Therapeutic Measures

As for therapeutics, the range of remedies is composite and bears the signs of the anatomical tension between head and chest Galen will stigmatize as contradictory in the formulations of other doctors.Footnote ¹⁰ They can be summarized as psychotherapeutics; dietetic measures and other bodily interventions; and pharmacology.

Psychotherapeutics or soothing measures are the first to be mentioned by the Anonymus Parisinus, at the very beginning, and mostly match the directions found in Celsus, perhaps reflecting the same trend in approaching distress of a mental kind: to place patients in the light, dimming it if necessary (1.1, 4.18–21 Garofalo),Footnote ¹¹ and most importantly, to calm them when they experience delirious fantasies (en de tais tōn parakopōn phantasiais) ‘with the help of words (tēi apo logou boētheiai)’ and persuasion (parēgorēsomen); to convince them that those around them are ‘friends, not enemies’; but also to rebuke them when necessary (hote de kai epiplēxomen). These details recall Celsus’ advice and must derive from a common source: one ought to gratify patients in various ways (synaresthentes), announcing unknown facts to them,Footnote ¹² and bringing their wives and children or someone to whom they have an erotic attachment (ei de kai pros tinas erōtikōs echousin) into their presence (1.6, 6.16–24 Garofalo).

Also common to the measures recommended by Celsus and the Anonymous are restraining or coercing these patients, procedures classical medicine ignored (1.3, 8.22–10.2 Garofalo). When the disease worsens, frightening them (ekphobein) might be a necessary last resource, if patients become aggressive and violent, or misbehave more generally; when they pose a threat to others, whether physicians or family, ‘slaps and blows’ (rhapismois kai epiplēxesi) may be used. Only through physical restraint are these patients led to understanding and reason and calmed down (apodeiliōsi); otherwise ‘they will not understand (ou syneisousin ei mē sōmatikōs biasthōsi)’ – explicit early advocacy for a cognitive impact of physical intervention on patients’ bodies. That passive exercises such as the use of hammocks, in accord with individual strength and the state of sleep or delirium (1.3, 6.12–13 Garofalo), are also present, is part of the same ‘holistic’ approach, which aims at mental health qua psychological datum. There is also a class element at work here: bonds are more necessary for individuals of lower social provenience (slaves) than for those who lead an ‘honest, free life (epi tōn biou eleutherou kai katharou)’. The latter constitute a class of patients whom restraint would exacerbate rather than tame (1.3, 10.3–7 Garofalo). Holding them tightly by the hands and embracing them gently is recommended instead, a use of physical contact that recurs in late-antique physiological therapy as seen in nosological discussions of mental disorders.Footnote ¹³

These points all go in the same direction as the ethical approach testified to by Celsus, with cognitive, emotional and relational aspects inserted within the nosological picture. In addition, they expand the social frame to include children, wives, friends and lovers, as well as the controversial (and popular) feature of the erotic remedy, a topos in the early centuries of our era.Footnote ¹⁴ Class and ethical discriminations are also part of the patient’s profile and determine different therapies for different social statuses.

Somatic measures to be adopted include bleeding and purging (1.2, 4.22–5 Garofalo) and phlebotomy (1.3, 9–13 Garofalo). Fasting and dietetic specifics are also recommended (1.3, 6.1–3 Garofalo), including drinking honey-water to relax the stomach (1.3, 10.8–10 Garofalo), bathing and a restorative regimen after improvement has begun to be apparent (1.3, 8.9–13 Garofalo). All these are directed to the respiratory tract in the chest and to the digestive parts. Other therapeutic measures centre on the head, such as embrocation with green rose oil and other ingredients (1.3, 6.4–15 Garofalo). At a later stage of the disease, inflammation ‘of the middle part’ may appear (en tois mesois phlegmonē), against which cupping with scarification is prescribed: the involvement of the lower location in the body for phrenitics returns here. Haircutting is mentioned in parallel with this, although it is to be avoided at the beginning of the illness (1.3, 8.10–12 Garofalo), and application of somniferous ointments to the face is also recommended. Sleep-inducing agents should also be given as draughts or suppositories (with various recipes offered at 1.3, 7, 8, 9, 10).

Neighbouring Diseases: lēthargos, pleuritis, and pneumonia

Nosological treatises are a precious source for exploring the relationships and overlaps among neighbouring diseases and their position in the taxonomy to which they belong. AP also explores and highlights points of contact with phrenitis in its discussion of other diseases. lēthargos comes just after phrenitis in the treatise, reflecting the important association between the two which recurs for centuries to come in all medical sources.Footnote ¹⁵ Surveying the causes mentioned by thinkers in the medical tradition (1.1–3, 10.16–27 Garofalo), the Anonymous mentions ‘affection of the psychic faculty in the meninx (pathos tōn peri tēn meninga psychikōn dynameōn), where (eph’ hōn) it is precisely that lēthargos occurs’ (attributed to Erasistratus, 1.1); affection around the heart (‘the chilling of the psychic pneuma around the heart’, attributed to Diocles, 1.2); and the brain again burdened by excessive cold phlegm and causing the patient to fall into a comatose state (kataphora) (attributed to Hippocrates, 1.3).

The signs of lēthargos are continuous fever and a distinctive pulse (2.1, 12.1–5 Garofalo); difficulty in conversing and interacting, with delirium and oppression (2.2, 12.5–8 Garofalo); a swollen, flushed face; and various signs traditionally regarded as mental. As in the case of phrenitis (2.5, 4.11–13 Garofalo), when the illness becomes worse, ‘the hypochondrion is pulled up (hypochondrion anaspatai), the hands tremble a bit, and patients have difficulty swallowing (katapinein ou dynontai) (2.6, 12.13–16 Garofalo). In the therapy, interestingly, other points also connected with phrenitis return: a concern about light (2.1, 12.1–2 Garofalo); embrocations (2.1–2, 12.22–14.3 Garofalo); phlebotomy (2.3, 14.12–14 Garofalo); the phenomenon of kōma (2.4, 14.15–18 Garofalo); and a lack of awareness of natural functions such as excretion (2.5, 14.19–16.7 Garofalo) and swallowing (2.6, 16.8–13 Garofalo). Scarification and cupping are suggested, although these are common measures (2.6, 16.8–10 Garofalo). Also recommended are hot water to the head (2.8, 16.20–18.2 Garofalo), shaving and passive exercise (2.9, 18.3–4 Garofalo).

Pleuritis is located by ancient authors in or around the pleura or lungs, according to the report by AP (e.g. by Hippocrates: 8.1–4, 56.26–58.16 Garofalo). The localization of pleurisy in AP is the same as that of phrenitis, in line with what appears to have been the case in the Hippocratic texts (8.4, 58.11–16 Garofalo). Its symptoms are a sharp, piercing sense of pain in the pleura or upper chest, and fever and expectorations, accompanied by various mental or mind-related symptoms: ‘They suffer roughness of tongue, sleeplessness, agitation, distress.’ Most relevant, ‘sometimes … they become delirious, the hypochondrion is pulled up, difficulty in breathing increases’ (8.1–3, 58.18–60.9 Garofalo). Pneumonia/peripleumonia, finally, is only briefly described in this text as an inflammation of the lungs (pneumonos phlegmonē), and in a report of Praxagoras’ views it is seen as contiguous to pleurisy: one is located ‘in the part near the ribs’, the other ‘in the part near the lobes’ (9.1–2, 64.16–21 Garofalo). Signs are fever, a heavy chest, difficulty in breathing, a thick pulse and coughing. The appearance of the face is affected (glossy eyes, blushing, bulging blood vessels). As for therapy, the vast majority of the suggestions are dietetic and pharmacological, and aim at curing the bodily physiology of the disease. At 9.11 (68.23–24 Garofalo), however, it is again said that ‘we shall allay the delirium with embrocations on the head and sponging of the face’.

Still in this imperial author, then, perhaps precisely because of his comprehensive interest in doxography and lack of systematic ambitions, the ambiguity between the chest (with lung symptoms and breathing issues) and the head (partially in aetiology, but always in the signs and therapy) remains irreducible and even dominates. Compromises vis-à-vis localization and a potentially ‘holistic’ nature are reaffirmed as a marked peculiarity of our disease. At the same time, Anonymus Parisinus offers a sample of the themes addressed by nosology at this stage in Greek medicine, marking a profound difference from the Hippocratic works: the discussion of the ‘name’; the question of localization; the definition of causes and systematic description of manifestations; the therapy; and the relationship of the disease to other, similar ones.

Fever

Since early times, fever had been a central marker of phrenitis.Footnote ¹⁷ In the Hippocratics, it was a key part of the disease’s affiliation with winter chest ailments. In later authors such as Diocles and Erasistratus, it apparently converged into the concept of inflammation, phlegmonē of a topical kind (the brain, meninges or diaphragm being affected) that accompanies it up to modern times. In others, such as Celsus, fever seems to sustain the delocalized, systemic, atopical account of the disease. In nosology, fever becomes a differential element to distinguish phrenitis from other mental afflictions, notably mania. Fever also remains important for another fundamental reason: it constitutes a gravitational point for many of the observable manifestations of phrenitis, which are often of a typhoid kind and associated with overheating and drying.

‘Fever’, of course, must be defined. In modern medicine, the term might be taken to indicate, rather straightforwardly, ‘a body temperature that is higher than normal’ (with ‘normal’ usually indicated as a range). But for a world that lacked the concept ‘temperature’ as continuum (as opposed to ‘hot’ vs ‘cold’), and that had no way to measure such entities with precision and no interest in them as a physical datum, the use of the modern term needs qualification. If we can, as I would argue, legitimately read pyr (πῦρ) as an experience to a substantial extent superimposable upon our ‘fever’, we must nonetheless be cautious, especially since this pathological sphere is too predominant in ancient medical literature to be taken as a strong indicator of a disease state we can recognize. Hamlin has carefully explored and exposed the network of demographic, environmental, scientific and socio-medical variables and biases that must be discounted when we apply the term to premodern contexts.Footnote ¹⁸

Aretaeus, in his therapeutic discussion, speaks of a fever ‘of a continuous type’ as characteristic of phrenitis: ‘Nor do they have long intermissions, but they experience short and ill-marked remissions’ (Th.Ac. 5.1, 92.33–93.2 Hude). For Galen, an accompanying continuous fever is also a particular element differentiating phrenitis from other kinds of insanity, as explained at Caus. Symp. 2.7 (7.202 K.): ‘All forms of delirium (paraphrosynai) are dissonant movements (plēmmeleis … kinēseis) of the hegemonic faculty (tēshēgemonikēs dynameōs), caused by malignant humours or by a bad mixture of the cerebral humours. Those with fever are called phrenitis, those without it mania.’Footnote ¹⁹ In Comm. Hipp. Epid. VI, 1.29 (52.7–20 Wenkebach = 17a.882–83 K.) Galen discusses various typologies of fever based on their heat, and in particular the nature of the plague described by Thucydides. He criticizes the medical categorizations offered by other authors and writes: ‘Some of the ancients called this kind of fever (i.e. that causes ulcers on the skin) phrenitic fever, like lethargic, pleuritic, peripneumonic.’ Galen disagrees, however, because ‘the fever of the phrenitic is found to display a biting heat (tēn thermasian echōn daknōdē) in every part of the body equally and continuously to the touch (dia pantos homotonōs en panti chronōi tēs epiballomenēs haphēs)’.Footnote ²⁰ Likewise at Diff. Resp. 3.9 (7.937 K.) we read that ‘these diseases that happen with continuous fevers are of the kind [Hippocrates] demonstrates in his book On Regimen in Acute Diseases. These are acute, those the ancients call pleuritis and peripleumonia and phrenitis and kausos and all the others of this kind, whose fevers are mostly continuous.’Footnote ²¹

Among the symptoms of fevers described by Galen at De Cris. 11 (200.2–5 Alexanderson = 9.752 K.) are ‘strong pains to the head and neck, heaviness with or without fever. In phrenitics, spasms sometimes with yellow vomit; some of them die very quickly.’ Several details described here recur for phrenitis elsewhere as well, along with heaviness of the temples, darkened vision, tension and pain in the hypochondria, and epistaxis; the latter is also mentioned as a sign of phrenitis at Loc. Aff. 5.4 (8.330 K.).Footnote ²² Galen is well aware of the generality and frequency of the signs that characterize fevers (kausoi and other diseases with ardent fever) and, as we have seen, is very concerned with the cogency of signs as a methodological question. In this spirit, at Comm. Hipp. Prorrh. I, 1.15 (31.1–5 Diels = 16.545–46 K.) he comments on the following Hippocratic point: ‘Those who are severely out of themselves with fever and sweating become phrenitic.’ He writes: ‘We define this formulation as strident/contradictory (asymphōnon); its sense is so obscure, that the nouns in it can be interchangeably separated or conjoined.’ Galen proceeds with a critique of the unclear, ambiguous syntax of this author, which in his eyes fails to establish any clear interdependence between basic signs such as fever, derangement, sweating and so forth. What is notable for us is the role of fever as container already perceived by Galen himself to be dangerously loose, as by Celsus before him. Celsus in fact drew the distinction between insanity due to fevers and insanity due to phrenitis, but did not develop this as fundamental to the definition of the disease (122.17–24 Marx).

Already in the Hippocratics, fever came with a plethora of heat-related signs, such as a rough tongue, thirst and dryness; these symptoms are picked up by imperial authors as well. As expected, one of them is sweat: at De Cris. 3.3 (170.7–9 Alexanderson = 9.707 K.) it is said that ‘the good kind of sweat resolves phrenitis, and especially if abundant from the head and if warm, with the whole body sweating’. The idea, it seems, is that pressure and heat are relieved via the head, a process blood flow can also favour: ‘Through haemorrhages through the nostrils, phrenitis is even more safely resolved.’ In fact, fevers are directly related to the rise of bile to the head, as explained at Comm. Hipp. Epid. III, 3.12 (117.5–7 Wenkebach = 17a.661 K.): ‘High fevers (kausoi phrenitikoi) derive from the excess of bile falling on the liver and stomach, and become phrenitic when they rise to the head.’Footnote ²³

At Comm. Hipp. Prorrh. I, 2.2 (53.14–26 Diels = 16.592 K.) Galen writes that headaches, insomnia and asapheia – a lack of clarity in speech – should be reckoned among phrenitic signs (tōn phrenitikōn esti sēmeiōn), and ‘since we have seen phrenitis to be a particularly dry (xēron malista) illness, any symptom of dryness occurring in the organs close to the head or sharing something with it also signals oncoming derangement, by virtue of which signs the disease is called the ‘the one with thirst/the thirsty one’ – to dipsōdei/τὸ διψώδει is the transmitted form – ‘in the discussion above’. These are all classic manifestations of high fever, and their constant presence in phrenitis testifies to the strong embodied nature of the syndrome.

Sensorial Receptiveness

We have already observed that a notable element in Aretaeus’ analysis is the importance he assigns to the ambience created around the patient to protect his sensory health; the physician opens the chapter on precisely this topic. ‘A house of moderate size … a mild temperature’ are prescribed; the patient and those who live with him should ‘be ordered to preserve quiet’ (hēsychiēn agein, 91.12–15 Hude).Footnote ²⁴ The reason for these recommendations is the extreme sensory sensitivity, tactile and visual, of phrenitic patients: they ‘have acute hearing and are affected by noise’ (oxyēkooi gar ēde psophou kathaptomenoi, 91.16 Hude), and are extremely prone to visions. For this reason, ‘walls should be smooth, level, without projections, unadorned with a frieze or paintings; for painting on a wall creates excitement’ (91.17–18 Hude). And again, since ‘certain false appearances float before their eyes (pro tōn ophthalmōn amphaireousi tina pseudea indalmata, 91.18–19 Hude)’ and easily cause them to grope and become busy with their hands (91.20–21 Hude), bedclothes should be plain, to avoid giving patients the opportunity to surrender to the urge to pluck. Light and darkness should also be modulated to suit each individual and the nature of the attack under way (92.2–8 Hude):Footnote ²⁵ light is recommended, for instance, to keep the patient from being scared by confusing perceptions or ‘strange images (xena indalmata)’ (92.5 Hude). This hypersensitivity of the sensorial faculties is present in nuce in some Hippocratic remarks, such as those about the vividness of dreams in phrenitics,Footnote ²⁶ and in the mention of floccillation as a recurrent behaviour. In this later period, medicine combines these traditional details and traces an image of impaired cognition: the senses impart deceptive information, and patients fall prey to images larger than life, both in dreams and awake.

The Hippocratic discussion of the vividness of phrenitic dreams just referred to is corrected by Galen at Comm. Hipp. Prorrh. I, 1.5 (20.10–21.18 Diels = 16.524–27 K.), in a long passage that nicely illustrates once again the complex interpretation imposed by imperial medicine on traditional signs. The observations made by physicians from the past are fitted into a comprehensive system: reading that ‘dreams in phrenitics are conspicuous/clear’ (Prorrh. I, 5, 75.10–11 Polack = 5.512 L.), Galen comments as follows:

It is thus the dryness of this disease and of these patients’ physiological states that causes the neatness of the images they perceive, just as humidity dulls the imagination, and torpor makes perceptions heavy and opaque. Through the language of dryness, wetness, fluid engorgement and flow, Galen is thus able to sketch out a mechanism of interaction between physiology and cognition based on the received Hippocratic sign, and forges a vocabulary for it.

Damage to Cognitive Faculties

Senses and images constitute only one level of the psychological and psychopathological portrait of the phrenitic, although perhaps the one most readily mentioned in medical literature on the history of mental disturbance.Footnote ²⁷ While Galen is not as interested as Aretaeus or Celsus are in the emotional and personal sphere touched by phrenitic pathology, his elaboration on cognitive and imaginative damage has a depth and richness unmatched in other authors. In Comm. Hipp. Prorrh. I, 1.4,Footnote ²⁸ as we have seen, Galen distinguishes precisely among types of mental damage in phrenitis, with – according to him – unprecedented precision. As he points out, in the presence of such damage the physician must check whether the ‘muscles’Footnote ²⁹ (myes) of these functions are affected, or if the problem is with the source of their impulses, the brain:

We learn more about the ‘types’ of mental affection at Loc. Aff. 4.2 (8.225–26 K.), in a passage which explores problems in the sensory organs. Here three kinds of phrenitis are distinguished, depending on which type of damage prevails:

In a remarkable passage at Comm. Hipp. Prorrh. I, 1.27 (39.22–41.26 Diels = 16.564–68 K.), Galen combines humoral explanation with hard-wired encephalocentrism to account for the variety of symptoms, sensory-motor and dianoetic, which phrenitis produces, each of the two kinds ramifying in turn into more manifestations, depending on the section of the brain affected.Footnote ³¹ Discussing the Hippocratic aphorism that ‘frequent changes in phrenitis are spasmodic’ (ta en phrenitisi pykna metapiptonta spasmōdea), he takes the occasion to scrutinize the nature of sudden changes in cases of paraphrosynē and in phrenitis in particular. At issue is not the change from bad to better, but from one type of bad symptoms to another, the quality of the symptoms (40.7–8 Diels = 16.564–65 K.). These manifestations are caused by variations in humoral flows, and each case is appropriate to the body part where the imbalance fixes itself, and reflects the power of the individual humour. His explanation is long but worth quoting. With phrenitis

Different clinical manifestations, Galen adds, clearly follow the affection in different regions of the brain, involving now sight or hearing, now smell, now touch, and so forth:

So much concerning sensory stimuli and their interpretation by the patient. Other types of damage are more ‘purely’ cognitive, independent of sensory appraisal, such as memory or emotional excitement:

Remarkably, other capacities may remain intact throughout these episodes of derangement:Footnote ³⁵

The broad variety of forms of disturbance, finally, depends on the regional complexity of the brain as it is struck by different humours with different intensities:

A comprehensive physiological picture of humoral overflow in this way explains emotional, imaginative-sensory and reasoning-cognitive disturbances, as well as motor impairment: the source of everything is in the brain and the nerves originating there, with the humoral element allowing for a flexibility and complexity of internal reactions that encephalocentrism alone could not provide – a picture very similar to that of De morbo sacro, despite Galen’s surprising lack of engagement with that Hippocratic treatise.Footnote ³⁸

We thus discover two accounts of the distinct cognitive damage that occurs in the disease phrenitis. The first is subdivided into hallucination, on the one hand, and impaired judgement, on the other (with a mixed version to complete the picture). The second is tripartite, depending on the type of cognitive damage (to the intellectual faculty, the sensory faculty, or the memory), partly superimposable on the first.

In various texts, Galen offers precise clinical examples of phrenitic patients which better illustrate the distinction. The first case is a famous one, namely his own personal experience. As a young man, Galen too once fell sick with phrenitis:

The patient, Galen, is here beginning to hallucinate, but his judgement remains sound and he is capable of intervening promptly by asking for help. Even more precise theoretical distinctions regarding the nature of derangement and hallucinations following damage to the hēgemonikon are made at Symp. Diff. 1.4 (224.9–226.8 Gundert = 7.60–61 K.). In this case, different kinds of impairment are listed and assigned a precise vocabulary, articulating mental damage along various branches of activity and faculty, which can be weakened individually or together: ‘Often delirium exists in both at the same time, in the ill-functioning [faculty of] representation (phantasiousthai) and in the improperly functioning reasoning (logizesthai), but sometimes in only one of those two.’ At Symp. Diff. 1.4 (226.13–17 Gundert = 7.61 K.) Galen offers another famous phrenitic case for the sake of illustration:

At Comm. Hipp. Epid. VI, 7. 30, 31a and 31b (1315–23 Vagelpohl),Footnote ⁴² commenting on the Hippocratic passage at Epid. 6, 8.10 (175.5–9 Manetti–Roselli = 5.348.1–3 L.), Galen tackles a difficult Hippocratic lemma: ‘VIII 30. Hippocrates said: The mind, distinct from the organs and the things it resides in, thinks inwardly: it feels pain or pleasure, experiences fear or courage, hope or negative thoughts.’Footnote ⁴³ This passage gives Galen the opportunity to offer some additional comments on mental faculties, with phrenitic parallels regarding damage to reason but not to sensation (nor memory):

‘Neurological’ Signs

Some markers of phrenitis are also of psychiatric interest from a modern perspective, if more on the neurological side, on our understanding of the term.Footnote ⁴⁵ These are often associated with fever and dryness in the ancient accounts. For example, there are tremors due to the ‘dry character of the disease’ and its ‘tensionsFootnote ⁴⁶ of the nerves (ai … eutoniai tōn neuron)’, and once the patient’s energy has dissipated due to prolonged wakefulness and exertion, ‘the nerves dry out and tremors appear’.Footnote ⁴⁷ The gesturing of the phrenitic is disorderly and uncontrolled: ‘Some puff loudly … others move their head and hands in a disorderly fashion (alogōs)’. Later on, ‘their strongest sign is agrypnia, and most of all that of the troubled kind (hē tarachōdēs): this is characteristic of the phrenitic. It is troubled, as I said, if in the course of the hallucinations they scream and jump and can barely recognize their family.’

It is interesting that Galen can superimpose both a phrenitic interpretation and his own neural understanding on a patient for whom neither is explicit,Footnote ⁴⁸ as at Comm. Hipp. Epid. III, 3.91,Footnote ⁴⁹ a young man who develops a fatal fever after drinking and sexual excess (ek potōn kai aphrodisiōn pollōn). Galen comments that ‘drinking too much harms the nerves and their origin in the brain. Sex also damages them, as it affects the strength and debilitates the patient. And so this young man, once a toxic amount of humours had accumulated, was taken by a slight fever, as expected. Had it got worse over the course of the days, it would have evolved into phrenitis proper (eis phrenitin akribē)’. In this case, quite unusually, Galen seems to reconstruct a history of unhealthy lifestyle as antecedent to the humoral imbalance, sketching a chain of causation and a landscape of predisposing circumstances that can lead to phrenitis. At the same time, this shows the many venues through which he remoulds his Hippocratic sources to his own purposes.

Within the neurological manifestations, motor disturbances, such as spasms, are especially important. At Comm. Hipp. Progn. 3.39 (365.16–23 Heeg = 18b.294 K.), the discussion of violence and tremors is an occasion for a neurological assessment of the disorderly movements of the phrenitic:

Children present an extreme version of the severe motor symptoms phrenitis may cause in adults.

Spasms, it is explained elsewhere, originate in the overheating and drying up (hyperxēranthentōn) of the brain and meninges through the accumulation of yellow bile.Footnote ⁵⁰ In extreme cases, spasms can be violent at the end, as Galen states when he comments on the Hippocratic lemma ‘The phrenitic affections end with violent tremors’ (ta phrenitika neanikōs tromōdea teleutai) at Comm. Hipp. Prorrh. I, 1.9.Footnote ⁵¹ If these are extreme cases, it is a general fact that ‘the vigour of the nerves, because of the dryness of the disease, affects phrenitics for a long time. And when their strength is diminished (katalytheisēs … tēs dynameōs) by their troubled insomnia (agrypnia) and their many movements, once the nerves are entirely desiccated, at that time the tremors occur’.

This dryness and parching of the nerves may also explain yawning as a symptom – although phrenitis is only one possible factor. At Comm. Hipp. Prorrh. I, 1.11,Footnote ⁵² Galen reflects on the Hippocratic ‘Experiences of pain in the pharynx: dry, small, suffocating, when yawning, with difficulty clenching and closing the mouth, and links them to derangement; among such cases, the phrenitics are in danger.’ He adds: ‘When, in the presence of these symptoms, a phrenitis should arise, of whatever kind, it is dangerous, as is rightly said. But you should not presume that it is unavoidable that phrenitis emerge from these symptoms.’ For Galen, as he goes on to explain, these signs are related to a variety of possible forms of damage at the origins of the nerves, in the brain; phrenitis could be one such circumstance, but not the only one. As in several of these discussions, Galen takes the occasion of a description of a phrenitic sign to challenge its semiotic cogency, and in the vast majority of cases to deny that it is idion (‘specific’) to the exemplary disease phrenitis. But for our purpose of offering a sketch of how phrenitis was medically perceived and described, all these signs are equal in weight, despite Galen’s ranking and discussion, and following his own pragmatism and realism.Footnote ⁵³ In a similar spirit, at Meth. Med. 12.8 (10.872 K.) Galen points out that a state in which patients ‘lie stretched out and in pain due to severe dryness’ indicates ‘the need for moisture’. This is especially hard to treat in case of fevers. He adds: ‘In particular, it follows the deadly phrenitides (tais olethriais phrenitisi), and I myself have seen no one who has been saved after having suffered convulsions in this way’; when the cause is dryness rather than biting humour, there is no hope of curing the patient.

Sleep is an important area of psychopathology in ancient medicine, observed in fine detail by doctors from the time of Hippocrates. In Aretaeus, sleep disturbance is an important element in the portrayal of phrenitis. A range of ad hoc soothing measures for this condition is contemplated in his text on therapy, including head fomentations, applications under the pillow, rubbing the nostrils, ears, face or feet of the patient, and bespoke relaxing measures (94.14–95.3 Hude). He recommends various activities and diversions conducive to sleep, and in particular those familiar to the lifestyle of the individual patient (94.30–95.3 Hude):

Restoration of the conditions for a peaceful rest are fundamental: insomnia and excessive sensory response seem to go together.

In Galen, sleep disturbance is also characteristic, and phrenitis is defined to an important extent as both identical and contrary to lēthargos:Footnote ⁵⁴ excessive wakefulness and tension, for which, however, the physician from Pergamon notably avoids any psychotherapeutic involvement. In particular, agrypnia of a troubled kind (tarachōdes) is typical (idion) of phrenitis, as seen above in the methodological discussion.Footnote ⁵⁵ In Comm. Hipp. Prorrh. I, in fact, Galen devotes considerable attention to articulating sleep disturbances in cases of phrenitis and lēthargos in a differential spirit: kōma, agrypnia, kataphora and the presence of sleep proper or sleepiness are variously combined in complex ways to describe the pathology, with levels of fine distinction that are at times impossible to grasp.Footnote ⁵⁶

The topic of sleep was obviously important for Galen, since he devoted an entire treatise, his De comate secundum Hippocratem, to commenting on the Hippocratic concept of kōma, a condition of pathological sleepiness. At Com. 2.14–15 an important discussion involves phrenitis:Footnote ⁵⁷ reading Hippocrates, Galen first distinguishes between an ‘oppression, heaviness’ (catafora) that is sleepy in kind (somnolentia) and one that is not so (catafora non somnolentia).Footnote ⁵⁸ Further on, on his reading, Hippocrates distinguishes two types of sleepless (insomnis) catafora, one that is ‘dull/somnolent’ (pigra) and one that is not so. While the first is characteristic of the lethargic, the second befalls phrenitics (188.29–33 Mewaldt = 7.656 K.); under its influence, patients ‘speak and have delirium with no grip on their mind, are particularly ready to be startled’ – all the opposite of lethargics (189.20–27 Mewaldt = 7.655 K.). Further, phrenitics are delirious about matters that make no sense, and are strong enough to get up, which is impossible during lethargic kōmata, in which patients do not respond readily to any stimulus. The phrenitic kōma is thus an alert comatose state, with no weakening of sensation or movement:

Likewise, agitation and a lack of peaceful sleep (hē agrypnia kai hē tarachē) characterize phrenitis – they are phrenitika sēmeiaFootnote ⁶⁰ – and show the involvement of the brain. As a consequence, phrenitic patients ‘scream through their sleep, and get up due to the vividness of their dreams/visions (dia tēn enargeian tōn phantasmatōnFootnote ⁶¹). Galen also differentiates them from persons suffering from torpor and oppression in Comm. Hipp. Epid. I:Footnote ⁶² ‘If these things [certain affections involving the diaphragm and the hypochondrion] arise with troubled sleep and without oppression (baros), then he will die phrenitic.’

At Com. 1.3 (181.15–16 Mewaldt = 7.644 K.) Galen notes that Hippocrates’ use of the term kōma (κῶμα) differs from the traditional one. ‘Hippocrates … says (phēsi) that kōma often arises with troubled sleep/sleeplessness (agrypnia) and accompanies the phrenitic condition (phrenitikois synedreuein)’, and Galen comments:

At Comm. Hipp. Prorrh. I, 1.33 (46.18–27 Diels = 16.578–79 K.) Galen returns to the same passage:

It is clear that this particular kind of kōma characterizes a version of our disease, since it appears, despite variations, in a number of different sources.Footnote ⁶³ It is also clear that Galen considers types of sleep to be indicators of states of mental health generally, with these exemplified by phrenitis and lēthargos. The underlying physiology is described at De causis pulsuum 3.10 (9.140 K.), where a distinction is drawn between two different causes of sleep, a dry and a moist one, with opposite pathological outcomes:

Voice and Tongue

The feverish dryness of phrenitis has consequences for the voice and tongue of these patients, as repeatedly noted in the Hippocratic texts, where a ‘rough tongue’ or ‘lisping tongue’ often accompanies high fevers. At Comm. Hipp. Prorrh. I, 1.3,Footnote ⁶⁴ the Hippocratic aphorism under discussion attributes to phrenitics precisely ‘muffled and dry tongues’ (hai daseiai glōssai kai kataxēroi), which Galen connects with those that are tracheiai (‘rough’), emphasizing the dryness and roughness caused by the heating generated by yellow bile. At Comm. Hipp. Prorrh. I, 1.20,Footnote ⁶⁵ ‘a trembling tongue is a sign of a mind not well composed’: what is at stake here is this sign and a weakened psychic faculty, as also in the case of phrenitis: ‘For when the brain suffers and there is a hot affection, it cannot stay still.’ In both cases, the issue involves heating, dryness and the state of the organs of speech.

Galen also considers this sign in terms of semiotics and cogency vis-à-vis phrenitis. At Comm. Hipp. Prorrh. I, 1.19Footnote ⁶⁶ he comments: ‘Derangements with a shrill voice and trembling spasms of the tongue, when these grow tremulous, [the patients] are out of themselves, and in these cases hardening (of the tongue) is fatal.’ This sign, Galen observes, is characteristic but not exclusive:

In this way, the sign is revealed as characteristic of fevers generally, but not of phrenitis specifically. In the same spirit, at Comm. Hipp. Epid. III, 3.33 Galen comments on the Hippocratic statement regarding a phrenitic quality of certain kinds of voices, writing:Footnote ⁶⁷

As was the case already in the Hippocratics, a lack of clarity in articulated speech – which in the older sources is often identical to a lack of mental clarity – is associated with overheating and dryness.Footnote ⁶⁸ Overheated, feverish patients may suffer from a characteristic insecurity of speech, the ‘trembling tongue’ (hai tromōdeis glōssai), a general consequence of a weakened ‘mental power’ found in phrenitis or due to other causes. This too is not a defining sign for Galen (ouk … tōn oikeiōn tēs phrenitidos sēmeiōn, Comm. Hipp. Prorrh. I, 1.20).Footnote ⁶⁹ The trembling tongue, he says, is seen by some as a sign of psychic weakness, while the lack of clarity is instead ‘a sign of cerebral suffering caused by heat that does not allow the brain a state of calm’.

In conclusion, just as this manifestation is not exclusive (idia) to phrenitis, neither are the muffled tongue or the quality of the voice – the ‘metallic voice’.Footnote ⁷⁰ These are all interconnected for Galen as features of the dry and hot disease, which also involves urinary incontinence while asleepFootnote ⁷¹ and a dry tongue. As such, they are ‘common’ but not exclusive (ouch henikōs phrenitikon alla plēthyntikōs).Footnote ⁷²

Urine, Sweat and Other Secretions and Excretions

As we have seen, the urine of phrenitics was described by the Hippocratics as whitish with sediment. Urine and the excreta generally are an object of scrutiny in ancient medicine from its early origins. This tradition of observation continues through the imperial age with the work of late-antique doctors and is substantially developed there, expanding into a separate branch of medical diagnosis.Footnote ⁷³

For Galen, as we have seen, the quality of urine lacks cogency as a nosological marker. Urine, he explains at Comm. Hipp. Prorrh. I, 1.13,Footnote ⁷⁴ can be white for various reasons, especially diet-related ones. At Comm. Hipp. Prorrh. I, 1.4Footnote ⁷⁵ he notes again that neither urine nor sweat is a sufficient sign. For the vast majority of patients, in fact, bodily products – stools, urine, vomit, sweat, exanthema, sputum and a sense of oppression/unwellness in one particular body part – are not cogent. At Comm. Hipp. Aph. 4.72,Footnote ⁷⁶ Galen also points out that the quality of the urine reflects the general state of the individual, although this is particularly true for acute cases like phrenitis: ‘Those pertaining to urine are signs of extreme indigestion/crudity, on which account the disease becomes chronic. Some of these are very damaging when they attack already fading strength, as in the case of phrenitis.’ Likewise, he writes later on (Comm. Hipp. Aph. 4.72, 17b.760 K.) that ‘a watery kind of urine is most negative; such things appear especially in phrenitic patients who are doing very badly’.Footnote ⁷⁷

Other secretions are also discussed. Sweat is similar, associated with fever generally rather than with phrenitis in particular: ‘Those who are insane with fever and sweating are phrenitic’ (Comm. Hipp. Prorrh. I, 1.15Footnote ⁷⁸); ‘Phrenitic difficulties accompanied by chilling and sweating in the upper parts with fevers, as for Aristagora, are fatal’ (Comm. Hipp. Prorrh. I, 1.26Footnote ⁷⁹). Linked to heat and dryness is also a symptom that often recurs after Galen, the dense acridic lacrimation of phrenitics: ‘When they are about to suffer from phrenitis, they have very dry eyes, or a single acridic tear flows from one or the other’ (Loc. Aff. 5.4, 8.330 K.).

Expectoration – coughing and sputum – was important in the early history of phrenitis as well, since the association with derangement was consonant with a localization of phrenitis in the chest. Galen tests this sign too in terms of validity – as seen in Chapter 4 – and regards it as relevant but not restricted to phrenitis. This chest sign is thus retained by Galen, albeit minimized in its importance as non-exclusive, and is explained as a consequence of the impairment in the brain-centred proairetic capacities, and thus as entirely disconnected from any inflammation, clogging or pathology of the respiratory tract as primary.

Pulse

A fundamental diagnostic element in the medicine of the imperial period is the pulse, inspection of which is increasingly regarded as a major prognostic technique, as we have seen as early as the Anonymus Parisinus.Footnote ⁸⁰ In the case of phrenitics, the pulse is described by Galen as characteristically ‘low/small (mikros); but very rarely it may appear large (megas), and it has a moderate tone and is hard and sinewy (sklēros kai neurōdēs) and overly thick and fast (pyknos agan kai tachys). But it also comes in waves; sometimes it will be felt by you as trembling, but at other times as spasmodically intermittent’ (Caus. Puls. 4.14, 9.184 K.). At De causis pulsuum 4.14 (9.186 K.) we read that ‘spasmodic intermission in the movement, and its stopping for a rather long interval of time throughout, belongs to phrenitics, as if the heat were taking over and the organs becoming hard’.

The cause of these qualities of the pulse is the bilious humour that causes heating and hardness (sklerotēs) in the arteries (De Caus. Puls. 4.14, 9.184–86 K.).Footnote ⁸¹ Rufus, writing in the first/second century ce, likewise says in his Synopsis de pulsibus 6.2 (227.1–2 Daremberg) that ‘the pulse of the phrenitic is short and vigorous, because of the continuous motion of the breath due to the lack of sleep’. The second-century ce medical writer Marcellinus in his De pulsibus (289–90 Schöne) also describes the pulse of phrenitics as generally frantic and stressed: ‘fast, thick, and irregular, in many cases small/frequent … In some cases, it also appears to tremble. There are in addition cases in which the artery falls down and rises up again suddenly. In some cases, there is only shrinking of the artery, in others indeed its collapse. Such a state develops quickly into a “tickling” feeling (formicatio).’Footnote ⁸² Again at De pulsibus 431 Schöne, discussing Herophilus, he claims to have often observed the ‘gazelle-like pulse’ the Alexandrian mentioned as a common feature of phrenitic and cardiac dispositions (en … phrenitikais kai kardiakais diathesesi), with a noteworthy conceptualization of the phrenitic ‘disposition’.

Respiration

A kind of pathological respiration is also associated with phrenitis. Respiration is an important point of connection between the physiology of pulsation, with its distribution in the body perceived as holistic, which is delocalized, and the chest function of respiration, localized in the lungs and heart, and which phrenitis affects or involves, at least in its Hippocratic formulation, where this is explicit.Footnote ⁸³ At Diff. Resp. 3.10 (7.940–41 K.), Galen cautiously discusses a connection between respiration, thirst and phrenitis:

In the chapter of Loc. Aff. (5.4 = 8.332 K.) that concerns the phrenitis that involves the diaphragm, Galen carefully differentiates between the different affections of respiration in these cases, as opposed to cases where the phrenitis affects primarily the brain: in the second case, respiration is ‘deep and slow’ (mega kai araion), in the first ‘rapid and spasmodic’ (mikron kai pyknon).

Drinking, Thirst and Lack of Awareness Thereof

Thirst is also an area where mental distress manifests itself at the crossroads between physiological alteration and mental-behavioural disturbance. This is already noted in the Hippocratic texts in several cases where mental disturbance is preponderant, as well as in concomitance with fever.Footnote ⁸⁶ As such, phrenitis is an obvious case, although the classical sources do not discuss thirst as a specific sign in connection with it. Thus at Comm. Hipp. Prorrh. I, 1.16 Galen reflects on the lemma ‘Phrenitics drink little, are bothered by noise, tremble (hoi phrenitikoi brachypotai, psophou kathaptomenoi, tromōdees)’Footnote ⁸⁷ and comments:

Galen here decisively interprets a lack of thirst as having to do with a lack of self-awareness as a psychopathological sign somehow analogous to unmotivated fears, bringing in parallels from other physiological functions also discussed by the Hippocratics.Footnote ⁸⁹ At Comm. Hipp. Epid. III, 3.45,Footnote ⁹⁰ in the same spirit, he comments on a mention of lack of thirst in the Hippocratic text, writing: ‘The talk is about phrenitics, for [Hippocrates] says that they have become thirstless not so much because of having excessive moisture at the mouth of the stomach, but because of being unaware of what happens to them, and because the oretic power at the mouth of the stomach has perished in them.’

Psychology and Behaviour

As far as character and psychology are concerned, aggressiveness is a recurring behavioural trait in the disease. This is an interesting ethical elaboration if we compare the imperial material with earlier classical medicine, where a dangerous character is not emphasized as much: the insane may be agitated, easily startled or prone to shouting, but there is no parallel for the complexity of these examples of aggressiveness or for the consequent moralization of the motor phenomenon they allow.

Phrenitics do not display a particular ethical makeup in the Hippocratics, where the focus is on their physiological state. In the late-antique period, a character, an ethical typology, and a peculiar emotional state begin to take shape. This is most evident in the non-technical literature, but also appears with increasing frequency in medical authors. Galen is not a rich source here, however. Outside the impermeable container of his ethical treatises, Galenic psychology remains fundamentally reductionist. This position is most evident in his account of phrenitis, which is extensive on all physiological levels, broadly intended (neurological, encephalic, humoral, sensory-motor and cognitive), but close to non-existent when it comes to psychology in the sense of the subjective, conscious life of patients (emotions and character).Footnote ⁹¹ It is no coincidence that phrenitis, Galen’s favourite case in many discussions of the physiology of the body, is mentioned only once in his ethical treatises,Footnote ⁹² while mania and melancholia are evoked a few times as examples of impaired states of health impacting the state of the mind. For the physician, phrenitis was perhaps simply too hard-wired a disease to be subject to ethical or psychological scrutiny – which in turn, I suggest, made it ideal material for allegory in non-medical authors.

Galen’s comments about the eyes of the phrenitic open up a perspective on this. This body part is seen in Greek medicine in a quite literal sense as an expression of the state of the individual’s mental and ethical health,Footnote ⁹³ an element that reflects a wider cultural belief, and ‘encrusted eyes’ are explicitly mentioned as manic signs (ommata epichnoun echonta, manika) in this sense in Prorrh. I, 17 (77.1–3 Polack = 5.514 L.). Galen has an interesting comment on this passage (Comm. Hipp. Prorrh. I, 1.17):Footnote ⁹⁴ this sign, he says, while common to various diseases – and especially the putrescent sort – appears in phrenitics as well, and in the most aggressive cases (tōn sphodrotata phrenitizontōn). Moreover, the eyes of these patients ‘have a bold glance (to blemma thrasy)’, while in putrescent patients the glance is meek (deilon). When phrenitics display this sign, they ‘are frantic in a furious way (maniōdōs parapaiousin)’ due to their overwhelming dryness. Here we see Galen wrestling with the variety of Hippocratic data, returning again and again to phrenitis as an inclusive category, even when mania – a disease he pointedly differentiates from phrenitis by virtue of the presence or lack of fever – is being explicitly discussed instead. Galen’s engagement with the psychological event tends to return to the bodily manifestation and physiological account, in this case specifically dryness.

Extraordinary strength is also a fundamental characteristic of the portrayal of violence, linked, visually in particular, to the spasms, restlessness and compulsive movements from which phrenitics suffer. At 3.5 in the Problemata attributed to Alexander of Aphrodisias, it is observed that these patients are identified as strong during the disease but weak during remission, again due to the drying effect of the illness, emphasizing the polarity between the alternating states:

Cassius Iatrosophista, the author of the Quaestiones Medicae et Problemata Naturalia (possibly from the late second/early third century ce) likewise discusses this remarkable strength in a medical problem (62.1–2 Garzya–Masullo):

We now come to variation and inconsistency of character. In this determinist account of phrenitic derangement, mental alterations with their duration and chronology are fundamental. All forms of behaviour that are out of character are seen as characteristic. At Comm. Hipp. Prorrh. I, 2.8,Footnote ⁹⁶ as he comments on the fact that ‘an aggressive reply from a kind person is a bad sign’, Galen explains that the discontinuity in itself signals phrenitis, just as the contrary change, from bold to mild, signals lēthargos: ‘A person who habitually has a gentle nature, not only reveals his state when he is deranged in a fatal way, but also reaches the point of phrenitis (hekei phrenitidos) when he answers in an aggressive way. In turn, a polite reply in a bold character foresees kataphora and lēthargos in the patient.’

Aretaeus’ extant testimony, with its focus on therapy, is by contrast especially dense in clinical information aimed at the psychology of the patient in a more comprehensive sense. He opens his discussion of the care of phrenitics with psychotherapeutic aspects: the whole initial section at Th.Ac. 1 (91.12–92.8 Hude) stresses elements of psychology rather than strictly physiological ones. Patients ‘ought to lie in a house of moderate size and mild temperature’; peace and quiet should be maintained by family and guests; the walls should be smooth, devoid of any image, since images might trigger the patients’ disturbed imagination; likewise covers should be smooth, so as not to excite the ill to compulsive picking with their hands (floccillation). The company of friends should be encouraged, but without producing excessive excitement, and an appropriate modulation of light should be obtained to suit the mood of the patient. This approach presents phrenitics as primarily patients of a mental kind, although the usual dietetics and physiological measures follow.

In Aretaeus as well, explicit mental and neurological signs are included: impaired cognition; sensory alteration, especially hallucinations; pathological insomnia; or restlessness and uncontrolled movements of the limbs. Even the voice may change in these patients, this being a traditional marker of psychic alteration in ancient medicine:Footnote ⁹⁷ ‘Insomnia (agrypniē) and false visions (phantasiē) are present … They become disordered in understanding (tēn gnōmēn parakineontai) and their voice changes (tēn phthenxin exallassontai) … The delirium becomes more violent’ (93.31–94.3 Hude). Degrees of delirium signal stages in the progression of the disease and demand different pharmacological options to keep derangement (paraphorē) in check (92.17 Hude).

In addition to these general categories, numerous features of general behaviour are important indicators for mental cases, communicating impairment on a holistic level or simply characterizing the patient, the ‘human being’, as phrenitic in the reality of his or her existence. Despite his attention to physiology and the poverty of his comments on phrenitic personal psychology, Galen offers a great deal on the level of assessment through direct observation, again following the path of Hippocratic clinical activity. The behavioural portrait of phrenitics includes disparate elements such as gesturing, a lack of desire or ability to drink, a fixed gaze, sudden weeping and incoherent responses to questions. Patients are deranged and speak senselessly, are afraid for no reason, and pick flocks with their hands. ‘Sometimes they speak aggressively, others remain despondent and hardly answer. Even if they feel pain in some parts, sometimes they do not feel physical contact, even if one touches them forcefully (ē merous tinos odynēran echontos diathesin oud’ holōs aisthanesthai, kan sphodroteron tis autou thigēi)’, as described at Loc. Aff. 5.4 (8.331 K.).

The most representative individual visible sign of phrenitis is surely floccillation or crocydism, which we have already encountered many times.Footnote ⁹⁸ Galen explicitly interprets it as a form of hallucination, a misrepresentation of reality belonging to the same category as visions. (He pays no attention, however, to the compulsive specifics of the focus on small items, whether dust, pieces of wool, threads or insects.)Footnote ⁹⁹ We have seen how Galen at Loc. Aff. 4.2 (8.226–27 K.) relates his own experience as a phrenitic patient beginning precisely with this sign: ‘Stricken by a burning fever during summer, it seemed to me that I saw sticks of dark straw protruding from my bed, as well as similar pieces of wool from my garment.’Footnote ¹⁰⁰ He explains the nature of this disturbance, which was in his case accompanied by nightmares:

The process is also considered at Problema 2.54 by ps.-Alexander of Aphrodisias, where the optical pneuma is discussed. The text explains that in phrenitic patients the vapours (hoi atmoi) go directly from the damaged brain to the optical pneuma, making it difficult for them to see things the way they are.Footnote ¹⁰¹

Different causes can produce the malignant vapours which obscure vision, although phrenitis is one of the most common, and Galen takes it as his chief example:

And a bit later:

The Centrality of the Brain and its Ventricles

Oribasius takes the encephalic location of phrenitis for granted. Elaborating on the Galenic ventricular articulation and encephalic localization more generally,Footnote ¹³⁵ at Coll. Med. (Libri incerti, 159.19–23 Raeder) he firmly defines phrenitis as damage to the first part within the tripartite model of the living body (brain, heart, liver).Footnote ¹³⁶ Likewise, AetiusFootnote ¹³⁷ (whose writing on phrenitis is much more extensive) presents the brain as the most straightforward and clear localization of the disease in his discussion of the doctrine of Poseidonius of Byzantium (Medical Books 6.2, 125.4–128.5 Olivieri).Footnote ¹³⁸ The disease is here ‘an inflammation of the meninges which surround the brain, accompanied by acute fever which brings derangement and impairment of the mind (hē phrenitis phlegmonē esti tōn peri ton enkephalon mēningōn meta puretou oxeos parakopēn kai paraphoran tēs dianoias epipherousa)’ (125.4–6 Olivieri). A description of the damage caused by phrenitis to the three ventricular areas of mental functioning, engendering different variants of the disease, familiar from the Galenic discussion, follows:Footnote ¹³⁹

Already at Libri Medicinales 5.72 (46.30–47.1 Olivieri) as well Aetius identifies a category of nervous diseases to which phrenitis belongs: ‘Some suddenly suffer from orthopnoea, oppression, lēthargos, phrenitis, parotid gland tumour, with spasms, tremors or apoplexia, and to summarize, the whole nervous system and the head suffer.’ Paul of Aegina’s chapter dedicated to phrenitis (3.6, 144.4–6 Heiberg) offers a similar formulation: ‘Phrenitis is an inflammation of the meninges, when the brain becomes inflamed together with them, or when there is an unnaturally overheated state in it.’

The Survival of the Chest Localization and Pathology

Aetius, in his compilation, mentions the ‘split’ location of phrenitis – encephalic as well as in the torso – but does so indirectly, on the occasion of the mirror discussion of lēthargos, according to Archigenes and Poseidonius. At 6.3 (128.6–10 Olivieri) he describes two versions of the disease, one located in the phrenes and splanchna, the other in the brain:

It is significant that the discussion of lēthargos that follows presents many of the well-known points of complementarity with phrenitis. More explicitly, at 5.48.13 (29.20–21 Olivieri) Aetius speaks of the relationship between phrenitis and yet more diseases, saying that haemorrhages through the nose often resolve phrenitis but not lēthargos or peripleumonia, again pointing at the parallel with a lung disease, exposing the lasting trace of the archaic association with the chest.Footnote ¹⁴¹

Paul of Aegina’s chapter dedicated to phrenitis (3.6, 144.8–28 Heiberg) explicates the possibility of sympathy with the diaphragm, again following Galen in On the Affected Places 5.4:

Alexander of Tralles’ discussion of phrenitis at 1.13 (509–27 Puschmann, Peri phrenitidos) uniquely emphasizes the controversy regarding the localization as a well-known point of conflict. This is an important bit of information, since it acknowledges something about phrenitis which is hidden in plain sight in most other authors in this period: its problematic location.

Later the question of the phrenitic location is tackled and resolved by dismissing it:

The Relation of phrenitis to lēthargos and other Diseases

The traditional association is perpetuated by all these authors and remains central in Byzantine and medieval medicine as well. Oribasius (Syn. ad Eust. 8.1.2 = 244.8–11 Raeder) pairs phrenitis and lēthargos as diseases which attract similar therapeutic measures, mostly phlebotomy and applications with oxyrrhodinum. The two are seen by him as mirror images and capable of curing each other (Coll. Med. 45.30.55 = 195.30–33 Raeder): ‘Phrenitis is a cure (iamata) for lēthargos, and lēthargos tames those who are continuously out of themselves and undoubtedly phrenitic (aparalogistōs phrenitikous).’

At 6.2 Aetius as well mentions lēthargos as parallel to phrenitis: ‘For mostly in those who, coming from a phrenitis, have been cooled through narcotic pharmaka, there is a change to lēthargos’ (128.10–12 Olivieri). At 6.3 (= 131.16–19 Olivieri) he reports in regard to Archigenes and Poseidonius ‘about katochos and katalepsis’, diseases seen as a combination of phrenitis and lēthargos already in Galen:Footnote ¹⁴³ ‘You will find that there is a disease in the middle between phrenitis and lēthargos, which is a kind of paranoia or parakopē (eidos paranoias ē parakopēs). Doctors usually called it katochē or katalepsis because of the settling humour, especially melancholic.’ Again at 6.4, in regard to patients with katochos, who manifest symptoms similar to phrenitics, he says: ‘Sometimes they scratch the nearby walls and speak foolishly (haplōs eipein), in ways not at all similar to phrenitics or lethargics (oute phrenitikois to pan eoikasin oute lēthargois)’ (132.9–11 Olivieri). Paul of Aegina also underlines the contiguity with lēthargos: ‘And lēthargos, a form of damage affecting the logistikon, has the same location as phrenitis, I mean the head, but through an opposite substance. For it arises through moister and colder phlegm running through the brain’ (3.9.1 = 147.6–8 Heiberg). He too mentions the disease katochos as a comparable ailment: ‘We have already clarified the substance of the disease phrenitis in the chapter on this disease. But [consider now] the signs that are on the whole common somehow to phrenitis and lēthargos, as the opposite substance prevails’ (3.10.1 = 149.1–5 Heiberg). Most interesting, Alexander of Tralles (1.17 = 591.10–12 Puschmann) identifies a link between melancholia and phrenitis, where some patients with melancholia can display phrenitic behaviour: ‘Some of them (the melancholic) laugh all the time and their imagination is always full of hilarity, while others appear to suffer from anger and tension, as in the case of those who are called phrenitic (phrenitikois onomazomenois)’. Here ‘phrenitic’ already appears to embody a type, despite the fact that earlier literature had repeatedly recognized and classified different typologies for the behaviour of such patients;Footnote ¹⁴⁴ Galen in particular described the comatose, passive type alongside the aggressive one. The profile offered by Alexander is that of the furious, violent madman, the ‘so-called phrenitic’.

The existence of different versions of the disease phrenitis is thematized in these authors as well. Alexander of Tralles in his discussion (Peri phrenitidos) follows Galen in distinguishing phrenitis from paraphrosynē:

He continues:

He also mentions the ‘false phrenitis’ Galen describes, the peculiar state of ‘phrenitics who are already chronic’, and the issue of differential diagnosis. All these authors engage with such ‘false phrenitis’, which will be picked up by medieval medicine and, with the discomfort with definition it betrays, constitutes an interesting point of taxonomic maturity.

Therapeutics

Aetius reports on the therapeutics for phrenitis in general and independent of locus affectus, and regardless of the ventricular localization of the illness he had explored; as we have often noted, these are the more holistic and psychotherapeutic kinds of measures. Detailed suggestions are accordingly offered about the ideal environment for the disturbed patients (6.2 = 125.27–126.6 Olivieri):

Aetius also mentions venesection (although for him it should be practised cautiously),Footnote ¹⁴⁵ purging of the stomach and embrocation of the head with warm rose extract,

In this summary, Aetius combines traditional physiological measures with classic remedies from the tradition of soft medicine for the mentally disturbed: the importance of a particular environment, the role played by calm, the modulation of light and darkness. Elsewhere in his Libri Medicinales Aetius summarizes the manifestations and therapy of phrenitis and lēthargos combined: at 1.146 (72.15–19 Olivieri) he discusses pain in the head and its therapies in chronic cases of lēthargos and phrenitis and reports on the use of oxyrrhodinum for both, since ‘it stops the upsurges of blood’. Combining a psychotherapeutic tradition with the more strongly deterministic Galenic account, when he returns to therapy at 3.6 (= 264.1–5 Olivieri), he recommends use of a hammock for patients weakened by fever or hellebore, but also for phrenitics. Unlike Galen’s practice, psychotherapeutics and soft measures are combined with physiological interventions.

Paul of Aegina as well offers a combination of bodily measures (venesection, pharmaceutical interventions, head embrocations) and environmental and other psychotropic remedies, for example the creation of a suitable ambience, modulating light and darkness, and soothing or binding patients as necessary. Here Paul offers an especially competent summary of the character of the phrenitic, based on Galen and others:

Some comments appear attentive to social distinctions and a consciousness of class:

In a different version, the feet should be fastened with ropes, but not tightly, and examined/palpated for the sake of preventing spasms (3.6.2 = 146.2–3 Heiberg). To conclude, ‘it is important to aid the recovery of phrenitics by avoiding excess of wine, strong emotional alterations (orgas), excessive food and most of all exposure to the sun (hēliokaias)’ (3.6.2 = 146.17–18 Heiberg).

Alexander of Tralles gives similar indications: again venesection and embrocation of the head with rose oil and vinegar, especially if hallucinations become more severe. There are also specific indications regarding houses (519 Puschmann):

The same psychological and social advice returns:Footnote ¹⁴⁶

Finally, massage and physical interaction can do some good:

In addition, dietetic details are offered which cannot be summarized here (519.6–521.3 Puschmann). Wine (525–27 Puschmann), generally considered a fortifying but strong substance, even dangerous, remains a point of therapeutic controversy. Alexander too recommends caution: ‘(One should) venture to give phrenitics wine not treated with gypson, in cases when the trouble with sleeping is serious and their strength is fading and the fevers are no longer vehement or very hot, but there appears to be a form of coction in the urine’ (525.28–527.1 Puschmann). It is especially appropriate to give wine to those who were already accustomed to drinking it while healthy. Here Alexander introduces a note regarding the character of the phrenitic: ‘In addition to these, it is appropriate to give wine to everyone who suffers from paraphrosynē with moderation, for it changes their thymos and their angry disposition into benevolence, and brings sleep by producing “coction of food” (= digestion) quickly, and promotes the recovery of the whole body’ (527.4–8 Puschmann). He also refers to the gastric area as relevant: ‘In cases in which the inflammation in the hypochondria is not severely fierce and the dynamis is not fading, I strongly urge giving wine.’ In this case, in fact, the benefit will exceed the damage. Fundamental with wine is balancing the benefits and the risks, a calculation which ultimately lies with the physician. This repeats the point already made by Galen:Footnote ¹⁴⁷ for Alexander, ‘the doctor is stronger than wine’ and ‘it is the task of the doctor to measure and judge such matters (iatrou d’ esti to metrein kai krinein ta toiauta)’ (527.17 Puschmann).

Other Themes

Finally, several other elements from previous pathologies are retained by these compilers; their presence is fundamental for the future portrayal of these patients. The quality of urine (mentioned for example by Aetius at 5.37 = 22.26–23.4 Olivieri) remains important as an indicator. The same is true of the pulse (Paul at 2.11.24c = 93.4–8 Heiberg) and for the whole variety of clinical manifestations, largely traditional: neurological (on our definition), sensory, motoric (alteration of sleep patterns, spasms, hallucinations, tremors), psychological (strong emotions, anxiety, torpidity), behavioural (crocydism, aggression, recklessness), sometimes with additions which appears less technical in their provenience. Alexander of Tralles, for instance, stands out for reporting a belief about prophecy (509–11 Puschmann):

The usual manifestations (aggression, hallucinations, crocydism, altered respiration) accompany this; these appear also in Paul of Aegina (144–46 Heiberg).