Impaired consciousness in the Hippocratic corpus: delirium case studies
Over half a millennium separates the literary emergence of Hippocratic medicine from the authors – such as Rufus of Ephesus and Aretaeus the Cappadocian – who usually play starring roles in scholarship on ‘mental disorders’ in antiquity. Similarly, the appearance of affections such as mania or melancholiaFootnote 1 is a product of Hellenistic medical developments. In contrast, Hippocratic texts generally include forms of mental derangement and disturbance – delirium, coma, incoherent speech, hallucinations – as symptoms within a larger array of signs, but there are very few allusions to mental derangement as affections in themselves. This pattern reflects a general Hippocratic looseness in the notion of disease, a preference for listing signs rather than providing abstract definitions. These circumstances notwithstanding, scholars have tended to take these notes about episodes of delirium as proof of a larger category of madness underlying these glimpses, thereby drawing generalising conclusions about ancient psychology and body–mind relationships.
As we shall see below, even if the distinction between chronic mental diseases, on the one hand, and acute and changeable episodes of delirium, on the other, can be found in the corpus, the bulk of cases fall into the latter category. Let us examine three groups of disorders or case studies: two forms of delirium affecting young girls, two cases of alcohol-associated delirium and several discussions about phrenitis.
Delirium in young girls
One of the detailed case histories in Epidemics III relates to the daughter of Euryanax: ‘A fever seized her’ and:
… περὶ δὲ δεκάτην μετὰ τὸν ἱδρῶτα τὸν γενόμενον παρέκρουσε καὶ πάλιν ταχὺ κατενόει … διαλιποῦσα δὲ δωδεκάτῃ πάλιν πολλὰ παρελήρει … ἀφ’ἧς δὲ παρέκρουσε τὸ ὕστερον ἀπέθανε ἑβδόμῃ … ἀπόσιτος πάντων παρὰ πάντα τὸν χρόνον οὐδ’ἐπεθύμησεν οὐδενός. ἄδιψος οὐδ’ἔπινεν οὐδὲν ἄξιον λόγου. σιγῶσα, οὐδὲν διελέγετο.
… On the tenth day, after sweating, she was delirious (parekrouse) and was soon again rational … after a brief interlude, on the twelfth day, she became very delirious (parelêrei) again … She died on the seventh day after the last delirium (parekrouse). She had an aversion for all food during the whole period, and she desired nothing. Not thirsty, she did not drink anything worth mentioning. She remained silent, did not speak at all.
The author seems to be describing a condition that causes intermittent attacks of impaired consciousness, by introducing certain ‘delirium terms’ such as parakrouô (krouô means ‘hit’ or ‘strike’) and paralêreô (lêreô means ‘speaking nonsense’).Footnote 2 First this girl parekrouse, then palin katenoei and then palin parelêrei. The first palin points towards an opposition between parekrouse and katenoei, assuming that her consciousness was initially intact, whereas the second palin suggests the equivalence between parekrouse and parelêrei. Moreover, the identity between the latter pair of verbs is further reinforced by the relative clause that places the death on the seventh day after the last delirium (aph’ ês … parekrouse to husteron). It is implied, thereby, that the two episodes – namely the first one, where the girl parekrouse, and the second one, where she parelêrei – were similar, and the terms, therefore, were interchangeable.Footnote 3 (This is the reason why I used ‘delirium’ and its derivatives as a general term to translate different words.)
Towards the end of the passage, the author recaps the main features of the process and further defines the nature of the disorder: throughout the whole time, the girl presented hypoactive responsiveness. That is why she neither ate, nor drank, nor desired anything, and most importantly, did not say a word. In terms of the course of the disease, the whole thing lasted nineteen days altogether, which – added to the episodic nature of the attacks – seems to point towards an acute disease with delirious fits, rather than a psychiatric condition.
Although probably referring to a different and longer infirmity, the short treatise On diseases of girls addresses the general age-group into which the daughter of Eurianax – also a parthenos – falls, and seems to contrast mental illness with episodes of impaired consciousness. The condition described is one that can develop if girls reach marriageable age but are not married. They are then affected by ongoing mental problems within which sudden episodes of delirium or, arguably, acute psychosis can trigger suicidal behaviours in the affected young women. Based on its chronic course and regular pattern, we could label this disease as one of the rare examples of mental illness (according to our current understanding) in the Hippocratic corpus. However, the author also describes acute episodes within this longer-lasting process, where consciousness seems impaired. The account begins with a reflection upon the nature of diseases in general, and the characterisation of a group of affections in particular. Eventually, the author focuses on the topic of his core discussion:
… περὶ τῶν δειμάτων, ὁκόσα φοβεῦνται ἰσχυρῶς ἄνθρωποι, ὥστε παραφρονέειν καὶ ὁρῆν δοκέειν δαίμονάς τινας ἐφ’ ἑωυτῶν δυσμενέας … ἔπειτα ἀπὸ τῆς τοιαύτης ὄψιος πολλοὶ ἤδη ἀπηγχονίσθησαν…
… about the terrors, which make people particularly afraid, to the degree that they become delirious (paraphroneein) and they think that they can see spirits hostile to them … Then, as a result of such visions, many end up strangling themselves.
The text expands on this latter condition, and the author appears to be describing a basal state of anxiety and fear (a common accompanying symptom in psychosis) with crescendos where hallucinations take place (hôste paraphroneein), which can be potentially mortal because they may lead to self-harm. It is during such acute episodes that consciousness becomes temporarily altered.
After this general outline of the course of the disease, the author explains the mechanism of these sudden attacks. Blood is collecting in the womb. It should run out as menstruation begins, but the mouth of the womb does not open, and so more and more blood builds up, with nowhere to go except upwards to the heart and the diaphragm:
ὀκόταν οὖν ταῦτα πληρωθέωσιν ἐμωρώθη ἥ καρδίη, εἶτ’ ἐκ τῆς μωρώσιος νάρκη, εἶτ’ ἐκ τῆς νάρκης παράνοια ἔλαβεν … ἐκ δὲ τῆς καρδίης καὶ τῶν φρενῶν βραδέως παλιρροεῖ – ἐπικάρσιαι γὰρ αἱ φλέβες – καὶ ὁ τόπος ἐπίκαιρος ἔς τε παραφροσύνην καὶ μανίην…
When they [the heart and the diaphragm] are full, the heart becomes sluggish. Next, from the sluggishness it grows numb, and then, from the numbness, delirium (paranoia) affects [the young girls] … From the heart and the diaphragm [the blood] flows back slowly, as the veins are twisted. The site is critical for delirium (paraphrosunên) and raging (maniên).
The passage seems to confirm the idea of sudden fits within a longer-lasting process, thereby reinforcing our hypothesis of impaired consciousness. Through it, the author is offering a pathophysiological explanation as to why these acute episodes that happen within the chronic condition subside so slowly. Namely, due to the anatomical conformation of the vessels.
Undoubtedly, much more can be extracted from these passages. Suffice to say here that these cases of delirium that affect young girls illustrate the short-lived and changeable nature of the episodes of impaired consciousness (as opposed to the longer and more stereotyped characteristics of the disease that affects unmarried virgins).
Drunkenness or alcohol-associated delirium
A second group of conditions, two cases of delirium associated with alcoholic intoxication (among other examples in the corpus)Footnote 4 will illustrate the hyper- and hypoactive nuances that delirium can acquire. It is again the author of Epidemics III who comments on a Meliboean youth that ἐκ πότων καὶ ἀφροδισίων πολλῶν πολύν χρόνον θερμανθεὶς κατεκλίθη (‘took to his bed with fever after indulging in drinking and sexual pleasures for a long time’).Footnote 5 On the tenth day παρέκρουσεν ἀτρεμέως, ἦν δὲ κόσμιός τε καὶ σιγῶν (‘he was delirious (parekrouse) but calm (atremeôs), rather well-behaved and quiet’).Footnote 6 Later on, though, on the fourteenth day, his silence became irrational talk: παρέκρουσεν, πολλὰ παρέλεγεν (‘delirious (parekrousen), much wandering talk (parelegen)’).Footnote 7 Finally, on the twentieth day ἐξεμάνη, πολὺς βληστρισμός (‘agitation (exemanê), very restless’).Footnote 8
It is clear from the account that the author is describing a succession of repeated and limited episodes of impaired consciousness, where the boy was not his usual self. Even more explicit about the nature of impaired consciousness is a different case described by the author of Epidemics IV.
Ὁ πρῶτος παρενεχθείς, μειράκιον … οὗτος παρέκρουσεν, οἶμαι ὀγδόῃ, τρόπον τὸν ἀκόλαστον, ἀνίστασθαι, μάχεσθαι, αἰσχρομυθεῖν ἰσχυρῶς, οὐ τοιοῦτος ἐών … ὕπνος ἐγένετο ξυνεχής … ἔπειτα ἐξεμάνη τε αὖτις καὶ ἀπέθανε ταχέως ἑνδεκαταῖος, προφάσιος οἶμαι πιεῖν ἄκρητον συχνὸν πρῖν ἐκμανῆναι ὀλίγῳ.
The first affected by delirium (parenechtheis) was a lad … He had, I think, on the eighth day the uncontrolled (akolaston) type of delirium (parekrousen): leaping up, fighting, and swearing a lot – although he was not that kind of person … He developed continuous sleep … Afterwards he was delirious (exemanê) again and suddenly died on the eleventh day. The cause (I believe): drinking abundant undiluted [wine] shortly before the frenzy (ekmanênai).
Of note in this passage are both the contrast that the writer highlights between the subject’s usual character and his behaviour during the affection, as well as the constant changes in his levels of consciousness described. Indeed, his symptoms oscillate between impaired consciousness at the hyperactive side of the spectrum and sleep at the hypoactive one.
In terms of vocabulary, the author of Epidemics III uses parakrouô not only for describing calm impaired consciousness, but also the restless type. Furthermore, in this description, ekmainomai seems to denote – like maniê in the disease of the young virgins – a more intense nuance. Also, for the author of Epidemics IV the terms convey a similar ambiguity. In this account, parakrouô seems to be rephrasing parapheromai (another word associated with delirium), and the adverb autis (like palin earlier) suggests that ekmainomai is picking up the meaning of the former two. Namely, all three verbs are referring to a hyperactive type of delirium. In another chapter within the same book, however, the author explains that his patient was παραφερόμενος ἐξ ὕπνου, οὐκ ἐξεμάνη (‘delirious (parapheromenos) after sleep, not agitated (exemanê)’).Footnote 9 When collating all these elements, it appears that these authors acknowledged at least two types of delirium characterised by their behaviour as hypoactive (atremeôs) and hyperactive (akolaston), respectively, which they described with the same terminology.
Although strictly from a medical point of view, both cases seem like alcohol-associated affections rather than drunkenness, the acuteness (none of the processes prolong in time), the episodic nature as well as the constant fluctuations and changes in both excerpts suggest,Footnote 10 once again, remarkable swings within the intermediate areas of the spectrum of consciousness (which we would nowadays define as alterations in the level of consciousness and not mental illness). Moreover, the association with alcohol further reinforces this view, as there seems to be an element of intoxication to them.
Phrenitis
The last condition under scrutiny is broadly alluded to within the Hippocratic corpus and illustrates many of the above-discussed phenomena. It should be emphasised that phrenitis was associated by the Hippocratic medical writers with a large array of symptomsFootnote 11 – particularly pain – among which delirium was only another element (and not always the most remarkable). Some nosological treatises that address it are particularly useful for catching a glimpse of what impaired consciousness must have looked like for these doctors. Diseases I, II and III (written by different authors) all address phrenitis and provide various and useful perspectives. Let us begin with Diseases I:
… παρανοέει τε ὥνθρωπος καὶ οὐκ ἐν ἑωυτῷ ἐστιν … προσεοίκασι δὲ μάλιστα οἱ ὑπὸ τῆς φρενίτιδος ἐχόμενοι τοῖσι μελαγχολώδεσι κατὰ τὴν παράνοιαν· οἵ τε γὰρ μελαγχολώδεις … καὶ παράνοοι γίνονται, ἔνιοι δὲ καὶ μαίνονται˙ καὶ ἐν τῇ φρενίτιδι ὡσαύτως˙ οὕτω δὲ ἧσσον ἡ μανίη τε καὶ ἡ παραφρόνησις γίνεται, ὅσῳπερ ἡ χολὴ τῆς χολῆς ἀσθενεστέρη ἐστίν.
… The person becomes delirious (paranoeei) and is no longer himself … Patients with phrenitis most resemble those affected by black bile as regards their delirium (paranoian) … Indeed, the latter also become delirious (paranooi), and some of them even have an outbreak of frenzy (mainontai). The same occurs to those affected by phrenitis, but both the frenzy (maniê) and the delirium (paraphronêsis) are less insofar as their bile is weaker than the [black] bile.
Interestingly, the writer interprets the state of the patient as ‘not being himself’, similar to the previous case, where the drunken boy ‘was not that kind of person’ (Epid. IV.15. LCL: 104, 1). This estrangement from the pre-existing characteristics of the sufferer helps the doctor in the diagnosis, which points towards an acute rather than chronic condition (when symptoms prolong in time it becomes more difficult to separate the baseline personality of the individual from the actual illness). Also important to remark is that melancholia is not yet a disease in its own right. The author is simply referring to individuals affected by black bile, as opposed to the bile that characterises phrenitis, which is weaker, and hence, so too the symptoms. Regarding the delirium terminology, the partial synonymy persists. The author uses paranoeô-paranoia-paranoos as equivalent to paraphronêsis, whereas mainomai-maniê – like ekmainomai in the Meliboean boy’s description – seems to express a more extreme and hyperactive level of derangement.Footnote 12
Other nosological treatises are more explicit about what the actual symptoms looked like, namely, they go into details about the nature of the impairment in phrenitis. Diseases II specifies that the patient φοβεῖται, καὶ δείματα ὁρᾷ καὶ ὀνείρατα φοβερὰ καὶ τοὺς τεθνηκότας ἐνίοτε (‘is in panic and sees terrible things, frightening dreams and sometimes, even the dead’).Footnote 13 Indeed, this is not completely different from the symptoms described for the young girls or the drunken lads. Ultimately, the writer is describing disturbing hallucinations.
The author of Diseases III, finally, presents us with a different kind of alteration in the hypoactive side of the spectrum of consciousness that he also associates with phrenitis:
… ἔκφρονές εἰσι, καὶ ἀτενὲς βλέπουσι, καὶ τἆλλα παραπλήσια ποιέουσι τοῖσιν ἐν τῇσι περιπλευμονίῃσιν, ὅταν ἔκφρονες ἔωσι.
… they are delirious (ekphrones) and stare fixedly, and do the rest of the things in a similar way as those affected by peripneumonia when they become delirious (ekphrones).
These phrenitic patients seem to be suffering hypoactive impaired consciousness, for they do not move. Nowadays we would probably define this symptom as ‘vigil coma’, that is, a condition where individuals are completely disconnected from the environment, but with their eyes wide open.
It is remarkable that three different medical writers described rather different manifestations of phrenitis, which nonetheless defined, in their understanding, the same condition: various states of extreme hyper- and hypoactivity, along with diverse hallucinations, were all subsumed within the notion of phrenitis; in other words, one single condition that causes several variations of what we nowadays consider as impaired consciousness.
A similar conclusion could be drawn from all three conditions that we have analysed. There is a set of related signs and symptoms, which are present in and characteristic of – but not exclusive to – certain unrelated conditions. This acute and short-lived clinical presentation has several similarities with our idea of delirium, but not necessarily of mental illness. As a matter of fact, the distinction between impaired consciousness and madness in the Hippocratic texts was not a major concern for the authors because they mostly disregarded madness and mainly focused on delirium.Footnote 14
Symptoms, location, cause and treatment of delirium: the loose notion of disease in the Hippocratic Corpus
As highlighted above, impaired (or abnormal) perceptions and speech disorders – amid several other symptoms – are very characteristic of our current idea of wakeful impaired consciousness. When chasing these two major clinical manifestations across the subsequent authors and periods, it will become clear that not only ideas about impaired consciousness but also the understanding of the notion of disease among ancient doctors changed over time.
Undoubtedly, in the previous examples hallucinations were important for the Hippocratic doctors. The young girls ὁρῆν δοκέειν δαίμονάς τινας ἐφ’ ἑωυτῶν δυσμενέας (‘think that they can see spirits hostile to them’);Footnote 15 a phrenitic patient δείματα ὁρᾷ καὶ ὀνείρατα φοβερὰ καὶ τοὺς τεθνηκότας ἐνίοτε (‘sees terrible things, frightening dreams and sometimes, even the dead’);Footnote 16 and the author of On the sacred disease explains that when the brain is ill, μήτε τὴν ὄψιν ἀτρεμίζειν μήτε τὴν ἀκοὴν, ἀλλ᾽ ἄλλοτε ἄλλα ὁρᾷν καὶ ἀκούειν (‘neither sight, nor hearing remain still; instead sometimes we see or hear certain things, whereas at other times others’).Footnote 17 It cannot be emphasised enough that these abnormal perceptions are framed in the texts as only one clinical finding among various others, such as fever, pain, abnormal movements in the hands, photophobia, etc. We shall later see that their status and relevance in post-Hellenistic and Galenic accounts will increase.
On the other hand, speech disorders will suffer the exact opposite process: namely, they were consistently related to delirium in the Hippocratic collection, but their importance waned in later periods. Above is the example of Euryanax’s young daughter, whose hypoactive delirium – described as parelêreiFootnote 18 – caused her to not talk. I have elsewhere mentioned several other cases where the symptom was so strongly related to this condition that the terminology denoting senseless talking was used interchangeably with delirium (as opposed to normal speech, which was utilised to convey the idea of lucidity).Footnote 19
In terms of the bodily parts, although the locus affectus is a post-classical notion,Footnote 20 Padel has remarked that among the tragic poets, and also in the Hippocratic corpus, there are several attempts at associating states of altered consciousness with some splachna or ‘innards’. In her insightful analysis, these were often identified with specific organs (heart, brain, liver, lungs), certain liquids (blood, bile) or airy substances (including the breath); they could also be assimilated to specific tissues (blood vessels, the diaphragm) or even to more abstract concepts (thumos, menos, nous, psuchê).Footnote 21 Regardless of their anatomic placement, which was different in different texts, they tended to be involved in or enabled feeling and thinking.
Accordingly, the author of On the sacred disease (Morb. Sacr. 14.5: 26, 14–15) attributes hallucinations to the brain, whereas in On diseases of girls the heart and the diaphragm as well as the poor state of the blood are responsible for similar phenomena.
… ὑπὸ δὲ τῆς περὶ τὴν καρδίην πιέξιος ἀγχόνας κραίνουσιν, ὑπὸ δὲ τῆς κακίης τοῦ αἵματος ἀλύων καὶ ἀδημονέων ὁ θυμὸς κακὸν ἐφέλκεται. ἕτερον δὲ καὶ φοβερὰ ὀνομάζει· καὶ κελεύουσιν ἅλλεσθαι καὶ καταπίπτειν ἐς φρέατα ἢ ἄγχεσθαι.
… due to the compression around the heart, [girls] strangle themselves, due to the bad condition of their blood, the thumos, restless and in anguish, tempts them to another evil. Moreover, it [the thumos] mentions frightful [apparitions], which order them to leap and throw themselves down wells or to strangle themselves.Footnote 22
What is interesting about this passage is the fact that the author relates specific symptoms to specific innards. Although he does not explain how the heart, the thumos or the state of the blood cause those hallucinations, there is a link between anatomical location and clinical manifestation, which approaches a description of our way of thinking about diseases. Similarly, according to On breaths, drunkenness is associated with changes in the blood:
πάλιν ἐν τῇσι μέθῃσι πλέονος ἐξαίφνης γενομένου τοῦ αἵματος μεταπίπτουσιν αἱ ψυχαὶ καὶ τὰ ἐν τῇσι ψυχῇσι φρονήματα, καὶ γίνονται τῶν μὲν παρέοντον κακῶν ἐπιλήσμονες, τῶν δὲ μελλόντων ἀγαθῶν εὐέλπιδες …
Again, during heavy drinking, as blood suddenly becomes more abundant, the psuchai undergo change along with the phronêmata that are in them (in the psuchai). Hence, we become oblivious to our present miseries, and cheerful about a happy future …
This excerpt is only mentioning mood changes. Nevertheless, if alcohol mainly affects the volume of blood, thereby compromising the psuchai – which seems to be the core implication of this passage – we can presume that the alterations of consciousness described in the examples of the young drinkers should also be attributed to similar occurrences.
Concerning phrenitis, finally, some Hippocratic texts consider it to be caused by bile. The discrepancy, though, emerges regarding where it causes the damage. The author of the nosological treatise On affections considers that ἡ δὲ νοῦσος γίνεται ὑπὸ χολῆς, ὅταν κινηθεῖσα πρὸς τὰ σπλάγχνα καὶ τὰς φρένας προσίζῃ (‘the disease occurs due to bile, when it sets in motion and settles in the organs and the diaphragm (ta splachna kai tas phrenas)’),Footnote 23 whereas for the author of On diseases I it needs to enter the blood:
φρενῖτις δ᾿ οὕτως ἔχει· τὸ αἷμα ἐν τῷ ἀνθρώπῳ πλεῖστον συμβάλλεται μέρος συνέσιος· … ὅταν οὖν χολὴ κινηθεῖσα ἐς τὰς φλέβας καὶ ἐς τὸ αἷμα ἐσέλθῃ … παρανοέει τε ὥνθρωπος καὶ οὐκ ἐν ἑωυτῷ ἐστιν.
Phrenitis is like this: the blood in man accumulates most of his sunesis … When bile sets in motion and enters the vessels and the blood … the man suffers delirium and is no longer himself.
Ultimately, the debate that all these Hippocratic authors are having concerns their idea of mind and its localisation (which – as Padel points out – is not alien to the philosophical questions that the tragic poets were debating at the same time).Footnote 24
As far as mechanisms and treatments are concerned, we have already caught small glimpses in the previous discussion: delirium in young virgins stemmed from an abnormal accumulation of blood that affected the heart and diaphragm due to obstructed drainage from the uterus. Not surprisingly, the author acknowledged that the release came when the discharge of blood stopped being obstructed.Footnote 25 The recommended treatment to achieve this, however, seems to be more related to sociological needs – he advised marriage and pregnancy – than to the biological mechanism that caused the disease.
In cases of drunkenness the author of On breaths mentioned the increase in the volume of blood, but neither blood-letting nor any other treatments are suggested.Footnote 26 Regarding phrenitis, as McDonald has pointed out, the therapeutic approach is fairly non-specific.Footnote 27 Authors tend to group the condition with other diseases,Footnote 28 particularly with peripneumonia and pleuritis,Footnote 29 and recommend general treatments for specific symptoms. Purgation, (upwards and downwards),Footnote 30 warming (especially in the painful site) and drinks except for wine are recommended.Footnote 31 Interestingly pain is the doctors’ main concern and the main target of their treatment. Unlike what we will see in the post-Hellenistic sources, there are almost no remedies specifically aimed at delirium. Only the author of On affections posits that λούειν δὲ πολλῷ καὶ θερμῷ κατὰ κεφαλῆς ἐν ταύτῃ τῇ νούσῳ συμφέρει· … αὐτὸς αὑτοῦ ἐγκρατέστερος γίνεται (‘it is convenient to bathe those suffering of this disease in abundant hot water from the head downwards … for individuals become more in control of themselves’).Footnote 32
As we have seen, the articulation between symptoms, affected parts, pathophysiological mechanism and treatment is rather loose at best, or non-existent in most cases. There are very few accounts that link symptoms to affected parts, and there seems to be a complete divorce between therapeutic methods and physio-pathological mechanisms.Footnote 33 Consequently, it is safe to suggest that these doctors’ notion of illness – compared to ours and to their successors – is rather loose. In other words, impaired consciousness in general and phrenitis in particular are framed as clusters of related symptoms not clearly bound to their triggering mechanism and need to be treated like other acute conditions, not too far from our own ideas about impaired consciousness, but quite different from our notion of disease.
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