Chapter 1 - Preface and Methodological Issues

Summary

In the first chapter I introduce some methodological issues pertaining to the history of mental health: on the one hand, the issue of anachronism, the problem of retrospective diagnosis, 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 medical sources in Greek and Latin, and our limited access to the medical 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 label such as phrenitis. Finally, in this chapter I consider the label phrenitis, its etymological meanings 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 ‘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.

Preface

A good beginning for a history that stretches over 2,500 years is a glance at the debris still visible in our own time. The disease phrenitis is no longer seriously discussed by medical handbooks or taught in faculties of medicine, but traces of the notion are still to be found in the medical consciousness. Consider these two examples of widely available current medical information:

Phrénite Phrénitis

Pneumologie, médecine générale – N.f. … La phrénite est l’inflammation du diaphragme. Syn.: diaphragmatite. Le phrénitis est l’inflammation simultanée du diaphragme et de la plèvre qui entoure le diaphragme (ou plèvre diaphragmatique). Certains neurologues psychiatres ‘anciens’ parlaient également de phrénitis pour désigner une inflammation du cerveau, non accompagnée de folie.¹

Phrenitis means an inflammation of the brain, or of the meninges of the brain, attended with acute fever and delirium … Phrenitis is no longer in scientific use. Nowadays meningitis or encephalitis are diagnosed. Relating to phrenitis: suffering from frenzy; delirious; mad; frantic; frenetic.²

In the online medical dictionary cited in the first quote, phrenitis appears to fall under the category of ‘pneumology’. It is inflammatory in nature; involves ‘the diaphragm’ and the ‘pleura’ of the patient; and in its ‘ancient history’ was taken to involve the brain, although it did not express itself in madness. In the second text, drawn from Wikipedia, the condition is firmly identified with an inflammation of the brain. These short bits of medical reception, with their own imprecisions and simple misunderstandings, are instructive, since they manage to touch on all the features which, in various forms and combinations, constitute the foundations of this disease throughout its history. They do not, however, appropriately depict any individual stage of the history they represent, and the image of the disease phrenitis they offer remains full of contradictions. Where is it seated in the body? What causes it? What is its relationship to madness?

This book aims to reconstruct this history, unpacking the construction of phrenitis, tracing its various shifts, and assigning each of the apparently incongruous elements in the definitions quoted above its correct place, as far as possible. These definitions can figuratively be understood as the debris of a lost, larger pathological story, which is all that has reached us.

We can begin by defining phrenitis as a disease with mental implications first described in the Greek writings of the Hippocratic corpus (fifth and fourth centuries bce). It is acute and often deadly, and is characterized by a high fever and a variety of behavioural aspects suggesting a form of derangement. The label ‘phrenitis’ survived in Western pathology for twenty-four centuries:³ it is included in nosological lists, and is discussed and diagnosed as late as the nineteenth century, having undergone a tortuous series of changes, reshapings and elaborations, only to disappear seemingly forever at the turn of the twentieth century.

I discuss phrenitis as a ‘label’. No one familiar with the history of medicine, and in particular the difficult anthropology of historical psychiatry, can today accept at face value the idea of a ‘history’ of a disease as ontologically robust as a ‘history of metallurgy’, for example, might be.⁴ Diseases are experiences, constructions and representations long before they become epidemiological or biological data. Freud’s use of the now long-dismissed nosological concept and label hysteria, for example, has nothing in common with the Hippocratic gynaecological ‘hysterical’ complaint.⁵ Nor should we think that non-mental disease entities are safer for transhistorical comparison: typhus and tetanus, for example, are familiar nosological labels to us, but their – merely nominal – continuity with a Greek past does not legitimate any essentialist move.⁶

Three important methodological issues thus pose a challenge to this discussion.

1. 1. First, the distinction if not opposition between mental health and mental illness. The history and anthropology of medicine have recently been inclined to dismiss this dichotomy and consider the continuum of human health their object instead.⁷ This shift in perspective is especially important for a discussion of ancient medical sources, where a sharp opposition between health and illness is missing, and where we even find Galen explicitly rejecting an abstract, fixed concept ‘health’.⁸ The same is true in the realm of mental pathology, and perhaps even more emphatically so: mental life is observed and assessed with an eye to its nuances and changes, but a fixed, permanent category of mentally ill or disabled individuals is difficult to discover.⁹

2. 2. Second, the opposition between mental and bodily health and illness. As I have argued in more detail elsewhere, with reference to Hippocratic medicine,¹⁰ historians of ancient medicine generally assume that what prevails in the Graeco-Roman context is the idea of soul and body, of the mental and physiological spheres, as continuous and indissolubly linked – although various articulations of this nexus can be identified.¹¹ Against this background, an increasingly precise idea of mental or psychological suffering begins to be delineated after the end of the classical era.¹² Even with respect to this period, however, we are never safe from the fallacy of anachronism when we trace parallels between ancient psychiatric concepts and our own, which are informed by previously unknown and radically different kinds of dualism. The concept of phrenitis was accordingly born within a firmly materialistic environment, and its strong physiological roots are of great importance in all stages of its history.

3. 3. Third, the recognition of disease entities, the construction of a disease taxonomy. In the field of mental pathology in particular, although disorders and diseases we understand as ‘mental’ were already recognized in the Hippocratic texts, no reliable list of ‘psychiatric entities’ qua psychiatric can be found. The label ‘disease of the soul’ was not used in medical texts, and the approach to disturbances of the mental sphere or the physiology of the body was, as noted above, similarly materialistic. As anticipated, phrenitis is perhaps the best candidate for the first psychiatric entity of antiquity – a disease in which derangement was constitutive from the beginning. But the question remains open: when and why did the ancients begin to engage with the idea of ‘disease entity’ (a pathological experience characterized by a recognizable pattern of onset, symptomatology, course and outcome) in the mental sphere? In other words: when did this concept emerge not only as a label, but as a mark of an awareness of a conceptualization of ‘mental nosology’ with all its implications and historical significance? The emergence of a classificatory tendency is a shaping aspect of medicine at the beginning of our era: this is evident in the importance Galen attributes to the study of nosological semiotics and definitions, but also in the work of Aulus Cornelius Celsus (first century ce), in nosological treatises of the imperial era such as the one known as Anonymus Parisinus (first–second centuries ce), and in the collections on acute and chronic diseases composed by Aretaeus, Soranus and Caelius Aurelianus, or the monographs on individual diseases produced by Rufus (on melancholy, and on satyriasis and gonorrhea).¹³

The unstable nature of disease concepts is not only evident to the modern scholarly gaze. A sophisticated relevant discussion is preserved by Plutarch (first–second centuries ce) in his Quaestiones convivales, where the philosopher addresses a key question, ‘If it is possible that new diseases should arise and why’ (Quaestiones convivales, 8.9 = 731a–732b):¹⁴

Philo the physician stoutly affirmed that the disease we call elephantiasis was a disease recognized only a bit earlier (ou pro pollou pany chronou gnōrimon); since none of the ancient physicians speak a word about it, though they often enlarge upon small, frivolous and obscure trifles. And I, to confirm it, cited Athenodorus the philosopher, who in his first book of Epidemic Diseases says that not only that disease, but also the hydrophoba or water-dread (occasioned by the bite of a mad dog), were first discovered in the time of Asclepiades. At this the whole company were amazed, thinking it very strange that new diseases should first take origin and arise at a given time in nature, and no less strange that these occurrences (symptōmata) should not be noticed (to lathein) for such a long time. Yet most of them inclined to this last opinion, as being most agreeable to man, not in the least daring to imagine that Nature created novelties (tēn physin … philokainon einai), or would in the body of man, as in a city, create new disturbances and tumults. For diseases and conditions follow their own wonted, familiar path (nosēmata kai pathē koinēn tina kai patrion hodon badizein). And Diogenianus added that even the passions and diseases of the mind go on along the same old road they formerly did; and yet the viciousness of our inclination is exceedingly prone to variety, and our mind is mistress of itself, and can, if it pleases, easily change and alter. Yet all her inordinate motions have some sort of order, and the soul has bounds to her passions, as the sea to her overflowing. And there is no sort of vice now among us which was not practised by the ancients. There are a thousand differences of appetites (pollai … epithymiōn diaphorai) and various motions and types of fear (myria … kinēmata phobou kai schēmata); the forms of grief and pleasure are impossible to number,

       Yet are not they of late or now produced,

       And none can tell from whence they first arose.

How then should the body be subject to new diseases, since it has not, like the soul, the principle of its own alteration in itself (idian … hōsper hē psychē kinēseōs archēn oikothen ouk echonti), but by common causes is joined to Nature, and receives a temperament (krasin) whose infinite variety of alterations is confined to certain bounds, like a ship rolling and tossing in a circle about its anchor? Now there can be no disease without some cause, it being against the laws of Nature that anything should lack a cause. Now it will be very hard to find a new cause, unless we fancy that some strange air, water or food, never tasted by the ancients, should descend to us out of other worlds or intermundane spaces. For we contract diseases from those very things which preserve our life; since there are no peculiar seeds of diseases, but the disagreement of their juices with our bodies, or our excess in using them, disturbs nature. These disturbances have still the very same differences, although now and then called by new names.¹⁵ For names depend on custom, but the passions on Nature; and these being constant and those variable, this mistake has arisen. … The intensification or increase of a thing makes it more or greater, but does not trespass on the essence of that thing. Thus elephantiasis, being an intense scabbiness, is not a new kind; nor is water-dread distinguished from other melancholic and stomachic affections except by degree. And I wonder that we did not observe that Homer was acquainted with this disease, for it is evident that he calls a dog rabid from the very same rage with which, when men are possessed, they are said to be mad

(my italics).

For Philo, the ancients’ silence regarding a disease was an argument for its absence from their world tout court. The victorious objection to this is that diseases cannot suddenly come into existence: nature does not capriciously create new things. New pathological causes cannot emerge, since there are key environmental and bodily invariables in the human condition, so that diseases always gravitate around the same points ‘like a ship rolling and tossing in a circle about its anchor’. The same diseases thus always existed. Especially in the realm of mental – in Plutarch, moral – life, the same old vices always afflict humanity. The only variation, it is suggested, is one of degree: previously mild diseases can become more intense, and vice versa, but their character remains substantially the same across time.

In this long passage, Plutarch touches all the central nodes for any discussion of nosological taxonomy: the dichotomy between labelling and entity, meaning the difference between the actual existence of an object in nature – a disease – and its conceptualization and recognition; a notion of Nature and an unalterable human biological base; and the opposition between kind and degree.¹⁶ These three points show great sophistication, but are also perhaps a reaction to the abundance of disease labels that seem to flourish in the first centuries of our era, as is apparent from a quick glance at the works of the authors listed above. This is one of the most fundamental changes in medicine at the turn of the age and has important consequences for a ‘history of a disease’ such as this one. Does phrenitis, as Plutarch’s Diogenianus maintains, exist as a solid fact underlying all its pathological descriptions and conceptualizations? May we practise the essentialist approach defended by Plutarch on the problematic Hippocratic pathological descriptions, for example? Modern readers of ancient texts have indulged in various exercises of retrospective diagnosis, offering parallels with malaria, typhoid fever, meningitis and encephalitis.¹⁷ To what extent can we relate phrenitis to a medical reality, either in the history of medicine or in our own biological understanding?

Why Look at phrenitis?

The case of phrenitis is a special one, given the challenges mentioned above. It is in fact the only ancient disease of the mental sphere (and one of the very ancient few diseases generally) that can be discussed in anything approaching a continuous manner. This is true for various reasons, which will be illustrated in the coming chapters, but which we can begin sketching here.

First, phrenitis has a strong connotation in its very name, being explicitly associated with the Greek root phren- (φρεν-), which points to the mental sphere. Notwithstanding the technical nature of the term in -itis, its meaning and implications must have been obvious to Greek ears, as anyone who knows any Greek today can guess. Phrēn (φρήν) and phrenes (φρένες) are among the oldest, most traditional terms in Greek psychology, variously used to indicate mental life from as early as our evidence goes, in Homer and the lyric poets. The verb phroneō (and cognates) is also commonly used to describe thinking and mental performance, and other cognate terms feed into the same semantic group;¹⁸ this is thus an immediately understandable name and sphere. The speaking name of the disease suggests (a) a concrete localization (the diaphragm and the chest) or an abstract one (‘the mind’, as well as the subject’s character and self); (b) a function (the ‘mental functions’); (c) an activity (‘thinking’). The disease thus displays ‘psychiatric’ credentials from the very start.

Second, as already noted, phrenitis is eminently a technical term. This has to do not only with the name’s classic nosological formation (in -itis/-ιτις), but also with the minimal employment of it in non-medical literature for a long part of its early history. Until the beginning of our era, phrenitis remained a scientific and philosophical notion and failed to offer material for comic caricature, tragic hyperbole or transfer into metaphor. As a consequence, it was largely protected from the ‘folk’ appropriation of medical categories that makes the study of mania or melancholia, for instance, so tortuous and scattered despite apparent elements of persistence and the considerable popularity of the two labels.

Third, right from the start – unlike any other mental pathology in ancient medicine – phrenitis appears remarkably codified, firmly attached to a strong physiological indicator that made it easily identifiable and even functioned in some authors as a differential factor: acute fever,¹⁹ accompanied by a firm but changing localization. The localization is firm in the sense that most discussions place the locus of the disease at the centre,²⁰ but changing, since the locus oscillates from chest to head, mimicking the key dialectic in the history of Western biology between cardiocentrism and encephalocentrism.

Finally, phrenitis somehow establishes itself in the Graeco-Roman medical tradition as a core example of insanity, as its best nosological exemplum, therapeutic discussions of which can inter alia be seen as instructive on a general level: it is paradigmatic both as mental disease and as disease entity. As we shall see, it is significant that two of the best discussions of the disease, by Celsus and Caelius Aurelianus, place it at the beginning and allocate their most extended efforts to it, and also that Galen returns again and again to phrenitis when he discusses what a ‘disease’ is, what the safe indicators and symptoms for the diagnosis of one are, and so forth. These factors allowed phrenitis to survive with recognizable, consistent features throughout the history of ancient medicine and to remain relevant to modern medical thinking.²¹

Looking back at the four points made above brings out a major contrast inherent in the conception of phrenitis. On the one hand, there is an explicit appeal to traditional vocabulary, and on the other a strong element of novelty. Despite its conventionally popular, vernacular name, this is a ‘new’ disease concept, whose firm physiological hardware avoids continuity with archaic and classical poetic models of mental life with their corporeal as well as immaterial components. These tensions deserve more attention than they have received. Indeed, I believe that this combination may be key to making sense of the immediate, highly technical presence of phrenitis in medical literature and of the cultural viability the concept enjoyed, guaranteeing its relative consistency across the ages (in contrast to the shifting trajectories taken by mania or melancholia and their literary appeal).²²

This book explores the history of phrenitis in part chronologically, from the Hippocratics to the end of the late-antique era (Chapters 2–5), when the foundational discussions of the disease were produced. It then looks, if more briefly, at the post-antique history of the concept, including sources in Latin and Semitic languages, and traces the survival of phrenitis in medieval medicine (Chapter 7). Along with establishing this medical landscape, the book offers an in-depth exploration of the parallel history of phrenitis and the ‘phrenitic’ as a human type from imperial literature to early modernity (Chapters 6, 8). Finally, it considers the revitalization of the notion within the context of advances in anatomical medicine from the beginning of the fifteenth century up to the final mentions of it in the work of eminent nineteenth-century psychiatrists and clinical practitioners (Chapter 9), and then until its final evaporation and dispersion into a number of pathological, psychiatric and lay concepts in modern times (Chapter 10). The archaeology of the disease is my particular subject and focus, although its modern and premodern afterlife confirm these observations and locate phrenitis as an exemplary case for historians of psychiatry.

But this study does not trace a chronological trajectory alone. The history of medical concepts is not a linear sequence but a three-dimensional figure, whose various socio-cultural layers greatly complicate the picture. There is a ‘phrenitis’ of scientific narrative, the technical term used by professionals and understood by intellectual elites. But there is also a concept received (or not received) in lay contexts and hyperbolically or allegorically employed in non-technical genres beginning at a certain point in its history (Chapters 6, 8). All this belongs to the story of phrenitis as well.

The Traditional Background

The Name, the Body Part, the Damaged Function: phren-itis (φρεν-ῖτις)

I begin with the name. As already noted, mental terms with the root *phrn form a traditional cluster in Greek.²³ These include the nouns φρήν-φρένες (phrēn/phrenes), the verbs phroneō and cognates (φρονέω, σωφρονέω, ἀφρονέω, παραφρονέω, ἀλλοφρονέω); the abstract nouns sōphrosynē, paraphrosynē, aphrosynē and paraphronēsis (σωφροσύνη, παραφροσύνη, ἀφροσύνη and παραφρόνησις); and the adjectives phronimos, ekphrōn, aphrōn and emphrōn (φρόνιμος, ἔκφρων, ἄφρων and ἔμφρων).²⁴ The following points can be made regarding the linguistics of the term phrenitis:

a. Vis-à-vis the semantics of - itis (-ιτις) names, especially disease names in Greek, it is obvious and uncontroversial that phrenitis is a denominative from phrēn/phrenes. This leaves a key question open, given the double meaning of phrēn/phrenes: should we interpret this as ‘a disease localized in/of the phrēn/phrenes’ or as ‘a disease which affects the mental sphere (phrēn/phrenes)’?

b. Anatomically speaking, what are the phrēn/phrenes, and where are they located? What do they do?

c. Why is phrenitis (or the adjective phrenitikos and the verbs phrenetiaō, phrenetizō) almost never found in our evidence outside technical literature until the beginning of our era, unlike other terminology of mental disease (not only the common term mania, but also the more technical melancholia and their cognates, for example²⁵)?

A search in Kretschmer and Locker’s Rückläufiges Wörterbuch²⁶ for words ending with the suffix -itis suggests that the majority of these nouns, especially the technical ones, are formed from nouns; the most obvious denominative genesis is perhaps that of diseases, following the pattern ‘disease of the kidney’ = nephr-itis from nephros, or pleur-itis from pleura, and so forth.²⁷ Phrenitis can thus reasonably be taken to be denominative;²⁸ the Hippocratic texts provide analogies.²⁹ Morphological discussion of the nature of the compound is not mere pedantry: the denominative origin of the name invites us to think first that localization is core to the original definition of the disease, and second that phrēn/phrenes are here anatomical terms (by analogy to similar disease names, but also in consideration of the locative nuance of the psychological term phrēn elsewhere in non-medical literature, even where the use is abstract and mental³⁰). In classical medicine, in fact, no disease name in -itis is constructed to describe a disorder that affects a faculty (e.g. ‘disturbance of vision’ or ‘sleep disorder’). Most important, no disease is called after the alteration of a psychic aspect considered in the abstract: there is no ‘psychiatric’ category as such. In sum, the etymology suggests that, at the beginning of its history, this mental disorder is strongly localized in the body: in the Hippocratics, it is precisely ‘the disease of the phrēn/phrenes’.³¹

What and Where Are the phrēn/phrenes?

But this is only the beginning of the problem, not its solution. What are the phrēn/phrenes, in fact? Much has been written on the topic, and this is not the place for more than a brief survey of what is known, particularly since conclusions remain ambiguous in many respects.³²

Where?

Both the singular and the plural forms of the word indicate a mental event or function with a bodily localization or association. Despite variations in details – always important, as discussed below – we can broadly say that the phrēn/phrenes are among the mental organs and functions that form what can be labelled a ‘composite mind pattern’.³³ Recurring elements of this group include noos, phrēn/phrenes, psychē, thymos and kardia. As Clarke notes, in the Homeric psychological system these tend to be active not in the head but in the torso; this is the case in tragedy and lyric poetry as well.³⁴ Various readers have proposed more precise corporeal identifications for phrēn/phrenes. Chantraine, following Ireland and Steel, explored the various hypotheses for localization. In Homer, an identification with the diaphragm, the sheet of muscle situated under the lungs, seems to be suggested.³⁵ But other interpretations point to the pericardium,³⁶ the entrails generally,³⁷ the lungs in particular,³⁸ or generally any organ in the upper torso – what in Figure 1.1 is identified as the epigastric and hypochondrial regions.³⁹ Most recently, Stefanelli rejected this traditional repertoire of interpretations and proposed a physiologically more refined hypothesis of localization, identifying the φρήν with one of the two main cavities found in the torso according to early Greek thought,⁴⁰ the more important upper one (‘la camera per eccellenza’), linked inter alia to the physiology and psychology of the thymos.⁴¹ This association, together with the use of the terms in Homer and other literary sources, points to an analogy between physical breathing (inhaling the thymos into the phrenes) and mental facts that locates the phrēn/phrenes in the upper part of the torso.

Figure 1.1 Regions of the abdomen, illustration.

Getty Images/Carol & Mike Werner/Science Photo Library.

Regarding the identification with the diaphragm (see Figures 1.2, 1.3 for a modern anatomical illustration), which will become central in Greek medicine, Galen comments that Plato was the first to replace the traditional (and misleading) term phrenes with diaphragma to indicate that portion of the body.⁴² The clear identification of phrēn/phrenes with this ‘separating wall’⁴³ (at least when the term is used literally) is first found in the Hippocratics, then in the Timaeus (as an upper limit for the location of the appetitive soul at 70a3; as pathologically important at 84d7). It is often employed by Aristotle, who speaks of the phrēn/phrenes at HA 506a7 as a diazōma, ‘frame’ or ‘belt’, and elsewhere as a paroikodomēma kai phragmon, ‘partition wall and fence’ (PA 672b20).⁴⁴ At the same time, diaphragma (absent from Homer and the tragedians) also appears as a synonym in technical vocabulary to indicate the muscle sheet below the lungs proper, as well as partitioning cartilages generally.⁴⁵ Finally, to hypochondrion/ta hypochondria is also a relevant term (see Figures 1.1–1.3 for imaging in current anatomical terms) due to its location in the upper chest as well as its general character, which becomes important in ancient psychopathology.⁴⁶ This term is used by the Hippocratics to identify the ‘“part(s) lying below the cartilage”, i.e. the soft abdominal region below the ribs stretching to both sides of the body’,⁴⁷ the epigastric-lung region on the side of the chest.

Figure 1.2 Diaphragm, illustration.

Getty Images/SCIEPRO/Science Photo Library.

Figure 1.3 Human respiratory system, illustration.

Getty Images/PIXOLOGICSTUDIO/Science Photo Library.

What?

The question of localization, important for our medical discussion, is subordinate to the function indicated by phrēn/phrenes in non-technical use. What are the pragmatic uses of the terms in regard to mental life?

First, these are the most frequent mental terms used to indicate the individual mind in ancient epic and drama, and especially in tragedy. These two genres, although highly stylized and conventional, and as such far removed from medical texts, are fundamental for the reconstruction of ancient psychology due to their attention to and richness of detail in both descriptions of mind–body interactions and the exploration of ethical questions. The singular phrēn/φρήν is found in poetry (Homer, tragedy, lyric) to indicate the mental sphere in a personal sense, with a high degree of abstraction and even, one might say, metaphorically.⁴⁸ It appears to have a fundamentally locative and comitative sense,⁴⁹ that is, the phrēn acts in cooperation with the self rather than in opposition and dialogue with it (unlike, for example, the thymos). Notably, no one ever ‘speaks’ or ‘listens to’ his own phrēn,⁵⁰ as in the famous idioms in which a character speaks or listens to his θυμός in epic or lyric poetry; the phrēn is rarely presented as an independent active agent in Homer, and even when it develops into an entity separate from the foregrounded subjectivity, it generally entertains a harmonious rather than antagonistic relationship to the self. (To use a modern expression, it tends to be ego-syntonic rather than ego-dystonic.) As a mental term, φρήν has no strong qualitative characteristics; unlike thymos or kardia, it does not suggest intense emotions such as anger or courage, and it can also identify life and vitality.⁵¹ It is the place where thoughts are ‘slowly pondered’,⁵² and where e.g. artistic creativity operates, as in Democritus 68 B 129 D.–K. ‘[The poets] think divine things in their mind (phreni theia nountai).’⁵³ phrēn can also be qualified by a wide range of adjectives, qualitative aspects and emotions, suggesting that none of them is specific to it.⁵⁴ It accordingly seems to approach the sense ‘character’ or ‘seat of self’, a person’s deepest core:⁵⁵ this is seen most poignantly at Euripides, Hippolytus 612, where the hero famously justifies himself for not keeping his promises by saying that ‘My tongue swore, but my phrēn did not’ (hē gloss’ omōmoch’, hē de phrēn anōmotos). In the singular, phrēn appears only once in the Hippocratic texts;⁵⁶ in general, it seems to have a more abstract, mental meaning and perhaps lends itself less well to technical use.⁵⁷

In Homer and tragic poetry, the plural phrenes has basically the same semantic range as the singular and the same usage characteristics.⁵⁸ Notably, it appears to refer more stably and clearly to a bodily location than the singular phrēn: it is more concrete and localized, and more exposed to affection. (An example is Io’s ‘distorted mind’, diastrophoi phrenes, as a result of derangement at [Aeschylus] Prometheus Bound 673.)

It is not only the poets who are aware of the mental associations that appear to be traditional to, and perhaps immediately felt in, this part of the body. The fifth-century encephalocentrist author of the Sacred Disease takes time to scathingly refute any association between phrenes and phronein,⁵⁹ as does Aristotle (if more positively, recognizing the participation of this part in mental reactions, in a cardiocentric spirit) when he discusses the phrēn/phrenes as the physical diaphragm, but also as a neighbour of the seat of the soul, the heart.⁶⁰ In general, the medical idea of a mental relevance of this body part seems to have been widespread, if controversial.⁶¹ All these suggestions, anatomical and psychological, are active in the name phrenitis and will later participate in the richer and more psychologically rounded late-antique elaborations on the disease.

A Fuzzy Label

Returning to the disease label phrenitis in light of the history of the phrēn/phrenes sketched out above, the lack of unanimity about the latter necessarily affects how we understand the former. Although phrenitis is certainly derived from phrēn/phrenes, the nature of the disease cannot, or at least cannot entirely, be accounted for via etymology. The Hippocratics, as we have seen, are uneasy about the traditional associations of phrenitis with phrenes⁶² and completely ignore phrenes as a mental item. These associations, with all their vagueness and contradictions, nonetheless remain active in the reception of the term by classical audiences and maintain their potential precisely through their polysemy and contradictions and the disputes they never fail to engender. In ancient framings of phrenitis, we thus encounter denials of its localization in the diaphragm; localization in the diaphragm, but denying any mental quality to this part; and localization in the heart, with phrenes interpreted abstractly as ‘mind’. Perhaps we should compare the linguistic concept ‘iconym’⁶³, Silk’s term for a traditional word which

has no circle, no centre. It has only a few scattered connotations: a set of random associations, like ghostly rings, perhaps randomly overlapping, but largely unrelatable, and all in all leading nowhere. The random association will consist partly of earlier literary contexts (from which the knowledge of the word presumably comes), partly, perhaps, of aural associations of the kind that we tend to read as ‘re-etymology’. There is a diffuse reference, then, too diffuse to begin to derive a referent from it.

This description of untranslatable Homeric poetic terms illumines a general principle of pragmatic linguistics relevant to phrēn too: the key role played by usage and interconnections, as opposed to neatly defined semantic areas. The label phrenitis, despite the controversies regarding its relation to phrēn/phrenes, and about where the latter are located and what they do,⁶⁴ functions in a similar way, by performing at least the following functions: it gestures towards mental life, expresses pathology and indicates a location – or rather locations. As a label, it is thus both fuzzy and broad, qualities that are valuable for constituting efficient taxonomic orders: a label or category must constitute a ‘hub’ for medical or epistemological concepts.⁶⁵

Technicism

Finally, a survey of non-medical literature shows beyond any doubt that phrenitis is eminently a technical term in the initial centuries of its existence. Aristophanic characters can use the verb melancholaō (‘to be atrabilious’, ‘to be melancholy-mad’) hyperbolically for ‘raving’;⁶⁶ the common term mania is found everywhere in non-medical material to indicate a pathology, but also to mean ‘madness’ in a generalized or hyperbolic sense;⁶⁷ and the ‘sacred disease’ is diagnosed as explaining deranged and morally unsound behaviour in Herodotus.⁶⁸ But phrenitis seems not to enter the pool of recognized medical commonplaces as either possible material for comic exaggeration or an erudite specification, or as part of intellectual remarks until much later on.⁶⁹

Status quaestionis

The scholarship on the Greek vocabulary for mental life, and on φρήν/φρένες and related terms in particular, is extremely rich. But not one of the many scholars who have devoted attention to this traditional branch of ancient studies has addressed the medical use of phrēn/phrenes or the obviously pertinent term phrenitis as part of the story. Apart from the seminal discussions by Pigeaud (1981/2006) 71–100 and (1987/2010), the only extensive studies of the disease are an unpublished doctoral thesis by McDonald (2009, 2014), a competent and thorough survey that does not aim, however, to problematize the term in cultural-historical terms; another thesis, by Murphy (2013), which surveys phrenitis, together with mania and melancholia, in Aretaeus and Caelius Aurelianus; and Bornemann’s (1988) doctoral study of the Arabic tradition, with a general discussion of the disease. Other, article-length contributions are Byl and Szafran (1996) and Pigeaud (1994) on individual texts (Hippocratics and Caelius Aurelianus, respectively),⁷⁰ and more recently the reconstructions of the Arabic milieu by Carpentieri, Mimura and others, and reflections on the Christian material, with particular reference to the localization in the brain in Wright’s dissertation (2016), article (2018) and book (2022). More surprising, no attention has been paid to the disease outside the restricted field of the history of medicine. As a result, one of the most important pathological categories in ancient medicine, and a highly visible medical concept in Western intellectual life from the beginning of our era to modernity, remains obscure.

Images

Images of objects, whether pictorially or photographically produced, are never a neutral reflection of reality. When it comes to the human body, there is no externality of a ‘reality’ or ‘true image’ we can look at from a distance. Most decisively, from an epistemological point of view, the emergence of any image of the body necessitates the intrusive actions of opening, dissecting, contrast colouring, slicing, desiccating, displaying and disposing in perspicuous ways, irradiating with radioactive waves or locating in a magnetic field.⁷¹ The hyper-clear images on pp. 13–15, as products of artificial modern didactic simplification, would perhaps have meant nothing to a Homeric audience. I nonetheless offer them as pragmatic guidance to my use of the main referents, on current anatomical understandings, of the key bodily locations in our discussion of phrēn/phrenes: diaphragm, lungs, heart, stomach, epigastrion and hypochondriac regions.