A Hybrid and Widespread Body of Evidence
By the second quarter of the seventh century, the post-classical world, discussed here as receiver and source of preservation of a specific medical topic within the Graeco-Roman intellectual tradition, stretched from modern Europe and North Africa to the Middle East, and was increasingly a combination of separate centres dominated by different governments, authorities and intellectual spheres engaged in various independent yet intertwined processes of preservation, interpretation, selection and rewriting of medical thought.Footnote 1 As we read through these texts, following the changes and transformations of the nosological concept phrenitis, it is difficult to trace the elements of change or novelty within an intricate, slow-moving tradition.
After the seventh century, inquiry into the history of the disease phrenitis as diagnostic label and object of clinical attention can be pursued along two main lines: a medical tradition mostly devoted to copying and commenting on the great sources of the past, rooted in Graeco-Roman authorities but infiltrating the East via intensifying translation and elaboration activity in Syriac, Arabic and Hebrew; and the reception and dissemination of these concepts in texts that are not primarily medical but are nonetheless interested in a competent use of technical aspects of medical concepts.
The medical sources for folk culture and the concreteness of patient experience in this period are unfortunately much less generous than earlier ones, such as the works of Galen: clinical reports and individual patient cases, an important part of Hippocratic and Galenic medicine, essentially disappear in Byzantine times. As for the second category described above, aside from the intriguing parallel history of phrenitis as moral and metaphorical concept explored in Chapter 6, little clinical testimony survives to help us understand how well known and widely experienced the syndrome was. Was it a common pathological reality, whence its metaphorical-allegorical appeal? Or was it instead more of a dead topos, made prominent by the prestige of medical authorities and idiomatic habit, semantically effective but devoid of any connection with actuality, like ‘hysterical’ in everyday language today? And was it in many respects a sufficiently general concept that lay people could confuse it with other diseases, like ‘the flu’ and ‘a cold’ today?Footnote 2 The truth must lie somewhere in the middle, since the weight of tradition and cliché determined a persistence in actual diagnosis, while at the same time the flow of diagnoses and professional mentions of phrenitic patients continued, each feeding the other. We may hypothesize that the survival of doctrinal discussions of this disease entity, on the one hand, and its metaphorical, antonomastic presence, on the other, together supported its continuity, especially in light of its solid reinstatement as a key encephalic disease at the beginning of the modern era.
It is impossible, of course, to offer a comprehensive discussion of ten centuries of post-antique medicine in both halves of the Roman Empire, but coverage that is a bit more than impressionistic can be attempted. In this chapter, I focus on the following central bodies of material:
(1) Technical references in non-medical texts (fourth–thirteenth centuries ce).
(2) Byzantine sources (centred on two locations: Alexandria in the sixth–ninth centuries ce and Constantinople in the ninth–fifteenth centuries ce) in Greek.
(3) Medieval sources of both Western and Eastern provenience (most notably those of the so-called School of Salerno; the activities of translation and study in the Arabic centres on the Iberian Peninsula; and work produced in universities, especially commentaries and compendia). These sources are in Syriac, Arabic, Hebrew and of course Latin.
Within such a long time frame and wide geography, there is a patrimony of medical texts which can be categorized as ‘technical’ (Byzantine Greek medical documents, Arabic medical treatises, and the Western medical tradition flourishing after the thirteenth century ce). But there are also various ‘hybrids’, in which a genuinely medical piece of information is mentioned or discussed, although outside a technical context and with no medical purpose (be it educational or practical) or professional audience in mind,Footnote 3 but also with no metaphorical colouring.Footnote 4
The Late-Antique and Medieval Periods: Technical References in Non-Medical Texts
Before turning to the medical sources proper, we should look briefly at the diffusion of phrenitis as a technical concept outside medicine, as part of the popularity of medical knowledge that is increasingly apparent in the late-antique period. For example, what should we make of information such as that preserved by the author of three scholia on the pseudo-Aeschylean Prometheus Bound,Footnote 5 which come from a commentary on the play that the editor locates possibly in Constantinople ‘in the second half of the twelfth century’ and in any case between the tenth and the thirteenth centuries ce?Footnote 6 The scholarly comment on the tragic passage offers testimony for an understanding of phrenitis which is technical in its vocabulary and concepts, but simultaneously lay in its indifference to the development of scientific debates about the disease up to that point:
A phrēn is a membrane (hymen) that stretches from the pharinx to the hypogastric parts. It thus extended from this part to that one, like a kind of girdle that is called a diaphragm. It is in between the respiratory and the digestive parts (esti de meson tōn anapneustikōn kai tōn threptikōnFootnote 7). Respiratory parts are the lungs, the heart; protective/curative parts are the spleen, the liver. As long as this membrane is safe, the animal is healthy; but when it suffers a breach, then the animal becomes deranged, and the disease phrenitis comes about (mechris an oun sōizētai ho hymēn houtos, hygiainei to zōion; hotan de pathēi kopēn, tote paraphronei, kai symbainei hē phrenitis nosos).
The scholiast had some medical knowledge, or at least sufficient medical-anatomical vocabulary to express himself, but only an incompetent, grossly localized, ‘Homeric’ view of human physiology: a wound (kopē) is mentioned, and the view of phrenitis centres on the diaphragm and is thus more reminiscent of details from earlier accounts than of the description of phrenitis in Graeco-Roman medicine after Celsus. This shows how archaic versions of our story, or at least debris from them, continued to be carried along by the rivers of information that described the disease, despite running contrary to the dominant encephalocentric tendency in ‘official’ medicine. For the non-technical, lay part of this medical history, exceptions and dissonances such as this are an important component and perhaps actually more significant than the dominant narratives.
Some of the most interesting of these ‘hybrid’ instances go back to earlier centuries and are found in both pagan and Christian texts, where medical knowledge is on rich display outside the purposes and scope of actual medical activity.Footnote 8 It is at this juncture between the scientific and the more broadly intellectual – here specifically theological – spheres that we can locate Gregory of Nyssa’s project in his De opificio hominis (fourth century ce). Gregory explains the nature of the human body and its anatomy in terms of divine teleology, and addresses phrenitis explicitly. Most surprisingly, he retains the chest location for the disease and refers to the stomach as the locus affectus.Footnote 9 This author engages with anatomical details and has strong opinions about the localization of the affection he discusses. But he does not place himself within the mainstream affirmation of Galen’s views (De opificio hominis 12 (157):
We have learnt that the forms of derangement do not arise only from oppression (karēbareia) but also through empathy with the membranes arranged to cover the pleura (tōn tas pleuras hypezōkotōn hymenōn). Similarly, those competent in the medical art distinguish the illness of the dianoētikon, calling the affection phrenitis, since this is the name of these membranes. And the sensation arising from the pain in the heart is wrongly (esphalmenōs) suspected; for it is not a disease of the heart, but of the damaged cavity of the stomach (tou stomatos tēs koilias drimyssomenou), and they associate the disease with the heart through incompetence
Elsewhere (172) Gregory recounts a (rare) phrenitic case at which he personally assisted, offering a wealth of physiological detail. He takes the occasion to make a point about body–soul interaction and holism. Again, there is no reference to the brain:
I also recognized another cause of what happens during sleep when I was attending one of my relatives who was suffering an attack of phrenitis (healōkota phrenitidi). Being annoyed when more food was given to him than his strength would allow, he kept crying out and finding fault with those who were around him, alleging that they were imposing on him by filling his intestines with dung. And when his body was now rapidly beginning to perspire, he blamed those who were with him for having got water ready in order to soak him with it as he lay there. Nor he did cease crying out until the result showed the source of these complaints: for all at once copious sweat broke out all over his body, and a relaxation of the bowels made sense of the weight he felt in his intestines. This very condition which, while his sober judgement was dulled by disease, his nature endured, being sympathetically affected by his physical condition of the body, because this prevented (his nature) from being unable to perceive what was amiss, but being unable to make clear what was causing pain, due to the distraction resulting from the disease – this, if the intelligent principle of the soul were lulled to rest, not as a result of infirmity but by natural sleep, would most likely appear as a dream to one in such a situation, the breaking out of perspiration being indicated by water, and the pain occasioned by the food by the weight of intestines.
The disease operates here entirely on the level of the belly, striking the bowels in particular. The patient’s imagination is involved – he has a pathological ideation regarding eviscerated intestines – but only as an intuition of the soul regarding the state of the body, not unlike what dreams do in healthy patients, as Gregory says.
In the different context of his homily In ebriosos (31.452), the bishop Basil of Caesarea (fourth century ce), Gregory’s brother, mentions phrenitis alongside drunkenness. Basil offers a different, fully physiological and brain-centred explanation of the cognitive impairment that comes with drunkenness, via a comparison with phrenitis, which is used to illustrate corrupt pleasures and the impairment that follows excessive wine-drinking:
Disturbance in the reasoning faculties resulting from trouble arising from wine (thorybos de dia tēn ek tou oinou tarachēn engignomenēn tois logismois), and unpleasantness resulting from bitter exhalations deriving from the pleasure of drinking. In these cases, the feet are fettered and the hands are tied up as a result of the fluxes that attack them as a consequence of drunkenness. Yet even before these affections, at the moment of drinking, the affections of phrenitics befall them (ta tōn phrenitikōn autois sympiptei pathē); for whenever the meninges become full of vapour, which the evaporating wine causes to rise, the head is struck by unendurable pains.
A full description of phrenitic behaviour follows. Phrenitis as a dangerous fever localized in the head and associated with madness, or generally as a quintessential grave ailment, appears to be established in these theological authors. Gregory’s primary localization in the chest is rarer: as we have seen, in most such writers the head and especially the meninges are the locus affectus.Footnote 11 But traces of the ancient ambivalence in the meaning of phrenes persist, and the Greek statesman (and Byzantine emperor) John VI Kantakouzenos (fourth century ce) gives a nice example of this in the course of making a general point apparently devoid of technical knowledge. Here again the heart, not the brain, is the centre of a passing comparison:
But of course it is reasonable that the whole is larger than its parts! Otherwise, how is it that when the heart is heated or cooled, melancholia or phrenitis results, and the soul’s ability to reason is damaged (pōs tēs men kardias mallon ekthermainomenēs ē psychomenēs melancholiai ginontai kai phrenitides kai tēs psychēs apolluntai to phronein), but if the hand or foot is inflamed, nothing of the kind happens?Footnote 12
These examples are unrelated to medical practice or scientific research. But an assimilation of technicalisms (in vocabulary and chosen themes), as well as the adoption of certain fixed points, is nonetheless evident in them: the head (and heart) as locus; a specific pattern of behaviour; an association with abuse of wine as an ethical flaw. Examples of such ‘hybrids’ vis-à-vis nosology and medical knowledge continue to be found throughout the centuries. The Byzantine scientific compiler Leo the Mathematician (ninth century ce) also elaborates on the canon of Greek medical sources in his De natura hominum synopsis, referring to the phrenes simplistically as the part which, when inflamed, generates phrenitis: ‘There are also other muscles/tissues under the other pleurai in the middle, referred to as mesopleuria and phrenes, through the inflammation of which people become phrenitic (dia to autous phlegmēnantas phrenitian tous anthropous)’ (10.4.58). On the encephalocentric side, the eleventh-century ce Byzantine author Michael Psellus (a man of wide interests and vast erudition, who composed inter alia didactic poems on medical topics) speaks of our disease at Poemata 9.729–31:
The technical principles expressed here are those established from Galen onwards, assimilated and elaborated by a Byzantine intellectual at the turn of the first millennium. Another leap forward: the French theologian Hugues de Miramar (thirteenth century ce) was no doctor, but in his autobiographical Liber de hominis miseria, mundi et inferni contemptu (uersio breuis) (1.5.15.312) he wonders: ‘Does not frenesis often disturb your brain, lethargy your occipital bone, apoplexia your intellect, migraine the pia mater and the cranium? (Nonne sepe tibi frenesis perturbat cerebrum, litargia occipicium, appoplexia intellectum, emigranea piam matrem et craneum?)’, creating a random, faux-technical map of mental faculties, diseases and bodily parts that produces only a superficial impression of competence.
In all these authors we notice a phenomenon perhaps less explicitly accounted for by historians, located between the dominant Galenism of higher medical contexts that is rightly stressed in the classic accounts,Footnote 13 and the centrifugal forces represented by ‘popular’, magical underworlds that enjoy a continuity of their own in their preservation of medical knowledge:Footnote 14 the half-technicalism of a multitude of late-antique, Byzantine and early medieval authors, who do not, or not always, appear to be incompetent or passive readers of medicine, but who also escape dominant trends and share neither the rigour of ‘official’ scientific debate nor the philological caution of erudite translators. It is interesting that in several of these cases the chest-based account is kept alive and even tends to prevail, in counter-tendency to what Jessie Wright describes as the brain’s ‘critical’ positioning vis-à-vis ‘formulations of human nature and human identity in late antiquity’ – especially in theological discourses.Footnote 15
The Late-Antique to Medieval Periods: Medical Sources on phrenitis (Sixth–Fourteenth Centuries ce)
As for medicine in a more restricted, technical sense, the subsequent phases in the history of the transmission of phrenitis from the ancient Graeco-Roman world to the modern one are marked by the following key phases and components: the preservation of Galen’s doctrines on the disease in Byzantine medicine, largely in the form they are given by the encyclopaedists;Footnote 16 the translation of a rich corpus of texts into Syriac and Arabic by Eastern and Iberic scholars and philosophers, from the ninth century onwards; and the subsequent translation of these works back into Latin, for the use of scholars and doctors in Europe, especially from the twelfth century on and in connection with the activities of the Salernitan School of medicine, which flourished from the tenth century in southern Italy and became the major centre for medicine in Europe.
It is against the background of these movements, linguistic vicissitudes, cooperative efforts and fragmentations that we will attempt to map the form phrenitis maintains, develops and finally hands over to modern medical research. This search will necessarily remain partial and episodic. But its goal is to highlight core elements of permanence and continuity, as well as meaningful breaches in this development.
Late-Antique and Byzantine Sources in Greek
The vast majority of specifically medical sources after the sixth century follow in the tradition of encyclopaedias, compendia and commentaries based on the cornerstones of the earlier Greek tradition, especially Galenic (and Hippocratic). In his Commentarii in Hippocratis librum sextum de morbis popularibus, the sixth/seventh-century medical author Palladius of Alexandria comments on a physiognomic portrayal of mania or phrenitis based on the Hippocratic facies found in the Prognostikon and other Hippocratic texts. It is noteworthy, and clear, that he is conflating Hippocratic information about mental disturbance generally into a phrenitic-manic portrait, which becomes a kind of umbrella image for deranged persons:
Hippocrates tries to grasp the state of the body, for he says that we know the signs of anger/spiritedness (thymos): the trembling of the voice, the redness of the face, the wildness of the eyes. These features are often present in a person in the absence of anger, naturally. The art (technē) ought to help [us] predict that [the patient] is gripped by no other phrenitic disease than mania
Palladius not only discusses the profile of phrenitis, but also offers rare testimony to clinical interactions with actual patients. At Commentarii in Hippocratis librum sextum de morbis popularibus (2.113–14) he reflects on an episode relevant to the deontological aspects of a doctor’s profession which has a phrenitic patient as protagonist, and reports concretely on the particular sensorial sensitivity such individuals are thought to experience. This patient is oversensitive and reactive, especially to wine:Footnote 18
For if your mouth – you being the doctor – has a bad smell either from garlic or onion, then do not eat them. And if your perspiration has a bad smell, sometimes because of an unguent, make it milder using aromatic herbs, and resort to nice-smelling plants, and the patient will be very grateful. And do not risk putting yourself in the same position as the one Anitos (sic: Ἄνιτος is printed here by Dietz for Quintus) once was [here Palladius inserts and elaborates a Galenic anecdote in which a prominent Roman patient with fever and kephalgia, although not phrenitis, is visited by the famous physician QuintusFootnote 19]. For he once drank a large quantity of wine and visited a phrenitic (eisēlthe pros phrenitikon). But [the patient] could not stand the smell of wine coming from his mouth, and said to him: ‘The smell of your mouth really exacerbates me’. And the other replied harshly: ‘I bear every day the smell of your fever, and you cannot bear the bad smell of my mouth just once!’ These, however, are the favours (charites) one owes to patients, and they appear to be inexpensive, and they make us, as well as the patient, happy – us, because he becomes obedient to the doctor (peithēnion tōi therapeuonti), and him – and us – (because this leads to) the cure of his ill body
Byzantine medical commentators in general perpetuate Galen’s doctrine and his reading of Hippocrates with respect to phrenitis. The medical author Stephanus of Byzantium (sixth/seventh century ce) in his Commentary on Hippocrates’ Prognosticon is an example. He offers remarks on crocydism, giving it the hallucinatory interpretation known from Galen (1.9.27);Footnote 20 on respiration (1.10.101); and on urine (In Magni Sophistae Librum de Urinis 11.34). Urinology was an important branch of Byzantine medicine, and the theme of a specific ‘phrenitic’ kind of urine is accordingly recurrent: the seventh-century Theophilus Protospatharius comments on the quality of urines along familiar lines in his commentary on Hippocratic texts,Footnote 21 as does Joannes Actuarius (thirteenth/fourteenth century ce) at great length in his De urinis.Footnote 22
The topic of the different types of phrenitis and their possible localizations survives and is further refined. Theophilus Protospatharius addresses it in his De pulsibus,Footnote 23 for example, mentioning the various versions of the disease sketched out by Galen, focussing on the pulse and reporting two versions, a primary, encephalic one and one that strikes the chest: ‘The throbbing in phrenitic diseases changes according to the form of phrenitis. For one kind is an inflammation of the parts around the brain (phlegmonē tōn peri ton enkephalon), which happens as a primary affection; another phrenitis is an inflammation of the diaphragm, from which the brain gets a share through sympathy.’ He also recognizes phrenitis as belonging to larger groups of diseases based on the humours that cause it, the localization, the patient’s age and the like: ‘paroxysms, phrenitis, pleuritis and others’ (Comm. Hipp. Aph. 1.12 = 17b.385 K.); ‘diseases of this age are asthma, pleuritis, peripneumonia, lēthargos, phrenitis, ardent fever, chronic diarrhea’ (Comm. Hipp. Aph. 3.30 = 17b.644 K.);
Heating and fever remain central. Paulus of Nicaea (seventh or ninth century ce) in his Liber medicus (10.13) defines the illness thus: ‘What is phrenitis? An acute derangement with acute fever, when the moisture in the brain dries up, from which agrypnia follows. Such an illness comes from hot and dry.’ Photius (ninth century ce) elaborates in a similar fashion, noting that the disease is caused by distension of the meninges and spoiling of the blood (Bibl. 130.2 Bekker) via a ‘pleonasm with heating’ (Bibl. 130.5 Bekker) and ‘with inflammation’ (Bibl. 130.6 Bekker). Leo Medicus (sometime after the late ninth century ce) in his Conspectus Medicinae (2.11) has a chapter ‘On phrenitis’, in which he defines it as ‘an inflammation of the meninges with fever: at the same time, these patients are deranged, and their heads must be soaked with vinegar-rose’. The historian and philosopher Michael Psellus (eleventh century ce), already mentioned, reflects on damaged sight with reference to phrenitic hallucination in his Opuscula.Footnote 24 His elaborations specifically concern colours:
If the vapour is overabundant, they see big/distant things; if it is yolk-coloured,Footnote 25 they see golden things; if it is smoky, they see white from the inflammation; and all in all, according to the shape and colour of what appears. In phrenitics, the vapours travel from the brain itself to the optical (organ?, to optikon); and those who experience cataract see the same way.
At Opusculum 55.8, we read: ‘Phrenitics are weaker after release (meta tēn apallagēn), because when they are released from the dry dyskrasia overpowering the brain and slackening their nerves, they feel the fatigue and the cleansing of their discerning faculty, and their nerves become weak as they recover moisture.’ Opusculum 55.142 comments on the pulse: ‘Phrenitics have a small pulse (are smikrosphyktoi), because the pneuma in their meninges is rarefied. Lethargics, on the other hand, have large pulses (are megalosphyktoi), because the pneuma thickens in them and grows heavy.’Footnote 26
Joannes Actuarius (thirteenth–fourteenth centuries ce) as well, in his De diagnosi, connects phrenitis to the dryness or heat of humours settling into an unbalanced mixture, a dyskrasia.Footnote 27 At De Diagnosi 1.7, he categorizes phrenitis among the diseases of the nerves that strike the brain and spine: ‘of the brain, the spine,Footnote 28 and the nerves connected to them, lack of perception and faulty perceptions, and forms of paraphrosynē; epilēpsia, melanch0lia, phrenitis and lēthargos; katalepsis, insomnia and kōma; forms of tetanos and paralysis; and other such problems’,Footnote 29 while at 1.35 he writes: ‘As the blood specifically contrives mania according to how it changes and settles around the brain, the black bile causes melancholia, and yellow bile phrenitis, so too variations in the quality of the settlings or risings of the phlegmatic substance cause forms of kōma and dullness, as well as lēthargos and impaired perception (dysaisthēsias).’ In sum, in these authors received medical tradition connects the qualifying factors of the disease phrenitis with the topics of pulse, urine, overheating, fever, crocydism and hallucinations, with loci in the head, brain and meninges, and secondarily in the diaphragm and heart.Footnote 30 The emphasis on altered vision and the question of wine also recurs frequently.
The Reception of Greek phrenitis in Syriac and Arabic Medical Sources: qarānīṭis (karabitus), birsām, sirsām
The medical texts of the Syriac and Arabic tradition also largely reproduce Galenic (and to a lesser extent Hippocratic) doctrines, receiving them through the filter of late-antique commentaries and compendia (in the case of our disease, especially Oreibasius, Aetius, Paul of Aegina and Alexander of Tralles).Footnote 31 Here too, therefore, we cannot expect completely new information. But the ways in which received ideas are managed, adapted and translated into the Semitic languages and specifics of the receiving cultures, academic-scientific as well as lay, are nonetheless worthy of attention.
The questions faced by these translators and scholars reflect tensions, concerns and intellectual interests that add to the itinerary being traced here, causing it to alter direction slightly or giving voice to side-branches of the tradition that had previously been dismissed. At the same time, problems of translation allow ancient ambiguities to re-emerge and revive. As we shall see, this is the case with the ancient discussion of the name of our disease, the meaning of the archaic term phrenes, and the debate about localization that accompanies these issues.
The Name The vicissitudes of the label phrenitis in the choices made by translators at the end of antiquity offer a miniature of the whole story of the disease, including the ambiguity of its etymology from the very beginning with reference to its locus affectus, as well its overall physiological make-up. The earliest phase in this regard is represented by Syriac authors, who constitute the bridge between the Graeco-Roman originals and the Arabic translations and elaborations,Footnote 32 laying the earliest foundation of the reception and translation of Greek texts into Semitic languages.Footnote 33 Barry’s analysisFootnote 34 of two tenth-century Syriac lexica in relation to the Arabic and Syriac translation of the Hippocratic Aphorisms offers useful insights regarding phrenitis. The disease is already established here as a ‘swelling’ in the brain of the hot kind – the ‘hot apostēma’ which will become standard in medieval discussions:
1497:16 Pêrniṭis in a manuscript, chronic ravings occurring with fevers, phrenitis (sarsām), he introduced phrenitis (birsām).
1607:3 Prêniṭis in a manuscript, chronic ravings that (occur) with fevers, phrenitis (sarsām), which is phrenitis (birsām). It is said (to be) swelling of the brain. (According to) Paul, phrenitis (birsām), and according to Zakariya and bar Serošway, hot swellings that are in the head, hot swellings that happen in the head, phrenitis (birsām), madness. A hot swelling that occurs in the brain, hot swellings that occur in the brain.Footnote 35
In these entries in the lexica, a key element is visible: the alternation between transliteration (prêniṭis) and two different terms, sarsām and birsām, to which we shall return. Also relevant are the entries in which the scholar comments on the occurrence of Greek phrenos/φρενός (from phrēn/φρήν):
1606:23 Prêyas according to bar Serošway, judgement, thought. Prênas in a manuscript, diaphragm (ḥijāb). According to Paul, the peritoneum (ṣafāqāt) of the chest.
Barry notes that the term phrēn/φρήν, which occurs three times in the Aphorisms, is translated in the various Syriac versions ‘with a form of the borrowed Greek word’ (i.e. prêyas), while ‘Ḥunayn’s Arabic version utilizes forms of al-ḥijāb, diaphragm’ in two cases; in the third (Aph. 6.18), he uses al-kulyā, ‘kidney’, in a list of body parts.Footnote 36
Phrenos/φρενός in the Syriac authors thus seems to indicate the diaphragm, as well the related meaning ‘mind’, but is not placed in relation to phren-itis. In a similar fashion, in Arabic sources the translation of the term phrenitis oscillates between transliteration (which results in qarānīṭis, and karabitus in the Latin translation of Avicenna by Gerard of Cremona, which was the most influential in the Latin West) and adoption of the two Persian words found in the Syriac lexicon, birsām and sirsām.Footnote 37 Literally interpreted, the first term indicates an inflammation of the chest (bir, ‘chest’ + sām, ‘inflammation’ in Persian), the second an inflammation of the brain (sir, ‘head’ + sām, ‘inflammation’).Footnote 38 These labels were long taken by scholars to be basically synonymous and scarcely distinguished in Arabic usage.Footnote 39 But Carpentieri and others have recently corrected this view, tracing instead a development;Footnote 40 here I largely follow and summarize their expert reconstruction. Birsām earlier described ‘two illnesses with similar symptoms. It referred to an inflammation of either the meninges (brain fever) or the diaphragm (diaphragmatic fever). Both inflammations would cause delirium with high fever and were typically fatal. In the second and later stage, the usage of birsām became more restricted, designating only diaphragmatic fever. Brain fever, on the other hand, came to be referred to exclusively as sirsām’.Footnote 41
This confusion – which reproduces the differentiation Galen sketched out in On the Affected Places between the two kinds of phrenitis, one in the brain, the other in the diaphragmFootnote 42 – originated with Ḥunayn’s reference (in the ninth century ce) to phrenitis with the term birsām. In his translation of Galen’s commentary on Aphorisms 6.11, on phrenitis, Ḥunayn offered the following commentary: ‘[Doctors] mean by birsām a fever from a hot inflammation occurring in the meninges or in the ḥiǧāb, and delirium necessarily occurs with it. They call it in Greek frānīṭis’. Al-ḥijāb, erroneously translated in the past as ‘meninges’, actually means ‘diaphragm’ (translating διάφραγμα or φρήν);Footnote 43 in sum, Ḥunayn is using birsām for affections of both the brain/meninges and the chest.Footnote 44 Elsewhere, in fact, he speaks of a kind of ‘birsām that is called sirsām’, indicating specifically the meningitic version.Footnote 45 He then employs the chest-centred label birsām as the umbrella term, contrary to the encephalic focus the disease will subsequently have, perhaps because it transliterates with a precise semantic transference the Greek for ‘diaphragm’: phrēn-itis.
Readers of and translators into Arabic, however, early on show an awareness of the risk of confusing the two locations and anatomical parts the labels birsām and sirsām designate with their respective pathological data, and eventually discard the conflated use of birsām to indicate both. This move is evident in a number of Arabic authors from the middle of the tenth century onwards.Footnote 46 Consider the wording chosen by al-Kashkarī (tenth–eleventh centuries ce), by al-Rāzī (ninth/tenth century ce), and most influentially by the philosopher and physician Ibn Sīnā (Avicenna, 980–1037 ce), the author of the al-Qānūn (Canon).Footnote 47 Al-Kashkarī already distinguishes the terms birsām and sirsām, along with the diseases which ensue with their different localizations. Al-Rāzī states that the term birsām is used for two different diseases, one of the chest and the other of the brain, but that the second is more appropriately called sirsām: ‘In his al-Ḥāwī fī l-ṭibb, Rāzī states that birsām is used for two diseases: one is shawṣa, a kind of pleurisy or inflammation of the chest, and the other is an inflammation of the brain, which is properly called sirsām.’Footnote 48 Birsām and sirsām correspond here, respectively, to pleuritis and phrenitis proper, articulating once again the ancient parallelism – although elsewhere some confusion remains.Footnote 49 Ibn Sīnā, finally, clarifies the distinction between the names at greatest length. When he discusses Qarānīṭis (karabitus in the Latin transliteration) among the diseases of the head in Book 3 of his al-Qānūn fī l-ṭibb, or Canon of Medicine (3.1.3), he criticizes the use of birsām and sirsām as synonyms as linguistically incompetent (2:76):Footnote 50
Book 3, fann 1, maqāla 3
Qarānīṭis refers to a hot swelling of the membranes of the brain, either the tender or the tough one [i.e. the pia and the dura mater], without damaging it. But if the brain is damaged, it might swell. The physicians who think that the brain itself does not become swollen are mistaken. They adduce that everything that is tender, like the brain, or hard, like the bones, does not expand, and therefore the brain does not swell. This statement is wrong, because tender and viscous [organs] expand, and bones also swell. Galen has confirmed that, and I will explain this in the chapter on teeth, but now [it is enough to] say that everything that is nurtured expands and grows with nourishment and, similarly, it must expand and grow with residues: this is the swelling.
Therefore, if the brain becomes swollen, qarānīṭis and sirsām are the names that refer specifically to the swelling of the membrane of the brain when [the swelling] is hot. This [name] might occur in some places referring also to the body of the brain (jawhar al-dimāgh); this is a specific use of the term transferred from the name of the symptom that [the swelling] brings about, namely delirium (hadhayān), mental confusion (ikhtilāṭ al-ʿaql) and burning heat (ḥarāra muḥriqa). The common [use of] the name is associated with the symptom, the technical use with the swelling.
The transfer of this name is similar to the adoption of the name ‘forgetfulness’ (nisyān), which is a symptom, when used to refer to a disease that necessarily presents itself with [this symptom]: the cold sirsām. When the term sirsām is used in a general sense, it also refers to the sirsām of the brain, which is this [disease].
People unacquainted with the vocabularyFootnote 51 believe that birsām is the name of this swelling and that sirsām refers to a milder form of it; but it is not like that. Birsām is a Persian word: bir means chest, and sām means swelling. Sirsām also comes from Persian: sir means head, and sām means swelling, illness. Sirsām is the disease caused by fevers and by the burning mixture [of humours] in the mouth of the stomach, and it might also be caused by swellings in the outer parts of the head or in the external membrane (ghishāʾ).
Sirsām occurs together with birsām as a result of the sympathetic relationship with the diaphragm (bi-mushārakat al-ḥijāb), its swelling and that of all the muscles of the chest. There is one caused by the swelling of the bladder, the uterus and the stomach.
Due to common use of this term, the authors disagree in their descriptions, just as they disagree about [the term] ‘lethargy’ (lītharghus), which is the cold sirsām called forgetfulness (nisyān). However, the real sirsām, according to the technical use of the name, is [the disease] we have described. It is possible that the brain becomes swollen along with it due to sympathy (mushāraka) or transmission (intiqāl). In this case, there is great damage and it kills in four days. If [the sick person] goes beyond [this time], he will survive, but most of those who die of sirsām die due to the damage to their breathing capacities
In sum: sirsām is found in lay usage indicating a swelling/abscess of the brain which can be accompanied by fever and have multiple origins and causes, with the involvement of stomach, bladder or womb; most prominently, it can affect the membranes of the brain or its external part, but also the body of the brain itself; and it manifests itself in multiple versions (e.g. the hot one under discussion and the cold one, oblivion or ‘lethargy’). Birsām, on the other hand, is specific to the chest. For Ibn Sīnā, there is no gradation of severity between the two, but only a shift in localization; birsām can in fact occur together with sirsām, with the second becoming the umbrella term.Footnote 53 But ‘real phrenitis’ is used in medical language to refer to an inflammation of the membranes of the brain, sometimes with involvement of the brain itself.
Another eleventh-century source in Arabic, the dictionary Kitāb al-Māʾ by an author apparently from Oman, al-Dhahabī,Footnote 54 preserves important parallel information in the entries for Birsām, Sirsām and Qarānīṭis. The dictionary is largely based on Ibn Sīnā, of whom the alleged author was a student, but is interesting for how it centres the perceived connection between the membranes of the chest and those of the brain to explain the derangement common to both pathological forms: the term used is ittiṣāl, which indicates a concrete anatomical ‘bridging’ between brain and chest, and is much stronger than sympatheia, which Galen had used in On the Affected Places and elsewhere in his accounts of the type of phrenitis which involves the diaphragm as well as the brain.Footnote 55 Discussing the disease the Greek sources call phrenitis, he writes first at 1:203–04:
B.r.s.m
al-Birsām, an Arabized Persian word, means chest-swelling because bir means chest in Persian, and sām means swelling. This is a warm swelling in the membrane (ḥijāb) between the liver and the stomach which provokes delirium (hadhayān) due to the connection (ittiṣāl) of this membrane with the membranes of the brain (ḥujub al-dimāgh).
This could be caused either by unmixed blood (dam ṣirf), given that its symptoms are spasm (tamaddud, which translates the Greek syntasis, ‘rigidity’ or ‘tension’), redness on the face, an intense pulse (ʿiẓm al-nabḍ), and shortness of breath; by blood with yellow bile (dam ṣafrāwī), given that its symptoms are great distress (shiddat al-nakhs) and pain, intense fever and accelerated pulse; or by blood with black bile (dam sawdāwī), in which case the symptoms are great distress, a dry mouth, strong fever, and coarseness and blackness of the tongue. It is lethal in most cases.
Those called mubarsimūn (i.e. affected by birsām) are persons affected by melancholic delirium/delusion
Then again, our phrenitis returns as sirsām later at 2:286–87, as the hot variety of meningeal swelling (the cold one being lēthargos) – and, only by extension,Footnote 56 of the body of the brain as well. The membraneous nature of the locus affectus is central for this author in the definition of birsām and sirsām.
S.r.s.m
Al-Sirsām: there are [two kinds] of it, the cold one, called l.th.gh.r.s in Greek, and the warm one, which is the qarānīṭis.
The cold sirsām is a disease called after the name of its symptom, because the translation of l.th.gh.r.s is forgetfulness (nisyān). Many physicians have been wrong about it, for they did not know that the disease that results from cold swelling is only a symptom of it; rather, they believed that this disease was one and the same as forgetfulness.
[Sirsām] can be phlegmatic (balghamī), since its cause is the phlegmatic matter inside the skull and inside the conduits of the brain. Its symptoms are a mild headache, light fever, abundant salivation and yawning, whiteness of the tongue, laziness in answering, confusion of the mind and unavoidable forgetfulness. The eyes [of the sick] are completely open and fixed [on a point]. Treatment of it consists of the evacuation of the matter with enemas and pills; sometimes bloodletting is in order, because it reduces the matter.
As for the warm sirsām, this is the one called qarānīṭis, which is a swelling of one of the membranes of the brain or of both of them. This is the proper sirsām, but [the name] may be figuratively applied (ʿalā sabīl al-majāz) to the swelling of the substance of the brain.
It may be caused by fine blood (dam raqīq), since its symptoms are constant fever with heaviness of the head, redness in the eyes and face, and an intense pulse. This is treated by bleeding the cephalic vein and relaxing the nature [of the patient’s body], cooling the head with rose-water, rose-oil or something similar.
Another cause is [blood] with yellow bile, since its symptoms are an intense hot fever, insomnia, lightness of the head, yellowness of the face, an accelerated pulse and delirium (hadhayān).
Treatment of it consists of evacuating the yellow bile by administrating barley and pear water, and cooling the head with rose water and gourd peel.Footnote 57
Finally, the dictionary also discusses Qarānīṭis as a separate item:Footnote 58
Qarānīṭis.
This is the Greek name for the hot sirsām, which is a swelling in one of the membranes of the brain or in both of them. This is the real sirsām, but [the name] might be figuratively applied to a swelling in the body of the brain (jawhar al-dimāgh).
This disease might be caused by fine blood (dam raqīq), in which case the symptoms are constant fever, heaviness of the head, redness in the eyes and face and an intense pulse. This is treated by bleeding the cephalic vein, relaxing the nature [of the body] and cooling down the head with rose-water or rose-oil.
Another cause could be the yellow bile, since its symptoms are an intense hot fever, insomnia, lightness of the head, yellowness of the face, an accelerated pulse and delirium. This is treated by evacuating the yellow bile, administrating barley water and pear water and cooling down the head with rose water and gourd juice.
Later Arabic commentaries continue to articulate the distinction between the two versions of the disease, one centred in the brain and the other in the chest. As Carpentieri shows, ʿAbd al-Laṭīf al-Baghdādī (twelfth century ce), for example, paraphrases Ḥunayn’s text, but writes ‘inflammation in the meninges of the brain or in the ḥijāb’, conflating the two locations. So too the Syriac physician Ibn al-Nafīs (twelfth century ce) points out that ‘when delirium happens because of an inflammation, if the latter is in the brain, it is called sirsām; if it happens in the chest, it is called birsām’; the derangement common to both is emphasized here. A similar statement differentiating between brain and diaphragm is found in Ibn al-Quff:Footnote 59 ‘in the meninges, and that is called sirsām … an inflammation of the diaphragm, and this is called birsām’ (ii.2). According to this text, the diseases that derive from the ailment – one an inflammation of the ‘membrane called the afraġmā’, namely birsām, the other of the membranes of the brain or in the whole brain, namely sirsām – are very similar, but their localization and manifestations differ: ‘On the one hand, in sirsām delirium precedes shortness of breath, whereas in birsām, the opposite occurs. On the other hand, sirsām does not cause a fever as intense as birsām does’ (iv.50).Footnote 60
In sum, the Arabic commentators and scholars, reading the Greek sources afresh and from outside the long tradition of chest–brain dualism, turn their attention to the philological problem posed by birsām and sirsām as if it were mostly a point of vocabulary. The ambiguity or ambivalence between chest and head, however, continues in the centuries of translation and commentary that follow, with different authors returning to the point, at times misunderstanding the terms and variously glossing the relationship between pathology of the brain and pathology of the chest (pleuritis, for which bar-sām is still used in Arabic today) which birsām and sirsām spell out.Footnote 61
The Disease Phrenitis is still firmly associated in this period with mental disturbance. The ninth-century Christian Syrian physician Ibn Serapion (Yaḥyā ibn Sarafiyūn) speaks of the association between phrenitis (quarānīṭis) and mania (maniya), ‘especially severe madness (al-junūn al-hā’ij)’,Footnote 62 since they can cause similar pain. While other key symptoms are common – insomnia, anxiety, delirium, a firm pulse – phrenitis is distinguished by fever. Proposed therapies include massages (‘the lower limbs should be massaged and the stomach moistened, and the patient bled and purged with a potion made of myrolaban’ – the plant Terminalia chebula, native to India and South-East Asia and a late addition to the materia medica), embrocations and anointing the head. In addition, there is a relational-psychological expedient, the recommendation of contact with persons towards whom the patient feels reverence and shame, ‘lest his derangement increase and become habitual’ (al-Ḥāwī, i.208).Footnote 63 The final point remains an isolated one: as Dols observes, these authors generally agree with a humoral aetiology for mental disorders, so psychotherapeutic measures are not systematically suggested.Footnote 64
Al-Rāzī is credited by some scholars with a persuasive account of phrenitis (sirsām) as ‘meningitic’ disease.Footnote 65 But some of these retrospective identifications have become conventional without having been examined in depth.Footnote 66 The case of sirsām as equivalent to meningitis is one phase of ‘delimitation’ of the disease phrenitis in the course of its history: its restricted assignment to the brain, synchronically, and its retrospective identification by medical historians with the inflammatory disease ‘meningitis’. In the Book of Cases, Álvarez Millán, for instance, writes: ‘Three patients are said to suffer from meningitis (sirsām), one of them accompanied by pleurisy (shawṣa), another by hiccups.’Footnote 67 Four patients are described as suffering from birsām, which appears to correspond here to pleurisy.
In his Divisions (Taqāsim al-ʿIlal),Footnote 68 al-Rāzī also devotes a chapter to swellings of the brain, addressing the hot and the cold ones, phrenitis and lēthargos, respectively. The former can originate in a condition of the blood or bile (reflecting the doctrine also followed by Byzantine medicine). The pathological signs differ as a consequence: with the first there is continuous fever and redness of the face and eyes, a rapid pulse and swollen veins. With lēthargos the fever is more intense, and there are convulsions, intense delirium, pain in the head and swollen eyes. Surprisingly, however, both variants are called birsām, not sirsām.
Pathologically, an important theme addressed by this author is the distinction between swelling of the brain and swelling of the meninges. Quoting from Jacquart’s paraphrase from the Discussion of the Differences between Diseases (Kalām fī l-furūq bayna al-amraḍ), a text of dubious attribution,Footnote 69 the physician sees both states as morbid, hence the unavoidable mental confusion and fever. But they are distinguished by their localization and signs. The first, which strikes the brain, is obvious: pain is felt from the start, accompanied by oppression/heaviness, and is penetrating. Worsening mental confusion, combined with a palpitating pulse and a lighter fever, follow. Some authors, writes al-Rāzī, nonetheless deny that the brain matter can swell due to its viscosity. As for the second variant of the disease, when the meninges are affected, there is ‘intense pain from the start, extending to the forehead and the cranium; the pulse is hard, like the teeth of a saw; fever is acute, but mental confusion comes long after the pain and is lighter’. Fever and confusion are thus in an inverse relation, reflecting the degree of the brain’s involvement, of which confusion is the direct consequence.
This issue also touches on the differentiation between phrenitis and mania, as posed in another question of the Furūq: ‘What is the difference between maniya (mania) and qarānīṭis (phrenitis)?’ They share the same localization in the brain, the hot matter and the confusion of the spirit; but they differ in signs and causes. Maniya is caused by inflamed bile, qarānīṭis by putrid blood or bile. As far as signs are concerned, there is no swelling or fever in maniya, and despite the heating, the brain matter is not damaged; in this case, therefore, there is corruption of the language only in the sense of an inability to combine words. In qarānīṭis, on the other hand, even the combination of letters fails due to the involvement of the brain matter, and the patient can only articulate sounds.Footnote 70 Fever and alteration of the brain are again central to the definition; information about language is also important and reveals the criticality of the brain to the affection. In mania, only the heat increases, whereas in phrenitis the working of the brain is altered by the swelling. We thus pass from the milder delirium of the manic to the phrenitic’s more extreme inability to articulate words by combining letters, from a derangement of judgement to a deeper modification of the senses in their entirety.
Language is also discussed in al-Ḥāwī, where al-Rāzī describes an evolution in the course of the disease over time. At the beginning, words are disorderly; then the patients cease to speak; and at the end, in the most acute phase, they have no voice at all.Footnote 71 More generally in terms of the pathological picture, at al-Hāwī I:200 al-Rāzī lists prodromic signs as well as proper manifestations of the disease: the first are a light fever on the surface of the body, a face congested with blood, continuous insomnia, disordered words, intense sadness, indolence, continuous movement in bed, redness of the eyes, lacrimation, coldness of the extremities, feeble emission of urine, a hammering feeling in the temples, buzzing ears, pain in the heart, a swelling of the hypochondria and a fixed gaze. Once sirsām is established, there is acute fever, a small and frequent pulse, crocydism, substantial insomnia, confusion of the senses on the fourth day, a burning feeling inside accompanied by anger and fury; the patient has a fierce look in his eyes, stretches out his hand, no longer speaks and shies away from light. In the acute phase, diarrhoea appears along with a swelling of the eyes and face, trembling hands and an irregular pulse, until at last the hypochondria become sensitive, the tongue swells and the patient loses his voice. Intriguingly, there is no reference to crocydism, and the question of hallucinations gets less emphasis than in the ancient authors.Footnote 72 But the richest and most comprehensive account is found in Ibn Sīnā’s al-Qānūn fī l-ṭibb (Canon of Medicine), discussed below.Footnote 73
A Twelfth-Century Syriac Source: The Book of Medicines
So far, the landscape we have surveyed has mostly consisted of official trends in professional medicine or elevated intellectual life in late-antique and medieval times. As we consider this evidence, however, we should bear in mind that it is in many ways partial and unbalanced in terms of geographic and political proximity to the cultural centres of the time and their significance in subsequent reception in the history of medicine. Ancient historians are generally plagued by a lack of access to alternative narratives provided by less institutional or decentred environments. Sometimes, however, ancient sources that at first glance appear directly derivative of central authors in the canon offer access to bodies of knowledge far from the mainstream perspectives which dominate historiographies of medicine.
This is partially the case for the main Syriac medical source available to us, the so-called Book of Medicines. The Syriac manuscript of this text was presented to the scholarly world by Ernest Wallis Budge, who discovered it in 1884 in Mesopotamia and had it copied and published with an English translationFootnote 74 as
a series of Lectures upon human anatomy, pathology, and therapeutics … which were translated from Greek into Syriac by a Syrian physician, who was probably a Nestorian … He may well have been attached to one of the great medical schools, which existed at Edessa (Urfa) and Âmid (Diarbekîr) and Nisibis, in the early centuries of the Christian era.Footnote 75
The manuscript was composed of three parts, schematically – and inadequatelyFootnote 76 – described in Budge’s first publication as the first ‘scientific’, the second ‘astrological’ and the third ‘popular, sympathetic or magical’.Footnote 77 The first part (chapters 3–21) interests us here, since it contains what initially appears to be discussion of straightforward medical topics. These are organized a capite ad calcem, thus with head affections at the very beginning. The author refers to Hippocrates as an authority and calls the brain the ‘head’ or ‘governor’, but also sees the heart, together with the liver, as a key organ for other functions. The discussions are followed by recipes which appear to come partially from ancient Mesopotamia.Footnote 78 This first part also contains a lengthy discussion of phrenitis which seems at first glance to derive in a straightforward fashion from the relevant sections on phrenitis in On the Affected Places (5.4).Footnote 79
If the dating of at least part of the text to the early centuries of our era is accepted by most scholars, recent work has persuasively challenged the neat picture in which the recognizable Greek sources and the Eastern astrological and pharmaceutical elements of the later parts remain as separate as oil and water. An ‘intrusion’ of astrological elements, for example, in the ‘scientific’ section has been noted; according to Bhayro, the text is thus best described as a twelfth-century stratified compilation, in which Graeco-Roman elements from earlier medical translations into Syriac are blended with ‘local’, possibly much more ancient Mesopotamian material in a more complex manner than simple juxtaposition (let alone interpolation of so-called ‘popular’ elements).Footnote 80 As such, the book would offer an example of syncretism between Western medical material and a much older tradition going back to ancient Babylonia.Footnote 81 It is in this light that we will consider the Book of Medicines as at least in part a specimen of an ongoing alternative medical tradition beginning much earlier, which elaborated and assimilated Greek material while reshaping it in different directions from those of the Galenism dominant in later European medicine.
This topic is interesting for the reconstruction of phrenitis, because the text offers an account of the disease in which the proportion between ‘head’ and ‘chest’ is reversed. At first sight this presentation reflects the organization of the topic of phrenitis in Galen’s On the Affected Places,Footnote 82 the key source of this passage (and indeed the entire book): there phrenitis was discussed at length in the section about the diaphragm, not the brain, in contradiction to the general presentation of the disease by Galen as encephalic. Thus the author of the Syriac Book of Medicines discusses the head and its diseases in chapter 3 (the first chapter preserved in the manuscript we have).Footnote 83 In stark opposition to the tendency first of official imperial medicine, then of encyclopaedic sources, and finally of Arabic readers of Greek medicine nearer in time to the compilation of the Syriac book, phrenitis is not included in this chapter, although the discussion focuses on the brain as source of the impairments in the ‘spirit’ or ‘soul’ which cause inter alia melancholia, epilepsy, fear and vertigo. Phrenitis is found only in chapter 13, as an important topic within the discussion of symptoms and injuries to the lungs (‘Of the symptoms of the injuries that take place in the lungs, and in all the organs of the breast’, 241, p. 216, folio 104a). This straightforward adoption of On the Affected Places 5.4 as an exclusive source by the Syriac author (motivated perhaps to a large extent by the popularity and practicality of the work, as opposed to other texts by Galen) results in a presentation which resonates with a more Eastern, ‘cardiocentric’ or ‘enterocentric’ – as opposed to neural and encephalic – representation of human psychic life. Notwithstanding the complexity and sophistication of the discussions of the brain in the early chapters (which largely reproduce Galenic ideas and principles of humoral medicineFootnote 84), phrenitis is ultimately framed by the Syriac compiler as a chest disease, located just after ‘pleurisy’ (‘the disease which is called perforation’, 250, p. 225, folio 108b) among the ‘perforations of the lungs’ produced by ‘abscesses in the moving membrane of the chest … accompanied by fever and by stabbing pain’. Among its symptoms are short breath, a hard pulse and coughing (251–54, pp. 226–29, folios 109a–10b). Following Galen’s argument in Loc. Aff., there is also a section within the section devoted to the chest (253–54, pp. 228–29, folio 110a–b) that treats inflammation of the brain, reproducing the persistent duality in the approach to the disease. Galen’s authority in that treatise, however, is concomitant rather than causal to the choice of the Syriac author, who ‘selectively’ emphasizes the one chest-centred account of phrenitic derangement in Galen, sidelining the much stronger encephalic elaboration in his work, as well as in other authors of the imperial era. In line with an Eastern Mesopotamian representation of the human body, the disease is here primarily assigned to the chest, reversing the structure that dominates the medical sources from Hellenistic medicine to Avicenna.Footnote 85
Let us consider the text (Book 13, pp. 226–29, folios 109a–10b) a bit more closely to illustrate these points.Footnote 86 First a discussion of etymology is introduced: ‘All the early physicians have called the lower boundary of the chest parnôs, because when an abscess exists in it, the understanding (or knowledge) of those who suffer is injured.’ In the Greek original at this point, Galen has a crucial sentence: ‘or because it came to them simply like that’. Galen’s point is that the name is randomly assigned and has a lay origin. The Syriac author omits this dismissive second point, validating the involvement of the chest in disorders of the reasoning faculties as fact rather than as a misperception. The word parnôs, continues the author, translated into Syriac means
that by means of which we carry on the process ‘of thought and the process of making calculations’ [sic] … Some have called it the diaphragm, others the ‘understanding’, for they thought that this filled the need for boundaries in animals, because it distinguishes and defines the ferocious (or wrathful) part of the soul, which is situated in the heart, from the lustful portion, which dwells in the liver.
Here, again the author translates phrenes (his parnôs) as ‘understanding’, taking seriously a cognitive implication of the term which had been dismissed by Greek physicians as early as Hippocrates.Footnote 87 These are subtle variations inserted within what is fundamentally a faithful translation or paraphrase of Galen, but they are telling as to the retention of the heart/chest as the focus: the part the ancient physician indicated with phrenes receives a new, unquestionably cognitive value as parnôs.Footnote 88
In sum, for all its compilatory characteristics and ambiguities, this text preserves traces of an Eastern reception of and syncretism with a ‘canonical’ Western topic (using ‘Eastern’ and ‘Western’ in the somewhat simplified way described above): cognitive disturbance and the disease phrenitis. The most interesting feature is not the content itself – the information it preserves is Galenic at its core, as we have seen – but how it arranges and positions that content and engages with it. Although the sources and authorities may have been largely the same for many centuries, the emphasis was on different points and different body parts in different regions (or different genres, or for different audiences). The Syriac book is perhaps best understood as a small but meaningful example of resilience in the face of the hegemony of Greek science on the part of an Eastern and in part much older medical tradition,Footnote 89 in whose Babylonian beginnings diseases in many ways similar to phrenitis had been observed and described but had generated very different representations and arguments (as can be seen in the evidence offered by Scurlock, although her strong claims of affiliation are flawed in various waysFootnote 90). This local Eastern medical tradition, in many ways independent of the slow but steady developments of Graeco-Roman science in an encephalocentric direction, put more emphasis on the inward partsFootnote 91 and on the heart–chest localization of vital processes and disorders at the expense of the head in its representation of mental life and health.Footnote 92 More generally, this tradition did not adopt a localizing view of human health, to which it seemingly preferred a de-centred, compositely organized model of the living body endowed with a greater holistic and metaphysical appeal.Footnote 93 As such, it found an ideal textual interlocutor, among those available from Greek science, in the diaphragmatic and organ-based discussion of phrenitis offered by Galen in Loc. Aff. 5.4.
Medieval Medicine in Latin Europe
The next phase in our reconstruction of the transmission of the disease phrenitis and of the history of the questions and themes that accompanied it is an examination of teachings and writings in medieval Europe, especially in its intellectual centres in the Iberic peninsula and the Scuola di Salerno in southern Italy, with their philological and medical activities of Arabic–Latin translation and commentary.Footnote 94 Although some ancient medical texts were translated into Latin as early as the sixth century ce, it is with the school of Salerno and the rise of scholarly work in Arabic and Jewish contexts in Spain that activity in this language is stimulated and revived in an important way, especially beginning in the eleventh century and reaching a peak in the twelfth, in parallel with the rise of university-based medical learning.
Salernitan Medicine and Other Medical Authors
We begin with the texts in the Collectio Salernitana collected by De Renzi and others.Footnote 95 Frenesis is discussed in the third volume, in the Regulae Urinarum Magistri Mauri (vol. 3, pp. 32–34 De frenesi). The author on urinology has assimilated a number of different categories of phrenitis, as already noted. In particular, he distinguishes between the ‘true and proper’, vera, deriving from accumulation of bile in the anterior ventricle of the brain (de colera in anteriore cellula capitis ad apostema collecta), and the non vera, deriving from blood, phlegm, black bile, smoke rising upwards (de sanguine vel flegmate, vel melancholia vel fumosititatibus petentibus superiora) or other humours. The text offers a detailed discussion of the variation in urine colour in each case, as well as of the possible cures. Symptoms are summed up thus: pain in the head, alienation due to the abundance of fumes affecting the brain (alienatio mentis propter multitudinem fumositatum inficientium cerebrum), wakefulness, movement of the eyes caused either by madness or by the severe obfuscating vapours which, passing through the eyes, corrode them and force them to move (motus oculorum vel propter insaniam, vel propter acutas fumositates, que, dum per oculos transeunt, mordicant ipsos et moveri compellunt) – an interesting double explanation which adds a psychological factor to the received Galenic one – movements of the hands to protect the face, as if in reaction to someone attacking the patient (manuum frequens motio ad faciem, tamquam si aliqui ab extrinsecis lesionem inferret), and irrationality. These are all commonplaces, but the assimilation of the ideas into the pragmatic observations of a Regula urinarum is worth noting.Footnote 96
Philosophically more striking information is offered in the vocabulary referred to as Alphita.Footnote 97 Under fren, this medical lexicon preserves an intriguing entry (217.41–46 García González):
The term fren, or frenes, means ‘membrane’; hence the ancients up to the time of Plato used the term frenes for what we call today the diafragma, and Plato is said to have invented this term dyafragma. Thus the two membranes which cover the brain, namely the pia mater and the dura mater, are called the frenes, and hence the apostema which occurs in them is called frenesis, and (the brain) is called fren, frenis (fren, vel frenes, interpretantur pellicula; unde antiqui ante tempus Platonis vocabant frenes, quod nos hodie dicimus diafragma, et dicitur Plato fuisse primus inventor huius nominis dyafragma; inde dicuntur due pellicule quae obvolvunt cerebrum frenes, scilicet pia mater et dura mater; et inde dicitur frenesis apostema factum in eis, et dicitur hic fren, huius frenis).
García González comments that ‘any membrane which covers an organ was identified as much with the dyafragma < Gr. διάφραγμα … as with the pia mater and dura mater’. But he does not comment on the paretymology the author might be offering,Footnote 98 of dya- as opposed to dia-fragma, in which the prefix is seen to allude to the duality of the meningeal membranes.Footnote 99 He also cites a parallel from another lexicon, the Clavis Sanationis of Simon of Genoa: ‘Frenes, in Greek dyafragma (frenes grece dyfragma (sic))’ and ‘Frenitis, frenesis, actually rabies; this is not the name of the disease, but of the symptom itself, for the disease is the apostema that precedes as a result of overheating (Frenitis, frenesis, ipsa rabies, hoc nomen non est morbi sed ipsius accidentis, nam morbus est apostema quod ex calido antecedens).’Footnote 100 This reference reveals other phenomena in this stage of the history being traced here: the separation of disease from symptom and the creation of a ‘set of symptoms’ designated ‘phrenitic’, which becomes the repository of the rich patrimony of patient observations the tradition preserved.
In line with this creation of a phrenitic ‘semiotic’, in the Practica Maestri BartholomaeiFootnote 101 several details which recur in our disease are scattered throughout a comprehensive discussion of affections of the head/caput (De doloribus capitis/De dolore capitis qui fit ex sanguine/De dolore capitis ex melancholia, followed by De ceffalea, De emigranea, De inflamatione cerebri 372–74). This is offered before any mention of frenesis, despite the rich nosological discussion of the disease in the section De diversitate egritudinum, demonstrating the creation of a nosological phrenitic-encephalitic ‘type’. That dolor capitis is in many details similar to a form of our frenesis, even if the standard markers are not emphasized. Instead, it seems to constitute a purified, more general version of it, cleansed of idiosyncrasies, sometimes accompanied by fever, caused by blood or by some humour. Most telling is what follows, where pain in the head is said to be caused by heat or obstruction (aliquando ex calore, aliquando ex opilatione), ‘depending on the case’.
After a paragraph on scotomia, at 374–77 Bartholomaeus treats the maladies described in De frenesi, De mania and De litargia as all implicitly localized in the head. (The diseases which follow are organized ad calcem.) Frenesis is defined thus: ‘a swelling in the brain or in the meninges of the brain in the anterior part of the head, accompanied by acute fever, with the following signs: a quick and thick pulse, strength of the limbs, a rapid convulsion of the face and eyes (est autem frenesis apostema in cerebro vel in meningis cerebri anterioris partis capitis cum acuta febre, cuius hec sunt signa: pulsus velox et spissus, fortitude membrorum, velox conversio vultus et occulorum)’. It is important to note his concept of swelling, which we have already encountered, and which is a defining feature of the humoral and tumoral explanations of our disease (and others) in medieval medicine. The reference to a ‘swelling’ or ‘tumour’ represents a fundamental new development in the way phrenitis and the group of diseases to which it belongs are represented. The Greek term apostēma/ἀπόστημα, ‘tumour, abscess’, is not used in Galen for phrenitis and is in general not central in earlier medicine;Footnote 102 it becomes so in medieval times, when it features in standard definitions of the disease.
After the definition, Bartholomaeus continues with the usual therapeutics. At the same time, some eccentric elements mostly encountered in non-professional late-antique sources resurface,Footnote 103 notably the application of animal parts to the top of the shaved head: a sheep’s lung (pulmo pecorinum), the warm flesh of a cockerel (caro galli calida), young deer (capriole calida) or a kitten that has been cut open and placed on top. Practical information about the ideal location and activity for patients in everyday life is also offered: a dark bedroom (in lecto obscure iaceant), a peaceful setting free of loud chattering, and no excessive variation in the images to which the patient is exposed (non utantur publicis hominibus confabulationibus, nec voces varias audient, nec diversa videant).
Although this is the chapter dedicated to frenesis, the author attributes phrenitic details to a variety of other diseases apart from the general section on dolor capitis. At 339–421, the various paragraphs devoted to fevers accommodate many elements which compare well with the idea of frenesis in this period. This is particularly true of the discussion of summer fevers and of quartan fever caused by bile.Footnote 104 There is a fever ad insomnietatem (346) and later, at 359, also a separate ‘fever caused by red bile (febrium ex colera rubea)’ accompanied, like phrenitis, by ‘a quick, thick, hard pulse (pulsus velox et spissus et durus)’. Types of apostema are discussed separately, at 367 (de generibus apostematum), but with no specific mention of the head or brain as locus affectus. These duplications in pathological categories pose no problem for our purposes: this medicine does not need to comply with the requirements of ‘economy’ and cogency of modern medical manuals and operative diagnostics. But it is instructive that the ‘building blocks’ which constitute the disease phrenitis in the medieval period begin to emerge separately from one another, as elements in a semiotic with its own joints and pieces: fever, brain, apostema, humours, vapours, summer seasonality, mental aspects, the head.
Along similar lines, in his Egritudines tocius corporis (vol. 4, 415–505 De Renzi, also organized a capite ad calcem, at 469–70) Copho discusses the ‘cephalic disease’ (cephalico), which appears to be his ailment that comes closest to phrenitis. Here too we see frenesis begin both to expand into a general category of brain inflammation and to fragment into the variety of its symptomatic units. The cephalicum disease has various natures, Copho says, physiological but also psychological, such as anger (ira), but he will concentrate on the type caused by bile (‘We shall speak of the one which is caused by humours’, dicamus ad presens de illa que fit de humoribus, 469). He then discusses the nature of the brain in Galen as exposed to the action of different humours in different parts: the front to blood, the back to phlegm, the right side to bile, and the left to melancholia. The cause can be privata (idia, primary) or remota (secondary), and the manifestations can vary depending on all these points. At 470, Copho mentions the possibility of the disease having an origin even in the womb, for female patients; this is the apostema of the womb encountered elsewhere, as in stomach and liver variants.
A fundamental text for teaching in the medical school of Salerno was the Pantegni,Footnote 105 the main source of medical knowledge in the twelfth and thirteenth centuries, surpassed in importance, from the second half of the thirteenth century onwards, only by Avicenna’s Canon. The Pantegni opens with an initial theoretical section (theorice). At Book ix.iv and v of this section, it takes up the topics of ‘hot phrenitis’ (frenesi calida) and ‘cold phrenitis’ and lethargy (et [frenesi] frigida, … lethargia).Footnote 106 The former is defined as ‘either coming from a hot complexion suffered by the brain or its membranes; or deriving from a hot swelling/tumour (apostema) in the membranes of the brain itself or in the brain; or from an abundance of bile in the veins (in venis) of the brain’. Different degrees of pain, dolor, are observed, depending on the kind of frenesis. A full set of possible physiologies is thus indicated, all located in the brain: swelling, heating and humoral overgorging in the brain’s vessels. The idea of tumour or swelling is also confirmed as central: one of the earliest central pieces of Medieval medical education, the Articella (which contained the translation of Galen’s De Arte known as the Microtegni or Tegni, and was used as a textbook and reference manual from the thirteenth to as late as the sixteenth century) contains in its so-called IsagogeFootnote 107 an illuminating discussion de modis apostematum, ‘about kinds of swelling/tumours’, that clarifies the topic in detail.Footnote 108
Regarding signs of phrenitis, the Pantegni mentions continuous fever and ‘strong heat to the touch (calor vero fortis in tactu)’, especially on the head and face compared to the rest of the body (tactus capitis et faciei est calidior in tactu qual totius corporis). Patients experience mental alienation and a state of restlessness (alienatio habetur mentis vigilie), and sometimes ‘sleep accompanied by hallucination/dreaming (somnus cum imaginatione)’. Phrenitics ‘are startled, with violent movements and screaming (fucitantur cum fortitudine et clamore)’; their tongue becomes thick and black, and ‘they pick fleeces from their clothes due to the corruption of their imagination (accipit de vestimentis fiosculos propter imagionationis corruptionem)’; ‘sometimes their eyes lacrimate, and they present a discharge, occasionally of the dry kind (eorum oculi aliquando lacrymant et lippi sunt aliquando sicci)’. When the illness arises through a swelling/apostema caused by blood, all the symptoms appear, including laughter and sleepiness, red eyes and alienation; the heating is severe; and the patient’s face is not particularly red, but is dry due to citrinity. Those who suffer from the bilious swelling/apostema present all the above-mentioned symptoms but accompanied by ‘anger, quarrelsomeness/tendency to pick fights and perfidy (cum ira contentione et perfidia)’. If the swelling/apostema is caused by black bile, on the other hand, the same symptoms are found, but ‘along with vanity and a perpetual state of lightness, alienation and excessive fear, suspicion and wailing (cum vanitate et levatione assidua alienatione nimia timore suspectione et ploratione)’.
Constantinus mentions the pulse as well, along lines by now familiar to us. He then moves on to the chest version of the disease, devoting particular attention to it:
There is also another frenesis which is born in the brain from the swelling/apostema of the diaphragm (nascens in cerebro ex apostemate diaphragmatis) because of the link with the nerveFootnote 109 which descends from the brain (propter colligantiam nervi ex cerebro discendentis). This frenesis has all the above-mentioned signs; in this case, however, they are not as severe. Fever is more serious around the whole body; moreover, heating arises due to the vicinity of the affected place to the heart,
and the hypochondria are heated as a consequence. Constantinus elaborates significantly on this expansion towards the chest and the lower torso. In the final paragraph, we read of
another kind of frenesis caused by heating of the liver in the diaphragm rising to the brain and its membranes because of their interconnections (ex calore epatis in diaphragmate ad cerebrum et eius pelliculas ascendentem propter colligantias eorum). A form of alienation also results from the powerful heating when the smoke caused by fever rises, and the head is damaged as a consequence.Footnote 110
Noteworthy here, in comparison with the Graeco-Roman sources being elaborated, is the greater inclusion of psychological types, moralized qualities and the hydraulics of humoral overgorging.
If the theoretical (theorice) part of the Pantegni articulates fine psychological and anatomical distinctions within phrenitis, the practical part (practice) perhaps reflects a more composite provenience: while the first ten books appear to be a fairly faithful version of Constantine’s Persian source,Footnote 111 the practice suggests the assimilation and incorporation of a variety of other material. For frenesis, consider 655, where Book 5 de passionibus membrorum interiorum begins. The sections de frenesi and de frigida frenesi are found at vii and viii, where therapy is mostly described along known lines: phlebotomy, and clysters in case of stypsis. Here too, the use of animal parts is mentioned as a therapeutic measure: Constantine recommends tying the organs of a recently slaughtered sheep to the patient’s head (pulmo recens pecoris capiti alligatus valet) and stimulating his or her sense of smell with aromatic substances, along with the usual caution about wine, and prescriptions for the use of vinegar in various preparations. These details offer a glimpse of the enduring subterranean flux of ancient therapeutics, which remained at the periphery of professional medicine but were never completely eliminated. Constantine also discusses the cold variant, de frigida frenesi; here too, at the end, the stimulant use of animal organs is mentioned.
Another key text within the Pantegni is the Viaticum, a practical treatise of travel medicine similarly popular in its time, although less ambitious in its intellectual scope. In the first book, Constantine describes a number of therapeutic measures, starting from the external portions of the head with affections of the hair and skin (e.g. dandruff). At 754 (1.18) some indications de frenesi are found. The disease is again qualified as a hot swelling or tumour in the meninges and sometimes in the brain matter (suba), ‘which is the worst and most damaging case (quod pessimum est et molestissimum)’. It is said to arise perhaps from two causes, one centred in the brain and involving the ascent of burning red bile (ex incensione choleri rubri cerebrum ascendentis), the other involving blood and, intriguingly, the heart and the blood it contains (de sanguis ebullitione in corde).
In the Viaticum, dire symptoms (terribilia accidentia) are listed more synthetically than in the texts by Constantinus already discussed: ‘excessive thirst, dryness of the mouth, blackness of the tongue, a sense of unease, disturbance, anxiety, excessive despondency (sitim nimiam, oris siccitatem, nigredinem lingue, asperitatem, molestationem, angustiam, nimiam defectionem)’, as well as sudden changes in external appearance, in the direction of redness or icterus, depending on the humoral cause. Constantinus also points out that frenesis can derive from another illness (alia passione nascitur) involving the diaphragm, stomach or womb via a sympathetic connection (vel est ex diaphragmate apostemate; vel ex stomachi passione; sive ex matrice; et quorum colligantia per nervos cerebrum patitur). There is also an analogy and possible association with mania and melancholy, perpetuating a conceptualizing ‘psychiatric’ move alongside the powerfully anatomical account. The therapeutic section addresses phlebotomy, dietetic recommendations and in some cases clysters.
Among the general medical compendia, one of the most influential was the Compendium medicinae by Gilbertus Anglicus (c. 1250s ce), possibly ‘the first great Latin survey of medical knowledge to have been composed after the arrival of Greek and Arabic texts in western Europe’.Footnote 112 At xxvii, in the section de medicatione frenesis and de frenesi Gilbertus defines the disease as an ‘inflamed apostema born in the anterior portion of the brain or its membranes (apostema ignitum in anteriori parte cerebri vel eius pelliculis natum)’. He also discusses the Greek name: ‘It acquired this name from the frenes (a frenibus), which surround the brain (quod cerebrum circumvolitant).’ This slight variation – from the frenes as any membranous part in the body to their being identified precisely with the meninges – is extremely significant, because it shows that the ‘membrane-like character’ of the part has become at least as important as its location. In the archaic world, the phrenes were the chest, lungs and heart, that is, a general area of the body. Then they became the diaphragm; then, in parallel with this, the soul and mind, and thus the brain as seat of soul and mind; then any membrane (diaphragm, spinal, meninges); and here specifically the membranes of the brain. Closing a circle of functional transmigration, the mental faculties have thus moved from chest to head via the vehicle of this histological item – no matter how inert, secondary and irrelevant its actual role in the body – or perhaps precisely because of this neutral, flexible quality of the Greek phrenes.
Gilbertus also distinguishes among different humoral causes and different types of frenitis: vera and non vera, and occurring in the body of the brain or in its membranes. As for symptoms, he mentions the common derangement, wakefulness, anger and fury, restlessness, disorderly tossing of oneself around, and being suddenly startled (alienatio; vigilie; ira et furor; inquietudo iacendi; inordinatio et proiectio, et erectio subita). But he points out that there are also variations depending on the causes. He also speaks of the pulse, the urine ‘thin and white (tenuis et alba)’, and the waxy discharge from the eyes, in line with other authors of the period. A whole chapter is devoted to the cause of the blanching of the urine (218–19), with detailed specification of the consequences of heating in various parts of the body, while in the course of offering a general account of the physiology of phrenitis, he elaborates much more than others on the pathology, anatomy and histology of the brain. Consider folio 101, where Gilbertus explains why moisture accumulates most in this body part:
This happens for two reasons. One, because of the great number of veins which go to the head, through which there is a rheumatism of the inferior part, as is clear in the anatomy (per quas reumatismus fit inferius, ut in anatomia apparet). The other cause is that the brain is in a state of continuous motion, and (its matter) is spongy (spongiosus). Hence, like a vacuum cup (velut ventosa), it will attract the humours which are mostly subject to attraction, and the hotter the brain becomes, the stronger will be its power of attraction
This argument is unique in the medieval material I have seen, and curiously evokes both Asclepiades’ corpuscular theory of phrenitis,Footnote 113 where the inflamed, overheated part creates a void to which the particles are swiftly attracted, almost ‘sucked’, causing a clogging of the passages through which they travel, and the Hippocratic idea that the head might work as a ‘cupping instrument’.Footnote 114 In this way, Gilbertus offers one additional anatomo-pathological element to the itinerary of the disease on its way to becoming an meningo-encephalitis, by focusing on the blood vessels. It is thus no coincidence that he mentions Aristotle earlier (218, folio 101)Footnote 115 or that he refers to anatomy and the positioning of the veins in the head as especially important, while also mentioning the liver as a possible locus of co-affection for phrenitis. The process of ‘suction’ described here, moreover, recalling Asclepiades, is another modality of explanation that emerges to rival the principle of humoral and ‘gaseous’ movement through the body.
Also particular to this discussion is the importance of food as a moistening and heating agent, as well as the role played by pain, dolor, in exacerbating the pathological movement of humours and the illness that follows (219, folio 101). At 221 (folio 102) Gilbertus offers some indications regarding therapy, involving massage, applications to the head and dietetics; we also read that the head should be shaved for the applications. The application of animal viscera found elsewhere is recommended here as well: ‘Suckling kitten/cubs should be cut open in the middle through their back, or a chicken or the lung of a ram, and after the intestines have been extracted, they should be applied on the forehead while still warm (catuli findantur lactantes per medium ex parte dorsi vel pulli vel pulmo arietinus, abiectis igitur intestinis applicentur fronti calidi).’ Phlebotomy is discussed as well. Here too, a change into lethargy is contemplated (222, folio 103) and said to be lethal.
University Medicine
In the Iberic context, the translations produced in the Toletan tradition include a fundamental one in this period: the eleventh-century Canon (al-Qānūn) by the Ibn Sīnā already mentioned, Latinized as Avicenna (980–1037 ce). This work was translated from Arabic into Latin by Gerardo da Cremona in the twelfth century and after that became a standard reference work in university teaching.Footnote 116 The doctrine put forward in the Canon was fundamentally humoral and accordingly identified madness with an imbalance of humours, or with a localized alteration in the imaginative faculty (at the front of the brain), in the rationality (in the central brain) or in the memory (at the back of the brain). Phrenitis is recognized as one of three key kinds of madness, together with mania and melancholia, reflecting the traditional tripartition first observed in Celsus.Footnote 117
Avicenna plays a special role in this story due to the extraordinary importance and wide dissemination of his Canon in Europe for centuries, especially after its translation into Latin.Footnote 118 I accordingly offer a detailed account of the section devoted to phrenitis, named karabitus (from the transliteration into Latin of the Arabic f-r-ā-n-ī-ṭ-s/qarānīṭis,Footnote 119 which in turn transliterates the Greek phrenitis/φρενῖτις), by summarizing the Latin translation in dialogue with Dols’s faithful summary of the same text from the Arabic original; I thus quote the Latin and occasionally give the corresponding Arabic term based on Dols.Footnote 120 This text deserves such detailed consideration because of its massive importance in shaping Western medicine and psychiatry.Footnote 121
In the third part of the Canon, devoted to ‘diseases of the bodily parts’, Chapters 3–5 deal with inflammations of the brain. Karabitus is found in Chapter 3, with discussion of symptoms and treatments. The disease is placed first, at the very opening of the chapter on swelling/abscess of the head, de apostemate capitis. First a definition is offered:
karabitus is called a hot swelling/abscess (apostema) in the membranes of the brain, the thin and the thick one [i.e. the dura mater and the pia mater], without involving the body of the brain itself, although an abscess to it can sometimes also occur
Here Avicenna disagrees with the opinion expressed by others, that ‘what is soft like brain, or hard like bone, cannot expand, and what cannot expand, cannot have an abscess’: the brain too, in his opinion, can suffer apostema.Footnote 122 He offers a terminological discussion, already commented on above: the term sirsām is properly applied to the disease suffered primarily by the meninges, and sometimes by the brain as a whole.
As for pathology, Avicenna believes that most patients (plurimi) die due to an impediment ‘in their breathing capacities (propter impedimentum in spiritu, Arabic: nafs)’.Footnote 123 He also proposes a regional account of the affection of the brain,Footnote 124 in which ‘the abscess has different locations according to different parts of the brain (apostema hoc habet loca diversa secundum partes cerebri diversas)’, and distinguishes two cases: that of two co-suffering parts and involvement of the brain as a whole. Here Avicenna is elaborating on Galen’s nosological tripartition at Loc. Aff. IV, 2 (8.226–27 K.): there are two simple kinds of phrenitis (with lesions of the senses and with damage to judgement, respectively) and a third which is a combination of them. Avicenna adds another kind, which involves memory, and also mentions carphology as a form of hallucination due to a lesion in the anterior portion of the brain.Footnote 125 When the central region is damaged, impairment in reasoning follows involving delirium and speech impediments; when the posterior portion is struck, patients forget what they are looking for or what they have just asked; when all parts are involved, all these signs appear together. Avicenna thus elaborates considerably on Galen and creates a theory of the ‘cerebral localization of the internal senses’ endowed with more complexity than those of his predecessors.Footnote 126
For Avicenna, the cause of phrenitis (eius … principium) is of course humoral: blood, pure yellow bile, pure red bile or bile burnt black, which is the most dangerous (sanguis, aut citrina cholera pura, aut rubea pura, aut adusta trahens ad nigredinem, et est vehementer malum). Relief is offered by purging, which takes various forms: sweating (sudore), epistaxis (fluxu sanguinis ex naribus) or venesection on the head can help resolve the condition, as can opening the cranium to allow the congestion to be released. Later on, bleeding through haemorrhoids is also said to be helpful (et karabitus quidem multotiens resolvitur per hemorroides cuum fluuntFootnote 127).
As for the relationship between karabitus and other diseases, Avicenna mentions the possibility of a change from pneumonia (permutatio ex peripleumonia) or, often, from ‘false’ to ‘real’ karabitus (non verum in verum). Some indicators can predict how hopeful a case is: ‘a reasoning disposition which combines laughing and crying together (permistio rationis composita ex fletu et risu)’ is dangerous, while ‘continuous laughter (risus aroonatiFootnote 128)’ can be a hopeful sign. Some doctors are said to claim that there can be an illness without fever similar to phrenitis; in regard to this, Avicenna describes a severe diseaseFootnote 129 characterized by great anxiety (fortis inquietudo), yawning (oscitatio), restlessness – ‘s/he cannot stay still, and at times attempts to climb the walls by jumping (habens eam non tolerat quietem, et fortasse saliendo ascendit parietes)’ – strong laughter, suffocation and thirst. Such patients cannot drink without suffocating (‘when s/he drinks water, s/he chokes on it and spits it out’, cuum bibit aquam strangulatur ea et expellit ipsam). ‘The day (when this final symptom occurs?) is fatal, according to opinion’; should the disease last for four days, no one escapes. At this point, ‘it happens that the patients’ faces turn dark, as do their tongues; their eyes are frozen/fixed (accidit ut ipsorum facies nigrescant: et lingue: et sint ipsorum oculi congelati)’; and their behaviour expresses fear and weakness (‘the disposition of those in fear’, dispositiones timentium). Death follows, as ‘their movements slacken (ipsorum lenientur motus)’, ‘their strength recedes, and their pulse weakens (cadunt eorum virtutes et pulsus)’. Death often occurs through suffocation (cum strangulatione) and is spasmodic: ‘You can see the patients running about, and then suddenly collapse and die (vides eos currentes, deinde vides post illud eos statim cadere et mori)’. In this version of the disease, without fever, as noted, a sympathetic reaction takes place between the brain and another ‘organ of higher functions’, such as those of respiration. This feverless variant is a syndrome which also accommodates the chest manifestations that belong to phrenitis, suggesting a coaffection of brain, throat and chest.
Avicenna then moves on in chapter 2 to describe the signs common to all kinds of true karabitus (signa autem communia speciebus ipsius veris). These are intermittent alienation (alienatio); an ‘aversion to talking or a lack of any desire to do so’ (abominatio loquele, et pigritia ab ea); intellectual confusion (permistio intellectus); and obsessively inspecting one’s fingertips (inquisitio extremitatum). Corporeally, ‘the extremities are cold, and there is agitation (extremorum frigus, et agitatio)’ and a ‘tension on the surface of the bones of the chest (extensio ossium pectoris ad speriora multa)’, perhaps what ancient sources called ‘tension of the hypochondrium’;Footnote 130 tremor; troubled sleep (somnus inquietus), from which patients emerge abruptly; and they cry out both when they are sleeping and when they are awake (clamant, et quandoque dormiunt, et quandoque vigilant). Patients are prey to nightmares, visions and voices. ‘Their sleep is most troubled; it is disturbed by hallucinations and by awful, unspeakable dreams, with spasmodic movements and mixed with shouting’ (commotus cum fantasiis, et somniis corruptis terribilibus, et eius excitatio est permista cum vocibus). They are also immoderate and uncharacteristically ashamed, bold or angry (verecundia, et audacia, et ira ultra consuetudine). They ‘avoid the sunlight and shrink away from it (abhorrent radios, et avertunt se ab ipsis)’, ‘move their tongues about frantically and twist them (agitant lingue eorum vehementer, et stringunt eas)’, and their voice often falters (multotiens abscinditur eorum vox). They yearn for water, but drink only a bit (et desiderant aquas, et bibent ex ea parum). Their extremities are cold (infrigidantur eorum extremitates); their urine tends to be thin and clear (ipsorum autem urine sunt declinante ad tenuitatem et subtilitatem); and their pulse is hard ‘because of the nervous nature of the swelling in a hard part (propter essentiam apostematis in membro nervosam duro)’ and spastic.
The preceding signs are psychological: ‘forgetfulness of the context surrounding’ the patient (oblivio rei propinque), ‘sadness for no reason (tristitia sine causa)’, ‘bad dreams (somnia mala)’, and considerable affection of the head (which is called soda), ‘oppression and bloating (gravitas et repletio)’. In previous stages, ‘a yellow complexion, a transfixed state of wakefulness and troubled sleep (citrinitas faciei, et vigilie prolixe, et somnus inquietus)’ are noted. The upsurge of bile towards the brain causes exacerbation, as the toxic humour revolves through the veins and drenches the brain matter, causing a sensation of pain which begins in the back of the head, where the neck joins the head; dry eyes; and lacrimation from a single eye. Often ‘these patients’ veins are a vivid red (veni ipsorum forti afficiantur rubedine)’, and ‘sometimes their nostrils bleed (distillationes sanguinis ex naribus)’. Their eyes often itch (plerumque fricant oculos suos), and ‘their body tends to a maximum of relaxation, in most of the body with the exception of their hands (declinant ad quietem et requiem in maiori parte corporis nisi in manibus)’.
This is the notorious crocydism, which Avicenna joins other authorities in describing: those who suffer from karabitus grope/search the air with their fingers or pick at their hair. ‘This happens mostly when their eyes are shut, sometimes accompanied by spasmodic movements of the pupils and moaning (fit illud plurimum cum clausione oculorum. Et quandoquam fit cum pupillatione et querela)’. The patients become lazy about speaking (pigri fiunt in loquendo) and do so only weakly, and can run out of control or lose awareness of their physiological functions, such as passing urine or the sense of pain, so that they do not react to touch (‘They are unable to say if they feel pain in one of their limbs, and if someone touches them suddenly in one of the sore limbs, s/he does not realize it’, obliviscunt doloris, si est in membris ipsorum: immo si aliquis de membris ipsorum dolorosis impetuose tangit, non percipiut ipsum). For Avicenna, this phenomenon has to do with the localization of the abscess in the frontal part of the head (in parte anteriore), which affects the imagination: ‘Patients begin to pick hair and flocks from their clothes, or to try to remove flecks of straw or the like from walls, and they imagine fantastic objects they do not find (incipient colligere villos ex vestibus et paleas et que sunt similia illis e parietibus; et imaginant aliquas fantasias que non inveniunt)’.
Later Avicenna also describes a set of symptoms that precede ‘true’ sirsen (folio 144, col. 2, end).Footnote 131 Intriguingly, these strike the chest: they originate ‘in the diaphragm and in the musculature of the chest (ex partibus velaminis distinguentis, et lacertorum pectoris)’ and resemble the signs of birsen and pleurisis: ‘a piercing pain in the side when inhaling, asthmatic breathing, a thumping pulse, and an incessant dry cough, followed by large quantities of sputum once the part is abundantly moistened (dolor pungitiuus in latere apud anhelitus: et strictura anhelitus, et pulsus ferrinus, et tussis plurima sicca, deinde humectatur quam plurimum, et expuit)’. There is fever, and the heat tends towards the chest, causing ‘tension above the chest bone (extensio ossium pectoris ad superiora)’; there is spasm as well. In all these matters, Avicenna makes nuanced distinctions between sirsen (the Latinization of sirsām) vera, non vera, manifesta, birsen (the Latinization of barsām) and karabitus. These cannot be summarized or quoted in full, but include lacrimation from the eyes, which materializes the hallucinations these patients experience (‘their eyes exude tears, and a dense residue’, distillant oculi eius, et lippitudinem). What matters most is the nosological stemma he is drawing, the multiple aetiologies and manifestations alongside the double localization, and the regional subdivisions within the inflammation of the brain.
Avicenna’s account also includes ‘sketches’ of such patients’ character and physiognomy. With pure red bile (ex cholera rubea pura), for example,
their character shows a certain rapacity and a melancholic prowess and boldness in discussion, almost as in those who want to pick a fight, and their noses become sharper, as do their extremities; and there is a strong tension upwards in their foreheads
With burnt bile (ex cholera adusta) there are ‘signs common to daemonic possession and quarrelsomeness, accompanied by deeper respiration and groping with the hands (signa ut quod communitas accidentium accidit cum demonio, et rixa; et spiritus magnificatur; et magnificatur inquisitio)’. ‘Their eyes are troubled, and the cause is sibare – indeed, the condition is almost equal to sibare proper (et sunt oculi eorum perturbati, et eius causa est sibare, et est quasi ipsa)’.
What sibare is, is explained in a discussion at the end of the section (de sibare). The Arabic name indicates daemonic possession that comes with a bilious, hot sirsen (dicitur sibare demonium superfluum, accidens cum sirsen calido cholerico) whose signs are a combination of those we have seen already, including alienation and confused reasoning. When sibare appears, the signs of sleep disturbance and insomnia follow shortly thereafter: agitation, hyperventilation and forgetfulness; inconsequential responses; dull, red eyes. A sensation spreads to the back of the head; there is pain caused by the vapours and involuntary weeping. With fever, a parched, dried tongue and then an inability to speak appear. The patient should be kept moist, and ‘it is necessary to restrain the patient by binding his limbs’ (50).Footnote 132
In terms of therapy, in chapter 3 Avicenna offers a compendium of the known pharmacological remedies, but also other bodily interventions and soothing measures. First he mentions ‘phlebotomy of the capital region’ (flebotomia ex cephalica) aimed at opening an outlet for the humours. He specifies the various cautions to be applied when phlebotomizing the forehead or the hands, difficult operations which might produce conflict with the patient. Massage with rose oil and vinegar, the oxyrrhodinum mentioned by Greek doctors, and other cooling treatments are mentioned; various applications with specific herbs are also suggested (e.g. emplastrum ex foliis senticis). The suggestions regarding the ideal environment for the ill found in Celsus, Aretaeus and Alexander of Tralles are mentioned by Avicenna as well: a quiet house, clean air, no images or decorations which might provoke the imagination or damage the membranes of the brain.Footnote 133 The fragrance of ‘cooling flowers’ is beneficial,Footnote 134 as is the company of ‘friends, especially close and sympathetic ones, but also people before whom the patient might feel ashamed (amicos suos prudentes sibi caros, et misericordes eius: et ex quo verecundetur)’, since their presence invites calm. Sleep should be induced through means such as opium, poppy syrup and other applications. Clysters can also serve to draw matter downward by purging, as can foot massages with hot water, as well as binding, constraining and cupping. Various nutriments are recommended: oxymel, cucurbita, herbs, grains, fruits considered cooling, or restorative items such as goat or human milk. Embrocations are also suggested. Tying the patient up can be helpful at times. Avoiding certain meteorological extremes is also advised; these include ‘open air and malignant hot winds, as well as the heat, the days of the Dog (the summer) and the sun, in order to avoid relapses (ab aeribus, et ventis malis, et calidis, et canicularibus diebus et sole ut non incurrat recidiva)’. Soothing baths are useful to promote sleep, which is key to recovery; the consumption of lean meat is as well. To these universal cures for phrenitis, Avicenna adds others that depend on whether the patient is affected by the bilious or the bloody type of charabitus (aliud cholericum, aliud sanguineum). A combination of pharmacological, dietetic and bodily interventions is described for each, although these will not be surveyed here.
In Avicenna’s account – which, as noted, remained a standard in European medical education for centuries – the encephalic interpretation is central, and its backbone is the Galenic material. Avicenna’s loyalty to this version of the story is maintained despite his otherwise complete support of the Aristotelian, cardiocentric view of the human body and his disregard for Galen as a ‘philosopher’. This compromise reveals phrenitis as a perspicuous illustration of another phase in the competition between these two systems in the development of modern medicine, biology and science, in which the encephalocentric model is integrated and ultimately prevails.Footnote 135 At the same time as Avicenna depicts an encephalitic phrenitis, he also insists at length on the involvement of the chest, lungs and viscera (following Galen’s presentation in On the Affected PlacesFootnote 136), expands on the ethical-characteriological aspects of the disease and inserts foreign elements, such as references to a kind of rabies and to the daemonic ‘sibari’.
Quite different in this respect are other fundamental Arabic medical texts from the same period, such as those authored by the Andalusian Ibn-Rushd (Abū l-Walīd Muḥammad Ibn Aḥmad Ibn Rushd, 1126–1198 ce), known as Averroes, a royal physician at the Almohad court and author of a number of medical treatises, and by his friend and collaborator Ibn Zuhr (Avenzoar). Averroes’s al-Kulliyāt fī l-ṭibb (‘General Principles of Medicine’, Latinized in the West as the Liber ColligetFootnote 137), written around 1162 ce, is the more medical text. For the history of phrenitis, however, it is of little help: it mostly discusses general principles of physiology, elaborated in an Aristotelian frame, rather than nosology, and does not thematize the diseases of the head as of particular medical importance.Footnote 138
The title of the Colliget, with its general scope, is complementary to that of the Kitāb al-Taysir (‘Book of Simplification Concerning Therapeutics and Diet’) written by Avenzoar on a commission from Averroes himself; the two men collaborated and their texts are best understood together. An instance parallel to phrenitis is found in the first section of the Taysir,Footnote 139 de egritudinibus capitis. Here caput is given a literal, concrete meaning, indicating a firmly tangible localization.Footnote 140 (Thus dandruff, lice and other affections of the hair are treated here.)Footnote 141 At 1.3.5 (folio 4) discussions relevant to our topic begin, regarding ‘inflammation of the meninges (de apostematibus paniculorum capitis)’ and at 1.3.6 (folio 5) ‘of the brain and the rethe mirabilis’ (de apostematibus cerebri et rethe mirabilis, folio 6)’.
Two kinds of swelling or apostemata are found here. The first, ‘in the membranes of the head’, happens ‘with no external cause (absque causa extrinseca)’. It can strike the external membrane in the cranium or the harder, internal one, called the dura mater, and is caused by acrid humours (ex humoribus acutis); excruciating pain, red eyes and disturbances of the senses and the intellect follow. For both cases, phlebotomy and specific diets are recommended and described in detail, taking up the majority of the space devoted to the disease. Suffering, lack of sleep and oppression are mentioned, but no specific clinical element connects the passage to phrenitis in a detailed way. The next section, ‘on the apostemata of the brain (de apostematibus cerebri)’, opens with the key point that the brain’s own substance produces the humour which causes the swelling (apostema procreat in sua propria substantia). This is a particularly serious disease, which can also involve the so-called rethe mirabilis. Its symptoms are implicated by one another and unmistakable (inseparabilia et certa), in the same way that darkness and clouds (umbrositas et nebulositas) inevitably accompany rain, a meteorological simile which underlines the determinism of the account and the strength of the corporeal semiotics: ‘a reddening of the white of the eyes (rubedo albedinis oculorum)’; ‘swelling of the eyelid … with difficulty of movement … acute fever (grossities palpebrarum … cum difficultate motorum … fortitudo febris)’. All this is quite compatible with our phrenitis; on the other hand, the passage is neatly encephalic, devoid of the elements which make phrenitis a disease and a human experience with a mental component.
The discussion of phrenitis proper appears at 1.14 (folio 12), de sirsen calido cum alienatione. Avenzoar first distinguishes a proper phrenitis from one deriving from other diseases. Only once the disease has fixed itself in the brain does it require dedicated care (postquam in cerebro confirmata fuerit indigent cura speciali et propria). Its causes are acidic and mordent humours and the vapours they generate as they rise from the stomach to the head. A strong, hot fever can also generate the disease. These two types require different treatments.
In the centuries that followed, Avicenna’s text acquired enormous influence in medical and university quarters, as already noted. The Concordanciae by the thirteenth-century medical author Jean de Saint-Amand, for instance, a key reference work in medical education at the Faculté de médecine in Paris for over two centuries thereafter,Footnote 142 offers at the lemma Frenesis (136 Pagel) seven statements which emphasize precisely the points Avicenna included as key in his account of the disease.Footnote 143 The sheer number of copies and commentaries on the Canon, moreover, testify to its importance. Space allows for mention of only one notable specimen of this academic and scientific activity, the commentary by the medical master of Padua and Perugia, Gentile da Foligno (d. 1348), called ‘speculator’ for the fineness of his theoretical engagement with medical problems. Gentile was the best-known doctor of the fourteenth century and, with Taddeo Alderotti, the key figure of medical scholasticism in the Middle Ages; his lengthy commentary on the whole of Avicenna’s Canon became an important instrument for the use of this influential text by teachers of medicine, students and practitioners. If we look at how Gentile reads and explains the section of the Canon devoted to karabitus (phrenitis), and the way he raises questions and objections, we get a good sense of which points were extracted and discussed as central to our disease, as well as what the matters of contention were and which passages were seen to require further explanation.Footnote 144 At folio 55,Footnote 145 Gentile begins by commenting on apostema as an essential element of charabitus (phrenitis) and on its pathological significance per se. He then notes a number of dubia – points where questions, uncertainties or objections arise – for instance, ‘he is uncertain whether there could be phrenitis without apostema’ (dubitat utrum charabitus possit esse sine apostemate, dubium 1). A look at the dubia Gentile proposes is instructive for reconstructing the agendas of contemporary scientists and physicians. He points out that there are two types of charabitus (dubium 1), one ‘real’ (verus), in which there is continuous fever and apostema, and another not ‘real’, involving no alienation of a continuous kind and similar to the state which occurs in fevers. This second kind is caused by vapours exhaled from the stomach or the belly: the continuity of fever, the alienation and the differentiation between real and non-real phrenitides are confirmed as central themes. Gentile also discusses the matter (materia) of the brain and the nature of the paniculi (meninges) in order to ask whether these too can suffer a ‘hot’ affection.Footnote 146 In fact, they are made of materia frigida or are membra frigida (dubium 2), and Gentile remarks that charabitus is most often caused by ‘hot, thin matter (materia calida et subtili)’, a histological point that acquired importance from Rāzī onwards, as already noted.Footnote 147
Next Gentile asks which membrane is more exposed to apostema, the so-called pia mater or the dura mater (in subtili scilicet pia matre an in grosso, dubium 3), and whether an apostema can occur in the brain matter as well (dubitat utrum charabitus sit apostema solius paniculi; vel etiam sit apostema substantie cerebri, dubium 4). He also asks which of the two types should be regarded as worse (dubium 5), exposing and discussing Avicenna’s views on all these points at length (folios 55–56). Gentile’s arguments and distinctions cannot be recounted in detail here, nor would they add much to the discussion. What is notable is how the terms of the discussion vis-à-vis this disease increasingly coalesce around anatomically localizing,Footnote 148 histological-biochemical topics (to use anachronistic terms): the shape and texture of the affected parts, the hot or cold quality, the humours involved. Gentile devotes dubia 6–10 (folio 56) to the latter question, reflecting on the humours mentioned by Avicenna for phrenitis – cholera pura, rubea, citrina, sanguis cholericus or bile mixed with phlegma – comparing Avicenna’s views with those of Avenzoar, offering a glimpse into the ongoing debates about humoral determinations. Dubium 11 discusses the different possibilities for extinguishing or resolving phrenitis, including bleeding from the nose or the belly and sweating (folio 56), while Dubium 12 treats lethargy and its conversion into phrenitis (folio 57); conversion from peripleumonia was discussed previously (folio 56).
Of the themes addressed by Gentile, some involve clinical aspects, such as the behaviour of these patients. At folio 56, for example, he speaks of the continuous laughter, and at folio 57 of the restlessness and yawning (inquietudo et oscitatio) of phrenitics, as often discussed by medical authors. He also mentions their ‘climbing the walls’ and their pathological drinking and thirst. These signs of distress and overheating are described one by one and dissected in the section on signs (folio 57): alienation and disturbance with talking (abominatio loquele et pigritia ab ea), confusion (permistio intellectus), as well as a variety of physical symptoms (de signibus eius communibus). Among the latter, the insistence on the agitation of these patients stands out: agitatio, spiritus agitatus, tremor membrorum, etc. Gentile also focuses on the psychology and moral existence of phrenitics (folio 58): they shout and jump due to awful dreams (propter terribilia quae in somniis viderunt … excitantur cum vocibus propter terribilia somnia), and physical suffering causes morally flawed behaviour, such as shamelessness (inverecundia) due to the damage to their judgement (propter errore extimative), or boldness and anger due to overheating (audacia et ira propter fervorem caloris). A lengthy passage is also devoted to the patients’ pathological relationship to drinking water (folio 58). At folio 59, Gentile returns to the topic of hallucination and crocydism, offering a highly detailed explanation of the process of the obfuscation of the eyes as body part. Here he is reproducing Avicenna, of course, but he further materializes and localizes the cognitive, psychological datum – the confused imagination of these patients – formalizing this corporeal version of phrenitis even further, while populating it with more and more details.
This dense commentary illustrates the process of preparation, so to say, of the nosological datum phrenitis for its final meningitic outcome in modern medicine.Footnote 149 Other features perpetuate traditional elements while corroborating this development, especially the reference to the chest. Folios 59–60 accordingly contain a discussion of birsen, sirsen and pleuritis, and of the communalities of the two membranes (cerebral and diaphragmatic/pleural) as a vehicle for pathological similarity. This again confirms the relevance of the histological connection, as well as the interest in the distinction between ‘real’ and ‘false’ phrenitis, and the relationship of the disease to lethargy. At folio 62, in the middle of various observations on Avicenna’s therapeutics of phrenitis, Gentile devotes a section to the ideal domus, the domestic environment which should be offered to soothe these patients, and to light and darkness, while also mentioning sleep, phlebotomy, embrocations, oxyrrhodinum, massages, dietetics and all the usual topics.
In conclusion, the main points Gentile extracts, by choosing specific lemmata in Avicenna, offer a telling picture of what is preserved in the tradition, studied, elaborated and taken for granted in this period. No great new ideas are found here. But the traditional elements are by now fully digested, so to speak, and assimilated with both intense scrutiny and a translation of old – sometimes millennia-old – doctrinal intricacies into living medical practices. Since these texts continue to circulate as key medical materials for centuries, they offer solid confirmation of how phrenitis persists, despite other changes, as a consistent set of signs and symptoms, but simultaneously advances along a trajectory of greater and greater embodiment, still keeping chest and head together and touching on key topics of psychological and ethical life.
Two Medical Masters: Arnau and Bernard
A unique perspective on medieval reflections on mental health comes from two other authors who were not part of the established teaching syllabus, the Valencian (or French?)Footnote 150 medical doctor Arnau de Vilanova, author of the De parte operativa (c. 1306–08 ce), i.e. ‘on the practical, operative part of medicine’, a work not intended for university teaching but more theoretical in scope;Footnote 151 and Bernard de Gordon, master of the faculty of medicine at Montpellier, who authored a Practicum or Lilium medicinae (1305 ce).
Only the initial part of Arnau’s De parte operativa, entirely devoted to damage to and disorders of the mental sphere and related cures, survives. For us, this section of Arnau’s work is important as an extensive attempt to organize a kind of ‘psychiatric manual’ complete with a form of classification and conceptualization of the diseases of the mind. Arnau devotes a chapter to frenesis at the very beginning of the collection, followed by lethargy. The text first offers its own version of how to tackle the problem of the name of the disease and its oscillating indication between brain and chest in the Arabic terms birsām/sirsām:
The Greek term Frenesis properly corresponds in Latin to a lesion of the membranes or pelliculae and the like. The term is thus attributed indifferently with a change of name, despite its seeming meaning, to any hot apostema of the membranes, those of the head as much as those of the chest, because it is by the affection of either of those that that highest and absolute damage to the human individual, which is the loss of reason, occurs
It is worth noting that this author, unlike Avicenna, but in line with other medieval texts,Footnote 153 stops well short of dismissing the ambiguity in the name as merely a linguistic problem: derangement, the gravest damage a living being can suffer, can be caused by either meninges or diaphragm. He then proceeds to explain the Persian origin of the terms barsām and sirsām, and how the name karabitus (or variations of it) arose from the different vocalism of the Arabic when the Greek φρενῖτις was translated into that language.Footnote 154 The fact that the double localization is here an ontological point and no longer a question of nomenclature is confirmed by what follows: ‘The true kind of frenesis is the one of the head, but one of the chest is also known under this name, and occasionally, following a comparable kind of apostema, there is one in the womb or stomach (Species frenesis vera est capitalis, nota est pectoralis et interdum ex simili apostemate in matrice vel stomacho).’ The possible involvement of other parts of the body is made clear, and the ranking of the variety in the head as vera and that in the chest as nota offers a telling commentary on the possible understandings of phrenes discussed in the early chapters of this book. The true damage is that in the centre of mental life, but that in the chest and the illness that results from it is ‘notable’ (nota, ‘well-known, widely recognized’, sc. in medical authorities).Footnote 155 The importance of chest and stomach resurfaces when Arnau summarizes the causes of the disease: alongside any external factors ‘which generate or exacerbate the hot humours, or move them towards a place of collection (que humores calidos aut generant aut acuunt aut movent ad locum collectionis)’, there are antecedent humoral causes but also constitutional ones (‘a weakness … a bad disposition’, debilitas … mala dispositio). These are localized elsewhere than in the head, especially in the heart, which can exude acridic vapours and hot humours upwards (potius cordis, mandantis acutum vaporem aut calidum humorem), with dire consequences for the head.
The mention of the heart as a source of impediment to the centre of cognition through harmful exhalations – not only the direct involvement of the cor, but the adoption of the narrative of De partibus animalium,Footnote 156 whereby the ‘south of the body’ invades the purity and operative clarity of the ‘north’, impairing it – is a noteworthy Aristotelian insertion.Footnote 157 Additional damage can be done by other fluids and humours, such as boiling blood (sanguis fervens) in the membranes or various biles and vapours. When these are excessive, they cause illness by accumulating and being further compressed (coartatus/coartata) into pathological places, especially within the membranes.
The signs Arnau recognizes are the well-known ones, which dominate in Galen and are transmitted by the encyclopaedic authors (although in his case mostly filtered through Avicenna): ‘daemoniac alienation, with false and interrupted laughter; violent distress; sticking out the tongue, and blackness of the tongue; whitish and very watery urine; a spasmodic, frequent, trembling pulse (alienatio demoniaca, cum falso risu et interpolato; inquietudo vehemens; emissio lingue eiusque nigredo; urina alba et maxime aquosa; pulsus spasmosus, frequens, tremulus)’. He then discusses the change into lethargy, as well as the signs of ‘apostema of the body of the brain’ (as opposed to the membranes) and ‘of the anterior and middle part’. These manifestations are partly familiar to students of ancient medicine from the portrayal of distress already found in the Hippocratic authors:
disappearance of the coloured part of the eye and display of the white; choice of a supine position when lying down; swelling of the belly and extension of the bones of the chest (occultatio nigredinis oculorum et aparicio albedinis; electio decubitus resupini; inflatio ventris et extensio ossium pectoris); decrease in febrile inflammation; insensibility to the fever in the patient; blackness of the body
There is a reference to the pulse, familiar from imperial nosology onwards, and again ‘tremor, much throwing of oneself around; grinding of the teeth; twisting eyes and neck (tremor; multitudo iectigacionis; stridor dentium; tortio oculorum et cervicis)’. The classic resolution occurs through a release of fluid: ‘Signs of resolution of the disease through haemorrhage through the nose or haemorrhoids or menstruation or bleeding from the womb: abundant evacuation through the above-mentioned parts, with recession of the alienation and recovery of the correct pulse’.Footnote 158 Arnau also mentions conversion into other illnesses: lethargy, of course; ‘ethic’ fever (with daily oscillations, associated with phthisis), ethica febris; spasm; and in the case of apostema, of the substance of the brain in its anterior or middle part (in apostemate substantie cerebri et partis anterioris aut medie).
Bernard de Gordon’s Practicum or Lilium medicinae (1305) achieved great fame and diffusion, becoming required reading for medical students at Montpellier and being widely consulted elsewhere.Footnote 159 He opens his treatise with fevers, and within this topic mentions in the first place frenesis as an example of the dangerous ardent kind. The dedicated section is found at 216, in de passionibus capitibus, Particula II, xxii, de Phrenesi. Here the disease is defined as apostema calidum in panniculis cerebri generatum, ‘a hot apostema originating in the membranes of the brain’; its cause is pure bile and the boiling of blood in the heart or liver (causa est cholera pura, aut ebullitio sanguinis in corde aut hepate). Localization, concreteness and a focus on the body seem to prevail, as phrenitis increasingly becomes swollen, hot, organ-based and tangible, and the heart–brain cooperation is maintained in varying forms.
The text becomes especially interesting when Bernard discusses the concomitant causes: here the accent is heavily on ‘heating’ in all its manifestations and possible vehicles. Youth, the summer season – the Dog Days in particular – staying out in the sun without a hat, as well as eating warm or warming food, can all play a role as concomitant causes.Footnote 160 Bernard also recognizes the two kinds of phrenitis. There is a phrenitis vera that arises ‘from pure red bile or burnt red bile, or vapour rising from blood boiling in the heart and liver, as it gathers in the membranes of the brain and in the substance of the marrow (in substantia medullari)’, and a non vera, of multiple localization and aetiology (‘from yellow bile, or following fevers of different kinds, as well as apostema of the lung, the diaphragm, the stomach, the liver, the womb and so on’, 216). In the first case, the signs are ‘continuous fever, alienation, wakefulness, thirst, blackness of the tongue, disorderly movement of the feet and hands, agitation of the whole body, continuous talking and terrible furious symptoms’. In the second case, the non vera, the signs are milder in their course and intermittent: omnia sunt remissa, et aliquando quiescent. There is a ranking of severity among these various types: deterior is the one in the substantia of the marrow, followed by the one in the pia mater, then the one in the dura mater. The worst is the kind caused by burnt and not-burnt red bile; then the one caused by blood; then the one caused by yellow bile. Especially certain signs of impending death are urine that turns white after having been coloured, continuous alienation and a wakeful state, urine retention and spasms. Finally, two visible symptoms are mentioned which are also not found elsewhere in the ancient and medieval material, but appear in modern medical cases:Footnote 161 if the tibiae are extended and the patient cannot bend the leg (conduplicare),Footnote 162 and if a vesica appears in the thumb. In these cases, the physician is advised, ‘Best to run!’ (medicus igitur confestim fugere debet).
The cure Bernard proposes consists of phlebotomy, various cooling measures, limited food intake and a light diet, and again the application of the viscera of slaughtered animals, cockerel or goat lungs, to be extracted from the back while the animal is still alive (de gallo et de pulmone arietis et quod per dorsum extrahatur animali vivente). A cold environment and cold water are helpful (domum … frigida, et aspergatur aqua frigida). In the case of extreme behaviour (218), patients should be tied up to prevent them from doing harm to themselves or others. In some instances, phrenitis can combine with ‘wolf-like mania (mania lupina)’, with dire consequences: the patient climbs walls and the like (et tunc accidentia terribilia, quoniam ascendit parietes et similia).
These two works effectively reflect learned medicine from the first half (Gilbertus) and late thirteenth century (Bernard). Both were very popular in their time and enjoyed a wide manuscript diffusion, and were translated into the vernacular and then widely printed in the Renaissance, representing the background against which modern anatomists set their own understanding of phrenitis. As these two examples show, then, medically speaking in the course of the Middle Ages phrenitis is confirmed as a strong nosological label, while simultaneously becoming a salient collection of symptoms independent of a diagnosis.
Phren(es) and phrenitis in Jewish Communities and Andalusian Judaeo-Arabic Sources
Arabic translators and medical authors form the largest non-Latin corpus of testimonies to the reception of Graeco-Roman medicine in the medieval West. But an important role in this history, inextricable from the Arabic tradition as a whole, is played by philosophers and medical thinkers from Jewish communities, who also mediated and transmitted Greek medical doctrine, studying it in Latin or more often Arabic versions.
A glimpse into the Andalusian Jewish milieu is offered by the glossary compiled by Marwan ibn Ǧanah (Rabbi Jonah, tenth/eleventh century ce), the so-called Kitab at-Talkhis.Footnote 163 Here the entries for phrenitis and phrenes are clarified in an interesting way combined with what appears to us to be greater confusion. Entry 795 Bos et al. (folio 67r,13–v,2), first of all, shows that here as well controversy about the meaning of Greek phrenes is alive, inviting comparison with the Alphita entry:Footnote 164
Frinās (phrenes/φρένες) is the midriff (ḥijāb) known as diyāfrāghmā (diaphragma/διάφραγµα, diaphragm). Plato applied this term to feeblemindedness. It was called frinās since they assumed that if (the midriff) is afflicted by swelling or fever, a man becomes mentally confused and it causes an absence of mind. They therefore thought that this is the seat of the mental faculties. Galen disagreed with this (idea) – from Ahrun’s book.
Note the ambivalence regarding the localization – the midriff – and the pathology, ‘feeblemindedness’, which Plato identified with phrenes neither in the Timaeus, to which this passage refers, nor anywhere else. The disease phrenitis, this superimposition suggests, is automatically evoked by the term phrenes and the mention of the related body parts. At 899 Bos et al. (folio 76r, 4–8) Marwan ibn Ǧanah defines the term phrenitis itself, Qrānīṭus: ‘qrānīṭus (sic, i.e. phrenitis/φρένιτις) is the midriff (ḥijāb), called qrānīṭush, which can be translated “the mind” (al-ʿaql), Aristotle said this in his Book on Animals (Kitāb al-Ḥayawān). From Galen’s Book on the Crisis (Kitāb al-Buḥrān): Qrānīṭus is an inflammation of the brain (waram al-dimāgh) in the Greek language. The Persians call it birsām.’ Here again, locus and affection are confused,Footnote 165 and qrānīṭus – which derives from the disease name – is said to be the diaphragm and figuratively the mind. The brain is omitted from the definition of the disease; the early, imprecise term birsām, with its reference primarily to the chest, is brought in instead. The swelling of the brain known to us from other medieval sources as sirsām, on the other hand, appears at entry 1002 Bos et al. (folios 81v, 14–82r, 2): ‘shirsām (phrenitis) is a swelling (waram) occurring in the brain which is caused by either heat or cold – from al-Rāzī’s Kitāb al-Taqsīm wa-l-tashjīr. From (Galen’s) Book on Causes and Symptoms (Kitāb al-ʿIlal wa-l-aʿrāḍ): Hot phrenitis (shirsām) is a mental confusion which occurs in combination with fever, if the brain is affected by a swelling.’Footnote 166 The vast majority of these Jewish texts are not translated into European languages, but one of the most representative is available in a recent edition, the Medical Aphorisms of the Andalusia-born Sephardic scholar Moses Maimonides (twelfth century CE).Footnote 167 This work, originally written in Arabic possibly when Maimonides was living in Cairo,Footnote 168 is an important complement to the general picture I am sketching: as Bos reiterates, it was widely read and copied for centuries and enjoyed ‘great popularity in medieval Western Europe. In the thirteenth century it was translated into Latin … Until the fifteenth century the Aphorisms was, as Muntner remarks, “the most widely known and wanted repetitorium of Galen”.’Footnote 169 In addition, Maimonides’s Aphorisms became influential in Jewish circles through two major Hebrew translations.Footnote 170 This evident popularity shows that the Greek medical corpus not only circulated among Jewish doctors and intellectuals, but was meditated upon and abridged for practical use,Footnote 171 and that in these communities too phrenitis was recognized and perpetuated as a useful nosological concept and a concrete clinical reality by practitioners and students.Footnote 172
Phrenitis is mentioned nine times in the Aphorisms in a relevant manner, in connection with a general prognosis (Treatise 6), the pathological topic of swelling (Treatise 9) and the general definition of diseases (Treatise 23). At 6.11 (3 Bos) Maimonides discusses the connection between melancholy and phrenitis: ‘Sometimes melancholic delusion and phrenitis occur together. An indication of this is that at one point [someone suffering from it] talks continually; for this is a symptom of phrenitis, while at another point he is continually silent, for this is a symptom of melancholic delusion.’ At 6.37 (9 Bos) the author offers a description of the disease and a summary of its chief symptoms. Just as in the Syriac Book of Medicines, the apparent source is Galen’s On the Affected Places 5.4,Footnote 173 where diaphragmatic phrenitis is found. This is perhaps the most significant aphorism for our purposes – a firm, numbered list of items is selected with respect to phrenitis:
The signs of phrenitis are sixteen: sleeplessness or disturbed sleep, delirium manifesting itself gradually, acute fever which never subsides, short-term memory loss, lack of thirst, very aggressive and insolent behaviour displayed by the patient, deep and intermittent respiration, a small and hard pulse, picking flocks from garments or straw from walls, roughness of the tongue, pain in the back of the head, a dry discharge from the eyes and an acrid tear streaming from one eye, drops of blood dripping from the nose, acoustic hallucinations, loss of the sensation of touch throughout the body even [when the patient is touched] with force, and the patient lies prostrate and is unresponsive to questions. All these symptoms can occur simultaneously, but sometimes only a majority thereof.
At 6.53 (12 Bos) the diaphragmatic implications are mentioned, again following Galen’s Loc. Aff. 5.4:
Contraction of the hypochondria is a special sign of an inflammation of the diaphragm and appears from the very beginning. Similarly, when phrenitis has been established, the hypochondria contracts at the very end. During an inflammation of the diaphragm, respiration is variable; sometimes it is shallow and frequent, while at other times it is deep and similar to groaning.Footnote 174
At 9.17–19 (63 Bos) Maimonides thematizes phrenitis and lethargy as mirror-image diseases caused by a swelling, called a tumour in Bos’s translation:
The cold brain tumour, namely lethargy, and the hot one, namely phrenitis, have in common that in the beginning both should be treated by phlebotomy and by the application of rose oil and vinegar in order to expel the harming humour – whatever humour it is – from the head. [This should be done] although one disease goes with sleeplessness and the other with torpor. Hereafter, one should try to calm [the person suffering from] sleeplessness and to awaken and stimulate the person who suffers from torpor.Footnote 175
At 23.62 (51 Bos) Maimonides reaffirms the seminal Galenic and traditional distinction between mania and phrenitis based on fever: ‘Madness/mania is a chronic mental confusion without fever, whereas phrenitis is a chronic mental confusion with fever.’ In medical and philosophical Jewish circles, then, phrenitis was assimilated as a medical concept, following standard Galenic authorities, but leaving ample room for a chest-centred account.
Talmudic Medicine
With the exception of the Syriac Book of Medicines, with its composite history, in all the Arabic sources, whether Islamic or Jewish, examined so far it is easy to recognize a core that is fundamentally a form of reception – and elaboration – of Graeco-Roman medicine. It is thus appropriate to speak of them all in terms of an ‘Andalusian’ or ‘Judaeo-Arabic’ milieu. If we consider instead the testimony of Jewish medicine preserved by the Talmud over the course of several centuries and from a much earlier period (300 bce–500 ce), we find a richer (if problematic) intercultural parallel to phrenitis:Footnote 176 the disease kordiakos/qordiakos. Scholarship flags this as a parallel to our disease, although the need for anthropological caution is sometimes recognized.Footnote 177 At first sight, the label evokes the ‘cardiac disease’ mentioned in Celsus as explicitly contiguous to phrenitis, and described by Caelius Aurelianus at Morb. Ac. 2.30 (240–88 Bendz). This disease is accompanied by fever, is localized in the heart and/or stomach (or more generally in the viscera of the torso), and is accompanied by hallucinations.
To examine the description in more detail, we must consult the section on kordiakos in chapter 11 on ‘Mental Disorders’ of Preuss’s edition of Talmudic Medicine.Footnote 178 The discussion of the disease opens with a legal note: the actions of the kordiakos patient have no juridical consequence, since he finds himself in a state of ‘semi-consciousness’. The cause highlighted is related to wine: ‘According to Mar Samuel, this illness occurs when a person is overcome by new wine from the vat.’ Preuss swiftly identifies the disease ‘with the morbus cordiacus (sic) of the heathen physicians’, referring especially to Caelius Aurelianus, and describes the Talmudic instance, assigning wine an important role and listing confusion and babbling among the symptoms. What we find in the Talmud, however, is only partially superimposable on the Graeco-Roman cardiac disease, and other readers have challenged the simplistic transliteration on which Preuss relies. Hankoff interprets this as instead an ‘ancient description of organic brain syndrome’, seeing it as ‘one of the earliest references to what is currently known as delirium tremens’,Footnote 179 and directly references phrenitis (‘phrenesis, phrenisy, frenesis or phrensy’Footnote 180) as a parallel. As he summarizes the disease, it manifests itself in ‘a state of confusion’ in which the patient experiences ‘dizziness, and from the discussion of his conduct and mental incompetence, seems to be like a madman or one who has had his throat cut and is unable to speak’Footnote 181 (i.e. he cannot speak and is considered legally incapacitated as a consequence). Specific to this condition among other forms of madness are two aspects: an inability to distinguish coloursFootnote 182 and, most important, curability after a short time, which differentiates it from the grave, often fatal course of phrenitis. Causes are new wine, but also a daemon. In Hankoff’s view, the pathological resemblance or parallel with the syndrome of delirium tremens are precise, while the cardiac, chest-centred echoing in the label must be eschewed in toto: despite the similarity of the names, he takes them to have no etymological relation. Instead, the Talmudic label kordiakos might be a corruption of crocydismos, the well-known phrenitic sign.Footnote 183 For Rainbow, the daemonic account rather than a bodily localization is the explanatory element:Footnote 184 kordiakos is for him the actual name of a spirit. A Greek origin for it might also be plausible, referring to the suffering heart when the mind is oppressed by a daemon: ‘the act of ravishing the heart,Footnote 185 … not the heart itself … a daemon who was capable of acting to harm a person’s mental and moral faculties’.Footnote 186
In conclusion: kordiakos is a disease that involves crocydism, confusion and a loss of cognitive capacities; is linked to wine drinking; and brings inflammation and fever. It strikes the viscera or resembles ‘brain fever’, and its name seems to contain a reference to the heart. We cannot identify it with certainty with any item outside the Talmud, although one might acknowledge an aural connection between the label phren-itis and the illness cardiac or crocydism-os (carphology, crocydism): they share some symptoms and the involvement of alcohol. The final point, the implication of wine and other alcoholic beverages, is an association to which modern readers are drawn when navigating the uneasy waters between body and soul in discussions of pathology: delirium tremens, wine and intoxication are immediately understood as interfaces between the two. As we shall see, delirium tremens and alcoholism are one of the outcomes of ancient phrenitis in modern pathology. Perhaps kordiakos offers an early instance of the same co-implication.
The Talmudic testimony is intriguing for a parallel it offers to the ambiguities in the Syriac Book of Medicines, especially its selective categorization of phrenitis in the chest with the involvement of other viscera. Kordiakos also features a symptomatic correspondence with phrenitis (crocydism, madness, hallucination, the reference to wine, the legal questions); a localization in the chest and attribution to brain fever; and a strange name that – depending on the interpretation – may involve the heart or daemons (a daemon sitting on the chest being an important Mesopotamian source of illness generally, and of mental illness in particular, as already noted). These elements of Mesopotamian medicine are integrated via the influence of Arabic and Jewish readers into the coreFootnote 187 European medical curriculum – most notably, the daemonic variation of phrenitis, the karabitus named sibari described by no less of an authority than Avicenna.
Conclusions
We have followed the traces of our disease in a variety of Byzantine and medieval sources in Greek, Latin, Syriac and Arabic (Eastern, North-African and Iberian). The complexity of these interlacing traditions evades quick survey. But for the purposes of our nosological biography, we can draw some conclusions about this phase of the medical history of phrenitis, from the seventh century ce to the beginning of the early-modern era, focusing on a number of key developments, which reflect developments in scientific and medical culture more widely:
The concept apostema, ‘swelling’ or ‘tumour’, becomes central, accompanying if not replacing that of inflammation.
There is a thematization of ‘texture’ or, anachronistically expressed, of the histological quality of the locus affectus; the starting point is the question, possibly stemming from a remark in Galen, of whether not only the membranes but also the body of the brain, despite its viscosity, can undergo swelling. In most sources, phrenitis is precisely the inflammation and swelling of the membranes of the brain, the pelliculae, foregrounded for their meningeal nature, their being ‘membranes’. It is important to note this involvement of the membrane qua membrane alongside that of the membranes of the brain qua encephalic; through this histologic communality, a link with the diaphragm, as well as with other membranes of the body, such as that of the spine, is reaffirmed. This is important because it (1) is a striking way to keep the phrenes/diaphragm in the equation; (2) inaugurates a holistic approach to pathology as striking what we would call a certain kind of ‘tissue’, as opposed to a certain locus in the body; (3) revives the heritage of the great ‘delocalizing’ narratives of the forgotten past, Caelius and Asclepiades in primis, with their moral and psychological implications.
In addition to the histological concreteness of the account, there is a visible progression towards physiology and anatomy, and away from psychology. Blood and humours, brain and membranes, heart and other organs are involved – the eyes, the stomach, the womb, even the heart and the liver, as well as parts such as the nerves and blood vessels. Within this turn, a cardiocentric, Aristotelian line of inquiry is activated, as well as a new materialistic turn, to which the body closely and minutely examined is central: lippitudo (the fat discharge from the ocular cavity), the behaviour of the eyes, the complexion, epistaxis, blackness of body and tongue … phrenitis is more and more concretely painted on the body and identified by material symptoms, from the traditional heat and fever, to white urine, to new details such as the patient’s convulsed leg.
Taxonomy becomes an increasingly flexible instrument: many subgroups and types of phrenitis are recognized. Phrenitis can be vera or non vera, on varying accounts; the apostema can be hot or cold, generating phrenitis or lēthargos; there are subgroups or similar and parallel diseases, such as sibari, erysipelas and rabies, as well as ramifications of humoral and physiological aetiologies and of ventricular or brain localizations; and various types strike different organs, such as the diaphragm or the heart, but also the pleurai, liver, stomach and womb.Footnote 188 The hydraulics of humours and other fluids play a central role, and these fluids are listed schematically with their respective consequences: blood, fumes and vapours; red bile, burnt red bile, yellow bile, ochre bile; boiling and putrefied blood.
In parallel with this pathological expansion, the idea emerges that, while the apostema is the real, antecedent disease, the label phrenesis or phrenitis should only designate its symptom, or even only the part affected. In the Semitic lexical examples, for instance, there is a recurring linguistic confusion between ‘affected part’ and ‘disease’.
Some eccentric elements return or persist: the use of animal viscera and the reference to daemons and prophecy.
The name and etymology of the disease are constantly interrogated. The question regarding the name phrenitis, its connection with phrēn (as in ‘mind, diaphragm, heart, brain’) is posed again and again, and answered with the ancient Aristotelian and Platonic arguments. In some cases (Avicenna, the Alphita) the brain is emphasized. In others the diaphragm/heart/chest is kept in focus, combining neo-Aristotelian influences with Eastern or Semitic ethnic roots (as most visibly in the Syriac Book of Medicines and the example from Rabbi Jonah’s lexicon). In all instances, at any rate, the phrenitis ‘tag’ is corroborated and re-advertised by these discussions.
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