‘Insanity in Classical Antiquity’,by JL Heiberg (1913)

[Part 2 ^* ]

Madness can manifest itself in the form of excessive happiness; the patient laughs, plays and dances incessantly night and day, at times he walks around enwreathed in the belief that he has won a sports competition. Insane people like that are harmless towards their surroundings. Worse are those maniacals, who abandon themselves to violent outbursts of anger, rip their clothes and, at times, even kill their servants or attempt suicide. The nature of morbid ideas varies according to the patients’ educational level. Those patients, who are educated and have studied, foster their fantastic astronomical theories and philosophical systems or believe that they are inspired by the muses to the creation of original poetic works; the uneducated, on the other hand, imagine that they would be capable of performing tests of strength by carrying burdens or that they are skilled potters, carpenters and stonemasons. Examples of peculiar fixed ideas are given to the effect that some believe that they are pots of clay and, therefore, are fearful of having a fall and breaking, others believe that they are of unfired clay and fear being dissolved in water. There is a story of a carpenter, who was absolutely rational in his workshop and workplace, performed everything that his trade demanded of him to full satisfaction, could make contracts with his employers and accounts for his payment without anything noticeable about him; but when he wanted to put his tools away to go to the market or take a bath or similar, at first, he sighed deeply and then took the tools on his shoulders, bringing them with him wherever he went. When he lost sight of his neighbours and workplace, he had a maniacal attack, but if he turned around and went home, he immediately came to his senses again.

Religious madness is given special mention. The sick person mutilates himself in the belief that thus he will become pleasing to his gods and fulfil their command. Such patients can be woken from their madness with music, merriness and inebriety or with serious admonitions by those present, and they are completely rational except for their fixed ideas; when the attack is over, they are happy and have peace of mind and believe that they are initiated to their god, but they are pale and lean and weakened by the wounds they have inflicted upon themselves; “in this form of madness one traces the finger of god”.

When the insanity is more serious, the patient’s senses can become sharpened, he is guarded and irascible, either excessively dejected or happy, at times sleepless; his looks become changed, he has headache or heaviness in his head, though his hearing is sharp enough, but he apprehends slowly; some have buzzing of the ears, which can amount to the volume of a trumpet or flute-playing. At a more advanced stage, the patient becomes puffed up and nauseated, greedy for food (due to sleeplessness), but he is still lean and pale, his eyes hollow, he rarely blinks, at times they are red and livid; he sees all sorts of forms and images, dark and black if he is a melancholic, otherwise more red and purple; many believe that they can see lightning and express anxiety of being hit. During the culmination of the disease they suffer from involuntary ejaculations and feel an uncontrollable desire for venery, which they unashamedly indulge, in front of others; if they are admonished or taken to task, they become absolutely furious. The last stage of the disease can assume very different characters; some roam aimlessly, and obliviously continue to return to the same place, others pick quarrels with their surroundings or loudly complain of having been robbed or mistreated, others shun human society and seek solitude and talk to themselves. In their lucid moments they are lethargic, apathetic and despondent as they become aware of the disease and feel oppressed by it.

Unfortunately, Archigenes’ treatment instructions for this form of insanity have been lost, whereas his very thorough description of the treatment of phrenitis has been preserved (80). Among others, he emphasizes the importance of the sickroom and the bed being suitably prepared; the room must be spacious, aired and the temperature in accordance with the season, the walls must be smooth without projections and without paintings; the patient feels tempted to touch any unevenness, and wall paintings easily cause hallucinations. The room must be light or dark, depending on the condition of the patient; it is a good sign when light has a calming effect on him. There must be complete calm and quiet, not only in the room but in the whole house; the patient’s hearing is sharpened, and any noise affects him strongly. The bed must be neither so broad that he can toss and turn in it, nor so narrow that he risks falling out of it during the paroxysms; it must be soft in order not to irritate his affected nerves, and the blankets must be smooth lest they give him the opportunity to pick off fluff. It is important to keep the patient in good spirits. Therefore, his best friends must visit and cheer him up with stories and harmless talk. The disease often causes sleeplessness; it can plague the patient such that he cannot find rest night or day, his eyes become staring and stiff as if they are made of horn (Note 6), he throws himself around on the bed and jumps up. In that case, one must use sleeping remedies, head baths, massage under the soles of his feet, scratching in the temporal regions or behind the ears (as in animals). It can also help to provide the patient with the conditions under which he usually sleeps; the sailor can be placed in a boat, to let him rock in the waves and sense the smell of sea and ship and hear the surf and the whistle of the wind; the musician must be played and sung to sleep, and the teacher must be lulled to sleep with childish talk. Apart from that, numerous medicaments are recommended against phrenitis.

Also, the other influential medical school from the time of the Roman emperors, the Methodic, has left us with a collected exposition of its views on insanity and its treatment. It is attributed to its most prominent man, Soranus of Ephesus (first half of the 2nd century), and is preserved in Latin translation by a much later author (81). As expected, it is based on the teachings of Asclepiades (he is considered as halfway associated to the school), but he is very sharply criticized, and also the theories and treatment of other doctors are given consideration, and, generally, in conformity with Soranus’s learned inclinations, the exposition has a literary stamp. Thereby, it assumes a special value as a well-informed overview with respect to the achievements of Antiquity in this domain, except that the odd new and independent remark is also made; but regarding the freshness of the observation and the lucidity of the description, it cannot match that of Archigenes.

Soranus operates with the two usual forms of insanity, mania and melancholia, and he emphatically refutes the assumption that melancholia is simply a form of mania. This has its seat in the head, whereas melancholia is in the abdomen. The description of mania starts with a reference to Plato’s peculiar statement in “Phaidros” (82); after a brief note on the theories of the Stoics and Empedocles and some (incorrect) etymological explanations (though these might be additions by the translator), mania is defined as a chronic madness without fever. Thereby, it differs from phrenitis, and even if an accidental fever supervenes, a mistake is excluded as the fever in phrenitis is primary. Madness occurs most frequently in young and middle-aged men, rarely in old men and is even more rare in children and women; it can occur as a sudden attack, but can also develop successively from internal as well as from external causation such as indigestion, inebriety, keeping late hours, shocks or blows to the head, and also mental overexertion, strong passions (infatuation, anger, and the like), superstition, sorrow and fear; also intoxication with certain kinds of medicaments (especially love potions), cessation of haemorrhoid bleedings and in women menstruation disturbances, can cause madness.

The symptoms of incipient madness are the same as in epilepsy and apoplexy; for epilepsy (83) the following premonitory symptoms are mentioned: lethargy, buzzing in the head, dizziness, stiff eyes, buzzing in the ears, or weakened hearing, things going black, defective eyesight, swimming eyes and visual hallucinations, which are manifested in the form of cobwebs, light clouds or small black animals, sparks of fire or lightening rings, and, moreover, dryness of the throat, swelling of the hypochondria, yawning, sneezing, too much salivation, lack of appetite, or gluttony, or anxious dreams, indigestion, abnormal lust to indulge in venery, at times accompanied by involuntary ejaculations, worry, unmotivated irascibility and forgetfulness. Attempts have been made to establish different distinguishing features, and, to those who are closest to the patient, point out special symptoms of imminent insanity; in this way, heavy sleep is supposed to herald epilepsy, whereas light and short-lasting sleep, madness. Also mentioned as insanity-specific symptoms are tensions in the head in attacks of anger and the feeling of having gone mad, alternating with persistent silence due to unmotivated anxiety, sorrow, boasting, greed, frequent blinking of the eyes, palpitations, anxious dreams, indigestion and frequent flatus, small and frequent pulse, whereas in those who are predisposed to epilepsy, it is voluminous and slow. However, Soranus does not consider these symptoms to be enough to distinguish between the two closely related diseases.

Pronounced insanity can manifest itself in many different ways: as impetuosity and merriness, as depression, apprehension and fear of imagined dangers, as when the patient is harbouring constant anxiety of falling into holes in the ground, with memory loss and hallucinations. Mentioned as examples of paranoid ideas are that the patient believes he is a sparrow, a rooster, of clay, that he is a god, a speaker or an actor; one patient walks around holding a pipe in his hand (like a sceptre) and believes he is taking count of the whole world, another patient screams like a baby and wants to be carried. An older doctor is referred to concerning a case where a “grammarian” became disturbed in the head due to fright over a crocodile, which he happened to step on; he imagines that his left leg and hand have been eaten by a snake and suffers complete loss of memory so that he could not even remember the alphabet.

The insanity can be either continuous or interrupted by lucid moments. During the attacks the eyes become bloodshot and the gaze stiff, continuous sleeplessness occurs, there is tension in the blood vessels, the face turns red, the body stiff; it can show an unusual hardiness. The symptoms attest to the presence of a tightening in the body, and that the head is the seat of the disease. It is a mistake when some people believe that the mental illness is the primary cause; the cause of the illness is physical; consistently with this, one has never heard a philosopher make rules for the treatment of insanity.

With respect to the therapy, very thorough recommendations are given; they take up more than double the space than the description of the disease does. The patient must lie in a rather light and warm room, without noise from the outside; no paintings must hang on the walls, and the windows must not be situated too low; preferably, the room must not be located in a higher storey as it carries the risk that the patient will jump out the window. The bed, which must be soft, should be placed such that patient cannot see the visitors enter through the door, lest that their changing facial expressions have a disturbing effect on him. There must not be too many visitors, especially people he does not know. Nor must the nursing attendants always try to placate the patient to avoid reinforcing his mad ideas, nor always contradict him so as not to agitate him. They must readily fall in with his ideas, but rather gently try to correct them. If the patient is inclined to jump out of bed or is adversely affected by being on his own, the number of nursing attendants must be increased and discretely advised to keep the patient in bed, for instance, under the pretence of massaging him; if he cannot tolerate the sight of other people, as gently as possible he must be tied to the bed with a belt, but at the same time protecting his joints by covering them with wool. If the patient harbours fear of or respect for one particular person, he must not be seen by the patient too often so as not to lose his influence on him; he must be available for situations of distress, to prevent fright and impressions to affect the patient. If he suffers from depression, he must be cheered up by being told something pleasant. If he cannot tolerate the light, his eyes must be protected against it without depriving the rest of his body of it. The food must be light and sparse, and the bowel motions kept regular. In addition, warm packs are recommended against topical pain, mouthwash and, if the strength allows, bloodletting.

When the disease is stationary, one must shave the patient’s head, cup him there and on his back or apply leeches; then apply restringent dressings and wash off with warm water. For sleeplessness, the usual remedies are recommended: rocking in a hammock or a litter, a splashing fountain; the eyes can also be rubbed with a sponge with lukewarm water. To provide motion, a wheelchair is also mentioned; when the patient’s strength permits, he must be forced to walk and use his voice. He must be made to read aloud, preferably things that can challenge his criticism to force him to reflect. For the same reason, one must keep putting questions to him, which can give him the opportunity to refute them or to enlighten him, and thus boost his self-esteem. After such a mental effort, one must leave him to his own devices and give him something to read, but one must make certain that it is something which does not exceed his comprehension or which stresses him, for in that instance it is harmful. Afterwards, he can be shown dramatic performances, merry if he is depressed, tragic and moving if he is fatuously merry. If this suits him well, he can be allowed to give speeches, but he must be watched to ensure that the medical recommendations for the use of the voice are being followed. The introduction should be delivered in a light tone, the main theme, however, firmly and loudly, and the end in a mild and lowered voice. The audience must be made up of his friends and acquaintances, and they must cheer him with applause. After the speech, he must be brought back to his room and rubbed with oil, followed by some exercise. The uneducated must be asked questions, which fall within their profession; a farmer is to be spoken to about farming, and a sailor about navigation; if he is too lethargic for this, the most everyday questions are discussed, or one lets him play board games; this keeps his thoughts suitably occupied, especially if his fellow player is more than a match for him. When the patient has rested and has gone for a short walk, he must be anointed and massaged, have a bath and a meal; he must only drink wine sparsely now and then. When no new symptoms are manifested, and the patient is able to tolerate a certain exertion, a change of air is desirable; he can also be recommended to attend the philosophers’ lectures, which “with their words dispel fright, worry and anger” (Note 7).

If the disease does not remit, one must repeat the treatment from the first stages; exercise and sensible diet are the main things; music is also recommended. Moreover, various medicaments are mentioned, especially hellebore and other cures, for instance, exposing the body to sunshine, but with the head covered; the use of natural mineral waters, which, however, must not be too ill-smelling, travels by land and by sea, and also distractions. Against buzzing in the ears, rinsing with different sharp and cleansing solvents is recommended. That the disease has remitted is shown, as in epilepsy (84), by the fact that sleep, appetite and healthy colours return, and the digestion is regular, and that the usual work tasks can be carried out over extended periods of time without causing stress.

To this exposition of his own therapy regime, Soranus, as is his custom, adds sharp criticism of his predecessors. Also, the rule that Celsus fought against, namely that the sickroom should be dark, is rejected because many insane people are afraid of darkness, and because it is not compatible with the restringent nature of the disease, which, on the contrary, demands light to counteract it. Likewise, starvation cures that are too vigorous are disapproved of, as they weaken the patient far too much; some have argued for their use by referring to wild animals becoming most easily tamed with starvation, but Soranus finds this motivation so bad that its supporters should be regarded as mad rather than as doctors. A warning is also given against inconsiderately restraining the patient, which can easily give him a shock; it is preferable to hold him in bed by hand. Sleeping medicaments such as poppy are also warned against, with the argument that they cause heaviness of the head. Head baths with rose oil and the like, as recommended by Celsus, are advised against because they are restringent instead of relaxing. For similar reasons cooling remedies, which are said to have been recommended by Aristotle and Diokles, are rejected; their use is based on the misunderstanding that the internal heat in the patients is the cause of the disease, whereas, in fact, it is only a symptom; cooling worsens the condition by condensing the body. Bloodletting must not be overused, and arteriotomy is objectionable as useless harassment. Nor does Soranus approve of the use of enemas and strong diuretics and laxatives. Measures to cheer up the depressed and to quieten down the overwrought with flute-playing, for which purpose, respectively, the Phrygian and the Dorian key have been recommended, are dangerous as experience shows that flute-playing can have an agitating effect, even in healthy people. Methods such as letting the insane patient get inebriated or beating him can only make matters worse. There is a lengthy polemic against the opinion that efforts must be taken to make the patient fall in love. It is “the naked truth”, though, that madness is often caused by love. Admittedly, it has happened that someone, because of love for the queen of the underworld, Proserpine, has descended down into the underworld, another has thrown himself into the sea because he was in love with Amphitrite, and the daughter of a king has killed her own children out of jealousy (Note 8). The view that love is a kind of insanity, probably cannot be dismissed completely – the symptoms bear a certain similarity – and if so, it would be both objectionable and silly to cause the disease that one is wanting to cure. Besides, it is difficult to make an insane person fall in love as he has lost all sense of beauty and lives in his hallucinations. And even though it would succeed, it would be just as wrong to permit the insane patient to indulge in venery with the object of his love as it would hinder him in this; the former would weaken him, the latter excite him.

From Soranus’s final remarks it transpires that this criticism, for the most part, is largely aimed at Asclepiades and his school; it is admitted that the founder of the Methodic school, Themison, has also recommended objectionable cures such as baths, wine and venery, but the blame for this must be ascribed to his teacher, Asclepiades, from whose doctrines he could not readily extricate himself.

Soranus deals with melancholia more briefly. It has been thus named because the patient often vomits black bile; that its cause should be the black bile is an unfounded hypothesis, indeed outright wrong. The disease mostly attacks middle-aged men, almost never women or men of other ages; it is caused by constipation, violent vomiting, taking the medicaments after food (Note 9), spicy dishes, worries and anxiety. The initial symptoms are similar to those in mania. The disease is manifested by worries and a depressed mental state, accompanied by reserve and animosity towards the surroundings. At times, the patient wishes to die, and at other times he suffers from fear of death and believes that attempts are being made on his life; he cries without reason and mumbles unintelligibly to himself; after meals an enlivened state can occur. The physical symptoms are swelling of the hypochondria, cold extremities, mild sweat, abdominal pain, also in the cardia and in the back, heaviness of the head, grey-green or sallow facial colour, loss of weight and lethargy, indigestion and ill-smelling ructus. The disease is chronic. The therapy is the same as for mania. Bloodletting and hellebore are rejected as well as the strong medicaments such as aloe and absinth, used by other doctors; one must use relieving and invigorating remedies, against violent vomits also restringent dressings.

In contrast to the Pneumatics and Methodics, Galen does not seem to have taken much interest in insanity; in all his discursive works, there exists no collected and systematic exposition about it (Note 10), and the scattered remarks he makes here and there contain virtually nothing new.

It is well known that Galen praises the presumably Hippocratic teachings on the four humours, which control the condition of the body, and, consequently, from them also deduces the different forms of insanity. Accordingly, he opines that those who have not understood the importance of the four humours, for instance Erasistratus and his school, have not been able to say anything about melancholia and its origin (85), and Galen himself does not tire from reiterating that mania is caused by the thin yellow bile, and melancholia from the black bile (86). These humours affect the brain, in which, consistently with the Hippocratics, he sees the seat of mental life (87), and therefore the mentioned diseases paralyse the functions of the intellectual faculties and the senses (88). In one place only (89), Galen goes into greater detail in a very interesting way, illustrated with informative examples. When the conceptual ability is paralysed, so-called catalepsy occurs; if it is weakened, lethargy occurs; if its operations are disturbed and irregular, madness. The same can be said when the ability to think is disordered; if it is paralysed, paranoia (άνόιά) occurs; if it is weakened, lethargy (μόριά). Paranoia usually attacks both the ability to conceptualize and to think simultaneously, but it can also happen that only one of them is disturbed. Such was the case of a doctor, who in all other respects was in possession of his reasoning power, and he knew those around him and could converse sensibly with them. However, he held the paranoid idea that some flute-players had occupied a corner of the room where he was lying and incessantly played day and night; he could see them clearly in front of him, some sitting, others standing, and he constantly yelled for them to be chased away. Once recovered, he could recall all that had happened during his illness, as well as the hallucinations with the flute-players. As an example of disturbed ability to think, but without hallucinations, mention is made of a man who had secluded himself and one by one passed all the kitchen utensils out through the window and asked the passers-by whether he should throw them out; he mentioned every piece by its correct name and only suffered from the obsession that everything should be thrown out.

But apart from this attempt at distinguishing between the different brain activities, which almost appear modern, Galen, as mentioned, limited himself to the two old, broad terms: mania and melancholia.

Mania is usually separated from phrenitis by virtue of the fact that it is not accompanied by fever (90) (Note 11). Also, the other remarks about its causes and symptoms closely follow Hippocrates and most often appear as explanations for and defence of statements in the Hippocratic teachings. Thus, a keen defence of the Hippocratic hypothesis is that disturbances of regular respiration heralds madness (91) and also, adhering to Hippocrates, it is emphasized that the danger of spring and, to some extent, autumn predispose some to insanity (92), and the beneficial effect of haemorrhoid bleedings (93). It is remarked (94) that patients also forget their bodily necessities, such as urination, bowel motions, food and drink. Even when they have requested something, they forget to eat, remain standing with the chamber pot in their hands without using it, or remain sitting on the night commode until their surroundings remind them to get up. This state of mind is strikingly illustrated by comparing it with momentary absent-mindedness in healthy people. If, while walking quickly for a specific purpose, one thinks of something which occupies one strongly, one spontaneously slows down until one becomes mindful of the planned errand, and therefore concentrates on walking at a suitable pace. In a similar way (95), maniacal attacks are compared to intense outbursts of anger in otherwise normal people, who out of indignation lash out and kick, rip their clothes, smash windows and doors, bite stones and keys, etc.

There are more numerous and detailed statements on melancholia in Galen, although again he adheres to Hippocrates. Melancholia is a chronic condition (96), which is caused by the cold and dryness of the black bile (97). As Hippocrates has already remarked, it is closely related to epilepsy (98). Those who are predisposed to melancholia must keep a close watch on various foods which nourish the black bile, for instance meat, especially beef, hare and wild boar, pickled food, cabbage (99), vinegar (100). From his own practice, Galen gives an example to illustrate that sexual abstinence can lead to melancholia (101). Silence and reticence, when not habitual, herald melancholia (102). Contrary to his custom, Galen disputes the Hippocratic Aphorism that describes the sudden occurrence of lack of control over the tongue as a symptom of melancholy (103). Otherwise, closely adhering to the Aphorisms (104), the disease is characterized as a sustained state of depression and excessive anxiety (105). If the patient is asked what might be the reason for his depression, he can give none; some wish themselves dead, others fear it, but also fear things for which there is no reason to be fearful. The patient has very vivid dreams (106). Moreover, his worries and paranoid ideas can assume the most varied and peculiar forms; one believes he is made of clay and steps aside from those he meets, fearful that he might be broken to pieces; one flaps with his arms and attempts to crow when he sees a rooster do it; one believes he is Atlas, who holds up the celestial sky and walks in constant fear of becoming tired and losing it and, thus, crushing himself and his surroundings. Anxiety and depression, discontentedness with life and misanthropy are common to all melancholics; however, longing for death is not. On the contrary, in some the disease consists of constant anxiety of dying, others are both afraid of it and at the same time wish it (107).

Concerning the aetiology, Galen distinguishes between three forms, in that the black bile can either have taken possession of the whole body or solely have afflicted the brain (108) or, finally, the source of the disease can be the stomach. This last form is termed hypochondria (109) and, following Diocles, is described as accompanied by stomach ache, ructions and vomits, which cause the gums to bleed, copious salivation, burning sensation in the hypochondria, etc. (110).

The therapy varies somewhat for the various forms, but the main remedies are bloodletting (when the whole body is afflicted) and purging, especially when vomiting occurs; as a medicament, hellebore is recommended (111). Galen prefers purging to bloodletting (112); it should be performed early in the spring (113). From his own practice, he mentions a man who, if he did not have purges, suffered an attack of melancholia every year, but this cure would help him instantly (114). In other cases, Galen limited himself to baths and diet (115).

The “medical definitions” of insanity, preserved under Galen’s name, only contain the following two (116): “Mania is a disturbance of the ability to think and a deviation from the normal and usually occurring when in a healthy state, without fever”; “Melancholia is a suffering, which harms the intellect, associated with strong depression and animosity towards the relatives, without fever; in some also the stomach is ruined by the black bile, which is present in abundance with the effect that they develop vomits and thus with ruinous effect on the intellect”. The work is by a later author, who belongs to the Pneumatic School, but with a leaning towards eclecticism (117).

Of more interest is a small compilation “On Melancholia”, which has also been published together with Galen’s works (118). It contains excerpts from his writings, and also from those by Rufos of Ephesos (time of Trajan), Marcellus of Side (in Pamphylia, first half of 2nd century AC) and others. It is based on the division of the three forms of melancholia, as drawn up in Galen. As an example of hypochondria, a man is mentioned who believed he had no head, and who was cured by being made to wear a leaden hat, which, by its weight, convinced him that he did have a head (119). The disease is described as follows: most melancholiacs have a tendency to indulge in venery, they are melancholic, anxious, whining and crying and seek solitude. Some believe that they are possessed by demons by virtue of the necromancy of their enemies, others are afraid of having been poisoned, and they are confirmed in their beliefs by the ill-smelling ructions that the disease brings with it. By and large, the disease is very varying and manifold in its manifestations; some are afraid of their nearest relatives, others of all people; some shun darkness, others cannot tolerate the light, but prefer to stay in dark places, in burial chambers and the like, and this is the general pattern; some are scared of water, wine, oil and, on the whole, everything fluid, as if they had contracted rabies. Only the anxiety and the depression are common to all of them (120).

In the excerpt from Rufos, emphasis is placed on the motley character of the symptoms and the impossibility of deducing them all from one basic disease, for example, unmotivated and varied anxiety. But for quite a number of symptoms, an explanation is sought, based on humoral pathology. Thus, when some believe that they are made of clay or feel that their skin is like dry leather, this is derived from the dryness caused by the disease (121). Imagining being without a head is rooted in the feeling of lightness caused by the pneuma mounting to the head. The “coldness” of the disease (121) causes an urge for much food and wine. The suicidal urge is caused by the fear of greater accidents, or perhaps, “like some of the barbarians”, some consider death as bliss (Note 12). Indigestion is caused by a surfeit of bad humours. When patients blink incessantly, have protruding eyes and, as a rule, thick lips, it is due to inspissation of the pneuma. The colour of their skin is dark because the tainted humour is widely diffused over the whole body; as a rule, they have strong growth of body hair due to the thick perittomata of the humour; they speak fast, stutter and with a “dry” voice because, due the condition of the pneuma, they cannot control their tongues (Note 13). The treatment must be determined according to the origin of the malady. Melancholia can be either congenital due to the temperament or acquired through an unhealthy diet; in the latter instance, lethargy and depression are predominant, whereas those whose madness is caused by overheating of the bile are wilder and more irate; in their paroxysms they lash out and commit all sorts of violent acts; during the intermissions they are depressed by sadness and anxiety. With respect to therapy, the directions of various doctors are given, which mainly agree with those of Galen, but there are also several more, some of them very composite medicaments (122).

As a special form of melancholia, the above-mentioned compilation cites (123) so-called lycanthropy (or cynanthropy), which is described in accordance with Marcellos of Side. His description of it is probably the first that we have, and it recurs in all later manuals right down to Byzantine times. It has already been mentioned rather often as a paranoid idea that was not unusual, namely that the patient believes he is some animal. Lycanthropy, which is stated to be periodical and to occur especially in the month of February, is manifested with the patient’s belief that he is a wolf or a dog, and he behaves accordingly. He goes out at night and frequents burial places especially, where he breaks open the graves; it is not until the next morning that he comes to his senses again and returns home. The symptoms are pale and sallow facial colour, dry and sunken eyes, which cannot shed tears, weakened eyesight, dry tongue and lack of saliva; the patient suffers from thirst and his shins are full of wounds, which cannot heal as, during his nocturnal roving, he constantly bumps into things and gets bitten by dogs. The disease is treated with bloodletting, purging and diet; when an attack is imminent, soporifics can be used.

The reality of this singular malady cannot be doubted. There exist too many testimonies about it from the most diverse countries and times. But already in Antiquity it was linked to various myths, especially the story about King Lycaon of Arcadia, who slaughtered children and had them eaten. Later, all sorts of superstitious beliefs were attached to this; an offshoot of it is the popular belief in werewolves (124).

The collection of notes “On Melancholia”, referred to here, actually forms part (125) of the large medical manual (Iatrica), compiled in 16 books by Aëtius of Amida (born in Mesopotamia), doctor at the Eastern Empirical court at the beginning of the 6th century; these were in accordance with older sources, first and foremost Galen, but also others. The same work contains (126) a description of mania and its treatment in accordance “with Archigenes and Poseidonius” (a doctor from the Empirical School, 1st century BC), which contains nothing particularly new, but gives a rather good and succinct overview.

Mania arises from afflux of blood to the brain, either when it is too copious, as in inebriety, or when the blood is polluted by bile. In the first instance, the patient laughs incessantly and sees ridiculous visions, his facial expression merry, he sings incessantly and believes that he can hear flute-playing; his memory is unaffected (he can remember his songs), but his perception and thinking ability are disturbed. The admixture of bile, however, causes shooting pain in the brain, and the patient becomes irascible and violent; if the bile gets stuck in the brain, it causes maniacal attacks, during which it can happen that the patient bites in his own flesh, or kills or mistreats his closest relatives in the belief that they are after his life. According to the changing amount of the materies morbi, the patient can alternate between exalted mirth and agitation and, at times, a suitable diet is enough to bring about a pause; the disease can also be periodical, once, twice or more times in a year. As a rule, only mature men fall victim to the disease, especially those who suffer from psychic abnormalities such as excessive light-heartedness, indulgence in sarcasms, pig-headedness, irascibility, brooding and avarice, or who are given to drink and have indigestion. Women are mostly affected when they experience menstrual cessation. Symptoms of an imminent illness attack are unmotivated mirth or anger, buzzing in the ears, swimming eyes, persistent sleeplessness; unreasonable worries, heaviness and throbbing sensation in the head. These symptoms get stronger and stronger; ill-smelling ruction occurs, an abnormally strong drive to indulge in venery with constant involuntary ejaculations, and the eyes become hollow and stiff. The treatment is the usual: diet, bloodletting, purging and baths; hellebore is recommended, and also soporifics, which, however, must be used with caution.

Aëtius has one other chapter (127) on “feeble-mindedness” (μόρόσις, idiocy), which like “maundering” (λήρήσις), is assumed to stem from cooling of the brain. Feeble-mindedness differs from it in that there is coherence in the patient’s speech and behaviour, whereas the maundering patient constantly changes subject and speaks incoherently. It can attack all ages, also children and young people, whereas maundering is characteristic of old age. The cure for it is the same as for epilepsy, but it is of no use for treating the disease when it is inborn.

Aëtius’s nearest model (and partial source) was Orabasius, Physician-in-Ordinary to Emperor Julian the Apostate, but in the preserved parts of the latter’s large manual there is nothing about insanity; however, in the excerpt from it, which Aëtius edited himself (“Synopsis”), a chapter on melancholia is included (128). This reproduces Galen’s teachings about the three forms of the disease and their treatment, and includes a brief note about a medicament for mania in accordance with Philumenus (a Methodic from the 1st century AC), and Marcellus of Side’s description of lycanthropy; and, as something new, there is a chapter “On love” (129), endorsing a few suggestions by earlier authors, and here, for the first time, it is included under mental illnesses. It is said that the sadness of lovers and their sleeplessness have misguided some doctors to the wrong treatment of forbidding baths and keeping them on a strict diet; on the contrary, they must take baths, drink wine, be entertained and diverted, at times, also frightened. Idleness is the best nourishment for evil; therefore, one must rouse their ambition and interest in some task that is suitable for their habits. External symptoms mentioned are hollow dry eyes, seemingly radiant with happiness, fluttering eyelids; the eyes do not share the weakness of the rest of the body.

Paulus Aegineta (7th cent.) was quite dependent on his predecessors, especially Galen and Oribasius. Apart from the same chapter on lycanthropy (130), he has a piece on mania and melancholia and their treatment (131), which offers nothing really new. He mentions the usual peculiar paranoid ideas that the patients hold in their belief that they are some animal or other, made of clay, etc., and have maniacal attacks provoked by the black bile, rendering them dangerous to their surroundings; therefore they must be tied to their beds. If they will not take medicaments, it is recommended mixing these with food. Melancholia is said to be curable simply with baths and diet and, when the attack is milder, suitable amusements. Adhering to Oribasius, Paulus also has a chapter on love (132), which he introduces with the remark that this condition can be suitably dealt with as described under insanity, as it consists of “worry” and a tiring effect on the ability to think. He deals with a well-known story about Erasiatratus, who had detected that King Seleucus’s son, the nature of whose illness no other doctors could understand, suffered from lovesickness towards his stepmother; her presence strongly increased his pulse rate. Paulus remarks that it is wrong to try to establish that there is a special pulse for lovers; a disturbed pulse accompanies every affect, and therefore also the one that arises when one thinks and hears about or sees one’s darling.

Alexander of Tralles (6th cent., brother of the builder of the Sophia church, Anthemius) is the only person among these later compilers, who, despite all dependency on their sources, gives some independent ideas, based on his own practice and experience.

According to the preface to Alexander’s work (133), it provided a short and comprehensible exposition of his experiences in his practice regarding the treatment of various diseases, but he does not hide the fact that he also uses the works of earlier doctors, especially those of Galen.

Alexander (134) defines phrenitis, which is sharply separated from both febrile deliria and from insanity proper, as an infection of the brain or its membranes, caused by the bile; according to the nature of the materies morbi, it can occur in milder or more violent forms. Symptoms of the disease are persistent or broken sleep with disturbing dreams, distraction so that the patient starts to give orders but then jumps to something else and forgets what he wanted to say, vehemence and irascibility in conversation, deep and rapid respiration, small and hard pulse. When an attack is imminent, the eyes become stiff and red, unclear and swimming. The patient starts to pick fluff, speaks unclearly and becomes lethargic; he neither listens, hears nor answers. When the malady is of longer duration, the symptoms wane; no longer does he speak so unclearly, but lies still in a state of lethargy; no longer does he jump up bewildered from his bed, but simply lies fumbling with his hands as if searching for something; at times, due to lack of strength, he cannot open his eyes and quickly shuts them again when, once in a while, he opens them. This apparent calm must not trick one into believing that the disease has remitted.

Apart from washing the head with rose oil, vinegar and the like, which must be strengthened and repeated when the disease is at its acme, the most important remedy is bloodletting from the elbow. It often happens that the patient resists, not wanting to stretch his arm out to the doctor; in that case, one must open the frontal blood vessel. Alexander recounts such a case from his own practice, where the patient behaved in such a state of agitation and rage that he had to be restrained by several strong men; had he got hold of a weapon he would have killed several of those around him. Therefore, because further bloodletting would have caused too much difficulty, Alexander proceeded to bleed him only once and get a sufficient amount of blood from him by opening his frontal blood vessel; the patient tried to slurp up the blood, which ran down his face, and to spray it at those standing around him, even causing “most of them to laugh about it”. He made a quick recovery. Moreover, sleeplessness must be combated in every aspect; however, when the patient is very weakened, strong sleeping remedies must not be resorted to; they can cause death.

As we know from Archigenes and Soranus, concerning the sickroom, almost the same rules are given. Its air must be neither heavy nor humid, neither too warm nor too cold. Preferably, the room should be light rather than dark so that the patient can recognize his usual surroundings. His closest friends must pay visits and stay with him so that, with their gentle reproaches, he can be brought to feeling shameful over his insane behaviour. In contrast to this, no relatives or slaves who have ever caused him sorrow or bother must present themselves before his eyes; this exasperates and agitates him, leading to fierce attacks. Nor must too many people visit him at the same time; this causes noise and pollutes the air. Visitors must walk quietly to avoid making the bed shake, which disturbs the patient and prevents him from sleeping. They must hold all his limbs and massage them gently. As regards diet and baths, exact directions are given, although, essentially, they contain nothing new. It must only be remarked that Alexander recommends moderate use of wine, except in cases of strong febrile attacks; the beneficial effects of wine outweigh the harmful ones; it removes the sleeplessness and gives strength. Overall, wine can be given with success to those insane who are used to drinking wine; it transforms their impetuosity and ferocity into well-being and facilitates sleep.

Alexander (135) also deals extensively with melancholia. He uses the term as a general designation for insanity; he has no special section on mania, which, apparently like Archigenes, he considers as a form of melancholia.

The causes of melancholia are several; the humours that cause it are not always the same, and according to their nature and seat, the symptoms differ. Some patients laugh incessantly, full of bright and happy thoughts; others, as in phrenitis, are irascible and agitated; yet others are lethargic like idiots and unwilling to talk, while others suffer from paranoid ideas and believe that they are in possession of a prophetic gift; some long for death and harbour suicidal thoughts, and others fear it relentlessly. The condition can be continuous or interspersed with bright moments during which the patient can attend to his usual activities. In other words, as constantly reiterated, the symptoms are all the same; the new view is simply that they all fall under the concept “melancholia”. In accordance with Galen, the seat of the materies morbi is described to be either the brain only, or the whole body, or the stomach and the hypochondria. But in the later specialization of the different forms of “melancholia” and their treatment, another division and aetiology are made the basis.

The first form that is put forward is caused by an excess of blood. It is more likely to attack men who have heavy growth of body hair and dark skin, and who are leaner than those with a whitish skin and are well-nourished; they are most often men in their prime of life, who eat sparsely, and are irascible and have many sorrows and worries and suffer from bad moods. The doctor should also establish whether some of the patient’s usual evacuations have stopped, in men especially haemorrhoid bleeding, in women their menstruation, and whether there is a distinct feeling of heaviness in the body. He must also note whether the colour of the patient’s face is redder than usual, and whether the blood vessels are prominent and tense. If these symptoms are present and especially if lucid moments occur, when the patient shows pleasure in attending to his usual activities, the diagnosis “melancholia due to unsound blood flow to the brain” is certain. If the attacks are manifested by hilarity, it is only the quantity of the humour, not its quality that causes the malady. The cure in this form of melancholia is, first and foremost, bloodletting and abstinence from meat and other food that increase the amount of blood.

[The second form] If it is not clean blood that causes the disease, but blood polluted by bile and spicy food, the patient is more irascible and more restless and difficult. In addition, if his temperament is warm and dry, and his previous food spicy and overheating, and if he is in his most vigorous years, the diagnosis is certain. One moment he is merry, the next he is wild, and the paroxysms alternate with quiet periods. Such patients must be emptied of bile by purging, but one must refrain from using too vigorous and overheating remedies that can cause acute attacks of madness. A proper diet and warm baths often suffice, and for both of these there are detailed instructions. The remedies that “the old” recommended, i.e. cupping and leaches on the head, are rejected by Alexander; at any rate, they must only be used in emergencies. If the patient will not take his medication in any form, one should mix it with wine or serve it in a soft-boiled egg, and then he does not notice it.

[The third form] When the blood gets overheated, the third form of melancholia occurs where, as the symptoms show, the black bile is predominant. The patient suffers from unmotivated concerns and worries, is depressed, wishes himself dead, shuns his best friends, believes that attempts are being made on his life with a dagger and poison, etc. The usual fixed ideas are mentioned as examples: the patient believes he is made of clay or leather, crows like a rooster, or imagines that he is a nightingale, who cries at the loss of his son, or believes that he is Atlas, who holds up the celestial sky, etc. From his own practice, Alexander mentions a lady who binds her index finger, because she believes that she is carrying the world with it, and is fearful that everything will collapse if she bends her finger. If the disease is at its onset and stems from a prior sorrow or other emotion, one must turn the patient’s thought in another direction by letting him see or hear something that interests him. Apart from the story about the man who believes that he has been beheaded but was cured by wearing a leaden hat (Note 14), Alexander recounts a couple of peculiar cases of fixed ideas that were cured by purely psychic influence. One lady believed she had swallowed a snake and was cured by placing in her vomit a small animal which looked like the one she believed she had swallowed. Another lady, who had become insane and was sorrowful over her husband’s long absence travelling, recovers immediately, delighted by his sudden and unexpected return. But if the malady had been given time to take root, this kind of psychic remedy has no effect; then bloodletting and purging of the harmful humour must be resorted to. As well as various other remedies, Alexander recommends the “Armenian stone”, dissolved or in tablet form, which he prefers to the hellebore cure of “the old”, due to its more painless and safe effect. After purging, the patient must be served a light meal with fruits, then given time to rest and sleep. Having regained his strength in this way, he must take a bath, both in warm and cold water, and then enjoy some bread, dipped in wine or mead, and then be brought home to bed. After an invigorating sleep, his intimate friends must be allowed to talk with him. If he answers sensibly and calmly, one serves him a plentiful meal of lean wildfowl and then keeps him on a stricter diet to avoid all foods that produce black bile. If the improvement is sustained, the patient can be permitted to change his place of abode, visit his good friends, keep himself busy with what delighted him before, watch plays, etc. And although the malady is protracted and difficult to cure completely, one must not give up hope of finally overcoming it with continued use of suitable diet and baths.

As late as the 14th century, the Byzantine Physician-in-Ordinary (actuarius) Johannes wrote a learned medical manual, following Galen especially, giving a brief yet concise and well-arranged overview of insanities (mania and melancholia and including lycanthropy) (136).

Finally, when one compares the instructions of these later Greek physicians regarding the treatment of the insane with the much later maltreatment to which the insane were subjected in the Occident, on the whole one gains a strong impression of the blessing of an old and continuous culture. Although the rays of sunshine of Antiquity that have shone down upon the offshoots of Antique medicine are faint and refracted, nonetheless, they have always been bright enough to dispel the darkness of superstition and ignorance in which demons and other theological ghosts dwell. Also in this respect, the Greek medical art has continued to revere the old Hippocratic motto “to help, or at least do no harm”.