Sixteenth–Seventeenth Centuries: phrenitis and the Flourishing of Anatomo-pathology (André du Laurens and Daniel Sennert)

In line with the ‘anatomizing the past’Footnote ¹² visible in Beniveni’s revisitation of Celsus, I focus here on two discussions of phrenitis which further reflect the elaboration and new understanding of ancient medical ideas about the disease between the sixteenth and the seventeenth centuries, by André du Laurens (9 December 1558 – 6 August 1609) and Daniel Sennert (25 November 1572–21 July 1637), the first centred on the diaphragm and brain locations, the second granting a key role to the blood and meninges.

While du Laurens’s Historia anatomica: controuersiis, obseruationibus, published in 1599/1600, had a predominantly anatomical-descriptive rather than pathological focus, in his subsequent Controversiae anatomicae (Liber ix, Quaestio iiii) we find an instructive chapter De phrenitide diaphragmatica with a Demonstratio anatomica. The initial focus in the first is on the diaphragmatic location, a choice that takes us back to Galen’s On the Affected Places 5.4.Footnote ¹³ In fact, du Laurens faithfully reproduces Galen’s approach at the opening of the Quaestio:Footnote ¹⁴ under the heading de phrenitide diaphragmatica, he distinguishes the ‘primary’ phrenitis idiopathica, quae ab inflammatione meningum contingit, from the ‘secondary’ phrenitis diaphragmatica/sympathica, and describes their respective symptoms (respiration, pulse and so on), while at the same time mapping the disease anatomically onto his own professional observations.

This fresh anatomization of phrenitis is given a central place in the argument. After initial treatment of the diaphragmatic type, the localization in the brain is discussed in terms fundamentally reflecting the structure of Galen’s exposition, but corroborated, concretized and enriched with what appear to be autoptic observations of the tangible body part, as the preceding detailed anatomical description of the diaphragma shows. Galen firmly retains his place as key authority, but the ancient text is inscribed on the human body, which now lies before the scientist, thus receiving reconfirmation and a deeper meaning.

The second example of ‘anatomization’ of the past is offered by the renowned German academic and physician Daniel Sennert, who discusses De phrenitide in his Practica Liber i, ii, vii (1635).Footnote ¹⁵ Sennert too follows the authority of Galen, but relies on other parts of the corpus which prioritize the brain as the key locus affectus in phrenitis, especially the fundamental Commentary to Prorrheticon I, to which he refers explicitly. Phrenitis is thus defined by Sennert as ‘properly intended, an affection of the membranes of the brain (proprie membranarum cerebri affectio)’; the diaphragmatic name it received in antiquity is returned to the status of an accident.

At the beginning of Sennert’s discussion we find a key move already seen in the Medieval practicae, but here with an unprecedented degree of explicitness: that by which phrenitic symptoms begin to be ‘spread’ among various pathological forms – headaches, apostemata and the like. There is an overlap between nosological concept, Phrenitis with a capital P, so to speak, and a phrenitic phenomenology that can arise under various circumstances. Sennert writes: phrenitis can be ‘understood in two ways (dupliciter considerari): either as a disease, which is, as an inflammation of the membranes of the brain … or as symptoms (ut symptomata), namely as a damaged functioning of the ruling [mental] faculty (depravata actio facultatum principum)’ (p. 87). We see here an explicit understanding of the disease as an abstract notion and of its manifestations as carrying multiple significances and combinatory power.

Another point of theoretical interest is the Galenic distinction between lesions in the imaginative faculties and in the power of judgement, described in the famous case of a patient throwing objects out of a window.Footnote ¹⁶ Sennart poses a dubium of great modernity in its psychological relevance in this respect (following the objection advanced by the medical writer Eustachius Rudius): When one of the two faculties suffers, must the other also be affected? What is the link between the twin functions of representation and judgement?

The rest of Sennert’s discussion focuses, first of all, on causation: phrenitis is an inflammation of the meninges (membranarum cerebri inflammatio) following an overgorging with bilious blood and its fumes. Pathological differences are only in the manifestations of the disease, not its cause, which is only one. This pragmatic approach supersedes the medieval distinction between a plurality of pathogenic humours and places blood at the centre as a unifying element, in line with progress in the knowledge of heart and blood physiology in this period as a result of William Harvey’s studies of the heart and its workings. (Harvey’s De motu cordis was published in 1628) Blood, variously spoilt, is always the cause (omnis phrenitis … est a sanguine), but different kinds of corruption can have different outcomes:

and so forth. Phrenitis varies depending on the intensity of the causal factor (pro causarum vehementia), affecting different faculties accordingly.

This account clearly expresses a ‘biochemical’ (as we might put it) interpretation of the disease and its variations. Not only different causes in terms of substances, but different loci affected by them determine different versions of the disease. Here, however, it is no longer the diaphragm/brain controversyFootnote ¹⁷ or alternative which takes centre stage, but the ‘histological’ question of the substance of the brain. For Sennert, like others before him, the body of the brain can sometimes become involved, although the primary locus of phrenitis is in the membranes.

Sennert’s discussion of diagnostic signs is also sophisticated in how it distinguishes between signa of the disease ‘impending (imminentis)’ and ‘already present (praesentis)’. The former are the well-known visible signs noticed on the face (such as redness), as well as delirium, hypersensibility, hallucinations, irascibility and aggressive glances. The disease present is manifest in continuous fever, delirium and a state of insomnia; to this list Sennert adds jumping about and being highly reactive, on the one hand, and being prey to torpidity and excessive stillness, on the other. By means of these symptoms, for him and in agreement with Galen, phrenitis can be differentiated from melancholia (by fever), from lethargus (by insomnia), from other forms of delirium (by its continuous character), and from inflammation of the diaphragm (by the quality of respiration).

Therapeutic measures (curatio) involve purging via venesection, soothing sleep induced with hypnotic substances, curbing mordent humours and cooling body parts that might be suffering (the heart, liver and even genitals). Soothing measures are also considered. Dietetic recommendations mostly quote Celsus and his psychotherapeutic proposals: modulation of light, diversion, consolation and constraint when necessary. The ancient material, in conclusion, including Celsus’ notably non-anatomical account of phrenitis, is thus reshaped and adapted to a new, highly corporeal model,Footnote ¹⁸ which gives both blood and encephalic pathology a central role and has their effects involve different body parts.

Seventeenth and Eighteenth Centuries: phrenitis in the works of Boerhaave, Van Swieten and Morgagni

Fundamentally the same lines of development are visible in the works of anatomo-pathologists at the beginning of the modern era, as I shall illustrate through three central examples: the Aphorismi de cognoscendis et curandis morbis of the Dutch scientist Herman Boerhaave (1668–1738), in which phrenitis is discussed (Pars II. Morbi Interni, Acuti, Chronici 771); reflections on that text by Boerhaave’s colleague Gerard van Swieten (1700–72), who compiled a Commentaria in Hermanni Boerhaave aphorismos de cognoscendis et curandis morbis – for our purposes, the two are best read in dialogue with one another – and the De sedibus et causis morborum per anatomen indagates libri quinque of Giovanbattista Morgagni (1682–1771).

First, the criterion of fever is now dominant. In his Aphorismi (1728), Boerhaave includes phrenitis among the morbi acuti febriles and recognizes a second type of the disease, which can be identified with almost any fever (fere omnis morbus acutus cum febre) and strikes a variety of locations in the chest: the ‘side’, the pleura, the lung and the diaphragm, which is said to be ‘the worst’ case (quae pessima). Boerhaave also offers an overview of the various classifications of types of the disease current in his time:Footnote ¹⁹ phrenitis can be ‘real’ (vera), but also symptomatic (symptomatica), or akin to other diseases (i.e. variolosa, morbillosa, verinosa, aphrodisiaca), without fever (apyrta), linked to heat (calentura), caused by grief or pain (a dolore), or linked to rabies (hydrophobica). These many sub-types contain a number of by now familiar implications: the true vs false disease; the cluster of symptoms; the delirious affection deriving from entirely different diseases; the variety without fever, the variety that follows pain, and the variety linked to rabies.

Van Swieten’s comments on this first part (ad 771) is a rich excursus, which begins by discussing the label and etymology of the disease. He explains the suffix -itis as indicating inflammation and adds: ‘They accordingly called the disease of that corporeal part, from which human understanding depends (illius ergo partis corporeae, unde humana sapientia pendet), phrenitis … for which reason Pliny too referred to it as an “illness of understanding (sapientiae aegritidinem)”.’ He elaborates on Boerhaave’s observations with close reference to ancient authors, especially Galen and Hippocrates, but also Celsus, Caelius and Asclepiades. The modality adopted is that of free retrospective diagnosis: like Galen before him,Footnote ²⁰ Van Swieten reads Hippocratic patient cases, but also other ancient tales (for example the summer epidemic fever in Abdera described in Lucian’s Quomodo historia conscribenda sit),Footnote ²¹ as straightforward examples of phrenitis. There is a meaningful confidence in the way the semiotics of this disease, as understood by the anatomo-pathologist, appear to be beyond controversy or debate: every sign in the ancient patient, every ancient remark or bit of therapeutic advice, is explained – made to make sense – in the light of contemporary science and in terms of a new image of the physiology of the human body, in which the account of the nervous system, blood circulation and a view of psychology in which the brain is defined, via a remarkable expression (ad 773), as the ‘seat of our humanity (unde humanitas nostra pendet)’,Footnote ²² are all taken for granted and treated as beyond explanation.

At Aph. 771, Boerhaave distinguished phrenitis vera and symptomatica. In response, Van Swieten (23) takes the occasion to elaborate at length on the topic of transference, metastasis in the phrenitis of the symptomatic kind: the inflammation migrates from an organ to the brain, with some localizations more dangerous than others. For example, ‘It was shown there that filth/residue gathering around the praecordia can impair all the functions of the brain’. Along similar lines, at Aph. 772 Booerhave sketched a distinction between ‘antecedent’ and ‘present’ elements in the state and behaviour of phrenitis. The first are heating, powerful pains of the inflammatory kind inside the head, abundant blood, red eyes and face, trouble sleeping and mild delirium. But there are also potential triggers, such as youth and exposure to heat (adulescentia … calidorum usus, insolatio), as well as elements of lifestyle, habits and character (wakefulness, anger, grief, aggressiveness or quarrelsomeness, sudden forgetfulness, dryness of the whole body, especially the head, and floccillation; vigiliae, ira, moeror, protervia seu ferocitas; oblivio subitanea; siccitas totius, maxime cerebri; collectio flaccorum). Van Swieten comments on each element of this semiotics and pathology, beginning with those that characterize the vera phrenitis: heat; intense pain in the head, inflammatory in kind; excessive blood (calor, dolorque internus capitis ingens, et inflammatorius; sanguis copia nimia), connecting the engorgement of vessels with inflammation of the brain. There are also aspects of individual constitution, the dispositio inflammatoria, a kind of pathological vulnerability in certain patients. Then come the observable details: red eyes and face (rubor oculorum, faciei); the important marker of disturbed sleep (somni turbulenti); and the presence of a milder grade of derangement (desipientia levis). As for age (adolescentia), youth (flos aetatis) is confirmed as a factor, along with exposure to heat (calidorum usus); van Swieten notes with regret that youths full of hope (optimae spei iuvenes) fell prey to inflammation due to excessive consumption of wine and spirits (vinis generosis vel & spiritibus fermentatis liberalius haustis) and then died of phrenitis.

In a direct way, meteorological heating (insolatio) can be responsible: the warmth absorbed by the head causes the blood to coagulate, producing a fatal phrenitis. This is even more so in the case of individuals who are asleep, which is most dangerous. Van Swieten recalls the case of two reapers who were otherwise quite healthy (messores sanissimos certe & robustissimos) but died within two days after having fallen asleep under the sun on a stack of hay.Footnote ²³ Wakefulness (vigilia) too affects the brain and the blood, making it thicker.

A most intriguing development is offered by emotional causes in their physiological effects, which are definitely marginal in ancient medical literature and here betray the influence of popular culture. Ira is defined as a ‘short bout of fury (brevis furor)’, and the similarity between the actions of an angry man and those of a phrenitic have the power of an argument: the complexion, fiery eyes and pulse are the same. Grief too can have adverse consequences. Van Swieten repeats one of Boerhaave’s examples, that of a woman (as is typical in these portrayals of pathologized grief):

Van Swieten compares the phrenitis of this bereft woman to the Hippocratic patient at Epid. 3, 17, case 15 (110–11 Jouanna = 3.146 L.), the wife of Dealkes,Footnote ²⁴ who became feverish and flocillated obsessively ‘as a consequence of grief’ (ek lypēs). The subsequent signs equally belong to character, at least in part: ‘arrogance and even ferocity, sudden amnesia, flocillation (protervia seu ferocitas, oblivio subitanea, collectio floccorum)’ – the latter being a sign of disturbance of the senses (turbari sensorium commune). Aggressiveness is especially serious if out of character for the person, according to the well-known principle that sudden radical change is always bad. Aridity, especially of the brain, is dangerous (siccitas totius, maxime cerebri); to be humidum et molle, ‘moist and soft’, is a general mark of physical health in any animal, in the depths of the viscera as much as on the surface.

The symptoms of phrenitis that originate elsewhere and are then translated to the brain, so-called symptomatica (27), are similar to fever in the brain. It is interesting that van Swieten corroborates the point by tying in Hippocratic parallels not previously associated with phrenitis, notably the bold man in Larissa suffering from fever and derangement, and who will die, presented at Epid. 3, 17 (98–99 Jouanna = 3.118–20 L.). On the second day this patient felt a sudden pain in the leg (de repente femur dextrum doluit) followed by derangement. The pain grew milder, but then death ensued. The adoption of the odd delocalization of the sympathetic affection in the leg to the brain (which might make sense on a contemporary medical understandingFootnote ²⁵) nicely represents the radicalization and concretization of the bodily symptom of phrenitis that ultimately transforms it into a non-psychiatric item. Van Swieten is so persuaded by the meaningfulness of this that he quotes a parallel from his own clinical experience (27): ‘I saw a similar case in a woman whose left leg was overcome by extremely sharp pain when a continuous fever arose (cui oborta febre continua acutissimus dolor sinistram suram occupabat).’ Here too, just as the pain abates, derangement follows, after which comes death.

As in other cases in which pain arises, such as in the side, what is happening is understood as a ‘bad transference to the brain (mala metastasis ad cerebrum)’ that occurs precisely when the original ailment seems to improve. The pain produced by peripleumonia and pleuritis is a key example of the same process. For certain manifestations, Van Swieten offers parallels from the medical past (Hippocrates), but also from classical culture (e.g. Lucian),Footnote ²⁶ which are in turn set in dialogue with his own observations.

On the topic of floccillation and the sudden nature of the phrenitic attack, Van Swieten mentions a case reminiscent of a Galenic description,Footnote ²⁷ that of a ‘gardener who, on the third day of a “real” phrenitis, in the course of which he was silently delirious and was picking flocks, in the blink of an eye jumped out of bed and ran very rapidly up to the top floor of the house. The wretched man would have jumped straight from the window, if his wife had not rushed to hold him back; and as she was fighting with her husband and calling those nearby for help, the patient managed to hurl himself forth and died immediately thereafter’ (hortulanum tertia die phrenitidis verae, in qua tacite tanto delirabat, & floccos carpebat, uno momento lecto exiliisse, & celerrimo cursu adscendisse in superiorem domus partes; deque fenestra praecipitem se dedisse miser, nisi uxor advolans retinuisset; dumque illa cum marito luctatur, & vicinos in auxilium vocat, convellitur aeger, & moritur subito).

All these instances illustrate the complexity of the dialogue with ancient sources, a dialogue that plays out in the territory of doctrine as much as that of clinical cases, and is traced on the limbs, flesh and blood of living (and deceased) patients. Galen’s more theoretical but also clinical observations, as well as the many depiction of phrenitics as self-harming and hurling themselves down from windows or cliffs, all contribute to and sustain the nosological account.

There is also an interesting detail concerning sputum. In Galen, this sign is connected to damage to the proairetic function, the physical ability to control oneself.Footnote ²⁸ In Boerhaave we find instead ‘frequent and undignified spitting at those around (sputatio frequens et indecora in adstantes)’, with a reference to propriety and behaviour that is nonetheless an elaboration on the corporeal event. Van Swieten too is interested in this behavioural aspect in his commentary ad loc. (34):

Here too Van Swieten refers to this pathologization of mores or judgement – and lack thereof: ‘All voluntary actions which lack or overstep measure or dignity are signs of phrenitis (omnes actiones voluntarias, quae praeter modum ac decorum deficient, vel exsuperant, phrenitidis esse signa).’Footnote ²⁹

The inspection of corpses, as noted at the beginning of this chapter, is a key part of this project of anatomization of health and the ancient medical tradition all in one. At 775, Boerhaave describes and discusses in close detail the cadavers of phrenitic patients. These are said to display inflamed meninges, gangrene, abscesses and rotten, ‘sphacelous’ brains, as well as mordent ichor (i.e. the liquid which surrounds the meninges). These observations also articulate a distinction between phrenitis vera and paraphrenitis.

The therapy for the disease, finally, is arduous. For the form with varices, purging helps (779) and can be accomplished through haemorrhoids, alvi fluor, pain in the chest with coughing or general haemorrhage. The real kind, phrenitis vera, requires extremely rapid measures to curb the inflammation of the arteries leading to the brain: venesection; purging; cleansing of the nostrils, eyes and ears; shaving the head; and various methods of refrigeration. For sympathetic phrenitis, finally, topical remedies are mostly recommended.

In the work of the Italian anatomist Giovanbattista Morgagni, the development of the concept of phrenitis through practices of post-mortem inspection is especially evident. Morgagni’s De sedibus et causis morborum per anatomen indagatis libri quinque (1761) discusses pathology on a clinical case basis, reserving key space for the post-mortem examination of patients. In its Epistola Anatomico-medica VII we find the Sermo … de phrenitide, paraphrenitide, & delirio. This by now fully blown, case-specific, dissectional and autoptic approach is a wonderful illustration of how hardwired the once ‘mental’ disease phrenitis has become: it is now visible in the inanimate body, inscribed on it despite its lifelessness, evident in the state of the meninges and brain and their secretions and accompanying substances, as well as reflected in the state of other parts of the body. Morgagni presents nine cases, all of which end in death: (1) a young man, adulescens, Ep. VII, 2, ill with fever and delirium, who dies after seven days; (2) an approximately 35-year-old adult man, vir, who dies after ten days, having suffered pain in the chest with fever (in thorace, cum febre); (3) a porter, bajulus, ill with ardent fever and delirium, who passes quickly; (4) another 35-year-old vir suffering from fever, delusions and a rapid pulse; (5) a senex of 80 years, who dies after the fifteenth day with fever, delirium and convulsions; (6) a potter, figulus, of 70 years, in whose case Morgagni offers a portrayal enriched with aspects of character and lifestyle; (7) a worker weakened by a professional malaise: the dust from the hemp he worked, we are given to understand, damaged his respiratory tract and affected his voice, causing phrenitis (vir procerus & macilentus ex cannabis carminatione, quae ars eius erat, thoracis inflammationis obnoxious); (8) a mulier who was confined to bed due to a blow to the head (ex ictu capitis … decubuerat); (9) an old man, anus, suffering from fever and delirium.

When we look at these cases collectively, the autoptic post-mortem observations make it evident that the disease is seen as meningitic and inflammatory. The membranes are the important locus affectus, central in several cases but also accompanied by other elements. In (1), for example, thick, blackened blood accompanies the gelatinous matter under the cranium and the laceration of the meninges at its base, with a milky serum produced. In (2) the pain is in the torso, and the affection appears to first affect the lungs, where pulpous concretions are found in the cadaver. Morgagni describes this as a peripneumonia with ‘translation’ to the head. In (3) the pain is in the head from the start, and the autopsy shows gelatinous concretions between the blood vessels of the meninx.

After the presentation of (4), Morgagni inserts a long excursus on the vexed question of whether the brain as well, or only the membrane, could be inflamed in cases of phrenitis – a general matter of contention we have already encountered.Footnote ³⁰ He answers in the positive, reinforcing the point with evidence from his own observations and those of many other doctors regarding pathologies of the body of the brain in such phrenitic cases, in which it appears, for example, to be sphacelous or full of black marks. The damage, he concludes, may in some cases strike the brain, even if the vast majority of cases affect the meninges. In case (5), the torso and its contents are under scrutiny instead during the autopsy. The patient’s entrails are still hot to the touch (calentia … viscera) at the time of the post-mortem examination, despite the cold room; the intestines are reddened, the liver dark, and there are observations about the pericardium and the cor.

The potter, figulus, discussed in (6) bears an interesting resemblance to some ancient patients in the details regarding his lifestyle, as Morgagni describes it, as well as to popular portrayals of phrenitics: hilarity, heavy drinking and a general state of anxiety (natura hilaris, potor strenuus, post animi curas). The potter complained of pain in his side and breathing problems, and his dissection closely details the structures in his torso. Morgagni inserts an excursus here (12) to account for this case of peripneumonie/pleuropnumonie with delirium, framing it within a cluster of similar cases, all fatal, that occurred in the winter of 1754, and explaining them all as examples of paraphrenitis. The case described in (7) is even more explicit about the role played by lifestyle: the professional activity of this patient, hemp-carding, is indicated as a plausible factor in his respiratory tract ailment, accompanied by vomiting and delirium. The patient’s phrenitis is ferox in kind, and his breathing gravely disturbed; the autopsy shows damage to the lungs, inflammation of the diaphragm, and distention of the vessels of the meninges. In his commentary, Morgagni indicates dust (pulvis) as the causal factor for the formation of tubercles in the lungs, and the lungs are indicated as a possible origin of phrenitis, although with qualifications. In (9) as well, finally, the belly (venter) is at the centre of the autoptic inspection.

For practical examination, then, Morgani accepts a localization of the disease between lungs and brain as unproblematic (just as Galen in On the Affected Places had already understood localization to be a complex affair); this has no consequence, since the localization of mental life is no longer part of the discussion. Delirium is not an activity of the hegemonic function located in the brain, but is now pragmatically approached as a symptom, a manifestation, which can have various causes. Giving double or multiple loci is then a move whose relevance is entirely symptomatic and concrete: this is Hippocratic – extremely Hippocratic, in fact, coming full circle by entirely eliminating the ‘mind’ of the phrenitic as a problem of nosology.

What’s in a Leg? Text-Based Medicine, Clinical Observation and Human Experience

The role of Hellenism and ‘humanistic medicine’ (and the dissent against them) in the forging of medical ideas and practices in early-modern and modern Europe is a central topic for the understanding of the medical cultures of the period.Footnote ³¹ Discussion usually emphasizes the doctrinal, ideological and textual net of references and reception, while less attention is given to the body of medical actors – in this case, the patient – as an element in this trade. I want to offer here precisely this: the case of a rather unexpected body part in our disease, the leg of the phrenitic.

In the Hippocratic Coan Prenotions 76 (122 Potter = 5.600 L.), we read that ‘Forms of derangement (parakrousies) with trembling and with groping with the hands are phrenitic (phrenitikai); in these cases, pains in the calves (hoi kata gastroknēmiēn ponoi) lead to a disturbance of the mind (gnōmēs paraphoroi).’ This leg-sign is also discussed in the Hippocratic Prorrh. I, 36 (79.5–6 Polack = 5.519 L.), although without specific reference to phrenitis. At Comm. Hipp. Prorrh. I, 3 (49–50 Diels = 16.584–86 K.), commenting on this lemma, Galen wrote:

Galen dismisses the notion that the sign should be specific to derangement, much less phrenitis, and ridicules the idea that it should be considered so when ‘in remission’. He might be quoting from memory and confusing this case with another in Epidemics 3,Footnote ³³ that of a bold man in Larissa, in which the cessation of pain in the leg is indeed associated with derangement. But Galen’s slip or expression of personal opinion is unimportant here. What matters is instead the tenor of his discussion and his reference to a category of reader who had a different opinion on the matter (hoi boēthountes tēi rhēsei prosypakousai). This shows that mention of the leg-sign was seen as noteworthy, and that pain in one leg as a manifestation of mental disturbance was a significant point for the HippocraticsFootnote ³⁴ and attracted discussion by readers in Galen’s time.

If Galen’s engagement with this detail can be explained by his devotion to the Hippocratic text, with which he is always in dialogue, the fact that this element pops up in Van Swieten’s discussion of phrenitis symptomatica is more striking. At Comm. Aph. Boer. 772 (27), as we have seen, the Dutch physician speaks of the metastasis that can cause the disease to move to different parts of the body in this type of phrenitis, and recalls the passage Galen also had in mind (although no phrenitis is explicitly mentioned there):

At this point, Van Swieten adds a case of his own:

We find this same sign in one of the child patients with phrenitis aestiva in a clinical report from over a century later, Samuel Gee’s observations in Saint Bartholomew’s Hospital Reports of 1876. He opens with a Hippocratic epigraph:

He then describes the case he had treated:

Gee then moves on to mention a fifteen-year-old boy who also suffered from headache and fever. At some point, ‘delirium, and begun to complain of left thigh’. The pain is scrutinized and no other cause for it found; this patient too died. Gee concludes with explicit reference to the authority of both Hippocrates and van Swieten: ‘This early pain in the thigh would seem to be a condition different from that which sometimes happens to the end of a typhus, typhoid fever, and peripneumonia, … whether the patient described by Hippocrates and van Swieten suffered from the same kind of disease, I will not take upon myself to say.’Footnote ³⁶ Making medical sense of the sensation of pain in the thigh with phrenitis and derangement is not obviously the point; it might be a fantasy, or a localization of the muscular and joint aches that typically accompany fevers, or one of the signs that modern medicine ascribes to meningitis, such as versions of ‘panneuritis’ (or ‘polyneuritis’), stiffness of the neck or Kernig’s sign (the inability to bend the leg at the knee). But deprived of any explicit anatomo-pathological specificity, what is this painful leg about in literary terms? For us, at the end of our history of phrenitis, and especially in light of Gee’s concluding statement of aporia vis-à-vis the nature of his predecessors’ cases, it makes an important point. Human bodies are constructed, in a very literal sense, of history and of texts; indeed, they are texts.Footnote ³⁷ There is a rationalized and less interesting version of this point: the educated physician will project his reading onto the patients he visits, or patients will try to fulfil the expectations of the physician’s erudition. But there is also a deeper sense, according to which the physical experiences of the living human body express themselves through clusters of tropes, some cultural, some social, some textual, some more or less constructed. The bio-medical, with its relatively predictable and – at least theoretically – replicable and controllable chains of reaction, is only one of many equal possibilities.

Renaissance Medicine and phrenitis Delocalized: Paracelsus and his Influence

Here we come again to a kind of ‘minority report’ in the history of our disease: if the dominant textual scholarship and medical teaching on phrenitis (and generally), as well as learned therapeutic practices in the period from the second half of the fifteenth century onwards, are undeniably rooted in anatomical pathology and based on the authorities of classical medicine, alternative narratives exert an important influence on a variety of medical and natural sciences, and this is reflected in the itinerary followed by phrenitis as well. A key personality in this chapter of the story is the Swiss doctor and thinker Theophrastus von Hohenheim, known as Paracelsus (1493–1541).Footnote ³⁸ Paracelsus elaborated a vast body of doctrines about disparate aspects of natural science, anthropology, theology, astrology and medicine, with Hermetic and alchemic influences among other things. The significance of his work in the development of modern science cannot be overestimated; within medicine and in the restricted area of nosology, he is notable for expressing himself against the ‘errors of medicine’ from which the authority of ancient doctors, Galen especially, is not immune,Footnote ³⁹ and against the very idea that diseases should be located in the body or are curable through traditional pharmacology or purging. Thus Paracelsus vehemently opposes received medicine altogether and does so with conspicuous radicalism.Footnote ⁴⁰ Disease for him is best accounted for in terms of bodily forces (spiritus) and universal energies and in terms of their harmony and disharmony, substances and life style, and environmental circumstances; ‘disease’ itself as status is deeply questionable. In his judgement, effective cures should be based on the principle of similarity rather than allopathy,Footnote ⁴¹ and on the employment of precise ‘chemical’ substances. Holistic and moral factors come into play in the portrayal of pathology, bringing Paracelsus in this respect closer to folk conceptions of mental illness as a marker of an existential status, that of the sinner or the weak. When it comes to the history of psychology, then, it is no surprise that Ellenberger, the great historian of psychoanalysis, saw in Paracelsus an important predecessor in the development of dynamic psychiatry, especially via Mesmer’s theory of animal magnetism and trance-inducing therapeutic practices at the end of the eighteenth century.Footnote ⁴²

If we summarize Paracelsus’ approach to pathology as psychosomatic, delocalizing,Footnote ⁴³ interpreting the body as a complex ensemble of semiotic fulcra, and holistic in its emphasis on the connections between micro- and macrocosmic forces, we can easily see the rupture his take on such a heavily somatized disease as phrenitis represents. For example, in the Paragranum (74 Weeks):

The body’s state is determined by the behaviours of its spirits; the mercurius moves following different paths, one of which, the sublimatio mercurii, causes mania or phrenesis. Another Paracelsian causative framework for phrenitis is tartarus, an alchemic-transformational-digestive concept, the ‘pathogenic embodiment of a failed or aborted process’ (Paragranum, Tract. IV, 569 Weeks).Footnote ⁴⁴

If this pathological doctrine remains marginalized from the main discourses and practices of official medicine, by the end of the sixteenth century Paracelsianism is capable of exerting an important influenceFootnote ⁴⁵ and contributes to the rise of the ‘Vitalism’ that took hold in the French academy in the eighteenth century, centred on the University of Montpellier.Footnote ⁴⁶ It also influences the development of dynamic psychiatry and psychoanalysis, and is visible in some of the outcomes of phrenitis in the twentieth century: the affection of ‘stress’ or ‘stress syndrome’, as we shall see in Chapter 10.

An earlier representative of this strand of thought regarding phrenitis is the 1765 article Phrénésie in the Encyclopédie (12: 530). The author engages, on the one hand, with the contemporary encephalic understanding – phrenitis is in fact defined as ‘continuous delirium or corruption of the functions of the brain, caused by inflammation in the vessels of this organ, accompanied by a fever of the intermittent or putrid kind (délire continuel ou dépravation des fonctions du cerveau, causée par une inflammation dans les vaisseaux de ce viscere, accompagnée d’une fievre synoche ou putride)’:Footnote ⁴⁷

On the other hand, his interpretative frame is holistic and systemic: the inflammation is just one form of the disease that can affect different localizations (head, chest, etc.), and the cause is the clogging up of the vessels around the brain: ‘Dissections show that phrenesis is not caused by inflammation of the meninges, nor paraphrenesis by that of the diaphragm, but by varicose engorgement of the vessels of the brain and meninges; it is sometimes with inflammation in the forms, and other times without inflammation.’Footnote ⁴⁹ We recognize here, on the material level, a strong analogy with the account Asclepiades offered.Footnote ⁵⁰ And as in Asclepiades, the holistic, delocalized story leaves room for psychological and holistic causation: ‘Thus all the causes that lead to the engorgement of these parts are those of phrenesis. Thus sorrow, the strong and continuous application of the mind to the same subject, pain, strong passions, such as anger, fury, love, the excesses of uterine fury, are all causes of phrenesis.’Footnote ⁵¹ Despite still referring to the familiar descriptions of phrenitis by the Greek doctors, the presentation here is open to a more holistic model of the body, shows a unique concern with psychological aspects, and is interested in psychotherapeutic remedies. Indeed, its themes and authorities connect to a large extent with those discussed in Chapter 3, especially Celsus and Caelius Aurelianus, and resonate with this psychosomatic vein regarding pathology proposed by Paracelsus and developed through Paracelsianism.

Phrenitis Delocalized: Strong Emotions, crapula, immoderatio

The general, dominant tendency in the pathological authors of the early-modern era, as we have seen, is nonetheless to tie phrenitis firmly to physiology around the following points: inflammation, fever and histology. The body as matter is at the centre: observed in life, cut open and delved into in death, with its colour, texture and condition scrutinized as telling a story.Footnote ⁵² The affected mind, the delirium, is a consequence of the bodily state. Is there any space left, then, for the ethics of mental disorder, whereby phrenitis is associated with immoderate habits and character flaws?

The moralizing discourses about the ‘phrenitic man’ (and mental illness in general), often popular and approximate, also had an important impact on medical views of the disease, although this part of the story is progressively submerged in the modern period. The behavioural and existential focus in the discussion ‘of Phrensie occasioning self-killing’, for instance, in John Reference SymSym’s 1637 Lifes Preservative against Self-killing, seems to be a rarity: ‘The seventh motif occasioning self-killing, is phrentick distemperatures; which are either voluntarily contracted and entertained, as in violent passions of love, anger, and the like; whereby some kill themselves; or else they are involuntary, and such as man is but passively affected with.’Footnote ⁵³ In the majority of cases, however, phrenitis is more and more firmly positioned as a pathology among bodily diseases.

But there are two areas in which the ethical dimension of the disease is still integrated into the medical outlook, and one of these is especially important for the afterlife of the disease. First, there is the role of the emotions as trigger, as we have seen: anger can lead to phrenitis, as Van Swieten recognized, and other exacerbating emotions, such as grief, can as well. Second and more important, there is alcohol abuse. Excessive consumption of wine and spirits recurs as a cause of the disease, and an early picture of what will eventually be ‘delirium tremens’Footnote ⁵⁴ seems to be sketched in its wake: the phrenitis potatorum, or phrenitis caused by potato-gin.

The syndrome still called delirium tremens today was fully described for the first time by Thomas Sutton in 1813.Footnote ⁵⁵ At the very beginning of his Tracts on Delirium Tremens, Sutton acknowledges the similarity between his pathological object and phrenitis, but emphasizes the differences when it comes to treatment, hence the need to find a novel pathological approach for this type of inflammation of the brain. Even before his explicit conceptualization (and distinction), however, the role of wine and drinking in some cases of phrenitis had been emphasized, and hallucinatory, distressed, ‘frenetic’ and tremulant manifestations were part of the disease from its ancient beginnings. An illustrative description of this stage of the story is offered by Wilhelm Ecke in his inaugural dissertation Delirium cum tremore Potatorum (1845), whose opening nomenclature exposes yet another version of the cluster of illnesses now being formed under the umbrella of phrenitis: ‘delirium tremens (Sutton); Meningitis seu Phrenitis Potatorum; Oenomania (Rayer) Delirium Vigilans; Delirium cum tremore potatorum; Mania a potu; Encephalitis tremefaciens (J. Frank), Säuferzittern; Gehirnentzündung der Säufer; Säuferwahnsinn; Zitterwahnsinn’.Footnote ⁵⁶

These two aspects – strong emotions, especially connected to aggressive behaviour, and excessive consumption of wine or spirits – were not part of the sphere of causation of phrenitis in the ancient tradition, although they were sporadically mentioned as exacerbating elements. And since they are soft, ‘behavioural’ features, it is at first sight surprising to find them gaining ground now, within this modern, starkly embodied, and restricted version of the disease as ‘brain fever’. But if we step away from the medical material and consider the testimony of larger cultural discourses, a consistent picture begins to emerge. We have explored in Chapters 6 and 8 how theology, sermons and popular expressions such as drama and satire exploited, elaborated and distorted the medical construct phrenitis in the service of a moralizing or parodic discourse. This multifaceted ‘phrenitic’ was largely characterized by excess (in alcohol, food and sometimes desire for wealth and sexual pleasure) and aggression, with violent and dangerous behaviour, all integrated with the medical themes most apt to theatricalization of the illness phrenitis: shouting, trembling, groping about in the air, hurling oneself around, fever, hallucinations, a lack of self-awareness and delirium. Most important, this human character became the object of what was judged an appropriate stigma and disapprobation, a speculum of human flaws: lack of awareness of one’s situation, akrasia, an absence of dignity and a pitiable inability to control oneself. All these traits kept phrenitis alive as a cultural concept and were absorbed in the Victorian (and subsequent) condemnation of the drunken wretch, as well as in various discourses on alcoholism and addiction generally.Footnote ⁵⁷ In this way, the popular, ‘irrational’, non-scientific public discourse is shown to be inseparable from and as important, in the development of medical concepts, as the erudite doctrine of learned doctors and their continuity with an authoritative ancient past.

University Research

Both medical university research and clinical observations testify clearly to this inflammatory development. Two inaugural dissertations, some sixty years apart and unworthy of much notice except as nominal testimony to this state of affairs, offer a glimpse of the accepted vulgate and status quaestionis, from the Netherlands (the Dissertatio medica inauguralis of the physician Michaëlis Jacobus de Vries, 1757, written in Latin)Footnote ⁵⁹ to Maryland (John Hooper’s Inaugural essay on phrenitis, Reference Hooper1815).

The first, de Vries, relies fully on the ancient Galenic distinction between phrenitis vera or idiopathica and phrenitis symptomatica or paraphrosyne, with symptoms ‘wild and persistent wandering together with high fever and a tense wrist (pulsus durus): these are the three symptoms that characterize phrenitis’.Footnote ⁶⁰ In terms of localization, ‘Phrenitis involves an inflammation of the brain, including the dura mater and pia mater, and also of the brain substance’ (III, 6). The anatomo-pathological teachings of Morgagni, Boerhaave and Van Swieten are repeated as assimilated, and now provide the main narrative for phrenitis for intellectuals, scientists, operating clinicians and students alike. The disease is fixed and canonized as meningo-encephalitis, and the pathological conception juxtaposes to it a variety that affects the brain in a secondary manner, starting from a variety of other organs in the body, including the diaphragm in particular.

The second text is a degree thesis from Maryland submitted in 1815, the Inaugural Essay on Phrenitis by John Hooper, which offers a further sample of this state of medical opinion, in this case written in English. Hooper’s opening words show a perfect rewriting of Hellenism in terms of modern anatomo-pathology and experimental method: ‘By dissection, it has been discovered, … the disease consists either in an inflammation of the brain, or of the membranes investing that organ.’ For this doctor fresh from medical school, the ancient medical construct of brain phrenitis is the incontrovertible pragmatic result of a momentous discovery for which post-mortem, anatomic autopsy is to be awarded the credit.

The second interesting feature in the change of perspective is the section on symptoms. First, Hooper opens directly with a focus on the subjective feelings and personal disease experiences of the patient, now made to ‘make sense’ and to correspond to the conclusive evidence the dead body will offer. In its first phase,

The disease progresses in the second stage, exacerbating the signs: ‘enlargement of the capillary vessels’ and deterioration, so that ‘we discover a pallid countenance, dilated pupil, strabismus, sick stomach’.

As for causes, Hooper distinguishes the exciting from the predisposing ones. Exposure to the sun and ‘exercise in warm water’Footnote ⁶² are mentioned as triggers, as well as ‘the passions of the mind and certain poisons’, by which he means intoxicating substances, although ‘their mode of action is not well understood’. For Hooper, the interpretative grid is vascular: there is ‘general increased action of the arterial system’ leading to an accumulation of blood in the brain. Antecedent causes predisposing the patient, on the other hand, are ‘fatigue of body and mind, and suppression of usual evacuations’, as well as ‘marsh miasmata’, which can induce ‘general debility of the system’. A sense of inexplicability nonetheless remains imbedded in the picture of the disease; not only are the physiological effects of strong emotions or substances ill understood, but phrenitis ‘sometimes arises from causes with which we are unacquainted. Sometimes it is symptomatic of fever and sometimes from a peculiar disposition of the atmosphere.’

In both De Vries and Hooper’s expositions – not outstanding ones, which basically reflect the views circulating in medical faculties between the eighteenth and the nineteenth centuries – ancient doctrines and modern anatomo-pathology are blended into a fairly homogeneous amalgam. But we should not forget that these professional doctrines both shape and gain life from the actual patients in whom phrenitis is diagnosed in the final century of its existence, patients who actually suffered the disease in their living bodies. A look at the stories of some of them is unavoidable, if we are to understand the relevance of medical/textual history to the actuality of human life. The following phrenitic cases from American and British contexts, intriguingly, share a remarkable (if upon reflection unsurprising) feature: while moulded on the lived experience of actual people, and thus positioned chronologically in the modern era (1807, 1838, 1849 …), by comparison with coeval anatomical or theoretical writings, the reports on clinical activities appear more conservative – better put, they display a more direct continuity with the ancient narratives. If the anatomo-pathological studies evolve more rapidly away from ‘Hellenistic’ authorities, the clinical observations and patient cases still readily rely on and in turn maintain agreement with the ancient physicians vis-à-vis the signs displayed by the human beings seen and touched, and possible remedies to relieve their conditions.

Clinical Observations

Over the course of the nineteenth century, phrenitis remains an operationally useful diagnosis, observed with a good degree of consistency in patients. Consider the ‘apparently idiopathic phrenitis’ described in a 1819 communication by the Halifax physician Robert Paley, which refers to a case from 1807 and largely follows an ancient narrative.Footnote ⁶³ The patient is reported to have had a sore throat, and after a month a severe headache, which initiated the illness proper and lasted for twelve days; the case concluded with recovery, thanks to a felicitous decision to let blood and meanwhile support the patient with wine. The signs exhibited were a shooting pain through the head, a furry tongue, vomiting, ‘turgid vessels’ on the ‘tunica conjunctiva of the right eye’, sensitivity to light and sound, and delirium. He continued subsequently to suffer from delirium, fever, unsettled sleep and a comatose state, and the involuntary passing of faeces and urine, all accompanied by excruciating pain. The initial phase of therapy included washing the head and extremities, and later bloodletting from the templar artery. On the final day before recovery, there was an ‘unpleasant sensation in the right ear, which proved to arise from the bursting of an abscess’, with discharge of matter.Footnote ⁶⁴ Both respiratory and head ailments thus characterize this case, and both description and therapy closely reflect ancient Greek phrenitis and its remedies.

Another case, described by a certain Robert Howard in an Reference Howard1838 issue of The Lancet, is of ‘premature parturition preceded by Phrenitis and accompanied by peculiar symptoms’, in Heptonstall in Yorkshire, and is interesting for its reference to antecedent mental distress.Footnote ⁶⁵ The patient, Mrs Waterhouse, was ill for twenty days in July. Her personal patient history referred to mental disturbance, a previous state of ‘violent mental agitation, alarm and surprise’ which occurred some twenty days before, with ‘excito-motory organs … disordered, but more especially the uterus’. Various unpleasant symptoms followed, including ‘neuralgic tremors, pain in the head, uneasiness about the back, hips, and inferior part of the abdomen’. The use of the term phrenitis in this case evidently identifies a neurological and mental set of symptoms, rather than the inflammatory disease with fever, in this case connected with pregnancy. The illness, it is said, was resolved by the early birth of the child, in the twenty-second week of pregnancy; it died two hours after delivery. In the course of the illness, the woman suffered what the physician calls ‘spurious parturient pains’ and encephalic distress: signs of ‘pain in the anterior lobe of the right hemisphere of the brain’, ‘headache’, ‘cephalgia … flushing of the face, some redness of the conjunctiva, with an aversion to noise … the least movement of the head increased the pain, and noise created confusion in her mind; her urine passed involuntarily’. The therapy, as in the Halifax case, included bloodletting, silence and rest (dimming lights and the like), and opening a blister on the patient’s neck. After her state had worsened (headache, nausea, perspiration), at the disease-peak her state appears to have resembled the most traditional ‘phrenitic’ state: ‘A somewhat formidable symptom presented itself … an appearance of profound thought on the part of the patient, accompanied by an occasional lateral shaking of the head; tremors of the hands were also observable’. A psychological remark offered by the author here is most evocative of ancient female patients afflicted by a lypē, as he judges that the anxiety of the pregnant woman played the decisive role: ‘The alarm seems to have been the origin of this complex and apparently dangerous affection’, together with ‘a highly nerveless and irritable state of the system’.

Lifestyle and a predisposing constitution are also now updated and integrated into patient observations. William Adams was a phrenitic patient described in an 1849 communication in The Medical Times, ‘a weaver from Dumfries aged forty-two, of spare make and dissipated habits. He is admitted on 3.08.1848 with fever, soon head symptoms and petechiae over the body.’ He seems to recover, then worsens again: ‘On the 26th he is declared convalescent … on 1.09 suddenly, without any visible cause, a state of stupor supervened, from which he was partially aroused by counter irritants and stimulants.’ Then came tremors, rigidity of the joints, laboured respiration and involuntary urination; he died on the 3rd of September. The report is accompanied by an a capite ad calcem post-mortem examination which appears to expose a meningitic inflammation: the dura mater appears thicker and tougher than natural; the thorax and abdomen are inspected for abnormalities; the pus and tissues are examined ‘under the microscope’. In particular, the author points out that the damage to the cranium appears to him disproportionate to the mildness of the symptoms, a remark which shows a professional expectation about how the disease, in its gravity and fatality, should be ‘inscribed’ on the body, in histological correspondence with the patient’s behaviour.Footnote ⁶⁶

The second case in this report involves a certain Berney Gallocher, a phrenitic ‘labourer, from Ireland, aged twenty-two’, admitted on 1 August 1848 with a continued fever of a week’s duration. As in the previous case, he seemed to recover, but then worsened again. Most suggestively for us, the focus of his perceived ailment was not the head but the chest: ‘He appeared to be very nervous … he complained of nothing except a slight pain in the epigastric region.’ Then he had a violent crisis, with heightened symptoms: ‘On the 12th day he was very delirious; broke the window; threw his clothes out; and was reckless of danger, his skin was hot; and the pulse 120 … 13th day. He was violently delirious till four o’clock AM, when he became calm. The eyes were sunk and the features sharp.’ Despite these symptoms, the patient survived and after almost two and a half months was dismissed as cured.Footnote ⁶⁷

These are all adult cases, and all are fatal or very serious. A report from 1857Footnote ⁶⁸ focuses instead on an ‘unprecedented number of cases of phrenitis and meningitis, occurring in children under five years of age’. The author does not describe the illness, which seems to be sufficiently understood by its label as phrenitis, and his implication is that it involves derangement. (‘Intellect’ is said at some point to ‘return’.) Instead, he focuses on the therapy, and especially the ineffectiveness of traditional purging methods in several cases (leeches, prussic acid for vomiting); he suggests instead means of cooling the head, ‘enveloping the body in a blanket wrung out of hot mustard and water’, ‘quietude and exclusion of light’. Many instances ended in death until the doctor, as a last resort, turned to bichloride of mercury (a highly poisonous substance long used inter alia to treat venereal diseases) combined with a diuretic treatment, which apparently resolved many of the cases.

Our most detailed and narratively complete set of cases is a group of patients from the end of the nineteenth century described in the Saint Bartholomew’s Hospital Reports (1876).Footnote ⁶⁹ The author, Samuel Gee, opens with a statement which indicates both the strongly somatized approach to the pathology, and the semiotic and antiquarian status the label phrenitis had by then acquired. Gee writes explicitly that he ‘cannot call these … cases by the name of meningitis, for that is an anatomical term, and the anatomical proof is lacking here. Wherefore I choose the name phrenitis, for that is a semeiotic term [my emphasis], suited to my present purpose.’ The name, he explains, was given by the Greeks to ‘(1) a disease of the mind, with a continuall madnesse or dotage, which hath an acute feauer annexed, or else (2) an inflammation of the braine, or the membranes or kells of it, with an acute madness, which causes madnesse or dotage’. The label he chose to give in his title, phrenitis aestiva (‘of the summer’), is ‘simply because they all happened in hot summer weather, and because I believe that there is more than a mere coincidence herein’.Footnote ⁷⁰

The study reports on four cases, children between 22 months and 6–7 years, all in good health ‘until attack of phrenitis’. Gee is a systematic thinker as well as a clinician, and his detailed reports are accompanied by a summary of recurring circumstances he regards as relevant. The children, first of all, fell ill in the summer; at least two were exposed to the hot sun for many hours. The attack struck variously the gastric area (‘L.S. vomited in the evening; fit of convulsions, and was relaxed in her bowels’; R.M. ‘vomited once’; E.C. ‘vomited … the bowels became relaxed’ – repeatedly) and the head (‘headache and pains in her feet’ for R.M.), causing chills and weakness, and a comatose state (W.P.), while one patient ‘became exceedingly cold’ (R.M.).Footnote ⁷¹ The pathology, both bodily and mental, is related in a detailed manner. R.M., for example, was at some point ‘passionately screaming out at the top of his voice in fancied talk with persons not present, noise almost continual’.Footnote ⁷² This is a girl of 22 months. The course of the illness is characterized by heating, fever, problems with speech, weakness of the limbs and, at the end, deafness and unintelligible speech which persist after the recovery: ‘three years afterwards, totally deaf; speech has become thick and unintelligible except to nearest friends; can read; well-grown; slight squint; mother thinks he has not quite the proper use of his legs’.Footnote ⁷³ E.C., a girl 6 years and 5 months old, dies only 19 hours after the attack. She vomits continuously, falls asleep, and ‘on awakening was mildly delirious, talked nonsense, picked at bed-clothes’. Later there was deep coma, livid lips and ‘skin everywhere injected, mottled, livid’; here as before, the reference is perhaps to one reliable visible sign or complication of meningitis on our contemporary understanding, septicaemia. The girls dies comatose, with dilated pupils, and the post-mortem confirms the presence of blood clots in the brain and meninges.Footnote ⁷⁴ W.P., a boy between 6 and 7, died on the fifth day after the initial attack of the disease. He had phases of unconsciousness and was from the beginning half-comatose and unresponsive, with a throbbing in the heart and arteries. On the fifth day, ‘a few small papulae and blotches of no very characteristic appearance upon the skin’.Footnote ⁷⁵ Delirium, coma, dilated pupils and distress followed; at the end, ‘pupils remained unequally dilated, the larger one insensible to light’.Footnote ⁷⁶

As already noted, Gee’s work is remarkable for its combination of clinical detail, theory and taxonomy – all elements of contemporary hospital medicine in similar cases – and for what one could almost call an exquisitely poetic reference to ancient medicine. At the end of his exposition, Gee offers a methodological statement worthy of careful attention:

These words show an awareness of the impossibility of perfect retrospective matching, on the one hand, but also an acknowledgement of underlying deeper validity despite the opposition between ancient concreteness and modern ‘abstraction’, on the other. The move to allow such validity is to describe the Hippocratic construct phrenitis not as a disease but as a cluster of events: Gee shows instinctively and unreflectively how pathology appropriated the ancient material at the price of fragmenting it into blocks, converting its actualized understanding into ‘symptoms’. He accordingly continues: ‘It is remarkable that nearly all the histories which Hippocrates narrates in the first and third book of “Epidemics” are instances of phrenitis; and this combination of symptoms (high fever and delirium) seems to be the chief bone of resemblance between his cases.’ He then lists and scrutinizes the symptoms in a summary which works well as a final concentrated portrayal for us:Footnote ⁷⁸ fever and heat in the head; ‘delirium and phrenitis’, noting that infants seem less exposed to delirium, having convulsions instead; comatose state and lethargy, here understood as a symptom and consequence of heat-stroke; convulsions; rigors; coldness of extremities and lipyria (interior burning accompanied by severe cold in the extremities); lividity; pain in the thighs; shaking/throwing oneself about; a throbbing heart and arteries; vomiting; diarrhoea or constipation; crocydism; insomnia; rash; symptoms ‘of an affection of the base of the brain and cervical cord’, such as ‘pulse infrequent and irregular; unequal pupils; internal squint of right eye; deafness; cervical episthotonus’;Footnote ⁷⁹ tache cérébrale.Footnote ⁸⁰

In line with this ‘symptomatization’ of phrenitis is the dilation of pathological consequence into the future of the recovered patient. Gee emphasizes the permanent impairment suffered by those who survive:

To illustrate the extent of the possible damage, Gee refers to two additional cases, again children, H.R. and L.O. Both survived, but ten weeks after the first was still ‘very restless; does not look very idiotic; less clean than he was, probably deaf; speaks a great deal, but what he says cannot be understood’. The second child ten months after recovery was affected by ‘general paralysis; walks feebly, like a child just beginning to walk; arms clumsy and weak; … mind seems right, but she is less lively than before her illness; speaks distinctly; subject to nightmare’.

Infective phrenitis: An Epidemic Occurrence in Neumünster at the End of the Eighteenth Century

One final fundamental theme in modern pathology intersects our story: that of infectiousness and epidemic waves. In his discussion of phrenitis, Morgagni mentioned a cluster of cases of paraphrenitis, all fatal and similar among themselves, which occurred in the winter of 1754. As phrenitis is more and more often compared to inflammation with high fever of various kinds, it makes sense that aspects of epidemic should come to notice for phrenitis, and we are lucky to have a full case study to illustrate this: the epidemic witnessed and described by the German physician Ferdinand Saalmann in 1788 in his Descriptio Phrenitidis et Paraphrenitidis Monasterii in Westphalia circa Medium mensis Martii grassari incipientium vere contagiosarum earumque factae curationis (Description of Phrenitis and Paraphrenitis at Neumünster in Westphalia, around mid-March, of the truly contagious beginnings of its attack and the measures adopted towards their cure).

The disease here called phrenitis is highly infectious and dangerous; it is described closely and is embedded in the socio-material circumstances of an urban proletarian population. With its translation of the Coan Praenotions in an appendix and its wealth of clinical observations, this booklet is both the first available document on phrenitis as an infectious disease and yet another instance of the coexistence of skilled crisis medicine, classical erudition and analytic thinking. The Descriptio is in fact a marvellous witness, far from both university faculties and the private study, to human suffering in the course of the events in Münster, Westphalia in March to June of 1788.

In Saalman’s own words, the epidemic was terrifying, ‘ravaging [its prey] in a way horrible to behold, devastating with beastly fierceness (horrido spectaculo eviscerans, ferinaque rabie devastans)’ and of frightening contagiousness, and reached beyond immediate contacts. Indeed, the disease was ‘disseminated far and wide, and able to expand … through transference (late disseminatum, translatumque … propagetur contagium)’.Footnote ⁸¹ The first onset of this phrenitis was accompanied by fever, vertigo and migraine, a heavy head, backache and an odd relaxation of the limbs, and a desire for sleep, but a sleep brief and anxious, which brought no repose (fugitivus, pavoribus distinctus, insomniisque deliriis, nec recreans). Next came forgetfulness, delirium and deafness; ‘a sense of strangulation (strangulatorius sensus), especially in women’;Footnote ⁸² a feeling of disturbance and ill ease around the diaphragmatic area and the heart (anxietas … circa praecordia); then open delirium, with blood-shot, tear-filled eyes (sanguinolenti oculi & lacrymosi) and deep breathing. The stomach was also involved, occasionally with icteric signs, the yellowish appearance of the body, sometimes with worms (quibusdam alvus fluida biliosa est cum copiosis vermibus & lubricis & ascaridibus descendentibus).

Many elements of the general portrayal do not surprise: the acute, fatal quality of the disease; the busy hands, hypervigilant eyes and acute hearing; the coughing, white urine and diarrhoea; the grave tremor and wheezing breath, signalling disturbance in the lungs; and the fluctuating fever. The clinician’s interest has left aside the brain – a part he cannot observe, much less cure – as locus of affection or seat of causation, and focuses on the vital functions whose actions he can concretely observe and monitor: breathing, evacuation and movement. But he adds observations of the psychology of the patients, their ‘sort of additional anxiety caused by the exacerbating disease (anxietate quoque aliqua ob malum quoddam ingruens)’, fretfulness (morositate) and ‘a type of atypical irascibility (iracundia quadam inconsueta)’.Footnote ⁸³

As far as prognosis is concerned, elderly patients were more at risk than the young or infants, as were those with antecedent illnesses. Violent trembling, bilious discharges, abrupt changes, and sudden disturbance of the eyes and face, accompanied by bouts of anger, as well as the quality of urine, copious sweating and clenching of the teeth were observed. The well-known crocydism returns (‘deeply engaged and intense search for straws and pieces of wool’, profundae et sollicitae palearum & floccorum venationes), along with delirium and angst (‘delirium about the things which usually occupied them when they were healthy’, deliria de rebus, quas sani agitare confuerant).Footnote ⁸⁴ Imminent death is announced by various signs, several of them of Galenic or Hippocratic memory: a more rapid succession of exacerbations, torpidity (sopores) and the regurgitation of fluid through the nostrils.

Unlike the dissertationes medicae and the anatomo-pathological treatises, Saalman’s work (like the clinical cases we have surveyed) stresses human, even personal detail at its finest. The chest-respiratory ailment is in this case foregrounded, and the subjective experiences of psychological distress, the repeatedly described terror and anger, are visibly at the centre of the account.Footnote ⁸⁵ In the spirit of his profession as community doctor, Saalman insists on the contagious quality of the epidemic,Footnote ⁸⁶ for him caused by putrid matter coming from dead animals – matter that can be ‘volatile salts, oleaginous, fetid stuff (salia volatilia, oleosa, foetida)’ – affecting healthy bodies.Footnote ⁸⁷ There is also a socio-urbanistic dimension to his analysis: he finds the initial cause of the contagion mostly in the filth of proletarian homes and the ‘most unsuitable and dirty objects’ used every day by the poor (the curtissima & spurcissima supellectile egeni populi); he had noticed from the start that the poorest individuals appeared most susceptible.Footnote ⁸⁸

In addition, Saalman further qualifies the categories most affected: people who travel, those who attend the sick, and so forth.Footnote ⁸⁹ Only at page 22 does he address the meningitic frame: cerebri & meningum inflammatio is central for phrenitis, of course, but there might be other latent inflammations, such as of the liver. A number of corpses of the dead in fact had swollen, dark, gangrenous parts in the lower body, with livid areas. Despite the contagious causation, in cases of paraphrenitis, lifestyle and morals also played a role: Saalman insists that abuse of food and wine (crapula) and debauchery generally, beginning in youth (pregressa iuvenilibus in annis intemperantia), favour the disease.Footnote ⁹⁰ Like the other phlegmasiae, this phrenitis leaves behind it a predisposition to future attacks.Footnote ⁹¹

Four new nosological elements thus pop up here that the history of medicine had not yet included in phrenitis: the environmental element (the ‘marshes’ and animal carcasses); its possible contagiousness; the predisposition to recurrent attacks;Footnote ⁹² and the demographics. In an appendix at the end,Footnote ⁹³ some statistical information which had been added in the aftermath of the event is offered: there were over 450 cases in Neumünster between April and June that year, 32 of them fatal. Patients mostly had a specific profile: old or elderly, or weakened by excessive consumption of wine, and male. The treatise concludes with praise for the immortal Hippocrates and his prognostic genius, and with selected passages from the Coan Prenotions which most closely match Saalman’s own observations about the unhappy fate of the Westphalian victims of the epidemic.

Of Horses and Men: Veterinary Parallels

I have mentioned somatization and have illustrated it through anatomo-pathological doctrines, patient cases and clinical reports at the turn of the modern era. The label phrenitis becomes more and more pathological, localized and corporeal, its nature inflammatory and neurological rather than psychiatric, and psychological only in its side-effects. The disappearance of the disease from the mind and its movement into the body also occurs by means of the involvement of the ‘animal’ in its sphere of action. From the end of the sixteenth century, in fact, a veterinary concept phrenitis emerges and is variously described, with a wealth of parallels to the human affection – a final stage towards the allocation of phrenitis ‘to the body’.

Ancient veterinary science developed relatively late as a separate discipline, and its relationship to medicine was also established later. In earlier stages, it belonged instead to agronomy and mostly concerned itself with the care of cattle, hunting dogs and other useful domestic animals, or of animals such as horses that had an obvious military use. In the Byzantine period, veterinary science developed more and more as a separate branch of medicine, in particular for horses in the case of hippiatrics. In no case, however, were mental disorders such as melancholia attributed to animals (nor would we have expected them to be). Epilepsy, hydrophobia or rabies, and opisthotonos are as far as veterinary science typically goes with what are, on our understanding of the matter, neurological diseases in animals.Footnote ⁹⁴ Mentions of mania and phrenitis – as manifestations of disorder in terms of variation in intensity rather than quality – are sometimes referred to, but metaphorically and outside technical texts. Thus in Chapters 6 and 8 we saw, in respect to phrenitis, pathologized behaviour in horses, dogs and wild beasts evoked as an image of the phrenitic person.Footnote ⁹⁵

It is accordingly significant and noteworthy that in the modern era phrenitis begins to appear in a variety of veterinary works. The celebrated veterinary surgeon William Youatt, for example, devoted a section of his lecture xlvi to ‘apoplexy and phrenitis in horses, cattle, sheep, dogs and swine’,Footnote ⁹⁶ a discussion that allows us to see animals serving, as they often do, as the zero degree of a human malady, in this case the constructed item phrenitis: ‘primary inflammation of the brain or its membranes’. Here as well, first of all, the disease has a lethargic counterpart, as in the case of human phrenitis: ‘The farrier calls this disease mad staggers, in distinction from the quieter malady, which we have been considering, and which he terms sleepy staggers’. The symptoms are weakness and drowsiness, falling asleep while eating, oppressed breathing and a slow pulse. At a second stage of the illness, however,

The animal grows violent and aggressive, with a ‘change to ferocity’: he whirls around and then collapses, having exhausted his strength. This is the first occurrence of paroxysm. The

A final paroxysm is followed by stupor and death. Colic and rabies can perhaps be confused with this disease. It is interesting that, in the words of this experienced doctor, a post-mortem examination can only help up to a point, making him doubt the usefulness of autopsy at all. He explains:

The therapy, with emphasis on bloodletting and sedatives, resembles that for human beings.Footnote ⁹⁸ The ‘frenzy’ or ‘sough’ in cattle is discussed next, and the subtlety of psychological distinction between rabies and phrenitis deserves attention. After displaying ‘oppression and heaviness’, the eyes ‘protrude and are red; the respiration is hurried, and delirium more or less intense rapidly succeeds’. Pathological, even wicked behaviour follows:

The ‘mischievous purposefulness’ of the beast is an ethical trait of the portrayal of the phrenitic, between playfulness and vice, as seen in Chapters 6 and 8.Footnote ⁹⁹ The violence and fearless aggressiveness of the phrenitic ox, Youatt writes, is greater than those of the horse or even the rabid ox.

The cause is blood engorgement, and parallels with human beings (from the working class, probably, the ‘neighbourhood of London’Footnote ¹⁰⁰) are seen as legitimate:

Sheep can also suffer the disease – Youatt mentions their bright, prominent eyes – and especially lambs,

Dogs, finally, are in Youatt’s experience ‘comparatively exempt from phrenitis’.Footnote ¹⁰² If this is one of the best and most vivid discussions, several others along the same lines are found in veterinary texts from the eighteenth and nineteenth centuries. Blaine also discusses ‘inflammation of the brain’ in horses (and mentions cattle and sheep as well as subject to the same). The ‘mad staggers’ or ‘frensy fever’ is not distinguished here from apoplexy, and the primary-idiopathic form is distinguished from the secondary.Footnote ¹⁰³ A stomach ailment can accompany it, and a ‘delirious state’ is explicitly named. The Italian veterinarian Carelli discusses the well-known medical topic of light in its pathological consequences, especially for horses. When exposed for a long time

What can we learn from this regarding the ontology of phrenitis and of mental disease generally? Omissions and sudden trends should not be taken on their own as powerful positive evidence for cultural shifts. On the other hand, discussions of phrenitis ‘of the animal’ precisely at the time when the disease increasingly crystallizes in its most conspicuous bodily form, meningitic inflammation, is surely an element of corroboration of its achieved status as bodily inflammation purged of metaphysics. The latter is left to ‘soft’ forms of behavioural disturbances, as will be seen in Chapter 10. In this way, as often in our tradition, the animal provides a mirror for the human being in its barest and most essential form. Phrenitis is now increasingly ignored as ethical or spiritual in medicine, but extends its relevance to veterinary science, having become truly ‘of the body’.‘

Figure 9.1 Horse with phrenitis. ‘Von der Hirnwüthigkeit, Unsinnigkeit Dollen Coller, zu Latein Phrenitis genannt’ (Georg Simon Winters. Wolerfahrner Roß-Arzt oder Vollständige Roß-Artzney-Kunst. Nürnberg, Endter, 1678).

If I only had a heart’: Cardiocentrism and Encephalocentrism in the History of phrenitis

As the modern fate of phrenitis draws to a close, we must return to the theme of localization and to the ‘victory’ of the brain or head over the heart or chest in our anthropology as it has emerged through the long history of the disease.

From its beginning, the localization of the disease was heavily thematized. This brought with it gain and a focus on the rivalry, parallelism, duality, combination and ambiguity between two images and two gravitational systems in the human body, one centred on the ‘head’, the other on the ‘chest’. The science and history of science of these alternatives is well known and was briefly discussed in Chapter 1.Footnote ¹⁰⁵ Roughly expressed, from the composite picture offered by the Hippocratics, we move to a general prevalence of the heart as centre of human biology in Aristotelian thought and Aristotelianism. With Galen and the bulk of the medical tradition after him, the brain is more and more firmly designated as the ‘hegemonic’ seat of human reasoning and ethos, and as the managing centre of the vital functions of the body, and it remains so in the late-antique and early medieval worlds. In medicine, the ‘heart’ is restored to biological importance beginning in the twelfth–thirteenth centuries, with the rise of Aristotelianism in European science and natural philosophy, encouraging debates and attempts to harmonize this doctrine with Galen’s tripartite model of the soul.Footnote ¹⁰⁶ But the brain retains its chief position as far as cognition and neurology are concerned, while the heart receives fundamental attention as the centre of animated life, corroborated by the new theorization and detailed mapping of the blood system circulation which began with William Harvey’s De motu cordis, from the first quarter of the seventeenth century onwards.

In terms of cultural history, however, an interesting parallel phenomenon impinges directly on the history of phrenitis. The ‘triumphant’ brain displays a quality of mechanical sturdiness, or of untouchability and separation from the rest of the body (via its position in the safely secluded cranium), which makes it the fulcrum of human ethics and accountability.Footnote ¹⁰⁷ But the ‘heart’ is increasingly confirmed at a cultural, popular and poetic level, although with parallels in medical thought, as the locus of vulnerability, holistic embodiment, character and emotions – of humanity in the affective and ‘romantic’ sense. When Van Swieten calls the brain the ‘seat of our humanity’, therefore, he makes a strong scientific claim about what dignifies and qualifies us as human in terms of faculties and functions: our ability to judge and to reason. But he also offers only one side of the wider history of ideas about the ‘centre’ of man, a history written differently in every culture, cultural instance and period. The shift to a focus on the materiality of the brain and its stake in human subjectivity in the seventeenth century of our era, after the English doctor Thomas Willis’s seminal studies on its anatomy, substance and functions as solid organ, and its relevance to the working of the soul, is effectively a ‘cerebralization of the subject’, to paraphrase Vidal and Ortega.Footnote ¹⁰⁸

In parallel to the cultural history of the brain, whose ancient chapter Wright has carefully explored in its intellectual relevance to theological debates,Footnote ¹⁰⁹ runs a history of the ‘heart’ as ‘deep core of humanity’, in an emotional, personal sense from the early centuries of our era. This ‘heart’, as my quotation marks acknowledge, is not so important anatomically or medically. More than the tangible muscle of our cardiologists, it is the location high in the torso of which – in sharp contrast to the brain – we are sensorially aware. It pulsates, ‘jumps’ and ‘leaps’, accelerates, feels pain, undergoes sudden alteration in response to strong emotions, and is as such holistically connected to the rest of the body.Footnote ¹¹⁰ In this way, the ‘heart’ becomes the embodiment of our whole self, as in Augustine’s inquietum cor striving to find rest in God.Footnote ¹¹¹

This ‘heart’ is entirely a place of the imagination, just as the ‘brain’ is; in neither case are we allowed to see our own. The imaginary ‘heart’ – and the viscera generally – represent strong passions and a vulnerability to violence: the cult of the bleeding ‘heart of Christ’, still alive in some Christian communities,Footnote ¹¹² is one powerful representation of this, as is the topos of the broken, bleeding or wounded heart as an allegory of human passions.Footnote ¹¹³ These are enormous themes and imaginary worlds, deserving of their own lengthy discussions, which do not belong here. Moreover, they are not only imaginary in a poetic sense: the ‘heart’ and the ‘brain’ are also political and ethical strongholds, concretized in the operations of current policies on and technological revisions of the idea of human ‘life’ and ‘death’ (and what a ‘life worth living’ is). As Giorgio Agamben has argued, the combination of technologies of reanimation and transplant in contemporary medical science has brought confusion and contradiction, as well as new, unstable certainties, to the search for what allows and substantiates human life, with ‘cerebral death’ and ‘cardiac arrest’ now becoming two stages of ‘dying’ and two versions of ‘death’, as well as marking two different conceptions of ‘being alive’.Footnote ¹¹⁴ It is thus important to insert our history of phrenitis between chest/heart and head/brain against the background of these various simplifications of humanity, the ‘brain’ vs ‘heart’ stories, a duality with a long past as well as a familiar, banal idiomatic present in most languages, and now with biopolitical repercussions.

As for phrenitis itself, we have seen the brain prevail in post-classical European cultures as its locus affectus (most definitively in Galen; confirmed by the encyclopaedists; in the fundamental authors of the Middle Ages, the anatomo-pathologists of the sixteenth–seventeenth centuries; and the final ‘meningitis’ account). At the same time, the chest location has maintained its position in the doctrines of cardiocentrist or non-encephalocentrist authors, such as some Hippocratics, Diocles, Praxagoras and Aretaeus, but most of all in the interlacing of the main narrative of the affected brain with a secondary but fundamental one about the chest, often retained via the etymology of phrenitis. This chest location involved the diaphragm, the heart and the lungs, but also by extension other organs below, such as the stomach, liver and womb. We have traced this secondary ‘diaphragmatic’ and more widely thoracic story from the medicine of classical antiquity onwards, in the criticism and intellectual attachment to the problem posed by the etymology of phren-itis in various medical authors (the Hippocrates of De morbo sacro, Diocles, Anonymus Londinensis, and then Galen, as well as their readers in medieval and early-modern times); the manufacture of a dual or sympathetic disease phrenitis involving brain and torso in Aretaeus and Galen, in the latter case with massive consequences for the subsequent tradition; the additional problem of translating phrenitis in the Arabic sources, between birsām and sarsām; the more visible reappearance of the heart in medieval discussions of phrenitis, influenced by the return of Aristotelianism; and finally the numerous, variously localized forms of ‘phrenitis’ in the early-modern and modern eras, when doctors become increasingly interested in pathology as the ensemble of phenomena which illnesses provoke in bodies, and consider the abstractions of ancient nosological labels only when they might be useful for a pragmatic understanding of patient states.

Phrenitis had the unique advantage of developing as firmly encephalic while maintaining a name and a history that continued to remind patients, doctors and readers of the heart, chest and viscera. This advantage matched a fundamental aspect of the history of mental pathology in modern clinical psychiatry, and in psychology generally. As Berrios and Porter note,

This feature embedded phrenitis in various cultural discourses and medical developments having to do with mental life and health, preventing it from being reduced to a ‘merely’ bodily disease. As seen in Chapter 3, holistic approaches found this a good place to practise their psychotherapeutic skills, and phrenitis long remained a mental disorder observed in a psychopathological frame. At the same time, it remained alive and relevant to both encephalocentric and cardiocentric discourses about human health until the opposition ceased to make scientific, anatomo-pathological sense, depriving phrenitis of its usefulness as an ‘umbrella’ concept.