Notes on Phrenitis in Galen and Sextus Empiricus

Mental faculties and cognitive capacities can be damaged, compromised, twisted, and affected in all sorts of different and interesting ways. [2] The ones who undertake to discuss the wide range of attending dysfunctions are usually doctors; among them, Galen stands out as the most systematic and insightful physician in antiquity—not only when it comes to this particular subject, but generally.

The medical condition that I will be concerned with in this paper is identified in ancient medical texts as phrenitis. It takes its name from phrenes, the “diaphragm”—a metonymy for mental life—and it is diagnosed as a sudden and acute illness which makes its presence felt through symptoms of high fever, delirium and a rapidly increasing loss of touch with reality. [3] In what follows I will look at some examples discussed by Galen and I will attempt a close reading of them, pointing to parallels drawn from Sextus Empiricus. These are issues of fundamental importance for both physicians and philosophers, and although the discursive practices and contexts for discussing an illness may vary from one author to another, the same questions obtain, relating ultimately to what we understand reality to be and how we interact with it, in health and in illness.

My first text comes from De locis affectis (Περὶ τῶν πεπονθότων τόπων), Book 4. Galen states in this instance that:

Theory in Galen always comes hand in hand with examples drawn from clinical experience at the level of everyday life and medical practice, and so the author, in the text that follows, goes on to report on cases of phrenetic patients corresponding to each of the categories he has just outlined. The first concerns a patient who exhibits symptoms of type A of phrenitis—which is to say that the affected individual can see and hear perfectly fine, but he develops a strange, to say the least, way of thinking:

This is an incredibly rich and layered story. We have no way of knowing whether Galen actually saw this happening or whether it was reported to him by others. In fact, there is a fairly good chance that some of these stories were invented by the author himself, [5] so as to back up experientially the validity of his theories and delicate distinctions about how the human mind works or what happens when it stops functioning properly. This is an important methodological point, because it makes us ponder on the extent to which Galen is operating with established preconceptions which he then projects, as it were, onto everyday reality, or if it is the other way around: that is, whether it is everyday reality which constantly feeds Galen with incidents and patient-profiles of all sorts and kinds, which he then tidies up into neat abstractions. But since this is a question that primarily concerns how we study the history of mental illness and, specifically, what kind of hard evidence we take into account as historically reliable, I will leave it aside for the moment.

Back to Galen’s text. The whole incident is orchestrated as a spectacle of sorts (δι’ ἧς οἷόν τ’ ἦν ὁρᾶσθαί τε αὐτὸν καὶ ὁρᾷν τοὺς παριόντας … ἐθεάσαντο)—one that starts on a light-hearted tone that reminds us of comedy (τῶν δὲ μετὰ γέλωτος ἀξιούντων … οἱ δὲ γελῶντες ἐκεκράγεισαν [6] ), and then suddenly takes a tragic turn (γελῶντες μὲν ἐπαύσαντο, πεσόντα δὲ προσδραμόντες ἀνείλοντο συντριβέντα). The element of laughter in the story should not strike us as unusual: mentally incapacitated people were not always treated with kindness in antiquity, and there are several sources testifying to incidents of ridicule and inhumane abuse. [7] Such lack of empathy applied generally to deformity and disability—categories of the abnormal and the deviant, under which illness seems to be finding its place, time and again. Suffice it to be reminded here of the evidence provided by Plutarch at the point where he is telling us of the people in Rome who, instead of taking pleasure in paintings and works of art, haunt, instead, “the monster-market” (τὴν τῶν τεράτων ἀγοράν), driven by a morbid and twisted fascination with the sight of disabled people:

The inherent cruelty of an emotionally distanced crowd who are watching the ill and the deformed with a mix of curiosity and enthrallment is a common denominator between the texts of Galen and Plutarch. But there is also a crucial difference, and this has to do with the fact that, unlike Plutarch’s poor freaks who are exhibited as silent and passive objects, Galen’s madman is not at all disempowered. In fact, he is the one to engage the crowd in dialogue in the first place, insidiously luring them into his twisted game.

Medically speaking, this helps Galen illustrate the point he has made about phrenitis at the beginning of the text. The condition does not necessarily come with a total blindness of one’s mental faculties; sometimes, the patient is developing weird notions and ideas (οὐ κατὰ φύσιν ἔχουσι ταῖς διανοητικαῖς κρίσεσιν) but, other than that, he remains perfectly functional (οὐδὲν ὅλως σφαλλόμενοι περὶ τὰς αἰσθητικὰς διαγνώσεις τῶν ὁρατῶν). Affected by his illness as he may be, the mad patient who makes his appearance at the window of his house, retains, in this sense, a considerable degree of touch with reality; he can tell one glass vessel from the other, he can interact with the sane people who are watching him (just in the same way as he is watching them), and he has an absolutely clear idea of what it means to entertain a crowd and satisfy their demands. As it happens, the crime committed in the end [10] is equally his and the people’s responsibility; after all, it is them who, when asked if he should throw the woolworker, prompt him to do so.

What I am suggesting is that the whole scene implicates a delicate sense of mirroring, [11] one that ultimately makes us question the thin line between sanity and insanity. Just as a phrenetic patient is not entirely lost in madness, so the ‘sane’ audience prompting him to throw the slave from the window manifests a dark and irrational taste for a bloody spectacle. This is not that shocking, of course, when one considers that such tastes and spectacles were deeply embedded in Rome’s pop culture and mass psychology. One has only to think of the spectacles in the arena where, typically, an emperor would ask the crowd if a gladiator’s life should be spared or not; and the crowd would then act as a jury, condemning the gladiator to death or saving his life. [12] This script is implicitly present also in Galen’s text: [13] the phrenetic patient is fully aware that he is addressing an audience which is used to the idea that, when asked en masse, they have control over other people’s lives. It is worth noting, in this respect, that the word used by Galen for the window (ἐπὶ τῆς θυρίδος) through which the madman presents himself to the people below, has connotations of an imperial [14] appearance; cf. e.g. Plutarch Quaestiones Romanae 273c: ἐπεὶ δὲ Ταρκυνίου Πρίσκου τοῦ βασιλέως ἀποθανόντος ἡ γυνὴ Τανακυλλὶς ἔμφρων οὖσα καὶ βασιλικὴ διὰ θυρίδος προκύψασα τοῖς πολίταις ἐνέτυχε καὶ συνέπεισεν ἀποδεῖξαι βασιλέα τὸν Σέρβιον. [15] Read in this way, the main character in the story entertains a typical illusion of grandeur; only, as it turns out in the end, this is not simply an illusion but an actual reality: the patient, excused because of—or, rather, empowered by—his illness, can ultimately manipulate the crowd into complying with his own sick phantasies.

Added to this is another intriguing aspect of the text that seems to have gone so far unnoticed. On the face of it, the patient’s problem lies in the fact that he cannot distinguish between a (worthless) glass [16] vessel and a (precious) human life; to him it is all the same. But again, we need to ponder a bit more on the detail that the victim is not a random human being; he is a slave. [17] And a slave’s life—it is worth remembering—does not matter as much (if at all) as a freeman’s life. Notoriously, Greek and Roman antiquity saw slaves as objects. [18] Aristotle, for instance, maintained that a slave is a “thing” you possess, just as you possess cattle, coins and furniture (Politics 1267b11–13: ἔστι δὲ καὶ δούλων καὶ βοσκημάτων πλοῦτος καὶ νομίσματος, καὶ κατασκευὴ πολλὴ τῶν καλουμένων ἐπίπλων). [19] Varro is no different when claiming that a slave is an instrumentum—a “tool that has its own voice” and one that occupies the same ontological space with cattle and the rest of instruments we use in farming (Res rusticae 1.17.1.3–1.17.2.1: nunc dicam, agri quibus rebus colantur. Quas res alii dividunt in duas partes, in homines et adminicula hominum, sine quibus rebus colere non possunt; alii in tres partes,instrumenti genus vocale et semivocale et mutum,vocale, in quo sunt servi, semivocale, in quo sunt boves, mutum, in quo sunt plaustra). [20] Placed in this social and cultural context, the madman’s error of judgment in Galen is not, factually speaking, an error. True, the medical author mentions the whole incident as a means of illustrating what can happen when the mind stops functioning properly; But in doing so, Galen is wise enough, I think, to hint at the fact that often madness can also reside in the deep structure of an “ordered” society. Stories of punishing slaves with death—as though their lives did not matter—abound in antiquity; and in most of those cases nobody is said to be suspected of madness, for the simple reason that killing or inflicting great physical injuries on a slave, as long as the wrong which he had committed was deemed serious enough, was just the “natural” and “sane” thing to do: because a slave was essentially conceived and treated as an object, even under normal circumstances. It is tempting to speculate that Galen’s report of the incident with the man at the window articulates, albeit implicitly, a kind of social critique, one that invites his readers to ponder on the extent to which sometimes culturally validated and established notions concerning the value of human life, and more precisely the idea some lives matter more than others, may be flawed at their very core. His way of fleshing this out is by presenting us with a mentally confused, deranged patient whose problem is that he cannot tell the difference between a glass vessel, an inanimate object, and a human being [21] —a belief, on second thought, that many “sane” people at the time would be willing to share and take for granted. [22]

So much for type A of phrenitis. But what about type B, the one in which the patient, as we are told, thinks rationally, but he sees and hears strange things? Galen illustrates this type with the following story:

Two observations are pertinent at this point. Τhe first concerns the clinical details of the story. What Galen is describing here is a typical case of “carphology,” otherwise known as floccillation, defined in medical idiom as the action of grasping at imaginary objects or plucking at one’s bed clothes, and recognized as a characteristic of people affected by high fever and delirium. [23] The second observation relates to what modern psychiatry defines as “gradualism.” According to the gradualist approach, mental illness is not a matter of fixed and tidily delineated nosological categories which are easy to identify and to distinguish from a positive state of “health”; gradualism posits that illness should instead be approached in terms of degrees by which certain pathological states manifest themselves, without necessarily establishing a clear-cut break from the realm of reason. [24] This is to say that Galen’s medical case, in which he presents himself as conversing, rationally, with his friends is no less phrenetic than that of the patient who has lost it and throws stuff from the window. Crucially, Galen warns his friends that they should help him so that phrenitis does not take full hold of him (καὶ βοηθεῖτέ μοι, μὴ φρενιτίσω)—meaning that the illness is already there, although not to an advanced degree.

The important term in this case is paratuposis, translated by Liddell-Scott-Jones as a “counterfeit representation.” At the beginning of the text, Galen points out that Type B of phrenitis occurs when a patient is still able to form rational judgments but receives distorted impressions, that is, images which do not exactly correspond to existing objects: … ἔνιοι δ’ ἔμπαλιν ἐν μὲν ταῖς διανοήσεσιν οὐδὲν σφάλλονται, παρατυπωτικῶς δὲ κινοῦνται κατὰ τὰς αἰσθήσεις. The medical episode of carphology falls into this category. Plucking at one’s bed clothes because one thinks that she sees tiny flocks of wool standing out might not sound that big a deal; but it bears emphasizing that even this minimal optical illusion, when considered in association with other symptoms, raises, in Galen’s mind, a red flag.

I am talking here of minimal optical illusion in the sense that the cognitive and perceptual mistake involved in floccillation is not a major one; it is a sensory mistake that sometimes can take place even under normal circumstances, when, for instance, one is tired or feels dizzy. But in other instances, paratuposis can lead to grave illusions. In the context of discussing Stoic epistemology, Sextus Empiricus mentions that the Stoics allow for a distinction between representations which they call “vacuous” and those which they label “distorted”: for the first case Sextus invokes the example of tragic Orestes who sees the Furies chasing him; for the second case, that of the ‘distorted’ representations, he is citing the case of Heracles who kills his own children under the impression that they are the children of Eurystheus:

The distinction outlined in this passage is, in modern terms, that between a hallucination and an illusion. [27] When (Aeschylus’) Orestes sees the Furies chasing him, there is no existing person or object near him that he is misperceiving as such; what he comes face to face with is a fully formed hallucination which is entirely a product of his own imagination. Heracles, on the other hand, sees his children (who are actually present), but driven by a fatal spell of madness, mistakes them for something else—someone else’s children. This is what Sextus describes as a paratuposis.

The Orestes whom Sextus has in mind in this passage is the one from Aeschylus’ Choephori. Consider the following lines (1048–1062):

Orestes’ unmistakable symptom of madness in these lines takes the form of a visual hallucination. Where the Chorus sees only Orestes and the corpses of Aegisthus and Clytemnestra, Orestes sees the Chorus and the corpses, but also Erinyes. Glenn Most observes:

Glenn Most’s reading is supported by Sextus Empiricus’ distinction between Orestes’ hallucinations and Heracles’ illusions; according to Sextus, the crucial difference between the two is that in the first case the image of the Erinyes is entirely conjured up in the patient’s mind.

This is not the only time that Orestes makes his appearance in Sextus’ text. In Adversus Mathematicos Book 8, the paradigmatic example of the mad hero returns once again, only this time it is not the Aeschylean but the Euripidean Orestes. The difference is important; for while in Aeschylus Orestes is hallucinating the Furies, in Euripides he is mistaking Electra for one of them. This time it is not a hallucination but an illusion that the matricide is suffering from (Adversus Mathematicos 8.247.1–249.15):

For historians of philosophy, this is an incredibly important passage, as far as Stoic epistemology, the notion of phantasia and the distinction between cataleptic and non-cataleptic impressions are concerned. [32] For the purposes of the present chapter, it is worth drawing attention to Sextus’ employment of the term φρενιτίζοντες, which, in association with μελαγχολῶντες, are used as generic labels for everything that counts as “mental illness.” [33] One does not expect to find in Sextus the delicate distinctions made by Galen between mania, phrenitis and melancholia; [34] after all, this is a philosophical text and Sextus’ main concern lies with illustrating philosophical issues such as: what is true and false, existing and non-existing, plain and deceptive, and so on. To the extent that mental illness signals a violent break from—what is commonly and conventionally agreed, among sane people, to constitute—“reality,” it offers Sextus a prime opportunity to explore through it the very essence of what it means to be present or not, real or unreal; [35] but other than that, he is not interested in pursuing further details of a more clinical sort; a couple of prominent tragic examples of insanity [36] suffice to do the job for his argument.

Yet, despite the different priorities imposed by each category / genre of texts, philosophical and medical, phrenitis stands as a common denominator in the sense that both Galen and Sextus use it in order to draw a distinction between (i) a loss of touch with reality that remains, to some degree, anchored to the objects or persons which surround the patient and (ii) a loss of touch that is total, in which case the image that the patient is seeing are concocted entirely in his mind. What is more, just as Sextus borrows from medical terminology, so does Galen turn his eye on philosophical jargon. Here is what we read at De symptomatum differentiis 3.4 (7.60.3–7.61.19 K.):

The story of the physician Theophilus (for whom we know next to nothing, other than Galen’s report of his episode of delirium) is incredibly interesting in its own right and would deserve a discussion of its own. For now let us just note the fact that in the context of an extremely systematic discussion of mental affections, Galen seizes the opportunity to stress, once again, that when someone is “not quite right in his mind,” this can manifest in two ways: either the patient makes strange thoughts [38] or he sees and hears things that are not there (there is, of course, a third distinct possibility, arising from the combination of these two mental affections). This time, Galen speaks of παραφροσύνη by which we should understand something fairly similar to phrenitis. What is more, the misperception of distorted or empty images is given in a language (ἔν τε τῷ μὴ καλῶς φαντασιοῦσθαι) that directly involves the notion of phantasia, which, as we have seen above, is the terminus operandi through which Sextus Empiricus discusses the case of Orestes.

The interaction between medicine and philosophy, philosophy and medicine in antiquity is constant and deep, and it should thus be no surprise that Sextus and Galen are found to make use of shared terminologies and distinctions. What I would like to highlight, by way of conclusion, is the importance of mental illness as a meeting point of sorts between medical and philosophical discourses and practices. One of philosophy’s main preoccupations is to define the essence of reality; and it seems to me that there are roughly two ways to address this fundamental question. One, obvious, way—as long as we maintain our health—is to trust our senses, thoughts, judgments and notions as reliable mediums that give us access to the world of sensible and intelligible things around us. The other way is to try and grasp reality by looking into what happens when the human mind stops functioning properly. In this latter case, a mental patient is not just an impaired individual: he, too, testifies to what reality is by letting us know, unwittingly and involuntarily though rewardingly in the end, what happens when we are deprived of our free and unimpeded access to it. There is a lot that remains to be done in this direction. I am referring to how reality is often formally understood and defined, in philosophical contexts, in contradistinction to falsehood and to deceiving appearances, and to how this sort of negative definition of reality might be forming a background for all those mental patients in medical texts, who—by means of their derangements, illusions, hallucinations and the alternate landscapes which they inhabit—function essentially as manifestations of the real, the unreal, and the line in-between.