BMCR 2022.03.14

Les troubles psychiques selon Galien: étude d’un système de pensée

, Les troubles psychiques selon Galien: étude d'un système de pensée. Collection d'études anciennes. Série grecque, 159. Paris: Les Belles Lettres, 2020. Pp. 435. ISBN 9782251451220. €55,00.

This is an important, learned and engaging book on a key topic in the history of ancient medicine and philosophy, as well as on the relationship and territorial disputes between the two in the time of Galen. It also addresses timeless problems in history and the philosophy of psychiatry for those interested in both worlds. Its title, with a focus on ‘Les Troubles Psychiques’, is slightly off: the study really concerns the problems posed by the soul in Galen, tackling them through the example of psychopathology, restricted for this purpose to a physiological and encephalic concept. Finally, this is a book about a ‘system of thinking’, with questions and attention directed more to larger and methodological examples than to clinical ones. Both in the sources chosen and the questions asked, therefore, the idea of ‘psychopathology’ addressed is entirely internal to Galen’s categorisations, ambitions and limitations — as Devinant acknowledges.

The stated methodology of the book is to interpret ‘Galen through Galen’, a choice which goes against current trends: most recent publications look instead at the sociology, performative aspects and communication-strategies of Galenic medicine, and (unlike Devinant – p. 264) do not shrink from occasionally interrogating its medical effectiveness. Devinant choses instead to probe, and celebrate, Galen’s coherent ‘system of thought’ and careful demarcation of territory. This includes attention to the strategies and modes of his arguments, thematic choices and emphases, but also his silences and avoidances, all interpreted as fully purposeful and intentional, as bricks in a coherent intellectual edifice. It is in this spirit that Devinant explicitly, and more than once, formulates the question of why and to what purpose Galen takes a certain path and not another at key doctrinal junctures. This strong investment in a sense of authorial agency and the postulate of a unity of intention and execution is uncommon, and perhaps slightly out of fashion; at the same time, the commitment to this perspective is refreshing, and the clarity and control of the material discussed, obviously the result of long exploration and reflection, make Devinant’s exposition a worthwhile read.

The book is divided into five parts of varying length. Thematically and in terms of sources, it proceeds so to say from top to bottom, i.e. from general to individual, theoretical to clinical, abstract to concrete, Plato to medicine. For a book that argues for Galen’s medical and therapeutic pragmatism as doctor curing patients, this structure may at first appear to run counter to the vein of the argument. On the other hand, this might well be considered the correct order in Galen’s train of thought, and surely his education, from metaphysical questions and philosophical doctrines to the evidence and the exigencies of professional clinical practice and accumulated experience.

Part 1, ‘Approche théorique: le matérialisme galénique en question’ is the longest and theoretically most bulky, setting the philosophical context and key questions, as well as firmly framing the project within trends in Galenic scholarship. Devinant differentiates his work from some scholars’ insistence on a certain compartmentalisation of the Galenic corpus (ethics and medicine especially), but also from concern for the socio-cultural, extra-philosophical aspects of his work (‘performance’) proposed by others, undertaking instead to treat the corpus as evidence for a system and a consistent philosophical-medical agency. The frame is that of pragmatic, operative convenience: Galen is a doctor, and his span of interest is limited and sharpened by this objective and agenda.

The first and foremost question is that of the soul and Galen’s agnosticism about it, despite his claim that the soul exercises a strong influence on the body (in Quod Animi Facultates, QAF), an apparent incongruence that has been interpreted as opportunistic. In Chapter 2 (‘Matérialisme et instrumentisme’), the two attitudes in Galen’s approach to the soul are explored alongside the evidence of De Usu Partium (UP), and the charge of contradiction between this strong teleology and the position adopted in other texts is scrutinised and explained as medical pragmatism. In Chapter 3 (‘L’agnosticisme galénique quant à la nature de l’âme’), Devinant tackles the second fundamental, well-known feature of Galen’s thought about the soul, namely his declared agnosticism. Devinant persuasively argues that Galen’s position should not be taken as ‘aporetic or skeptical’, but as pragmatic and fixed on what is useful for medical purposes. It is a flexible expression of Galen’s pragmatism on the topic that he regularly speaks of the dynameis, ‘functions’ of the soul as its qualifiers within the animal body.

In Part 2 of the book, Devinant moves from abstract theory to his concrete object of analysis in Galen’s oeuvre, ‘Le trouble psychique comme objet médical’. This section asks directly about the extent to which the space reserved for the soul in the Galenic medical project yields notions of psychic health and illness. In Chapter 1 of this section, ‘La question d’un interventionnisme médical’, Devinant discusses Galen’s purpose as he argues for a legitimate medical intervention in the soul, a soul that is pragmatically redefined and identified with encephalic locations and processes. Chapter 2, ‘Une Psychopathologie’, defines the topic further, introducing important discussions of methodology in ‘histories of madness’ in general and as applied to Graeco-Roman medicine. This is a valuable discussion, perhaps slightly too sceptical about the possibility of discovering continuity in mental health in ancient texts based on the evidence of vocabulary. Chapter 3 is excellent on a topic that only a deep knowledge of an author can reveal. This is the issue of Galenic ‘avoidance’; that is, the absence in his work of any direct, explicit and thematic engagement with physical psychopathology — moral psychopathology, the ‘ethical writings’, is a different matter, as Devinant reminds us —so that the theme remains ‘evanescent’ (91), with no articulated nosology or diagnostic psychopathology. Various explanations have been offered for this, including, among others, a lack of interest; I personally prefer Devinant’s formulation of a Galenic ‘perplexity’. Chapter 4, ‘Les Mots Pour Le Dire’, analyses patho-nosological vocabulary in Galen in detail and with examples, crucially also vis-à-vis the fundamental topic of ‘perceptibility’ of the state of illness. Devinant notes that Galen does not see a problem in lexical indeterminacy, and regards the absence of a name as a non-issue. This is an intriguing point which deserves further attention (113–18).

Part 3, ‘The unity of psychic disorders’, probes the concept of psychic disorder and its degree of operative application in Galen, as well as the field it delimits in his medical approach. Mental disorders emerge as first undetectable or very difficult to detect and, second, with a contradiction that is only apparent, as eminently encephalic in localisation (Chapter 1, ‘Affections occultes, affections de l’encéphale’). Devinant returns to Galen’s marginal, instrumental use of nosological taxonomies, and contrasts it with the more flexible ‘topographical diagnostic method’ of De Locis Affectis, the text where Galen has the most to say about mental disorders. Book III, which treats diseases of the brain, in particular is central to illustrating this, as an ‘encephalic’ list of disorders replaces that of ‘invisible disorders’ here (134). The invisible processes behind mental damage mean that a neat categorisation based on signs alone is impossible, while the central element in the Galenic diagnosis is the topological causation shaped by the encephalic schema. Chapter 2 (‘Affections “Psychiques”’) delves more deeply into the problematic move of replacing soul with brain, encephalos. The root of the problem is in the transference of the Platonic tripartite model of the soul, which Galen endorses, from theory to medical practice. The object of medicine thus remains a ‘truncated soul’, identified with the hēgemonikon alone, with the other components of mental life, and the emotions in particular, left to the care of ethics. This is an important moment of reduction in the sphere of psychological experiences as part of the history of psychiatry.

Part 4, ‘Comprendre les troubles psychiques’, moves closer to the sign and to the living patient. Symptomatology and semiotics are analysed here in great detail, with a useful table of affections and signs (183) and with reference to particular examples (notably phrenitis). The cause of disease (which in turn motivates the therapy) is fundamental to how diseases are understood: diseases are not an ensemble of symptoms, but should be understood as a full aetiological story. Chapter 2, ‘Étiologie’, centres precisely on therapy as the main drive behind theorisation in the operativity and pragmatism of Galen’s psychopathology. The complex variety of diairetic subdivisions through which Galen traces the typologies of psychopathological illness make sense only in the individual context of discussion, and instances may even appear to be in competition or contradiction with one another. Qualities and humours, for example, are responsible for mental disturbance. But homeomeric damage is also distinguished from organic, localised damage, as primary affections are from secondary ones, and a fundamental disharmony, the dyskrasia in the qualities, above all cold and hot, is the matrix ruling over all of these. All this betrays the desire to adapt a model to the complexity of reality, as well as the overarching importance assigned to therapy.

The final part (Partie 5 – ‘La prise en charge des troubles psychiques’) turns to the most practical and purpose-driven level of consideration: the care of patients. Devinant returns to interrogate Galen’s reluctance to take full charge of his patients’ mental disturbance. The motivations he offers, partly implicit in what has already been said, are on different levels. First (Chapter 1, ‘Mesures thérapeutiques et conjecture technique’), Devinant notes that therapeutics is not separate from theory in Galen, and is dictated by the initial cause rather than the epiphenomenon. Second, psychopathology is a difficult case, so conjecture and approximation are often just unavoidable. In Chapter 2, the analysis moves to the patients’ bedside (‘Au chevet des patients’): after a methodological discussion (272–9) of the difficulty of categorising patients and the problems posed by labelling affections and interpreting subjectivity, Devinant mentions a famous example, the ‘Atlas patient’ (real person or repertoire case that he may be). The resort to koinos logos, common sense and conjecture, in this case should also be understood in the light of a socio-cultural factor, response to performative pressure (280–1, 288). Here Devinant concedes the importance of cultural practices and performance as interpretative element.

In his conclusions, Devinant praises Galen’s ‘undeniable spirit of system’ coupled with ‘remarkable methodological prudence’: in his oeuvre, the physician established an interconnection between body and soul, and dismissed any metaphysics which might exceed the scope of diagnostics and therapy. In the process, however, he failed to conceive of an articulated psychopathological project which could bring these together — something not impossible in principle. The category ‘psychopathological’ exists in Galen, but remains significantly nameless. Devinant summarises the ‘resistance factors’ which explain it: most important, the physician’s over-broad and complex, un-implementable view of the soul, and his own doctrine that the soul should be present throughout the body, which clashes with the topological approach; the transposition of soul to encephalos as a solution to these difficulties; and finally, the sheer difficulty, once again, posed by psychic disorders as medical phenomena.

The limitations, and delimitations, in Galen’s moves on this topic thus emerge as motivated not by indifference, lack of interest, or weakness in theoretical engagement but, in Devinant’s view of the matter, as a remarkable ‘knowing where to stop’ coherent with the philosophical and medical edifice the physician built. Within this effort, Devinant illustrates, Galen identified many of the key questions in psychopathology that still challenge us today regarding localisation, affection, sympathetic processes and interdependence, logical semiotics, approximation and observation, and the localisation, hardware and qualitative ‘biochemistry’ of mental health. He made different moves in search of a solution: functionalism; encephalism and neurology; qualitative humouralism; a discomfort with matching ethics and physiology; and finally, a humble admission of aporia and powerlessness in the face of mental suffering and the subjectivity of others as such (in Galen’s case, not in so many words).

In conclusion, this is an admirable study, dense with ideas and textual evidence, but also clear and coherent, never taking shortcuts or evading possible objections. It is painstakingly embedded in past, recent and contemporary scholarship; the 80-page bibliography is an advantage in itself, as are the discussions of the status quaestionis which open several chapters. Along the way, it throws in several insightful and exciting smaller remarks which invite further investigation. It is also an important repository, almost an anthology, of key sources on the topic (carefully indexed), some of them inaccessible in modern languages, translated and with a Greek text where applicable. On the whole, this is really a book for Hellenists, for scholars of Galen, ancient medicine and philosophy — or better, for scholars of all these areas together. Beginners in any of these topics would find it difficult to benefit from every point of emphasis or question. For specialised readers, however, this is a precious contribution, which addresses the topic for the first time closely and at length, and with an interest in the history of psychiatry. No future study of Galenic psychology and physiology more generally, or the history of Western psychiatry can ignore the themes and questions this book so competently discusses.