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As discussed in class, trepanation was the first invasive surgery used to alleviate symptoms of the mind. This later was extended to individuals who suffered mental symptoms, including hysteria. This procedure dates all the way back to the Neolithic age, the B.C. era¹. Doctors used this treatment to alter human behavior¹. At this time, evil spirits were a popular reason why trepanation was used as individuals believed these spirits could be relieved by making a hole in the skull that allowed them to escape. Epilepsy, headaches, and other abnormal behavior patterns were also some other reasons why trepanation was used¹. Despite the fact that many physicians and philosophers believed the soul lay in the heart, this procedure was one of the first methods to support that the behavior might be a result of what is going on in the mind, which rested in the head, even though this ideology was not accepted until later. There was an unconscious agreement that by trying this procedure, there could be a possibility that the soul and mind connected. Unfortunately, there are very few records on the improvement or decline of the symptoms experienced by patients, but nonetheless, the procedure was tried¹.

Source 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640229/

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As the idea of trepanation was no longer the primary ideology or procedure for mental illnesses, it was now up to those in science to find a way to explain what was going on in the body and brain. In the late 5th century of the B.C. era, after trepanation was used, Hippocrates came along to describe what would be called the humoral theory¹. Hippocrates was one of the first physicians to acknowledge the fact that maybe there was a physical explanation for something not so tangible: the mind and behavior. He established four humors: black bile, yellow bile, blood, and phlegm1. Each of these was connected to the four elements of the earth and the four seasons of the year¹. Furthermore, these humors were used to describe the imbalances occurring within the body and mind as they would result in abnormal behaviors or emotions. For example, one common belief for extreme sadness was having too much black bile within the body¹. To be fully emotionally well, there had to be a balance between all humors. In addition to the humoral theory, Hippocrates believed there was a connection between the body and mind and thought certain body parts played a role in mental illness¹. This theory was accepted and used until the 19th century when more modern medicine and treatment proved otherwise1.

Source 1: https://fherehab.com/learning/humors-ancient-mental-health

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FHE Health - Addiction & Mental Health Care

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Hippocrates and Mental Health

Humans have been aware of mental illness since about 6500 BCE. Back then, of course, they didn't refer to it by that term. Superstition ruled over views of what we know as mental illness in ancient times. A mentally ill person had been possessed by an evil spirit or, on the other hand, had been touched by a god.

Treatment depended upon which point of view prevailed. Possession by an evil spirit could result in a painful exorcism, torture or death. Ancient cave dwellers drilled holes in the skulls of those they believed possessed by an evil spirit to allow the spirit to escape. Belief that an individual had been touched a god could elevate their standing in the community. Ancient Islam stressed that these individuals needed to be cared for and protected.

The classical Greek physician Hippocrates of Kos (460-375 BCE) first postulated his humoral theory in the late 5th century BCE. He used it to explain a wide range of biological concepts and illnesses, moving people away from superstition as a cause of illness toward more natural causes. What may not be well-known is the connection between Hippocrates and mental health.

Who Was Hippocrates?

Hippocrates may be the ancient physician most recognized in modern times. After all, every physician must take the Hippocratic oath where they swear they will treat all patients and do no harm. The oath is one reason Hippocrates is known as the father of medicine.

Hippocrates is credited with having written (or at least inspired) the Hippocratic Corpus, which gathered more than 70 medical texts together. It was in this work that he first advanced his theory of the four humors to explain the main causes of illnesses in humans. It was Hippocrates' attempt to separate the causes of illness from superstition. His work was later widely disseminated by the Roman physician Galen (129-216 CE). This strengthened the role it played in the treatment of illnesses, both physical and mental.

What Was "Humoral Theory"?

Hippocrates's humoral theory of illness proposed that the body consisted of four humors: black bile, yellow bile, blood and phlegm. These humors represented different aspects of a human, connected to the four elements (wind, air, earth and fire) and the four seasons (spring, summer, fall and winter). While these four humors could be used to describe physical illnesses, they could also be used to describe mental conditions. Black bile was associated with someone who was melancholic, yellow bile with a choleric temperament, blood with someone who was sanguine and phlegm with a person who was phlegmatic.

If someone was too melancholic, this meant they had too much black bile in their body. A manic person could have either too much blood or too much yellow bile. Ultimately, the way to restore emotional well-being was to find a way to balance the four humors.

Hippocrates also believed body parts played a role in mental illness. Sadly, this was to become a curse for women for two millennium. The Greek word for uterus is hyster. When describing diseases that affect women, Hippocrates thought that one of the causes of illness in women was a "wandering womb." Thus, the idea of hysteria was born. This idea was to be used against women who might or might not have been suffering from mental illness until the early part of the 20th century.

How Much Support Did This Theory Have?

As a medical philosophy, humoralism remained the primary way to treat mental illness until the middle of the 19th century - almost 2,500 years after Hippocrates first proposed it. It wasn't only physicians who viewed humors as connected to mental illness. Great writers like Shakespeare and Ben Johnson frequently refer to humors in relation to character. Shakespeare used the word many times in sonnets and plays. Hamlet, for instance, was thought to have too much black bile, which played a role in his melancholic attitude towards the world.

Hippocrates' humoral theory remained a treatment for mental illnesses for centuries. Yet in the Middle Ages, parts of Europe slid back toward superstition. Beginning in the 13th century, mentally ill individuals, especially women, were thought to have been possessed by the devil. This belief remained strong until the middle of the 17th century, when humoralism regained its predominant position during the Enlightenment.

When Was Humoral Theory Phased Out?

Humoral theory continued in some form until the mid-19th century. More modern treatment of mental illness began in the 16th century with the establishment of hospitals and sanatoriums like Bedlam in England. While we look upon these things in modern times as horrific, in the 16th century these institutions were seen as a more humane way to treat the mentally ill.

In the mid- to late 19th century, men like Joseph Breuer (1842-1925) and Sigmund Freud (1956-1939) started to articulate psychological explanations for mental illness rather than physical ones. These were the first steps of psychoanalysis, which dominated much of the first half of the 20th century.

While we've moved away from the theories Hippocrates originated, new ideas towards mental illness that include an approach towards healing the whole body, not just the symptoms of mental illness, have strains of Hippocrates' ideas running through them.

Today, treatment of mental illness is a combination of medication and psychotherapy, as doctors aim to treat and cure the whole person rather than only focusing on the symptoms of mental illness. This has led many doctors to reevaluate Hippocrates in a more modern light and his emphasis on finding a life balance as a cure for illnesses, including mental ones

If you think your deteriorating mental condition may be more than fatigue or just an off-day and that your condition is a mental illness, the best thing you can do is reach out for help. That's why we're here. You can contact us seven days a week at (833) 596-3502. Our team of trained and compassionate counselors is ready at all hours to help you start your journey to recovery.

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The Humors: Ancient Perspectives on Mental Health

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Learn how ancient physicians treated mental illness, how their theories dominated treatment for millennia and why they're getting a fresh look today.

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During the Renaissance, in the 13th century, there was an increase in firearms that resulted in more skull injuries, primarily fractures¹. While mental disorders and abnormal behavior were treated with this method, there was a branching out of what this procedure was used for, and became increasingly more popular and accepted. Many acknowledged a more scientific approach to imbalances as opposed to evil spirits and spiritual abnormalities that were reflected in behaviors¹. During this time, the procedure itself remained the same, but technology allowed for more advanced tools and equipment to be used as well as techniques in the operating room¹. This allowed for a more precise procedure as well as better outcomes of the surgery. At this time, because there were so many advancements in the medical realm, many described the post-op look of the surgery on the patient as a work of art¹.

Source 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640049/

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Andreas Vesalius, a physician in the 16th century, became an important and large contributor to the advancements in medical knowledge and published his first version of “De Humani Corporis Fabrica” in 1543¹. He was a skilled artist and allowed his talent to show through his depictions of the body. At this time, there was no publishing that truly showed the magnitude of the body. His book allowed physicians and other individuals to understand more in-depth what the body looked like and how that could change procedures, including the craniotomy, moving forward. Insights into structures and more functions of the brain allowed even more advancements in the brain. This included shutting down previous ideologies made by previous individuals, including Galen¹. There was more of a clear and precise direction in what procedures should look like and how to go about them. His anatomical contributions revolutionized modern medicine, including neurology.

Source 1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462973/

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Emphasis on treating behavior, not the brain

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Emphasis on treating behavior, not the brain

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Moving to the 1800s, mental health treatment continued to take a downfall. At this time, some mental institutions were established and allowed patients who were considered mentally ill to be admitted and cared for. Only after a little bit of time did it come out that these patients were being treated terribly and unethically. Physical abuse, isolation, and many other conditions were put on these patients to cure what mental illnesses they were experiencing¹. Prior to the opening of mental institutions, there was hesitance among the community as to whether or not these establishments were moral in the first place and the harsh treatment patients endured caused distress and frustration¹. There soon emerged advocates for these types of institutions and eventually they all were shut down and patients were able to see what other treatments best fit them. Unfortunately, this left many patients on their own with nowhere to go¹.

Source 1: https://www.everydayhealth.com/pictures/worst-mental-health-treatments-history/#:~:text=In%20the%2018th%20century%2C%20some,about%20an%20individual's%20wrong%20beliefs.

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In the early 1900s, Wilder Penfield finalized his training in medicine to specialize in epilepsy and soon other nervous system disorders¹. He was in the midst of his career when he received a letter from his mom on the state of his sister: her seizures and headaches were increasing as they had for the past decade at this point². He then decided to operate on her in late 1928 where he discovered a very solid tumor at the bottom of her skull². What was believed to be the end of a successful procedure, Penfield found himself staring at a piece of the tumor that attached itself at the bottom of her skull, making it impossible to remove the entirety of her tumor². Despite buying her some time to spend with her husband and kids, he was unable to relieve her entirely of her tumor. After only several months, her seizures and headaches resumed¹. Because of his guilt for not recognizing his sister's symptoms earlier, he dedicated himself to neurology research. He opened his own institution and while trying to find the origin of seizures, he ended up creating a precise map of sensory and motor functions in the brain, allowing future physicians and researchers to know more specifics about the brain that could guide them in their future advancements of localization¹. This enabled them to more precisely investigate what brain regions could be connected to psychoses and where those connections lay in the brain.

Source 1:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221191/

Source 2: https://archive.org/details/isbn_9780316182348

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Antonio Egan Moniz, the man who won the Nobel Prize for the leucotomy for specific psychoses, found his love for neurology in the 1920s¹. Through his work and research, he hypothesized that the mentally ill suffered from abnormal neural networks within the brain that reflected in behaviors and thoughts¹. He also worked on the frontal lobe as previous work established there was a connection between behavior and the frontal cortex. His decision to perform his first psychosurgery in 1935 would later become an incredible landmark in the field of psychosurgery. His 63-year-old patient, who suffered from depression, anxiety, hallucinations, and more, underwent a cutting of the white fibers in her frontal lobe and after two months, her psychiatrist noted her anxiety and depression decided rapidly¹. This was one of the first successful leucotomies and was possible through trial and error as well as extensive work done by previous physicians. His more defined technique allowed the reduction of mental illness symptoms but kept cognitive functions intact.

Source 1:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291941/#:~:text=Moniz's%20first%20psychosurgery%2C%20performed%20on,%2C%20paranoia%2C%20hallucinations%20and%20insomnia.

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At this time, the news was spreading about the success of Moniz’s procedure of cutting white matter fibers in the frontal cortex which resulted in a decrease in mental illness symptoms. These results were also more thoroughly discussed at the 1935 Neurological Congress where Walter Freeman, a neurologist in the U.S., took Moniz’s accomplishments and worked on his own advancements in the procedure¹. In 1936, he and James Watt performed the first lobotomy in the U.S.¹. Using a similar method, Freeman drilled two holes in the skull but excised more white matter than Moniz1. He later advanced his own procedure to be more transorbital, being described as an ice pick method for its precise access¹. He did so well advancing his own procedure that his method was described as so simple and easy to the point surgeons could learn the technique within half a day of training¹. If it weren't for the start of Moniz’s procedure and the sharing of his results, the advancements made around the world could not have been possible. It is when physicians and those in the medical field come together that they are able to advance the field for everyone’s benefit and good. This domino effect all started with Antonio Egas Moniz.

Source 1:  https://thejns.org/focus/view/journals/neurosurg-focus/43/3/article-pE4.xml?tab_body=fulltext#b11

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The early argument for prefrontal leucotomy: the collision of frontal lobe theory and psychosurgery at the 1935 International Neurological Congress in London

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The pathophysiology of mental illness and its relationship to the frontal lobe were subjects of immense interest in the latter half of the 19th century. Numerous studies emerged during this time on cortical localization and frontal lobe theory, drawing upon various ideas from neurology and psychiatry.

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In the late 1800s, Gottlieb Burckhardt, a physician, became the first to introduce the idea of psychosurgery¹. After becoming a physician, he decided to focus on conditions relating to the nervous system and later on schizophrenia where he published multiple reviews on current research on psychiatry within the illness¹. Throughout his career, he collected all information he could to create his own encyclopedia version of the nervous system. In his book, “The Physiological Diagnosis of Nervous System Diseases,” he defined more anatomically and physiologically the nervous system and gave a basis as to what the nervous system was¹. After being the supervisor at a hospital, he decided to experiment on several schizophrenia patients where he performed topectomies, the removal of frontal cortex parts¹. Only two of his patients died and unfortunately, his other patients experienced aphasia and seizures afterward¹. Despite the controversy after presenting his results as well as the aftermath of the procedure, he was one of the first to perform psychosurgery and made way for what would become the lobotomy. His failures allowed for improvement in the field of psychosurgery in the future.

Source 1:  https://journals.sagepub.com/doi/full/10.1177/1553350620972561

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Phineas Gage and the connections between his behaviors

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Phineas Gage and the connections between his behaviors

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In the mid-1800s, Phineas Gage, a foreman at the time, was working on a railroad when an iron rod impaled his frontal lobe. The rod did end up leaving his skull, but it left a hole both in his cheek and skull¹. To everyone’s surprise, Gage did end up surviving and none of his cognitive skills were compromised; he was able to walk and talk normally. Afterward, he was able to recall details of the event and describe accurately the amount of time that had passed since the accident when he woke from a semi-coma¹. Despite the fact that there were no physical changes after his injury, his behavior took a drastic change. Once described as a pleasant and hard-working man, he soon turned into a heavy drinker and was unable to hold a job for very long¹. After studying the extent of the brain damage in the late 1900s, it was noted that his areas of decision-making and emotional processing were damaged, which was reflected in his behaviors¹. It was this accident that proved life with excessive brain damage was possible, but that there was a connection between brain damage and behavior, mainly in the frontal cortex, which allowed more investigation in the future on how neural networks and structures contribute to behaviors.

Source 1:https://www.verywellmind.com/phineas-gage-2795244

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While psychosurgery is rarely used today, research on finding more methods aimed at the brain to reduce mental illness symptoms have continued. Research has evolved in finding more ways neural networks and their abnormalities contribute to abnormal behavior and psychoses. One of these methods is electroconvulsive therapy. Instead of being cut open, this is a noninvasive way for patients who suffer severely from mental illnesses, including depression. While this is an underused treatment, it is a way for patients to have their whole brain electrically stimulated to create a small and well-controlled seizure that alters brain chemistry to improve symptoms¹. TMS, or transcranial magnetic stimulation, is another stimulant method used in the brain that uses magnetic fields to stimulate nerve cells in areas that control mood¹ . This also stimulates this area of the brain to improve mental illness symptoms. Without the establishment of neural connections in the brain related to psychosis, these more used and invasive treatments would not be in place today. These modern treatments allow for quicker recovery and more frequency in treatment administration and would not have been possible without the first step in psychosurgery.

Source 1: https://www.nami.org/About-Mental-Illness/Treatments/ECT-TMS-and-Other-Brain-Stimulation-Therapies

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Antonio Egan Moniz, the man who won the Nobel Prize for leucotomy for certain psychoses, was born in Portugal and soon made his way to France to study neurology¹. After some training, he went back to Portugal in 1911 as the head of neurology at the University of Lisbon¹. At first, his research consisted of precisely mapping tumors in the brain with radiographic material but soon saw his attempt fail with the death of one of his patients¹. He later had more success with being the first to map out peripheral structures using this kind of material in the human brain¹. As he continued on, his curiosity about blood vessels being more visible by using opaque materials to radiographic substances lead him to be the first to discover arteriography in the brain¹. This lead him to further investigate the white matter in the frontal cortex after observing many psychoses in patients. When he used previous methods, such as using radiographic material, losing several of his patients showed his ways of treatment to be inconsistent, but still used that thinking and decided there was only one option left: the leucotomy. This technique would later win him a Nobel Prize for establishing a connection between neural networks and psychosis.

Source 1:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4291941/

Source 2: https://www.britannica.com/biography/Antonio-Egas-Moniz