Phrenitis and the pathology of the mind in western medical thought (fifth century BCE to twentieth century cE)

The project phrenitis

This book (Thumiger, 2023) belongs inter alia to the genre of the ‘biography’ of a disease, or a nosological profile through a historicising lens. Such works usually reflect on the name label and its etymology, trace the chronology and diffusion of its use, and list variations in causes, prognostic and diagnostic features, manifestations and therapies. They also look at patients and medical experiences, professional and less so. Any project of this kind has potential pitfalls. Anachronistic projections and identifications across eras may be illusory, despite shared names (consider the ‘false friends’ typhus, tetanus, phthisis and epilepsies, but also anorexia and boulimia, Greek terms whose ancient meaning is far from what we mean by them today). The incidence, demographics and experience of a disease are largely lost in the transition from one community to another, while patient experience often defies the historian. Also, the common use of a nosological term in popular literature or colloquial speech is subject to generic conventions and dynamics of irony, mockery and hyperbolic exaggeration. Such a biography thus risks turning into a gallery of disconnected episodes, with the guiding thread ultimately lost.

Despite all this, phrenitis proves to be a good example to tackle. Although the concept went through tortuous passages, patterns of branching and rejoining, and apparent discontinuities, it has remained visible from its origin, in fifth-century BCE medicine, to its ‘death’ over the course of the nineteenth century. Moreover, this book shows that phrenitis is not a case of phantom persistence, unlike melancholy or epilepsy, which were immensely influential labels covering illness experiences that varied widely depending on the century or text. Phrenitis is different, for it has a fundamental core: mental disorder, with fever, localised in the body, and strongly connected with the position and processes of cognition and the senses.

As such, phrenitis is deeply connected to a fundamental topic in the history of ancient science, that is, the question of whether the mental faculties are to be located in the heart or the head: cardiocentrism (Aristotle, Praxagoras, the Stoics, as well as much of traditional culture, and several Hippocratic accounts) versus encephalocentrism (the author of De Morbo Sacro, Herophilus and Erasistratus, and of course Galen). The disease name phrenitis in fact evokes the diaphragm, or phrenes, the seat of emotions and reasoning in a number of archaic poetic texts and in tragedy. At the beginning of its history, then, phrenitis is seated in the chest as a winter disease akin to pneumonia, with respiratory affections and fever. As medical theories change and develop, however, it is more and more identified with an inflammatory fever that takes hold of the head and brain, or meninges, causing derangement, delirium and hallucinations. In this way, evolving physiologies of cognition are rendered apparent to our view, while, at the same time, a vast repertoire of clinical experiences can be harvested as part of the disease portrait, allowing for a systematic organisation of symptoms, causes and possible therapies.

Much of this work of conceptualisation begins as a highly technical medical enterprise. Phrenitis was not a common term for the first four to five centuries of its life, and it appears in non-medical texts only at the beginning of our era. Already early on, it establishes itself as a major disease, acute and often mortal, and a challenge for doctors. It also gradually becomes useful material for metaphorical and allegorical elaboration, by moral philosophers and comedians more than anyone else.

By the end of antiquity, phrenitis has established itself as a major, mortal, ‘psychiatric’ disease with fever, (mostly) localised in the brain and meninges, and causing a panoply of mental and neurological impairments. As such, it is transmitted through Syriac, Arabic and then Latin translations and commentaries through the, Mediterranean, imperial and post-imperial and modern worlds, and remains an important resource in nosology and anatomo-pathology until the nineteenth century. After its demise, it disappears in a radical way from medical practice and general culture, as shown by the typical reactions by audiences in 2024: ‘Phrenitis? What is this?’

The book: a synoptic view

What follows is a brief sketch of the book and the historical territory covered in its 10 chapters. In the first chapter, I introduce methodological issues pertaining to the history of mental health: on the one hand, the issue of anachronism and the problem of retrospective diagnosis, and on the other, the importance of maintaining intelligibility across cultures. When it comes to the ancient world, there are specific problems related to the nature of Greek and Latin medical sources and our limited access to the practices underlying them. In addition, the genre ‘biography of disease’ has its own pitfalls, namely those of attributing ‘essence’ to what appears prima facie to be most of all a construct, a disease concept or a label such as phrenitis. Finally, I consider the phrenitis as a term, its etymological significance and the implications of the name vis-à-vis localization (Chest? Lungs? Diaphragm? Heart?) and mental life (Mind? Character? Soul? Mental capacities?). I also discuss the traditional poetic (‘Homeric’) appeal of the phrēn/phrenes, the name of the body part from which the label originates. The poetic archaism of phrēn/phrenes combined with its medical use made it both understandable as a generic term for mental life and specifically a ‘medical’ term to indicate the diaphragm, and contributed to making phrenitis a long-lasting disease concept.

Chapter 2 begins with classical medicine (the ‘Hippocratic Corpus’ and coeval testimonies), exploring the sources of so-called Hippocratic medicine, nosological and clinical, as well as other lesser-known authors from the fourth century BCE, such as Diocles and Praxagoras. The limited material on our topic preserved from Hellenistic medical writers (Herophilus and Erasistratus) is also surveyed. The richest information is found in the Hippocratic writings, where phrenitis first appears and where it is richly described, both in nosological profiles and with reference to specific patients. Its core traits are established by this point: fever, localization in the chest, and an association with winter also apparent in the co-morbidity with, and analogy to, pleuritis and pneumonia. Interestingly, the phrēn/phrenes are seldom mentioned in discussions of phrenitis, and when they are, it is not in their traditional, ‘Homeric’ psychological function or directly as locus affectus, thus signalling a desire to distance the pathological narrative from traditional poetic models.

Localisation is arguably a key move in the history of medicine across cultures. But a parallel, if not alternative, narrative can be seen in the Graeco-Roman tradition (and elsewhere). I call this ‘delocalisation’, an approach to disease, especially mental disease, in terms of ‘holistic’ impact on the patient, and discuss it in Chapter 3. Delocalisation surfaces prominently only in certain authors, but can also be noted in discussions of the locus affectus by thinkers such as Galen. In this particular strand of the history of phrenitis, the key sources preserved for us are the Roman author of De medicina, Celsus; the Atomist philosopher and doctor Asclepiades; and the thinkers of the Methodist tradition, represented most extensively as far as phrenitis is concerned by Caelius Aurelianus. This chapter surveys the relevant texts by Celsus and Caelius and the fragmentary evidence for Asclepiades, in which an important cluster of shared principles emerges: an interest in psychology and in the health of the individual ‘as a whole’; a disregard for the localisation of the disease in a specific body part and of fever as a key pathological indicator; and a strong inclination towards psychotherapeutic and ‘soothing’ measures.

Chapter 4 moves on to the medical texts of the imperial age, first addressing theoretical approaches under the subdivisions ‘localisation’, semiotics, chronology and aetiology. The time frame involved here is the first to sixth centuries CE, with a primary focus on Aretaeus and Galen. These two famous physicians offered powerful accounts of phrenitis in terms of localisation (around the heart, in the first case, and the brain, in the second), and introduced sophisticated discussions regarding ‘sympathy’ and co-affection in the disease. They also addressed symptomatology and, in the case of Galen especially, took phrenitis as an exemplary case for semiotic discussions and the exploration of causes.

Chapter 5 covers the clinical part of the account left by the medical authors of the imperial period: case histories, pathological descriptions and clinical narratives as they appear in Anonymus Parisinus, Aretaeus and Galen, as well as medical developments in the following centuries, which proceed very much along the lines traced by Galen. This is illustrated by the late-antique sources included in the final section of the chapter: Oribasius, Aetius, Alexander of Tralles and Paul of Aegina. The topics analysed include: patient profiling and behaviours; ‘neighbouring diseases’ and ‘similar diseases’ to phrenitis (pleuritis and pneumonia, but especially lethargos as a cold brain fever, symmetrical to the hot brain fever which is phrenitis); and recurring symptoms. By now, these form a clear picture, featuring fever, sensory disturbance, cognitive damage, various ‘neurological’ signs such as (notably) ‘flocillation’ (the compulsive plucking of hair or fluff from one’s clothes or blankets), sleep disturbance, voice alteration, expectoration, a certain quality of the urine and pulse, respiratory issues, and rich and varied psychological disturbances, in which hallucination stands out.

Chapter 6 looks at the construction of the phrenitic patient in wider culture, from non-technical discussions of the disease to its allegorical or hyperbolical honing to a paradigm of folly, ignorance, depravity and moral weakness. In this chapter, I consider the earliest occurrences of the term in Greek in non-medical writings, which are fairly late (Hellenistic, in Menander’s Aspis), and then the bulk of the ancient evidence, which is largely ethical-philosophical and found in theological, prudential and hagiographic contexts. Augustine is the central author here, and his construction of the phreniticus becomes an influential model in the centuries to come.

As the narrative moves beyond the Graeco-Roman medical tradition and enters the post-antique reception and elaboration of this canon, the dynamics of translation and assimilation into different languages and cultural milieus become more relevant. Chapter 7 explores the Byzantine transmission of the ancient material, at first sight faithfully based on Galenic models and their encyclopaedic abridgements, and then the Syriac and Arabic traditions and the problems posed by the translation of a loaded term like phrenitis. The chapter moves on to the medieval medical sources in Latin (translations from the Arabic, as well as original elaborations in Latin, especially those of the school of Salerno) and to the medical writings produced on the Iberian peninsula by Arabic and Jewish authors.

Chapter 8 picks up on Chapter 6 and looks further into the history of the moralisation of mental illness from the late antique period to the end of the Middle Ages, with discourses focusing on the topics of debauchery, wine consumption, sexual excess and general depravity in the case of phrenitis. The lines are those traced by the Church fathers, among whom Augustine stands out as the most prolific source; the moral allegory is then elaborated through adaptation to the themes and concerns of medieval theology and developments in physiological concepts and pathological ideas in medicine. The chapter concludes with the figure of Falstaff, the Shakespearian character who best represents this early-modern outcome of ‘ethical phrenitis’ as a disease of squalor, drunkenness and sexual licentiousness.

In Chapter 9, the focus moves to the afterlife of phrenitis in the early-modern and modern eras, in three main directions: the ‘anatomisation of the past’ and the trajectories of Hellenism in the texts and doctrines of medical doctors in this era; the development of Renaissance anatomy and post-mortem pathological discussion of the localisation of phrenitis; and alternative approaches represented by Paracelsus and Paracelsianism. In the second part of the chapter, the modern era is addressed through a number of episodes or case studies: university medicine; patient reports; an episode of phrenitis contagiosa; the parallel of phrenitis in veterinary studies; and the topics of drunkenness and a lack of moderation in lifestyle, and their role in phrenitis.

Chapter 10, finally, is both a conclusion and an epilogue devoted to the ‘death of phrenitis’. The end of the active life of the disease can be described as taking place through three avenues and producing three outcomes. First, in a somatic sense, phrenitis gives way to meningitis and meningo-encephalitis, the inflammation of the brain and its membranes; second, its symptomatology evolves into what modern pathology defines as a syndrome, ‘delirium’; third, one final, ‘softer’ outcome of phrenitis is the lay concept of stress, classified as ‘stress syndrome’ in contemporary taxonomies. In the conclusion, this story of a specific disease is treated as exemplary of the dynamics behind the ‘birth’, ‘life’ and ‘death’ of biological concepts generally.

Phrenitis as an example in the history of psychiatry

While covering this territory in historical terms, the monograph engages with a number of points which pertain to phrenitis and its specifics as pathology. On the other hand, it offers a general consideration of the history of medicine and body history, the evolution of disease concepts, the creation of psychiatry as a branch of medicine, and the interweaving of technical and non-technical discourses in discussions of mental health and its care. I will now discuss the most salient questions the book raises regarding the methodology of cultural history, the history of medicine and patient history in particular.

History of psychiatry, history of medicine: stories of human bodies

Finally, the individual outcome of this particular story, outlined in Chapter 10, illustrates a general point. In different cultural circumstances, socio-economic and political contexts, and scientific cultures, diseases change or may appear to ‘die’. Of course, they never really do. The human body is one and the same, despite evolving bacteriological surroundings and metabolic conditions, but its ‘stories’ and territories are bound to change. Once a certain balance is tipped, a disease that had survived with reasonable consistency for over 2000 years falls irreparably out of fashion, with a redistribution of its features among other entities (in this particular story, meningitis, stress syndrome and delirium). The example of this case restores the human body in its role as guarantee for the persistence of pathologies, the ideal centre of a story, 95% of which might change, but with a resilient core that resists annihilation. As well as historical and medical knowledge, then, literary appreciation is indispensable if we are to follow these developments in full, since their movements and effects are much like those of poetic genres, artistic representations, literary tricks and conventions, and much less like stable, quantifiable achievements.