As stated in Chapter 1, Galen’s system was centred in the intersection between an anatomical axis, which determined the site to which the treatment needed to be applied, and a humoural-physiological axis that guided the quality that needed to be allopathically counterbalanced, as well as the quantity of the correction required. This shift of focus, from the Hippocratic emphasis on clinical descriptions, and the post-Hellenistic stress on nosologic taxonomy, conditioned a different understanding of impaired consciousness and mental illness.Footnote 1 Although Galen did not disregard diseases and symptoms, in his approach these elements are subordinated to his main concerns: the organ affected, the type of duskrasia and the degree of impairment in the qualities (required by his system to choose an adequate treatment). Such a change of emphasis had powerful consequences, for it often blurred the boundaries between impaired consciousness and madness.
The efforts that we have seen in On medicine and in Aretaeus’ work (also in the Introduction and the Medical definitions) to distinguish phrenitis from other forms of mental conditions – particularly from melancholia and mania – will change.
γίνονται μὲν οὖν καὶ μετὰ πυρετοῦ βλάβαι τῶν ἡγεμονικῶν ἐνεργειῶν, ὡς ἐπὶ φρενίτιδός τε καὶ ληθάργου γίνονται δὲ καὶ χωρὶς πυρετοῦ, καθάπερ ἐπὶ μανίας τε καὶ μελαγχολίας· ὥσπερ γε καὶ κατὰ συμπάθειάν τε καὶ πρωτοπάθειαν ἐγκεφάλου· τὰ μὲν ἠκριβωμένα τοῖς ἰδίοις συμπτώμασι καὶ διηνεκῆ καὶ μὴ προηγησαμένων ἑτέρων γενόμενα κατὰ πρωτοπάθειαν τὰ δὲ … ἐφ’ ἑτέροις τε συστάντα κατὰ συμπάθειαν …
The activities of the hêgemonikon (‘ruling part’) can be damaged sometimes with fever as in phrenitis and lethargy, and sometimes without fever as in mania and melancholia. Additionally, the damage to the brain can be sympathetic or protopathetic (that is, the primary affection is in the brain). We can accurately detect the latter when the symptoms are characteristic [of the brain], continuous, and are not preceded by symptoms of other parts. The former … is associated with [symptoms] proceeding from other parts [of the body] through sympathy …
Although I consider that Galen’s approach strongly distances him from his forerunners’, this passage suggests that he still engaged in the debate around boundaries between different forms of impaired consciousness (phrenitis–lethargy), and the fuzzy edges that separated the former from mental illness (mania and melancholia). Additionally, the passage highlights how the distinction between chronic and acute diseases, which was a key organising feature in the post-Hellenistic authors to differentiate these conditions, is irrelevant for Galen. The only time-reference included is the continuous nature of the symptoms in primary diseases of the brain.
Actually, Galen’s main concern here seems to be the localisation of the disease. It is crucial for him to know whether the damage was produced in the brain or somewhere else in order to decide where to apply the treatment. In a very similar passage from On the causes of symptoms he adds:
ὀνομάζονται δε φρενίτιδες μὲν αἱ μετὰ πυρετῶν, μανίαι δὲ αἱ χωρὶς τούτων, ποτὲ μὲν τοῖς δακνώδεσι καὶ θερμοῖς ἐπόμεναι χυμοῖς, ὁποῖος ὁ τῆς ξανθῆς χολῆς ἐστι μάλιστα, πολλάκις δὲ κατὰ τὴν δυσκρασίαν τὴν ἐπὶ τὸ θερμότερον αὐτοῦ τοῦ ἐγκεφάλου συνιστάμεναι μόναι δ’ αἰ μελαγχολικαὶ παράνοιαι ψυχρότερον ἔχουσι τὸν αἴτιον χυμόν.
[Deliriums, paraphrosunai] with fever are called phrenitis, whereas [deliriums, paraphrosunai] without fever are called mania. Sometimes they follow pungent and hot humours, particularly yellow bile; many other times they are associated with a hot duskrasia of the brain itself. Only melancholic deliriums (melancholikai paranoiai) have a colder humour as a cause.
In this case the aim is to explain the kind of humours involved in each condition. Because both phrenitis and mania happen in the brain, and are caused by similar kinds of humours, they will very likely receive a similar treatment. As a result, for Galen it is not as important as it was for the other post-Hellenistic doctors to distinguish one from the other, and therefore, he will not put as much effort as they did into trying to expose the difference. As a matter of fact, allusions to mania are very scarce in the works under scrutiny.Footnote 2 Only the presence or absence of fever is enough to put a label to either condition, which – in all probability – will anyway be treated in a similar manner. On the other hand, melancholia is caused by the opposite mixture and therefore will require the opposite treatment. Hence, as we will see later, it is worth distinguishing this condition from the other two.
Going back to the dichotomy phrenitis–mania, Galen classifies as the former several conditions that other authors had associated with the latter.
εἰσὶν μὲν γὰρ αὐτῆς ἁπλαῖ μὲν δύο, σύνθετος δὲ ἐξ ἀμφοῖν ἡ τρίτη. τινὲς μὲν γὰρ τῶν φρενιτικῶν, οὐδὲν ὅλως σφαλλόμενοι περὶ τὰς αἰσθητικὰς διαγνώσεις τῶν ὁρατῶν, οὐ κατὰ φύσιν ἔχουσι ταῖς διανοητικαῖς κρίσεσιν ἔνιοι δ’ ἔμπαλιν ἐν μὲν ταῖς διανοήσεσιν οὐδὲν σφάλλονται, παρατυπωτικῶς δὲ κινοῦνται κατὰ αἰσθήσεις, ἄλλοις δέ τισιν κατ’ ἄμφω βεβλάφθαι συμβέβηκεν.
There are two types of it [of phrenitis] that are simple and a third type, which is a combination of both. Some phrenitic patients are not at all mistaken about the perceptual distinction (aisthêtikas diagnôseis) of what they see, but their intellectual judgement (dianoêtikais krisesin) is not normal. Others, on the contrary, do not suffer from intellectual errors but their perceptions are misrepresented (paratupôtikôs). In yet certain others both damages are combined.
The extreme types are illustrated by a corresponding example: the first one involves a patient whose perceptions were sound enough to recognise the objects that he threw through the window, but whose judgement did not allow him to acknowledge the senselessness and danger of what he was doing. For the second kind the author uses his own experience with phrenitis, when he started to have visual hallucinations but was still intellectually sound enough to tell his friends what to do to cure him of the disease. The similarities between these two typologies of phrenitis, and the other authors’ contrasts between mania and phrenitis, respectively, are not difficult to spot, particularly if we apply the analysis of connectedness and alertness that was used in Aretaeus (indeed the first variety of Galenic phrenitis is conceptually equivalent to Aretaeus’ definition of mania in SD I.6. CMG (H).III: 43, 1–4).Footnote 3 Clearly, Galen was not particularly interested in clinically distinguishing two diseases that required the same treatment, even if he was able to clinically differentiate the diverse nature of the symptoms.
On the other hand, in diseases that warranted an alternative therapeutic approach due to their different pathophysiology or bodily localisation, the distinct clinical presentations are more explicitly stated. Such are the cases of melancholia and various conditions with fever. In the case of melancholia, there is a thorough description of the kind of mental disturbance that one should expect.
οἱ φόβοι συνεδρεύουσι τοῖς μελαγχολικοῖς, οὐκ ἀεὶ δὲ ταὐτὸν εἶδος τῶν παρὰ φύσιν αὐτοῖς γίγνεται φαντασιῶν, εἴγε ὁ μέν τις ὀστρακοῦς ᾤετο γεγονέναι καὶ διὰ τοῦτ’ ἐξίστατο τοῖς ἀπαντῶσιν, ὅπως μὴ συντριβείη θεώμενος δὲ τις ἄλλος ἀλεκτρυόνας ᾄδοντας ὥσπερ ἐκεῖνοι τὰς πτέρυγας προσέκρουον πρὸ ᾠδῆς, οὕτω καὶ αὐτὸς τοὺς βραχίονας προσκρούων ταῖς πλευραῖς ἐμιμεῖτο τὴν φωνὴν τῶν ζώων. φόβος δ’ ἦν ἄλλῳ, μή πως ὁ βαστάζων τὸν κόσμον Ἄτλας ἀποσείσηται κεκμηκὼς αὐτὸν, οὕτως τε καὶ αὐτὸς συντριβείη καὶ ἡμᾶς αὐτῷ συναπολέσειεν· … διαφέρονται δὲ ἀλλήλων οἱ μελαγχολικοὶ, τὸ μὲν φοβεῖσθαι καὶ δυσθυμεῖν καὶ μέμφεσθαι τῇ ζωῇ καὶ μισεῖν τοὺς ἀνθρώπους ἅπαντες ἔχοντες, ἀποθανεῖν δ’ ἐπιθυμοῦντες οὐ πάντες, ἀλλ’ ἔστιν ἐνίοις αὐτῶν αὐτὸ δὴ τοῦτο κεφάλαιον τὴς μελαγχολίας, τὸ περὶ τοῦ θανάτου δέος …
Fears accompany melancholic patients, but the type of abnormal apparitions is not always the same: someone believed that he had become a pot and therefore he warded off everybody to avoid being crushed; another one, after hearing a cock crow and observing how it flapped its wings before crowing, imitated the voice of the animal and beat his arms against his sides. Somebody else was afraid that Atlas, who bears the [weight of the] universe, might somehow shake out of exhaustion, thereby destroying himself and killing us all … Melancholic patients differ from one another; all of them have fears, are despondent about their lives, dissatisfied, and hate mankind, but not all of them want to die. There are some whose main melancholic feature is the fear of death …
Naturally, if mania, phrenitis and melancholia all occur in the brain, and they all involve hallucinations or impaired judgement, but the former two are caused by hot and dry humours, whereas the latter is due to cold and moist ones, it is crucial to differentiate them, for they will have opposite treatments. This might be the reason why Galen’s description of melancholia is so thorough, while beyond the fever, mania and phrenitis are barely distinguished. Concerning the specific symptoms, it is interesting to highlight that – like with Aretaeus – the kind of mental disturbances that Galen is describing would be now considered as delusions rather than hallucinations or delirium, for they seem to be structured, stable in time, and apparently, reasoning is not affected (judgement is). Furthermore, the story about the man who believed himself to be a pot and was afraid of being crushed reminds us of Aretaeus’ patient who thought he had become a brick and avoided water, for fear of dissolving.
Apart from melancholia, the other diseases that could be easily confused with phrenitis – and therefore needed to be more accurately distinguished – were several other conditions with fever and delirium, which did not originate in the brain.
παραφροσύναι μὲν οὖν γίγνονται κᾀπὶ τῷ τῆς γαστρὸς στόματι κακοπραγοῦντι καὶ διακαέσι πυρετοῖς καὶ πλευρίτισιν καὶ περιπνευμονίαις· ἀλλ’ αἱ διὰ τὰς φρένας ἐγγὺς τῶν φρενιτικῶν εἰσιν· ἐπὶ μὲν γὰρ τοῖς ἄλλοις μορίοις πάσχουσι καὶ τοῖς διακαέσι πυρετοῖς ἐν ταῖς παρακμαῖς αὐτῶν ἡ παραφροσύνη καθίσταται· ταῖς φρενίτισι δ’ ἴδιον ἐξαίρετον ὑπάρχει τὸ μηδ’ ἐν ταῖς παρακμαῖς τῶν πυρετῶν παύεσθαι τὴν παραφροσύνην· οὐ γὰρ ἐπὶ συμπαθείᾳ κατ’ ἐκείνην τὴν νόσον ὁ ἐγκέφαλος πάσχει, ἀλλὰ κατ’ ἰδιοπάθείαν τε καὶ πρωτοπάθειαν κάμνει, καὶ διὰ τοῦτο κατὰ βραχύ τε συνίσταται τοῦτο τὸ πάθος καὶ οὐκ ἐξαίφνης παρακόπτουσιν ἢ ἀθρόως … οὐκ ὀλίγα τε συμπτώματα προηγεῖται τῆς κατασκευῆς αὐτοῦ, καὶ καλεῖται γε πάντα ταῦτα φρενιτικὰ σημεῖα…
… μέγα μὲν γὰρ καὶ διὰ πολλοῦ χρόνου τὸ πνεῦμα τοῖς ἐπ’ ἐγκεφάλῳ φρενιτικοῖς ἐφεξῆς ἐστιν ἀεί· τοῖς δ’ ἐπὶ ταῖς φρεσὶν ἀνώμαλον, ὡς καὶ μικρόν ποτε γενέσθαι, καὶ πυκνὸν, αὖθίς τέ ποτε μέγα καὶ στεναγματῶδες.
Deliriums also occur in dysfunctions of the mouth of the stomach, ardent fevers, pleuritis and peripneumonias. Those that originate in the diaphragm are nearly phrenitic. Whereas in affections of other parts and ardent fevers, delirium declines during the abatement of the disease, it is singular and characteristic in phrenitis that delirium does not cease when the fever is descending. Indeed, in such a disease [phrenitis] the brain is not affected through sympathy but suffers primarily by itself. This is the reason why this disease progresses slowly and frenzy neither appears suddenly nor immediately … Not a few symptoms precede this condition, and they are all called phrenitic signs…
… Breathing in phrenitics of the brain is always deep and with intervals between one another; in [phrenitics] of the diaphragm, conversely, [breathing] is uneven: sometimes superficial and frequent, sometimes deep and like sighs.
Galen’s clinical description in these passages is thorough. He goes through all the phrenitic symptoms,Footnote 4 which mostly coincide with the descriptions of the disease that we have found in the other surviving post-Hellenistic medical writers. The nuance comes in Galen’s practical approach. As stated above, he only goes to great lengths to distinguish between conditions whenever such a distinction impacts on the treatment. In this case, the locus affectus is at stake: by being able to tell phrenitis from pleuritis, peripneumonia or ‘diaphragmatic near-phrenitis’, he will know the correct part of the body to which the treatment needs to be applied.
Finally, this focus on anatomical location and physiologic mechanism is even more evident when Galen contrasts phrenitis with drowsy impaired consciousness (lethargy), because they were construed as perfectly opposite conditions in terms of symptoms, humours and qualities involved. Actually, they are conceived as the two prototypical extremes of a spectrum, in the middle of which one can find a mixture of both (which is designated by some authors as tuphomania).Footnote 5 Its characterisation is the only example that reminds us of the Hippocratic description of vigil coma:
invenies enim multos freneticos <nec> surgentes omnino nec elevare potentes oculos, sed in eodem loco manentes similiter letargicis.
You will find many phrenitic patients who cannot get up at all, nor open their eyes. Instead, they remain in the same place, like lethargics do.Footnote 6
So far, we can suggest that, on the one hand, Galen’s system obscured the distinction between impaired consciousness and a specific form of mental illness (mania), which had reached a rather sophisticated degree of characterisation during the post-Hellenistic period. On the other, it preserved clear boundaries between phrenitis and certain conditions that – according to his system – required different therapeutic approaches (melancholia and lethargy). The subordination of every finding to his tripartite theoretical framework becomes even more evident when trying to independently explore the different components of the notion of disease that we have been chasing in the other sources. The system is so closely knit that it is virtually impossible to isolate each element: we cannot choose to only explore symptoms, or affected organs, or mechanisms or treatments without mentioning the other three.
Galen’s notion of disease: the perfect meshing of symptoms, loci affecti, mechanisms and treatments
Undoubtedly, hallucinations still constitute an important element of phrenitis: ἀγρυπνίας ἢ καὶ τινας ὕπνους θορυβώδεις ἐπὶ φαντάσμασιν ἐναργέσιν, ὡς καὶ κράξαι ποτὲ καὶ ἀναπηδῆσαι (‘insomnia, or some turbulent dreams with such vivid apparitions that [affected individuals] sometimes scream and jump up from bed’).Footnote 7 However, there is a coherent theoretical framework that underpins the strong links between such a symptom (abnormal perceptions), a certain part of the body and the mechanism that explains it.
ὅτ’ ἄν γὰρ ἀθροισθῇ τις ἐν ἐγκεφάλῳ χολώδης χυμὸς ἅμα πυρετῷ διακαεῖ, παραπλήσιόν τι πάσχει τοῖς ὑπὸ πυρὸς ὀπτωμένοις, καὶ κατὰ τοῦτο λιγνύν τινα γεννᾷν πέφυκεν … ἥτις λιγνὺς συνδιεκπίπτουσα τοῖς ἐπὶ τὸν ὀφθαλμὸν ἀφικνουμένοις ἀγγείοις, αίτἰα γίνεται τῶν φαντασμάτων αὐτοῖς.
When a certain bilious humour accumulates in the brain accompanied by fever it overheats, resembling something being roasted by fire, from which some smoke comes out … This smoke, flowing through into vessels that arrive in the eyes, becomes the cause of their apparitions.
This passage relates the abnormal perceptions to a primary problem in the brain, a secondary problem in the eyes and a mechanism involving humours. Furthermore, Galen elsewhere clarifies that
καὶ τοίνυν αἱ βλάβαι τῶν αἰσθητικῶν ἐνεργειῶν κοιναὶ μὲν ἁπασῶν ἀναισθησίαι τινές εἰσιν, ἢ δυσαισθησίαι … καὶ πρὸς τούτοις ἔτι δύο ἐξαίρετα, τὸ μὲν ἀγρυπνία, τὸ δὲ κῶμα … ἐφεξῆς δ’ ἂν εἴη τὰς τῶν ἡγεμονικῶν ἐνεργειῶν βλάβας διελθεῖν, καὶ πρώτης γε τῆς φανταστικῆς. ἔστι δὲ καὶ ταύτης … ὃ δὲ κάρος καὶ κατάληψις … παραφροσύνη … τὸ δὲ οἷον ἐλλιπὴς καὶ ἄτονος [κίνησις], ὡς ἐν κώμασί τε καὶ ληθάργοις…
The damages common to all the perceptual activities are certain anaesthesiai or dusaesthesiai … apart from these, there are also two special ones: sleeplessness and kôma … Subsequently, the damages to the hêgemonikon [itself] should be discussed, and firstly those that affect the imagination (phantastikon). Amongst them are … torpor (karos) and catalepsy, … delirium (paraphrosunê) … [and] something akin to a defective [movement] lacking tone, as in kômas and lethargies …
In a nutshell, paraphrosunê (which invariably presents hallucinations) is associated with a primary dysfunction of the phantastikon, dependent on the hêgemonikon. It is in the seat of this ruling part of the psuchê (the brain) that the problem is generated, and from there it travels to the eyes – the visual organ of the aisthêtikon. In other words, according to Galen hallucinations are generated in the brain, and impaired perceptions are a consequence of this phenomenon.
Regarding the other symptom associated with delirium in the HC – speech disturbances – the waning tendency that we have remarked among post-Hellenistic authors persists in Galen. One of the very few occasions where it appears unequivocally associated with a state of impaired consciousness is the intermediate state between phrenitis and lethargy.
εἰ πυνθάνοιό τι καὶ εἰ διαλέγεσθαι βιάζοιο, δυσχερεῖς ἀποκρίνασθαι καὶ ἀργοὶ, τὰ πολλὰ δὲ παραφόρως φθεγγόμενοι καὶ οὐκ ὀρθῶς ἀποκρινόμενοι καὶ ληροῦντες εἰκῇ.
If something is asked of them or they are forced to speak, they will answer slowly and with difficulty. Most times they will mumble deliriously, will not reply correctly and chat randomly.
Because Galen’s theoretical framework is so consistent, we have already discussed several examples where the locus affectus plays a defining role in the definition of disease. What I would like to emphasise now is how – through his particular approach to this concept – Galen succeeded in coherently integrating most of the organs or affected parts, which had been appearing in the medical tradition since the HC onwards (without resorting to Celsus’ uncommitted stance or to Aretaeus’ inconsistencies).
Undoubtedly, the primary organ involved in all psychic activities for this author was the brain. Its relevance is revealed in The art of medicine: after defining the four archai or principles of the body, namely, the brain, the heart, the liver and the testicles (Ars. Med. CUF 5.2: 287, 1–2. K.I: 319), Galen places the hêgemonikon in the brain and associates certain psychic conditions with the impairment in its qualities.
ἡ μέντοι τῶν ἡγεμονικῶν ἐνεργειῶν ἀρετή τε καὶ κακία τῆς ἀρχῆς μόνης ἐστὶν αὐτῆς καθ’ ἑαυτὴν γνώρισμα· καλῶ δὲ ἡγεμονικὰς ἐνεργείας τὰς ὑπὸ τῆς ἀρχῆς μόνης γινομένας· ἀγχίνοια μὲν οὖν λεπτομεροῦς οὐσίας ἐγκεφάλου γνώρισμα, βραδυτῆς δὲ διανοίας παχυμεροῦς· εὐμάθεια δ’ εὐτυπώτου, καὶ μνήμη μονίμου· … καὶ τὸ μὲν εὐμετάβολον ἐν δόξαις θερμῆς, τὸ δὲ μόνιμον ψυχρᾶς.
The virtue and defect in the activities of the authoritative part (hêgemonikon) are only dependent on the principle (archê) in itself. I designate only those [activities] that arise from the archê as activities of the hêgemonikon. Sagacity (anchinoia) is a property of the thin-particled substance of the brain, whereas sluggishness of intellect (dianoia) of a dense-particled one; a gift for learning [depends on] a malleable [substance], memory on a stable one; … and changeability of opinion [is peculiar] to the heat, whereas stability [of opinion] to the cold.
The localisation of the hêgemonikon in the brain (enkephalon), and its possible alterations as a direct result of the characteristics of its substance (dense–thin, malleable–immalleable, stable–fluid, hot–cold) are explicit.Footnote 8 Moreover, there is a surprising degree of sophistication when describing the exact location of the damage:
ἡ δὲ ἀποπληξία διὰ τὴν ἐξαίφνης γένεσιν ἐνδείκνυται ψυχρόν χυμὸν, ἢ παχὺν, ἢ γλίσχρον ἀθρόως πληροῦντα τὰς κυριωτέρας τῶν κατὰ τὸν ἐγκέφαλον κοιλιῶν, οὐ κατὰ δυσκρασίαν ὅλης τῆς οὐσίας αὐτοῦ γίνεσθαι, καθάπερ ὅ τε λήθαργος καὶ ἡ φρενίτις, αἵ τε μανίαι καὶ αἱ μελαγχολίαι καὶ αἱ μωρώσεις, ἀπώλειαι τε τῆς μνήμης, ἀμυδρότης τε τῶν αἰσθήσεων, καὶ τῶν κινήσεων ἐκλύσεις.
The quick onset of apoplexy shows that it originates in a sudden filling of the main cavities in the brain with a cold, dense or viscous humour, and not in a bad mixture (duskrasia) of all its [the brain’s] substance, which is the case in lethargy, phrenitis, mania, melancholia and folly (môrôsis), as well as in destructions of memory, faint perceptions and feebleness of movements.
The intersection between the anatomical and the humoural axes is clearly revealed here.Footnote 9 Psychic diseases can be differentiated according to the exact location in the brain (the ventricles versus the parenchyma) and the nature and quality of the humour involved.Footnote 10
Other examples illustrate how mapping the locus affectus onto the actual body determined where the treatment needed to be applied:
… ἀλλὰ τοῦτό γε τὸ ὀξυρρόδινον ὃ τῇ κεφαλῇ προσφέρομεν ἐπὶ τῶν φρενιτικῶν … οὐ μόνον τοὺς ἀμεθόδους Θεσσαλείους, ἀλλὰ καὶ τοὺς ἄλλους ἅπαντας ἐξελέγχει φανερῶς, ὅσοι κατὰ τὴν καρδίαν ἡγοῦνται τὸ ψυχῆς ἡγεμονικὸν ὑπάρχειν … καὶ μὲν δὴ κἀπὶ τῶν ληθαργικῶν οὐδείς ἐστιν ὃς οὐ προσφέρει τῇ κεφαλῇ τὰ βοηθήματα· καὶ τοῦτο γὰρ τὸ πάθος … γίνεται δ’ ἐγκεφάλου πάσχοντος, ἐν ᾧ τῆς ψυχῆς ἐστι τὸ ἡγεμονικόν.
… This oxyrrhodinum that we apply to the head of the phrenitic patients unquestionably refutes … not only the amethodical followers of Thessalus, but also all the others who believe that the authoritative part of the psuchê (hêgemonikon) resides in the heart … neither is there anybody who would not apply the treatment to the head in lethargic patients, for this affection also occurs when the brain, where the hêgemonikon of the psuchê lies, suffers.
Apart from illustrating Galen’s self-advertising technique of discrediting his opponents to highlight his own skills, the passage very clearly shows the way in which his anatomical understanding serves the crucial purpose of providing him with a rationale to guide the treatment of each condition.Footnote 11 Furthermore, even the specific location within the brain (for example, the body as opposed to the ventricles, Loc. Aff. 3.12. K.VIII: 200, 12–19) can have therapeutic relevance:
διὰ βάθους δὲ κειμένου τοῦ πεπονθότος, ἐπιτεχνᾶσθαι χρὴ τοιοῦτον ἐργάζεσθαι τὸ ὑγιεινόν, ὡς μὴ φθάνειν ἐκλύεσθαι κατὰ τὴν ὁδόν· εἰ μὲν οὖν θερμότερον εἶναι δέοι τοῦ συμμέτρου, μὴ τοσοῦτον μόνον ἔστω θερμότερον, ὅσου δεῖται τὸ πάθος, ἀλλ’ ἐξ ἐπιμέτρου προσκείσθω τὸ διὰ τὴν θέσιν ἀναγκαίως προσερχόμενον.
If the affected part is deeply located, it is necessary to devise [a remedy] to bring about health in such a way that it does not lose its effect prematurely in the passage. Thus, if it needs to be hotter than the normal balance, the heat should not only be increased to the degree that the affection requires, but an extra measure should be added necessarily, in order for it to arrive at the position.
An impressive awareness, indeed, of the pharmacokinetic notion that we currently define as the ‘bioavailability’ of a drug is shown in this passage. Galen seems to understand – as we currently do – that some fractions of any drug or treatment are lost before they reach the site of action, and therefore, those losses need to be compensated for when calculating the dose. Additionally, there is an unambiguous illustration of the interplay between anatomy and humoural theory. In this sense, I agree with Devinant that l’humuralisme hippocratique is reinterpreted in qualitative terms, but I would also add the quantitative dimension.Footnote 12
The system so far described might appear straightforward and simple: psychic diseases are to be found in the brain, and therefore treated in the head. However, there are nuances. The concept of sympathy (sympatheia) complicates the anatomical location of the illnesses.
It is this idea of sympathy that will allow Galen to integrate all the different organs that were considered to be affected in phrenitis throughout the tradition. This notion explains how certain conditions that affect different parts of the body (and not primarily the head) can also compromise the hêgemonikon and cause psychic disturbances. As Holmes has accurately described, the brain is enmeshed in ‘networks crisscrossing the body’, thereby making it vulnerable to conditions that originate in distant locations.Footnote 13 Several examples of sympathy can be found in On the affected parts.
ὅταν μὲν γὰρ ἐκ τῆς κοιλίας ἤτοι γε ἀτμῶν μοχθηρῶν, ἢ καὶ τῶν χυμῶν αὐτῶν ἀναφερομένων ἐπὶ τὸν ἐγκέφαλον, ἡ διάνοια βλάπτηται, πρώτως μὲν οὐκ ἄν τις φαίη πάσχειν τὸν ἐγκέφαλον, οὐ μὴν οὐδ’ ἀπαθῆ γε παντάπασιν ὑπάρχειν, ἀλλ’ ὅ τι περ ὑπ’ αὐτῶν ἐκείνων ὀμολογεῖται, διὰ τοῦ συμπάσχειν ῥήματος ἀληθέστατόν ἐστιν.
Whenever deleterious vapours from the bowels or some of the humours in them move up to the brain, intelligence (dianoia) is damaged. Nobody would say that the brain is primarily suffering, neither could one claim that it remains completely unharmed. Everybody [all the doctors] agrees that the clearest [way to express it] is through the verb ‘sympathise’ (sumpaschein) [that is, suffers together].
This passage supports Devinant’s remark that Galen went one step further than Archigenes: not only did he diagnose the locus affectus, not only did he suggest a sympathetic link between the organs, but he also described the mechanism that drove the problem from one organ to the other.Footnote 14 The practical importance of the whole explanation is, again, to establish where the treatment should be applied. In this respect, Galen offers one of his several self-aggrandising anecdotes. He tells the story of a young man who had fallen from a certain height and hit his upper back. The patient developed speechlessness and paralysis in both legs, which other unskilled doctors were trying to treat:
βουλομένων οὖν τῶν ἰατρῶν ἐνοχλεῖν εἰκῇ, τοῖς μὲν σκέλεσι, διότι παρεῖτο, τῷ δὲ λάρυγγι διὰ τὸ τῆς φωνῆς πάθημα, κωλύσας ἐγὼ, μόνου προενοησάμην τοῦ πεπονθότος τόπου, καὶ γενομένου ἀφλεγμάντου τοῦ νωτιαίου μετὰ τὴν ἑβδόμην ἡμέραν ἐπανῆλθεν ἥ τε φωνὴ καὶ τῶν σκελῶν κίνησις τῷ νεανίσκῳ.
I stopped the doctors who wanted to pester him purposelessly in his legs because of the immobility, and in the larynx due to the affection of the voice, and took care of the affected part. Once the inflammation in the spinal cord disappeared after the seventh day, the youth recovered both the voice and the movement in his legs.
Beyond the marketing purposes, the story illustrates how the locus affectus is not always obvious, and the extent to which it is key in order to provide an effective cure. Other examples of sympathetic versus protopathetic delirium were presented above, where Galen explains how to distinguish pleuritis, peripneumonia and diaphragmatic near-phrenitis from actual phrenitis (Loc. Aff. 5.4. K.VIII: 329, 5–19; 331, 15–18). All of them illustrate how he was able to embrace the long tradition of organs affected by phrenitis without renouncing his encephalocentric position.
As exemplified throughout this section, allusions to pathophysiological mechanisms are ubiquitous in most Galenic discussions about symptoms and affected organs. I would now like to place the focus on therapies, in order to show how all four elements articulate in an integral and rational notion of disease. Galen’s construction of impaired consciousness as a spectrum that ranges between hot and cold offers a good starting point to illustrate the above: ἀγρυπνητικαὶ μὲν αἱ ἐγκαύσεις, καταφορικαὶ δ’ αἱ ψύξεις γινόμεναι (‘heat triggers insomnia, whereas coldness triggers drowsiness (kataphora)’).Footnote 15 Naturally, the treatment is aimed at counterbalancing such disturbances:
πραΰνειν μὲν γὰρ προσήκει τὰ μετὰ τῶν ἀγρυπνιῶν, ἐπεγείρειν δὲ τὰ μετὰ τῆς ἀκινησίας. εἰκότως οὖν ἀκμαζόντων αὐτῶν τοῖς μὲν ἀγρυπνιτικοῖς καὶ περικοπτικοῖς νοσήμασι τὰς διὰ μήκωνος κωδειῶν ἐπιβροχὰς προσοίσομεν … καρῶσαι γὰρ χρὴ καὶ ναρκῶσαι ποιῆσαι το ἡγεμονικόν, ἐμψύχοντα δηλονότι τὸν ὑπερτεθερμασμένον ἐγκέφαλον. ἐπὶ δὲ τῶν ἐναντίων παθῶν ἐπεγεῖραι καὶ τέμνειν καὶ θερμῆναι προσήκει τὸ πάχος τοῦ λυποῦντος χυμοῦ … ἐναφεψοῦντες οὖν ὄξει θύμον καὶ γλήχωνα καὶ ὀρίγανον … τῇ ῥινὶ … προσοίσομεν, ὅπως ὁ ἀτμὸς ἐπὶ τὸν ἐγκέφαλον ἀναφερόμενος τέμνῃ τὸ πάχος τοῦ χυμοῦ.
It is convenient to soothe those who are sleepless, and to stimulate those who are motionless. We can reasonably administer washings with poppy heads when diseases with insomnia and delirium peak … for it is necessary to make the ruling part (hêgemonikon) somnolent and numb by cooling the evidently overheated brain. In the opposite affection it is appropriate to revive, to thin and to heat the thickness of the distressed humour … We should apply thyme, pennyroyal and oregano boiled with vinegar … to the nose … so that the vapour carried up to the brain can thin the thick humour.
We have already seen several of these elements in Aretaeus’ discussion: the thickness, the heat or coldness of the humour according to the affection, and the intervention of atmos. However, in his eclectic approach it was not so clear how they interacted, nor was the way in which the treatment affected the body so elaborately explained. Galen justifies carefully and specifically the mechanism of his therapies, as well as their impact on the disturbance, through his theoretical model. He even explains through it the route of administration. Drugs are to be applied to the nostrils because they can easily reach the brain – the affected part – when the patient breathes in. These explanations highlight Galen’s constant interest in rationality, particularly when contrasted with Celsus’ or the author of the Anonymus Parisinus. Even when they recommend similar products (for example, poppy), they only consider the effects, with no attention whatsoever on the kind of interaction that the drug produces.Footnote 16
Galen’s use of opium as an analgesic is also useful in contrasting his understanding of drowsiness and anaesthesia as separate – even if often simultaneous – phenomena. Unlike Celsus, who considered them both as one and the same thing (therefore he considered that papaver cured pain through sleep),Footnote 17 Galen distinguishes different mechanisms through which opium produces sleep and relieves pain that is resistant to treatment.
εἰ δὲ καὶ τοῦτο ἀδύνατον, διὰ τῆς τὼν ναρκωτικῶν φαρμάκων προσφορᾶς … λεπτὰ γὰρ ὑπάρχει ταῖς συστάσεσι καὶ θερμὰ ταὶς δυνάμεσι τὰ πλεῖστα τῶν τοιούτων ὑγρῶν· ὅσα δὲ δι’ ὀπίου καὶ ὑοσκυάμου … σκευάζεται φάρμακα, ψύχει τε ἅμα καὶ ξηραίνει πάντως … οὐ μόνον ὡς αἰσθήσεως ναρκωτικὰ χρήσιμα καθέστηκεν, ἀλλὰ καὶ ὡς συνιστάντα καὶ παχύνοντα τὴν τὼν ὑγρῶν λεπτότητα καὶ προσέτι καὶ τὴν θερμότητα σφοδρὰν ὑπάρχουσαν ἐμψύχοντα.
If this [therapeutic measure] is also impossible, the administration of some narcotic drug [is required] … The majority of such humours [the humours of patients with pain that is resistant to treatment] are thin in consistency and hot in capacity. The remedies that are prepared with poppy-juice and henbane, simultaneously and fully cool and dry … Not only do they produce a useful numbing of perception, but they also cause the combination and thickening of the thin humours. Additionally, they cool the excessive heat that predominates.
While in the discussion on delirium the drug seems to be useful because it cools the overheated brain, the relief of pain needs, apart from its cooling capacity, its drying and thickening powers too. Once again humoural physiology is at the centre of the explanation both of the disease and its treatment.
The basics of this theory are outlined in On the causes of diseases, where Galen establishes the correspondence between the humours and their qualities.Footnote 18 In On the difference of diseases Galen explains that the imbalance (duskrasia) of such qualities is the necessary cause of an illness.Footnote 19 However, in his personal reading of Hippocrates neither all humours, nor all qualities have the same status.Footnote 20 There seems to be a hierarchy:
… ἔγκαυσίς τε καὶ ψύξις τῆς κεφαλῆς ἐνδείκνυται ταὐτόν· ἀγρυπνητικαὶ μὲν αἱ ἐγκαύσεις, καταφορικαὶ δ’ αἱ ψύξεις γινόμεναι. καὶ μὴν καὶ τὰ χολώδη τῶν νοσημάτων καὶ θερμὰ τὰς ἀγρυπνίας καὶ παραφροσύνας καὶ φρενίτιδας ἐργαζόμενα φαίνεται· τούτοις δ’ ἔμπαλιν τὰ φλεγματικὰ καὶ ψυχρὰ νωθρότητάς τε καὶ καταφοράς. ἡ μὲν πρώτη δύναμις ἐν τῇ κατὰ τὸ θερμὸν τε καὶ ψυχρόν ἐστι δυσκρσίᾳ, τῶν ἀγρυπνητικῶν τε καὶ καταφορικῶν νοσημάτων· ἐφεξῆς δ’ αὐτῆς ἡ καθ’ ὑγρότητα καὶ ξηρότητα. τὰ τε γὰρ λουτρὰ πάντας ὑπνώδεις ἐργάζεται τὴν κεφαλὴν ὑγραίνοντα, καὶ οἴνου πόσις εὔκρατος, καὶ ὑγραίνουσαι τροφαὶ πᾶσαι … ταῦτ’ οὖν ἅπαντα τεκμήρια γενέσθω τοῦ δευτέραν μὲν ἔχειν χώραν εἰς ἀργίαν ψυχῆς τὴν παρὰ φύσιν ὑγρότητα, προτέραν δ’ αὐτῆς εἶναι τὴν ψυχρότητα.
… The heating up and cooling down of the head can demonstrate this: heat triggers insomnia, whereas coldness triggers drowsiness (kataphora). Also, the bilious and hot diseases seem to produce insomnia, delirium (paraphrosunas) and phrenitis, as opposed to phlegmatic and cold [ones, which cause] sluggish (nôthrotêtas) and drowsy (kataphoras) conditions. The main [affected] capacity of sleepless and drowsy diseases resides in the imbalance (duskrasia) of heat and cold, subsequently in that [in the duskrasia] of moist and dry. Indeed, baths are sleep-inducing for everybody, for they moisten the head, as is drinking well-tempered wine, and all the wet nourishment … Let all this be a proof that moistness opposite to nature has the second position in causing idleness in the psuchê, whilst coldness has the first.
For certain, bile and phlegm are more frequently mentioned in these kinds of diseases, and the pair hot–cold seems to have pre-eminence over dry–moist. Moreover, the antithetic character of the humours and their qualities enables Galen to explain with a persuasive logic the opposite nature of certain symptoms, such as insomnia–drowsiness. In other words, what we nowadays consider as hyperactive impaired consciousness is associated by Galen with heat, whereas hypoactive impaired consciousness is associated with coldness. By distinguishing two hierarchies in the status of the contrasting pairs of qualities, he adds complexity to the theory, thereby increasing the level of expertise required to treat the conditions.
The humoural theory is further complicated by Galen’s gradual understanding of it. In this sense, I disagree with Jouanna’s hypothesis of the dual nature of madness that he finds to be similar to the Hippocratic corpus.Footnote 21 On the contrary, Galen conceives the qualities of humours as a continuum where properties are dependent on the gradation of a certain quality:
ὅτ’ ἄν δ’ ἐν αὐτῷ πλεονάσῃ τῷ του ἐγκεφάλου σώματι, μελαγχολίαν ἐργάζεται, καθάπερ ὁ ἕτερος χυμὸς τῆς μελαίνης χολῆς, ὁ κατωπτημένης τῆς ξανθῆς χολῆς γενόμενος, τὰς θηριώδεις παραφροσύνας ἀποτελεῖ χωρὶς πυρετοῦ τε καὶ συν πυρετῷ, πλεονάζων ἐν τῷ σώματι τοῦ ἐγκεφάλου. καὶ διὰ τοῦτο τῆς φρενίτιδος ἡ μὲν τίς ἐστι μετριωτέρα, τὴν γένεσιν ἐκ τῆς ὠχρᾶς ἔχουσα χολῆς· ἡ δέ τις σφοδροτέρα, τῆς ξανθῆς ἔγγονος ὑπάρχουσα· καὶ τις ἄλλη θηριώδης τε καὶ μελαγχολικὴ παραφροσύνη γίνεται κατοπτηθείσης τῆς ξανθῆς χολῆς.
Whenever [black bile] is in excess in the body of the brain, it produces melancholy, just like the other black bile humour that originates in the concoction of yellow bile, which – by excessive accumulation in the body of the brain – causes wild delirium (paraphrosunas), with or without fever. This is the reason why one type of phrenitis is more moderate: because its origin is pale bile; whereas a more violent type is the result of yellow [bile]. There is yet another wild and melancholic delirium (thêriôdês te kai melancholikê paraphrosunê) that is generated when the yellow bile is concocted.
In this way, humours have simultaneously a qualitative and quantitative dimension that determines the specific characteristics of diseases. The degree of their violence is, in this case, directly related to the darkness of the bile.Footnote 22 Accordingly, the treatment should compensate for the degree of distortion. In Galen’s own words: δύο εἰσὶν οὗτοι σκοποὶ περί τε τὸ ὑγιεινòν καὶ τὸ νοσερόν, ἡ ποιότης τε καὶ ἡ ποσότης τοῦ προσφερομένου (‘there are two aims concerning health and disease: the quality and the quantity of what needs to be provided’).Footnote 23 Further down he expands:
… ἐάν δέκα μὲν ἀριθμοῖς ἐπὶ τὸ θερμότερον ἐξεστήκῃ τοῦ κατὰ φύσιν, ἑπτὰ δ’ ἐπὶ τὸ ξηρότερον˙ εἶναι δήπου χρὴ καὶ τὸ ὑγιεινὸν αἴτιον ἐπὶ ταῖς τοιαύταις διαθέσεσι δέκα μὲν ἀριθμοῖς ψυχρότερον, ἑπτὰ δὲ ὑγρότερον·
… If [the duskrasia] has deviated from the norm by ten numbers towards the hotter, and by seven towards the drier, it would – of course – be necessary, for the cause that brings about health in such conditions to be ten times colder, and seven times moister.
The actual interaction of all these ideas can be clearly seen in Galen’s self-promoting anecdote regarding his discovery of the treatment for memory loss:
ἐκ τίνος, ᾽Αρχίγενες, λόγου πιθανοῦ πεισθέντες ἐπὶ τὴν κεφαλὴν ἀφιξόμεθα τὴν καρδίαν ἀφέντες, ἧς ἓν μὲν τι τῶν συμφύτων ἔργων ἐστὶν τὸ μεμνῆσθαι, τὸ πάθος δὲ τῆς ἐνεργείας ἐστὶν ἡ ταύτης ἀπώλεια; τίνα δὲ διάθεσιν ἡ τῇ κεφαλῇ προσφερομένη σικύα θεραπεύουσα τῆν μνήμην ἀνακελέσεται;…
τὸ δὲ σικύαις μόναις κεχρῆσθαι χάριν μὲν τοῦ θερμῆναι χρήσιμον, ἄλλως δ’ οὐδαμῶς· ἐπισπῶνται γὰρ ἐκ τοῦ βάθους εἰς αὐτὰ αἱ σικύαι τὴν ὑγρότητα …
ὡς εἶναι δῆλον αὐτὸν ὑγρότητα καὶ ψύξιν ἡγούμενον εἶναι τὴν διάθεσιν ἤτοι κατὰ τὸν ἐγκέφαλον, ἢ τὰς μήνιγγας· οὐ γὰρ δὴ κατά γε τὸ κρανίον ἡ τοιαύτη διάθεσις γενομένη τῆς μνήμης ἀφαιρήσεται τὸν ἄνθρωπον.
Based on which persuasive reasoning, Archigenes, are you going to convince us to get hold of the head and disregard the heart, one of whose innate actions is to remember, and whose activity is destroyed when affected?Footnote 24 By curing which condition will the cupping-glass applied to the head bring back the memory?…
The use of the cupping-glass on its own is useful in order to heat, but nothing else. The cupping-glass sucks up the humidity from the depths towards itself…
It is evident that he [Archigenes] believed that a humid and cold condition was affecting the brain and the meninges, for such a condition in the skull could not deprive a person of his memory.
This criticism of Archigenes is another case where anatomy indicates the site to apply the treatment (the specific location in the brain and meninges as opposed to the skull probably suggests a stronger remedy, for it needs to reach deeper). More importantly, though, the nature of the quality imbalance is crucial for deciding the kind of treatment. The cupping-glass, with its heating and drying effects, can only be justified for cold and moist conditions, in a clear example of opposites cure opposites.
Once again, Galen’s impressive achievement was articulating into a coherent whole the allegedly Hippocratic views concerning humours and qualities, with some Platonic and Aristotelian theorisations about the four elements, and with the latest discoveries of the Alexandrian anatomical revival.Footnote 25 In this way, he found a logical rationale for several treatments that were widely accepted because of their long historical tradition, and used this advantage to criticise his competitors, who could offer no coherent explanation, even if they chose those same therapies. In other words, this solid system, which conceived a tight and self-contained notion of illness, enabled Galen to build authority in the highly competitive and cultivated milieu that he inhabited.
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