Among the post-Hellenistic sources the opposition impaired consciousness–mental illness becomes more explicit. Modern scholars, however, have persevered in ignoring impaired consciousness. As far as the notion of disease is concerned, the different components that we have seen as barely theoretically related in the Hippocratic corpus will be more strongly linked among these authors.
Celsus
Celsus’ On medicine offers a good example of the above. It has triggered abundant discussion about madness where scholars have completely ignored consciousness.Footnote 1 The reason for this omission is that the modern debate tends to focus on insania as a whole but disregards the context in which it appears, especially the relations that the author establishes with the conditions addressed in the subsequent chapters. Indeed, Celsus presents delirium within a system of oppositions that aims at distinguishing it from mental illness, on the one hand, and from other forms of impaired consciousness, on the other.
The whole discussion is presented in the first part of the nosology section of On medicine (book 3). In it, chapter 18 tackles insania, an umbrella-term comprised of three nosological entities. Although a superficial reading might suggest that they are equally relevant, the first of them – phrenesis – has a different status. Not only does it take up most of the explanation, but it is also the only one explicitly referred to by its name, and whose relations to other conditions are clearly established.
Phrenesis is initially contrasted with the second and third types of insania – possibly melancholia and mania, which we would nowadays classify as mental illnessFootnote 2 – and subsequently, it is the only one of the three emphatically opposed to the conditions addressed in the following chapters, namely, cardiacumFootnote 3 and lethargy.Footnote 4 siquidem mens in illis labat, in hoc constat (‘While in [phrenesis] the mensFootnote 5 gives in, in [cardiacum] it endures’),Footnote 6 and in eo difficilior somnus, prompta ad omnem audaciam mens est: in hoc marcor et inexpugnabilis paene dormiendi necessitas (‘whereas in [phrenesis] sleeping is more difficult, and the mens is prone to any kind of insolence; in [lethargy] there is torpor and an almost overpowering need of sleep’).Footnote 7 It should be highlighted that the latter two diseases are the closest ancient equivalents to the other prototypes of impaired consciousness that I have chosen. As a matter of fact, among the post-Hellenistic writers phrenitis became the prototypical example of wakeful impaired consciousness, lethargy of drowsy impaired consciousness and cardiacum of total loss of consciousness.
The fact that Celsus feels the need to contrast only the first type of insania – that is, phrenesis – to these other forms of impaired consciousness constitutes a hint that such conditions were somehow related, or at least easily confused (whereas the second and third types of insania were perceived as more distinct entities).
The strongest hint to relate phrenesis to delirium, however, comes from the distinction among the different kinds of insania. Differential diagnosis between these three entities is based on the presence of fever, the length of the condition and some specific symptoms, particularly hallucinations. Indeed, the first kind of insania, phrenesis, et acuta et in febre est (‘both acute and with fever’), and causes deceptive apparitions (vanas imagines) to which the mens surrenders.Footnote 8 These patients can be alii tristes sunt; alii hilares; alii facilius continentur … alii consurgunt et violenter quaedam manu faciunt … (‘sad, others cheerful, some are easily controlled … and some resist and act violently’).Footnote 9 The second genus of insania oppresses for a ‘longer period because it usually begins without fever’ and ‘consists of sadness that black bile seems to bring about’.Footnote 10 The third kind, finally, is the ‘longest of all. So much so that it does not even compromise life, for it tends to occur in strong bodies’.Footnote 11 Some of the affected patients are ‘deceived not by their mens, but by imagines like those perceived – according to the poets – by Ajax or Orestes, when they were insane’, whereas in others ‘the animus becomes void of understanding’.Footnote 12 In this description (that is, in the characterisation of the second type of the third form of insania), mens, animus and consilium are used interchangeably.
The acute nature of phrenesis, the presence of fever and the various kinds of hallucinations (vanas imagines) that cause all sorts of disturbed behaviour – that is, impaired responsiveness – once the mens gives in to them, make it easy for us to identify it with the Hippocratic phrenitis, and therefore with a condition where (wakeful) loss of consciousness predominates. These coincidences notwithstanding, it should be noted that Celsus, probably influenced by the ongoing debates, feels the need to distinguish between this condition and others that no Hippocratic writer mentions (at least not as such, even accepting the leading hypothesis in scholarship that the second and third kinds of insania correspond to mania and melancholia, respectively).Footnote 13 Beyond the lack of fever and the more chronic course of the second and third subtypes, Celsus finds the cognitive disturbances themselves to be distinct in each condition. Whilst phrenesis can trigger virtually any kind of hallucination (thereby affecting connectedness to the environment) and compromise responsiveness (as any episode of delirium does), the other two are more stereotypical. The variant caused by black bile can only produce pathological sadness, whereas patients with the third type of insania either have their animus compromised or suffer from imagines. Yet, the latter are different from those caused by phrenesis because they do not affect the mens. Judging by what we know about Ajax and Orestes, we can suppose that those apparitions resemble what we would nowadays define as a structured delusion, that is, a condition where reasoning is preserved but the patient holds elaborated beliefs and ideas, which are stable in time and not shared by the others (quite different from the more chaotic thought disorders of acute deliriums).
According to Stok, On medicine is the first extant medical text where these three ‘psychiatric’ conditions appear related.Footnote 14 Beyond the fact that phrenesis is stricto sensu not a psychiatric condition, it is likely that the discussion of these three illnesses and their distinction was very much part of the post-Hellenistic debate. A hint to support this hypothesis can be found in the pseudo-Galenic Introduction (Eisagogê). Although the compiler of this introductory handbook discusses phrenitis among acute diseases, and melancholia and mania among the chronic ones, he defines phrenitis as ἔκστασις διανοίας μετὰ παρακοπῆς σφοδρᾶς (‘disruption (ekstasis) of the dianoia with strong delirium (parakopê)’),Footnote 15 and the other two – which are different forms (eidê) of the same illness – as περὶ τὴν διάνοιαν ἐκστάσεως (‘dianoia disrupted (ekstaseôs)’).Footnote 16 Considering the coincidence in terminology, it is not unlikely that these diseases were perceived as related entities, and it was the dichotomous classification (acute versus chronic) which prevented the author from discussing them together.Footnote 17 In other words, the difficulty of separating acute delirium from chronic mental illness is evidenced in other post-Hellenistic works.
In summary, according to Celsus, wakeful impaired consciousness is described in opposition to other forms of impaired consciousness (cardiacum and lethargy); it is contrasted to mental illness (second and third types of insania), and presented as an array of acute symptoms that change substantially during their course. As I will argue, the notion of disease that emerges from Celsus’ approach to delirium is strongly influenced by this system of oppositions.
Celsus and the notion of disease
From the large Hippocratic list of symptoms that characterised phrenitis, in On medicine the emphasis has patently shrunk to abnormal perceptions, which have become the key diagnostic finding. Most of the discussion, in fact, is aimed at describing how those vanas imagines and their effects on behaviour are useful in distinguishing phrenesis from the other forms of insania. This symptom in particular (and to a lesser extent the presence of fever and the length of the ailment) are used by Celsus to draw contrasts between the three types of conditions.
On the other hand, contrary to this increased pre-eminence of hallucinations in the discussions, the other symptom that was ubiquitous in Hippocratic descriptions of delirium, speech disorders, has become less relevant (even if they are still present and often associated with delirium). In book 2 (which addresses generalities about diseases) Celsus describes how in insania with fever one should expect patients to be expeditior alicuius, quam sani fuit, sermo subitaque loquacitas orta est, et haec ipsa sermo audacior (‘more chatty than when healthy, and such sudden talkativeness is often more aggressive’).Footnote 18 Afterwards, when he characterises phrenesis he defines this symptom as loqui aliena (Med. 3.18: 2) – a calque of the Hippocratic allophassein (Mul. I.41. LCL: 104, 3) – which he later on paraphrases as intra verba desipere (Med. 3.18: 3), and stulte dicere (Med. 3.18: 11). It seems that Celsus does still conceive a close association between delirium and incoherent speech,Footnote 19 but it is much less frequently mentioned than among the Hippocratic doctors.
Also relevant to this system of opposing symptoms is the emergence of wakefulness or sleep disturbances as a characteristic sign of phrenesis, paralleled by the association between lethargy and drowsiness (mentioned above). This appears to be a post-Hellenistic addition,Footnote 20 for such difficulty in falling asleep is not mentioned in any of the Hippocratic treatises that describe phrenitis.
In terms of bodily location, several of the obscure and vaguely defined Hippocratic innards are re-elaborated in later texts as distinct loci affecti. The Anonymus Parisinus posits that for Erasistratus phrenitis originated in the meninx, for Praxagoras in the heart and for Diocles in the diaphragm.Footnote 21 It could be argued that this wide variety of locations started to shrink, and towards the post-Hellenistic era the debate was predominantly dichotomous, namely encephalocentric against cardiocentric views. Celsus’ choice in this respect gives testimony of his harmonising stance towards conflicting views. It was not at all an innocent choice that he tackled phrenesis among other diseases that affect the entire body. In this way he did not have to commit to any of the positions, but at the same time did not have to challenge them either. I do not completely agree with Pigeaud’s remark that Celsus based his classification of diseases on the locus affectus, thereby disregarding the opposition acute–chronic.Footnote 22 In the case of insania, this indefinite location in the body is shared by all three forms of the disease, thereby uniting rather than separating them. On the contrary, their length is actually one of the factors that distinguishes them from one another (perhaps his ‘somehow in the middle’ attitude prevented Celsus from strictly defining them as acute or chronic, yet the time frame is crucial in his descriptions).Footnote 23 To a certain extent, we could posit that this ‘middle way’ was his form of navigating the strict oppositions imposed by the post-Hellenistic binary classification scheme. He managed to avoid positioning himself among either the encephalocentrics or the cardiocentrics, and at the same time he got away from the sharp distinction of acute versus chronic, although he did acknowledge the importance of the length of the conditions.
Pathophysiological mechanisms are often omitted in On medicine, and the treatment tends to be symptomatic and mostly based on post-Hellenistic sources. In this regard, Celsus mentions the ancients only once (Med. 3.18: 5), while he persistently juxtaposes different opinions with Asclepiadean practices (Med. 3.18: 5, 6, 14, 15). Even if some therapies suggested can be linked to allusions in the Hippocratic corpus, their use has evidently triggered larger debates during this period. A good example is the discussion about the convenience of light versus darkness for these patients:Footnote 24 Celsus contrasts the opinion of the ancients – tales aegros in tenebris habebant, eo quod iis contrarium esset exterreri (‘to keep such patients in darkness, for it is counterproductive to have them frightened’) – with that of Asclepiades – tanquam tenebris ipsis terrentibus, in lumine habendos eos dixit (‘because darkness is terrifying they should be kept in luminous places he said’)Footnote 25 – and opts, in a clear example of his encyclopaedic method, for the middle way (that is, he recommends allowing the patient to choose light or darkness according to his preference). The Anonymus Parisinus parallels in a much more succinct manner both the opposing points of view and the uncommitted conclusion (Anon. Paris. I.3, 1: 4, 18–21), thereby confirming that the matter was being debated.
Other treatments are completely foreign to the Hippocratic collection, but rather common in post-Hellenistic sources. Such is the case with therapies using the spoken word,Footnote 26 flogging and restraints,Footnote 27 and sleep-inducing drugs. Given that one of the dichotomous oppositions to distinguish phrenesis from lethargy is its wakefulness, Celsus recommends poppy (papaver) (Med. 3.18: 12), which amongst a few other options, was popular in post-Hellenistic treatises to achieve sleep.Footnote 28
Of note is the fact that Celsus does not mention any pathophysiological mechanism for phrenesis.Footnote 29 As a result, the treatment is unrelated to the workings of the body and the disease, and it only targets symptoms, which it aims at counteracting. Naturally, because hallucinations and wakefulness have become the most prominent symptoms in this period, most remedies are aimed at controlling them. In other words, Celsus’ strategy opposes each specific manifestation (represses aggressive cases, sedates the wakeful, offers light or darkness depending on their needs, etc.). Unlike the Hippocratic doctors, whose therapeutic approaches were aimed at several related diseases, Celsus describes a specific treatment that is exclusively meant for phrenesis. In this way, Celsus offers a particular and separate list of procedures for each of the different types of insania.
It could be argued, therefore, that the notion of illness in Celsus is less loose than amongst the Hippocratic doctors. He does not link the treatment to the causes and mechanisms but he does describe a specific combination of therapies that are linked to the specific symptoms and are unique to a particular disease (phrenesis).
Aretaeus
Like Celsus, Aretaeus’ work supports the post-Hellenistic view of impaired consciousness and mental illness as easily confusable phenomena that needed to be separated through opposing features.Footnote 30 His attempts at distinguishing phrenitis from melancholia and mania are proof of this.Footnote 31 Regrettably, only the chapter on the cure of phrenitis is extant (unlike the one on causes and symptoms); therefore, most conclusions will be based on passages drawn from it, as well as on various scattered allusions that Aretaeus made when he addressed other conditions.
οἵδε [οἱ φρενιτικοί] μὲν γὰρ παραισθάνονται, καὶ τὰ μὴ παρεόντα ὁρέουσι δῆθεν ὡς παρεόντα, καὶ τὰ μὴ φαινόμενα ἄλλῳ κατ᾽ ὄψιν ἰνδάλλεται. οἱ δὲ μαινόμενοι ὁρέουσι μόνως ὡς χρὴ ὁρῆν οὐ γιγνώσκουσι δὲ περὶ αὐτέων ὡς χρὴ γιγνώσκειν.
Phrenitics are subjected to misperceptions, and they see whatever is not present as though it was, and whatever is not apparent for somebody else, does appear in their sight. Maniacs, on the other hand, see what there is to see, but they do not recognise about it what needs to be recognised.
This passage offers a clear distinction between the cognitive impairment that characterises phrenitis, as opposed to the one that occurs among maniacs (and also melancholics, whom – like the author of the pseudo-Galenic Introduction – Aretaeus considered to be suffering from a different form of the same disease, SD I.3. CMG (H).III: 39, 28). In phrenitis, the abnormal behaviour is a consequence of impaired perceptions or disturbed connectedness (namely the hallucinations) but alertness is preserved, whereas in the others connectedness to the environment is intact, and the primary problem is their altered responsiveness due to impairment in their judgement. Generally speaking, both melancholia and mania present an altered responsiveness that manifests as abnormal behaviours, extreme emotions and delusions. Unlike the phrenitic delirium, these delusions are structured and persistent beliefs, which are not prompted by wrong perceptions, but by bad judgement (alertness is damaged).Footnote 32 Examples abound: those who mistrust remedies (SD I.5. CMG (H).III: 40, 1–2); the person who believed himself to be a brick and avoided water for fear of dissolving (SD I.6. CMG (H).III: 42, 19–20); the builder who could not be away from the building site (SD I.6. CMG (H).III: 42, 20–9); mystic delusions involving self-mutilation ordered by the gods (SD I.6. CMG (H).III: 43, 40–1; 44, 1), etc. It should be noted, however, that within these chronic conditions there are some specific moments where the author seems to be describing an acute delirium: μετεξέτεροι δὲ καὶ παραισθάνονται, παραφορῇ τῆς αἰσθήσιος (‘some suffer from illusory perceptions and disturbances in their senses’).Footnote 33 Nevertheless, this is still consistent with our understanding of mental illness, where some phases of acute psychosis can occur.
There is yet another clear delimitation between the domain of wakeful impaired consciousness/delirium and delusion when Aretaeus defines mania:
ἐκφλέγει γὰρ καὶ οἶνος ἐς παραφορὴν ἐν μέθῃ ἐκμαίνει δὲ καὶ τῶν ἐδεστῶν μετεξέτερα, ἢ μανδραγόρη, ἢ ὑοσκύαμος, ἀλλ᾽ οὔ τί πω μανίη τάδε κικλήσκεται. ἐπὶ γὰρ σχεδίου γιγνόμενα καθίσταται θᾶττον τὸ δὲ ἔμπεδον ἡ μανίη ἴσχει. τῇδε τῇ μανίῃ οὐδέν τι ἴκελον ἡ λήρησις, γήραος ἡ ξυμφορή.
The wine excites [one] towards delirium (paraphorên) during drunkenness; certain foodstuffs also cause frenzy such as mandrake or henbane, yet this would never be called mania (for having appeared suddenly, they subside fast, whereas mania persists for a long time). Neither does mania resemble senility (lêrêsis), a mishap of old age.
In this passage, beyond the longer duration of mania – which is implicit in its classification as a chronic disease – Aretaeus uses the same delirium vocabulary that he had used in phrenitis to refer to intoxications with wine and psychoactive herbs (paraphorê, ekmainei).Footnote 34 Again, like the young lads from the Hippocratic corpus, drunkenness seems to be – at least terminologically – close to phrenitis. Moreover, not only should mania be distinguished from these acute forms of wakeful impaired consciousness, but it also differs from lêrêsis. This condition (which we would nowadays probably consider as akin to dementia) has become a nosological entity in its own right, where there is αἰσθήσιος γάρ ἐστι νάρκη καὶ γνώμης νάρκωσις ἠδὲ. τοῦ νοῦ ὑπὸ ψύξιος (‘numbing of perception and altered gnômê or nous due to coldness’).Footnote 35
Aretaeus and the concept of disease
Let us now explore the notion of disease that emerges from the account of delirium. If we take a closer look at the description, Aretaeus’ understanding of the role of hallucinations goes one step further than Celsus’: altered perceptions are not only at the centre of the diagnosis of phrenitis, but their compromise is the cause that triggers the whole process.
ὀξυήκοοι γὰρ ἠδὲ ψόφου καθαπτόμενοι φρενιτικοί ἀτὰρ ὑπὸ τῶνδε μαίνονται … ἐρεθιστικὸν γὰρ τοιχογραφίη. καὶ γὰρ πρὸ τῶν ὀφθαλμῶν ἀμφαιρέουσί τινα ψευδέα ἰνδάλματα, καὶ τὰ μὴ ἐξίσχοντα ἀμφαφόωσι ὡς ὑπερίσχοντα … ἀστεργὴς γὰρ τοῖσι νεύροισι ἡ σκληρὴ κοίτη. οὐχ ἥκιστα δὲ τῶν ἄλλων τοῖσι φρενιτικοῖσι τὰ νεῦρα πονέει … μῦθοι καὶ λαλιὴ μὴ θυμοδακεῖς πάντα γὰρ εὐθυμέεσθαι χρὴ, μάλιστα τοῖσι ἐς ὀργὴν ἡ παραφορή … ἢν γὰρ πρὸς τὴν αὐγὴν ἀγριαίνωσι, καὶ ὁρέωσι τὰ μὴ ὄντα, καὶ τὰ μὴ ὑπεόντα φαντάζωνται, ἢ ἀνθ᾽ ἑτέρων ἕτερα γιγνώσκωσι, ἢ ξένα ἰνδάλματα προβάλλωνται, καὶ τὸ ξύνολον τὴν αὐγὴν ἢ τὰ ἐν αὐγῇ δεδίττωνται, ζόφον αἱρέεσθαι χρή ἢν δὲ μὴ, τοὐναντίον.
Because their hearing is sharp, phrenitic patients are sensitive to noise; in fact they become maddened by it … They are irritated by [decorative] paintings on walls. Indeed, they perceive in front of their eyes some false images, and reach to touch things that are actually not sticking out as though they were protruding … A hard bed is intolerable for their nerves: more than anything else, the nerves suffer amongst phrenitic patients … The topics of the conversations [with the visitors] should not be upsetting. It is necessary to cheer them completely. Especially those whose delirium tends towards anger … If they are annoyed by light because they see what does not exist, and imagine what has no underlying reality, or in front of different realities they interpret things differently, or alien images assault them, or they are frightened by the light or by what [they can see] in the light, then darkness should be chosen. Otherwise, the opposite.
It seems that phrenitis affects mainly the nerves and the senses (the aisthêseis), especially the sight through visual hallucinations, but also hearing and touch become particularly sensitive. So much so that sufferers mainontai due to noises, and a hard bed is astergês for them because the nerves are compromised. Even the abnormal movements of the hands (the karphologia and krokudismos),Footnote 36 which the Hippocratic authors had considered to be independent signs, in Aretaeus’ description are framed as a consequence of the abnormal perceptions that make patients want to touch what does not really exist (these interpretations take for granted that reasoning was not affected in these cases). In this way, delirium (mainontai, paraphorê) is conceived primarily as a disturbance in sense perception (oxuêkooi, pseudea/xena indalmata, phantazôntai – that is, impaired connectedness to the environment), which leads to aggressive behaviour or hyperactive responsiveness (erethistikon, es orgên, agriainôsi, dedittôntai).Footnote 37
On the other hand, there are no allusions to the other symptom that we have been chasing throughout the different sources. Speech disorders are virtually absent from this account of delirium. Only some changes, phthenxin exallasôntai (CA I.1. CMG (H).V: 94, 2), seem to be an occasional accompanying symptom but not an integral part of the syndrome. As commented above, even the term lêrêsis – often identified with speech disturbances in the Hippocratic collection – seems to have lost most of its previous connotations and has become an independent disease, which – furthermore – presents ‘numbing of perceptions’, thereby highlighting their relevance in this author’s conception.Footnote 38
To finish with Aretaeus’ symptomatic components of delirium, he also presents the association of phrenitis with wakefulness (in perfect opposition to lethargy and drowsiness, as we have seen in Celsus and other post-Hellenistic authors: γὰρ πάννυχοι μὲν ἐγρήσσωσι, μηδὲ δι᾽ ἡμέρης εὕδωσι, … βληστρίζωνται δὲ καὶ ἐξανιστῶνται (‘they are awake all night, and cannot sleep during the day … and toss about and wake up’).Footnote 39
Aretaeus’ approach to the debates about the organs compromised in phrenitis is particularly illustrative of his lax eclectic method. The loci affecti include the nerves: τοῖσι φρενιτικοῖσι τὰ νεῦρα πονέει (‘the nerves suffer in phrenitic patients’);Footnote 40 the head and perceptions: τὸ δὲ κῦρος ἐν τοῖσι σπλάγχνοισί ἐστι ἐπὶ μανίῃ καὶ μελαγχολίῃ, ὅκωσπερ ἐν τῇ κεφαλῇ καὶ τοῖσι αἰσθήσεσι τὰ πολλὰ τοῖσι φρενιτικοῖσι (‘the origin is in the organs (splachnoisi) in cases of mania and melancholia, as it is mostly in the head and the perceptions among phrenitics’);Footnote 41 the hypochondria:Footnote 42 ἢν ἐξ ὑποχονδρίων καὶ μὴ ἀπὸ κεφαλῆς ἡ νοῦσος ᾖ. ἐνθάδε γὰρ τῆς ζωῆς ἐστι ἡ ἀρχή (‘if the disease [phrenitis] comes from the hypochondria and not from the head (indeed, in them the origin of life resides’);Footnote 43 and thoracic organs, including the heart and the lungs: ἐπεὶ δὲ καὶ θώρηκα … ξὺν κραδίῃ καὶ πνεύμονι [in some patients, delirium originates from certain organs] ‘in the thorax … with the heart and lungs’.Footnote 44 Of note is the fact that Aretaeus always talks about the head (kephalê) and never about the brain (enkephalos) or its components (such as the meninges or the ventricles).Footnote 45 Nevertheless, we can still find in his descriptions – mutatis mutandis – a certain ‘family resemblance’ with Hellenistic theories about the nervous system, in that the nerves originate in the head and are related to perception: κεφαλὴ δὲ χῶρος μὲν αἰσθήσιος καὶ νεύρων ἀφέσιος (‘the head is the site of perception and the starting point of the nerves’; CA I.1. CMG (H).V: 92, 28–9).Footnote 46
This wide dispersion of body parts – which can remind us of the Hippocratic innards – reflects the way in which the author dealt with conflicting sources. His lax eclecticism allowed him to allocate the disease to different parts of the body throughout various explanations without the need to explain the contradictions. Apparently, when facing the crucial question about where the mind resides (hence, where delirium occurs), Celsus – faithful to his ‘middle way’– had avoided committing to any specific organ, whereas Aretaeus seems to be suggesting that it is mainly located in the head and nerves, but several other parts can also be involved. In this way, it could be argued that unlike Celsus, Aretaeus did embrace the dichotomous encephalo- versus cardiocentric dispute. This is especially evident when he opposes an affection of the head and the nerves (phrenitis) to conditions with altered emotions, behaviours and thinking, which originate in the thoracic organs (ἐν τοῖσι σπλάγχνοισι, SD I.6. CMG (H).III.6: 42, 31) – particularly in the heart (mania–melancholia). Of course, this scheme is far from perfect, and there are several instances where he contradicts this pattern. Nevertheless, his lax eclecticism enables him to incorporate these apparent contradictions without feeling the need to justify anything.
The discussion about pathophysiological mechanisms is also illustrative of lax eclecticism in action. Very schematically, a number of fixed solid organs (discussed above) and a few fluids and moving entities (humours,Footnote 47 pneuma and heat) are used to elucidate the workings of the mind, of consciousness and their impairment.Footnote 48 These elements are alternately involved, and different theories can be used to justify different findings and treatments regardless of their intrinsic contradictions.
The source of the phrenitic symptoms is τὸ πνεῦμα ξηρόν τε καὶ λεπτὸν ἐόν (‘the dry and thin pneuma’).Footnote 49 Therefore, the tension (tonos) of this pneuma becomes relevant for the treatment: if phrenitis has turned into syncope and the patient faints, the only cure is wineFootnote 50 because ‘it adds tonos to the tonos and awakens the benumbed pneuma’.Footnote 51 In this example the pneuma provides certain capacities and is clearly more than a mere vapour. Inevitably this shares a family resemblance to Stoic ideas about the pneuma. However, later on it is a ‘hot and dry breathing’ that causes delirium,Footnote 52 along with the ‘innate heat’ (oikeiou thalpeos).Footnote 53 The author is offering similar though not strictly identical ideas such as anapnoê and pneuma, or thermê and thalpeos. There is neither internal nor external evidence to be sure whether they refer to the same phenomenon. As a result, we can either hypothesise that Aretaeus was eclectically drawing his theoretical explanations from diverse sources, or that he was using the terminology in a sumphoretic manner. In any case, it is relevant to highlight that according to his view, some form of heat and some airy matter as well as dryness were at the centre of the problem (and also of the solution, because by adding tension to the airy matter through wine the symptoms allegedly subsided).
When trying to find further correlations between symptoms, mechanisms and treatment, we should bear in mind that impaired perceptions were the core problem in phrenitic patients according to Aretaeus, and that they triggered delirium. According to the previous explanations, this delirium was caused by a hot and dry airy matter. Thus, it is not surprising that the treatment needs to succeed at τὸ μὲν ξηρὸν ἀμβλύνεται (‘blunting the dryness’),Footnote 54 which allows that καθαρεύεται δὲ τῆς ὀμίχλης ἡ αἴσθησις (‘the senses become purified from the mist’),Footnote 55 which, in turn, cures the patient.
On the other hand, however, this dryness, which seems to cause delirium by compromising the aisthêsis, produces the exact opposite effect in patients with kausôn, that is, above-normal perception:
ἐξήρανται γὰρ τἄλλα … αἴσθησις ξύμπασα καθαρὴ, διάνοια λεπτὴ, γνώμη μαντική … ἐπεὶ δὲ τάδε ἐξήντλησε ἡ νοῦσος, καὶ ἀπὸ τῶν ὀφθαλμῶν τὴν ἀχλὺν ἕλε, ὁρέουσι τά τε ἐν τῷ ἠέρι.
Τhe other [organs] dry up … the aisthêsis is absolutely pure, the dianoia subtle, and the gnômê prophetic … Once the disease has drained it [the wetness] off, and has lifted the mist from the eyes, they can see what there is in the air.Footnote 56
The mist metaphor is also used in another passage, which contradicts yet again the previous two.Footnote 57 We have mentioned that post-Hellenistic medicine considered phrenitis to be a wakeful disease that could be treated with sleep-inducing remedies. Accordingly, Aretaeus considers that the treatment to achieve sleep ὀμίχλην τῇσι αἰσθήσεσι παρέχει: βαρὺ δὲ καὶ νωθὲς ὀμίχλη, ἥπερ ὕπνου ἀρχή (‘brings about mist to the aisthêsis; a heavy and dulling mist, which is the origin of sleep’).Footnote 58
In a nutshell Aretaeus has told us that dryness causes a mist that dulls perceptions in phrenitis, dryness can enable above-normal perception in kausôn by lifting the mist from the eyes and finally sleep cures phrenitis by bringing about mist to the aisthêsis. These inconsistencies are another testimony of lax eclecticism, of the syncretic usage of sources and of a flexible understanding of the primary qualities. (The contradiction could also evidence an important weakness in such a theory, which needed to explain all the available pathologies through a reduced number of possible combinations of qualities.)
On the other end of the spectrum, ‘innate coldness’ (psuxis emphutos) – an antonym of the phrenitic oikeiou thalpeos, bearing in mind Aretaeus’ lax use of terminologyFootnote 59 – was the cause of the opposite condition, namely, lethargy.Footnote 60 As a matter of fact, the emphasis on the coldness of lethargy as opposed to the heat of phrenitis is possibly the reason why Aretaeus did not consider fever to be part of this condition (unlike Celsus and other post-Hellenistic works). However, such an omission reveals a case of syncretism when addressing the treatment:
τέγξιες τῆς κεφαλῆς, αἵπερ καὶ τοῖσι φρενιτικοῖσι. ἀμφοῖν γὰρ αἱ αἰσθήσιες πλέαι γίγνονται ἀτμῶν, ἃς ἀπελαύνειν χρὴ ψύξεϊ καὶ στύψει, ῥοδίνου καὶ κισσοῦ χυλῷ, ἢ ἐξατμίζειν ἐς διαπνοὴν τοῖσι λεπτύνουσι…
Moistening of the head exactly like amongst phrenitics. In both [in phrenitis and lethargy] perceptions become full of vapours, which we need to drive out through chilling and condensing with juices made of roses and ivy, or evaporate them in transpiration through thinning treatments…
In other words, although this treatment seems to be targeting the pathophysiological mechanism in the case of phrenitis, the author is recommending moistening and cooling a patient affected by a moist and cold disease in the case of lethargy. In all probability, Aretaeus was transmitting remedies accepted by the tradition (as becomes evident when contrasting the passage with the Anonymus Parisinus, II.3 1–6: 14, 16). Remarkable, though, is the fact that his lax eclecticism admitted such evident contradictions.
This passage could also be hinting at another opposition between lethargy and phrenitis: we have discussed the dry and thin pneuma involved in the aetiology of the latter. Perhaps the atmoi that need to be cleansed are equivalent to pneuma? Be that as it may, there are yet other airy matters involved: phusas. ‘Lethargy causes a confluence of gas both in the abdomen and the whole body, through inactivity, lassitude and swoon. They need to be exhaled by movement and wakefulness’.Footnote 61 In summary, in both opposing conditions Aretaeus is involving different forms of airy matter (referred to with various terms) that affect consciousness and perceptions, which are somehow related to breathing and need to be removed through treatment.Footnote 62
Notwithstanding these examples of lack of coherence, it is of note that perceptions are often at the centre of most explanations of phenomena related to consciousness, and there is an explicit attempt to target the pathophysiological mechanism with the treatment, in order to cure the condition. On other occasions, however, it was not the bodily processes causing disease that Aretaeus targeted, but the locus affectus. In lethargy, apart from the gassy abdomen, the compromise of head and nerves justified the treatment with castoreum.Footnote 63
ἐκ προσαγωγῆς δὲ τὸ καστόριον ἀλεαίνει· κεφαλῇσι δὲ καὶ ἄλλως ξύμφορον, ὅτιπερ τὰ νεῦρα πάντη ἐνθένδε περιφύεται· νούσων δὲ νεύρων καστόριον ἰητήριον.
Castoreum makes them [the head and the aisthêsis] warm in a gradual manner. It is also otherwise useful for the head, precisely because from all around it the nerves originate, and castoreum is the cure for diseases of the nerves.
This compound illustrates very eloquently the way in which post-Hellenistic medical writers worked, and how extended the ‘pharmaceuticalisation’ of excessive sleep was. There must have been a powerful tradition of treating lethargy with castoreum; hence, each author justified its use through his particular understanding of the condition. Unlike Aretaeus, who based his justification in the locus affectus, other authors based it in the symptoms. Thus, Celsus emphasises its stimulating effects (Med. 3.19: 2), similar to the author of the Anonymus Parisinus, who also considered its awakening faculty (Anon. Paris. II.3, 7: 16, 16).
Finally, many other therapeutic recommendations in Aretaeus targeted specific symptoms and aimed at counteracting them without any evident consideration of the pathophysiological mechanisms involved. As seen in On medicine, most of them are described specifically for the treatment of phrenitis.Footnote 64 We can find the use of conversation (again therapy through the spoken word): non-upsetting words by visitors are advised (CA I. CMG (H).V.1: 92, 1–2). Also, a similar conclusion to Celsus is drawn regarding the debate about light–darkness: either choice should be based on the reaction – in each particular patient – to brightness or shadows; whichever triggers ‘false’ or ‘alien images’ should be avoided (CA I. CMG (H).V.1: 92, 2–7).
These coincidences, again, point towards debates that were likely taking place in his day. Aretaeus’ singularity is that, thanks to his lax eclecticism, he was able to combine phrenitic-specific approaches with general therapies for acute diseases, treatments justified by physio-pathological explanations with certain others whose rationale contradicted the previous ones, and yet other therapies – common to several post-Hellenistic sources – without any physiological correlate.
In terms of the notion of illness emerging from the relationship between pathophysiological mechanism and therapy, we could claim that Aretaeus’ position was intermediate between Celsus and Galen. On the one hand, as in Celsus, several treatments are aimed at specific symptoms regardless of the underlying mechanisms of disease; on the other, when Aretaeus advises targeting the mist or the dryness that compromises perceptions and the tonos, we can see a link between therapy and mechanism, which will be more developed in Galen. In any case, he is clearly distanced from the Hippocratic medical writers in the sense that diseases are conceived as individual nosological entities, where the links between clinical features, localisations, mechanisms and treatments are stronger.
In summary, we can see that an important aspect of the post-Hellenistic descriptions of wakeful impaired consciousness is to separate delirium, which was already well known to the Hippocratic doctors, from some more recently described diseases through a taxonomical system of oppositions. Some of these novel conditions, such as melancholia and mania, would be nowadays classified as mental illness; others, lethargy and cardiacum, could be subsumed in our idea of impaired consciousness, for they correspond to drowsy and total loss of consciousness, respectively; and yet others remind us of neurological disorders, such as dementia. Naturally, in this context – more constrained by the nosological classification – there is a stronger sense of unity in the notion of disease (particularly in the link between symptoms and treatments) than what we had seen among the Hippocratic authors.
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