetiology and curability from their discussion. For Hippocratic doctors, in contrast to modern Western psychiatrists, "theory and observation of pathological manifestations are ultimately different spheres, which may intersect but are determined by different epistemologies and interests" (42). The analysis that follows focuses on the physical (and mostly visible) manifestations of mental disorder, demonstrating through a systematic catalogue of examples the argument that it was through manifestations at the surface of the body that mental disorders were constituted as medical entities in Hippocratic thought.

The main body of the book is divided into two parts: 1. "The Body of the Insane" and 2. "The Mind of the Insane." By this distinction, Thumiger indicates two different perspectives on the symptoms of mental disorder: that of the physician, who gathers information from the appearance and functions of the body, and that of the patient, whose mental life (understood in terms of sensory experience, emotions, and cognitive activities) is accessible only through communication and self- report (273). Part 1 begins with a chapter dedicated to "The Body Perceived" (chapter 2), first in its parts ("the human face and its features, limbs and physical postures") and then as a whole ("voice, behaviours, gestures") (68). Rather than try to identify locations or organs of mental disorder, Thumiger maps out "gravitational centres" for mental activity (for example, the eyes), and establishes a "repertoire of signs" that appear across the medical works (172). This chapter is particularly successful in illuminating the distinctive picture of mental disorder that emerges when the surface of the body is focalised as the site of mental disturbance.

Chapter 3 ("The Vital Functions and Mental Life: Sleep, Food and Drink, Sex, Death") shifts from external perceptions of the body to its vital functions. Thumiger chooses sleep, food and drink, sex, and death because, as she explains, they generally affect sick people, are signs of mental disorders, and affect cognitive abilities (174–176). Thumiger makes a noteworthy contribution in shifting the conversation about food and mental disorder in antiquity away from retrospective diagnoses of modern eating disorders and toward an evidence-driven account of how excessive appetite and the rejection of food enter into ancient medical texts (206–213). This reader wished for a deeper analysis of sleep and drunkenness. The discussion of homosexuality was promising but abrupt, and more work is necessary to examine Thumiger's claim that Hippocratic authors offer a "value-free, cognitive description of sexual physiology and psychology," in contrast to the "normative, ethically-laden one" that appears in later medical works (264–265).

Thumiger's analysis of the role of death is the most intriguing part of this chapter. Observing that violence is a fundamental manifestation of insanity as represented in Greek drama (for example, the figures of Ajax and Heracles), Thumiger points out that aggressive behavior is almost entirely absent from Hippocratic accounts of mental disorder. She suggests that the trope of murderous insanity "rephrases the destruction of the body (or a body) that mental disturbance entails in medical texts in dramatic form" (266). Whereas medical literature foregrounds physiological disintegration, non- medical literature highlights death, violence, and fatal choices. The dramatic markers of insanity, while absent from medical texts, reflect the embodied character of mental disorder as it appears in the Hippocratic material: "Insanity," Thumiger concludes, "is not a phenomenon that occurs inside a person, within an internalised mind, but a matter of visible acts that ultimately destroy the body" (272).

Part 2 begins with a chapter titled "Sensory Perception and Its Impairments" (chapter 4). Thumiger opens by returning to the methodological concerns addressed in chapter 1, emphasizing the need to find a balance between "anthropological particularism" (senses as cultural history) and "biological universals" (sense experience as "recognisable biological facts") (278). Following a brief survey of "general remarks on the senses and their physiology" (279–282), she examines each of the senses in turn, paying most attention to vision, hearing, and touch. Since, on Thumiger's reading, the physician can only know a patient's sensory experience through self-report, Thumiger concludes that the central importance of patient's sensory experience indicates "an irreducible element of subjectivity" in Hippocratic conceptions of mental disorder, and "further anchors mental life to bodily activity"; the expectation that subjectivity might be a disembodied experience results from a "general poverty of awareness of sensory stimulation" among modern Western readers (334). At stake in this turn to the language of subjectivity is Thumiger's ambitious effort to detach the history of mental disorder in classical antiquity from the history of mind. As Thumiger will later conclude, "the search for subjectivity in our texts inevitably leads here [sc. to sensory experience], rather than where modern humanism leads us to expect, to the emotions and rational–logical thought" (419).

Chapter 5 ("Personality and Personal Psychology: Emotions, Character, Reasoning") turns, finally, to the symptoms and characteristics associated with mental disorder in contemporary Western psychiatry—and it is, for this reason, a chapter of negations. Thumiger proves her argument that Hippocratic mental disorder is a bodily phenomenon by demonstrating that emotions, character, and reasoning receive little attention in Hippocratic texts. This is, she argues, a strength: "the avoidance of personal, psychological topics in our texts is not a shortcoming but part of a programme that privileges an objective perspective on human health and disease" (339).

Thumiger concludes with four main findings about the representation of mental life and mental health in Hippocratic medical texts: mental disturbance is visible; mental disturbance is embodied; sensory changes are central; and, to the extent that symptoms we might associate with mental disorder are included, they are naturalised (419–20). She then offers a helpful list of contrasts between Hippocratic medicine and both non-medical and post-Hellenistic medical texts: Hippocratic medical texts avoid (1) biographical detail, (2) ethical evaluation, (3) motifs, themes, and experiences characteristic of contemporaneous representations of mental disorder, and (4) traditional psychological vocabulary, but include (5) emphasis on continuity between body mind (420–21). Thumiger's final move is to lay out two stories that might be told about Hippocratic accounts of mental disorder, based on the data she has so carefully gathered and interpreted: (1) Hippocratic texts offer "poorer, less perceptive and certainly more mechanical" accounts of mental illness than poetic and mythological texts; (2) Hippocratic texts are admirably scientific and non-metaphysical (421). It is clear that Thumiger advocates for the latter narrative.

This book makes an important contribution to the study of mental disorder in antiquity. Thumiger's thorough survey of relevant material offers an invaluable resource for the researcher, and her historiographical introduction is outstanding in its detail and clarity. The methodological remarks in the opening chapter offer a careful account of the role of medical anthropology in the history of medicine in antiquity. There is little doubt that this book will become a standard in the study of mental disorder in ancient medical and non-medical texts.