As we look back at the main medical sources analysed so far, one element persists in the history of phrenitis and its features as disease concept: its overriding non-ethical quality. This is unsurprising in classical medicine, where this is a general feature. But it is worthy of notice in later authors, in particular Galen who, in his so-called ‘psychological’ treatises,Footnote 1 largely identifies mental health with ethical soundness and at the same time speaks at great length about phrenitis elsewhere (in his works on pathology, anatomy and physiology). The discussion and definition of phrenitis in Galen remains firmly wired into a bodily, material, localized framework – along the lines described in Chapters 4 and 5. This picture fundamentally shapes medical discussion of the disease over the subsequent millennium and a half, with its pathology visibly recognized and its physiology univocally understood, despite various elaborations.Footnote 2
If this non-ethical narrative is dominant in medical quarters, elsewhere within medicine a divergent if minority view developed in regard to our disease. In Chapter 3, I reconstructed this parallel medical history of phrenitis through the works of Asclepiades, Celsus and Caelius Aurelianus, and labelled it with the umbrella term ‘delocalization’. This line of the story still operates within the parameters of traditional Greek medicine, but privileges a holistic, delocalized approach allowing more space for what one might call psychological aspects in mental disorder. In all these authors, phrenitis (or phrenesis in Celsus’ Latin) is still a bodily disease to be cured through dietetics and bodily interventions, but clinical interest and therapeutics are emphatically addressed to the mental, emotional and interpersonal experience of patients. The discussions of phrenitis in other physicians, such as Aretaeus, Galen and his followers, as we have seen, remained – albeit with some differences – fundamentally shaped by the anatomo-pathology of the disease. Within this approach, psychological elements of course also play a part (in Aretaeus, as already seen, and resurfacing perceptibly in encyclopaedists such as Aetius and Paul). But the centre of the discussion involves localization, fever and bodily therapy, and becomes increasingly bodily and concrete.
These parallel stories are kept fundamentally separate, a bifurcation that is seminal in the history of Western psychiatry generally.Footnote 3 The chief illustration is offered by Galen who, as noted, devotes considerable attention to human psychology as an object of medical action in his psychological writings. In this ensemble of works, he mentions phrenitis only once, in The Capacities of the Soul Depend on the Mixtures of the Body (Quod animi mores corporis temperamenta sequantur, QAM) 5.32–33 Bazou (4.788–89 K.), discussing how the soul can be overpowered by ills of the body, with phrenitis as an example of one such ill.Footnote 4 Mania and melancholia, by contrast, are mentioned in these works as relevant to the ethical discussion, making the absence of phrenitis all the more conspicuous in an author who considered it an object of great medical interest and repeatedly detailed the cognitive damage it could cause. Galen’s radical refusal to engage with phrenitis on a psychological level points to a redline in the division between matters of the body and matters of the soul, albeit an undeclared one, where our disease is so powerfully embodied and so precisely labelled in technical terms as to make comfortable ethical discussion impossible.
This is the broader landscape preserved by medical treatises, namely texts that are highly technical in style and have a demarcated purpose and audience. But an important part of the evidence, as we try to reconstruct the nature and significance of this disease in a wider cultural-historical sense, is how it is understood in the broader contexts of ancient cultures: its currency among individuals with no medical education or professional standing, or even by the general population, the assimilation of the concept into popular and material culture and within ‘folk’ models of medicine.Footnote 5 These two environments, we should always remember, are not separated as if in waterproof containers. Nor does the medical or technical always exert a one-way influence on the literary and the popular. The opposite traffic is also apparent, and we should spread our analyses as wide as possible.
Let us begin with an initial clear-cut datum: in the centuries before Cicero, there is no mention of phrenitis outside medical texts, apart from the comic scene in Menander analysed in Chapter 3 and one Pythagorean fragment which refers to it in passing qua bodily disease.Footnote 6 The term does not appear in Plato or Aristotle, which is even more significant. Other terms for mental illness offer telling contrasts. If we compare the diffusion not only of mania (a widely used word with numerous semantic levels) but also of melancholia and related terms,Footnote 7 which are found in tragedy and comedy as early as the fifth century bce, the absence of non-medical references to phrenitis argues for a strong technical character of the term and points to its intrinsic novelty as a nosological concept.Footnote 8 Both factors made the exactitude of its signs and symptoms unfamiliar, too concrete and less immediate, and on the whole less fitting material for comedy. In addition, its strongly embodied nature, with fever in the foreground, prevented it from being easily inserted into narratives of human passions and errors. Finally, its acute and deadly character may have made it too serious a topic to be lightly appropriated.
The technical nature and emphatic embodiment of phrenitis, on the other hand, provided perfect material for allegory and hyperbole at a later stage in literary and lay discourses of various kinds, as will be seen here and in Chapter 8. This popular, non-medical assimilation of phrenitis into the wider lay vocabulary regarding mental well-being comes rather late, in the first centuries of our era in parallel to a greater diffusion of technical medical discourses among the educated upper classes and in the larger population generally. In this period phrenitis suddenly becomes popular outside medicine, not only as a quintessential ‘disease’ – a paradigmatically acute and dangerous one, often discussed by professionals – but also in a hyperbolic and allegorical sense which tends to foreground the ethical, behavioural and interpersonal features of the pathology. This matches what is essentially a developing moralizing and prudential discourse, first philosophical-ethical but in time also specifically Christian and eudaimonistic.Footnote 9 This discourse exploits the language and themes offered by the state of affairs in medicine: Galen’s take on the disease, its presentations by encyclopaedic sources, and later – for medieval and Renaissance material – key texts such as Avicenna’s Canon and the treatises of the Salernitan school.
This non-technical, popular anthropology of phrenitis is extremely rich and is best approached in terms of recurring themes. An aspect so conspicuous as to almost disappear in full light is the male gendering of this set of pathological signs and symptoms. The social, interpersonal, political and behavioural patterns largely point to the sphere of action of male patients or to perceived traditional features of ‘male’ morality, among which a failure of reason to control the senses is prominent, and follow a logical consequence of thought and argument; aggression, violence and pathological strength; a lack of awareness of one’s surroundings and one’s diseased state; and strong, assertive emotions. There is also an important shared trait: phrenitis is the incarnation of a moral flaw, individually but also as a species and community, our ‘collective’ human folly.
These aspects are not only commented on in theory but also emerge directly in a number of poetic motifs and narrative patterns, standard ‘scenes’ involving phrenitics (and lethargics as their inverted double, in a diptych comprising two moral extremes). In these, the phrenitic is at the centre of a larger allegory about how the sick interact with their care-givers or loving friends and relatives, engendering a number of recurring vignettes which, despite their grotesque realism, disguise important political points: the legitimacy of authority, the irreducibility of free will, constraint vs freedom, and the paternalism of constituted power. These vignettes have phrenitics attacking the doctor, showing ‘diminished capacity’, and needing involuntary treatment as a matter of compassion. They are the carriers of a hateful sin, but are not to be themselves hated; they require ‘tough love’. Their exceptionality is confirmed in popular belief by their divinatory power and the fact that important leaders – already Alexander and Marius – are associated with the affliction.Footnote 10 The greatest elaboration of all these is found, of course, in Christian texts, both theological and hagiographic.Footnote 11 But the fundamentals are already laid out by pagan authors, following guidelines partly set by Hellenistic philosophy in its discussions of human health and well-being, and especially by Stoicism, as we will see in what follows.
The genres involved in this first, pagan set of sources are equally comic-satirical and philosophical-ethical. In the second period (from the third–fourth centuries CE onwards), almost all the references come instead from Christian authors. In addition to these discrete groups of authors, pagan and Christian, information about phrenitis can be extracted from other non-medical literatures in which the disease is literally referred to as a pathology, although not within a technical medical frame: astrological texts, legal material and the hybrid pharmacological evidence preserved by Pliny the Elder and others. These complete the picture of the socio-cultural diffusion of the disease in various degrees of technicality during the Roman imperial period.
Late Republican and Imperial Pagan Sources
Philosophy and Knowledge
Mentions of our disease in Latin literature outside medical texts, found already in the first century bce, are richer than in their Greek counterparts.Footnote 12 Seneca the Elder (54 bce–39 ce) uses phreneticus to refer to someone generally insane and lacking good judgement, speaking of ‘our phrenitic cases (nostri phrenetici)’,Footnote 13 which suggests a common category.Footnote 14 The more loaded suggestion of effervescence and of strong, febrile movements in the case of phrenitis is implied as early as Marcus Terentius Varro (116–27 bce), who uses a meteorological image in which winds are said to be the ‘phrenitic offspring of the North (venti … phrenetici septentrionum filii)’.Footnote 15 Perhaps the older association with winter and the north is at issue here; the winter star Sirius is mentioned later on.
More consistent is the hyperbolic use of the medical concept, which is seen already in Cicero (106–43 bce). For example, he excludes those who are ‘diseased in the soul (or body)’ from the art of divination, disagreeing with Aristotle: ‘Anything like this should be attributed to cardiacs or phrenitics; because divination belongs to a soul which is wholesome, not to a diseased body (nec cardiacis hoc tribuendum sit nec phreniticis; animi enim integri, non vitiosi est corporis divinatio)’ (De divinatione 1.81). Two diseases associated at least in part with the chest are mentioned as examples of a mental disorder one would be mistaken to connect to divination; this is our earliest reference to a prophetic power for these patients. Tertullian (150–220 ce) in De Anima 43.47 also couples phrenitis and cardiac disease as both ‘similar to sleep (aemulas somno)’.
So far these are mostly conventional, antonomastic uses. The occurrences of the term in Seneca the Younger (14 bce–65 ce) have greater depth and display many similarities to the notion in another philosophically minded author, Plutarch: in Seneca, phrenitis indicates incapacitation in general, in an exemplary sense, with ethical overtones. A good doctor is for him one who does not lose his temper with a phrenitic,Footnote 16 and likewise the bad temper of children and phrenitics (aegri rabiem et phrenitici verba, puerorum protervas manus) should not affect us.Footnote 17 The intensity of phrenitis (and of insania generally) can provide a parallel to anger and other excessive passions one might mistakenly admire as expressions of heightened strength:
One says, ‘anger (ira) is useful, because it makes us feistier.’ But so does drunkenness (ebrietas); for it makes many people arrogant and bold and readier with the sword than they would be when sober. In the same way, then, tell me that phrenesis and insania too are necessary for one’s strength, since fury often makes us stronger. But so what?Footnote 18
Marcus Cornelius Fronto (100–60 ce) emphasizes senseless talk as a feature of phrenitis: the inability of Roman emperors after Tiberius to speak elegant Latin is a kind of delirium in men who are seized by the disease phrenitis (quasi phrenitis morbus quibus implicitus est).Footnote 19
In all these sources, phrenitis seems to have become antonomastic for irrational, grossly incompetent and inconsequential behaviour. Given this, it is unsurprising that the second-century sceptic philosopher and doctor Sextus Empiricus (160–210 ce) is fond of the example of hallucinating phrenitics in an epistemological sense, opposing them to a healthy, normative reasoning ‘we’. In his Outline of Pyrrhonism, for example: ‘Those suffering from phrenitis and those in a state of ecstasy believe they hear daemons, while we do not, and they often claim to smell storax, or incense or some other scent, and perceive many other things as well, while we do not.’Footnote 20 Likewise in Against the Professors, reporting on the Stoic Chrysippus,Footnote 21 Sextus uses phrenitizein to qualify the ‘non-cataleptic’ among truthful representations, those which derive from external reality but under specific circumstances, and which are only casually apprehended: ‘Countless people are phrenitic (phrenitizontes) or melancholic but can draw a truthful fantasy, not cataleptic but falling down externally.’Footnote 22 Elsewhere phrenitics are compared epistemologically to individuals possessed by daemons,Footnote 23 since both are in a state ‘contrary to nature’: ‘Phrenitics and those possessed by daimones seem to hear things, while we do not.’Footnote 24
Satire
Where there is moralized and intellectual stigmatization, there is always also humour and caricature. Satirical and comic genres tend to borrow from technical vocabularies in Latin perhaps more than they do in Greek, and there are several references to phrenitis in Roman satire. Martial (40–103/4 ce) accuses Maron of being crazy and having phrenesis, namely a disease that involves fever and delirium (‘You declaim while feverish, Maron. If you don’t know that this is phrenesis, then you are not in good health’, Declamas in febre, Maron: hanc esse phrenesin si nescis, non es sanus).Footnote 25 Elsewhere a Nasica phreneticus, ‘phrenitic Nasica’, attacked his doctor Euctis (invasit medici Eucti) and ‘cut Hylas to pieces’ – a comic reference to the topos of aggressiveness, especially against one’s caregiver.Footnote 26 Petronius (14–66 ce) uses the term in his Satyricon to indicate derangement and to describe the death of a ‘Cappadocian fellow’ as narrated by Trimalchio.Footnote 27 The appearance of witches causes the man to rush out, having bared his sword, and kill an innocent woman, before collapsing on his bed and ‘dying phrenitic in a few days (post paucos dies phreneticus periit)’. Later a mad, possessed poet (literally ‘bellowing’, mugientem) is also deemed phreneticus:Footnote 28 grotesque, hallucinatory madness, aggressiveness and violence, and ultimately death, stand out here. Juvenal (60?–127? ce) uses the term in a moralizing sense close to the Stoic metaphor of a weakness of greedy humanity, the ‘madness of all mankind’:Footnote 29 ‘Is it plain madness and phrenesis to live in want in order that you may be wealthy when you die?’
Two High-Ranking Examples: Plutarch and Lucian
Plutarch’s (45–125 ce) interest in and acquaintance with medicine are well known.Footnote 30 His references to phrenitis show an awareness of medical knowledge, if at times banalized or superficial, as he often uses phrenitis as exemplary or antonomastic for madness. At De latenter vivendo 1128d, for example, he points out that the suggestion to ‘live in hiding’ should not be applied indiscriminately to everyone: ‘If you are talking to a fool, or a wretched or senseless person, you are no different from someone who says “Hide the fact that you have a fever!” and “Hide the fact that you suffer from phrenitis (lathe phrenitizōn), so that the doctor might not recognize you!”’ Phrenitis is here clearly a representative mental pathology in a medicalized sense, an appropriate object of a doctor’s attention. At Biogr. fr. 136.4, the phrenitic is a paradigm of the madman with whom one should not engage on equal terms, an aspect of dismissive paternalism which is important in the psychological portrayal of the disease: ‘Just as it is best to blame and admonish friends, if they have made a mistake, when they are in good health, so we are accustomed not to fight against or oppose the other in cases of deranged or phrenitic attack (en de tois parakopais kai tois phrenitismois), but to accommodate and agree with them (symperipheresthai kai synepineuein).’
In general, Plutarch mentions phrenitis as a typical severe disease that is difficult to cure. The interesting point here is that a communality with general fevers and pleuritis is still felt.Footnote 31 Plutarch uses the technical term antonomastically, in the same way one might say ‘schizophrenic’ or ‘psychotic’ today to refer to a mentally unstable person, or think of cancer as the typical frightening disease. In all these Plutarchan examples, phrenitis appears to be used as a representative illness of the mad patient, and as a typical severe disease or disease entity generally.Footnote 32
Although Plutarch recognizes phrenitis as a disease with a bodily origin, he sees it as especially difficult (like mania): in both cases unawareness and impaired judgement mean that patients are unable to seek help – unlike with standard diseases such as ophthalmia or gout. In fact, phrenitis, ‘raising inflammation to the pitch of delirium and confounding consciousness, as on a musical instrument, will touch the heart-strings never touched before’.Footnote 33 These patients, moreover, actively cause their own illness, and phrenitis is used idiomatically for ‘self-inflicted sickness’.Footnote 34
These examples already represent a rich selection of ethical-psychological implications of phrenitis as a lay concept honed to hyperbole. In addition, and as a novelistic subspecies of these, we find a narrative of phrenitis as cause or occasion for the death of a leader, which becomes topical and develops specific characteristics in later centuries. At Plutarch’s Life of Alexander 75, for example, the disease is found in the description of the death of the Macedonian leader, who dies phrenitic,Footnote 35 by now kataphobos, ‘prey to his fears’, with antecedent fever and thirst and after consuming wine.Footnote 36 In the Life of Marius, moreover, the days leading up to the death of the exhausted Roman politician are recounted, offering a ‘patient case’ that we may identify, I suggest, as a representation of phrenitis.Footnote 37 This would offer a uniquely detailed early psychological portrayal of a phrenitic patient case outside medicine. The passage runs as follows:
But Marius himself, now exhausted by toils, deluged, as it were, with anxieties and wearied (tais phrontisin hoion hyperantlos ōn kai kataponos), could not sustain his spirits, which shook within him as he again faced the overpowering thought of a new war, of fresh struggles, of terrors known by experience to be dreadful, and of utter weariness … Tortured by such reflections, and bringing into review his long wandering, his flights and his perils as he was driven over land and sea, he fell into a state of dreadful despair and was prey to nightly terrors and disturbing dreams (eis aporian enepipte deinas kai nykterina deimata kai tarachōdeis oneirous), in which he would always seem to hear a voice saying: ‘Dreadful, indeed, is the lion’s lair, although it be empty.’ And since he dreaded above all things the sleepless nights (tas agrypnias), he gave himself up to drinking-bouts and drunkenness at unseasonable hours and in a manner unsuited to his years, trying thus to induce sleep as a way of escape from his anxious thoughts (tōn phrontidōn). And finally, when someone came with tidings from the sea, fresh terrors fell upon him, partly because he feared the future, and partly because he was wearied to satiety by the present, so that it required only a slight impulse to throw him into a pleurisy (rhopēs bracheias epigenomenēs eis noson katēnechthē pleuritin), as the philosopher Poseidonius relates, who says that he went in personally and conversed with Marius on the subjects of his embassy after Marius had fallen ill.
The text offers no variants for pleuritin (πλευρῖτν), and the reading is duly accepted by editors. This nonetheless seems to be a case in which phrenitis (φρενῖτις) – still perceived as a technical term in Plutarch’s time and unknown to most modern editors – a nosological double for pleuritis and easily confused with it,Footnote 38 is in question; we have seen Plutarch pairing the two more than once. The nightmares, insomnia, anguish and fear, and abuse of wine all belong to the delocalized, mental version of the disease sketched in Chapter 3, and feature in Plutarch’s account of Alexander’s death from phrenitis, as we have seen. Pleurisy, by contrast, a lung inflammation associated with cold and winter, has no relevance here whatsoever. Interestingly, a similar exchange appears to have occurred in Polybius (an author Plutarch uses and repeatedly mentions) in an episode concerning another emotionally altered leader, King Agron:
When his galleys returned, and he heard from his officers the events of the expedition, King Agron was so beside himself with joy at the idea of having conquered the Aetolians, whose confidence in their own prowess had been extreme, that he gave himself over to excessive drinking and other similar indulgences, and was attacked by a pleuritis (pros methas kai tinas toiautas allas euōchias trapeis enepesen eis pleuritin) of which he died in a few days.Footnote 39
Here again we have a king overcome by excessive joy over a triumph and giving himself over to wine, finally (I propose) leading to the illness of feverish delirium which is phrenitis. The mental-moral profile of emotional excess is clear and symmetrical to that of Marius (and Alexander before him). A slip of the pen at some point in the tradition – or even at its beginning, with Plutarch influenced by Polybius, or conflating phrenitis with pleuritis – seems likely.
An instance of phrenitis in non-Christian literature of this period, and one which shows more detailed and direct medical acquaintance, comes from Lucian (120–80 ce), where we find a poetic, satirical elaboration of the ‘armed madman’ topos based on Galenic anecdotes. Symposium 20.1 features a scene with a phrenitic patient closely modelled on medical passages we have already examined:
It was now, not long after this match, that Dionicus the doctor came in. He had been detained, he said, by a phrenitis case; the patient was Polyprepon the piper (ton auletēn), and thereon hung an amusing tale (ti kai geloion). He had no sooner entered the room, not knowing how far gone the man was, when the latter jumped up, secured the door, drew a dagger (xiphidion spasamenon), and handed him the pipes, with an order to play them. When Dionicus could not, he took a strap and inflicted chastisement on the palms of his hands. To escape from this perilous position, Dionicus proposed a match (es agōna gar prokalesasthai auton), with a scale of forfeits to be exacted with the strap. He played first himself, and then handed over the pipes, receiving in exchange the strap and dagger. He lost no time in sending these out the window into the open court (dia tēs phōtagōgou es to hypaithron tēs aulēs), after which it was safe to grapple with the man and shout for help; the neighbours broke open the door and rescued him.
Lucian is here producing an amalgam of different cases and details. Not only the dangerous phrenitic and the madman’s sword, but also the piper’s deranged invitation to play (compare the phrenitic, hallucinating flute-players at Comm. Hipp. Prorrh. I 27, 39–41 Diels = 16.564 K.) and the act of throwing objects out of the window, are elements from Galenic cases: one patient hallucinates pipers, and another throws things through the window (cf. Symp. Diff. 1.4.3 (224.9–226.22 Gundert = 7.60.3–62.6 K.), exemplifying the two types of mental impairment the disease might cause, according to Galen. Lucian here effectively stages the third, ‘mixed’ type of phrenitis, in which both aspects are combined. Lucian’s reference shows that both the portrayal of the phrenitic and the Galenic text must have been known, at least among the elite.
The passage from Lucian is similar to Menander’s use of phrenitis in the AspisFootnote 40 in its crafting of an overloaded medical anecdote rich in picturesque pathological behaviours. Nor is it surprising that Plutarch, our other example, employs the term frequently; after all, he wrote an essay comparing mental and bodily diseases (Animine an corporis affectiones sint peiores), and the Moralia on the whole are rich in reflections on mental pathology and mental suffering as images of human philosophical weakness and existential vulnerability. In addition, Plutarch’s language is rich in technical terms taken from the medical realm. But it is again worth noting that these two authors are alone among Greek writers (in contrast to the Latin examples) before phrenitis is taken up by later philosophers, Christian authors, theologians and the like – and very extensively in the final case. These two – or three, including Menander – limited exceptions confirm that the term and concept had a strong technical quality; the philosophers prefer melancholia and related terms, or more general vocabulary for mental disorders.
To summarize, the non-technical use of phrenitis and related terms in non-Christian literature in the early Empire is antonomastic (‘mentally ill’, ‘acutely and fatally sick’) and hyperbolic (‘raving madman’). The word is employed to discuss incapacitation in examples ex absurdo; morally it represents the typical ‘folly’ of human deficiencies and lures such as greed or arrivisme. It inspires a paternalistic indulgence of the ‘phrenitic’ character of philosophically inferior interlocutors, as well as horror at the uncontrolled violence of the incapacitated ‘madman with a sword’ – a topos from Plato’s Republic which we will see enjoy an immense afterlife in the lay use of phrenitis in the late-antique, medieval and early-modern sources, especially the Christian ones.
In no case is a precise category – phrenitis as opposed to other mental diseases – in question. Rather, ‘madness’ in general, and in particular madness of a severe, hallucinatory kind, seems to be at issue. There is nonetheless some precision and technical allure to these references, although of an aural type and empty of academic competence: the specifics of fever, hallucination, delirium and violence are implicated, but in the way in which terms such as ‘schizophrenic’ or ‘psycho’ are used today as colloquial shorthand to mean ‘mad’, ‘needy’, ‘disagreeable’ or ‘inconsistent’. These instances show that by the first centuries CE phrenitis had become a staple word in Roman culture for a deadly disease characterized by derangement, with some noticeable features lodged in the imagination, and that although its medical features and implications were perhaps not known to laymen, enough was understood to make it a significant pathological symbol for the flaws and calamities that haunt human existence. This tendency will be most visible in Christian authors, who chose phrenitis to sketch a portrait of quintessential human toils and vulnerability to sin.
Christian (Patristic, Hagiographic, Theological) Texts and Authors
Christian authors from different eras refine phrenitis into a symbol for moral and spiritual degeneration in ways that are oblivious of the sophisticated medical debates surrounding the pathology and manifestations of the disease in the same period, while simplifying and exploiting its most vivid clinical traits. Phrenitis is mentioned with such frequency and persistence here that it is fair to take the phenomenon as a special case of metaphorical disease, which played a role in sustaining the viability of the nosological concept over the centuries and in guaranteeing its transmission to medieval and modern times.Footnote 41
Key to the strength of this metaphorical construction is the fact that phrenitis has a resilient corporeal basis, a concrete component which works well as a vehicle for the trope. This firm location of phrenitis in the body, and indeed within a body–soul distinction, also holds true among Christian authors, as is explicit in the words of Theodoret: ‘The wisest among doctors address this good balance of the body as “soul”, and they derive this opinion from the affections occurring to the body, I mean epilepsy, apoplexy and phrenitis.’Footnote 42 The recognition of phrenitis as a disease ‘of the body’ in some authors enables the allegorical extension of the category ‘phrenitic’ to include a vast group of morally and intellectually flawed individuals: ‘Every person who does not recognize the doctor (i.e. God as Salvator) is phrenitic.’Footnote 43 In these Christian reflections, various pathological details about phrenitis become prominent and are richly elaborated, as we shall now see.
Hallucinations
First of all, hallucinations. We have seen that derangement of the senses is especially important in clinical accounts of the disease phrenitis, notably in Galen. In philosophical quarters this aspect lends fitting material to epistemological reflections (What are the limits of human knowledge and of the reliability of the senses under changing health circumstances?) and ethical ones (human folly and flawed behaviour, determined by an erroneous evaluation of reality, are taken to resemble forms of phrenitic hallucination).
Hearing and vision are the most common examples of senses which can convey distorted representations, but others – touch and smell in particular, as we have seen in Sextus – can also be involved. Phrenitis and melancholia are examples of an impaired sense of touch in the discussion of intellectual error in the Christian author Origen (185–254 ce),Footnote 44 and the same is true in Rufinus’ translation of a – rather obscure – passage from Origen’s homilies: ‘Why does the sense of touch extend over the entire body? Does it perhaps illustrate, by way of a trope (tropikōs), phrenitis and melancholy or the condition characteristic of the age of infants?’Footnote 45
It is only a few short steps to turn this hallucinatory error into the hyperbolic image of more complex intellectual mistakes. Basil (fourth century ce) describes heretics who do not grasp the theological monogenetic mystery as suffering ‘something akin to those who are in the ecstatic state of phrenitis and see, in their fantasies, objects that are not there (tois en ekstasei phrenitikēi horan phantazomenois ta mē paronta)’.Footnote 46 In fact, ‘a person stricken by wine (oinoplēktōn) or deranged by phrenitis (ek phrenitidos paraphorōn)’ falls victim to false images by following those who say ‘He who does not honour the Son fails to honour the Father’.Footnote 47
Augustine (fourth–fifth centuries ce) makes by far the most use of the phrenitic metaphor.Footnote 48 Although he mostly devotes the trope to ethical and spiritual commentary, exercising enormous influence for centuries to come, he also considers the intellectual faculties impaired by the disease. Augustine employs phrenitis as an epistemological paradox, comparing the senses of these patients to those of sleepers,Footnote 49 and returns on many occasions to the phrenitic as the archetypal individual plagued by hallucinations, whose senses deceive him,Footnote 50 just as dreams can do. The association is grounded in medical debates about the agrypniē of these patients and the vividness of their dreams:Footnote 51 ‘For phrenitic individuals, without sleep, have their sensorial ways so disturbed in their head that they see the kind of visions sleepers see, when during sleep their attention is diverted from the sense of wakefulness and converts the images into seen objects.’Footnote 52
Lack of Judgement
The second cognitive flaw of the phrenitics Galen had described, impairment of the mind affecting judgement but not perception, is also exploited to construct a general charge of madness, ignorance and intellectual shortcoming in philosophical and intellectual debates, again specifically by theological authors. Phrenitics are unable to reason logically, to articulate arguments in a sound way or to judge theological and philosophical matters sensibly.
This allegorical pathologization of dissent is a typical feature of polemics in early Christianity and has been variously explored in relation to the marking of territory between ‘orthodoxy’ and ‘heresy’ or ‘heterodoxy’ in official Christian doctrine. Mania is also used idiomatically to represent a charge against one’s opponent of a ‘derangement’ which is both intellectual and moral-spiritual.Footnote 53 But phrenitis offered much more texture and nuance to this topos, perfectly incarnating the quintessential state in which the sick person refuses to be cured: ‘If one of those who knows how to cure these conditions wants to offer a medicine for this disease, they immediately leap away, just as those taken by phrenitis (hoi phrenitidi katechomenoi) push away the cure offered to them and flee medical treatment (tēn iatreian) as if it were a form of sickness (hōs arrōstian).’Footnote 54
Not only the Christian sides of the dispute, but also pagan parties express themselves through similar medical metaphors; the emperor Julian, for instance, accuses Christians of being phrenitic in their beliefs. This idiomatic reference to flawed reasoning as phrenitic is often trite, as in the documents of the Council of Constantinople and Jerusalem Anno 536: ‘The theopaschites [i.e. those who believe that god can suffer] [are driven] to say the kind of things phrenitis generally produces (ekeina legein haper hē phrenitis hypotithetai).’Footnote 55 So too in the polemical attack on heresy by Epiphanius (fourth century ce) a daemonic parallel is evoked: ‘Do you see how enormous is the silly nonsense of this wizard and his drunken forgetfulness? For the things said by him change into forgetfulness, and everything he seems to say changes and is carried away, … like phrenitics (kathaper hoi phrenitiōntes).’Footnote 56
Gregory of Nyssa (fourth century ce), speaking of theological disagreements, also resorts to the vocabulary of medicine, now deeming phrenitis a metaphorically ‘common’ disease (epidēmion): ‘I do not know what I should call this evil, phrenitis or mania or another such common disease, which causes the derangement of the intellect (tōn logismōn tēn paraphoran).’Footnote 57 Elsewhere, the term ‘phrenitic’ is used for disciples who are not ready for catechism and should be refused instruction, as in Cyril (fourth century ce), who may have a Galenic passage in mind:Footnote 58 ‘Also the ill seek wine. But if it is given to them in an inopportune way, this causes phrenitis, and then there will be two evils: the patient is destroyed, and the doctor is thrown into disrepute.’ And so the pupil ‘becomes phrenitic, for he does not know what he hears, and shames the procedure, and makes a mockery of what is being said’.Footnote 59
Existential phrenitis
As we saw in Chapter 3, a strand of medical discussion emphasized psychological, holistic and more eudaimonistic aspects of mental disorder with reference to the disease phrenitis as well. Celsus and Caelius AurelianusFootnote 60 are the richest medical sources in this respect, but an influence from Hellenistic philosophical discussions on these views is also to be considered. At the beginning of that chapter we explored the version of this eudaimonistic take on mental health visible in some passages from Middle and New Comedy: the theme of human grief, lypē (λύπη), was key to conveying the image of mental disorder as existential suffering. Interestingly, these themes also surface in some imperial and late-antique authors in association with phrenitis.
John Chrysostom (fourth–fifth centuries ce) obviously has a kind of moral wholesomeness in mind when he places disease, and phrenitis in particular, at the centre of a list of ‘intentional’ ills and pains for which man is responsible through his akrasia:Footnote 61 ‘Whence wickedness? And the fully evil? Whence, you ask? Tell me, whence comes the evil of diseases? Whence phrenitis? Whence deep sleep? Whence want of attention? If physical diseases take their beginning from a deliberate choice, even more so do those that are ‘intentional’ (ta proairetika). Whence drunkenness? Not from an akrasia of the soul?’Footnote 62 He continues to insist on the point by connecting his physiological determinism (fever and a lack of balance cause phrenitis) directly with his rigid moralism (ethical flaws cause the imbalance): ‘[Does] phrenitis [not come] from an excess of fever? The fever not from an imbalance of the elements in us? The imbalance of the elements not from a want of attention? For whenever we conduct one of those things in ourselves to imbalance through need or want of attention, we kindle that fire.’ The church historian Evagrius Scholasticus (sixth century ce) uses our disease, which is a ‘grief’, a lypē, as a full-blown allegory of spiritual malaise:
Grief, a disease of the soul and flesh, arrives (lypē, psychēs nosos kai sarkos, tynchanei); and it takes [the soul] as a war captive, and wastes [the body] in place. Pain is generated by opposite causes, wrath is generated by pain (ek de lypēs mēnis), and phrenitis and abuse (loidoria) are generated by these things. If you wish to subdue pain and wrath (lypēn kai mēnin), embrace the patience of love, and disseminate around yourself the joy of virtue, and let your joy not be pain for another.Footnote 63
Phrenitis is thus the bodily outcome of a number of existential evils and moral errors, all rooted in a lypē.
Dangerousness and Bestial Behaviour
Aggressiveness and physical violence are at the centre of accounts of the mentally ill from the classical era onwards in non-medical texts.Footnote 64 The well-known archetype of this is the incapacitated madman brandishing a sword at the beginning of Plato’s Republic: should one really return a sword which belongs to him to such a man, if justice is ‘giving to each his own’?Footnote 65 This proverbial sword becomes part of the representation of the phrenitic through the elaboration offered by Galen in his anecdote about a madman, possibly reflected in Lucian,Footnote 66 together with more general expressions of violence.
The motif of the brawl or duel provoked by aggressive phrenitics is standard. Galen mentioned the desire of one of his phrenitic patients to fight imaginary opponents,Footnote 67 a tendency Gregory of Nyssa (fourth century ce) turns into a prudential warning as he describes an imaginary fight:
It is as if a person suffering from phrenitis were imagining being locked together with someone, when he is not in fact wrestling against anyone, then striking himself with great strength, he thinks it is his opponent he is striking. Something such happens with the skilled writer, when he creates fictions we are unfamiliar with and fights against shadows which he himself formed in his own imagination.Footnote 68
The phrenitic’s violence poses a challenge to those around him, and later precisely this impasse is described: ‘just as those at a loss facing the implacable anger of the phrenitic do not know what they should decide’.Footnote 69
Augustine is again the most productive writer on the motif: ‘some are phrenitic, are dangerous (alii phrenetici sunt, molesti sunt)’.Footnote 70 Unlike the converse case, the lethargic who ‘dies without harming others’, the phrenitic ‘is to be feared by many healthy people, and especially by those who try to help them’.Footnote 71 At Sermones 359 Augustine even concocts a portrait of these patients as sadists:Footnote 72 ‘Phrenitics are destructive (molesti) individuals who have lost their minds, and they wander insane and furious, here and there, armed, looking for someone to kill, to blind (insani atque furiosi armati uagantur hac atque illac, quaerentes quos occidant, quos excaecent).’ The opponents of Epiphanius (fourth century ce) are cast as self-harming phrenitics armed with swords in his invective Against Heretics: ‘A person who suffers from phrenitis prepares a sword against himself, and on account of his epileptic outbreak, as he cuts his own flesh, he thinks he is warding off enemies.’Footnote 73
Animals are also directly if figuratively evoked in this portrayal of wild violence. Thus John Chrysostom, as he lists various human flaws in their most grotesque forms, mentions animals as correlative to the ways phrenitics behave towards those who wish to heal them. They become ‘like horses who are mad for women, and fierce wolves, says the Scripture, and malicious like camels, with no compassion for the poor, no pity for those who suffer, careless of those who gather in the assembly, despising anything sacred, not honouring their memory, shunning confession, towards their healers like those who suffer from phrenitis’.Footnote 74
Lack of Awareness of Disease
According to Galen, phrenitics are uniquely unconscious of the place in the body where they are suffering.Footnote 75 They are characteristically unaware of stimuli such as thirst and the need to urinate, and are generally oblivious to their own diseased condition. This pathological lack of awareness offers obvious material for prudential allegory regarding humanity’s ignorance and foolish arrogance in not realizing the depth of its sin, and the limitations of our imperfect mortal state.Footnote 76
In the words of Caesarius of Arles (fifth–sixth centuries ce): ‘But now, just as those who suffer from phrenitis or are alienated in their mind do not realize if they are wounded, because they lack their natural senses, so too we, either made mindless by worldly desires or inebriated by vices, cannot feel how many wounds, how much grief of the soul we inflict upon ourselves by sinning.’Footnote 77 Certain categories are singled out: ‘The Pharisee, wounded with the disease of depravity, feverish with the flame of arrogance, as a result of his frenesis did not know he was insane (per frenesim se nesciebat insanum)’, and ‘he commits crimes through frenesis, unaware of himself (sibi nescius), exiled from humanity’.Footnote 78 Due to his ignorance, the phrenitic cannot recognize the medicine he needs. Wine may come in again here, but in a positive sense, since the phrenitic cannot recognize its quality:
Just as the person with fever or suffering from phrenitis (ho pyrettōn kai phrenitiōn) refuses vintage wine as an enemy, while when he is in good health and strong it cheers his heart …, so the person who is ill in his mind (phrēn) and feverish with an evil disease flees an old friend as if he was an enemy.Footnote 79
This lack of awareness makes people follow the wrong leads, hence the warning ‘Do not wish to see … Christ with your senses, so that you do not ultimately become phrenitic (hina mē teleon phrenitikos genēi), embracing the wolf instead of the shepherd and kneeling down in front of the evil daemons!’Footnote 80
Lack of self knowledge, heauton agnoein, a traditional flaw according to Greek eudaimonistic principles, receives new moral and pathological positioning with phrenitis. Thus Cyril of Alexandria (fourth century ce): ‘For to be unaware of oneself is harder than the greatest mania and phrenitis’,Footnote 81 or Basil (330–79 ce): ‘He does not realize this (ouk aisthanetai), since he is similar to drunks or phrenitics, who although they suffer the worst things, think they are removed from suffering.’Footnote 82 In John Chrysostom this lack of awareness is equivalent to the temptations of material wealth:
Just as those who suffer from phrenitis could not know the state they are in (ouk an dynainto synidein en hois eisin), but need doctors (iatrōn de deontai) to deliver them from their madness; so too those taken by the oppressive raving of material wealth need other guides (heterōn deontai didaskalōn) in order to learn that they are raving.Footnote 83
In Augustine, a lack of awareness of true love is at issue: ‘The things you see and regard as good are failing you. You are not healthy, you are made phrenitic by an excessive fever (nimia febre phreneticus factus es); what you love is not true (uerum non est quod amas)’,Footnote 84 while Theodoret (fourth–fifth centuries ce) elaborates on phrenitics’ refusal of medicine: ‘just as those who suffer from the disease phrenitis and shake off the therapy they are offered and refuse medicine as a kind of weakness’.Footnote 85 John Chrysostom takes such awareness as the peak of illness, ‘for to be unaware of oneself is more difficult than the most serious kinds of mania and phrenitis’.Footnote 86 Such lost individuals cannot even feel their own wounds, be they moral or physical: ‘Just as those who suffer from phrenitis or are alienated in their mind do not realize if they are wounded, because they lack their natural senses (non sentiunt si vulnerentur, quia naturalibus sensibus carent), so too we, made mindless by the desires of the world or inebriated with vice, cannot feel.’Footnote 87
Pathological Joy
The misplaced, unwitting joy of the phrenitic who congratulates himself on his own madness is an important chapter in its own terms. This dysthymia, a trait of mental disorder the Hippocratics had already noticed in deranged patients,Footnote 88 becomes a specific qualifier for phrenitics. In them, euphoria is precisely a function of their lack of awareness of what is good or bad in their state of health, and of their lack of judgement: joy and sadness aroused by the wrong object. Various non-medical sources are explicit in this regard.
The Greek bishop Irenaeus (second century ce) chastises heretics precisely as prey to demented joy: ‘Just like those persons who fall into a fit of phrenitic illness (quemadmodum hi qui in phreneticam passionem inciderunt), the more they laugh, the more they imagine themselves to be well.’Footnote 89 Asterius (fourth century ce) even associates this joy with death: ‘For many prefer the lust of vanity and its pursuits … as a sort of phrenitis that brings death amidst laughter and jokes (hōsper tina phrenitin en tōi gelan kai paizein ton thanaton agousan).’Footnote 90 As usual, Augustine offers many examples, warning that ‘Your laughter moves more intelligent people to tears, not to laughter, as the laughter of phrenitics moves the minds of their friends who are sane to tears (sicut mentibus amicorum sanorum fletum commouet risus phreneticorum).’Footnote 91 The allegory of a ‘phrenesis of all mankind’ is developed in similar ways elsewhere as well: ‘But in the way a phrenitic rejoices the most in his madness, and laughs, and cries for the one who is actually sane; in the same way, dearest, we too, if we received the medicine that comes from heaven, since we too all used to be phrenitic (quia et nos omnes phrenetici eramus), are saved in the same way.’Footnote 92 To know, in these cases, means to grieve, while the damned remain cheerful: ‘Often the just man who sees them cries, but they, like phrenitics, are wept for but laugh (ipsi phreneticorum more planguntur et rident)’.Footnote 93
Pathological Strength
Violence, a lack of awareness and pathological joy: all these are manifest in the body through a form of pathological strength, a paroxystic vigour which deceives some onlookers – and especially the patient himself – into believing that the phrenitic individual is also doing well physically. Many authors allegorize this deceptive sign. In Augustine’s words:
For if one presumes that these are not strengths like those of healthy people, but like those of phrenitics (ne uires istae non sint, quales solent esse sanorum, sed quales solent esse phreneticorum), who, although insane, think they are sane, so much so that they do not look for a doctor and actually kill him as if he were a nuisance, just as [evil people] kill Christ;Footnote 94 for no one wants to be phrenitic, even if he sees that the strength of the phrenitic is greater than that of healthy people;Footnote 95
and, in an extreme formulation, in Enarrationes in Psalmos: ‘For nothing is stronger than phrenitics, and they are stronger than healthy people. But the greater their strength, the nearer is death (sed quanto maiores uires, tanto mors uicinior).’Footnote 96
The particular strength of these patients is elaborated medically in terms of a tension, a kind of pathological tone and undesirable rigidity which, as a quality of the nerves, is very different from real strength. The spurious Selecta in Psalmos of Origen (second–third centuries ce) makes this clear, drawing a telling connection between the technical and the moral: ‘‘The source of strength and support for sacred matters is the Lord; therefore no one can be strong or firm in the things that are not in God. Firm does not equal rigid, nor are the nerves of a phrenitic strong (ou tauton de to stereon tōi sklērōi, oude to ischyron tonois phrenitikois).’Footnote 97 From a philosophical quarter, in his Dissertationes ab Arriano digestae Epictetus (first–second centuries ce) had commented on this crucial difference between real strength and rigidity or mere stiffness, which are the case for the phrenitic:Footnote 98
About those who remain rigidly in what they have decided … first of all, the decision made must be healthy. For I wish that in the body there should be tone/nerves, but as in a healthy person, as in an athlete. If you show me the tone/nerves of a phrenitic and brag about them, I will tell you, ‘Sir, go for a doctor. For these are not nerves/tones, but a lack of a good tone/nerves’ (touto ouk eisi tonoi, all’ atonia).Footnote 99
Not only is this a false form of strength, but it actually reveals that the ill are on the verge of a crisis, as Gregory explains: ‘Clearly they are similar in their senses to those of the phrenitic, as they excel in madness, but regard it as virtue; … and they almost think that their strength is increased as they approach the end of life through an intensification of their languor (quasi creuisse se uiribus aestimant dum ad uitae terminum per augmenta languoris appropinquant).’Footnote 100
Ethical Flaw and Human Folly
The general implication of phrenitis as a moral flaw is evident from the early centuries of Christian literature and is clearly connected with arguments made by the pagan authors already discussed. The folly of all mankind is a well-known topos from the Stoics onwards.Footnote 101 This kind of discourse on phrenitis brings together a variety of human flaws, sins, shortcomings, emotional imbalances and wicked actions, and represents a step away from the material examined so far, in which the pathological, involuntary aspect prevailed. Here an element of responsibility and culpability is proposed, often resorting to images of turbulent mobs, the ‘phrenitic humanity’ which is out to lynch God. Dio Chrysostom (first–second centuries ce), for instance, refers to the cursed pressure that a concern for fame brings to human beings: ‘But like phrenitics, [the seeker of fame] is always suspended, by night and by day.’Footnote 102
Human folly in a more universal sense is often evoked, with the phrenitic imagined as a boiling mob: ‘What then should medicine of the Church do, seeking the health of all with its maternal charity, as if burning in the midst of phrenitics and lethargics (tamquam inter phreneticos et lethargicos aestuans)?’Footnote 103 The anonymous Liber de ortu et obitu patriarcharum sketches a portrait of the mob that killed Saint Stephen, and models it on the pathological, feverish, teeth-clenching phrenitic who becomes an image of threat: ‘The enemies of God, seeing these things, “gnashed their teeth at him” … were looking for a way to kill him; phrenitic, furious, full of frenzy, like dogs, they were barking against the saint.’Footnote 104
Other common sins and vices belong here. These typically include arrogance and vainglory, summed up as forms of raving madness similar to phrenitis: John Chrysostom (fourth century ce) writes: ‘He is deranged, he is a daemon, like a corybant he is seized by phrenitis … in his arrogance (eukaraphronētos)’.Footnote 105 Peter Chrysologus (fourth–fifth centuries ce) identifies this mob of sinners with the non-Christian Jews:Footnote 106 ‘He saw the synagogue lying in the darkness of its own depravity, oppressed under the weight of its sins, feverish with perversion to the point of frenesis (uitiis usque ad frenesem febrientem).’Footnote 107 Caesarius of Arles (fifth–sixth centuries ce) also speaks of idolatry among the Jews as the behaviour of dissolute phrenitics: ‘This group of Jews … even began to make jokes, once they had drunk wine in excess, and decided to fabricate idols for themselves, and in honour of these they began to lead dances, and like phrenitics they were distorting their limbs in various moves (more phrenetico diversis saltationibus membra torquere).’Footnote 108 These flaws are somehow connatural to humanity, as emerges in general discussions of pathology and health, nature and its perversions. Peter Chrysologus repeats the question: ‘From where? Because this is not reason, but languor; not life, but fever; phrenesis, not nature (frenesis, non natura).’Footnote 109 Later on the contact with medical discourse is even closer, and vivid imagery is employed:
What is this evil? Certainly some form of fragility lurks in the flesh, boils in the veins, enters the bones, conceals itself in the midriff, burns in the blood, and bursts out into the phrenesis of sin (Quod malum? fragilitas certe quaedam serpit in carne, in uenis aestuat, intrat ossa, conditur in medullis, febrit in sanguine, in uitiorum frenesim sic erumpit).
Emotional imbalance also belongs to the properly psychological portrayal of this ‘folly’, hence the (otherwise rare) suggestion that the excesses in these patients be approached gently, with consideration for phrenitics’ hypersensitive nature, a consequence of their inflammation, in John Chrysostom (fourth–fifth centuries ce). He proposes: ‘For this reason I summon you all to try to cure them according to your powers, speaking to them with gentleness and goodness, like those who have fallen into the disease of phrenitis (kathaper tous phrenitisi peripesontas) and been struck aside by it … For this reason, wise doctors cool such wounds with a sponge.’Footnote 110 Jealousy is at stake in John’s De virginitate: ‘[The jealous man], struck by this madness, is in no way better than those possessed by daemons or seized by the disease of phrenitis.’ Elsewhere, phrenitis is connected with the capital sin of arrogance, superbia.Footnote 111
The Parable of the Doctor and the Aggressive Patient
Violence and aggression are not as characteristic of mental disorder in Greek medicine as one might expect from literary parallels.Footnote 112 The violence of the mentally disordered begins to be part of the ethical profile of mental suffering in imperial medicine, and it becomes characteristic of the actions of phrenitics in particular, insofar as they are affected by forms of hyperactivity, spasms and generally heightened energy. We thus often find narratives with phrenitics as central actors interacting in a disturbed way with their caregivers and even their saviours (family, friends, doctors, allegorically those who love them, the wise advice of well-meaning friends, God himself) outside medicine. In these narratives, the violence and aggressiveness of the phrenitic are central, as are his (more rarely her) lack of awareness of what s/he desperately needs in order to be cured, and the ingratitude to the doctor, seen as a nuisance and an enemy to attack. The violence of these individuals against authority and caregivers is graphically described: pushing away and biting the healing hand; beatings and floggings; insults and even murder; smashing medicine flasks; and overturning tables. The support the medical portrayal of the phrenitic lends to this qualification of power relationships (religious and secular, or as part of the social hierarchy) teaches us a great deal about the developing image of medical professionals, their social reception, and the official chastising of the perceived ‘mad’.
Jerome (fourth century ce), for instance, casts himself as a valuable but unappreciated advisor when he rebukes his addressee: ‘Why do you try to insult others while neglecting your own flaw? Why do you assault me with your bite like a phrenitic (quid … morsu laceras, quasi freneticus), when I have always advised you well and with great care?’Footnote 113 So too Augustine revels in the trope and measures the severity of the illness based on the violence of the antagonism: ‘For if they had been sick in a milder way, they would not have killed their doctor, like phrenitics.’Footnote 114 The doctor par excellence, Jesus, remains forgiving nonetheless:
Not forgetting who he was while on the cross, and demonstrating his patience to us and offering an example of loving one’s enemies; when he saw the crowd clamouring around him, since he understood their illness, being a doctor, who understood the phrenesis in which they had lost their mind, he addressed his father: ‘Father, forgive them, because they do not know what they are doing’.Footnote 115
The relationship between patient and doctor is based on misunderstanding, a kind of paranoid fear and anger of the former towards the latter, producing a chain of action and reaction, aggression and containment. The asymmetry of the relationship between the two is explored by Augustine: ‘Hence when the phrenitic attacks the doctor, and the doctor ties up the phrenitic … it is not the doctor who attacks the phrenitic, but the phrenitic (who attacks) the doctor.’Footnote 116 Human beings are sick in many ways and turn against their benefactors: ‘Deaf, blind, crippled, dull people, who did not acknowledge their doctor and wanted to kill him, lost in their mind as if through phrenesis.’Footnote 117 Humanity as a mob of sinners, Jews and phrenitics are pitiful reflections of one another in this narrative: ‘Just as he did to the Jews who were raging against him when he found himself there, so he healed those phrenetic people, for whom he prayed as he hung on the cross.’Footnote 118 Gregory of Nyssa (fourth century ce) compares the Christian blessing to the healing action of a good doctor on a phrenitic, as he acts by ‘keeping his gaze firm and his voice calm, like a doctor curing with his art someone who is disgracing himself through phrenitis’.Footnote 119
The manipulation of the medical concept does not stop at the surface, but engages at times with key clinical themes. The well-known lack of sleep, for example, is conceptualized as an absence of the spiritual peace that only God can give: ‘Phrenitics are those who are insane through lack of sleep (phrenetici sunt, qui non dormiendo insaniunt).’Footnote 120
Jesus and the Phrenitics: A Theatre of Ingratitude
A more specialized level of this imagery speaks directly about the professional relationship between phrenitic patient and medical authority, as well as about other relationships that appear to mimic this one. In Augustine, Jesus is repeatedly depicted as the self-sacrificing doctor of diseased humanity, even made medicine for man: ‘For that doctor of ours was not afraid to be killed by the phrenitic, and out of his own death he made a medicine for the phrenitic (de ipsa morte sua phrenetico medicamenta confecit)’, and ‘he made out of his own death a medicine for phrenitics (de ipsa morte sua medicamenta faciebat phreneticis)’.Footnote 121 In particular, Jesus’ precious blood is offered as a cure: ‘For the voice of the doctor could not go amiss, despite hanging on the cross, as he was making a medicine for health for the phrenitic from his own blood (medicamentum sanitatis phreneticis de suo sanguine facientis).’Footnote 122 Jesus the doctor is dutiful and patient: ‘Did a doctor ever abandon his duty just because a phrenitic person was raving? (numquid deseruit medicus officium suum, quia phreneticus saeuiebat?)’ is asked rhetorically.Footnote 123 No. ‘He was being hit, but still cured [them]; he endured the phrenitic, nor did he abandon the patient (patiebatur phreneticum, nec deserebat aegrotum); he was being held, tied up, struck with fists … and he remained the doctor.’Footnote 124
The Jews, of course, are paradigmatic of these ungrateful patients: ‘For his land was Judaea, and it all perished when they crucified their lord through ignorance, phrenitics, furious against the doctor, refusing salvation/health in their madness (phrenetici saeuientes in medicum, et salutem insania repellentes).’Footnote 125 In particular, here as before the Pharisees are targeted as those who cannot understand the actions and duties of the charitable doctor. They
were criticizing our lord because, as a doctor, he was mixing with the sick. And they said: ‘Look, how he eats with them, with the publicans and the sinners!’ And the doctor replied to the phrenitic: ‘There is no need for a doctor among the healthy, but among those who are unwell. I did not come to call the righteous, but sinners’ (respondit medicus phreneticis: non est opus sanis medicus, sed male habentibus; non ueni uocare iustos, sed peccatores).Footnote 126
The medical allegory is also extended to include lethargici, who here represent, symmetrically to phrenitis, human laziness and failure to respond: ‘If we do not recognize the doctor yet, still let us not rage against him like phrenitics, nor shrink away from him like lethargici.’Footnote 127 This net of medical imagery is highly influential, as is evident from the multiple imitations starting with Augustine’s disciple Quoduultdeus (e.g. ‘The blood of the doctor was spilled and made into a medicine for the phrenitic (fusus est sanguis medici et factus est medicamentum phrenetici)’)Footnote 128 and including many other texts.Footnote 129
Not Worth Angering Oneself: Condescension to Phrenitics
The nexus of need and ingratitude involves further developments. One of these is relevant on a psychological level to the themes of deontology and professionalism in medicine. First, there is a basic paternalistic view of how human weakness and disease are to be dealt with that involves the father figure of a saviour, a savant doctor who ‘knows best’ and ‘knows better’. This individual is altruistically interested in the well-being of patients, knows what they are suffering from and what can benefit them, and engages with them emotionally. At the same time, he resists the temptations of anger or impatience towards the sick, however unsufferable they might become. And most important, he has the spiritual fortitude to apply force when necessary.
This doctor figure perhaps has less in common with the image of Jesus Christ offered by the Gospels than with that of detached, institutional figures of secular power and social or intellectual superiority found in various forms (political, religious, medical) in the ancient world. For example, he is partially reminiscent of the figure of the sage Galen (and other Hellenistic philosophers before him) envisaged as the ideal guide for improving one’s soul.Footnote 130 Early imperial pagan sources offer examples of the phrenitic in such contexts. In De constantia sapientis 13.1.3, for example, Seneca the Younger (first century ce) asked: ‘Which doctor grows angry with a phrenitic patient? Which doctor takes badly nasty words coming from a feverish person overheated by illness?’; and at De ira 3.26.1: ‘Why do you take badly the fury of an ill person, or the words of a phrenitic, or the insolent gestures of children? (quare fers aegri rabiem et phrenitici verba, puerorum protervas manus?)’. Likewise Plutarch (first–second centuries ce), Biogr. fr. 136.4: ‘Just as it is best to criticize and admonish friends, if they make a mistake, when they are in good health, so we are accustomed not to fight against others or oppose them in the course of deranged or phrenitic attacks, but to accommodate and agree with them.’
In Christian authors, this detached, superior figure is identified with God, but also constitutes a recommended model of authority, and the phrenitic patient met by the condescension of the doctor engenders a rich allegorical narrative that intersects with various themes. Augustine plays a fundamental role in several of these, exploiting the medical tradition and especially Galen.Footnote 131 One qualifying virtue of the doctor is his ability to suffer, bear, forgive and distance himself from the shortcomings of the patient qua patient, whose weaknesses and flaws belong to the pathology. Jesus interceded for humanity on the cross, just as the doctor pursues the health of his ungrateful patients: ‘Phrenitics even kill their doctors, and those who have compassion not only do not grow angry with them, but even seek the health of those who kill them.’Footnote 132 The paternalistic model of medical interaction centred on an idea of misericordia, as of endless tolerance, is foundational:
What compassion truly is, those can feel most clearly who must attend to sick people they love very much – their children or whoever is most beloved to them (tamquam filiis uel quibuslibet dilectissimis) – from whom, be they infants or phrenitics (uel paruulis uel freneticis), they must suffer much.Footnote 133
Basil (fourth century ce) speaks of the intellectual deficiency of phrenitics as a typical case not to be resisted or fought against: ‘If a small child (paidion nēpion) insults you, the offence is occasion for laughter. And when a person out of his head because of phrenitis pronounces dishonourable words, you deem him more worthy of pity than deserving of hatred (eleeinon hēgēi mallon ē misous axion).’Footnote 134 Ambrose of Milan (fourth century ce), Expositio psalmi 7.19.138.14 blends the figures of father, ‘good man’ and doctor, one the image of the other:
Just as the good father confronting the phrenesis of his son (bonus pater in frenesi constituti filii), when he is cursed by him, flogged, struck by blows, is not pained by his own disgrace and misfortune, but cries instead over that of the sick (son); … so the good man … suffers for him as if he were about to die, as if, hopeless, he was abandoned by doctors and wailing. And like a good doctor (ut bonus medicus), first he admonishes him, then … he does not abandon him … using not only the experience of his art but also the benign character of his mind (exercens non solum artis peritiam, sed etiam mentis benignitatem).Footnote 135
The daemons oppressing a sinner are thus fought off in the same way
a father would provide for a child who is sick with phrenitis – because the more the sick person (ho kamnōn) is aggressive and kicks violently, the more he pities him and cries for him (auton eleei kai dakryei) – so also this one, facing the attack of the daemons who bring on these things, takes aim against the disease in him and toils with greater solicitude.Footnote 136
The friendship and understanding of peers are also invoked: ‘Those who are sick with phrenitis say many bad things about those close to them/those present, but those who hear them do not take offence.’Footnote 137 Likewise Peter Chrysologus (fourth–fifth centuries ce) preaches that ‘A brother remains such when he harms his brother through fever, your neighbour remains such even when the neighbour commits crimes through frenesis, unaware of himself (fratrem frater est in febre cum laedit, est in frenesi proximo proximus cum delinquit, est sibi nescius).’
Also, there is a duty to kindness and assistance:
He who does not succour him with compassion, who does not cure him with patience, does not heal him with forgiveness, is not healthy, but is even more ill, has no inner parts, and demonstrates that he is alien from any human sense (sanus non est, aegrotat infirmius, uiscera non habet, et ab humano sensu monstratur alienus).Footnote 138
This shows how flexibly notions of health, sickness and even anatomy were applied to shifting elements of moral invective.
‘Tough love’ and involuntary treatment
In the passages just explored, the examples of fathers, mothers, brothers and friends project an image of amiability and loving care. But there is another side to authority over the phrenitic. Commensurate to the violence these patients inflict on those who seek to help them is the violence of the confinement, chaining and involuntary treatment they receive, an equally vivid part of the allegory. This topos of ‘tough love’ offers a sobering illustration of the easy steps from compassion to condescension, control and active abuse of those deemed mentally ill. As seen above, a lack of awareness of their condition and an inability to seek help belong to the psychology of phrenitics: they are resistant to good advice, whether clinically or only metaphorically. What follows is the idea that ‘involuntary treatment’ of the disease, be it of the violent or the soothing variety, becomes necessary. Dio Chrysostom (first–second centuries ce) is aware of the need for tough methods with a phrenitic: misplaced leniency ‘would be (as crazy as if) a man who is ill and has phrenitis, and needs, say, to recline and have a poultice applied, were instead given a crown and anointed with perfume’.Footnote 139
Two kinds of ‘tough love’ emerge, one directed at the phrenitic and one at the lethargic, symbolic of their symmetrical moral flaws: tying up and restraining, and pressing into action, respectively. ‘And although we are in this way displeasing to both kinds, by stimulating a lethargic and by tying up a phrenitic, still we are loving them both (et quamuis molesti sumus utrique generi, et lethargicum excitando, et phreneticum ligando, ambos tamen amamus)’, as Augustine explains.Footnote 140 He uses the verb amare explicitly: ‘The lethargic are stimulated (by the doctor), the phrenitic are tied up. But both are receiving love (this way) (lethargici excitantur, phrenetici ligantur; sed tamen utrique amantur).’Footnote 141 This ‘true love’ must at times entail prohibition and constraint:
Who, tell me, appears to have pity for a person with fever or suffering from phrenitis (ton pyretainonta kai phrenitidi katechomenon): the one who bends over his bed, and binds him, and forbids him to take inappropriate food and drink, or the one who gives him access to neat wine, and orders him to freely give in to excess and do everything a healthy person can?Footnote 142
In Augustine the ‘tying up’ is figurative, executed through words (phreneticos male saeuientes uerbis ligabat),Footnote 143 while elsewhere he resorts to another – related – paradox:Footnote 144 when a phrenitic runs toward a precipice, a true friend ties him up and stops him. The rope becomes the symbolic prop, in this patronizing and accusatory portrayal of the sick, for the phrenitic’s propensity to self-harm. Gregory uses it to qualify the Pharisee: ‘Of his own choice the Pharisee is ultimately tied up, like a phrenitic carrying around his own rope to be tied up with.’Footnote 145
Phrenitics in Larger Intellectual Life and Society
Contemporary with these more pervasive, often grand narratives of an ethical and eudaimonistic kind are several smaller stories and a whole collection of anecdotes about phrenitics in popular culture. These too are testimony to the diffusion of the disease in concrete life, lay imagination and wider intellectual awareness. The relationship of this material to technical knowledge is even feebler and more indirect than in the case of Christian authors, but it adds important evidence to the broader picture.
A popular belief holding together these assorted manifestations might be that expressed by the late-antique grammarian Servius (fourth–fifth centuries ce) in his commentary on Vergil’s Aeneid (In Vergilii Aeneidos Libros, 6.724.2). He sees phrenitis as a multifarious disease in which ethnic variations in disturbance of the animus (which is for him the same immortal entity across all beings) follow bodily disturbance (25–7): ‘As we see in the phrenitic: as soon as [the disease] comes to the body, it does not rely on its own nature, but mutates according to (the body’s) nature. Hence, we see Africans becoming versipelles (werewolves?),Footnote 146 Greeks lighthearted (leves), Gauls lazy (pigrioris … ingenii).’ This strange point seems to confirm the embodied quality of phrenitis by comparison with other mental disorders, causing different syndromes and ethnic variations in different bodies. Let us turn to some of these eccentric beliefs about phrenitics.
Supernatural Phrenitics: Prophecy
A recurring strand of folk-belief about phrenitics concerns their supposed prophetic faculties, an idea perhaps derived from medical claims about their heightened sensory sensibility and disposition to fantasy. Cicero very early on said something in this regard, and in medical quarters Alexander of Tralles in particular is the first to explore the matter.Footnote 147
Christian theology also engages with it. Augustine is the first to refer to daemons in connection with a rationalization of the prophetic powers of the phrenitic, in a long patient case worth reading in full:
We know, moreover, of a man who, being kept at home because he was suffering from an unclean spirit, used to say when the priest set out from twelve miles away to visit him, detailing where he was through all the stages of the journey, indicating when he drew near, and saying when he entered the estate, the house, the bedroom, until he stood in full view. Although the sick man did not see any of these things with his eyes, he nonetheless could not have announced them so accurately if he had not beheld them in some fashion. He was feverish, however, and said those things as if in phrenitis. And perhaps he truly was a phrenetic, but was thought on account of those things to suffer a daemon. He took no food from his own attendants, but only from that priest. Moreover, he struggled violently against his own attendants, to the extent he was able, and calmed down when the priest alone was on his way. He yielded to that man only, and responded submissively. Yet the alienation of his mind, or the daemon, did not give way even to that priest, until he was cured from the fevers, as phrenitics are typically cured, and he did not suffer anything of that kind ever again after this.Footnote 148
In this passage the chronological relationship between phrenitis and daemon is not clarified or established: are they parallel affections, or does the daemon establish himself in the weakened person? Or does he genuinely cause phrenitis? The author seems to feel no contradiction nor any necessity to choose between the two possibilities, while the connection is retained as plausible.
Astrological Indications of phrenitis
Another important domain as we evaluate the degree of penetration of knowledge of this disease is astrology, especially the astrological traditions connected with medicine or ‘iatrosophia’, which associates diseases, pathological conditions and predispositions with astral conjunctions. These mentions testify on a general level to the wider popularity of the disease concept. More concretely, they tell us which associations it engendered in non-medical circles in the imperial era, environmental ones among others: a connection to summertime; participation in the wider category of mental disorder; and a link with the head, the meninges and the heart.Footnote 149 In his Anthologiarum libri the second-century CE astrologer Vettius Valens specifies that ‘Capricorn is indicative of [involvement of] the sinews, the knees, internal and external spasms due to its enigmatic character; it causes dullnesses (of sight?), disabilities because of its horn, forms of mania, oppression by liquids, and even phrenitis.’Footnote 150 In the Astrologica Hermetica, (second–third centuries ce) Περὶ βοτανῶν τῶν ζ ἀστέρων we read that ‘if one’s birth is just before sunrise, it produces phrenitics and lethargics due to the increase of all these diseases that come from the heart’.Footnote 151 In his Matheseos libri Firmicus Maternus (fourth century ce) connects phrenitis to a variety of astrological figures, for example the sign Pisces, in connection with the summer: ‘Whoever is born under the sign of Pisces will be a phrenitic fisherman, and will die in his prime (In XII. parte Piscium quicumque habuerit horoscopum, erit piscator freneticus, et in prima aetate morietur).’ Elsewhere in the same work he mentions birth towards the final degrees of the sign Aries (‘in the last part of the tail’) as indicative of insanity, epilepsy and similar conditions (Arietis id est in extrema cauda quicumque habuerint horoscopum, erunt insani caduci frenetici oligochronii). He also writes that ‘those who have their horoscope in the right foot of the Wolf will die phrenitic in their prime (in dextro pede Lupi quicumque habuerint horoscopum, frenetici in primo aetatis tempore morientur)’ and that Mars and Saturn join together ‘alienated, delirious people, either cardiacs or phrenitics (alienos deliros aut cardiacos aut freneticos)’; Mercury and Venus bring together hepatics, phrenitics and melancholics; and so forth.Footnote 152
Among such ‘iatromathematical’ compilations of Late Antiquity, a rich tradition which preserves medical information of a more popular provenience, knowledge of phrenitis infiltrates into the cumulative material found in the fourth-century CE Cyranides. At Book 3 we find associations with the astrological sign of the Eagle, and affections of the chest, thymos: ‘Its wings are linked to (disturbances in) the thymos; when its wings are cloudy, they give rise to lethargics and to hysterical and phrenitic suffocation.’Footnote 153 In the Astrologica (fourth century ce) a certain astral conjuncture means that ‘the disease will be from the head. And this will appear to be let loose from the meninges. There will be continuous fevers, troubled sleep and a mouth like that in high fevers, and inextinguishable thirst, a troubled tongue, a feverish thorax and inflammation of the liver, pulse high and irregular. The disease will be a parakopē and phrenitis.’Footnote 154 And later in the same text: ‘There will be fever in the body, and derangement of the mind, and phrenitis, and damage about the head, and burning fevers, and strong thirst, and craving for wine.’Footnote 155
Curious Therapeutics: Animals and Human Heads
In the early centuries of our era a number of animal remedies associated with the therapy of inflammation emerge in non-professional contexts with reference to phrenitis; some of these will surface later in medieval works.Footnote 156 In his didactic poem, the (possibly) second-century Roman author Quintus Serenus Sammonicus, perhaps to be identified with the tutor to the emperors Geta and Caracalla,Footnote 157 follows medical principles that are quite Galenic in their substance but also reflect popular material, including an insistence on wine as an important trigger. Sammonicus devotes an entire section to our disease (Liber Medicinalis 1.7.87–101), emphasizing the efficacy of applying sheep entrails to the patients’ skin and offering them wool to smell, possibly to stimulate the sensitive phrenitics with its strong odour:
A similar mixture of learned traditions and folk knowledge characterizes the text of Pliny the Elder, further confirming that in the first century CE phrenitis had become an element of medical cultures at all levels. At Naturalis Historia 24.35 we read that the seed of agnus castus is beneficial ‘after it has been soaked in oil, when poured on the head in cases of phrenesis and lethargia (instillatur in oleo decoctum capiti in lethargia et phrenesi)’. Pliny also mentions cucumber seed (‘for phrenesis as well, doses of it are administered in a woman’s milk’Footnote 158) and various other ingredients, mostly targeting the head and often addressing phrenesis and lethargia together.Footnote 159 In addition, he mentions amulets made of marble (‘Some also recommend white ophites as an amulet for phrenesis and lethargia’),Footnote 160 and confirms that phrenitics benefit from their head being bandaged with warm sheep entrails,Footnote 161 again to stimulate them with the strong smell.Footnote 162 The use of fragrant substances is also recommended for the phrenitic and the lethargic, to soothe their sleep or stimulate them out of their torpor, respectively.Footnote 163
The use of animal entrails returns in the Cyranides (fourth century ce), which was mentioned above in connection with astrology. A passage elaborates a more complex technique: ‘In phrenitis, it brings great improvement (oninēsin) if a chicken is slaughtered and, while still alive (eti zeousa), cut apart, and after its entrails are removed it is applied on the head of the patient and kept pressed on him.’ This collection offers a useful (if messy) mixture of magical and more popular remedies, among other things. Specific stones, such as the beryl (6.7.3), are effective against phrenitis, and the author mentions the bird whose ‘feathers, if treated with incense, can cure lēthargos, hysterikē pnyx and phrenitics. And to put it simply, anything the nature of the eagle accomplished, the vulture does the same, and for this reason it is useful’ (3.9.54).
The idea of stimulating patients’ heads with such extreme measures is also found in the fifth-century CE Gallic ecclesiastic Caesarius of Arles, who even proposes placing burning coals on the phrenitic’s head, accompanied by a prayer: ‘To heal such a phrenitic, the Holy Ghost exhorts religious men and those burning with the fire of charity, saying: “You will place coals from the fire over his head”.’Footnote 164 The fact that phrenitis is a hot, feverish disease does not disturb him; the preacher may have lēthargos in mind or, in his lack of current technical knowledge, he may be happy with a homeopathic approach. More significant is the allegorical explanation offered by Caesarius a little later on: ‘As he begins now to repent, his rational senses – that is, his head – begin to light up with the fire of charity. And he who previously was, as it were, cold and phrenitic, and harboured anger against you, set aflame by the spiritual heat of your goodness will begin to love you with the whole of his heart.’Footnote 165
The Legal Standing of the Phrenitic
Legal sources, together with patient cases, are perhaps the closest we can get to the reality of patients as citizens and socialized human beings. When we read anecdotal mention in Gregory (sixth century ce), for example, of attendance at what appears to be a phrenitic’s sickbed in the strict sense of the word,Footnote 166 aside from cultural, medical-historical questions, we should remind ourselves of a set of material ones which arise concerning the jurisdictional, existential and patrimonial standing of terminal patients suffering from an impairment of the mind which only legal material can help address.
The legal issues surrounding madness in the ancient world pose rich and intricate historical questions, which have unfortunately received only limited attention. The notion of diminished capacity and incapacity is key to the legalities connected with mental disorder (and its allegories, as we have seen) and involves three domains in particular: inheritance, paternal responsibilityFootnote 167 and the value of slaves. Reference to the validity of repentance is also included here. In the Digesta 21.1.1.9 (530–3 ce), for example, the jurist Ulpian reflects on a concrete question: the financial damage a phrenitic slave represents for the owner. Here a question is posed by the jurist Vivianus as to whether a slave who does not always manifest signs of insanity and sometimes speaks rationally should still be considered sane. Vivianus says that he is sane nevertheless:
For we should understand that some persons are of sound mind although they may sometimes exhibit mental defects … More, however, is guaranteed with reference to soundness of body than respecting mental defects. For he asserts that a corporeal defect will sometimes extend to and vitiate the mind, for example, where a man is said to have his mind affected as the result of phrenitis (phrenitikōi). What must be done in a case of this kind? If the mental defect is such that attention should have been called to it by the seller, and he did not do so when he was aware that it existed, he will be liable to an action on purchase.
The same situation is contemplated in Byzantine law. In Book 19 of the Basilica, the phrenitic is singled out as an example of a sick person whose psychic disturbance derives from a suffering of the body – fever in this case. The seller is not obliged to make this fact explicit in advance, since the cause of the mental disturbance in the phrenitic slave is bodily (to psychikon apo sōmatikou synebē pathous). But he will incur sanctions if the cause is psychic and he withholds the information (ta aitia de tēs psychēs ean eidos ho pratēs mē proeipēi, 19.10.1).
A different case is that found in the exposition of canon law preserved by the Concilia Africae (345–525 ce), which gives specific instructions for how to deal in a valid manner with the confession and repentance of someone incapacitated by phrenitis (oppressus infirmitate obmutuerit uel in phrenesim uersus fuerit), especially if he is about to die: ‘He who repents while in a state of infirmity, if the priest comes to him invited, but because he is oppressed by the illness he is afraid or falls into frenesis, then those who had heard him before and received his repentance/confession should give testimony [in his place]’;Footnote 168 his statement is thus invalid.
Conclusions
When we turn our attention to larger cultural life in the first centuries of our era, there is considerable evidence for phrenitis being recognized as a serious, impairing disease by intellectuals, preachers, jurists and the wider population alike. This happens, of course, at varying levels of technicism and competence, and along a wide spectrum from concrete to metaphorical. But all instances point to a fundamental development compared to the state of evidence in the classical, Hellenistic and Republican contexts, where the disease belonged to the doctrines of physicians and their discussions of patients, and almost only there. This fact in itself testifies to a wider penetration of the technicalisms of medicine and the medical profession into social life, and to the appropriation of health, especially mental health, by a variety of power discourses and cultural contexts. Conversely, it also testifies to phrenitis becoming increasingly known and important as a human phenomenon.
Open access