So far, the story of phrenitis has been characterized by language and questions involving localization – albeit not a firm localization, but one which appears to shift from torso to head – and by fever and derangement. This can be explained by the physiological, materialistic psychology of Greek medicine, which integrates mental health within the overall medicine of the body by elaborating on traditional ideas about its cognitive and emotional seats. These inevitably take the form of a localizing discourse, with a rivalry between different views or ‘maps’ of the body.
A parallel account in Greek cultural and medical history, however, interlocks with the one best understood through a language of localization: a holistic understanding of embodied and mental health, promoting (or at least having the potential to promote) a more rounded, psychological view of clinical activity.Footnote 1 In this non-localized portion of the story, non-technical literatures are a richer resource in the classical period for the pathologization of mental health than medicine is. As I have argued elsewhere, Hippocratic medicine, unlike other literary genres, does not conceptualize a ‘disease of the soul’ of a psychological kind as categorically independent,Footnote 2 and if it does offer intimations of holism, we must wait until the early centuries of the Methodist school for a strong theoretical attack on localization.Footnote 3 Moreover, as the survey in Chapter 2 suggested, the Hellenistic period is remarkably under-represented in the medical material that survives. In this limited and fragmentary context, therefore, the evidence provided by non-medical literature helps fill the gap.
If we look for references outside medicine to the term phrenitis, we will nonetheless be disappointed. While anyone familiar with ancient literature knows that the words mania and melancholia are frequent and idiomatic in non-technical realms,Footnote 4 in non-medical Greek literature prior to the Imperial era phrenitis and derivatives appear in only one author, the comic playwright Menander (342/1–292/1 bce). This scarcity of evidence is further proof of the technical nature of both the nosological concept and the term; both aspects play a role in the comedian’s sole reference to phrenitis, in two passages of his Aspis. These references are instructive regarding the general currency of the disease in public knowledge.Footnote 5
The first passage, Aspis 336–42, associates phrenitis with pleuritis, superficially agreeing with the Hippocratic evidence in putting its dominant location in the chest. Despite the strong localization, however, these diseases are both also said to derive from pain, lypē (λύπη), and are thus psychological and ‘holistic’ – a topic that, intriguingly, recurs elsewhere in comedy of the period, pointing to an approach to mental health alternative to the medical, localizing one.Footnote 6 In the episode in question, the slave Davos is suggesting a plan to stage a ‘tragic’ scene and pretend that his master Chaerestratus has fallen gravely ill, so as to make his subsequent ‘death’ plausible in order to deceive the greedy old Smicrines. Chaerestratus must appear to fall prey to despondency (athymia, 331), ‘one of these suddenly arising … evils (tōn aphnō toutōn tini kakōn, 335–36)’. The explicit plan is as follows (336–42):
Various points can be made here. Phrenitis and pleuritisFootnote 10 seem to be akin, first because of their location in the chest, something that appears to be sensed immediately by a non-medical author (and audience), and also because of the assonance of the names. When reading this passage, of course, we must discount the comic context and the lack of interest in terminological precision. But this kind of amateur mention gives a sense of the degree of familiarity with the disease for the wider population. The incompetent – not because he is a slave, but because he has no medical training – speaker throws in faux-technicalities that might sound professional: the two diseases originate ‘in grief’ and in one’s character, and are thus perfectly fitting for a person burdened by athymia after a sad event. We thus have the localized affinity between phrenitis and pleuritis, on the one hand, but a whole psychology, on the other, which is new or at least extraneous to the medical material analysed so far. This might belong to the comic and parodic make-up of the situation. But it is also in line with the psychologization of mental health in medicine which is visible from the end of the Hellenistic era onwards.Footnote 11
Consider the even more precise reference in the second passage, Aspis 444–50.Footnote 12 Here the iatros, the doctor, actually visits Chaerestratus and effortlessly diagnoses phrenitis.Footnote 13 Sadly, the verses follow a lacuna, and we do not know what the first part of the consultation entailed. The doctor’s dialogue with Smicrines is as follows:
(Med.)
(Smicr.)
(Med.)
(Smicr.)
(Med.)
The lacuna means that we do not know what the doctor is doing physically as he indicates a]utas tas phrenas, ‘the phrenes themselves’: speaking of the mind, or touching the diaphragm, the chest or the head?Footnote 15 The use of the emphatic a]utas suggests greater concreteness, so I am inclined to imagine a palpation of the chest in the preceding scene. The disease is fatal: there is darkened vision, foaming at the mouth and a discharge of bile, the typical pseudo-scientific tokens of clinical madness at the time. Despite the concreteness of the pathology, Menander’s audience could plausibly understand a connection between existential suffering and phrenitis, which puts on display a psychologized discourse about the disease which might be a Hellenistic development but is also part of a discussion already present in the background, even if eschewed by the Hippocratics. Already in Aristophanes’ Wasps (1038–41), sycophants and the oppression they cause are metaphorically described as ‘shivers and fevers’, nightmarish presences who attack at night: ‘the nightmares and fevers, who strangled their fathers in the night and throttled their grandfathers, lying in their beds to attack the inoffensive’.Footnote 16 A para-technical notion of fever appears already here, in 422 bce, in a comic context: shivering, and nightmarish in nature, these hostile presences attack during sleep and provoke frightening visions.
The isolated, fragmentary hint at phrenitis in the non-technical testimony of Menander’s Aspis is thus fundamental to bridging the gap to the next extensive medical source,Footnote 17 Cornelius Celsus, but also to aspects of Asclepiades’ doctrine on phrenitis, as we shall see next. Celsus marks the beginning of a crucial period, that of medical discussions after the gap in the evidence in the Hellenistic era. But this is also an exceptional account in itself, which I categorize, together with Caelius Aurelianus (and his Methodist predecessors, whose works survive only in fragments), as the central testimonies in the tradition of the delocalized, holistic view of phrenitis (and of mental health, and thus of any antecedent to what we call ‘psychiatry’ as a whole).Footnote 18
Asclepiades (Second–First Centuries bce)
Although Celsus is the first medical source that survives entire to offer an organic picture of a discussion of mental health, we can trace a strand among his predecessors that testifies to a delocalized and holistic, although radically materialistic model of human health relevant to phrenitis and mental pathology in particular: the elusive doctor and philosopher Asclepiades of Bithynia, and the Methodist school controversially associated with him.Footnote 19 As already noted, only fragmentary and indirect information survives regarding Asclepiades (124–40 bce), a philosopher and physician of atomistic persuasion.Footnote 20 He enjoyed wide popularity, however, and was traditionally known as the teacher of Themison, the founder of the Methodist school. As a rigorously materialist thinker,Footnote 21 Asclepiades was the target of numerous polemical attacks, most notably by Galen and Caelius Aurelianus, the two fundamental sources who preserve his medical doctrine and his views about phrenitis, which reach us as a consequence of the biases of these authors.
First, let us consider the concrete data regarding Asclepiades on phrenitis. Galen’s account of his views in this respectFootnote 22 in Medical Experience (28.3 Walzer) focuses on pathogenic blockage in the cerebral membranes as determinant of the disease. The passage poses complex problems, since the text survives only in Arabic, and the modern translation most commonly used, by Richard Walzer, is very literal and therefore at times difficult to interpret.Footnote 23 Phrenitis is said here to be caused by intensified movements of the corpusclesFootnote 24 out of which reality is constructed. I quote a translation into English based on Walzer, but revised at key points, with specifications, corrections and problems commented on in the footnotes:
For you say: ‘Burning fever inflames the cerebral membranes, and it results from this that the corpusclesFootnote 25 make their way to the “thing that is light/subtle/rare in its parts”,Footnote 26 andFootnote 27 those of them that do so become extremely fast and violent in motion all at once; this is followed by a stoppage of the corpuscles in the pores,Footnote 28 which causes the disease known as phrenitis.’
Galen continues with a further explanation of this process:
Thereupon what lies beneath the cartilagesFootnote 29 spreads upwards, being attracted by the more rarefied areas (‘the thing that is light/subtle/rare in its parts’). Now when the very numerous corpuscles rise and scratch the [walls of the] narrow parts in which they tend to get clogged,Footnote 30 they revert and thus are purged. After this, they return to the roomy parts that are capable of absorbing them, and for this reason there is a voiding of the stomach.Footnote 31 Since this is the case, it is therefore necessary for the origin of the burning fever and its accompanying symptoms to come first, after which phrenitisFootnote 32 follows. Then comes the upward attraction of the regions of the cartilages, and the phrenitis is followed by a voiding of the stomach.Footnote 33
According to this account, the genesis of phrenitis for Asclepiades is the heating of the meninges, which causes a ‘rarefaction’, a vacuum in the affected area which the corpuscles are drawn in to fill.Footnote 34 They quickly move towards that area, causing a landslide of effects: blockage (in the upper parts), discharge, and a loosening (in the lower parts) of the body via sympathetic co-affection.Footnote 35 In this version of Asclepiades’ doctrine, then, phrenitis does not have a core location in the caput, although the origin of the inflammation is in the meninges. Instead, it is diffuse, striking the chest, head and stomach in successive phases.
The version of Asclepiades’ theory presented by Caelius, by far the most extensive account, also begins with a reference to the corpuscles and their movements, but more decisively accentuates the meninges of the brain as locus affectus, attracting Caelius’ criticism. As a Methodist, Caelius disregards the problem of localization altogether and even opposes raising it as a question, in the interest of medical pragmatism. He focuses, however, on Asclepiades’ views in this respect at the very beginning of the section on phrenitis at Morb.Ac. 1,6 included within the praefatio in the current organization of chapters,Footnote 36 which is fundamentally devoted to Asclepiades (24.17–32.26 Bendz). Here he seemingly exaggerates the importance of localization in Asclepiades in order to discredit his medical trustworthiness.Footnote 37 Caelius offers a critique of Asclepiades’ definition of phrenitis as a meningeal affair: Asclepiades (and some of his followers) defined the disease as ‘a stoppage or obstruction of the corpuscles in the membranes of the brain (corpusculorum statio sive obtrusio in cerebri membranis) frequently with no feeling of pain and accompanied by a loss of reason and fevers (frequenter sine <con>sensu,Footnote 38 cum alienatione et febribus)’ (24.17–19 Bendz). In addition, Caelius explains that the detail about fever offered by Asclepiades (‘with fevers’) is aimed at drawing a distinction between this mental affection and the one caused by intoxication by such ingredients as poppy seed, mandragora or henbane (papaver … mandragoran … altercum), by emotional turmoil (immensa ira aut nimio timore commoti vel maestitia etiam compressi), or by another disease altogether (aut epileptica agitati passione).Footnote 39
The head (the meninges of the brain) again appears at first sight to be at the centre of this definition, concretely indicated as the anatomical localization of the disease. On the other hand, Asclepiades’ belief in the importance of co-affection emerges from other cues more in line with the account offered by Galen in Medical Experience and despite Caelius’ dismissal of this feature of his doctrine. Further on (26.3–10 Bendz), in fact, Caelius mentions that ‘some of Asclepiades’ followers’ (eius sectatores quidam) spoke of ‘membranes of the brain’ in the plural as locus affectus. The discussion is apparently motivated by a desire to rule out the involvement of other membranes; Caelius refers here to the one covering the spinal cord down its full length (medullarum spinae membranae), whose inflammation does not cause phrenitis.Footnote 40 The inclusion of other membranes would expand the territory of the inflammation to the whole torso, rather than confine it to the head; the membrane that comes to mind, of course, is the diaphragm or phrenes, which plays an important role in the history and etymology of phrenitis. It is difficult to grasp Caelius’ precise philological and doctrinal point, but it is tempting to hypothesize that there was controversy regarding Asclepiades’ view about the meningeal location as exclusive; the co-affection between membranes bringing together chest and head in the pathology of phrenitis, after all, is a cornerstone in the history of the disease.
Other corroborating details offer reason to believe that an involvement of the chest might have been at issue. A little earlier, Caelius comments on Asclepiades’ statement that phrenitis should be sine consensu, ‘without pain’. Asclepiades intends this specification to distinguish phrenitis from pleuritis and pneumonia, whose patients also rave on the seventh or eighth day;Footnote 41 these two disorders are accompanied by pain (24.23–26.2 Bendz).Footnote 42 If we consider the history of phrenitis and early Hippocratic accounts of it as a winter disease occurring together precisely with pleuritis and peripleumonia, we can legitimately interpret this as proof that Asclepiades, like many others, localized the disease more flexibly than Caelius seems to imply. Other membranes and parts of the body are involved, especially the membranes of the chest (the diaphragm), the pleurai and the lungs, as the otherwise forced parallel with pleuritis and peripleumonia, of all diseases, clearly shows.Footnote 43 Not only this reference to a plurality of loci affecti, but especially the holism implicit in the corpuscular theory makes Asclepiades the first clear voice in favour of a delocalized version of the disease, despite the difficulties in discerning his thought within the disparaging presentation handed down by his opponents.
Further on in the discussion of phrenitis, Caelius devotes two more sections to censuring Asclepiades (ad Asclepiadem, 1.14–15). At 14 (28.29–30.6 Bendz) he offers an important criticism which further supports a holistic reading of Asclepiadean phrenitis, the contradiction between the materialist philosopher’s sense-based view of mind and his discussion of alienation:
Asclepiades holds that, in general, every case of phrenitis involves mental impairment (alienatio) and that the essence of mental impairment is in the senses (in sensibus). In fact, in his definition of mental impairment (alienatio) in his treatise On Definitions, Asclepiades explains the term in the following way: ‘Mental impairment is an affection of the senses, and in this affection the mental activity is sometimes too great for the capacity of the sensory passages (sensuales viae);Footnote 44 but in some cases the passages are too large for the motions [of the corpuscles]. When this disease (alienatio) is chronic (intardans) and without fever, it is called furor or, commonly, insania. But an acute (recens) case with fever and no feeling [of pain] (neque cum sensuFootnote 45) is called phrenitis.’
In agreement with his conception of mind, then, it is sensory impairment that matters in Asclepiades’ account. Moreover, fever is the differentiating factor, while the alienatio itself is delocalized and can have multiple causes.Footnote 46 This is stressed again at I, 20 (32.19–20 Bendz), where Caelius repeats that in On Definitions Asclepiades declares phrenitis to be ‘a sudden mental derangement (alienatio repentina) accompanied by fever (cum febribus)’. In this way, in Caelius’ view, the doctrine of the senses, if properly interpreted, would make phrenitis a ‘holistic’, delocalized disease for which the meningeal corpuscular aetiology makes no sense and with which it is in open contradiction (30.7–8 Bendz): ‘Now, if phrenitis is a disease in the senses, Asclepiades is wrong in defining it (non recte … dicit) in the first instance as an obstruction in the membranes of the brain.’
Diagnosis and Prodromic Signs
An important topic that stands out in Caelius’ depiction of Asclepiades is diagnosis: the possibility of detecting signs of coming phrenitis or of a disposition to the disease. At 1, 24–26 (34.28–36.9 Bendz) Asclepiades is credited with the view that there are signs of impending phrenitis, but that these do not point to inevitable death (unlike e.g. a wound to the heart). It is an approximation, not an inescapable verdict, frequentia futura significantia: ‘In the case of phrenitis, the signs that point to a coming attack indicate only what is probable, not what is inevitable. That is, while there are signs of the coming of phrenitis, patients manifesting such signs do not necessarily (non necessario) incur the disease.’ As Caelius moves on to describe patients ‘on the verge of slipping into the disease (proni, labiles)’, he attributes to Asclepiades an interesting psychological profiling that is the first such personal colouring in our history of the disease: at Morb.Ac. I, 32 (38.28–40.12 Bendz) we are told that ‘some physicians, and among them Asclepiades and his followers, consider as predisposing the influence of the weather, the season, the antecedent causes, the nature of the patient and his age’. The notion ‘antecedent causes’ (antecedentes causae) is central here: ‘if he is of inconstant temperament and easily angered, or much devoted to reading, or if his head is weak and prone to feeling congestion, or if he is easily subject to mental aberration (facile alienatione vexetur) whenever he suffers from illness’ (40.3–8 Bendz). The psychology implies a delocalizing move and here goes hand in hand with Asclepiades’ corpuscular materialism: there are no inescapable signs that make phrenitis inevitable, and the risk factors, to use a modern expression, are external circumstances such as season and environment, and broader, ‘holistic’ aspects of personality, lifestyle and the like.Footnote 47
It is in this spirit, then, that Asclepiades’ style of therapy is described by Celsus in terms of healing ‘safely, quickly and pleasantly’ (tuto, celeriter, iucunde, De Med. 3,4,1 = 104.27–28 Marx), and that he is mentioned by later authors for his musical therapies in connection with phrenitis, which might at first sight appear at odds with his radical determinism. Martianus Capella, in his De nuptiis Philologiae et Mercurii (LLA 710, 9, 926), also refers to Asclepiades for his use of musical therapy (‘for I healed phrenitics with my music, in this also following the example of Asclepiades the doctor’, nam phreneticos symphonia resanavi, quod Asclepiades quoque medicus imitatus), and others do as well.Footnote 48
Discussing therapy, Caelius offers numerous details about Asclepiades’ practices in the long section Ad Asclepiadem mentioned above (105–54, 80.19–86.21 Bendz). Referring to his Celerum vel acutarum passionum, Book I, he attributes to Asclepiades the following stances: first, the refusal of contrary measures (contraria adhibenda); second, attention to prevention and avoidance (how to keep a fever from turning into phrenitis: quomodo declinanda vel avertenda); and finally, treatment proper.
As to the first, in the first part Asclepiades is said to criticize clysters, the drinking of iris and oxymel, and mustard as means to favour the discharge of phlegm. He criticizes cutting hair; opposes the idea of making a patient lie in the dark, since darkness, as opposed to light, favours imagination and numbs the senses;Footnote 49 and stigmatizes venesection as a murderous act.
As far as the second is concerned, to avoid and prevent alienatio mentis, Asclepiades recommends observing the days of attack and remission. On the first, one should give minimal food, pearl barley, unpeeled barley, spelt groats, and lentils with beet: dietary variety is advantageous. If fever persists, on the next day one should draw off the obstruction (through a clyster) and offer rest, and make the patient drink limited amounts of water (one or two heminae) twice a day, and the same at night. On the following days, gruel of various sorts should be offered. If fever abates, soft food should be given; if it persists, abstinence is necessary. On the seventh day, bread, fish and wine.
At 128–29 (94.5–23 Bendz), in his criticism of clysters, Asclepiades again adopts a clear holistic position:
The bowels, inflamed by the honey and by the gripping effects of the other substances, give rise to an intense heat which passes upward from the lower parts to the membrane of the brain through passages that are somehow connected. For all the internal parts of the body … are joined by imperceptible connections; and among these internal parts there are the membranes of the brain. (my italics, 94.7–15 Bendz)
This inner sympatheia culminating in the brain is another important delocalizing move, which again brings in the caput as locus, but diffuses affection, pathology and physiology through the body.
More in general, finally, at 131 Asclepiades, like Heraclides, is said to distinguish between kinds of therapeutic approach. He says that ‘there are two different methods of treatment, one cautious and suitable in many cases of phrenitis, the other violent and dangerous, philoparabolos, as he calls it’ (94.30–96.2 Bendz). The former (96.3–24 Bendz) requires that all aromatic substances be stopped; that the patient be given sternutatory and honey drink; and that he be moved from a dark place to a bright one, and in the evening to a small room with no fresh air. If fever increases or there is numbness in the limbs, gruel should be given; otherwise, anointing and gruel-like food are appropriate. Rest should be encouraged, as well as passive exercise. At 102.12–22 Bendz the philoparabolos method is described: wine is given instead of honey, strong and undiluted, and mixed with brine. This is a quicker method, possibly dangerous, aimed at strengthening the pulse.
In summary, the sources suggest that the following factors characterize Asclepiades’ view of phrenitis – or the views attributed to him by his ancient readers. On the one hand, there is a materialistic, corporeal account: localization in the meninges, corpuscular explanation and aetiology in a pathological ‘blockage’, and fever. But there is also a more prominently delocalized, almost holistic approach, emphasizing sympathy and co-affection among different parts in the body, more hospitable to psychological elements and focusing on impairment of the senses, derangement and the profile of the individual as a whole, including predispositions and lifestyle. From a modern point of view, these two sides are not necessarily in stark contradiction, and Caelius’ mission to emphasize them as flawed precisely in this respect should not influence us. For the history of phrenitis, this is the first historical attestation of a move of this kind – provided, of course, that we can give at least some minimal credit to our doxographic sources on Asclepiades.
Cornelius Celsus
The first extensive surviving discussion of our disease after the Hellenistic era comes from the encyclopaedic work De medicina, composed by a Roman author who was perhaps not a physician, but who nonetheless produced a high-quality account that preserves important, otherwise lost information on the earlier medical tradition.Footnote 50
At Med. 3.18 (122.11–127.15 Marx) Celsus discusses ‘madness’, insania, in its three ‘types’ (genera), in which the Greek medical entities phrenitis, melancholia and mania can be recognized.Footnote 51 The first notable aspect of this discussion appears at the beginning of the section, where Celsus introduces the new topic as a move away from the fevers discussed in the previous chapter. These genera insaniae are defined as belonging to the category of ‘other affections of the body, which manifest themselves in it, and among those the ones which cannot be assigned to specific body parts (alii corporis adfectus, qui huic superueniunt, ex quibus eos, qui certis partibus adsignari non possunt, 122.12–13 Marx)’. The three mental syndromes are for him characterized precisely by their delocalization, by their not belonging to a precise locus of the body: a key marker of insania seems to be its delocalized nature.Footnote 52
This opening remark appears to apply in particular to the first of the three types Celsus discusses, which corresponds to our phrenitis. This is the first disease he discusses and the most extensively considered: 103 out of 154 CML lines of the text are devoted to it, including remarks that appear to be instructions valid for insane patients generally. The second aspect worth mentioning is the Greek name given to this first disease: it is a ‘madness … which is acute and occurs with fever: the Greeks call it PHRĒNĒSIS (insania … quae et acuta et in febre est: ΦΡΗΝΗΣΙΝ [PHRĒNĒSIS] Graeci appellant)’. This form, PHRĒNĒSIS, is not extant elsewhere in Greek or Latin literature.Footnote 53 If we look at the content of this section, the difference in focus between this account and the previous ones surveyed, from Hippocratic and Hellenistic thinkers, is striking. But there is also a difference from the localized, anatomical account of phrenitis that will prevail in Galen and others. An initial part, about 10 per cent of the text, focuses on the distinction between phrenitis and other forms of delirium with fever; the rest of the discussion is entirely devoted to the manifestations of the disease and its therapy, which are inseparable from a close study of the differences among types of patient. The account is thus eminently clinical and more precisely, as we will see, psychological and personal.
The initial section establishes psychology rather than physiology as the main area of the disease, although fever characterizes it. ‘Delirium and senseless talk (desipere et loqui aliena)’ are common in the paroxysms of fevers in general (122.16–17 Marx); although these are serious signs, they are not worrying and can recede quickly (122.18–19 Marx). Phrēnēsis proper, by contrast, ‘is truly there when a continuous dementia begins, when the sick person, although up to then in his senses, nevertheless entertains certain vain imaginings. The insanity is established when the mind becomes at the mercy of such imaginings’ (uero tum demum est, cum continua dementia esse incipit, cum aeger, quamuis adhuc sapiat, tamen quasdam uanas imagines accipit: perfecta est, ubi mens illis imaginibus addicta est, 122.21–24 Marx). This is the first time in the tradition that we encounter a reference to images and imagination (Greek φαντασία), which will become a central feature of the discussion of mental impairment through phrenitis in later medical and philosophical literature.Footnote 54 The thematization of the ‘mind’, mens, as key point of affection is also noteworthy. Hallucinations and vain fears were mentioned in the Hippocratic discussions of phrenitis, but they were not of comparable importance.Footnote 55 Our disease is thus conspicuously identified with lasting, uninterrupted insanity characterized by the perception of ‘false images’, to which the mind becomes accustomed. No physiological causation is mentioned. Instead, psychopathology takes centre stage, with intensity and duration as its main markers.
The second important novelty is the recognition of the existence of plura genera of this disease:
Some are sad (tristes), others cheerful (hilares); some are more readily controlled and rave in words only, others are rebellious and act with violence. And of the latter, some only do harm by impulse, others are artful as well, and show the most complete appearance of sanity while seizing occasion for mischief, but are detected by the results of their acts.
The variations in character among patients seem to lead to different pathological outcomes, and Celsus pays considerable attention to these aspects of personality. In the therapeutic instructions that follow, the overarching principle is again the importance of adapting therapy to different kinds of patient (122.29–125.26). The first therapeutic measure considered is coercion, which is useless (supervacuum) for ‘those merely raving or even making a trifling use of their hands’ (qui intra uerba desipiunt aut leviter etiam manu peccant, 122.29–30 Marx), but convenient for violent individuals ‘who ought to be restrained’ (uincire conuenit, 123.1–2 Marx). Here excellent psychological observations are found. The insane, for example, have a characteristic trick of pretending to be back in their senses: ‘Anyone so fettered, although he talks rationally and pitifully when he wants his fetters removed, is not to be trusted, for that is a madman’s trick (dolus insanientis)’ (123.2–4 Marx).
Second is the already mentioned expedient of modulating darkness and light (123.4–13 Marx): ‘The ancients (antiqui) generally kept such patients in darkness, for they held that being frightened (exterreri) was contrary to their good, and that the very darkness can confer something towards the quieting of the spirit (ad quietem … aliquid conferri)’; Asclepiades (123.6–7 Marx) thought the opposite, deeming darkness frightening (tenebris ipsis terrentibus) and recommending light (in lumine habendos eos). Celsus criticizes the establishment of a general rule, reinforcing the importance of trial and error in individual cases and of adapting measures to the inclination of each patient (123.8–12 Marx).
The next section surveys diet and pharmacology, appropriate timing and psychotherapy. This offers Celsus an occasion for methodological remarks, in particular again on the importance of considering each case on its own terms. First of all, he writes, it is useless to apply remedies at the peak of derangement (ubi maxime furor urget, 123.14 Marx); restraining the patient and offering relief are the only possible measures at this stage. Celsus surveys ancient opinions on the matter: Asclepiades was fiercely against bloodletting except during remission, and recommended inducing sleep via massage (in his somnium multa frictione quaesiuit, 123.19–20 Marx). Celsus objects that fever brings sleeplessness in any case, while rubbing also helps only during remission. He proposes instead applying remedies, including bloodletting, when the fever is at least not getting stronger; after a day, the patient’s head should be shaven bare (caput ad cutem tondere, 123.27–28 Marx) and fomented with water in which vervain or other repressive herbs have been boiled (in qua uerbenae aliquae decoctae sint uel ex reprimentibus, 123.28–124.1). These measures should be alternated and followed by pouring rose oil on the head and through the nostrils, as well as offering vinegar-soaked rue to the patient’s nose to provoke sneezing. Celsus underlines the importance of avoiding these measures in individuals who are weak, however: for them, he suggests only moistening the head with rose oil, thyme or the like. Finally, two herbs are recommended, regardless of the patient’s strength: bitter-sweet (solanum) and pellitory (muralis) (124.7 Marx). Once the crisis has passed, massage is prescribed, but ‘more sparingly in those who are over-cheerful than in those who are too gloomy’ (parcius tamen in is, qui nimis hilares quam in is, qui nimis tristes sunt, 124.8–9 Marx). As elsewhere, the head and chest are targeted.
The remark about the distinction among patients based on a psychological trait, their mood (hilares, tristes), reveals the most remarkable part of the whole section on phrenitis: a set of psychotherapeutic observations and instructions following ‘the nature of each case’ (pro cuiusque natura, 124.10–11 Marx). This becomes the chief measure for dealing with the ‘spirits’ of these patients (124.11–26 Marx):
Some need to have empty fears relieved, as was done for a wealthy man in dread of starvation, to whom supposed legacies were announced from time to time. Others need to have their violence restrained, as is done in the case of those who are controlled even by flogging. In some, overly untimely laughter must be put a stop to by reproof and threats; in others, melancholy thoughts are to be dissipated, for which purpose music, cymbals and noises are useful. More often, however, the patient is to be agreed with rather than opposed, and his mind is to be slowly and imperceptibly turned from irrational talk to something better. At times also, his interest should be awakened, as may be done in the case of men fond of literature, to whom a book may be read, correctly when they are pleased by it, or incorrectly if that very thing annoys them; for by making corrections they begin to divert their mind. Moreover, they should be pressed to recite anything they can remember. Some who did not want to eat were induced to do so by being placed on couches between other diners. But certainly, for all so affected, sleep is both difficult and especially necessary; for under its influence many get well.
This repertoire of psychological types and the convenient treatment for each is entirely concerned with moral-psychological aspects, occupational measures, diversions, entertainment, intellectual-cognitive engagement, and concern for social and emotional experience. The breadth and variety of existential levels in this passage point to a larger discussion than the disease phrenitis alone, to an identification of phrenitis with a larger category, making it a representative exemplum. The discussion ends with a list of beneficial substances, beginning with those which aid sleep and ‘help compose the mind itself’ (ad mentem ipsam conponendam, 124.26–27 Marx): saffron ointment; a decoction of poppy or hyoscyamus; mandrake apples under the pillow; cardamom, balsam or sycamine tears smeared over the forehead. Celsus also mentions fomentation, the application of a decoction of poppy seeds – something he says Asclepiades criticized, since they produce a change to lethargus (125.6–7 Marx). Asclepiades advised instead abstention from food, drink and sleep for the first day, and drinking water in the night and gentle massage; if excessive massage might cause lethargus, in the right measure it should bring about sleep.
Sleep as a characteristic issue in phrenitis appears here as a central topic for the first time in the tradition available to us, showing with some degree of certainty a development that must have occurred between the Hippocratic sources and the beginning of our era.Footnote 56 The contiguity of our disease with lēthargosFootnote 57 is confirmed by many later authors (especially GalenFootnote 58) and becomes topical. At 125.14–19 Marx various solutions specifically targeting sleep are illustrated – provided caution is taken lest an excessive dose make it impossible to wake the patient up again. In addition to drugs, the sound of falling water, rocking after food, and at night especially the motion of a slung hammock are helpful. Bloodletting in the occipital part of the cranium can be beneficial if sleep continues to be a problem, since this relieves the disease. Food should also be kept under check: not too much, ‘lest he be maddened’ (ne insaniat), nor too little, which might debilitate him (125.22–23 Marx), and a light option such as gruel is best.
The exemplary character of phrenitis as a model of insania is also confirmed by the fact that at 3.19–20 the disease features as a contrasting item to define the specifics of two others: the cardiac disease (cardiacum, 127.16–17 Marx) and lethargus (lethargum Graeci nominarunt; the affinity with sleep has already been noted, 129.2–3 Marx). Regarding the first, Celsus writes: ‘The kind of affection which the Greeks call cardiac is a complete contrast to the foregoing diseases (his morbis), although phrenitics (phrenetici) often pass over into it. In the former the mind gives way, whereas in the latter it holds firm (siquidem mens in illis labat, in hoc constat) (127.16–18 Marx)’.
A non-mental disease, then, is a version of illness that is a possible outcome of phrenitis. Its localization is in the torso (although seemingly more in the lower part, stomachus; see 127.19, 128.5–23 Marx for the description of the gastric aspects), and its therapy is strictly bodily and diet-based. The particular outcome described by Celsus, the development of phrenitis into this cardiacum disease, I suggest, is the more exclusively bodily counterpart to Celsus’ more ‘psychological’ phrenitis, in which the delocalized, quintessentially psychic form is materialized into a ‘mental disease’ proper. It is interesting that at 3.19 (127.22–23 Marx) the disease is said to ‘break out from the whole chest and from the neck, and sometimes even the head (ex toto thorace et cervicibus atque etiam capite prorumpit)’, touching on the dual localization of mental functions where phrenitis too is involved.Footnote 59
The next associated disease, lethargus, is in Celsus’ words aliter phrenetico contrario, ‘a contrast – in a different way – to the phrenitic’ (128.31 Marx):Footnote 60 ‘In it, sleep is got with great difficulty, and the mind is disposed to any foolhardiness (prompta ad omnia audaciam mens est)’. There is a fierce need to sleep, indulgence in which is often lethal; sneezing is one of the disease’s cures.Footnote 61 Among therapies for lethargus are pouring liquids over the head (129.19 Marx) and shaving it (129.23 Marx). Most interesting of all, attention is paid to the ‘part below the ribs’, the praecordia (129.20; 130.10–12 Marx), which, it is said, should not be too soft or too hard. We thus have another bodily feature of the Hippocratic make-up of phrenitis which is shifted to a neighbouring disease.
If we look at the Hippocratic antecedents to these nosological relations, cardiac and lethargic diseases, the first is not mentioned, but lethargy (lēthargos, λήθαργος) is discussed at Morb. 2.65 (204.3–10 Jouanna = 7.100 L.) and Morb. 3.5 (12.14–24 Potter = 7.122 L.). In both cases, the disease closely resembles pneumonia, which in the Hippocratics is a sister disease to phrenitis in its seasonality, location in the lungs and mental import, and is often mentioned alongside it. At Morb. 2.65 lēthargos has the patient coughing up a great quantity of material and talking nonsense, and the outcome is often death. At Morb. 3.5 the disease is openly said to be ‘the same condition (stasis) as peripneumonia, with coughing, drowsiness and weakness’; it is again said to be fatal. Localization in the respiratory system, drowsiness and derangement are thus obvious areas of similarity if not intersection with phrenitis already in the Hippocratics; what we notice in Celsus’ discussion is the overt delocalization of phrenitis, now assigned to the realm of psychological disorders, and the ‘reassigning’, so to speak, of its bodily features to separate pathological entities.
In summary: what is conspicuous in the discussion in Celsus is, first of all, what is not there. There is no aetiology, and not even any physiology. (Only in a miscellaneous collection of acute symptoms is it mentioned that thin, white urine is typical of phrenitis: diluta quoque atque alba vitiosa, at 2.5, 54.7–8 Marx.)Footnote 62 There is also an open delocalization of the disease, and no mention of the phrenes, nor any etymological interest in the name, although the mental aspect is overt throughout. The discussion focuses instead on the manifestations of the disease and of insania generally (cf. also 3.18, 123.4, 124.10 Marx), and on pharmacological and especially psychological therapy. Much attention is given to the principle of patient individuality and the adaptation of the cure to the case; all this, it is worth reminding ourselves, is found in a discussion that opened on a delocalizing note and framed this particular discussion of insania as a fever at the onset, but without catering to it medically afterwards, with all efforts directed towards the psychological sphere.
We are clearly far from the Hippocratic bodily accounts here, and none of the fragmentary material from Hellenistic times sheds additional light on the development of such a ‘clinical psychology’ in the intervening period.Footnote 63 Non-technical evidence such as Menander might testify to a different, pain/lypē-based view of mental pathology recognized outside medical circles; this is the first text we have where we begin to get some information regarding a psychological kind of nosology, as well as one that will remain isolated with its inclusion of phrenitis under an umbrella concept of insania. As such, Celsus’ discussion stands out within the Imperial-age medical discussions, most notably in Galen, for whom phrenitis is an exclusively physiological problem to be addressed and handled as such.
The Methodists and Caelius Aurelianus
Other medical writers from the early centuries of the common era contribute to the development of a psychological approach to mental disease, adopting philosophical strategies and methods aimed at addressing the person as a whole, his or her relationships, emotions, lifestyle and activities (although to various degrees and with numerous differences).Footnote 64 The handling of phrenitis is one of the most eloquent instances for considering this approach, and evidences a chasm between authors like Galen, who forcefully relegate phrenitis to the realm of localized physiology with no psychological interest, and those – most notably Asclepiades, Celsus and the Methodists – who in different ways reject or dismiss localization and thus establish psychology as a concern for the ‘person as a whole’. This position will remain more marginal in approaches to our disease, although some doctors, like Aretaeus, include psychological concerns in their operations despite a physiological conception of the disease.
The final author eloquently to display a continuity with the delocalizing approach offered by Celsus has already been discussed in his complex role as a key source for information on Asclepiades: the fifth-century ce physician Caelius Aurelianus. Caelius is not only of great importance for the quality and extent of his nosological work, but also a precious doxographic source for the history of ancient pathology, since he discusses the practice and doctrine of his predecessors extensively. His text preserves important information about medicine in the Hellenistic period and as late as the first century ce, as already noted. His remarks about others are for the large part critical, with the exception of the Methodist Soranus, whose work is one of his main sources. Caelius too, in fact, belongs to the Methodist medical sect, whose doctrine rejected theoretical (‘dogmatic’) speculation about causes and hidden processes and supported instead a focus on the patient’s reactions and a pragmatic approach to therapy. Caelius lived and operated in Sicca in Numidia (today Tunisia), wrote in Latin but was obviously bilingual in Greek at least, and had some literary talent. The rich clinical information preserved in his writings, which seems to suggest practical interaction with patients, raises the possibility that he was himself a practising physician. But any details about his activities must remain a matter of speculation and hypothesis, since the text shows that the sources with which Caelius engages explicitly do not reach beyond the first century ce. There is no doctrinal or intellectual element to prove that, intellectually at least, he went chronologically beyond his main source, Soranus. The argument e silentio is not strong enough, however, and a change of plan in the course of a monumental work which was becoming too vast to complete may well explain the neat chronological interruption in an otherwise engaged account.Footnote 65
The Methodist School and phrenitis
As noted above, Caelius is a major source for the reconstruction of other authors’ thought. In particular, to the purpose of the present chapter, he offers important information about the exponents of the Methodist school, notably Themison and Thessalus. Themison (first century bce) is traditionally described as the founder of Methodism, and as such is prominent in Caelius’ account. His take on our disease is preserved at Morb.Ac. 1, 16–17 Bendz 108.10–115.10 (fr. 28 MoogFootnote 66), in a long section offering a critique of the treatments for phrenitis he proposed (Ad Themisonem). Here Caelius, again despite his own Methodist affiliation, chastises Themison for his medical mistakes, illustrating various aspects of his doctrine: ‘Themison repeated errors of the ancients and left certain matters confused’ (108.10–11 Bendz). In cases of phrenitis, we read, Themison prescribes offering nourishment from the end of the first three-day period of the illness and giving gruels, gourd, plain honey drink and fruit; on the other hand, he bans other ingredients. He advises fomenting the head with vinegar and rose oil in winter, with rose oil and rue in summer. (After two or three days, fomentations should be carried out at intervals: ivy leaves or juice, thyme, mint or other simples, but not powerful drugs, in olive oil and vinegar.) One should anoint the chest during the attack, and generally avoid strong-smelling substances, and so forth, as Caelius describes Themison’s detailed prescriptions for fomentations, diet and exact days of administration. Head fomentation in combination with anointing the chest is of interest as an early marker of the persistent ambivalence between these two localizations – and one which did not sit comfortably with everyone. Despite his own eye-catching inclusion of the diaphragm in the portrayal of phrenitis,Footnote 67 Galen would be especially critical of this passage at Meth. Med. 13.21 (10.929 K.):
The Empiric says that he has come upon the discovery of such remedies by experience. But why does someone who disdains experience and shuns the search for functions choose to pour water on the head rather than on the chest in those with phrenitis? But this oxyrrhodinum, which we apply to the head in those with phrenitis, clearly refutes not only the amethodical Thessalians … but also all the others who think the hēgemonikon of the soul is in the heart.
The other Methodist mentioned by Caelius (I.22, 34.5–16 Bendz), Thessalus (70–95 ce), is referenced approvingly in the discussion of the warning signs of phrenitis. Thessalus adopts a more extreme position than Asclepiades when it comes to denying that any secure sign of the coming affection might exist. If such signs were reliable, he explains, ‘all those who display them would inevitably fall ill’, a concept of ineluctability that clashes with Methodist pragmatism and respect for the variations in individual outcomes. He insists that ‘no antecedens causa’ can indicate phrenitis or phrenitis any more than other diseases such as lēthargos, apoplēxia and epilēpsia. In all these positions, even through the partial and biased account offered by a polemical doxographer, the following common elements are visible: anti-dogmatism; a pragmatism regarding prognosis and therapy; and above all else a relaxed attitude towards, if not complete lack of interest in, localizing definitions.
Caelius’ Views on phrenitis
Doxographic reports aside, Caelius devotes a lengthy discussion to phrenitis which occupies the whole of the first book of Acute Diseases and as such inaugurates the work as a whole.Footnote 68 Following the usual practice, Caelius organizes his material a capite ad calcem, while also following the traditional bipartition into acute and chronic diseases. The insertion of phrenitis at the beginning seems to follow the conventional association of this disease (and the one that follows in the book, lethargus) with the mind as affected principle and locus. Caelius justifies this choice in the praefatio to his treatise on acute diseases with a subdivision of his material into two categories: acute diseases with fever (such as phrenitis, lethargus, pleurisy and pneumonia) and those without fever (synanche, cholera and others). Fever is for him most relevant to acute diseases (febres sunt acutis magis comites passionibus); here phrenitis is simply ‘to be taken up first (phrenitis praeponenda)’ (22.15–18, 20–22 Bendz). Not only does phrenitis come first in the book but, following a pattern noted already in Celsus and which returns in the nosological text Anonymus Parisinus,Footnote 69 Caelius discusses it at far greater length than any other disease, confirming its important status within ancient reflections on mental health as well as ancient nosology generally.
The Definition
Caelius begins his discussion by commenting that ‘phrenitis took its name from the impairment of the mind’ (difficultate mentis, 1, 24.1–5 Bendz), with mens intended here as locus affectus. (In a philological spirit, he compares the labels dys-yria and dys-enteria as similar formations, indicating disturbances concerning urine and the intestines, respectively.) He then continues: ‘For the Greeks called the mind phrenes; whose impediment, as we said earlier, is brought about by the phrenitic affection (phrenas enim Graeci mentes uocauerunt, quarum, ut supra diximus, impedimentum phrenitica ingerit passio).’ Caelius thus begins his discussion by treating the phrenes as the impaired ‘locus’ but simultaneously relying on circular argument reducing them to their abstract meaning ‘mind’ with no reference to the diaphragm as a location in the body. It is then the ‘mental impairment’ (difficultas mentis, 24.1 Bendz) and not a place in the body that is primary to the definition of the disease.Footnote 70 He returns to the topic later.Footnote 71
As he moves on to sketch the basic features of the disease, Caelius stresses mental derangement, alienatio mentis (for him not fundamentally different from delirium, deliratio, 24.10–11 Bendz), and fever. These two symptoms must accompany the disease phrenitis (necessario numquam sine febribus esse). A detailed doxographic discussion follows (5–21, 24.10–32.26 Bendz) before Caelius moves on to his own doctrinal beliefs and observations. His full definition (given at 32.23–26 Bendz, at the end of the doxographic section) is as follows:
phrenitis is an acute mental derangement accompanied by acute fever, a futile groping of the hands, seemingly in an effort to grasp something with the fingers, which the Greeks call crocydismon or carphologia, and a small, thick pulse
Three elements are thus highlighted: mental derangement, acute fever and crocydism, the compulsive movement of the hands. In addition, Caelius notes the presence of a particular type of pulse.
If the practical recommendation and descriptive aspects of the disease are in large part consonant with those of Caelius’ predecessors, several key emphases emerge as distinctive of his own intellectual outlook (or that of his main sources, or shared with them) in the direction of psychology and a soft approach to illness. Gourevitch poses this question when she asks if Caelius’ ‘humane approach’, which I argue here is directly affiliated to psychology and delocalization, should be seen as a result of Christian influence.Footnote 72 Pigeaud also discussed this aspect, emphasizing Stoic affiliations.Footnote 73 A definitive response to the question is impossible. But Caelius’ discussion of phrenitis certainly epitomizes the history of the disease up to the fifth century ce, following a delocalizing, psychological route which runs largely parallel to that of the dominant medicine of the time.Footnote 74 The Caelian themes or tendencies which illustrate this are:
(1) A thematization of patient disposition to phrenitis, with discussion of the prodromic signs of the disease. The illness is no longer an isolated event, but is integrated into the nature of each individual’s weaknesses and overall characteristics.
(2) The topic of differential diagnosis, important in other authors (such as Galen) as well: it is not only phrenitis that is contiguous and similar to lethargus and other fevers, but also other diseases and the pathological consequences of substance intake.
(3) The forms of the disease: two basic types.
(4) Localization itself is self-consciously posed as a question – a key epistemological point of questioning in Methodist environments.
(5) Therapy is given considerable space and detailed discussion.
Patient Disposition
Caelius discusses the opinion of various ‘representative sect leaders (sectarum principes)’ regarding prodromic signs, describing the polemical discussion between Thessalus and Asclepiades about the possibility that such signs might have epistemological value (34.1–38.2 Bendz). For his part, he declines the most radical version of Methodist pragmatism, which firmly rejects the idea of remote signs of predisposition to a disease (34.10–12, 17–18 Bendz). For Caelius as well, forecasts based on the assessment of a present pathological state that might lead to phrenitis may be legitimate, and he allows for the possibility of isolating such signs ‘of being on the verge of the disease (phreniticae futurae passionis)’. He discusses them in Morb. Ac. 1, 2:
Those who are on the verge of phrenitis or are slipping into the disease (in phreniticam passionem pronos uel decliues) show the following signs: an acute fever barely rising to the surface of the body, pulse low and thick, face somehow puffed up or full, blood dripping from the nostrils, continual sleeplessness or troubled sleep with confused dreams, unreasonable worry or concern (mentis sollicitudo ac gravitas sine ratione), frequent turning of the back while lying, and continual changing of position of the head; at times there is also giddiness without reason (sine causa hilaritas), redness of the eyes with slight tearing, tossing about of the hands (circumiectio manuum), absence of pain in the head, coldness of the limbs without trembling, abundance of urine, light-coloured, watery, thin and discharged a bit at a time. In some cases, there is also a sensation of noise in the head and ringing of the ears (sonitus capitis atque aurium tinnitus); also pains in the head suddenly abating for no obvious reason, praecordial tension (praecordiorum … tensio), and fixity of the gaze or frequent blinking.
General and Prodromic Signs of phrenitis
In Chapter 3, ‘How phrenitis is recognized’ (Quomodo intelligitur phrenitis, 34–39, 40–44 Bendz), a full, enlarged profile emerges, with two notable features: psychological richness (mood disturbance, gloom, laughter and anger) and a fundamental conflation of all signs of acute pathology recognized in Greek medicine starting from the Hippocratic texts onwards. Quellenforschung could map each item in this passage against precise Hippocratic and Galenic parallels.Footnote 76 In particular, we find material from prominent clinical cases (for instance, the patients’ characteristic lack of interest in food and drink, and the intermittent attacks in which they aggressively snatch what is offered to them, perhaps merely to chew it and then spit it out; talking to themselves, muttering and unexplained tears; hallucinatory hand movements and compulsory plucking; shunning light; troubled sleep); and visual features well known from Hippocratic prognostic texts (bloodshot eyes; a fixed gaze; eyes either unblinking or with fluttering eyelids; face contracted and spastic; bruxism). Especially notable in the portrayal are an uncomfortable posture and restless movements associated with the primary symptom of crocydism: these patients have a ‘disproportionate bodily strength’ (corporis vana fortitude, 42.20 Bendz), pull themselves in and out of bed, move their hands anxiously, trying to feel something before their eyes, plucking the wall and their own clothes, and so forth, before they fall into a state of stupor. In addition, there is a full psychology of anger, aggression and desperate self-harm:
such a state of anger (mentis indignatione) that the patient jumps up in a rage (in furore) and can scarcely be held back, is wrathful at everyone (iracundus omnibus), shouts, beats himself or tears his own clothing or that of his neighbours, or seeks to hide out of fear (metu), weeps, fails to answer those who speak to him, while he speaks not only to those who are present but also with those who are not, and even with the dead (mortuis) as if they were in his presence.
Within this selection of possible symptoms, the key indicators of gravity are duration and lack of respite: ‘We hold that those patients are gravely and dangerously affected who show many varied symptoms, as described above, continually and without remission or alleviation’ (44.3–5 Bendz). Aggressiveness and forcefulness generally also suggest the severity of the condition, with a parallel between exacerbation in a healthy state and during disorder (‘for even healthy people, if they are given to fits of anger, appear to be mad’, insanitiue etenim etiam sani, si iracundi esse perspiciuntur,’ 44.10–11 Bendz). Third, the tendency towards spasms is also a negative sign, forecast by facial contractions: ‘smiling to oneself … with gnashing of the teeth or hiccoughs (subridere … stridore dentium aut singultu affici)’. Finally, it is also a reason to worry ‘if the patient’s complexion changes, and he trembles, snores or shows distaste for everything’ (44.13–14 Bendz).
As a principle, Caelius supports the view that the potency (magnitudo, 44.24 Bendz) of the disease in its present version, so to speak, and of its symptoms determines severity, not other more abstract and general indicators. As a Methodist, he disagrees with those who say that ‘the gravity of the affliction varies with age, young people being more seriously affected than those of other ages, and also with sex and nature, men being more seriously affected than women, since the mind is more vigorous in young people and in men’. Caelius prefers instead to ‘take a general view (dicimus communiter)’, namely that everything depends on the severity of each occurrence of the disease: ‘Those whom the disease hits in potent form suffer gravely (graviter laborare quos passionis adficit magnitude)’ (40–41, 44.23–25 Bendz).
Differential Diagnosis (Morb. Ac. 1, 4, 42–44, 45.26–46.23 Bendz)
According to Asclepiades, writes Caelius, all circumstances are to be considered (season, age and environmental aspects) in order to differentiate phrenitis from other diseases as precisely as possible. This is a rare case in which Caelius agrees with Asclepiades (40.8–12 Bendz): for him as well, the physician needs to look for a combination of signs. Derangement and fever alone are insufficient, but the quality of the pulse and the presence of crocydism can make diagnosis of the disease secure (40.20–22 Bendz); ‘we recognize phrenetis through the overall combination of symptoms (intelligimus phrenitim ex toto signorum concursu’, 40.15 Bendz). In addition, a plethora of other signs enriches the picture, presenting variations of the disease, gradations of severity, and other ‘special features’ (40.23 Bendz).
According to Caelius, it is a problem that the disease phrenitis thus described is contiguous to and potentially easy to confuse with mania, melancholia, pleuritis and pneumonia, as well as with other conditions. This list reveals a tension between two taxonomic principles, a thematic one (based on the mental quality: mania and melancholia are thus involved) and another, traditional and Hippocratic in origin, that involves the chest localization and affiliation to the group of winter diseases (pleuritis and pneumonia). In addition, Caelius distinguishes the loss of sanity in phrenitis from what occurs under the effect of intoxicants such as henbane and mandrake (44.30–31, 46.14–17 Bendz); these can in turn also be a trigger of phrenitis, an interesting point Caelius mentions but fails to develop (‘phrenitis can even derive from a substance that is drunk, etiam de medicamine poto potest phrenitis evenire, 46.15–16 Bendz).Footnote 78 In short, since patient interrogation is arduous and deceiving and might make it impossible to discover if the patient has consumed such substances, fever and crocydism remain the best differential indicators to individuate a case of phrenitis.
Mania and melancholia are marked by the absence of fever and crocydism, and are generally chronic and painless. Moreover, melancholia presents additional signs, such as a dislike of company, vomiting black bile and a leaden complexion. As far as pleuritis and pneumonia are concerned, derangement is caused by physical pain and subsides with it; it is accordingly not a ‘primary’ madness. Chapters 5 and 6 (44–46, 46–48 Bendz) focus more precisely on mania with fever and on how it can be distinguished from phrenitis, on the one hand, and on distinguishing phrenitis with sleep from an incipient lethargus, on the other.
In the first case, mania with fever will be recognized because the fever follows insanity rather than preceding it, the pulse is different, and no crocydism is observed, unless we are to speak of an evolution from mania to phrenitis – that is, with a taxonomic definition coming to assist the ontological one. Conversely, sleeplessness in reposing phrenitic patients should not be hastily interpreted as a form of lethargus and handled as such; the difference is in the ‘complexion, expression, respiration, pulse, reaction to touch, position in bed and degree of fever (colore, charactere, respiratione, pulsu, tactu, schemate iacendi, febrium magnitudine’, 50.10–11 Bendz). The sleep of recovery in phrenitis, in fact, infuses the patient with a fresh complexion and a peaceful expression accompanied by regular breathing, a more vigorous pulse, no tension in the precordial region and a more natural posture.
Aside from the details of these differentiations, it is noteworthy that a mature nosological understanding is apparent in these discussions: a sense of the possibility of overlap, co-morbidity and resolution of one disease into another, on the one hand, and the epistemological problem of confusion, the mistaken diagnosis between two similar but distinct diseases, which is a key topic in Galen as well, on the other.
Different Kinds of phrenitis?
That there are variations and different kinds of phrenitis, reflecting varying circumstances, can be inferred from the rich clinical description Caelius offers. He refuses, however, to follow those who multiply types and categories to describe different versions of the illness: some ‘say that in one type the loss of reason is manifested by laughter and childish dancing, in another type by sadness, crying out, silence or fear’ (52.4–5 Bendz). But Caelius is keen to escape the constraints of nosological formalities, and he distinguishes two basic types of disease, following Methodist doctrine: one based on stricture and one on stricture combined with looseness (‘stricture’ and ‘looseness’ being the two ‘generalities’ or key states of health in Methodism). These can cover most of the variations that other physicians recognize in the different psychological and behavioural symptoms he lists (Morb. Ac. 1,7, 52.1–10 Bendz). By dismissing the robustness and cogency of symptomatological details, this move shifts attention away from localized physiologies and material individualities to the pragmatic whole of the patient. The result is that the definition of phrenitis is made broader and more composite and is perhaps as a consequence also ‘diluted’ in terms of severity: the much more limited attention to, if not complete absence of the mortal and most acute quality of the disease in Caelius is notable. Prognostically he appears by far the most optimistic, or at least the most open, of all medical writers on phrenitis.Footnote 79
The Topic of Localization (Morb. Ac. 1,8, 53.13–54.23 Bendz)
In his own self-styling as a doctor belonging to the Methodist school, and as such removed from the abstraction of doctrinal disputes regarding localization and aetiology, Caelius is sarcastic about the range of medical positions vis-à-vis phrenitis in medical history as showing ideological opportunism:
Now some say that the brain is affected, others its fundus or base, which we may translate sessio, others its membranes, others both the brain and its membranes, others the heart, others the apex of the heart, others the membrane which encloses the heart, others the artery which the Greeks call aortē, others the thick vein (phlēps pacheia), others the diaphragm … In every case they hold that the part affected in phrenitis is that in which they suspect the ruling part of the soul to be situated.
In his view, these are unimportant matters: ‘We … do not alter our general therapy on the basis of these places or the regions about them (sive locorum sive vicinitatis eorum causa). For in a given general type of disease, a difference in the parts affected is not an essential difference’ (52.15–18 Bendz). Indeed, Caelius is explicit about his holistic view of this disease: ‘We hold that in phrenitis there is a general affection of the whole body, for the whole body is shaken by fever (communiter totum corpus pati accipimus, etenim totum febre iactatur). And fever is one of the signs that make up the general indication of phrenitis, and for that reason we treat the whole body’ (52.29–30 Bendz). In addition, however, Caelius considers the head especially exposed, which justifies placing the disease at the beginning, with no motivation other than the pragmatic basis of observation:
We do hold, however, that the head is particularly affected, as the antecedent symptoms indicate, e.g. its heaviness, tension and pain, noises within the head, ringing in the ears, dryness and impairment of the senses; and the other symptoms which are found when the disease is already present, viz. the loss of function of each of the senses, eyelids stiff, eyes bloodshot and bulging out, cheeks red, veins distended, face puffed up and full, and tongue rough.
On the whole, for Caelius the debates about localization are mere dogmatic deductions thinkers make based on their own theories of mind: wherever they believe the seat of rational faculties is, they locate the disease there. Caelius nonetheless seems to let the encephalocentrism he has pushed out of the door back in through the window, although he addresses this objection as well, saying that he recognizes the brain being especially hard hit as an empirical datum, something observation shows to be true.
Treatment (Morb. Ac. 1, 9–11, 54–76 Bendz)
As often in authors in whom the clinical aspect plays an important role, treatment reveals more fundamental aspects of the view of the disease. In his illustration of ‘the treatment of phrenitis according to the Methodists’ (76.25 Bendz), Caelius sketches guidelines for different measures depending on the severity of the disease, in line with his generalization about intensity of illness being the only key difference; on the prevalence of stricture or looseness, also as per Methodist doctrine; and on the phases of the disease and the general condition of the body. The therapeutic discussion opens and closes with considerations of a psychotherapeutic nature, as elaborate and remarkable as those offered by Celsus, and includes additional elements.Footnote 80 Caelius also offers instructions about dietetics, fomentations and scarification, and discusses venesection and cupping as key procedures, along with their risks and qualifications.Footnote 81
The psychotherapeutics generally aim at soothing the patient’s derangement. A lengthy section is devoted to the importance of modulating light and darkness according to the preferences of the phrenitic individual, which should generally be followed (see 58.6–7 Bendz), but avoiding excess on either side. Likewise, excessive heat or cold are harmful (54.25–56.5 Bendz). Light should be let in but shielded from the eyes if necessary, and should come from ‘high windows’, since ‘it often happens in this disease that unguarded patients in their madness [jump out] of windows’ (54.28–29 Bendz).Footnote 82
The derangement and hectic alteration of the phrenitic demand that he or she be protected from excessive stimuli and demanding company (56.8–9 Bendz): no paintings should be hung on the walls of the room,Footnote 83 no bright colours, no distracting visits that might arouse hallucinations and turmoil. On the other hand, one should allow visits from ‘people who are regarded by the patient with awe or veneration … yet only at intervals, for “familiarity breeds contempt (parit enim frequentia contemptum)”’ (58.20–3 Bendz). Also, after venesection it is important that familiar servants attend the patient, ‘so that his mental derangement should not be further aggravated by the sight of new faces … Persons to whom the patients owe respect should also be present’ (62.23–27 Bendz). In the same spirit, the massage with oils that follows cupping should be performed by ‘persons who are already known to the patient through previous service, to avoid aggravating his disturbed mental state’ (66.24–26 Bendz). Soft bedding is also recommended – perhaps because rough textiles are more likely to trigger crocydism – as is a firmly placed bed capable of resisting the spasms and restless movements of the sick. The bed should face away from the door, to protect the patient’s quiet and isolation. (Sleep should be administered according to the same principle: under stricture, wakefulness is preferable, and under looseness, sleep.)
Caelius devotes considerable attention to the care bestowed on patients by attendants (seruientes), and this is an interesting elaboration on the interpersonal psychology of his account. They should ‘endure the crazy whims of the patient and deal skilfully and ingeniously with them, agreeing to some and rejecting others; sympathetically, however, to avoid exciting them’ (58.17–20 Bendz). There are explicit recommendations about how to deal with phrenitics to avoid exacerbating their condition: attendants should gently restrain the patient if he wants to jump out of bed, and tie him down if necessary but protect his body from friction against the ropes by the use of soft wool. In general, remarks about the dangerousness of patients are implicated with the topic of the personal involvement of assistants. These practical personal details contribute to a realistic, rich psychological portrayal of the ill, while also being part of the delocalizing narrative: 1.66, for example, recommends taking care when relieving the dry mouth of the phrenitic, ‘for patients under the compulsion of mental derangement have often bit the fingers holding the sponge’ (60.1–2 Bendz).Footnote 84
As we move to corporeal treatments, fomentations, scarification and shaving, as well as venesection and cupping, are fundamental elements. Applications should address both the hypogastrium (60.9–10 Bendz) and the head as the chief locus of the affection. These should be performed with odourless substances, however, ‘to avoid filling the patient’s head and aggravating his derangement’ (60.15–17 Bendz). Caelius proceeds to offer details and subtle distinctions regarding the quality of these applications to the head, always following the principle of avoiding excessive stimulation and triggering a heightened kind of insanity.Footnote 85 Venesection is discussed at Morb. Ac. 1.70 (62.3–11 Bendz), where it is said that the patient should be reasonably strong to undergo it without fainting. After venesection, fomentations are recommended.
The locations emphasized for these therapies are the head, of course, but also the hip joints, the praecordia and the chest, pecten (cf. the hypogastrion above), ‘for these parts are always sympathetically affected in phrenitis’ (62.17–18 Bendz). The gastric-diaphragmatic regions appear here alongside the head as well as the hips. At the end of the third three-day period, Caelius also suggests shaving the hair from the head (caput detondemus) to allow the affected parts to breathe freely (partes reflantur) and relieve the pressure exerted by weight (plurima grauitatione liberatae) (64.14.6 Bendz). At the end of the fourth three-day period, more shaving and the application of leeches (on the occiput, bregma and temples) also aim at giving relief to the head, along with cupping, to which the next section turns (Morb. Ac. 11). Here too we read that one should watch for any inflammation of the praecordia (66.10–11 Bendz), and scarification of the previously cupped parts is recommended. The regions in question are again head, praecordial area and hypogastrium, along with the pubic area.
The psychological profile that emerges from Caelius’ account is one of the phrenitic as a sensitive character exposed to bouts of anger and aggressiveness, constantly on edge and ready to respond to any provocation. The ability of attendants to soothe and deceive the patient as needed is duly emphasized, in ways often verging on the patronizing and manipulative and hinting at a top-down relationship between patient and medical authority. At 11.81, for example, patients who refuse appropriate food ‘will have to be deceived (erunt fallendi)’. But this will be easy, since this kind of patient ‘is also affected by disturbance of the mind’ (siquidem etiam mentis aegritudine afficiantur, 66.29–30 Bendz) and ‘if they have some measure of sanity, they can be controlled by exhortations or fear’ (si ex aliqua parte sapuerint, hortationibus aut metu compesci, 68.4–5 Bendz).
Wine should be avoided, since it is to be considered poisonous for such patients (68.9–11 BendzFootnote 86). Mild, passive exercise – swinging on a hammock or the like – is recommended. Finally, Caelius offers various details about the kind of ‘aftercare’ these patients need, which is especially psychological in nature. That this section closes his therapeutic discussion is significant: once the ‘period of anxiety is fully over and we see all grounds for suspicions removed’ (cum omnis deinde solicitudo recesserit atque omnia suspecta circumscripta uiderimus, 76.7–8 Bendz), and the derangement is cleared up, all the occupational, soothing and restorative measures should be applied together (passive exercise, anointing, bathing and varied food and wine). In this phase, the derangement might leave traces, and patients ‘remain in a state of sadness, anger or aberration right up to the return of physical health’ (76.13–15 Bendz). An allopathic approach should come in at this point: caregivers should speak ‘with grave and serious language (seuera uerborum atque tristi oratione) to those whose state had been one of hilarity’, while ‘those who begin to fall into a state of sadness or anger (qui maestitudine atque ira afficiebantur) must already be soothed with gentle encouragement and pleasant and cheerful language (leui consolatione atque nunc dictis hilarioribus et iucunditate releuare)’ (76.15–19 Bendz).
Conclusions
Through two sets of sources, the line that goes from Asclepiades to Caelius Aurelianus through the Methodist school, on the one hand, and the formidable section devoted to insania in Celsus, on the other, we have sketched a second, important thread of discourse in Western medical cultures that intersects with phrenitis, as well as with the history of psychiatry as a whole and of medicine generally: delocalizing, holistic approaches that ignore or marginalize the topic of bodily locus affectus, or that empty its language of relevance in order to place more emphasis on holistic, delocalized signs, therapies and causes. Ultimately, to borrow an expression from contemporary holistic critiques, these approaches foreground patients and the human beings they are, not the disease as construct. If this appears a crude sketch and a simplification of the complex world of Graeco-Roman medicine, comparison even between the therapeutics of these three authors and Galen makes deep cultural and anthropological differences stand out. To some extent, these involve the ingress of psychology as a science of the ‘whole’ man into professional medicine; the same is true of the influence of moral philosophy on medical discourses. Such shifts do not occur overnight or discontinuously: the language of traditional Greek medicine, the signs available to observation, and the traditional topics in physiology, dietetics or pharmacology raised by these authors, are familiar to historians of ancient medicine from Hippocrates onwards. Galen himself wrote a number of treatises devoted to the care of the soul, and elements of these delocalized, psychological discussions can also be found in Aretaeus, another key figure in medical science in the early centuries of our era who incorporates psychotherapeutic aspects within his prescriptions. In the panorama sketched here, however, Celsus and Caelius most firmly move the focus of their interest to these delocalized themes. They thus constitute for us as historians the most fitting bridge between medical discourses and the plethora of ethical portrayals of phrenitis which suddenly appear in non-technical literatures of the first centuries of our era – comedy, but especially theological and prudential texts, as explored in Chapters 6 and 8.
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