Melancholia and Mania: the Historical Contributions of Aretaeus of Cappadocia and Emil Kraepelin

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2020-04-27 Melancholia and Mania: The Historical Contributions of Aretaeus of Cappadocia and Emil Kraepelin

Marlier, Krystal

Marlier, K. (2020). Melancholia and Mania: The Historical Contributions of Aretaeus of Cappadocia and Emil Kraepelin ( Unpublished master's thesis). University of Calgary, Calgary, AB. http://hdl.handle.net/1880/111923 master thesis

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Melancholia and Mania:

The Historical Contributions of Aretaeus of Cappadocia and Emil Kraepelin

Krystal Marlier

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF MASTER OF ARTS

GRADUATE PROGRAM IN GREEK AND ROMAN STUDIES

CALGARY, ALBERTA

APRIL, 2020

Abstract

Two millennia ago, Aretaeus of Cappadocia, a physician from the first to second century CE, first presented a modern portrayal of the relationship between μανίη (mania) and μελαγχολίη

(melancholia). His understanding is reflective of the nineteenth-century German clinician, Emil

Kraepelin. I propose that Kraepelin and Aretaeus possess more similarities than differences.

They were homologous in research techniques and nosology, with one significant difference in aetiology. Presently, Aretaeus’ classification remains recognized in psychiatry, though with a slight deviation in understanding and under different psychiatric labels. Likewise, Kraepelin’s classifications remain highly influential in current clinical practices. Aretaeus’ De Causis et

Signis Diuturnorum Morborum (On the Causes and Symptoms of Chronic Diseases) and

Kraepelin’s eighth edition of Psychiatrie: Ein Lehrbuch für Studierende und Ärzte (Psychiatry: A

Manual for Students and Physicians) will be examined. By critically analyzing these writers, I intend to illustrate a remarkable continuity in the history of manic-depressive insanity.

Acknowledgements

My deepest gratitude goes first to my supervisor Dr. Peter Toohey, for his trusting guidance through both my undergraduate and graduate education. For his invaluable knowledge, and for editing multiple drafts of this thesis, scholarship applications, and conference papers. He has kept me sane in many moments of anxiousness and uncertainty.

I wish to thank the faculty and staff of the Department of Classics and Religion (CLARE) for their support. Thank you to the members of my examining committee, Dr. Reyes Bertolín

Cebrián and Dr. Hank Stam for their constructive feedback. Special thanks to Dr. Lesley Bolton, for lending an ear and offering sound advice; and to Professor Dr. Eric Engstrom of Humboldt-

Universität for his aid through email correspondences and for meeting with me in Berlin,

Germany. Many thanks also to Dr. Bertolín Cebrián, for your aid with German translations; to

Mr. James Hume, for your graceful teachings of Ancient Greek; to Dr. Lindsay Driediger-

Murphy for your encouragement and the invaluable treasured experiences; to Dr. Stam for your insights and honesty; to Dr. Frank Stahnisch for your encyclopedic knowledge; to Dr. Caterina

Pizanias for showing me Greek culture and arts; and to Dr. Britta Leise of the Max-Planck

Institut für Psychiatrie for granting access to observe the original sources of Emil Kraepelin.

I would like to acknowledge the financial and institutional support for my MA research that I received from the Queen Elizabeth II Graduate Scholarship, the University of Calgary, and

CLARE.

Finally, I wish to thank my parents for their support in the pursuit of this passion. Mum, thank you for taking me to the library as a toddler and entertaining my wish to spend hours hidden in the stacks reading ancient civilization books. Extended thanks to Mimi and Greg for checking in, coming to visit, and for the numerous tasty treats you have fed me over the years.

iii

Dedication

For my grandfather T.V.H, in memoriam— It is that time of year where I can completely dissolve into melancholy without regrets.

Table of Contents

Abstract ...... ii

Acknowledgements ...... iii

Dedication ...... iv

Table of Contents ...... v

Abbreviations, Texts Used, and Footnotes ...... vii

List of Tables ...... viii

List of Figures ...... viii

Chapter 1: Introduction ...... 9

1.1 A Brief History of Melancholia ...... 12

1.2 A Brief History of Mania ...... 20

Chapter 2: Emil Kraepelin ...... 26

2.1 Biography ...... 26

2.1.1 Dorpat, Estonia (1886-1891) ...... 35

2.1.2 Heidelberg University (1891-1903)...... 38

2.1.3 Munich (1903-1917) ...... 42

2.2 Editions of Psychiatrie ...... 46

2.3 Manic-Depressive Insanity (MDI) ...... 52

2.3.1 Manic States ...... 55

2.3.2 Depressive States ...... 58

2.3.3 Mixed States ...... 62

2.4 Aetiology ...... 64

Chapter 3: Aretaeus of Cappadocia ...... 69

3.1 Biography ...... 69

3.2 Translations and Use in Current Medical Scholarship ...... 73

3.3 On Causes and Symptoms of Chronic Diseases ...... 75

3.3.1 Melancholia ...... 76

3.3.2 Transitionary Phase ...... 77

3.3.3 Mania ...... 78

3.4 Aetiology ...... 82

Chapter 4: Bringing it all Together ...... 85

4.1 Conclusion ...... 99

Bibliography ...... 102

Appendices ...... 110

Appendix A: Kraepelin’s Zählkarten ...... 110

Appendix B: Aretaeus’ Case Studies ...... 120

Abbreviations, Texts Used, and Footnotes

Abbreviations

Aret. Aretaeus of Cappadocia

SD De Causis et Signis Diuturnorum Morborum

(On Causes and Symptoms in Chronic Diseases)

DSM Diagnostic and Statistical Manual(s) of Mental Disorders

Aret., SD 1.5.1 (Adams, 299) Hude’s Greek of Aretaeus, SD book.chapter.section

(equivalency in Adam’s translation, page number)

Texts Used

Aretaeus (Ancient Greek) Hude, K., ed. Aretaeus. CMG II. Berlin: Akademie Verlag,

1958.

(Translated version) Adams, F., ed. The Extant Works of Aretaeus, the

Cappadocian. Boston: Milford House, 1972.

Emil Kraepelin Wooding-Deane, C., trans. Memoirs. Heidelberg: Springer-

Verlag, 1987.

Barclay, M., trans. Manic-Depressive Insanity and

Paranoia. Originally from Psychiatrie: ein Lehrbuch für

Studierende und Ärzte, achte ausgabe (Psychiatry: A

Manual for Students and Physicians, eighth edition).

Edinburgh: E.&S. Livingstone, 1921.

vii

List of Tables

Table 1. Kraepelin’s Evolution of Thought (Mania, Melancholia, MDI, and Other Schemes) ...... 48

Table 2. Kraepelin's Manic States ...... 56

Table 3. Kraepelin's Depressive States ...... 59

Table 4. Summarization of Aretaeus' Melancholia and Mania ...... 81

List of Figures

Figure 1. Kraepelin's Manic-Depressive Insanity, States and Subgroups ...... 52

viii

Chapter 1: Introduction

This thesis aims to examine the understanding of melancholia and mania as separate and combined mental illnesses in relation to the medical works of Aretaeus of Cappadocia in the first to second century CE, and Emil Kraepelin of the nineteenth century. I will contend that these two medical writers possess more similarities than one would think, with one significant difference.

These similarities, I hope to show, are within their research methodology and nosology. In other words, the observational methodology and classification of melancholia and mania from

Aretaeus, nearly two millennia before Kraepelin, has remained somewhat consistent. The main hindrance in drawing parallels between ancient diagnoses to modern equivalents, in this particular case, is the imposition of Kraepelinian concepts upon the Aretaean concepts.1 In an attempt to circumvent this problem, I will discuss Kraepelin’s work Psychiatrie: Ein Lehrbuch für Studierende und Ärzte, achte ausgabe (Psychiatry: a Manual for Students and Physicians, eighth edition) in Chapter 2, separately from Aretaeus’ work De Causis et Signis Diuturnorum

Morborum (On the Causes and Symptoms of Chronic Disease) in Chapter 3. I am organizing it in this way to individually establish each writer’s nosology (classification of diseases), symptomology, and etiology (causes of diseases) before relating them to one another in Chapter

4. This Introductory Chapter is concerned with exploring how the terms melancholia and mania have historically developed and changed from antiquity to the nineteenth century.

Before embarking on this task, however, it is worth noting some other difficulties this study encounters. Firstly, written texts of any genre available in the Ancient Greco-Roman world span from a few fragmentary passages or testimonial references to completed passages or full

1 Glenda Camille McDonald, "Concepts and Treatments of Phrenitis in Ancient Medicine" (Newcastle University, 2009), 5.

9 collections of works. The availability of surviving texts limits our understanding of ancient concepts, and this is especially true in dealing with ancient medical writings. Secondly, the term mental illness is problematic for historians of ancient medicine. It is a modern word that did not exist in antiquity, and it implies that there is a separation of diseases of the mind from diseases that affect only the physical body. In ancient medicine, this difference did not exist because diseases of the mind were regarded as physical diseases.2 Thus, the elements of the mind, its nature, and its physical location vary throughout history due to an author’s era and the prevailing attitudes of medical theories of their time. Thomas Szasz in The Myth of Mental Illness (1961) and The Manufacture of Madness (1970) believed that mental illness was a man-made myth.3 He argued that the ‘sick role’ of the mentally ill were destructive of human responsibility and that the sick role ‘was convenient for doctors, patients, and the public because it begged and concealed certain moral issues.’4 Likewise, Michel Foucault argued that mental illness must be understood as a cultural construction that is ‘sustained by a grid of administrative and medic- psychiatric practices.’5 I would like to entertain the possibility that melancholia and mania are not products of ‘modern’ medicine or society but have previously existed in antiquity. As I hope to demonstrate in the proceeding chapters, the concepts of Aretaeus and Kraepelin have a familial resemblance to one another. It is my belief that, at the base of it all, human emotions such as sorrow, madness, and anger have remained unchanged throughout history.6 Thirdly, there

2 It is important to mention here that the ‘mind-body’ discussion has been theorized by ancient philosophers such as Plato and Aristotle. I understand it is an important lens to consider as it would be pertinent to the dialogue of this thesis. However, as I have stated on the following page, I will not be discussing philosophical or metaphysical concepts, as it is beyond the confinements of this paper. 3 Roy Porter, Madness: A Brief History (Oxford ; New York: Oxford University Press, 2002), 1. 4 Simon Bennett, Mind and Madness in Ancient Greece: The Classical Roots of Modern Psychiatry (Ithaca and London Cornell University Press, 1978), 37. 5 Porter, Madness: A Brief History, 3. 6 Andrew Scull’s view of madness is that it is found in all known societies. He believes the claim that madness is a social construction or label, is romantic nonsense. Andrew Scull, "The Art of Medicine: Madness in Civilisation," The Lancet 385, no. 9973 (2015): 1066. Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from the Madhouse to Modern Medicine (Princeton and Oxford: Princeton Universtiy Press 2016).

10 is the issue of information that has been filtered through the author. The descriptions of diseases, patients, and case studies that are available to us are likely what the author decided was absolutely necessary to record and publish. Information not mentioned in the works may very well have been essential to keep but was not considered as such by the author. The process of filtering information is additionally influenced by the author’s medical education, research knowledge, and preconceived ideas of the disease. The reports provided by these authors may reflect a generalized pattern of the disease, individual causes that have been overlooked, or case studies with no context of a disease pattern. A final hindrance is the author’s vocabulary style and limitations in transliterated texts. Although a term employed by an author may have pre- existed throughout antiquity, the author’s personal use and understanding of that term may vary from authors that came before. I will be dealing with transliterated texts from German to English,

Ancient Greek to English, and Ancient Greek to Latin. When translations are used, there are high chances of nuances being lost in translation and limitations such as the English language not having the equivalent word as in Ancient Greek, Latin, or German. As such, the exploration of the history of the words melancholia and mania will be necessary to construct the foundation for the rest of the thesis. I will be using italicised terms of the Latinised Greek words melancholia

(μελαγχολία) and mania (μανία) and subsequently depression and mania as a reference to the term and not the disease. Special attention will be given to changing views of both melancholia and mania over time. I will have avoided the words psyche or soul as it invokes philosophical discussion and metaphysical concepts, often having to involve pneuma and the works of Plato and Aristotle. All of which are beyond the confinements of this paper. Instead, I will be using the terms mind or mental as I find it to be the most neutral and appropriate for the topic at hand.

1.1 A Brief History of Melancholia

With a long period of existence of 2,500 years, the history of the word, melancholia, is rather complex to trace. It was a term predominately used in ancient medical writings and rarely used in other genres of writing. Its origin remains complicated as it lies ‘in the shadows of Greek medical prehistory.’7 The term melancholia dominated medical writings from antiquity and beyond. It was not until the nineteenth century that Kraepelinian theory somewhat replaced melancholia from its nosology and popularized the term depression. Today, it is reasonable to presume that the connotations of melancholia and depression have reversed. Presently, melancholia is often used by the creative arts (literature, film, photography, fashion); it is ephemeral and embraces an aesthetic quality of being strangely romantic, dreamy, and charming.8 Conversely, depression denotes a medical disease and is predominantly used by clinicians, psychologists, and psychiatrists. The evolution of these two terms invoke some curious questions: how exactly did we get to this differentiation of connotations? When and why did the terms change, and why wasn’t melancholia completely removed from our vocabulary?

Exploration into the history of the word will aid in answering these questions.9

Grammatically, melancholia translated as ‘black bile’ is made of two constituents: melas or melaina (black) and cholê (bile). In its adjectival form, melancholia dominates ancient sources in reference to people, constitutions, and pathological states.10 However, in medical tradition, the

7 Jacques Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," ed. Philip van der Eijk, Greek Medicine from Hippocrates to Galen (Brill, 2012), https://www.jstor.org/stable/10.1163/j.ctt1w76vxr.17. 233. 8 The most current example of melancholia inflicting such emotions can be observed in the Chanel Fall/Winter 2018 collection. Karl Lagerfeld prefers ‘melancholy’ rather than ‘beautiful sadness’ to be the descriptor of his autumnal collection. Suzy Menkes, “When the Leaves Start to Fall,” Vogue, accessed March 12, 2019. https://www.vogue.co.uk/article/suzypfw-chanel-when-the-leaves-start-to-fall. 9 For the majority of this section, I will be making use of three books: Greek Medicine from Hippocrates to Galen by Jacques Jouanna, Melancholia, Love and Time by Peter Toohey, and A History of the Mind and Mental Health in Classical Greek Medical Thought by Chiara Thumiger. 10 Chiara Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought (Cambridge: Cambridge University Press, 2017), 49.

12 noun form refers only to the illness and nothing else.11 Toohey has identified three traditions for melancholy: (i) the depressed individual (non-scientific literature); (ii) the individual whose melancholia stemmed from anger and violence (non-scientific literature); and (iii) the individual who exhibited fear, delusion, and debilitating sorrow without a cause (medical tradition).12 He proposes that depressive melancholia within non-scientific literature was not as accepted until

Seneca, during the same time that we find discussions of it in medical texts.13 Toohey’s first tradition of melancholy, the depressed individual, can be observed in the mythological Greek hero and leader of the Argonauts, Jason. Apollonius of Rhodes’ Jason in Argonautica is deemed to be suffering from depressed melancholia.14 On occasion, Jason is depicted as weeping and falling into silence,15 an uncommon characteristic in the traditional Homeric hero sense. As such, this may be the first instance of depressive melancholia in non-scientific literature.16 The second tradition is observed in Toohey’s interpretation of the ‘Purification of Orestes at Delphi’ depicted on a fourth-century BCE Apulian red-figure bell-krater attributed to the Eumenides Painter.17 In the scene, Orestes’ head is limp and tilted forward, his eyes are heavy, and his mouth is turned downward in an unhappy expression. His body position reflects that of his head (forward slumping), the left hand positioned as though it is supporting his own body, and the irresolute nature of the right hand scratching his chin.18 Drawing our attention away from Orestes, the

11 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 232. 12 Peter Toohey, "Blurring the Boundaries of the Self," in Melancholy, Love, and Time (University of Michigan Press 2010), 25-6. 13 Ibid., 26. 14 Peter Toohey, "Some Ancient Histories of Literary Melancholia," Illinois Classical Studies 15, no. 1 (1990): 156. 15 Some passages: 1.535 αὐτὰρ Ἰήσων δακρυόεις γαίης ἀπὸ πατρίδος ὄμματ᾿ ἔνεικεν (but Jason, in tears, turned his eyes away from his fatherland); 4.1703-5 αὐτὰρ Ἰήσωνχεῖρας ἀνασχόμενος μεγάλῃ ὀπὶ Φοῖβον ἀύτει,ῥύσασθαι καλέων· κατὰ δ᾿ ἔρρεεν ἀσχαλόωντιδάκρυα· (and Jason raised his hands and in a loud voice cried out to Phoebus, calling on him to save them, and the tears poured down in his distress;). Rhodius Apollonius, Argonautica, trans. William H. Race, Loeb Classical Library (Cambridge, Mass.: Harvard University Press, 2009). 16 Toohey, "Some Ancient Histories of Literary Melancholia," 157. 17 Collection & Louvre Palace. “CP 710” https://www.louvre.fr/en/departements. Curatorial Departments. Online. Accessed March 12, 2019. 18 Toohey, "Blurring the Boundaries of the Self," 15.

13 twins Artemis and Apollo display similar facial expressions. However, their bodies and movement contrast the limpness of Orestes. As she holds her weapons, Artemis strides with purpose. Her right foot is lifted and ready to move, her robe flows in the opposite direction of her forward motion, and the wafting of the cloth possibly implies an energetic stride.19 The dichotomy of facial expression to posture and melancholy to disturbed, are clear signs of agitated melancholia. Toohey interprets this depiction by the Eumenides painter as two states within

Orestes: the internal state of anxiety or flight of thought, and the external state of motor retardation.20 Euripides’ Hercules Furens and Plutarch’s Lysander attribute anger with melancholia.21 Herculean melancholia in the context of pseudo-Aristotelian Problemata is considered to be manic-melancholic because it exhibits manic phases. Yet, it does not align with the concept of Hippocratic melancholia or later medical writers such as Aretaeus and Celsus.22,23

Modern scholars trace melancholia as first appearing in the Hippocratic Corpus with the emergence of the tetradic model of humours: blood, phlegm, yellow bile, black bile.24,25 We must distinguish, though, the complexity of this issue. Nature of Man is thought to be the foundation of a complex relationship that embraces three concepts: black bile, melancholic temperament,

19 Ibid., 17. 20 Ibid., 18. 21 Toohey, "Some Ancient Histories of Literary Melancholia," 148. 22 Ibid., 148-49. 23 Jouanna in “At the Roots of Melancholy: Is Greek Medicine Melancholic?” discusses at length the melancholia temperament in Aristotelian Problemata (pages 238-248). Although it uses the concept of black bile, it does so differently than Hippocratic medicine tradition and is beyond the medical domain. Jouanna reports that the Hippocratic treatise was not known to the author of Problemata. Etymologically speaking, Hippocratic tradition relates to melancholy whereas Aristotelian tradition relates to black bile. He goes on to discuss the theory of the four humours versus the theory of the four temperaments (pages 240-247). However, for my purposes, I have chosen to not include this in as I am merely providing an overview of the term melancholia and not its philosophical implications. 24 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 230. 25 In Nature of Man: ‘φημὶ δὴ εἶναι αἷμα καὶ φλέγμα καὶ χολὴν ξανθὴν καὶ μέλαιναν.’ Hippocrates, Nature of Man, trans. W.H.S. Jones, Loeb Classical Library 150 (Cambridge, MA: Harvard University Press, 1931), 4.24-5. doi: 10.4159/DLCL.hippocrates_cos-nature_man.1931. Accessed February 12, 2019.

14 and the medical tradition of melancholia.26 Cold and dry elements define black bile, it is heightened in autumn (this season is dry and begins to chill the body)27 and departs in spring, and corresponds to maturity in men aged twenty-five and forty-five.28 Interestingly, while the

Hippocratic writers of Nature of Man invented black bile, they did not create melancholic temperament.29 Melancholia is not mentioned in the Nature of Man;30 there is a melancholic constitution dominated by black bile, but it is not a reported affliction.31 Thumiger reports melancholia as appearing only three times in the Corpus.32 The oldest appearance of melancholia as an affliction is found in Airs, Waters, Places.33 Jouanna asserts that ‘this [Airs, Waters,

Places] is of crucial importance because it is the first text in Greek literature where the word melancholiê is attested.’34 It was not until the fifth to the fourth century BCE that melancholia was seen more as a temperament.35 This is observed in the famous passage in Aphorisms from the fourth century BCE, ‘if the fear or despondency lasts for a long time, this is a melancholikon

(melancholic state) (6.23).’36 Here, fear or despondency are characteristics of melancholia, the illness. This passage links the non-scientific tradition to the medical tradition; the illness characterised in Aphorisms is reflected in Toohey’s tradition of depressive melancholia.

Furthermore, there exists in Hippocratic writings (although not in abundance) descriptions of mind disturbances and reports of a patient’s state of mind being melancholika (melancholic).37

26 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 229. 27 Hippocrates, Nature of Man, 7.30-40. 28 Ibid., 15.35. 29 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 231. 30 In Nature of Man the word (and variations) supplied is μέλαινα χολὴ. Hippocrates, Nature of Man, 4.25, 5.25-26, 7.43, 7.68. 31 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 231. 32 Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought, 49. 33 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 232. 34 Ibid. 35 Toohey, "Blurring the Boundaries of the Self," 54. 36 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 235. 37 Ibid.

This is highly significant because it highlights the turning point in which melancholia was considered an empirically observable disease that was affected by the human body, mind, and surrounding environment. According to Jouanna, ‘melancholy as an illness did not reappear in the direct tradition until Aretaeus of Cappadocia, a doctor from the first century AD, and Galen, a doctor from the second century AD.’38 The complexity of melancholia becomes further dishevelled as we look into the transition from Greek to Latin medical writings.39 The Medieval

Period observed Latin medical texts under the Aristotelian tradition, which made use of the temperament theory. This theory was attached to late antiquity Greek medical tradition, which claimed to be closely tied with Hippocratic writing.40 Despite these claims of ties to the

Hippocratic tradition, later ancient medical texts seemed to remove themselves from the foundation that was built by Nature of Man, which was long gone in the past and forgotten.41

The history of melancholia is generally considered to be clearer to outline than that of mania. From the tenth to the eighteenth century, mental disorders were attached to Christian concepts of demons and witchcraft.42 At the beginning of the seventeenth century, melancholia and mania were nearly identical in usage within medical texts of Greek and Roman antiquity, as they both signified black bile. Many cognates for melancholia, such as melancholy and spelling

38 Ibid., 241-42. 39 The complexity of melancholia is astounding. Even between the Greek tradition and Latin tradition we find differences in the characteristics of melancholy. Again, Jouanna in “At the Roots of Melancholy: Is Greek Medicine Melancholic?” delves deeper into different portrayals of melancholiacs from three Greek texts presenting the theory of the four humours. The first group has the use of rare Greek adjective philasthenoi ‘sickly’ which is characterized by cowardice (page 251). The second group discusses melancholic temperament which includes two Latin texts: Vindician’s Letter (a Latin treatise on four humours and temperaments) and Pseudo-Soranus’ Isagoge Saluberrima. As well as Hippocrates’ On the Pulse and the Human Temperament and On the Formation of Man. These sources in the second group contribute to the diffusion of the theory of four humours and four temperaments in the Latin Ages (Klibansky). The third group is made up of pseudo-Galen On the Humours and treatise Nature of Man by Meletus the monk (pages 251-252). 40 Jouanna, "At the Roots of Melancholy: Is Greek Medicine Melancholic?," 257. 41 Ibid., 258. 42 Michael Alan Taylor and Max Fink, "Melancholia: A Conceptual History," in Melancholia: The Diagnosis, Pathophysiology and Treatment of Depressive Illness (Cambridge Cambridge University Press 2006), 3.

16 variations, were used as synonyms. During the Renaissance Era, both melancholia and melancholy were used in the context of describing an illness or daily emotion of despair.43 It was only in the nineteenth century that a distinction between the two was made. Melancholia was restricted sternly to illness, and melancholy was used in day-to-day speech to indicate sadness and sorrow.44 Around the same time, the term depression was introduced and started to find its place in the medical context and discussions involving melancholia. Depression originated from the field of cardiovascular medicine, and was then taken into the field of psychiatry.45 Having no previous connotations in psychiatry, the assumption was that depression alluded to the ‘decrease in “psychic nerve force” and eventually a “sinking in spirits.”’46 The likes of Wilhelm

Griesinger47 and Daniel Hack Tuke48 used depression as a synonym for melancholia.49,50 Emil

Kraepelin continued this trend and used both melancholia and depression in his corpus.

43 Stanley W. Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times (New Haven: Yale University Press, 1986), 5. 44 Ibid. 45 In cardiovascular medicine, depression denoted the decrease or depression in the heart’s functioning. Judith Misbach and Henderikus J. Stam, "Medicalizing Melancholia: Exploring Profiles of Psychiatric Professionalization," Journal of the History of the Behavioral Sciences 42, no. 1 (2006): 47. 46 Ibid. 47 Wilhelm Griesinger was a nineteenth century German neurologist and psychiatrist. He is most notably known for initiating changes to asylum systems and the treatment of mentally ill patients. Griesinger will be mentioned again in Chapter 2: Emil Kraepelin. 48 Daniel Hack Tuke was a nineteenth century British physician and writer on psychological medicine. Anne Digby, "Daniel Hack Tuke (1827–1895)," (2004), https://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-9780198614128-e-27804. 49 Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times, 6. 50 Matthew Bell, Melancholia: The Western Malady (Cambridge: Cambridge University Press, 2014). Bell discusses the use of depression in folk psychology by explaining two metaphors: (i) downward motion (de-) and (ii) pressure, weight and mass (press-). He then describes ‘down’ and ‘weight’ in antiquity by providing examples in: the Sack of Troy by Arctinus of Miletus which illustrates mad Ajax as having a ‘mind weighted down’; the Odyssey uses adjectives of katephes meaning ‘downcast’ kat- meaning down, -phes meaning light or eyes when in plural. Downcast eyes have longer history (refer to Toohey, footnote 15). Near Eastern epics of Gilgamesh illustrate that downcast eyes are connected to grief. Mourning the death of Enkidu, Gilgamesh roams the countryside in tattered clothes: ‘your face dejected, your heart so wretched, your appearance worn out, and grief in your innermost being’. In other words, downcast eyes or face is a natural metaphor. Medical author, Rufus of Ephesus used the adjective katephes to describe melancholic (Klibansky et al. Saturn) (page 50). Depression deriving by analogy from traditions of down and weight eventually entered medical usage (pages 49-51). Matthew Bell is a Dr. LLB of German and comparative literature. He studied ancient Greek and Latin and teaches courses in hypochondria and melancholia in eighteenth century Europe. He specializes in eighteenth century anthropology and comparative literature.

Kraepelin used depression to describe an affect, but he considered melancholia to be a form of mental depression.51 His creation of manic-depressive insanity further solidified depression’s place in future nosology. Additionally, Jackson believed there to be a trend away from melancholia towards depression as the term was made more prominently by Adolf Meyer:52

Desirous of eliminating the term melancholia, which implied a knowledge of

something that we did not possess, and which had been employed in different

specific ways by different writers. If instead of melancholia, we applied the term

depression to the whole class, it would designate in an unassuming way exactly

what was meant by the common use of the term melancholia; and nobody would

doubt that for medical purposes the term would have to be amplified so as to denote

the kind of depression. . .53

Why then, would Emil Kraepelin name the illness as manic-depressive as opposed to manic- melancholic? The answer, according to Healy, was because melancholia had become an outdated term, and depression was simply preferred.54 This very phenomenon can be observed within

Kraepelin’s of his textbook Psychiatrie. In particular, Kraepelin’s sixth edition underwent a massive reorganization of categories, specifically with melancholic conditions. In his eighth edition, the main category of melancholia disappeared altogether, and depression came to be used in all diagnostic schemas.55 Although pursuing the history of melancholia is arduous, there

51 Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times, 6. 52 Adolf Meyer was a nineteenth to mid-twentieth century Swiss-born American psychiatrist who became a psychiatric professor at the Johns Hopkins Hospital and president of the American Psychiatric Association. "Adolf Meyer," in Encyclopaedia Britannica, ed. Encyclopaedia Britannica (Encyclopædia Britannica, inc.). 53 Melancholia and Depression: From Hippocratic Times to Modern Times, 197-98. 54 David Healy, "From Mania to Bipolar Disorder," in Bipolar Disorder: Clinical and Neurobiological Foundations, ed. Mario Maj Lakshmi N. Yatham (Wiley Online Library, 2010), 3. 55 Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times, 345.

18 should be no doubt of its existence in antiquity. It has had a broad continuity throughout history, both in non-scientific writings and medical writings.

1.2 A Brief History of Mania

The history of the word, mania, as it seems to me, is more readily documented than that of melancholia. The main difference being that mania is strongly fused with religious tradition in sacred insanity. In Greek thought, sacred insanity appears amongst the earliest writings, occurring either ritualistically or poetically. All of these were inspired by the gods and supernatural entities that personified insanity and madness. The word μαίνομαι and its cognates indicated madness, fury, frenzy, and rage. The origin of mania is in mythology, and its first account is found in Homer’s Iliad, used to describe the rage and anger of warriors. Works such as the Iliad and Odyssey were exaggerated reflections or even artificial representations of the ancient Greco-Roman world and by no means were they medical texts. Due to its origins in mythology, psychiatrists such as Jules Angst and Andreas Marneros consider the history of mania to be less clear.56 I believe mythology, epics, and tragedies are essential to the survey of the history of medicine: part of the purpose of these art forms is to describe human emotional states.

In non-scientific literature, mania is personified and given as punishment from the divine due to human opposition and disruption in the order of things. The fate of humanity was always in the hands of the gods; diseases were often inflicted by the gods. This is apparent in the Iliad, in which gods fought alongside and imparted either successful or wrathful experiences to man.

Sibling deities Apollo and Artemis were said to inflict acute diseases via fatal arrows of pestilence. A camp is said to have perished with ‘evil’ pestilence sent by Apollo, first by striking mules and dogs with arrows but later the soldiers themselves.57 Only when the god was appeased

56 Jules Angst and Andreas Marneros, "Bipolarity from Ancient to Modern Times: Conception, Birth and Rebirth," Journal of Affective Disorders 67 (2001). 57 Homer, Iliad, trans. A. T. Murray, Loeb Classics Library 170 (Cambridge, MA: Harvard Universtiy Press 1924), 1.11-15.

20 by prayers and offerings did the plague cease to exist. Homer’s Iliad expressed the term μανία

(mania) repeatedly. His understanding of madness and rage was reflected in the context of the battlefield and the warrior’s personality. In the Iliad, the wrath of Achilles against Agamemnon shows quite brilliantly, not only Achilles’ anger but also his grief. Following the events after the death of Patroclus (Book 16), the last book begins, and Achilles remains distraught. His grief forces him to drag Hector’s body once again. Other examples in the Iliad are Homer’s mention of Dionysus (Book 11) described as mainomenos, which refers to the madness caused by Hera.58

The same passage tells us of Lycurgus, who was punished with blindness because he was opposed to Dionysus. This is significant to note because later in the fifth century BCE, particularly in Bibliotheca of pseudo-Apollodorus, Lycurgus’ punishment is madness. Thus, blindness comes to be equivalent to madness in Lycurgus’ case.59 Supernatural entities such as

Ἐρῑνύες (the Furies), Λύσσα (Lyssa, the spirit of mad rage), and Maniae (spirits of insanity, frenzy, and madness) were the reasons for a person’s outrage within many tragedians.

Aeschylus’ Oresteia features the Furies tormenting Orestes into madness. Aeschylus’ Seven

Against Thebes contains a vividly gruesome detail about the warrior Tydeus. A god struck him with such madness that he ate his opponent’s brain. The three plays by Euripides have madness as the central theme: Heracles, Orestes, and Bacchae. Euripides’s Heracles characterized the demi-god’s delirious anger and rage. Virgil’s Aeneid represented the same rage-filled frantic state. Euripides’s Bacchae, in its entirety, is a representation of women under divine and ritualistic frenzy performing strange acts without reason. Agave ripped off her son, Pentheus’ head, and proudly put it on display because, in her possessed state, she mistook her son’s head

58 Patricia A Johnston, Attilio Mastrocinque, and Sophia Papaioannou, Animals in Greek and Roman Religion and Myth (Cambridge Scholars Publishing, 2016), 365. 59 Bennett, Mind and Madness in Ancient Greece: The Classical Roots of Modern Psychiatry 68.

21 for a lion. What can be interpreted from this is ‘in madness, delusion is accompanied by a blurring of the boundaries between the self and the other.’60 Again, the overall tradition of divinity being the obvious cause of madness and imposing it as punishment amongst humans had lasted centuries. These supernatural causal explanations were so intrinsically ingrained in the history and lore that, even with the attempt of the Hippocratic writers to explain madness physiologically and biologically, divine madness maintained its place in societal beliefs. Bennett has proposed that these ancient playwrights presented clinically accurate and believable pictures of men gone mad. He goes on to say that ‘psychoanalytically informed critics have also argued that several of the plays are quite accurate from a psychodynamic viewpoint in the manner in which they present the onset, exacerbation, and relief of madness.’61

Just as observed with melancholia, within the fifth century BCE, supernatural beliefs and possession were challenged by Greek medical writings. It was not completely removed as there remained a strong tradition of prayers and dedication to the deity Asclepius, God of Medicine.

But Hippocratic medicine naturalised madness and ‘brought it down from the gods.’62 This was what ‘set the mould for mainstream reasoning about minds in the West.’63 Hippocratic texts understood sickness in naturalistic terms, ‘men ought to know that from the brain, and from the brain only, arise our pleasures, joys, laughter, and jests, as well as our sorrows, pains, griefs, and tears.’64 When emotions and actions became unbalanced, ‘these things that we suffer all come

60 Ibid., 115. 61 Ibid., 101. 62 Porter, Madness: A Brief History, 16. 63 Ibid., 14. 64 Εἰδέναι δὲ χρὴ τοὺς ἀνθρώπους, ὅτι ἐξ οὐδενὸς ἡμῖν αἱ ἡδοναὶ γίνονται καὶ1 εὐφροσύναι καὶ γέλωτες καὶ παιδιαὶ ἢ ἐντεῦθεν, καὶ λῦπαι καὶ ἀνίαι καὶ δυσφροσύναι καὶ κλαυθμοί (17.1-3). Hippocrates, The Sacred Disease, trans. W. H. S. Jones, Loeb Classical Library 148 (Harvard University Press 1923).

22 from the brain, when it is not healthy, but becomes abnormally hot, cold, moist or dry.’65 In these passages, medicine excluded the supernatural in definition. However, Thumiger proposes:

…μαίνομαι and its cognates indicate mental disturbance and suggestion of violent

derangement…but no statement firmer than this regarding the meaning on this

group is allowed by our fifth and fourth century medical sources. There is no sense

that mania could entail a nosological entity similar to what will be conceptualised

by later medical writers (Celsus, Aretaeus…)66

It is found in later medical writings of the first to second century CE that madness was free from divinity, and diseases of the head were otherwise understood. These concepts were then repeated and further advanced by medieval doctors. That being said, it is observed in 313 CE, that madness returned to the sacred tradition within the Roman Empire. This was due to the recognition of Christianity by Emperor Constantine. In Christian divinity, the Devil and the Holy

Ghost fought for possession of the soul.67 Unclean spirits or possessed individuals were treated through spiritual methods. In the New Testament, a few passages depicting mania can be found.

Luke 8:26-9 describes an individual who seems to be possessed by the devil but is cured by

Jesus:

For a long time, this man had not worn clothes or lived in a house but had lived in

the tombs… they found the man from whom the demons had gone out, sitting at

Jesus’ feet, dressed and in his right mind; and they were afraid. Those who had seen

it told the people how the demon-possessed man had been cured.

65 καὶ ταῦτα πάσχομεν ἀπὸ τοῦ ἐγκεφάλου πάντα, ὅταν οὗτος μὴ ὑγιαίνῃ, ἀλλὰ θερμότερος τῆς φύσιος γένηται ἢ ψυχρότερος ἢ ὑγρότερος ἢ ξηρότερος, ἤ τι ἄλλο πεπόνθῃ πάθος παρὰ τὴν φύσιν ὃ μὴ ἐώθει (17.18-20). Ibid. 66 Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought, 49. 67 Porter, Madness: A Brief History, 17.

Mark 9:14-26 describes Jesus healing a boy possessed by an impure Spirit. The same passage is found in Matthew 17:14 and Luke 9:37:

Whenever it seizes him, it throws him to the ground. He foams at the mouth,

gnashes his teeth and becomes rigid…When the spirit saw Jesus, it immediately

threw the boy into a convulsion. He fell to the ground and rolled around, foaming

at the mouth…[Jesus] said, “I command you, come out of him and never enter him

again.” The spirit shrieked, convulsed him violently and came out.68

This sacred tradition occurred at both the collective level (via heresy-accusations) and the personal level (the belief of experiencing madness because of personal sins). In the late fifteenth century, uncontrolled speeches and manic behaviour were related to the Devil. The mad were possessed, and ‘religious adversaries were deemed out of their mind.’69 In the seventeenth century, Thomas Willis70 excluded possession and the Devil all together, explaining it to be ‘a matter of defects of the nerves and brain.’71 From here, the trend that was once observed in antiquity (the rise of discussions on naturalism and consciousness in the fifth and fourth centuries

BCE) took place again in Europe within the writings of prominent physicians who explained religious melancholy and mania naturalistically.72 Porter believes, from this Enlightenment

Period, that ‘indeed all belief in the existence of supernatural intervention in human affairs, was

68 Tradition of madness as divine-given punishment continues. In Deuteronomy 28:28 ‘If you do not obey the Lord your God…all these curses will come on you and overtake you…The Lord will affect you with madness, blindness and confusion of mind.’ Even here, we can see the same connection of blindness to madness as I mentioned before in Bibliotheca of pseudo-Apollodorus in Lycurgus’ punishment. 69 Porter, Madness: A Brief History, 21. 70 Thomas Willis was an Anglican and royalist. He coined the tern ‘neurologie’. Ibid., 29. 71 Ibid. 72 Ibid., 30.

24 turned into a matter of psychopathology.’73 Essentially, it was a movement of the

‘pathologization of religious madness.’74

I hope that reviewing the history of the words melancholia and mania has provided an appropriate introduction. The two terms followed similar paths morphing in tandem with social and political changes of its time.

73 Ibid., 31. 74 Ibid., 32.

Chapter 2: Emil Kraepelin

2.1 Biography

The great nosologist and German psychiatrist of the nineteenth century, Emil Kraepelin

(1856–1926) continues to be highly praised. He is most celebrated for his delinerisation of various forms of mental illnesses, including manic-depressive insanity (a term in which

Kraepelin himself coined, in the sixth edition of his textbook Psychiatrie) and dementia praecox

(now known as schizophrenia).75 Kraepelinian nosology has had significant influence over the

Diagnostic and Statistical Manual(s) of Mental Disorders (DSM) and continues to be discussed and debated in current classification systems.

I have read Kraepelin’s Memoirs in translation, which was written in 1922 after he retired from academia. In doing so, I hoped to gain insight into Kraepelin’s childhood, education, and academic career. I believe this will be of assistance in understanding what influenced Kraepelin, from where these influences originated, and why his methodologies were the way that they were.

Though it goes without saying, Memoirs must be taken with a grain of salt, as it is, after all, an autobiography. I should like to mention here the ‘other face’ of Kraepelin briefly. According to

Shepherd, Kraepelin (1919) ‘in effect, assume[d] the role of psycho-hygienic Führer, applying his own brand of biologically-based medical expertise to the political and social problems of the day.’76 Kraepelin on future measures writes ‘attention must be focused above all on the fight against all those influences threatening to destroy future generations, in particular hereditary degeneration and genetic influences resulting from alcohol and syphilis.’77 On individuals with

75 Twentieth century Swiss psychiatrist Eugen Bleuler criticizing the use of Kraepelin’s term dementia praecox, was the first to coin the term ‘schizophrenia’ in 1911. Since then, the definition of schizophrenia has continued to change. Theocharis Chr Kyziridis, "Notes on the History of Schizophrenia," German Journal of Psychiatry 8, no. 3 (2005). 76 Michael Shepherd, Conceptual Issues in Psychological Medicine (Psychology Press, 1998), 233. 77 Ibid., 234.

26 distinctly hysterical traits- dreamers and poets, swindlers, and Jews, Kraepelin writes, ‘the active participation of the Jewish race in political upheavals has something to do with this

[morbidity].’78 In other unbiased views of Kraepelin, reports of his disposition varied. The war influenced the reception of Kraepelin’s work because ‘hostility of his concepts [were] fueled by hostility to all things German.’79 It was argued, that Kraepelin was ‘an unimaginative German nationalist, whose thinking contributed to alter Nazi eugenics.’80 Some resistance was offered by the French (they had an issue with dementia praecox) and by the Germans. According to Healy, though Kraepelin is celebrated now, he was considered an outsider in Germany.81 Karl

Wernicke82 was lead of early German psychiatry; apparently, Kraepelin ‘operated in [his] shadow.’83 It was only in 1904 when Wernicke ‘was hit by a falling tree [that] Kraepelin’s path lay open. His competitor was eclipsed not by any achievement of Kraepelin’s.’84 Though many opposed Kraepelin, some scholars did not, stating that Kraepelin’s personality, training, and dedication were well suited for classifying clinical observations. Alexander and Selesnick said,

‘[Kraepelin] learned early to respect authority, order, and organization… “Imperial German psychiatry” was said to have gained its prominence under the chancellorship of Kraepelin.’85

78 Ibid., 233. 79 David Healy, Mania: A Short History of Bipolar Disorder (Baltimore, Maryland: John Hopkins Universtiy Press, 2008), 75. 80 Ibid., 76. 81 Ibid., 137. 82 Karl Wernicke (1848-1905) was a German neurologist. He related nerve diseases to specific areas of the brain. Karl Kahlbaum had a large influence on him. 83 Healy, Mania: A Short History of Bipolar Disorder, 136. 84 Ibid., 138. 85 Alexander and Selesnick, The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present (1966), 162-163. I have taken this quote from Frederick K Goodwin and Kay Redfield Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, Second ed. (Oxford University Press, 2007), 25.

Memoirs is written in a tone, especially in Kraepelin’s nostalgia, that can be associated with German Romanticism.86 It is clear that Kraepelin greatly valued his family. His father, Karl

Kraepelin, was a singer and music teacher who founded a society made of artisans and tradesmen.87 The society gathered in Kraepelin’s childhood home to discuss and exchange opinions on literature, and they held musical and theatrical performances.88 His parents and siblings went on long family walks (this is something he did in adulthood with his wife, Ina

Schwabe, and their children),89 and if they did not go, his father would read to them.90 His mother was caring and created the most comforting and cozy atmosphere in their home.91 It is obvious, then, why Kraepelin expressed such passion for fine arts, nature, and travel. He attributed the influence of his older brother, also named Karl,92 to his love for scientific matters.

When he was a young boy, Karl introduced him to botany and encouraged further inquiry into zoology, chemistry, and evolution.93 His father’s friend, a doctor named Louis Krueger, made such a lasting impression on Kraepelin that he decided then to study medicine.94 He was a highly motivated individual throughout his career.95 He possessed a constant desire to improve

86 Shepherd, Conceptual Issues in Psychological Medicine, 230. 87 Emil Kraepelin, Memoirs, trans. C. Wooding-Deane (Heidelberg: Springer-Verlag, 1987), 1. 88 Ibid. 89 Kraepelin and his wife, Ina Schwabe, had 8 children: first daughter (1885) died at birth; second daughter (1887- 1962); third daughter (1890) died at 18 months; first son (1891) died at 12 months; fourth daughter (1892-1983); fifth daughter (1894-1959); sixth daughter (1896-1972); second son (1900) died in infancy. The second daughter, Antonie, became a doctor and was entrusted to the foundation of the clinical department in Munich. She also cowrote the eighth edition of Psychiatrie. 90 Kraepelin, Memoirs, 1. 91 Ibid. 92 Karl Kraepelin was a botanist and zoologist. He became director of Zoological Museum in Hamburg. He was known for his work on scorpions, centipedes and anthropoids. Ibid., 209. They had another brother named Otto. Kraepelin did not mention Otto as much as Karl, this is most likely because Otto’s interests differed from Kraepelin’s. Otto was a commercial representative—not science or medical related. Ibid., 2. It was also Karl who travelled and holidayed with Kraepelin throughout his life. 93 Ibid. 94 Ibid., 3. 95 He began university studies at age 18, after serving in the army for seven months. During Easter holidays, he would buy a human brain and learned all the parts by labelling them and prepared cross sections. Other Easter holidays were spent taking ‘holiday courses’ to fast-track his studies. Ibid., 3 and 5.

28 conditions of the structure of psychiatric clinics and for patients in his care. He was a strong advocate against alcoholism, which, not surprisingly, made him very unpopular. He co-founded the Verein abstinenter Ärzte (Society of abstinent Doctors)96 and later, he took on work for the

Verein gegen den Mißbrauch geistiger Getränke (Society Against the Misuse of Alcoholic

Drinkers) and held talks on the psychology of alcohol.97 According to Engstrom et al., he was ‘a convinced social-Darwinist, he became a fervent advocate of alcoholic abstinence and actively promoted a policy and research agenda in eugenics and racial hygiene.’98 In his later years,

Kraepelin’s interests were mainly in the public health domain, specifically ‘the impact of urban life on mental health.’99 He believed that institutions ‘(such as the welfare state and the education system)—because they tended to contravene the processes of natural selection—subverted the

German people’s biological “struggle for survival.”’100 Interestingly, it was made known by his daughter, Frau Dr. Schmidt-Kraepelin, that during the last year of his life ‘he was preoccupied with Buddhist teachings and was planning to visit Buddhist shrines in India at the time of his death.’101

The movement of philhellenism in Germany from the eighteenth to nineteenth century expanded into a multitude of areas from private to public space of the academic culture. The first

German philhellenes borrowed ancient Greek ideals. After 1810, the philhellenes incorporated this with Prussia’s academies. It was later in the nineteenth century that archeology and

96 Ibid., 70. 97 Ibid., 71. 98 Eric J. Engstrom, Matthias M. Weber, and Wolfgang Burgmair, "Emil Wilhelm Magnus Georg Kraepelin (1856– 1926)," Am J Psychiatry 163, no. 10 (2006). 99 Ibid. 100 Ibid. 101 Shepherd, Conceptual Issues in Psychological Medicine, 230.

29 anthropology began to add yet another perspective on ancient Greek history and culture.102

Philhellenism was increasingly conventionalized and became a part of the Gymnasien education tradition.103 Kraepelin had experienced this and felt as though his childhood education consisted of ‘philology cultivated with great one-sidedness.’ 104 Despite this, I believe it influenced and encouraged Kraepelin’s interest to travel frequently around the Mediterranean in his later years.105 I hypothesized that Kraepelin might have been educated in reading Latin and ancient

Greek, as this was standard fare in the Gymnasium and because of the names that he gave to mental diseases, such as dementia praecox. To my surprise, my hypothesis was supported by

Kraepelin in his Memoirs:

As we sailed on the blue sea between Kephalonia and Ithaka, I read the

Odyssee, although unfortunately it was only the rather clumsy

translation by Voss. In these surrounding I was vividly reminded of the

ancient Greek culture and I began to appreciate the sentimental beauty of

the faded myths and the colorful yarns entwining the return of the divine

sufferer from his wanderings. I thought how little life had been put into

these stories at school.106

Naturally, many questions arise from this: Could Kraepelin have come across Ancient Greek and

Roman medical sources? Might he have read and known the Hippocratic writings, or even perhaps Aretaeus of Cappadocia? I think it would be more probable to say Kraepelin may know

102 Suzanne L. Marchand, Down from Olympus: Archaeology and Philhellenism in Germany, 1750-1970 (Princeton University Press, 1996), xix-xx. 103 Ibid., xviii-xix. 104 Kraepelin, Memoirs, 1. 105 Ibid., 81-82, 90-94, and 140-41. 106 Ibid., 141-42.

30 of the Hippocratic writings, but less of Aretaeus.107 The classical curriculum, then as now, focused on the most famous of ancient texts: the philosophers, the poets, the tragedians, and the rhetoricians.

Labels such as the ‘pioneer or founder of modern scientific psychiatry, psychopharmacology, and psychiatric genetics’108 and ‘the great classifier’ are commonly placed on Kraepelin. The reputation of having ‘the entire civilized world indebted to Kraepelin for his psychiatric nosology,’109 and other legacies built by contemporary scholars, have had considerable influence on how Kraepelin is perceived. Because of this, Kraepelin appears to be a figure that exuded confidence, greatness, and self-assurance. As such, it was surprising to find a display of humility by Kraepelin in his memoirs. For instance, earlier in his career, Kraepelin found his experience with mentally ill patients in Wurzburg (mentioned later) to be extremely difficult. He admitted that his work on the psychiatric ward was deeply upsetting and recalled

‘the intensity of unusual, disturbing impressions and the first feeling of personal responsibility

[of which] pursued me into my sleep and caused irritating dreams.’110 He wanted to leave the clinic after only fourteen days of arriving there, but stayed and eventually became accustomed to the difficult work. Likewise, he pointed out his youthful naïveté, stating that his ‘somewhat naïve

107 I have not come across Kraepelin’s mentioning of these ancient medial writers, let alone the mention of Aretaeus specifically. I inquired Professor Dr. Eric J. Engstrom, a scholar who has written and specialised on Emil Kraepelin. Dr. Engstrom has not come across Aretaeus’ name whilst studying Kraepelin’s works. Email Correspondence. February 2017. 108 Most articles or textbooks concerned with the history of bipolar disorder and Emil Kraepelin will describe Kraepelin as such in some form. To name a few: Angst and Marneros, "Bipolarity from Ancient to Modern Times: Conception, Birth and Rebirth"., "Emil Kraepelin (1856-1926) Psychiatric Nosographer," JAMA 203, no. 11 (1968)., Paul Hoff, "The Kraepelinian Tradition," Dialogues in Clinical Neuroscience 17, no. 1 (2015)., Eric J. Engstrom, "Emil Kraepelin’s Inaugural Lecture in Dorpat: Contexts and Legacies," Trames. Journal of the Humanities and Social Sciences 20(70/65), no. 4 (2016). 109 Quote is translated from German and found in: Eric J. Engstrom and Kenneth S. Kendler, "Emil Kraepelin: Icon and Reality," Am J Psychiatry 172, no. 12 (2015), https://www.ncbi.nlm.nih.gov/pubmed/26357868. Original quote from German psychiatrist: E Kahn, "Emil Kraepelin: Ein Gedenkblatt Zum 100. Geburtstag," Monatsschrift für Psychiatrie und Neurologie 131 (1956): 192. 110 Kraepelin, Memoirs, 7.

31 aim [was] to become a professor of psychiatry at the age of thirty.’111 Kraepelin on numerous occasions in his memoirs is revealed to have consulted with important people in his life (such as his brother, wife and Wilhelm Wundt)112 for major career-related decisions. After asking his brother Karl for advice, Kraepelin half-reluctantly and half-happily accepted the job of becoming the medical assistant in Wurzburg. Additionally, he had admitted to compiling an immature paper by using Wundt’s Mechanic of the Nerves and Nerve Centres, which he did not fully understand. This paper won him a competition prize, but Kraepelin claims it was because ‘no one else competed for the prize and it was awarded to me.’113 Kraepelin did not hide his admiration for Wundt, who later became a key supporting figure in his life.114,115 Wundt would later encourage him to write his first edition of Psychiatrie. Kraepelin’s description of Wundt was as follows: ‘He possessed a modest dignity…his fine sense of humour was captivating…his completely balanced state of mind was admirable…he faced life with great composure.’116

Kraepelin recalled the lecture hall being ‘spellbound by the strength of [Wundt’s] intellectual

111 Ibid., 9. 112 Wilhelm Wundt was a nineteenth century psychologist, philosopher, professor and physician. He became lecturer for physiology in Heidelberg (1857) and then a professor (1864). He founded the first Institute for Experimental Psychology in Leipzig (1879) where Kraepelin and many others worked. Wundt’s works and teachings have influenced a number of important figures, spreading further to American psychologists. As such, he is regarded as the “father of experimental psychology.” Ibid., 229. 113 I find this quite interesting of Kraepelin to mention. Not many people would admit to winning a competition simply because they were the only one who entered. Ibid., 8. 114 A most comical side remark: Earlier in Kraepelin’s career, he met Karl Kahlbaum (German psychiatrist; influenced Kraepelin but Kahlbaum’s catatonia is not the same as the one described by Kraepelin) at a conference and was offered a job to work for Kahlbaum. When Kraepelin told Wilhelm Wundt, he asked ‘why [Kraepelin] wanted to join personal slavery.’ After Wundt’s comment, and because Kraepelin held Wundt in the highest regard, no further thought was given to this offer. 115 Even in old age, it meant a great deal to Kraepelin to see Wundt again. In 1918, Kraepelin drove to visit him in Heidelberg. Kraepelin then “saw him twice for a longer period and was delighted by the mental alertness of the 86- year-old scholar. He still went on regular walks in the mountains but complained of the increasing difficulty to work caused by the state of his eyes.” Kraepelin, Memoirs, 186. 116 Ibid., 22.

32 personality,’117 thus Wundt’s lectures quickly became popular as the auditorium was always teeming with students.

Three key periods in Kraepelin’s life highlight the journey of his methodology: Dorpat,

Estonia (1886-1891); Heidelberg (1891-1903); and Munich (1903-1917). Some important employment positions he held before Dorpat that are worth mentioning, include work in

Wurzburg (1877-1878) as a medical assistant for psychiatrist Dr. Franz von Rinecker.118

Kraepelin was responsible for a department with approximately fifty to sixty patients. His schedule was as follows: before Rinecker left for the day, Kraepelin read to him the case histories of the patients, and at six o’clock in the evening, they did rounds on the psychiatric ward together.119 Although Kraepelin had formal training as a medical doctor, at this clinic, he was only responsible for the psychiatric cases. It was rare for him to tend to patients when they had a physical illness.120 His second job was as a medical assistant under director Bernhard von

Gudden121 at the district mental asylum in Munich (1878-1882).122 Gudden was obstinately concerned with the treatment of his patients; he often made rounds at irregular times and made discoveries of maltreatment. Despite his activism for patient care, Gudden oddly, permitted his staff only one free afternoon and no holidays.123 Kraepelin noted that to some, this would be considered as a ‘cruel regulation’ because the nature of their work in dealing with disturbed and

117 Ibid., 23. 118 Franz von Rinecker became professor of pharmacology in 1838 at a university in Wurzburg. In 1863, he took over the Psychiatric Clinic and in 1872 he took over the Clinic for Syphilis and Skin Diseases. Ibid., 5-8, and 219. 119 Ibid., 6. 120 Although from time to time he did and was capable of tending to physical ailments. From one patient, he had removed hardened earwax clots to cure deafness; for others, he bandaged and sewed wounds caused by violent acts. Ibid., 11. 121 Bernhard von Gudden was a psychiatrist and professor for psychiatry in Munich and director of the Upper Bavarian District Mental Asylum. He carried out neuropathological studies. Ibid., 204. 122 Ibid., 9-10. 123 It is unclear to me if Kraepelin meant one afternoon per week, per month or (unrealistically) per year.

33 unpleasant patients was mentally taxing.124 Under Gudden’s direction, Kraepelin observed the

‘no restraint’ principle: use of mechanical restraints (such as straight-jackets or leather straps) was not allowed, and chains were never used. Any restraints used on patients must be permitted by Gudden.125 During Kraepelin’s time at the asylum, a straight jacket was used once on a patient that unrelentingly tried to kill himself. Apart from this, the only method used was isolation, but Kraepelin noticed that long-term isolation produced unfavorable effects on the patients.126 I mention this because I believe Gudden’s ‘no restraint’ principle had considerable influence over Kraepelin when he ran his own clinics later in life. In the Dorpat, Heidelberg, and

Munich clinics, Kraepelin did not use methods of restraint unless absolutely necessary (usually only in cases where a patient threatened self-destruction).127 During instruction of his students at the Heidelberg clinic, Kraepelin created a little museum (of sorts) to give students an idea of the advances that had been made in coercive measures. The revolution of bed rest, frequency of baths, and newer narcoleptics and tranquilizers far outweighed the objects that were on for display such as straight-jackets, chairs, foot cuffs, muffs, gloves, chains and illustrations of old asylums.128 Lastly, in 1882, Kraepelin moved to Leipzig to work in Wundt’s laboratory. Under

Wundt’s mentorship, Kraepelin carried out measurements of mental reactions to poisons

(chloroform), alcohol, paraldehyde. He continued these measurement studies later in his career, with morphium, tea, and caffeine.129 It was here in Leipzig, where Kraepelin first learned experimental psychology.130

124 Kraepelin, Memoirs, 13. 125 Ibid. 126 Ibid. 127 Ibid., 67. 128 Ibid., 67-68. 129 Ibid., 20. 130 Juri Allik and Erik Tammiksaar, "Who Was Emil Kraepelin and Why Do We Remember Him 160 Years Later," Trames. Journal of the Humanities and Social Sciences 20 (70/65), no. 4 (2016): 320.

2.1.1 Dorpat, Estonia (1886-1891)

An important position became available to Kraepelin in 1886 when his past teacher Hermann

Emminghaus131 wrote to him after becoming the director of a private mental asylum in Dorpat,

(Russian) Estonia. Already I have mentioned Kraepelin’s modus operandi when having to make important decisions. Upon receiving this letter of offer, Kraepelin went to the Dresden moor with his wife, and together they ‘laid down under a tree and discussed the problem in detail. After a few hours, we had made up our minds and sent a telegram to Dorpat.’132 Upon arrival at the

Dorpat clinic, Kraepelin noticed many issues with the physical structure itself. It was made entirely out of wood, which caused great fears in Kraepelin as it could break out in a fire at any given time. The private clinic had acquired debt, but once that was dealt with, Kraepelin began improvements in the clinic.133 He attained and hung fire extinguishers everywhere; he installed a fire-alarm system himself (the electrician completed the job inadequately); he placed a huge barrel containing ‘many cubics of [salt] water’ in the courtyard; made lattices on the windows that were openable from its exterior; coated the wide corridors with linoleum; equipped the clinic with more laundry supplies, an updated kitchen range, and an icebox; and he extended the range of disinfection equipment.134 Despite these measures, and because of severe monetary restrictions and limited resources, Kraepelin was still unsatisfied. He wanted to reconstruct the patients’ wards and account for supervised wards, but this was not possible. The clinic was, however, fortunate with the availability of good baths that were often used for agitated patients,

131 Hermann Emminghaus was a German psychiatrist. In 1873 he was a lecturer of psychiatry in Wurzburg and in 1880 he was a professor of psychiatry and director of the newly founded Psychiatric Clinic in Dorpat. Kraepelin, Memoirs, 199. 132 Ibid., 34-37. 133 A thematic occurrence in Kraepelin’s career path. The constant restructuring and reorganization of not only his clinical work but also his physical workspace as well (for the betterment of bedside care, as well as his own clinical research agenda). 134 Kraepelin, Memoirs, 38-39.

35 as this was a better alternative than using isolation rooms.135 Kraepelin continued the use of baths throughout his career and reported this method at a meeting with other psychiatrists, but it had already become common practice in other institutions.136

The clinic’s structure was not the only difficulty Kraepelin faced whist at Dorpat.

Linguistically, understanding and communicating with patients proved to be challenging because the common language was Estonian, whilst some others spoke Russian or Latvian. This was a setback in Kraepelin’s research as he was not able to communicate with his patients without constant translation and was forced to limit the vocabulary used by patients. There was some effort made on Kraepelin’s part in understanding common requests and questions, but it was not enough to fully comprehend his patients. He noted the difficulty of perceiving any nuances in the speech of his patients because of ‘variations in the pronunciation, expression, formation of words, and sentences.’137 I find that this important information is not stressed enough when researching Kraepelin’s aetiology and nosology. Many concepts and basic understandings of the patient’s description of ailments can be lost in translation, wherein the original meanings and connotations could be misplaced and omitted. Perhaps the limitation placed on the patient’s vocabulary when required to describe their emotions and experience was equally as limiting to

Kraepelin’s work on classifying mental diseases. I believe that this lack of understanding between patient and doctor, as well as the influence of Wundt’s research methodology, is what made patient observation a primary technique in Kraepelin’s future research. At Dorpat,

Kraepelin held his inaugural lecture, which significantly outlined his thoughts on current and

135 Ibid., 40. 136 Ibid., 67. There were academics who contradicted his use of prolonged baths, but Kraepelin was supported by Alzheimer and others who had seen the baths and used this technique themselves. 137 Ibid., 40.

36 future clinical care and his thoughts on the direction of psychiatric research.138 Being well versed in experimental psychology139 and natural sciences, Kraepelin was extremely critical of ‘brain mythology.’140 He refuted the neuropathological approach which stated that the mechanics of the brains were sufficient for understanding and explaining mental illnesses. Kraepelin thought this approach was more interested in the disease than the patient and cures for mental illnesses were left unsolved. Kraepelin advocated for ‘psychophysic parallelism’ since he understood ‘mental and physical events as separate, but closely linked and act[ed] as “parallel” phenomena.’141 Thus,

Kraepelin found Griesinger’s efforts to push the conjoining of psychiatry and neurology to be disputable since they were in separate and different areas of medicine. Kraepelin was adamant in this argument even years later: in 1904 he claimed that Griesenger’s efforts led to the ‘alienation between university hospitals and mental asylums.’142,143

In summary, reading about Kraepelin’s time in Dorpat certainly suggests some parallels to be made with Aretaeus, the other focus of my study. Kraepelin placed a great deal of importance on observational skills, and he practiced this in not only his patients but the surrounding patient environment. It seems to me that the same could be said about Aretaeus (this will be evident in Chapter 3). Both medical authors seemed to be observers in the initial diagnosis process rather than interpreters. It was in Dorpat when Kraepelin first considered ‘the

138 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1191. 139 Some scholars claim that Kraepelin established the first experimental psychology in Dorpat and by extension, the entirety of Russia. Allik and Tammiksaar, "Who Was Emil Kraepelin and Why Do We Remember Him 160 Years Later," 325. 140 This is also discussed in my thesis section 2.2 Editions of Psychiatrie. 141 Hoff, "The Kraepelinian Tradition". 33. 142 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1192. 143 I should like to mention here that much divergence is observed over the course of the nineteenth century between the somaticists and the alienists (psychicists). Somaticists (such as Griesinger) were likely to be proponents of the unitary psychosis model. Somaticists turn to the body and physiology because they believed that the soul could not “fall ill.” Misbach and Stam, "Medicalizing Melancholia: Exploring Profiles of Psychiatric Professionalization," 46- 47.

37 importance of the course of the illness with regard to the classification of mental disorder.’144 I believe this to be true in Aretaeus’ methodology as well, as he often provided descriptions on the progression and worsening of diseases.

2.1.2 Heidelberg University (1891-1903)

Whilst still working in Dorpat, Kraepelin took some time to travel around Europe and attended the Internationaler Medizinischer Kongreß (International Medical Congress) in Berlin. A job opportunity in Heidelberg was offered to him at this congress. Having been appointed to this position, Kraepelin left Dorpat in 1891. Unlike the Dorpat clinic, the one in Heidelberg was well equipped, the number of admissions was greater, and there were no linguistic barriers.145 It was in Heidelberg that he first aimed to classify clinical pictures as ‘insanity’ and attempted to categorize them into groups. 146 By doing so, Kraepelin was able to differentiate between

Kahlbaum’s catatonia, dementia praecox, and dementia paranoides with hallucinations. Despite this, several groups of insanity remained. Kraepelin organized these remaining groups by their origin and content of delusions (the result was reported in Psychiatrie fourth edition).147 A colleague148 suggested that Kraepelin should ‘collect cases with the same final state as far as the mental disease was concerned, and then investigate what development had led to this particular final state.’149 For this reason, Kraepelin decided to examine patients who were transferred from his university clinic to the large mental asylums in an attempt to observe possible changes of the mental illnesses. At the time, the state was organized into three districts, each having a hospital

144 Kraepelin, Memoirs, 43. 145 Ibid., 58. 146 Ibid., 59. 147 Ibid. 148 Refers to Friedrich W. Hagen (1814-1888). He was a German psychiatrist who promoted physiological psychology as the foundation for the practice of psychiatry. Ibid., 204. 149 Ibid., 60.

(the University clinic at Heidelberg where Kraepelin worked was one of them). From these clinics, patients could be transferred to two asylums: Emmendingen (specialized in caring for patients who were able to carry out daily tasks), and Pforzheim (specialized in patients who suffered from chronic illnesses).150,151 The transfers of patients to these asylums were recorded on Kraepelin’s Zählkarten (see Appendix A). The Heidelberg clinic suffered from overcrowding, beds were constantly occupied, and patients were sleeping on mattresses on the floor.152

Regulations on state-run mental hospitals meant that admission of people was allowed only if they were declared by a district doctor to be mentally ill or dangerous to the public.153 This delayed the admission of Kraepelin’s patients which is of importance for two reasons: firstly, patients, if admitted, were further along in their mental illnesses and declining into chronic conditions which meant longitudinal observations of earlier symptoms could not be made; secondly, Kraepelin believed removing these bureaucratic regulations to make admissions easier would negate the issue of overcrowding. Kraepelin was faced with a less diverse group of patients for the purposes of his research and clinical training. These admittance conditions resulted in one-sided material to observe and learn from. The frequency of admission and transferring of patients made it nearly impossible to follow-through with his patients. As such,

Kraepelin continued his observations from the clinic to the asylums, in an attempt to observe the disease’s entire journey. This was met with resistance as Kraepelin felt his visits to the asylums were becoming increasingly unwelcome.154 He thought, by examining patients over time and

150 Richard P. Bentall, Madness Explained: Psychosis and Human Nature (London, England: Penguin Books Ltd 2003), 10. 151 These asylums were also overflowing with patients. They had regulations which allowed them to only take in patients from specific clinics. 152 Kraepelin, Memoirs, 102. 153 Ibid., 103. 154 He was met with misfortune that affected his research. Kraepelin applied to the ministry for permission to examine the mental asylum patients annually and was rejected because, as Kraepelin claims, one of the directors at the asylum considered Kraepelin’s behavior to be unfriendly. Ibid., 60.

39 studying the mental illnesses’ progression, it would be possible to distinguish between different types of insanity. That is to say, Kraepelin believed in conducting longitudinal studies.

In his attempt to distinguish diseases with similar syndromes through longitudinal studies, Kraepelin devised the Zählkarten or diagnostic cards (refer to Appendix A for scanned photos). The Zählkarten were designed to complement patient records and aid in understanding the categorization of mental illness groups.155 It was a useful clinical research system because the cards were a condensed resume of essential information for each patient and case. Although they had become an integral component in Kraepelin’s methodology, routine patient record-keeping was still required. Having been able to archive observational material into a usable system,

Kraepelin was able to apply a pattern recognition process to sort through usable information that was free from personal coloring or interpretations of patient experiences.156 Since he had collected one thousand patient cases, he presented these findings at a conference in 1896.

Kraepelin stressed that there was more work to be done because one thousand cases were far too little to arrive at nosological clarity. He stated that continued work was essential to ‘“uncover unknown [disease] patterns and, if necessary, to construct [new] groups and extend or restrict old ones as the increased knowledge of clinical experience” demanded.’157 In Munich, where he moved next, Kraepelin continued to expand on his classification system.

155 Email Correspondence. Eric J. Engstrom sent a transcript of a talk he had given titled Kraepelin’s Clinical Research Method at Virginia Institute for Psychiatric and Behavioral Genetics at the Virginia Commonwealth University. I have been given permission to reference this transcript in my thesis by Engstrom himself. Eric J. Engstrom, "Kraepelin’s Clinical Research Methods," in Research Seminar at Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University (2017), 2. 156 K. S. Kendler and A. Jablensky, "Kraepelin's Concept of Psychiatric Illness," Review, Psychological Medicine 41, no. 6 (2011), https://www.ncbi.nlm.nih.gov/pubmed/20809997. 157 Kraepelin, “Ziele und Wege der psychiatrischen Forschung,” 181-182, found in Engstrom, "Kraepelin’s Clinical Research Methods," 11.

An integral part of establishing categories in his classification of diseases was the diagnosis and prognosis of patients. He encouraged himself and co-workers that both should be made within the first four weeks of admission.158 Engstrom claims the pressure to speed up diagnoses was due to the clinic’s problem with overcrowding.159 For this purpose, Kraepelin created the ‘diagnosis box,’ which had two objectives expressed in little mottos: eventus docet

(experience teaches/ the outcome shows) and ex errore lux (light from error). (More proof of

Kraepelin’s education in Latin). A discussion on the ‘diagnosis box’ is provided by Kraepelin:

… after the first thorough examination of a new patient, each of us had to

throw in a note with his diagnosis written on it. Any questions were then

discussed, and each person had to justify his diagnosis. After a while, the

notes were taken out of the box, the diagnoses were listed and when the case

was closed, the final interpretation of the disease was added to the original

diagnosis. In this way, we were able to see what kind of mistakes had

been made and were able to follow-up the reasons for the wrong original

diagnosis.160

158 Especially important, in my case, as the prognoses was fundamental in Kraepelin’s differentiation between dementia praecox (incurable) and manic-depressive illness (curable). 159 Published in the newspaper, “in one case (Wilhelmine K.), Kraepelin discharged a patient to the custodial asylum for chronic patients in Pforzheim, only to see her then recover.” Engstrom, "Kraepelin’s Clinical Research Methods," 15. 160 Kraepelin, Memoirs, 61.

2.1.3 Munich (1903-1917)

Kraepelin was entranced by Heidelberg’s beauty and the property he had acquired, as well as the quietness of university life. However, the worsening of the conditions of his clinic (intolerable overcrowding, the impossibility of providing patients adequate care, and financial blockage from the Ministry) had made his position unbearable. This is why, when he was offered a position in

Munich in 1903, he could not refuse and moved with a heavy heart.161 Over the years of working in Munich, Kraepelin created and documented pictures of ‘epileptic, hysterical and paralytic fits, manic and catatonic states of agitation, mannerism, stereotypy, movements of mentally deficient patients, all kinds of movement disorders, which were a valuable supplement to the live observation material.’162 His continual drive to pave the way for clinical studies resulted in the further organization of the Zählkarten.163 Each index card was duplicated for every patient, and all features of the clinical picture were noted on these cards. One copy was called the

Stammkarte (main card), which was organized chronologically according to the date of admission. The Stammkarte was created for integrity purposes in case duplicates were made, or cards were lost.164 The second copy, called Arbeitskarte (working card), was organized by diagnoses for scientific purposes. Cards in the same groups of disorders were alphabetized.

Different colors were given depending on the patient’s sex: pink for women and white for

161 Ibid., 109-10. 162 Ibid., 127. He also created a large collection of biophysical evidence. Changes of important disease at a microscopic level in images of the ‘cerebral cortex, malformation of the skull, stigma of degeneracy, infantilism, mongolism, cretinism, catatonic positions and many others.’ 163 I should note that Weber and Engstrom conducted a re-analysis of the Zählkarten and found that: ‘about one half of the cards (46%) contain no categories, the other half comprises a heterogeneous mixture of senile dementia and arteriosclerosis ( 11 %), feeble-mindedness (4%), hysteria ( 1%), paralysis (4%), paranoia (3%) and epilepsy (2%); dementia praecox is mentioned in only 4% of the cards, catatonia in 3%, hebephrenia in 1 % and manic-depressive forms in 5% of all cases. At least 11% are marked as ’unclear’. Matthias M. Weber and Eric J. Engstrom, "Kraepelin Diagnostic Cards the Confluence of Clinical Research and Pre Conceived Categories," History of Psychiatry (1997): 382. 164 Engstrom, "Kraepelin’s Clinical Research Methods," 4.

42 men.165 Similar cases were grouped into larger or smaller groups, and the clinical characteristics of these groups were defined more precisely. Hence why Kraepelin found it necessary to collect

‘the hereditary, proven external causes, distribution of age, sex, and profession.’166,167 Further information on genetic development, physical and mental symptoms, the course and the outcome were recorded. Although the reorganization of these cards generated defined groups, there remained several unclear cases. These ambiguous cases were either incomplete or questionable and were thus put into a group called ‘different aspects.’

Just as in Heidelberg, Kraepelin attempted to follow-up on the progression and outcome of cases. Once again, however, he was far too busy due to the number of patients admitted to the clinic. To adjust for this restraint, he attempted to limit catamnestic168 inquiries to single important groups. Although Kraepelin knew this was restricting, he could not foresee a different method. However, his staff lost enthusiasm because much time and intensive labour was wasted.169 According to Engstrom, many cards containing uncertain cases remain. Within this group of uncertain cases, Kraepelin began to explore ‘different aspects of the ‘clinical specificity of individual disease processes (die klinische Eigentümlichkeiten der einzelnen

Krankheitsvorgänge).’170 He compiled smaller subgroups that, together, would begin to expose the ‘general outlines of a disorder (Krankheitsbild)’ and ‘the laws (gesetzmäßige

Abhängigkeiten)’ governing its clinical manifestation.171 By proceeding with this process,

165 Own observations. Visit to Max-Planck Institut für Psychiatrie. June 2019. 166 Kraepelin, Memoirs, 156. 167 Kraepelin collects information on religion as well. The purpose of doing so was never explained in his Memoirs. I suspect it aids in understanding the origin of hallucinations perceived and reported by patients. A majority of the descriptions were related to sins, angels and the Devil. 168 Catamnesis is defined as the follow-up history of a patient after they are discharged from medical care. Merriam- Webster, "Catamnesis." 169 Kraepelin, Memoirs, 124. 170 Engstrom, "Kraepelin’s Clinical Research Methods," 4. 171 Ibid.

Kraepelin was able to gain criteria to judge whether a grouping was ‘justified or should be altered.’172 By group comparison, new aspects were found, which was important in his overall interpretation of mental illnesses. Kraepelin recognized that his research tool was highly deficient; in his review, he found that it ‘was naturally impossible to consult thoughts of case histories, but instead [he] used the short summary in [his] index cards.’173 The reworking and reorganization of these cards were in preparation for their usage and easy accessibility in clinical work. This process took place concurrently with the founding of Deutsche Forschungsanstalt für

Psychiatrie (currently, the Max-Planck Institute).174 The cards had to be checked, completed, and grouped. An attempt to ‘close the case histories by registering the information’175 was done through follow-up examinations for individual cases. Kraepelin is said to have developed two more card types. One called Forschungskarte (research cards), which collected individual cases together under one concept, essentially these were extracts from the Arbeitskarte (working cards).176 The second card type was called Hilfskarte (helper cards), which simply listed the patient’s name and one special feature reading the case. The purpose of the helper cards was for scientific observations and the quick organization of a sub-group of working cards that shared common clinical characteristics, such as early-onset or rapid course.177

Although the Zählkarten were important, it was one component or the foundation of a more extensive organizational clinical system. It is worthwhile to remember that the Zählkarten complimented the standard clinical reporting procedures. The purpose of the Zählkarten was for

172 Kraepelin, Memoirs, 157. 173 Ibid., 158. 174 Same time as the ongoing war. However, modest expansions were made to the clinic. Kraepelin notes that in the middle of a world war, German was able to find ‘a scientific institute dedicated to the welfare of mankind and that a similar institute does not exist anywhere in the world’. Ibid., 189. 175 Ibid., 188. 176 Engstrom, "Kraepelin’s Clinical Research Methods," 4. 177 Ibid., 5.

44 clinical research: to easily cope with the overbearing nature of infinite patient information and illness progression, and to make it relatively easier to gain control on Kraepelin’s observational data. They undoubtedly participated in the process of sorting and the conceptualization of

Kraepelin’s nosology. Engstrom observes that Kraepelin’s Zählkarten were his idea alone; however, the term Zählkarte had been in use since the 1870s by the government as individual census cards and census cards for the mentally ill.178 Kraepelin likely filled these government- issued Zählkarten himself working as an assistant in clinics.179

From this discussion on the card systems, it would not be implausible to say that

Kraepelin seemed more concerned with observation and classification than perhaps, the causation of mental illness— another quality that is, as we will see, reminiscent of Aretaeus.

178 Ibid., 6. 179 Ibid.

2.2 Editions of Psychiatrie

I would like to slightly digress into a short but necessary discussion on the editions of

Kraepelin’s Psychiatrie. His compendium was frequently reworked with each edition reflecting on his findings, comprehension, and organization of mental illnesses. They displayed his recategorizing with additions and subtractions of various subtypes. The first edition reflected his keen interest in inheritance, incurability, and neurological conditions.180 However, it becomes clear through the editions that Kraepelin’s psychopathological method placed emphasis on changing the criteria for diagnoses.181 Kraepelin found the contemporary state of psychiatry to be insufficient. Due to Wundt’s vital role in Kraepelin’s life, I believe his influence on Kraepelin's methodology was continuous. Wundt had a reputation for relying on experimental techniques relating to cognitive faculties, rather than the preferred method of brain dissection by others in neighboring fields.182 Kraepelin had applied the same Wundtian concepts to his own understandings of mental illness. Kraepelin was adamant that pathological anatomy of mind and brain lacked reliable evidence to explain mental illness.183 As aforementioned, Kraepelin was critical of ‘brain mythology,’ a term he used to describe neuropathological and neuroanatomical approaches to psychiatry. He admitted that although these approaches were fruitful in making scientific discoveries, they would fail to fully comprehend the understanding of mental disorders.184 In his inaugural lecture at Dorpat, he stated ‘we must always be cognizant of the fact that this relationship [the parallelism between corporeal and mental] cannot be reduced to

180 Katharina Trede et al., "Manic-Depressive Illness: Evolution in Kraepelin's Textbook, 1883–1926," Harvard Review of Psychiatry 13, no. 3 (2005), https://www.ncbi.nlm.nih.gov/pubmed/16020028. 181 Richard Noll, "Kraepelin's 'Lost Biological Psychiatry'? Autointoxication, Organotherapy and Surgery for Dementia Praecox," History of Psychiatry 18, no. 3 (2007), https://www.ncbi.nlm.nih.gov/pubmed/18175634. 182 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1190. 183 Eric J. Engstrom, "Tempering Madness: Emil Kraepelin’s Research on Affective Disorders," Osiris 31, no. 1 (2016). 184 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1192.

46 the assumption that it is governed by a simple causal relationship, as Griesinger incorrectly did in his famous dictum ‘mental illness is brain disease.’185 Kraepelin’s opinion was that simply understanding mechanisms of the brain could not possibly incorporate all mental processes. This opinion had remained unchanged throughout the editions of Psychiatrie.186 On mental causes, from the sixth to the eighth edition, Kraepelin’s opinion of pathoanatomical factors ‘softened.’187

In the sixth edition, Kraepelin wrote that the individuality and sensitivity of the patient played a key role in the causation of insanity. Later in the eighth edition, Kraepelin proposed that perhaps mind and body [psyche and soma] may be correlated: ‘it may not be possible to provide an explanation of one strand [somatic or mental] based upon the respective other. But it does seem possible to draw conclusions about specific somatic changes based on observable mental disorders and vice versa.’188 In other words, the mental and physical may not have concretely linked, but acted in parallel.189 Kraepelin was convinced that this type of research was focused on the brain rather than the whole patient. As a result, applicability in therapeutic methods were also lacking. This is a notion that is very reflective of the ancient Greek medical tradition, especially with Hippocrates through to Aretaeus. Kraepelin was not in the least brain-focused; his general perspective relied heavily on internal medicine.190

Table 1 showcases Kraepelin’s evolution of thought throughout the editions of

Psychiatrie. The creation of this table will allow for a better comprehension of how different environments or methodologies may have shaped the outcome of the revisions.

185 Quote from Kraepelin’s inaugural lecture at Dorpat in 1887. Translated quote found in: Kendler and Jablensky, "Kraepelin's Concept of Psychiatric Illness". 1120. 186 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1192. 187 Ibid. 188 Ibid. 189 Hoff, "The Kraepelinian Tradition". 33. 190 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1193.

Table 1. Kraepelin’s Evolution of Thought (Mania, Melancholia, MDI, and Other Schemes) 191

1st Edition 2nd Edition 3rd Edition 4th Edition 5th Edition 6th Edition 7th Edition 8th Edition (1883) (1887) (1889) (1893) (1896) (1899) (1903) (1909-1913) Total 7 12 12 13 9 13 15 17 Number of schemes Melancholia Under Scheme of its own Under Under Involutional Moved Depressive Involutional insanities under MDI: disorders192 disorders mixed states Madness Under Under Madness Dropped from all subsequent editions Primary madness Verrücktheit Mania Under Scheme of its own Under Under Manic-Depressive Insanity [MDI] Excited Consti- - Mixed states introduced (includes states tutional involutional melancholia) Aufregung- disorders: szustände Periodic Periodic and Under Under Periodic & circular Under Under Under MDI: courses Circular Periodic insanity: Manic, Periodic Constitu- - periodic, circular, cyclothymic psychoses melancholic, delusional disorders tional disorders Dementia — — — Under Under Scheme of its own Under Praecox Psychic Metabolic Endogenous degenera- Disorders: psychoses tions Dementing - Expanded Dementia Scheme of its own Under Scheme of its own Paralytic Metabolic Disorders

191 Because only the eighth edition is available in English translation, I have adapted this table from: Trede et al., "Manic-Depressive Illness: Evolution in Kraepelin's Textbook, 1883–1926". 164-66. 192 Italicised words in Table 1 denote diagnostic schemes. i.e. Depressive disorder is a scheme, Neurosis is a scheme, Mania becomes a scheme in editions 2-4

1st Edition 2nd Edition 3rd Edition 4th Edition 5th Edition 6th Edition 7th Edition 8th Edition (1883) (1887) (1889) (1893) (1896) (1899) (1903) (1909-1913) Develop- Scheme of its own Renamed Developmental Renamed: Renamed: mental — retardation Mental Oligo- Disorders retardation phrenias (retardation) Neurosis Neurosis (epileptic insanity, hysterical, posttraumatic) Renamed: Neurosis (hysteria, — Psychogenic dropped, epilepsy) neuroses Hysteria its own scheme Intoxication Chronic (alcohol, morphine, cocaine) Differentiated into Acute and Chronic and expanded in — each edition. Chronic (alcoholism, delirium tremens, Karsakoff syndrome, hallucinosis, neuropathy, delusional jealousy, morphine, cocaine) in 8th edition.

The diagnostic scheme of manic-depressive insanity (MDI) was first introduced and coined by

Kraepelin in the sixth edition. Through the seventh and eighth edition, it had gone through some changes: other schemes eventually fell under MDI, and there was the inclusion of mixed states.

As can be interpreted from Table 1, periodic psychoses for conditions which included mania, melancholia, and circular insanity were more or less the same in editions one through five. Yet in another revision in 1899, Kraepelin bundled periodic psychoses along with all states of depression into the manic-depressive psychoses.193 Thus, the conception of MDI involved an entire spectrum of mood illnesses inclusive of mania and depression. For Kraepelin, all cases of affective disorders were to be considered predisposed to MDI.194 The size and complexity of

Psychiatrie increased with Kraepelin’s growth in the clinical and academic setting. The reorganization observed in Table 1 is reflective of the complexity of mental illnesses themselves, as well as Kraepelin’s struggle to find and create order.195 This comes at a time when German psychiatry for much of the nineteenth century was dominated by the Einheitpsychose (unitary psychosis model)196 proposed by Griesinger. For Griesinger, if melancholia worsened, it would eventually develop into mania. Whilst many favored this theory, many other German psychiatrists, such as Kahlbaum and Kraepelin disputed it. Instead, they proposed that the inclusivity of details from the clinical methods (such as family history, course of illness and outcomes), and symptoms that remained with the patient throughout their course denote several different schemes and subtypes;197 not just one unitary psychosis. Instead, Kraepelin devised a

193 Confirmed by: Jennifer Radden, The Nature of Melancholy: From Aristotle to Kristeva (Oxford University Press, USA, 2002), 24. 194 Edward Shorter, A Historical Dictionary of Psychiatry (Oxford University Press, USA, 2005), 166. 195 Trede et al., "Manic-Depressive Illness: Evolution in Kraepelin's Textbook, 1883–1926". 161. 196 Ibid., 157. 197 Ibid., 158.

50 dichotomy of dementia praecox and manic-depressive insanity.198 Though the details of his diagnostic system continued to change, Kraepelin’s nosology, unsurprisingly, remained steady.199 His comprehension and categorization of diagnostic schemes were discovered through his research (aetiology, symptomology, following the course of the illness, and carrying out longitudinal studies), as opposed to being constructed by research.200

I believe my overview of Kraepelin’s three key period in Dorpat, Heidelberg and

Munich, has provided sufficient information on Kraepelin’s influences. Specifically, in his development and emphasis on the importance of observational methods and the implementation of longitudinal clinical studies (we shall a reflection of this in Aretaeus’ methodology). In the next section, I will move away from Kraepelin’s biography, and instead focus on his notion of

MDI. I will be focusing on his nosology and its observational aspects. A result of this focus will, hopefully, allow for the more precise comparison to Aretaeus in the chapters to follow.

198 Also known as the Kraepelinian dichotomy, one of Kraepelin’s greatest achievements in psychiatry. "Preface," in Manic-Depressive Insanity and Paranoia, ed. George M. Robertson, Translated 8th Ed. Of Emil Kraepelin (Edinburgh: Livingstone 1921). 199 Hoff, "The Kraepelinian Tradition". 35. 200 Ibid. Hoff suggests that scientific discussion post-Kraepelin are reflective of many present-day debates. They inquire questions such as: What are the pros and cons of a bio-psycho-social model? Are there natural kinds of mental illness?

2.3 Manic-Depressive Insanity (MDI)

MDI as I interpreted it from Kraepelin’s eighth edition of Psychiatrie,201 is all- encompassing of three main groups: depressive states, manic states, and mixed states. Each main group has individual subgroups (for a summarization, refer to Tables 2 and 3).

Hypomania

Acute Mania Manic States Delusional Mania "Delusions and Hallucinations"

Delirious Mania

Melancholia Simplex

Stupor

Melancholia Gravis Depressive States

Paranoid Melancholia (MDI) (MDI)

Depressive Insanity Insanity Depressive Fantastic Melancholia -

Delirious Melancholia "Depressive Insanity" Manic Excited Depression

Depressive/ Anxious Mania

Mania with poverty of thought Mixed States Depression with flight of ideas

Maniacal Stupor

Stuporous Mania

Figure 1. Kraepelin's Manic-Depressive Insanity, States and Subgroups

201 I will be using Mary Barclay’s Manic-Depressive Insanity and Paranoia, an English translation adapted from Emil Kraepelin’s Psychiatrie: ein Lehrbuch für Studirende und Aerzte, achte ausgabe (Psychiatry: A Manual for Students and Physicians, eighth edition).

Maniacal forms, depressive forms, and all other states in between were brought under MDI, they

‘not only pass over the one into the other without recognisable boundaries, but they may even replace each other in on and the same case.’202 As for the concepts from French alienists203 in

1854 who proposed la folie circulaire (circular insanity) and la folie à double forme (double insanity or alternating insanity),204 Kraepelin found it impossible to separate simple, periodic and circular cases from one another. Because transitions existed between these cases, he did not think that they were separate entities. Throughout his career, he observed not only circular attacks or periodic and relapsing attacks, but also simple forms of melancholia and mania.205 In the patient cases that he had worked with, MDI never led to dementia. In fact, all morbid manifestations disappeared, and the disease ran its course in isolated attacks.206 He first distinguished manic states with the following morbid subtypes (or symptoms):207 flight of ideas, exalted mood, and pressure of activity. Then melancholic or depressive states with morbid symptoms: sad or anxious moodiness and sluggishness of thought and action. Finally, mixed states (mania and melancholia combined together) with morbid subtypes of the maniacal and melancholic variety, but these states could not be classified as orthodox mania or melancholia.208 Mixed forms were classified as ‘restless depression and mania with lack of thoughts’ due to the transitional periods between manic and melancholic attacks. Having observed these mixed forms, Kraepelin gained insight into the ‘inner homogeneity’ of a large group that had many different forms.209 This

202 Emil Kraepelin, Manic-Depressive Insanity and Paranoia, trans. Mary R. Barclay, Originally from Psychiatrie: Ein Lehrbuch Für Studierende Und Ärzte Achte Ausgabe (Psychiatry: A Manual for Students and Physicians, Eighth Edition) (Edinburgh: E.&S. Livingstone 1921), 2. 203 Specifically, French psychiatrists Falret (circular insanity) and Jules Baillarger (alternating insanity) in the same year (1854). 204 Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 5 and 7. 205 Kraepelin, Manic-Depressive Insanity and Paranoia, 190. 206 Ibid., 3. 207 These are either referred to ‘subtypes’ by contemporary scholars or ‘symptoms.’ 208 Kraepelin, Manic-Depressive Insanity and Paranoia, 4. 209 Memoirs, 65.

53 taught him that the customary grouping into either manic or melancholic attacks did not fit all of what he observed and an enlargement of the groupings was required to fit the different combinations of these morbid states.210,211 Kraepelin suggested that any one combination of these subtypes was possible in patients suffering from MDI, which primarily was varying degrees of states ranging between excitatory to inhibitory.

Asides from the morbid subtypes, general subtypes existed in both the psychic and bodily variety. Kraepelin outlined the details of these subtypes as a means of learning and assessing

MDI and all its morbid states. Psychic symptoms included: perception (the ability to perceive and understand conversations or the surrounding environment and the distractibility of attention); consciousness and orientation (clear or clouded); memory and retention (ability to recall information); hallucinations (auditory and visual, either heightened or lowered sensibility to their body); mental efficiency (flight of ideas or inhibition of thought. The capacity to access and develop own thoughts or ideas); delusions (ideas of sin, persecution, greatness); insight

(understanding the present state of mind and diagnosis); mood; and movement of expression

(excitement, inhibition, pressure of speech and writing). Bodily symptoms included: sleep; appetite; body weight; general state (physiology such as appearances of the skin, hair, or eyes); blood and circulation; respiration; temperature; and nervous diseases (reflex reactions and weather sensitivities). As with the conversation on multiple editions of Psychiatrie, the complexity of MDI asserts rigorous reclassification and continual examination. Simply put, if

Kraepelin were able to continue his research, the organisation of these subtypes might very well have changed again. He would have looked further into newer research techniques or referred to

210 Manic-Depressive Insanity and Paranoia, 192. 211 Limitations of MDI classification as recognized by Kraepelin himself: ‘mania’ and ‘melancholia’ are included in MDI but some other forms as in ‘toxic insanity’ and other small morbid groups have been moved to dementia praecox.

54 measurements and methodologies that he was not able to complete in the past due to a shortage of students and time. Does MDI’s classification perhaps reflect Kraepelin’s own weakness—the obsession of the overly observant and the desire to classify mental diseases by providing multitudes of mental states which have unknown biological origin and uncertain aetiology? Or does it reflect a problem of the contemporary classification of mental diseases and the oversimplification of the vast continuum of human psychology?

2.3.1 Manic States

Manic attacks hugely varied; rarely did it suddenly appear, it usually projected from a period of mourning or anxious mood and sometimes in depression that had lasted for months or years.212

The patient reached the height of their manic state within a few days, and the duration greatly fluctuated. On occasion, the manic attacks lasted a few days or a few weeks, and on rare occasions did they extend over many months.213 If the patient experienced normal behavior such as recognizing their surroundings and being more attentive, they were still very prone to flight of ideas. Manic states came and went; between the excitement, patients experienced periods of mournful moodiness.214 Unfavorable circumstances such as visiting family or consuming alcohol tended to set off mania. In later attacks, there were likely more violent raging or outbursts. Manic states from least severe to most severe ranked as such: hypomania, acute mania, delusional mania, and delirious mania. Only in delirious subgroups of mania do patients quickly approach normalcy; it was a rare occurrence in simple mania but most rare in hypomania. To make these concepts more conveniently readable, Table 2 was created to exhibit all manic states mentioned in the eighth edition of Kraepelin’s textbook.

212 Kraepelin, Manic-Depressive Insanity and Paranoia, 72. 213 Ibid., 73. 214 Ibid.

Table 2. Kraepelin's Manic States

Hypomania215 Acute Mania216 Delusional Mania217 Delirious Mania218 (least severe) (most severe) Perception Not accurate, but able to Extreme distractibility Imperfect: no Everything appears make remarks, puns, understanding of the changed comparisons surroundings Consciousness Glorious self- Within the first days of mania: Slightly dulled Extreme cloudiness, and consciousness, makes bold sensible and approximately dreamy, confused, Orientation proclamations oriented stupefied, bewildered. Lose orientation Memory and Memory of recent events Retention are not exact, but colorful and elaborated Mental Lacks an inner unity in the Extraordinary flight of ideas efficiency course of ideas; a slight flight of ideas. Rationalisation, although nonsensical, is highly active. Can always find an excuse for their actions Insight and Patient does not believe Hallucinations are Hallucinations their state or diagnosis. extraordinary, Feels healthier, more confusing, and highly capable than they are religious (spirits throw snakes)

215 MDI and Paranoia, 55-61. 216 62-68 217 69-70 218 70-71

Hypomania219 Acute Mania220 Delusional Mania221 Delirious Mania222 (least severe) (most severe) Delusions No delusions, but an Expressed in a humorous way Paranoid attacks Delusions are dreamy, exaggerated opinion of the related to religion. illogical and related to self Patients descend religion. Patients feel from royalty, have the devil in their chests died previously, are magical and invisible Mood Cheerful; lively and has a Unrestrained; merry; occasionally Cheerful; self- Mood varies and humorous trait. Has great pompous. Easily irritable. conscious; changes frequently: irritability (dissatisfied, Laments, weeps, is highly self- unrealistic; highly unrestrained merriment; intolerant, pretentious) and conscious and unmannered pretentious and erotic; ecstatic; is occasionally violent abusive unsympathetic; timid; indifferent Movement of Increased busyness (most Free, easy, imitate other patients, No severe Expression: striking feature). The lacks obedience, unapproachable, excitability, Pressure of patient feels the need to do resistant, cannot sit for long, jumps restlessness. Speech (PoS) more things, but the ability out of bed, takes off clothes, dives Interferes with and Pressure to do real work suffers. and splashes water while bathing, everything of Writing PoS: excited, lively, loud bites, spits. Makes faces, rolls (PoW) tones, speaks in the third eyes, theatrical. PoS: some are person, jokes, violent heard repeating the same phrases expression, quotations, for hours, laugh to themselves, uses foreign languages frequent rhyming. PoW: covers PoW: large, pretentious many sheets of paper, large, words flourishes, exclamations, crossing one another in all underlines, full of flight of directions. Composes poems, ideas letters, and petitions to highly important people

219 Kraepelin, Manic-Depressive Insanity and Paranoia, 55-61. 220 Ibid., 62-68. 221 Ibid., 69-70. 222 Ibid., 70-71.

I very much realise conceptualising and representing Kraepelin’s clinical states in this way can be highly delimiting and makes it appear arbitrary. However, I think it is necessary to do so to effectively observe the differences between the states. This will allow us to comprehend why the states are labelled, divided, and exist as such.

2.3.2 Depressive States

Depressive states were generally prolonged, especially in advanced ages. The development was onset by nervous disorders, slight irritability, and depressive moodiness for years before marked depressive states began.223 As with the manic states, these depressive states varied depending on age and progression. The duration of the disease was more prolonged than in manic patients and was able to fluctuate between a few days to more than ten years. Kraepelin noted that when depression rapidly subsided, this was indicative of an oncoming manic attack. When observed, the physical state of the patient reflected the looming manic attack. Although the depressive state subsided, the patient reported feeling unwell and possibly unhealthier than before. The ability to report feeling unhealthier than in their previous state was a sign of the patient’s awareness of their former disorder and a sign of the patient’s return to normalcy. Yet, if they had an increased feeling of wellness, this indicated the start of a manic state. Depressive states also ranged from least to most severe: melancholia simplex, stupor, melancholia gravis, paranoid melancholia, fantastic melancholia, and delirious melancholia. Table 3 enumerates the differences in each depressive state.

223 Ibid., 97.

Table 3. Kraepelin's Depressive States

Melancholia Stupor225 Melancholia Paranoid Fantastic Delirious Simplex224 Gravis226 Melancholia227 Melancholia228 Melancholia229 Perception Confused, the No Everything Correctly Bad, highly Highly influenced by head is heavy, perception. looks black. perceive influenced by hallucinations and inattentive, Does not conversations delusions230 delusions inwardly, the understand and activities, external world questions but is strange misinterpreted Consciousness Orientation None, but on Consciousness is Frequently Profound clouding of and restrained occasion, the mostly clear. clouded, cannot consciousness Orientation patient can Sense and form clear ideas return to orientation are and poor consciousness preserved orientation Memory and No memory. Memory is Retention is Retention Cannot recall clouded poor, cannot knowledge that hold a thought. the patient had Confused by in the past medicines Hallucinations None Mainly Heightened ideas Many Numerous and religious, self- of sin and hallucinations frightening accusation. persecution. appear hallucinations. Ideas of sin and Occur more Appearances of people persecution is frequently are changed and faces apparent231 distorted

224 Ibid., 75-79. 225 Ibid., 79-80. 226 Ibid., 80-85. 227 Ibid., 85-89. 228 Ibid., 89-95. 229 Ibid., 95-98. 230 Example given of delusions: man approaching is perceived as murderer coming 231 Hear abusive language, voices, sees figures, spirits

Melancholia Stupor Melancholia Paranoid Fantastic Delirious Simplex Gravis Melancholia Melancholia Melancholia Mental Thinking is Inhibition Absentminded, Cannot collect efficiency difficult, may be slight, forgetful, slow. thoughts cannot collect but simple Sometimes thoughts thoughts and report painfully because they activity are precise details. are paralysed too Train of thought complicated is generally reasonable Delusions All kinds of Fears of all Related to sin, Feel they are Greater Always changing and fear develop232 kinds: they they are being watched. development. confusing delusions have a crack disgraced and Appear dull and Delusions of develop in their brain, belittled. indifferent, but moral sins. they are being Everywhere is on occasional Hypochondrial sold dangerous233 good-humoured delusions234 and cheerful Insight Do not have They think they Able to give Know absolutely any idea of are no in a information nothing, give their position. proper institution about personal contradictory and with proper conditions but unconnected answers physicians. Due are susceptible to their to delusions, they annihilation235 think they are in a prison

232 Some fears mentioned by Kraepelin: agoraphobia, mysophobia, die of blood poisoning, committing all crimes mentioned in the newspaper 233 Patients feel as though their body is inconstant danger 234 Hypochondrial delusions included: insides are dead, rotten, burnt, progression of non-existent diseases such as syphilis 235 Annihilation included: patient no longer has a name, home, and was never born

Melancholia Stupor Melancholia Paranoid Fantastic Delirious Simplex Gravis Melancholia Melancholia Melancholia Mood Acts like an Insecure Strong tendency Dull automatic of suicide, despondency, machine, morbid feeling, sometimes inward gloomy, anxious. dejection, despondent, Sometimes gloomy, despairing. irritated, angry hopeless, Complain of and violent. indefinite inward anxiety, excitedness but restlessness, outward solitary, behavior. indescribably unhappy. Movement of Inward state Patients lie Inhibited, Anxious Strongly inhibited. Expression: labelled as mute in bed, influenced by restlessness Patients lie in bed, Pressure of ‘depersonalisat display their delusions more frequent, emotionally mute, Speech (PoS) ion’. Lacks catalepsy, and moods. Feel and alternates stare with vacant and Pressure of energy and lack will- tired, need rest, with stupor expressions. Writing (PoW) will-power, power, neglect states. Patients Automatic obedience indecisive. resistance to themselves, do do not remain in alternates with Their work external not eat, go to bed, wander anxious resistance. appears to be a stimuli. bed, lie their about and PoS: slow, detached, mountain PoS: rigidly, anxious lament non-sensical. utterances are restlessness.236 extremely PoS: flimsy monosyllabic, monotone, low, stutter. PoW: indistinct, rambling

236 Patients will run in scanty clothing and remain in the forest.

Table 3 illustrates the worsening of all psychic and bodily symptoms (left column: perception, hallucinations, movement of expression, etc.). It allows for comparisons between the least severe depressive state ‘melancholia simplex’ through to the most severe state ‘delirious melancholia.’

Overall, in the most severe state of depression, all psychic and bodily functions are hindered.

Patients are emotionally mute and strongly inhibited of all consciousness, yet they suffer considerably from hallucinations.

2.3.3 Mixed States

We know that Kraepelin’s observation of several patient cases allowed him to notice different forms within MDI, aside from the purely orthodox manic states or depressive states. There were multiple transitional phases between types of manic excitement and depression.237 Manic patients appeared sad when the height of their excitatory phase temporarily subsided, but they could be quiet and inhibited as well. Depressive patients outside of their inhibition sang, smiled, or ran about. Due to these oddities, there were many cases in which the state of the patient did not fit mania or depression, but a mixture of the two. A transitional phase that appeared and extended over a week to several months was clearly indicative of mixed states. Kraepelin stated, ‘if one examines transition periods, one is astonished at the multiplicity of the states which appear; some of them scarcely seem compatible with the orthodox attacks.’238 Within the eighth edition,

Kraepelin noted six mixed states: (i) ‘depressive or anxious mania’; (ii) ‘excited depression’ in which flight of ideas is replaced by inhibition of thought. On the one hand, they lacked thoughts; on the other hand, there was restlessness; (iii) ‘mania with poverty of thought’ involved the transformation of depression to cheerfulness. These patients were in a manic state but did not

237 MDI & Paranoia, 95 238 MDI & Paranoia, 99-105.

62 have flight of ideas, and their perception was inhibited because they were slow and inaccurate.

There were many fluctuations observed: patients were quick and clever, but at other times they were incapable of speaking and forming thoughts; (iv) ‘manic stupor’ manifested when a mournful mood was replaced by a cheerful mood; (v) ‘inhibited mania’ exhibited flight of ideas with a cheerful mood but had psychomotor inhibition. The difference lies in the appearance of flight of ideas that emerged in the inhibited manic state and not in manic stupor; and (vi)

‘depression with flight of ideas’ which resulted in an anxious, sad and hopeless mood. 239

239 A convenient table outlining the details of Kraepelin’s classification of mixed states can be found in Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 75-76.

2.4 Aetiology

It must be remembered that the only practical method of classification during Kraepelin’s time was by symptoms since very little was known about neuropathology.240 This is applicable to

Aretaeus as well, as neuropathology was not known and did not exist in his time. By directly observing the symptoms and subsequently recording them in the Zählkarten, Kraepelin was able to group together patients with the same illnesses and attempt to understand aetiology through heredity. The eighth edition of Psychiatrie was chiefly concerned with causes of hereditary taint, age, sex, personal idiosyncrasy, and influences of the external and psychic. In Heidelberg,

Kraepelin observed hereditary taint in 80% of the cases, but lower percentages in Munich due to an incomplete knowledge of the previous history of patients.241 In one-third of the cases, either mental diseases or alcoholism was observed in the parents. The frequency of MDI in parents, brothers, or sisters was inconsistent. However, Kraepelin claimed that in seven out of ten children with the same parents who were probably predisposed to be manic-depressive, became manic-depressive themselves, and by the second generation, four members fell into MDI. Similar results were found and reported by other psychiatrists.242 Kraepelin commented on the intelligence of patients, the majority of them seemed to be above average, with only a few patients considered to be weak-minded.243 The patients appeared to have an artistic predisposition, perhaps because they lived in a world of emotions. He also remarked on physical attributes, malformations, distortions, and the smallness or enlargement of the brain or cranium.

In 903 cases, Kraepelin observed dips and highs in the distribution of attacks depending on age.

The developmental period of ages twelve to fifteen was when the first attacks of MDI occurred,

240 Bentall, Madness Explained: Psychosis and Human Nature 13. 241 MDI and Paranoia, 165. 242 In particular, psychiatrists Ernst Rehm (1860- ) and Bergamasco (biography unknown). MDI and Paranoia, 166. 243 MDI and Paranoia, 167.

64 perhaps due to the increased emotional excitability of people of that age.244 In the following years until age thirty, there was an increase in the number of attacks. Subsequently, the number of attacks gradually fell. Ages forty-five to fifty-five were when the attacks rose slightly again, and but they descended after age fifty-five. Within this trend, different states of MDI influenced different age brackets. Purely manic states ran the course of youthful years before age twenty- five and decreased after. Depressive states showed an almost continuous increase in attacks as age advanced. Kraepelin suggested that perhaps the rise of depression was because, in youth, children are more adaptable to move past emotional injuries. Whereas in older age, mental personality, circumstances of life, and a more developed consciousness created an environment in which emotional injuries lingered and became deeply ingrained.245 Among Kraepelin’s patients, 70% of MDI patients were female, and they fell into the morbid states earlier than men.246 Kraepelin believed, that congruently with patterns between age and MDI, there was a connection between sexual lives of women and attacks of MDI. Women had more first attacks during the beginning of their menstruation, but the attacks decreased in more advanced age. Men were more suspectable to increasing attacks of depression as they aged.247 Men had more states of simple depression, whereas women had extraordinary delusions or anxious delusions. In males, pure manic attacks were more frequent, while women had more combined attacks and confused states. External influences of alcoholism were causes for 25% of the cases in male patients, and syphilis in about 8% of male patients. Head injuries and bodily illnesses (such as pneumonia, blood poisoning, typhoid, or disease of the stomach) could precede the development of MDI. Psychic influences such as the death of a loved one (child, husband, or pet dog), period

244 MDI and Paranoia, 167. 245 MDI and Paranoia, 170. 246 MDI and Paranoia, 174. 247 MDI and Paranoia, 175.

65 after an operation (dental operation or abortion), and occasional quarrels (with lawsuits, love ones, or neighbors) could initiate or fast track.

Kraepelin made use of many experimental techniques throughout his career in an attempt to explain mental illnesses and their causes. His explanations were physiological; he was reliant on physical measurements of the brain and inconsistencies in genetic make-ups. Earlier in his career, Kraepelin produced pulse curves and measured the skull of his patients. The results, he maintained, were that the skulls belonging to mentally ill patients were either too small or too large and that the skulls of epileptics had characteristics of flatness and wideness.248 Another concept that interested Kraepelin was the effects of coffee and tea on mental reactions. Many attempts were made to measure these effects. He bought himself a Hipp Chronoscope249 hoping to further measure mental reaction times of caffeinated test subjects.250 Kraepelin carried out measurements at certain hours, hoping to understand the ‘influence of daily fluctuations on the course of mental processes.’251 However, he could not publish the results as he found a technical error in his data. He also attempted to organize clinical pictures of his patients ‘by characterizing their utterances and behavior as exactly as possible,’ but this also failed as he was unable to detect certain aspects.252 In Dorpat, he wrote regular reports on psychophysical literature. He continued to set up equipment to measure mental reactions, carried out tests on aphasic patients, other psychiatric patients, and manic patients. To his surprise, the patients’ association times

248 Memoirs, 7. 249 A Hipp Chronoscope was a timing device used in reaction time experiments. The name Hipp, refers to Matthäus Hipp, a German clockmaker. Hipp improved the original designs of the chronoscope (which was developed by Charles Wheatsone), by making the movement of the clock more precise. University of Toronto Scientific Instruments Collection (UTSIC) to Psychology https://utsic.utoronto.ca/wpm_instrument/hipp-chronoscope/. 250 Kraepelin’s choice in using this method of research was most likely because of Wundt. Wundt, in his 1874 textbook Grundzüge der physiologischen Psychologie, mentioned the use of Hipp chronoscopes in reaction time experiments to ‘discover laws that may govern response behavior’. Ibid. 251 Memoirs, 31. 252 Memoirs, 31.

66 were not shorter but longer and were irregular. This led to his belief that flight of ideas was not due to an acceleration of mental images but were due to ‘volatile and instable emerging processes in the conscience.’253 He continued his tests on the mental effects of drugs and the influence of caffeine and tea on the speed of mental reactions. He suspected that these tests allowed for the measurement of fatigue and that their benefits were two-fold: they could give insights into overburdening, and aid in understanding psychopathic conditions and traumatic neuroses.254 From these various tests, the scientific classification of ‘drinker’ was made, and this allowed the identification of personal tolerance of alcohol levels.255 On the nature of the disease in his eighth edition, Kraepelin was still very uncertain. He mentioned studies of other scholars whose research may be related to MDI, such as inhibitory and excitatory process within nerves, fluctuations of body weight, the intoxication of the body, insufficient thyroid gland activity, or

MDI’s connection with pathological anatomy (via vasomotor paths).256

Jablensky was able to use a set of 721 Zählkarten from the year 1908 to determine the validity of Kraepelin’s work. Jablensky, Hugler, and others extracted and coded symptoms and various clinical features. Of the patients that were admitted to the Munich clinic in 1908, 134 cases were MDI patients.257 Jablensky states that Kraepelin’s patient symptom profiles

‘reconstituted three “pure types” of disorder clearly corresponding to bipolar affective disorder, recurrent unipolar depression, and dementia praecox.’258 Despite Kraepelin’s own pessimism for the possibility of a complete nosology of mental disorders, these findings suggested that

253 Memoirs, 44. 254 Memoirs, 44. 255 Memoirs, 46. 256 MDI and Paranoia, 180-185. Parhon, Marb, Maratow, Lange, Meynert, and Thalbitzer. 257 Assen Jablensky, "Living in a Kraepelinian World: Kraepelin's Impact on Modern Psychiatry," History of Psychiatry 18, no. 3 (2007), https://www.ncbi.nlm.nih.gov/pubmed/18175638. 258 Ibid.

Kraepelinian typology was high in content validity. He was well aware that individual differences in symptomology could affect causal agents, he reports ‘experience shows that under certain circumstances the same particular [clinical] phenomena can arise in otherwise totally diverging cases.’259

The unravelling of the classificatory methods for MDI as well as their links to

Kraepelin’s biography lends itself to understanding his cogitation within Psychiatrie. As examined in sections 2.3 and 2.4, the Kraepelinian perspective (what MDI is comprised of, how

MDI is organized, what caused MDI) and the importance placed on techniques such as observation has made a profound contribution to the history of melancholia and mania. As we will see, some observations made in Kraepelin’s diagnostic framework are reflected in the

Aretaeus’. I will now examine this further in the next chapter.

259 Kendler and Jablensky, "Kraepelin's Concept of Psychiatric Illness". 1122. The original quote comes from Kraepelin, Emil (1899a). Psychiatrie. Ein Lehrbuch für Studierende und Ärzte, 6. Auflage, 1. Band. Barth: Leipzig [trans. H. Metoui: Psychiatry, A Textbook for Students and Physicians, 6th edn, Vol. 1. Science History Publications: Canton, MA, 1990].

Chapter 3: Aretaeus of Cappadocia

3.1 Biography

Aretaeus has been increasingly discussed in modern scholarship,260 yet little is known of the Greek physician. He was from the Roman province in Asia Minor of Cappadocia. The time in which Aretaeus flourished is debated and varies between the first to the second century CE.261

There is an older view which proposes that both Galen and Aretaeus were active around the same time;262 a more recent view has moved Aretaeus to around 50 CE. 263 What survives of Aretaeus’ works are his eight-volume treatises On Causes and Symptoms of Acute and Chronic Diseases and On Treatment of Acute and Chronic Diseases,264 and the lost treatises On Fevers, On Female

Disorders, On Preservatives; and Operations.265 His treatises display influences from earlier writers such as Homer, Thucydides, and Hippocrates. This is also reflected in Aretaeus’ choice to write in Ionic Greek, closely resembling the language of both Homer266 and Hippocrates.267

Many other aspects of Aretaeus’ life have been subject to dispute of which I will proceed to mentioned briefly: where he actively practiced, to which school of medicine he belonged, and the degree of his influence. Although his epithet is the Cappadocian, it is generally believed that

260 Since August 2018, I have set up alerts for “Aretaeus and madness” and was surprised at the amount of scholarship published (whether it be articles or textbooks). Within one year and seven months, there were a total of twenty-eight articles and growing. 261 Francis Adams who translated Aretaeus’ work considered Aretaeus to be a contemporary of Galen. He argues that Galen did not mention Aretaeus, even though he referred to almost every medical writer from the past to his current time. Thus, making it unlikely that Aretaeus came before Galen. This was mentioned in: Kate Murphy, "The Conceptualization and Treatments for Phrenitis, Mania and Melancholia in Aretaeus of Cappadocia and Caelius Aurelianus" (University of Calgary, 2013), 9. 262 Vivian Nutton, "Humoral Alternatives," in Ancient Medicine (London: Routledge, 2012), 210. 263 Ibid. Nutton says this is because of the re-dating of Athenaeus and other Pneumatists. 264 Two books On Causes and Symptoms of Acute Diseases, two On Causes and Symptoms of Chronic Diseases, two On Treatment of Acute Diseases, and two On Treatment of Chronic Diseases. 265 William David Ross, "Aretaeus," in The Oxford Classical Dictionary (Oxford University Press, 2005). 266 For example, within the first book On Causes and Symptoms of Chronic Diseases, Aretaeus quotes Homer’s Illiad in order to embellish his writing. Aret., SD 1.5.2 (Adams, 298). 267 Aretaeus took on some quotations from the Hippocratic Corpus and his writing is similarly styled to ‘Hippocratic Greek dialect.’ Nutton, "Humoral Alternatives," 210.

Aretaeus studied in Alexandria and practiced in Rome.268 Murphy seems to think that Rome is a fair assumption because Aretaeus prescribes Italian wines, which could not have been possible if he had lived and worked in Cappadocia.269 It can be posited that he might have practised in Asia

Minor, which would explain his dialect and the lack of references to him in contemporary

Roman literature. The school to which Aretaeus belonged has been a discussion of a long dispute in modern scholarship. Aretaeus mentioned pneuma several times, thus prompting the belief from Adams and others that he belonged to the Pneumatic school.270 There are objections to this theory because Aretaeus does not attribute all causes of diseases to the disturbance of pneuma and mentions pneuma infrequently. Some scholars maintain he was an Eclectic, committing to no specified school of medicine.271 Because Aretaeus does not explicitly write about this, we can never obtain a satisfactory answer. What is worth mentioning, however, is the strong influence of

Hippocratic humoral theory, which runs as the basis throughout Aretaeus’ corpus.272 The degree of influence Aretaeus had on the Greco-Roman medical world is likewise unknown. Although there are similarities to Galenic writings, Galen does not mention Aretaeus.273 Perhaps his treatises were not well circulated due to his choice to write in Ionic Greek. Medical writings in the Western European world during the sixth to seventh century CE briefly mention Aretaeus by

268 Murphy, "The Conceptualization and Treatments for Phrenitis, Mania and Melancholia in Aretaeus of Cappadocia and Caelius Aurelianus," 10. 269 Ibid., 19. 270 For example, McDonald stated that Aretaeus’ corpus is the most complete pneumatic work that survives. McDonald, "Concepts and Treatments of Phrenitis in Ancient Medicine," 88-89. 271 Murphy, "The Conceptualization and Treatments for Phrenitis, Mania and Melancholia in Aretaeus of Cappadocia and Caelius Aurelianus." 272 I would agree with Murphy’s statement in considering Aretaeus as an Eclectic with strong influences from Hippocratic Medicine. I would also echo the same sentiment that perhaps Aretaeus wanted to appear strongly linked to the Hippocratic writers to establish himself as a knowledgeable (and legitimate) physician. Ibid., 12. 273 Nutton explains a story in Galen’s work that was reported twice and identical to Aretaeus’ story. However, Galen did not acknowledge the source or date during any of the reports. Nutton, "Humoral Alternatives," 210.

70 name. Arabic medical writings, to my knowledge, do not refer to him.274 The physician’s work was silenced for almost one thousand years until the middle of the sixteenth century in 1552 when a Latin edition of his work was published.275 Regardless of many unknown aspects in

Aretaeus’ biography, what can be observed from his writings was his keen observation of ailments and the importance of ethics in his medical practice. Aretaeus’ ability to write accurate descriptions of a plethora of diseases using precise wording is noteworthy. His observational skills have led to the discovery and differentiation of both physiological and neurological diseases. Contemporary scholars have attributed diabetes (διαβήτες)276 to Aretaeus because he rendered the earliest clear account of this now known disease, as well as neurological contributions such as: tension-type headache (κεφαλαίη),277 migraine (ἑτεροκρανίη),278 epilepsy

(ἐπιληψίη),279 paralysis (παράλυσις),280 vertigo or scotoma (ὀνομάζομεν σκότωμα),281 and melancholia (μελαγχολία).282 In fact, his observational skills reflected in nosographic descriptions made such an impact that even the Canadian physician, William Osler, commented this in his lecture (1913): ‘in the art of observation men had come to a standstill. I doubt very

274 Recently there has been some discussion on the tenth century CE medieval Arabic writer, Alī ibn Naṣr who wrote the Encyclopedia of Pleasure. According to Mryne, Alī ibn Naṣr has used information from “Aretaeus of Cappadocia, a physician who was rarely mentioned by Islamic medical writers, which discusses genital organs, simultaneous orgasms and the qualities of semen.” Mryne did not provide references to Aretaeus’ text, however she does state that “the attribution to Aretaeus is likely unauthentic.” In Myne’s book index, she listed “Aretaeus of Cappadocia (pseudo)”. Pernilla Myrne, Female Sexuality in the Early Medieval Islamic World: Gender and Sex in Arabic Literature (Bloomsbury Publishing, 2019), 51-53. The only discussions that I have found on sexual intercourse, discharge and semen in Aretaeus’ work are in the context of affections of the womb or hysterics (On Causes and Symptoms of Chronic Diseases, Book II, Chapter XI), on satyriasis (On Causes and Symptoms of Acute Diseases, Book II, Chapter XII) and on diabetes (On Causes and Symptoms of Chronic Diseases, Book II, Chapter II). 275 Klaus-Dietrich, Fischer. 2011. Aretaeus of Cappadocia. In Brill’s New Pauly Supplements I: Dictionary of Greek and Latin Authors and Texts. 276 Aret., SD 2.2.1 (Adams, 338). 277 Aret., SD 1.2.1 (Adams, 36). 278 Aret., SD 1.2.2 (Adams, 37). 279 Aret., SD 1.4.1 (Adams, 296). 280 Aretaeus states: apoplexy, paraplegia, paresis, and paralysis are generally the same (ἀποπληξίη, παραπληγίη, πάρεσις, παράλυσις, ἅπαντα τῷ γένεϊ τωὐτά). Aret., SD 1.7.1 (Adams, 305). 281 Aret., SD 1.3.1 (Adams, 295). 282 Aret., SD 1.5.1 (Adams, 298).

71 much whether Corvisart283 in 1800 was any more skillful in recognizing a case of pneumonia than was Aretaeus of the second century AD.’284 This sentiment of a skillful observer and the thoroughness in nosographic descriptions certainly has its echo in the work of Emil Kraepelin.

283 Referring to Jean-Nicolas Corvisart, a French physician for Napoleon and his family. Corvisart’s large work entitled Essai sur les maladies du cœur et des gros vaisseaux has been recognised as a large contribution to and an establishment of cardiac symptomatology. J.F. Halls Dally, "Life and Times of Jean Nicolas Corvisart (1755-1821): Section of the History of Medicine," Proceedings of the Royal Society of Medicine 34, no. 5 (1941): 243. 284 William Osler, The Evolution of Modern Medicine : A Series of Lectures Delivered at Yale University on the Silliman Foundation in April, 1913 (London, UK: Yale University Press, 1921), 200.

3.2 Translations and Use in Current Medical Scholarship

The primary source used will be Aretaeus’ first book On Causes and Symptoms of

Chronic Diseases. Chapter 5 on Melancholia and Chapter 6 on Mania will be closely examined.

For a brief moment, I wish to mention the use of Aretaeus’ work in current medical scholarship.

It is standard for medical articles and textbooks to provide a ‘Historical Background,’ ‘Historical

Roots,’ or ‘Historical Overview’ section in their introductory chapter. Within discussions of MDI or bipolar disorder, this quotation from Aretaeus is always mentioned:

I think that melancholia is the beginning and a part of mania. The

development of a mania is really a worsening of the disease (melancholia)

rather than a change into another disease…In most of them (melancholics)

the sadness became better after various lengths of time and changed into

happiness; the patients then developed a mania.285

What piqued my interest in this quote was that I was not able to find a citation to Aretaeus’ work.

I decided to consult both Hude’s Greek edition286 and Adam’s translation.287 I was not able to find this quotation en bloc. It appears to be composed of fragments, throughout Aretaeus’ chapters, that have been fastened together to create a more complete illustration of Aretaeus’ nosology. I have collected the fragments used to form this quotation within the primary source.

285 I first came across this quote in Angst and Marneros, "Bipolarity from Ancient to Modern Times: Conception, Birth and Rebirth". 6. Many other medical articles have cited Angst and Marneros for this exact translated passage. 286 Aretaeus, "Aretaeus: Corpus Medicorum Graecorum ", ed. Karl Hude (Berlin: Akademie Verlag, 1958). Karl Hude (1860-1936) was a Danish classical philologist. 287 "The Extant Works of Aretaeus, the Cappadocian," ed. Francis Adams (Boston: Milford House 1972). Francis Adams (1796-1861) was a Scottish medical doctor and translator of Greek medical writings.

From Aretaeus On Melancholy and On Mania:

I. δοκέει τε δέ μοι μανίης τε ἔμμεναι ἀρχὴ καὶ μέρος ἡ μελαγχολίη.

and it appears to me that melancholy is the beginning and a part of mania.

Aret., SD 1.5.3 (Adams, 299)

II. οἱ δὲ μαίνονται αὔξῃ τῆς νούσου μᾶλλον ἢ ἀλλαγῇ πάθεος.

these [people] become mad rather from the increase of the disease [melancholia] than

from change of the affection. Aret., SD 1.5.4 (Adams, 299)

III. …οἵδε καὶ μελαγχολῆσαι ἑτοιμότεροι, οἱ δὲ καὶ πρόσθεν ἐκμαίνονται.

…and these are carried into melancholia [or: and some are more ready/ about to

become melancholic], and also those who were before [or: who previously] driven

mad. Aret., SD 1.6.3 (Adams, 103)

IV. ἢν δὲ ἐξ ἀθυμίης ἄλλοτε καὶ ἄλλοτε διάχυσις γένηται, ἡδονὴ προσγίγνεται ἐπὶ τοῖσι

πλείστοισι: οἱ δὲ μαίνονται.

but if at one time or another a relaxation of hopelessness [in melancholics] should

occur, enjoyment occurs in most/ hilarity supervenes: and they go mad.

Aret., SD 1.5.7 (Adams, 299)

The point of this short digression is that the quotation observed in the current medical scholarship is not as neatly packaged as one would presume to find in Aretaeus. If one were to consult the Greek, one would find these remarks scattered between the two chapters. This somewhat changes the perspective on Aretaeus’ work. Though Aretaeus was comprehensive and provided vivid case studies, statements presented like the influential quotation above do not appear wholly but instead are peppered within Aretaeus’ chapters.

3.3 On Causes and Symptoms of Chronic Diseases

The proœmium provides Aretaeus’ definition of chronic diseases as illnesses that involve great pain with uncertain recovery because the patients were either incurable or chronic diseases relapsed.288 Aretaeus’ thought process can be observed in Chapters 1 through 4. For him, neurological diseases were constantly worsening into other diseases. From κεφαλαίης

(cephalaea), a disease in which the head is seized with pain form a temporary cause; things could, if not cured, worsen into σκότωμα (vertigo);289 and if that was untreatable, it would worsen to either μανία (mania) concerned with yellow bile, μελαγχολίη (melancholia) concerned with black bile, or ἐπιληψίη (epilepsy) concerned with phlegm.290 Thus, a linear progression is seen in Aretaeus’ nosography: each disease progressing in worsening pathways and arriving at one final disease from which recovery is uncertain. This pattern of progressive deterioration is reflective of the aforementioned nineteenth century Einheitpsychose (unitary psychosis model).291 This would seem to suggest that Aretaeus observed diseases throughout their progression. He either treated the same patients throughout their lives; or he followed the diseases themselves for an extended period (this statement is more plausible). The ability to categorize diseases into acute or chronic and to recognize progressive deterioration would require not only time but organization. Again, this is reminiscent of Kraepelin’s inclusion of

288 χρονίων νούσων πόνος μὲν πουλὺς, χρόνος δὲ μακρὸς συντήξιος, καὶ ἀβέβαιος ἡ ἄλθεξις. ἢ γὰρ οὐδ᾽ ἐξηλάθησαν ἐς τὸ πάμπαν, ἢ ἐπὶ σμικρῇ ἁμαρτωλῇ παλινδρομέουσι αἱ νοῦσοι. Aret., SD 1.1.1 (Adams, 293) 289 ἢν δὲ δηθύνῃ καὶ ἐς μέζον ἕρπῃ ἐπὶ τοῖσι πόνοισι, τὸ πάθος σκότωμα γίγνεται. Aret., SD 1.2.3 (Adams, 295) 290 εὖτε ἐπὶ μὲν ξανθῇ χολῇ, μανίαι γίγνονται∙ ἐπὶ δὲ τοῖσι μέλασι, μελαγχολίη∙ ἐπὶ δὲ τῷ φλέγματι, ἡ ἐπιληψίη. πασῶν γὰρ ἥδε νούσων τροπή. Aret., SD 1.3.1 (Adams, 296) 291 A reminder: the unitary psychosis model was later challenged by Emil Kraepelin, as previously discussed in chapter two of this thesis. Instead, Kraepelin contended that the division of mental diseases into two major psychoses: dementia praecox and manic-depressive. What current medical scholarship refers to as the Kraepelinian dichotomy.

75 details on the course of illnesses, outcomes of illnesses, and changes in symptoms. For a summarization of Aretaeus’ melancholia and mania, refer to Table 4.

3.3.1 Melancholia

For Aretaeus, patients suffering from melancholia perceived in ‘sorrow and despondency only.’292 Once melancholia commenced, patients appeared ‘dull, stern, dejected, unreasonably torpid, [and] without any manifest cause.’293 If the melancholia increased, the patient readily became sleepless (ἄγρυπνοι).294 When they did sleep, their dreams were clear and terrifying so that when they were awake, they had aversions to the visions in their sleep.295 Sufferers of melancholia were not all affected in the same way. Some were ‘either suspicious of poisoning, or flee to the desert from misanthropy,296 or turn superstitious, or contract a hatred of life.’297 The increase of melancholia brought on more intense symptoms (as one would expect—certainly

Kraepelin did). At the height of melancholia, patients were consumed with ‘hatred, avoidance of the haunts of men, and vain lamentations,’298 and they would ‘complain of life [and had a] desire to die.’299 As for the patients’ understanding, the worsening of melancholia led them to

‘insensibility and fatuousness,’ and they became ‘ignorant of all things, forgetful of themselves, and live[d] the life of the inferior animals.’300 Physical subtypes of melancholia included a dark-

292 ἄλλοτε δ᾽ ἐς θυμηδίην ἡ γνώμη τρέπεται, τοῖσι δὲ μελαγχολῶσι ἐς λύπην καὶ ἀθυμίην μοῦνον. Aret., SD 1.5.3 (Adams, 299). 293 ἢ γὰρ ἥσυχοι, ἢ στυγνοὶ, κατηφέες, νωθροὶ ἔασι ἀλόγως, οὔ τινι ἐπ᾽ αἰτίῃ, μελαγχολίης ἀρχή. Aret., SD 1.5.5 (Adams, 299). 294 Aret., SD 1.5.5 (Adams, 299). 295 ἢν ἐς αὔξησιν τὸ νόσημα φοιτῇ, εὖτε καὶ ὄνειροι ἀληθέες, δειματώδεες, ἐναργέες. Aret., SD 1.5.6 (Adams, 300). 296 μισανθρωπίῃ (misanthropia) = μῖσος (hatred) and ἄνθρωπος (man/ human). 297 ἢ γὰρ ἥσυχοι, ἢ στυγνοὶ, κατηφέες, νωθροὶ ἔασι ἀλόγως, οὔ τινι ἐπ᾽ αἰτίῃ, μελαγχολίης ἀρχή. Aret., SD 1.5.3 (Adams, 299) 298 ἢν δὲ ἐπὶ μᾶλλον τὸ κακὸν πιέζῃ, μῖσος, φυγανθρωπίη, ὀλόφυρσοι ἐς κενεαί. Aret., SD 1.5.6 (Adams, 300). 299 ζωῆς κακήγοροι, ἔρανται δὲ θανάτου. Aret., SD 1.5.6 (Adams, 300). 300 πολλοῖσι δὲ ἐς ἀναισθησίην καὶ μώρωσιν ἡ γνώμη Ρ῾έπει, ὄκως ἀγνῶτες ἁπάντων, ἢ ἐπιλήσμονες ἑωυτέων, βίον ζώωσι ζωώδεα. Aret., SD 1.5.7 (Adams, 300).

76 green complexion of the skin.301 If bile did not pass down and were diffused with blood, the body would become a different hue (unspecified).302 The bowels were dry, and there was no discharge. If there were any dejections, they were reported as ‘dry, round, with a black and bilious fluid.’ There were small amounts of urine; it was pungent and also ‘tinged with bile.’303

The pulse was mostly ‘small, torpid, feeble, dense, like that from cold.’304 The eyes saw images that were ‘azure or [a] dark color.’305

3.3.2 Transitionary Phase

This section, in which I have titled ‘transitionary phase,’ refers to Aretaeus’ mentions of melancholia turning into mania; the transitioning or worsening of one part towards the second part of the disease. Aretaeus wrote that if at any time there was a period of relaxation (διάχυσις

γένηται), hilarity would occur later in most cases, and these patients would become manic

(presumably from being in a previous state of melancholia).306 Once melancholia was heightened, patients were more prone to change their mind, they became ‘mean-spirited, illiberal, and in a little time…simple, extravagant…not from any virtue of the soul, but from the changeableness of the disease.’307 In Aretaeus’ chapter On Mania, he stated that at the height of the illness, patients had a changeable temper, and ‘their senses are acute, they are suspicious,

301 χροιὴ μελάγχλωρος. Aret., SD 1.5.7 (Adams, 300). Adams’ translation says ‘the habit of the body…a darkish- green.’ I opted for the phrase ‘complexion of skin’ for χροιὴ , in Thesaurus Linguae Graecae : a Digital Library of Greek Literature (Irvine, California). 302 ἢν μὴ διεξίῃ κάτω ἡ χολὴ, ἀλλὰ ἀναχέηται ξὺν τῷ αἵματι ἐς τὸ πᾶν. Aret., SD 1.5.7 (Adams, 300). 303 ἢν δέ κοτε ἐκδιδῷ, ξηρὰ, στρογγύλα, ξὺν περιρρόῳ μέλανι, χολώδεα. οὖρα σμικρὰ, δριμέα, χολόβαφα. Aret., SD 1.5.7 (Adams, 300). I used ‘small amount’ and ‘pungent’ for ‘σμικρὰ’ and ‘δριμέα’ respectively; Adams used ‘scanty’ and ‘acrid.’ 304 σφυγμοὶ ὡς ἐπίπαν σμικροὶ, νωθροὶ, ἀδρανέες, πυκνοὶ, ἴκελοι τῷ ψύχεϊ. Aret., SD 1.5.8 (Adams, 300). 305 …τῶν ὀφθαλμῶν ἰνδάλματα κυάνεα, ἢ μέλανα, οἷσιν ἐς μελαγχολίην ἡ τροπή. Aret., SD 1.6.9 (Adams, 304). 306 ἢν δὲ ἐξ ἀθυμίης ἄλλοτε καὶ ἄλλοτε διάχυσις γένηται, ἡδονὴ προσγίγνεται ἐπὶ τοῖσι πλείστοισι∙ οἱ δὲ μαίνονται. Aret., SD 1.5.4 (Adams, 299). 307 πρὸς τὸ Ρ῾ηΐδιον μεταγνῶναι εὔκολοι, αἰσχροὶ, σμικρολόγοι, ἄδωροι, καὶ μετ᾽ οὐ πολὺ ἁπλοῖ, ἄσωτοι, πολύδωροι, οὐκ ἀρετῇ ψυχῆς, ἀλλὰ ποικιλίῃ νοσήματος. Aret., SD 1.5.6 (Adams, 300).

77 irritable without any cause, and unreasonably desponding when the disease tends to gloom.’308

When they were cheerful, they were unable to sleep.309 Symptoms experienced physiologically included ‘headaches, heaviness of the head; sharp[ness] in hearing, [and] very slow judgement.’310

3.3.3 Mania

Aretaeus’ chapter On Mania is more in-depth. He begins by addressing possible misdiagnoses of mania. If the patient experienced chronic derangement of the mind with a fever, it was some other illness, not mania.311 Deliriums onset by wine and edibles could induce madness, but this should never be diagnosed as mania because these symptoms were temporary and quickly subsided.312 Aretaeus had clearly defined mania as ‘a chronic derangement of the mind, without fever…that is hot and dry in cause, and tumultuous in its acts.’313 He reported hallucinatory case studies writing ‘[patients] are also given to extraordinary phantasies; for one is afraid of the fall of the oil cruets…’314 For other reported case studies, refer to Appendix B of this thesis. Most interesting is Aretaeus’ organization and statement of three subgroups of mania: (i) madness with joy, (ii) madness with anger, and (iii) ingenious madness. This sort of subdivision is clearly reflective of Kraepelin’s categorization of manic states.315 In Aretaeus’ first state, madness with

308 ἢν οὖν μέγα ᾖ τὸ κακὸν, εὐκίνητοι, ὀξέες τὴν αἴσθησιν, ὕποπτοι, ὀργίλοι, οὐκ ἐπ᾽ αἰτίῃ τινὶ, δύσθυμοι μὲν ἀλόγως, οἷσι ἐς σκυθρωπὸν ἡ μανίη τρέπεται. Aret., SD 1.6.8 (Adams, 303). 309 οἷσι δὲ ἐς θυμηδίην, εὔθυμοι∙ ἄλλοι δὲ παραλόγως ἄγρυπνοι. Aret., SD 1.6.8 (Adams, 303). 310 …κεφαλαλγέες, ἢ πάντως γε βάρος τῆς κεφαλῆς ξύνεστι∙ εὐήκοοι δὲ, ἀλλὰ βράδιστοι τὴν γνώμην. Aret., SD 1.6.8 (Adams, 303). 311 εἰ γάρ κοτε καὶ πυρετὸς ἐπιλάβοι, οὐκ ἀπὸ μανίης ἂν ἴδιος γίγνοιτο, ἀλλ᾽ ἐκ συντυχίης ἄλλης. Aret., SD 1.6.1 (Adams, 303). 312 ἐκφλέγει γὰρ καὶ οἶνος ἐς παραφορὴν ἐν μέθῃ: ἐκμαίνει δὲ καὶ τῶν ἐδεστῶν μετεξέτερα, ἢ μανδραγόρη, ἢ ὑοσκύαμος, ἀλλ᾽ οὔ τί πω μανίη τάδε κικλήσκεται. Aret., SD 1.6.1 (Adams, 303). 313 μανίη δὲ θερμόν τι καὶ ξηρὸν τῇ αἰτίῃ, καὶ ταραχῶδ ες τῇσι πρήξεσι. Aret., SD 1.6.2 (Adams, 301). 314 ἐδεδίει γάρ τις ληκύθων ἔκπτωσιν…Aret., SD 1.6.6 (Adams, 302). 315 A reminder that Kraepelin’s manic states included: hypomania, acute mania, delusional mania, delirious mania. Refer to Table 2. Kraepelin’s Manic States.

78 joy, patients are described as laughing, playing, dancing all night and day.316 They sometimes would openly go to the market crowned as victors317 (this would be considered a delusion).

Madness with anger (ii) does not deviate far from the descriptions from archaic Greek non- scientific literature (for example, Homer’s Iliad, refer to section 1.2 of this thesis). Patients suffering from this type of mania would lay violent hands upon themselves and render their clothes and kill their keepers.318 Although madness with joy was harmless to those around, madness with anger was considered a ‘miserable form of disease’ and was most likely

‘danger[ous] to those around,’319 in addition to being harmful to themselves. Ingenious madness

(iii) was more difficult to encompass and describe, as ‘the modes are infinite to those who are ingenious and docile.’320 In this state, there seemed to be advantages from the disease. Patients had incredible phantasies321 and produced untaught astronomy, spontaneous philosophy, and poetry that truly came from the muses.322 At the height of (any form) of mania, patients were

‘flatulent, affected with nausea, voracious, and greedy in taking food.’323 Not only this, but patients had ‘impure dreams and irresistible desire of venery without any shame or restraint as to sexual intercourse; if aroused or restrained, they become wholly mad.’324 Again, Aretaeus noted some variety of patients’ experiences during heightened mania: some patients ran along unrestrainedly returning again to the same spot, or after a long time, return to their relatives;

316 καὶ οἷσι μὲν ἡδονὴ ᾖ ἡ μανίη, γελῶσι, παίζουσι, ὀρχεῦνται νυκτὸς καὶ ἡμέρης. Aret., SD 1.6.4 (Adams, 302). 317 καὶ ἐς ἀγορὴν ἀμφαδὸν, καὶ ἐστεμμένοι κοτὲ ὅκως ἐξ ἀγωνίης νικηφόροι ἔασιν. Aret., SD 1.6.4 (Adams, 302). 318 μετεξέτεροι δὲ ὑπὸ ὀργῆς ἐκμαίνονται. ἔσθ᾽ ὅτε ἐσθῆτάς τε ἐρρήξαντο, καὶ θεράποντας ἀπέκτειναν, καὶ ἑωυτέοισι χεῖρας ἐπήνεγκαν. Aret., SD 1.6.5 (Adams, 302). 319 ἥδε καὶ τοῖς πέλας οὐκ ἀκίνδυνος ἡ ξυμφορή. Aret., SD 1.6.5 (Adams, 302). 320 ἰδέαι δὲ μυρίαι, τοῖσι μέν γε εὐφυέσιτε καὶ εὐμαθέσι… Aret., SD 1.6.5 (Adams, 302). 321 γίγνονται δὲ καὶ ἀλλόκοτοι φαντασίαι. Aret., SD 1.6.5 (Adams, 302). 322 ἀστρονομίη ἀδίδακτος, φιλοσοφίη αὐτομάτη, ποίησις δῆθεν ἀπὸ μουσέων. Aret., SD 1.6.5 (Adams, 302). 323 ἢν ἐς αὔξησιν ἡ νοῦσος γίγνηται, φυσώδεες, ἀσώδεες, βοροὶ καὶ λάβροι ἐν τῇ ἐδωδῇ. ἀγρυπνέουσι γάρ: ἀγρυπνίη δὲ βορόν. Aret., SD 1.6.9 (Adams, 303). 324 ἐπὶ κορυφῆς δὲ τοῦ κακοῦ ὀνειρώττουσι: ἀφροδισίων δὲ ἄσχετος ἐπιθυμίη, ἀτὰρ οὐδὲ ἐς τὸ ἄμφαδον αἰδὼς ἢ ὄκνος ὁμιλίης∙ νουθεσίῃ δὲ καὶ ἐπιπλήξει ἐς ὀργὴν ἐκριπισθέντες ἐς τὸ πάμπαν ἐκμαίνονται. Aret., SD 1.6.10 (Adams, 304).

79 some others roared loudly and ‘bewail[ed] themselves as if they had experienced robbery or violence’; and some ‘fled the haunts of men and [went] to the wilderness to live by themselves.’325 Perception wise, manic patients ‘see only as others see, but do not form a correct judgment on what they have seen.’326,327 As for physical subtypes, patients did not experience appetite or digestion;328 their eyes appeared hollow and did not wink;329 in some other cases, the eyes appeared red and blood-shot.330 They saw red hues, along with ‘purple coloured phantasmata, in many cases as if of flashing fire; and terror seizes them as if from a thunderbolt.’331 Aretaeus also stated at the end of the mania chapter that any patients who were able to attain relaxation from mania became ‘torpid, dull, sorrowful, for having come to a knowledge of the disease they are saddened with their own calamity.’332 I would like to point out that Kraepelin had discussed a similar case in his textbook. He noted that patients might report themselves as feeling more unwell than before. Kraepelin states that this feeling of unhealthiness may very well be a reflection of the patient’s own awareness, having come down from the height of their former state (different from the normal state).333 Once again, for a summarization and review of Aretaeus’ Melancholia and Mania, refer to Table 4.

325 τοὐντεῦ θεν ἄλλος ἄλλῃ μαίνεται: οἱ μὲν θέουσι ἀσχέτως, οὔτε ὅπως εἰδότες ἐς ταὐτὰ παλινδρομέουσι: οἱ δὲ ἐς δηρὸν τοῖσι πέλας ἀφικνέονται: ἄλλοι δ᾽ αὖ βοῶσι ὀλοφυρόμενοι ἁρπαγὴν, ἢ βίην. οἱ δὲ φυγανθρωπεύουσι ἐς ἐρημίην, σφίσι αὐτέοισι ὁμιλέοντες. Aret., SD 1.6.10-11 (Adams, 304). 326 οἵδε μὲν γὰρ παραισθάνονται, καὶ τὰ μὴ παρεόντα ὁρέουσι δῆθεν ὡς παρεόντα, καὶ τὰ μὴ φαινόμενα ἄλλῳ κατ᾽ ὄψιν ἰνδάλλεται∙ οἱ δὲ μαινόμενοι ὁρέουσι μόνως ὡς χρὴ ὁρῆν: οὐ γιγνώσκουσι δὲ περὶ αὐτέων ὡς χρὴ γιγνώσκειν. Aret., SD 1.6.7 (Adams, 303). 327 There is a distinction made here by Aretaeus, between phrenitis and mania. Those that have phrenitis see things that are not there, and objects manifest themselves randomly. Mania does not make the sufferer hallucinate per se, but they are subject to delusions (i.e. falsely crowned victor in the market square). 328 ἢν δέ τι τῶν σπλάγχνων ἐν φλεγμασίῃ ᾖ γεγονὸς, τὴν ὄρεξιν ἢ τὴν θρέψιν ἀμβλύνει. Aret., SD 1.6.9 (Adams, 304). 329 ὀφθαλμοὶ κοῖλοι, οὐ σκαρδαμύττοντες. Aret., SD 1.6.9 (Adams, 304). 330 μετεξετέροισι δὲ καὶ ἐνέρυθροι καὶ ὕφαιμοι ὀφθαλμοί. Aret., SD 1.6.10 (Adams, 304). 331 ἐρυθρότερα δὲ οἷσιν ἐς μανίην, καὶ φοινίκεα φαντάσματα, πολλοῖσι μὲν ὡς ἀπαστράπτοντος πυρὸς, καὶ τάρβος αὐτέους ὡς ἀπὸ σκηπτοῦ λαμβάνει. Aret., SD 1.6.9 (Adams, 304). 332 εἰ δὲ ἐπ᾽ ἄνεσιν ἤκοιεν τοῦ κακοῦ, νωθροὶ, ἥσυχοι, ἐπίλυποι. ἐς ἐπιστασίην γὰρ τῆς νούσου ἀφικνεόμενοι, ἄχθονται τῇ ξυμφορῇ. Aret., SD 1.6.11 (Adams, 304). 333 Kraepelin, Manic-Depressive Insanity and Paranoia, 98.

Table 4. Summarization of Aretaeus' Melancholia and Mania Melancholia Both melancholia and mania Mania Aetiology Bile passing upwards or downwards Dryness (1.5.5); summer and autumn Chronic derangement of the mind, around the diaphragm (1.5.4) endanger, and spring brings it to a without fever (1.6.1); hotness (1.6.2); crisis (1.5.5)334 bile moving from the diaphragm to the head (1.5.4) Areas Hypochondriac region (1.5.4) Bowels (1.6.7) Head and hypochondriac region affected (1.6.7) Psychic Either:335suspicious of poisoning; If coming down from the psychic Silly, do dreadful and disgraceful symptoms flee to the desert from symptoms of mania, the patients things (1.5.3); impure dreams, flee, misanthropy;336 turn superstitious; or become torpid, dull, sorrowful bewail themselves. Three types: contract a hatred of life (1.5.3). (melancholia symptoms) madness with joy (laugh, play); Beginning of melancholy: dull, stern, (1.6.10) madness with anger (dangerous to dejected, unreasonably torpid themselves and those around); without any manifest cause.337 ingenious madness (spontaneous Become peevish, dispirited, sleepless talent); extraordinary phantasies (1.5.5)338 (1.6.5) Bodily Darkish-green hue; bowels and — Eyes hallow, red and bloodshot, see symptoms dejections dry; black bilious fluid; red color, purple coloured urine scanty and tinged with bile; the phantasmata, flashing fire and terror pulse is small (1.5.7) seizes them (1.6.9) Sex Men or younger than adult aged people (1.5.5)339 Women are worse affected (1.5.5)340 differences Young men, puberty phase most given to mania

334 ὥρη θέρος μὲν καὶ φθινόπωρον τίκτει, ἔαρ δὲ κρίνει (Adams, 299). 335 I noticed a slight difference in his use of prepositions. His language for melancholia when listing symptoms used the conjunction ‘or’ but when listing symptoms for mania he uses ‘and.’ Perhaps ‘or’ denotes only having to experience one of the characteristics to be considered melancholic; ‘and’ denotes inclusivity of all these symptoms to be considered manic. 336 μισανθρωπίῃ (misanthropia) = μῖσος (hatred) and ἄνθρωπος (man/ human). 337 ἢ γὰρ ἥσυχοι, ἢ στυγνοὶ, κατηφέες, νωθροὶ ἔασι ἀλόγως, οὔ τινι ἐπ᾽ αἰτίῃ, μελαγχολίης ἀρχή (Adams, 299). 338 ἔτι δὲ καὶ ὀργίλοι προσγίγνονται, δύσθυμοι, ἄγρυπνοι, ἐκ τῶν ὕπνων ἐκθορυβούμενοι (Adams, 299). More detail was provided in this thesis’ sections above. 339 ἄνδρες μὲν οὖν μαίνονται καὶ μελαγχολῶσι, ἢ καὶ ἀνδρῶν ἐλάσσους (Adams, 299). 340 κάκιον δὲ ἀνδρῶν αἱ γυναῖκες ἐκμαίνονται (Adams, 299).

3.4 Aetiology

Though I have mentioned the difficulty in attributing Aretaeus’ approach to any specific schools of medicine, it is probably fair to say that Aretaeus was, to a degree, influenced by the

Hippocratic humoral theory. This is especially true in On Causes and Symptoms of Chronic

Diseases, where terms such as ξανθῆ χολῆ (yellow bile); μέλαινα χολὴ (black bile); φλέγμα

(phlegm); θέρμός (hot); ξηρός (dry); ἔαρ (spring); and θέρος (summer) are used to explain the diseases. Aretaeus did not conceptualize melancholia and mania as some abstract entity that was unobservable in the mind. Instead, he imagined them as physical objects— black bile moved vertically within the bodily system. It did not have spiritual nuances, nor did it ever require any.341 Black bile makes an appearance in both acute and chronic diseases. In chronic diseases, if the bile moved downwards, it terminated dysentery (severe diarrhea with blood and mucus)342 and produced pain in the liver;343 in females344 it resulted in purgation instead of menses.345

Generally, if black bile collected around the diaphragm (moving in either direction), it caused melancholy;346 however, once the head was also affected, the condition became mania. Dryness was the cause of both melancholia and mania.347 The seasons of summer and autumn threatened the disease, but spring heightened the disease to a crisis.348 Aretaeus discussed predispositions to suffer from melancholia and mania. Certain people that were ‘naturally passionate, irritable, of active habits, of an easy disposition, joyous and puerile’ were more prone to mania. Those

341 Peter Toohey, Boredom: A Lively History (Yale University Press, 2011), 116. 342 E.A. Martin and Oxford University Press, Concise Medical Dictionary, Ninth ed. (Oxford University Press, 2015). 343 ἐν δὲ τοῖσι χρονίοισι, ἢν μὲν ὑπίῃ κάτω, ἐς δυσεντερίην καὶ ἥπατος πόνον τελευτᾷ. Aret., SD 1.5.1 (Adams, 298). 344 I am making the assumption here that Aretaeus writing ‘terminating dysentery and produce pain in the liver’ applies to men. Because Aretaeus makes a distinction of what women experience with the movement of black bile. 345 γυναιξὶ δὲ κάθαρσις ἀντὶ τῶν ἐπιμηνίων. Aret., SD 1.5.1 (Adams, 298). 346 καὶ διεξίει χολὴ ἄνωθεν, ἢ κάτωθεν μελαγχο λῶσιν. Aret., SD 1.5.4 (Adams, 299). 347 ἐπ᾽ ἀμφοῖν δὲ ξηρότης αἰτίη. Aret., SD 1.5.5 (Adams, 299). 348 ὥρη θέρος μὲν καὶ φθινόπωρον τίκτει, ἔαρ δὲ κρίνει. Aret., SD 1.5.5 (Adams, 299).

82 naturally ‘sluggish, sorrowful, slow to learn but patient in labour, and who when they learn anything, soon forget it were more prone to melancholy.’ 349,350 Those nearing puberty have general vigour or are young men themselves are most likely to suffer from mania.351 Relapse was a possibility in situations where mania was incurable. Aretaeus writes ‘we are not thoroughly healthy by the cure [medicine] for this illness or by the temperateness of the season’352 or ‘the season of spring, some error in diet, or some incidental heat of passion, has brought on a relapse.’353 Though his aetiology is difficult to piece together, and may be considered as unconvincing, one thing I am certain of is Aretaeus’ clearer perception of the relationship between melancholia and mania. Aretaeus writes that the condition becomes mania because the disease (melancholia) itself intensifies, not because it is a change of the affliction.354,355 This is the very pattern mentioned before; one state could intensify and worsen into other morbid states.

Remarkably, Aretaeus understood melancholia and mania to possess the same aetiology having also stated ‘it appears to me that melancholy is the commencement and a part of mania’ (δοκέει

τε δέ μοι μανίης τε ἔμμεναι ἀρχὴ καὶ μέρος ἡ μελαγχολίη).356 This could be interpreted as a cyclical disease. However, with his additional description of varying types of melancholia and mania (explained in sections 3.3.1 and 3.3.3), I would argue to say that he is describing instead, a

349 καὶ γὰρ δὴ νοσέουσι οἱ φύσι ὀργίλοι, ὀξύθυμοι, Ρ῾έκται, εὐμαρέες, ἱλαροὶ, παιδιώδεες∙ ἀτὰρ καὶ οἷσι ἐς ἐναντίην ἰδέην ἡ φύσις Ρ῾έπει, ὁκόσοι νωθροὶ, ἐπίλυποι, βραδεῖς μὲν ἐκμαθεῖν, ἐπίμονοι δὲ προσκαμεῖν, ποτὶ καὶ μαθόντες, ἀμνήμονες, οἵδε καὶ μελαγχολῆσαι ἑτοιμότεροι, οἱ δὲ καὶ πρόσθεν ἐκμαίνονται. Aret., SD 1.6.3 (Adams, 301). 350 Might I add, this is eerily alarming— with certainty, I am doomed. 351 οἵδε μαίνονται. τοῖσι ἀμφὶ ἥβην καὶ νέοισι καὶ οἷσι πάντων ἡ ἀκμή. Aret., SD 1.6.4 (Adams, 302). 352 I have had aid from Dr. Peter Toohey with translating this passage. Adams’ translation: ‘if it takes place in mania when the evil is not thoroughly cured by medicine or is connected with the temperature of the season’ (Adams, 301). 353 οὐκ εἰκότως ἀκεομέν ου τοῦ κακοῦ ἰητρείῃ, ἢ τῆς ὥρης εὐκρασίῃ. μετεξετέρους γὰρ δοκέοντας ἀσινέας ἔμμεναι, ἡ ὥρη τὸ ἔαρ, ἢ ἁμαρτωλὴ διαίτης, ἢ ὀργὴ ἐκ συντυχίης ἐς ἀνάκλησιν ἤγαγε. Aret., SD 1.6.2 (Adams, 301). 354 οἱ δὲ μαίνονται αὔξῃ τῆς νούσου μᾶλλον ἢ ἀλλαγῇ πάθεος. Aret., SD 1.5.4 (Adams, 299). 355 In the chapter On Melancholia, Aretaeus does write πρὸς τὸ ῥηΐδιον μεταγνῶναι εὔκολοι… οὐκ ἀρετῇ ψυχῆς, ἀλλὰ ποικιλίῃ νοσήματος· (they [patients] are prone to change their minds easily…not from virtue of the soul, but from the versatility or complexity of the disease;). Aret., SD 1.5.6 (Adams, 300). 356 Aret., SD 1.5.3 (Adams, 299).

83 spectrum on which there is no compulsory back and forth movement between the two conditions.357

Although Aretaeus’ conception may be broader than Kraepelin’s (less specification and no categorization of diseases into subgroups or schemes), Aretaeus does consider melancholia and mania as two aspects of the same condition,358 much like Kraepelin. Aretaeus’ model was not likely cyclical, because there was no requirement for mania and melancholia to cycle into one another with varying intervals in-between them. Likewise, Kraepelin’s model was not cyclical, but encompassed all forms and states (maniacal, depressive, and mixed (periodic, circular, cyclothymic) under MDI. Perhaps it could be considered that both Aretaeus’ and

Kraepelin’s mood disorders comprised a spectrum. Now, I must turn to investigating the relationship between the Kraepelinian perspective and Aretaean perspective.

357 I should point out that Aretaeus does curiously mention the possibility of a relapse on two occasions. Firstly, when the patient is not thoroughly cured, any number of causes (seasons, temperature, or diet) could bring about a relapse (ἡ ὥρη τὸ ἔαρ, ἢ ἁμαρτωλὴ διαίτης, ἢ ὀργὴ ἐκ συντυχίης ἐς ἀνάκλησιν ἤγαγε). Secondly, when the patient is predisposed to certain behaviours (sluggish and sorrow) they are ‘prone to melancholy, who have formerly been in a mad condition’ (οἵδε καὶ μελαγχολῆσαι ἑτοιμότεροι∙ οἱ δὲ καὶ πρόσθεν ἐκμαίνονται). Aret., SD 1.5.3 (Adams, 299); 1.6.2 (Adams, 301). 358 I believe this is the reason why Aretaeus’ work resonates evermore in present-day research in medical history. In the past, other’s have said that “[Aretaeus’] main merit is that he builds on the solid foundations of Archigenes.” Ross, "Aretaeus." There were several scholars (such as Wellman and Allbutt) who viewed Areateus’ work as lacking in originality as they felt it probable that he copied Archigenes’ work (J.M.S. Pearce, "The Neurology of Aretaeus- Radix Pedis Neurologia," European Neurology 70 (2013). But I digress—whether or not this is true—my stance is that Aretaeus’ main merit is the classification of melancholia and mania as relating to one another, in such a way that they are parts of the same disease.

Chapter 4: Bringing it all Together

Up to this point, I have fashioned a narrative showcasing Emil Kraepelin’s life and works separately from that of Aretaeus, whilst peppering these narratives with sentences that allude to the connection between the two medical writers. As I mentioned in the introduction of this thesis,

I chose to organize it in such a way to individually establish each writer’s methodology and set of symptoms and causes before relating them to one another. I believed this would allow me to remain impartial in my data collection of each medical writer in order to avoid imposing

Kraepelinian concepts on Aretaean concepts or vice versa. It is in this final chapter that I wish to bring together the ideas from Kraepelin and Aretaeus to tackle answers to questions such as: why make the comparison between two medical writers that are nearly 2000 years apart from each other; what can a comparative study such as this offer; and what does it imply (especially in today’s interests)? The answer to the first question, simply put, is because Kraepelin and

Aretaeus are ‘household names’ in current medical scholarship in any discussions on bipolar disorder. Writings on a historical overview or historical background of bipolar disorder, almost always attribute Aretaeus to be the first to understand a mental illness concept that closely resembles the current understanding of bipolar disorder, and attribute Kraepelin to influencing the DSM in its categorization of bipolar disorder and schizophrenia. The survivability of

Aretaeus’ work and the popularity of Kraepelin’s works are a testament to the importance of their observations and descriptions. Aretaeus may have grouped a more extensive range of states under melancholia and mania but his descriptions are akin to Kraepelinian nosology. The confusion around causal explanations in both writers seems to have been put aside by their contemporaries, leaving them to focus, instead, on Aretaeus and Kraepelin’s accomplishments that contributed to the foundation for future medical writers. As aforementioned, I believe

Aretaeus and Kraepelin have more similarities than differences. I would like to propose three final points: (i) Aretaeus and Kraepelin are similar in technique; (ii) Aretaeus and Kraepelin are similar in their nosology; and finally (iii) Aretaeus and Kraepelin’s significant difference was in their aetiologies.

Similar Technique (Observation, Longitudinal Studies, and Organization). For my first point, I suggest that Aretaeus and Kraepelin had similar techniques in three main areas: they both had a deep awareness of the significance in acute observation, they utilized organizational methods to systematically explain and classify illnesses, and they conducted longitudinal studies.

Referring back to Chapter 3, the possibility of Aretaeus being influenced by Hippocratic writings may be extended to being influenced by Hippocratic medical practices. Hippocrates’ medical doctrine stated that medicine could not exist without observing the patient.359 Hippocrates stressed the importance of investigating the entire patient in their entire environment;360 modern clinical practices remain established on this Hippocratic foundation of ‘expectant observation.’361

Aretaeus’ main methodological technique was observation-based, viewing the patient as a psychosomatic entity. From his nosology, we can ascertain that Aretaeus was wholly dependent on the observation of patients and their bodily functions. Likewise, Kraepelin stated that observation was an important factor when diagnosing. As we have seen in Chapter 2.1.1, Dorpat proved to be influential to Kraepelin’s acuteness in patient observation because of the language barrier. In Munich, Kraepelin mentioned the difficulty of getting his students to examine patients and ‘often noticed that the students had little talent for simple natural observations; they tended

359 A Katsambas and SG Marketos, "Hippocratic Messages for Modern Medicine," Historical Perspective 21 (2007). 360 Ibid. 361 Rudolph E. Siegel, "Clinical Observation in Hippocrates- an Essay on the Evolution of the Diagnostic Art," 301.

86 not to describe what had happened, but to try to interpret it, which was usually wrong.’362

Observation became a large part of his methodology and without it, Kraepelin would not have been able to differentiate between the symptoms, the course of the disease, or the categorization of depressive and manic states. What germinated from his extensive observation was the use of the Zählkarten for record-keeping and clinical research. He recorded personal data and information relating to mental disorders such as medical history, age of first onset, duration of treatment, correct diagnosis, and diagnostic errors.363 It can be speculated that Aretaeus must have had a similar diagnostic system to Kraepelin’s Zählkarten. Aretaeus may have lived in an illiterate society that would be fully dependent on oral tradition involving rote memorisation.

This would surely be a difficult feat in today’s literate society. However, in a society of only partial literacy, such as that of the descendants of Homer, one would have to rely on one’s own memory much more than we can imagine. It would not be implausible to imagine that Aretaeus kept mental diagnostic cards, in which he was able to recall and produce into his books. The

Zählkarten enabled Kraepelin to observe changes in symptoms over time and thus conduct longitudinal studies. The same cannot definitively be claimed of Aretaeus as he does not explicitly state that he followed the courses of illnesses over time. However, the organization of

Aretaeus’ work into acute and chronic illnesses speaks to this. The wording of certain phrases in his work, such as ‘worsening of the disease’ or ‘duration of time’ suggests that Aretaeus studied the disease long term but perhaps not the patients themselves specifically. He was able to denote periodic disease manifestations and the return to a more normalized behavior.364 Likewise,

362 Kraepelin, Memoirs, 127. 363 Olga Zivanovic and Aleksandra Nedic, "Kraepelin's Concept of Manic-Depressive Insanity: One Hundred Years Later," Journal of Affective Disorders 137 (2012): 16. 364 Theodore Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium (New Jersey: John Wiley & Sons, Inc., 2004), 29.

Kraepelin saw a limitation to being dependent on descriptors and categorisation and thus gave great emphasis to the importance of careful, detailed, and longitudinal observations. Kraepelin himself said, ‘we psychiatrists, have to deal not with isolated areas of mental life, but with the whole human being … to gain, to the extent possible, a complete picture of the disturbances caused by the disease process.’365,366 Kraepelin found it less challenging to determine illness by comparing a patient’s current state from a prior state than to judge purely on symptoms.367

Following this reasoning, it could be speculated that Aretaeus learned of different variations in the progression of melancholia and mania by comparing either: the same patient throughout the progression of their illness; or (more likely), the progression of the illness itself during various stages. Goodwin and Jamison stated that research on MDI, especially in longitudinal observations, has prompted interests in the influence of the physical environment on the course of illness and expressions coming from the illness.368 Aretaeus reports one such case study:

A certain joiner was a skillful artisan while in the house…While on the spot

where the work was performed, he thus possessed his understanding…But

when he had got out of sight of the domestics, or of the work and the place

where it was performed, he became completely mad; yet if he returned

speedily he recovered his reason again; such a bond of connection was

there between the locality and his understanding. 369

Aret., SD 1.6.6-7 (Adams, 302-303)

365 E. J. Engstrom and M. M. Weber, "Kraepelin, E. (1887) Die Richtungen Der Psychiatrischen Forschung: The Directions of Psychiatric Research by Emil Kraepelin," History of Psychiatry 16 (2005). Cited within Kendler and Jablensky, "Kraepelin's Concept of Psychiatric Illness". 1120. 366 Again, this echoes Hippocratic medicine, in the importance of assessing the patient as a whole in their surrounding environment. 367 Kendler and Jablensky, "Kraepelin's Concept of Psychiatric Illness". 1122. 368 Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, xxi. 369 Refer to Appendix B for the full report and the Greek.

Similar Nosology (Melancholia, Mania, and their Relationship). Engstrom reports that often, Kraepelin’s nosology is positioned closer to Hippocrates than others.370 I believe, however, that Kraepelin’s nosology is closer to Aretaeus’ due to the connection he makes between melancholia and mania. Millon claims that Hippocrates may have first provided the medical description of melancholia, but ‘it was Aretaeus who presented a complete and modern portrayal of the disorder.’371 Kraepelin argued that MDI included transitional forms between manic and depressive conditions. Aretaeus also spoke of a transition, he believed, ‘it appears to me that melancholy is the commencement and a part of mania.’372 Allowing for cultural differences, Aretaeus described patients who would likely be found in Kraepelinian criteria and the current modern criteria but under different labels.373 Swann views Aretaeus and Kraepelin as similar not only in emphasizing pathophysiology but in viewing mood episodes as combinations of three aspects of behavior: mood, action, and thought.374

Aretaeus observed patients as being ‘dull or stern, dejected, or unreasonably torpid.’375

Those afflicted with melancholia were prone to changing their mind, and as the disease progressed, the individual suffered from vain lamentation, ‘they complain[ed] of life [and had a] desire to die.’376 Kraepelin and many others in the nineteenth century used a strikingly similar range of mood descriptions. In depressive states, Kraepelin wrote that ‘mood is sometimes dominated by profound inward dejection and gloomy hopelessness…one disappointment and

370 Engstrom, "Tempering Madness: Emil Kraepelin’s Research on Affective Disorders". 164. 371 Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, 28-29. 372 δοκέει τε δέ μοι μανίης τε ἔμμεναι ἀρχὴ καὶ μέρος ἡ μελαγχολίη. Aret., SD 1.5.3 (Adams, 299). 373 Alan C Swann, "Mixed Features: Evolution of the Concept, Past and Current Definitions, and Future Prospects," CNS Spectrums 22, no. 2 (2017), https://www.ncbi.nlm.nih.gov/pubmed/28264741. 374 Ibid. 375 ἢ γὰρ ἥσυχοι, ἢ στυγνοὶ, κατηφέες, νωθροὶ ἔασι ἀλόγως, οὔ τινι ἐπ᾽ αἰτίῃ, μελαγχολίης ἀρχή. Aret., SD 1.5.4 (Adams, 299). 376 ζωῆς κακήγοροι, ἔρανται δὲ θανάτου. Aret., SD 1.5.6 (Adams, 300).

89 disillusionment follows another…the thought occurs to take his life.’377 Some patients described the world as dull and gray, and that their feeling of existence diminished as time went on. In

Psychiatrie, a good clinical picture of a depressed patient is illustrated via their letter to a family member: ‘I am loathsome of myself and wholly weary of life…I am a horror and am hounded by furies…life itself is a frightful torment…no medicine takes effect…my life is comfortless and only bearable so long as I am complaining of my distress…’378 Moving from the psychological symptoms to physical ones, parallelisms are observed as well. Aretaeus reported melancholic patients as having visions that were azure in color, they were cold to touch, their digestion was stunted, and their dreams were terrifying. Kraepelin reported similar bodily symptoms such as

‘lowered [body temperature] in severe states of depression,’ and high temperature in violent excitatory states.379 In addition to this, patients had heaviness in the limbs, poor appetite, strong aversion to food, suffered from constipation, skin was pale, dry, rough, the eyes lustreless, and dejections of the body were scanty and dried up.380 The resemblance of symptomology is eerily similar to what Aretaeus reported. All of Aretaeus’ descriptions of melancholic symptoms can be observed under Kraepelin’s depressive states.

Recall in Chapter 3.3.3, that Aretaeus observed three subgroups of mania: madness with joy, madness with anger, and ingenious madness. This is reflective of Kraepelin’s manic states

(refer to Table 2): hypomania, acute mania, delusional mania, and delirious mania. In Aretaeus’ observations, mania produced extraordinary phantasies that were unconventional and not cognitively sound. In one instance, Aretaeus tells us that ‘one will not drink, as fancying himself

377 Kraepelin, Manic-Depressive Insanity and Paranoia, 76. 378 Ibid., 79. 379 Ibid., 52. 380 Ibid., 44-53.

90 a brick, and fearing lest he should be dissolved by the liquid.’381 Extraordinary hallucinations are observed in delirious mania states. Kraepelin reported of one female patient who, in numerous attacks of delirious mania ‘fancied that she was surrounded by historical celebrities, Louis XIV,

Caesar, Elizabeth, called that her “historical delusion.”’382 At the height of the disease, Aretaeus reported manic patients suffering from ‘impure dreams and irresistible desire of venery, without any shame and restraint as to sexual intercourse; if aroused or restrained, they become wholly mad.’383 Likewise, Kraepelin noted sexual excitability in acute mania as ‘an outlet in obscene talk, forcible approach to youthful patients, shameless masturbations…’384 Aretaeus reports patients having ‘rendered their clothes and kill[ed] their keepers and lay violent hands upon themselves’385 and they ‘laugh, play, dance night and day.’386 Similar symptoms are found in

Kraepelin’s delirious mania state, patients are not still, ‘they dance about, perform peculiar movements, shake their head…smear everything, make impulsive attempts at suicide, [and] take off their clothes.’387 Kraepelin reports of one patient who was found naked in a park, another patient ‘ran half-clothed into the corridor and then into the street.’388 Likewise, Aretaeus recalls patients who ‘[went] to the wilderness to live by themselves.’389 In the accounts of both authors, manic patients seemed to display behavioral patterns that were peculiar, high energy, inappropriate, and impulsive.

381 Refer to Appendix B for the Greek. Aret., SD 1.6.6 (Adams, 302) 382 Kraepelin, Manic-Depressive Insanity and Paranoia, 70-71. 383 ἐπὶ κορυφῆς δὲ τοῦ κακοῦ ὀνειρώττουσι: ἀφροδισίων δὲ ἄσχετος ἐπιθυμίη, ἀτὰρ οὐδὲ ἐς τὸ ἄμφαδον αἰδὼς ἢ ὄκνος ὁμιλίης∙ νουθεσίῃ δὲ καὶ ἐπιπλήξει ἐς ὀργὴν ἐκριπισθέντες ἐς τὸ πάμπαν ἐκμαίνονται. Aret., SD 1.6.10 (Adams, 304). 384 Kraepelin, Manic-Depressive Insanity and Paranoia, 64. 385 μετεξέτεροι δὲ ὑπὸ ὀργῆς ἐκμαίνονται. ἔσθ᾽ ὅτε ἐσθῆτάς τε ἐρρήξαντο, καὶ θεράποντας ἀπέκτειναν, καὶ ἑωυτέοισι χεῖρας ἐπήνεγκαν. Aret., SD 1.6.5 (Adams, 302). 386 καὶ οἷσι μὲν ἡδονὴ ᾖ ἡ μανίη, γελῶσι, παίζουσι, ὀρχεῦνται νυκτὸς καὶ ἡμέρης. Aret., SD 1.6.4 (Adams, 302). 387 Kraepelin, Manic-Depressive Insanity and Paranoia, 71. 388 Ibid., 71-72. 389 οἱ δὲ φυγανθρωπεύουσι ἐς ἐρημίην, σφίσι αὐτέοισι ὁμιλέοντες. Aret., SD 1.6.10-11 (Adams, 304).

Aretaeus’ perceptive differentiation of these symptoms was ‘a striking achievement for his day’:390 one would expect to find this organization and notion of mental illnesses in later eras.

On the topic of possible relapses of the condition, Kraepelin stated that about one-third of the patients could make a recovery. However, there were residual symptoms that could affect day-today functioning.391 In some cases, morbid symptoms lingered even after a long time after the patient’s state returned to normalcy. A female patient reported ‘after recovery from a severe, confused depression still for a number of weeks heard in decreasing strength “her brain chatter.”’392 I think it may be fair to say that Aretaeus recorded something similar to this in his description of relapses. He reports these on two occasions. Firstly, when the patient is not thoroughly cured, any number of causes: seasons, temperature, or diet could bring about a relapse.393 Secondly, when the patient is predisposed to certain behaviours (sluggishness and sorrow), they are ‘prone to melancholy; who have formerly been in a mad condition’ (οἵδε καὶ

μελαγχολῆσαι ἑτοιμότεροι∙ οἱ δὲ καὶ πρόσθεν ἐκμαίνονται).394 In the context of circularity, it is not clearly outlined by Aretaeus if the disorder could manifest itself in a continuous cycle of melancholia and mania with varying intervals in-between. Again, I think it is more reasonable to comprehend Aretaeus’ nosology on a spectrum.

390 Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, 28. 391 Zivanovic and Nedic, "Kraepelin's Concept of Manic-Depressive Insanity: One Hundred Years Later," 19. 392 Kraepelin, Manic-Depressive Insanity and Paranoia, 98. 393 ἡ ὥρη τὸ ἔαρ, ἢ ἁμαρτωλὴ διαίτης, ἢ ὀργὴ ἐκ συντυχίης ἐς ἀνάκλησιν ἤγαγε. Aret., SD 1.5.3 (Adams, 299) 394 Aret., SD 1.6.2 (Adams, 301).

Significant Difference in Aetiology. Although the two writers used similar language and descriptors for the symptomology of melancholia and mania, I propose that they were not in fact so similar in the whole of their conceptualisation. In the current psychiatric understanding, we would label Aretaeus’ theory as following Griesinger’s395 Einheitpsychose (unitary psychosis model).396 In the nineteenth century, Griesinger considered mania to be the end state of a progressively worsening melancholia. Aretaeus, likewise, proposed the same logic. In Chapter

3.3, I mentioned that Aretaeus noticed a pattern of progressive deterioration of cephalaea, if not cured, would worsen into vertigo, which would worsen into melancholia, mania or epilepsy; and within this, if melancholia worsened, the patient would have mania. Kraepelin opposed this model. If Kraepelin ever came across Aretaeus’ work, I believe he would have challenged

Aretaeus’ notion of each disease progressing and worsening into one final disease. Kraepelin went against the grain of German psychiatric beliefs during his time397 as well as the opinions of other European psychiatrists.398 Instead Kraepelin introduced, what current scholarship refers to as, the Kraepelinian dichotomy of dementia praecox and MDI. Although some scholars deem this to be Kraepelin’s most significant achievement in psychiatry, Kraepelin himself was critical

395 I specify the model by Griesinger because he adopted this concept without the theoretical underpinnings of the original concept of unitary psychosis (the view that all mental diseases are placed along a single continuum). Thomas A. Ban, "Wilhelm Griesinger and Unitary Psychosis (Einheitpsychose)," Bulletin 29, no. Neuropsychopharmacology in Historical Perspective. Education in the Field in the Post-Neuropsychopharmacology Era (2018), http://inhn.org/home/central-office-cordoba-unit/education/thomas-a-ban-neuropsychopharmacology-in- historical-perspective-education-in-the-field-in-the-post-neuropsychopharmacology-era/bulletin-29-wilhelm- griesinger-and-unitary-psychosis-einheitpsychose.html. 396 Other articles support my argument that Aretaeus follows the unitary psychosis model. Such as in: Carlos Rojas- Malpica et al., "Revisiting Unitary Psychosis, from Nosotaxis to Nosology," Salud Mental 35, no. 2 (2012). Or in: N.Y. Pyatnitskiy, "To the Origins of The'unitary Psychosis' Doctrine: From Aretaeus to V. Chiarugi," Zhurnal nevrologii i psikhiatrii imeni SS Korsakova 118, no. 5 (2018). 397 Angst and Marneros, "Bipolarity from Ancient to Modern Times: Conception, Birth and Rebirth". 9. 398 Falret’s folie circulaire (circular insanity): a continuous cycle of mania, depression and free intervals of varying lengths between two extremes. And Baillarger’s folie à double forme (alternating insanity): mania and melancholia changed into one another but without a requirement for a free interval between the two extremes.

93 of his own taxonomy in the 1920 paper Die Erscheinungsformen des Irreseins (The

Phenomenological Forms of Insanity).399 In this paper, Kraepelin wrote:

The cases which are not classifiable (namely to manic-depressive insanity

or dementia praecox) are unfortunately very frequent (Kraepelin, 1920, p.

26). Two pages later he made a decisive and for him certainly not an easy

statement: ‘‘We have to live with the fact that the criteria applied by us are

not sufficient to differentiate reliably in all cases between schizophrenia and

manic-depressive insanity. And there are also many overlaps in this area…”

(i.e. between schizophrenia and affective disorders; Kraepelin, 1920, p.

28).400

I believe, had Kraepelin been able to continue researching and writing, he would continue his self-criticism. Interestingly, although Aretaeus understood disease progression as being linear

(melancholia worsening into mania), he also understood that melancholia and mania were two parts of the same disease. This is where things get a tad enigmatic. If we turn our focus onto this

Aretaean association (melancholia and mania being two parts of one disease), we will observe the same association within Kraepelin. He proposed the unification of all affective disorders of depression and mania to be under a single morbid process: manic-depressive insanity (MDI).401

All depressive and manic states, the transition period from depression to mania and vice versa,

399 A. Marneros and J. Angst, Bipolar Disorders: 100 Years after Manic-Depressive Insanity (Springer Netherlands, 2007). 400 Ibid., 15. 401 ‘Manic-depressive insanity . . . includes on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases of amentia (confusional or delirious insanity). Lastly, we included here certain slight and slightest colourings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders, on the other hand pass without sharp boundaries into the domain of personal predisposition . . . I have become more and more convinced that all of the above-mentioned states only represent manifestations of a single morbid process.’ [italics in original] Kraepelin, Manic-Depressive Insanity and Paranoia, 1.

94 mixed states of depressive and manic symptoms, mild and severe cases of depression and mania,

‘the whole domain of periodic and circular insanity,’402 alternating or not, all had one common underlying pathology,403 and all were placed into MDI. All things considered whether Aretaeus understood mania and melancholia as alternating (or not), his understanding of them as being one disease (not separate diseases)404 has a strong correlation to Kraepelin’s view of all forms placed into MDI.

I believe both writers are strong in their classification of diseases (nosology) and description of symptoms, however, they are not as similar in their explanations of causation

(aetiology). They both outlined sex differences, which I will briefly point out. However, for more an in-depth discussion, please refer to Chapter 2.4 for Kraepelin and Table 4 for Aretaeus. In manic states, Aretaeus observed that women were worse affected; likewise, Kraepelin found that statistically, 70% of MDI patients were female. For both melancholia and mania, Aretaeus noted that young men (before adulthood) were prone to the disease; Kraepelin found purely manic states to occur in males before the age of twenty-five. I would like to bring up now the conversation of premorbidity, the state of functionality before a patient’s onset of an illness. I believe Aretaeus and Kraepelin are similar in thinking that the susceptibility to diseases405 is dependent on premorbid conditions, such as an inborn temperamental disposition.406 According to Kraepelin, ‘the morbid picture is usually perceptible already in youth and may persist without

402 Millon notes that Kraepelin (like Kahlbaum) ‘viewed “circular insanity” to be a unitary illness.’Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, 182. 403 Zivanovic and Nedic, "Kraepelin's Concept of Manic-Depressive Insanity: One Hundred Years Later," 16. 404 Edward Shorter, "Bipolar Disorder in Historical Perspective " in Bipolar Ii Disorder: Modelling, Measuring and Managing, ed. Gordon Parker (United Kingdom Cambridge University Press, 2008), 5. 405 Kahlbaum (who was an influence on Kraepelin) did not have an opinion on susceptibility. Swann, "Mixed Features: Evolution of the Concept, Past and Current Definitions, and Future Prospects". 163. 406 Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, 182.

95 essential change throughout the whole of life.’407 As mentioned in Chapter 3.4, Aretaeus reported people who were predisposed to mania were characteristically ‘naturally passionate, irritable, of active habits, of an easy disposition, joyous, and puerile.’408 By contrast, those prone to melancholia were characteristically ‘sluggish, sorrowful, slow to learn but patient in labour, and who when they learn anything, soon forget it.’409 Kraepelin stated that MDI patients seemed to have an artistic predisposition. A similar sentiment is observed in Aretaeus’ categorization of the ingenious madness subtype where patients produced ‘spontaneous philosophy and poetry that truly came from the muses.’410 Kraepelin mentioned many other morbid predispositions (such as hereditary taint411 or alcoholism412), but was uncertain about other possible causes 413 noting:

‘about the nature of manic-depressive insanity, we are still in complete uncertainty.’414

Aretaeus was limited to the sources available in his own era, and the same can be said for

Kraepelin. Kraepelin, largely due to time restraints, frequently made use of his connections to scientists and scholars in other fields as well as his students and research assistants. Kraepelin concluded that the ignorance about the causes of mental disorders was not only due to the lack of research tools but also the deeper issue of the ‘very nature of mental disorders.’415 Mental disorders did not originate from just the inner states but also an individual’s ‘external

407 Kraepelin, Manic-Depressive Insanity and Paranoia, 123. 408 καὶ γὰρ δὴ νοσέουσι οἱ φύσι ὀργίλοι, ὀξύθυμοι, Ρ῾έκται, εὐμαρέες, ἱλαροὶ, παιδιώδεες∙ ἀτὰρ καὶ οἷσι ἐς ἐναντίην ἰδέην ἡ φύσις Ρ῾έπει, ὁκόσοι νωθροὶ, ἐπίλυποι, βραδεῖς μὲν ἐκμαθεῖν, ἐπίμονοι δὲ προσκαμεῖν, ποτὶ καὶ μαθόντες, ἀμνήμονες, οἵδε καὶ μελαγχολῆσαι ἑτοιμότεροι, οἱ δὲ καὶ πρόσθεν ἐκμαίνονται. Aret., SD 1.6.3 (Adams, 301). 409 Ibid. 410 Aret., SD 1.6.5 (Adams, 302). 411 Kraepelin reports that hereditary taint was demonstrated in a considerable number (80%) of cases observed in the Heidelberg Clinic. Kraepelin, Manic-Depressive Insanity and Paranoia, 165. 412 Kraepelin reports that alcoholism was demonstrated in the patient’s parents in one-third of the cases. Ibid. 413 Weber and Engstrom in their re-analysis of the Zählkarten found that ‘in about a half of all cases one or both of the categories “heredity” (54%) and “etiology” contain no entry. For the most part, general descriptions, e.g. “nervousness,” “mental illness,” “old age” or “alcoholic,” prevail in these card categories. The psychopathological status is also dominated by unspecified termini.’ Weber and Engstrom, "Kraepelin Diagnostic Cards the Confluence of Clinical Research and Pre Conceived Categories," 382. 414 Kraepelin, Manic-Depressive Insanity and Paranoia, 181. 415 Kendler and Jablensky, "Kraepelin's Concept of Psychiatric Illness". 1121.

96 dangers.’416 Kraepelin wished to separate and distance himself from cerebral pathology417 and adopted a larger whole-body approach that took into account several etiologic factors.418

Aretaeus thought of mental diseases as physiological and behavioral: such is his explanation that melancholia and mania are a result of afflictions to the head and bowels. Moreover, he offers a discussion on temperaments and behavioral abnormalities.419 Thumiger suggests that ‘the first conceptualisation of insanity is located on [an] invisible level, that of the thoughts and feelings of the affected individual.’420 There is no substantial evidence in the original text that hints at

Aretaeus’ perception of this unobservable level of the mind. The closest evidence we have is his mention that melancholia and mania affected the head. As an observer, and for an ancient writer,

Aretaeus was limited to descriptions of what he could see. The realm of the individual (and invisible) mind, and the ability to observe on a microscopic level (ability to see neurons, for example) was an impassable space of understanding. It could not even be ‘posited as territory one might try to penetrate.’421 As Zucker puts it, ‘ancient psychology’ does not concern itself with the ‘science of the inner mind (the self and personal identity) nor the study of hidden mental processes.’422 In examining Aretaeus and Kraepelin, their symptomologies were sound, yet both of their aetiologies were unsubstantiated and often not thoroughly discussed. Engstrom finds that

416 Ibid. 417 Engstrom, "Tempering Madness: Emil Kraepelin’s Research on Affective Disorders". 168. 418 Engstrom and Kendler, "Emil Kraepelin: Icon and Reality". 1193. 419 Swann thinks Aretaeus is biological and Kraepelin is behavioral. Swan writes: ‘Kraepelin looked systematically at components of observed behavior, while Aretaeus and his contemporaries looked at the consequences of proposed combinations of physiological factors.’ Swann, "Mixed Features: Evolution of the Concept, Past and Current Definitions, and Future Prospects". 162. Zucker also said: ‘Ancient psychology is mainly the study of the physiology and dynamics of living beings. Moreover, it ‘did not regard “study of the mind” as an autonomous subject with specific terms of reference (Long 1973, 1)’. Arnaud Zucker, "Psychology and Physiognomics," ed. Georgia L. Irby, A Companion to Science, Technology, and Medicine in Ancient Greece and Rome (John Wiley & Sons 2016). 1. However I think it is fair to assess that Aretaeus, in the case of melancholia and mania, looked at both physiology and behavior. 420 Thumiger, A History of the Mind and Mental Health in Classical Greek Medical Thought, 67. 421 Ibid., 73. 422 Zucker, "Psychology and Physiognomics," 1.

Kraepelin was trying to ‘close the empirical gaps in his clinical evidence’ via the exploitation of prison, school, and military records. As Hermsen effectively said: ‘Kraepelin remained agnostic about aetiology, believing only that the cause of mental disturbance was something unknown and thus unhelpful in developing a definitive classification system. His disease classes, like those proposed by others before him, were based on symptomology.’423

423 Lisa Hermsen, "Mania Multiplies with Fury: Textbook Descriptions of the Psychopathology," in Manic Minds: Mania's Mad History and Its Neuro-Future (Piscataway: Rutgers University Press: 2011), 25.

4.1 Conclusion

It is my hope by this point that the questions of what a comparative study such as this can offer; and what it implies (especially in today’s interests) have been answered to a degree. By tracing the semantics of melancholia and mania, their symptomology and epistemology— from

Hippocrates to Aretaeus, to Falret and Baillarger to Kraepelin— it can be said, without a doubt, that there exists a conceptual coherence. It seems the evolution of these diseases, and by extension, the report of these diseases has largely remained consistent.424 Recall in Chapter 1.1 on the discussion of mania in non-scientific literature, such as the heroes of the Homer’s Iliad, or the tragedies of Euripides and Aeschylus: scholars such as Bennett proposed that, although not traditionally considered medical writing, the representations of mania by several playwrights ‘are quite accurate from a psychodynamic viewpoint.’425 Aretaeus’ treatise influenced Western medicine from the sixteenth century onwards, and Kraepelin undoubtedly influenced (and continues to influence) nosology and modern psychiatry. I think both medical writers effectively highlighted the importance of perceptive observations (as opposed to just theorization) and conducting longitudinal studies as an essential technique in diagnosing. Goodwin and Jamison have said that Kraepelin ‘was the first fully developed disease model in psychiatry to be backed by extensive and carefully organized observations and descriptions. This model did not exclude psychological or social factors.’426 Arguably, to some extent, Aretaeus is considered by many to be the first to give an account close to our current understanding of bipolar disorder. The publications of classifying mental disorders from Kraepelin’s work written nearly one hundred years ago remains as ‘the foundation of psychiatric nosology and scientific psychiatry.’427

424 Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 7. 425 Bennett, Mind and Madness in Ancient Greece: The Classical Roots of Modern Psychiatry 101. 426 Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 7. 427 Zivanovic and Nedic, "Kraepelin's Concept of Manic-Depressive Insanity: One Hundred Years Later," 15.

Aretaeus certainly was not a psychiatrist; however, he was a physician with an acute ability to observe accurately. Some scholars consider Aretaeus’ treatise as comparable to a ‘modern handbook of medicine.’428 I believe his nosology, and by extension, treatment of diseases to be of substantial importance and displays his pursuit to compare clinical syndromes. I would like to echo the sentiments of Jackson in saying that there is a ‘remarkable continuity’ in the symptoms of Aretaeus’ melancholia and Kraepelin’s depression (as well Aretaeus’ mania to Kraepelin’s).429

Scholars have said that ‘the melancholia of Aretaeus is still observed in our time, although under different psychiatric labels.’430 Likewise, Kraepelin’s contributions to psychiatry are momentous.

The current psychiatric diagnostic system is said to have derived from Kraepelin, ‘the DSM-IV a direct descendant of his ground-breaking Lehrbuch.’431 It is to Kraepelin that ‘we owe our emphasis on documenting the longitudinal course of the illness.’432 If we allow for their different modes of expression and cultural norms, Aretaeus and Kraepelin have many similarities and one significant difference. I am not suggesting that we could (or should) reduce either author to the other. But we cannot erase the undeniable ‘air de famille.’433 There seems to exist, through a rich history, an established linkage and coherence of this melancholic-manic disease. Though this thesis is a short sweep of history spanning two millennia with its focus on only two medical writers, it certainly does not and (could not) shed light on the complete history of manic- depressive disease. I think what it does show is that by carrying out this research, I have been

428 Sotiris Kotsopoulos, "Aretaeus the Cappadocian on Mental Illness," Comprehensive Psychiatry 27, no. 2 (1986): 178. 429 Matthew Bell, "Introduction," in Melancholia (2014), 3. 430 Millon, Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium, 29. 431 Francis M. Mondimore, "Kraepelin and Manic-Depressive Insanity: An Historical Perspective," International Review of Psychiatry 17, no. 1 (2009): 52. 432 Goodwin and Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, xix. 433 Jackie Pigeaud, "La Rhétorique D'arétée," La médecine grecque antique. Publications de l'Académie des Inscriptions et Belles-Lettres 15, no. 1 (2004), https://www.persee.fr/doc/keryl_1275-6229_2004_act_15_1_1091.

100 able to determine whether there are differences in conceptualizations and classifications of melancholia and mania. And if differences exist, whether they are significant, and on the whole, if there is a depiction of continuity from the ancient Greeks to Kraepelin’s time. I am a proponent of neuroscientific research and believe that neuroscience can explain and understand the inner workings of the brain. However, might it be possible to suggest that perhaps, like the Greeks and like Kraepelin, we must not be so quick to fully eliminate our trust in full observations of the patient: mental illness manifests itself in all aspects of an individual’s life, including through human behavior and bodily appearance. In pursuing this topic, I hope to have proved in some way, the advantages of inquiring into the history of medicine. It is not only crucial for the process of amalgamating past medical writings, but it also brings about a critical way of thinking and understanding issues that link to current medical understandings and practices in both research and clinical settings. In writing this thesis, I hope to have provided some interesting research for anyone remotely curious about the roots of our Western medicine, in particular, within the case of Aretaeus’ and Kraepelin’s melancholia and mania.

101

Bibliography

Thesaurus Linguae Graecae : a Digital Library of Greek Literature. Irvine, California.

(UTSIC), University of Toronto Scientific Instruments Collection. "Hipp Chronoscope " In

Psychology

"Adolf Meyer." In Encyclopaedia Britannica, edited by Encyclopaedia Britannica: Encyclopædia

Britannica, inc.

Allik, Juri, and Erik Tammiksaar. "Who Was Emil Kraepelin and Why Do We Remember Him

160 Years Later." Trames. Journal of the Humanities and Social Sciences 20 (70/65), no.

4 (2016): 317-35.

Angst, Jules, and Andreas Marneros. "Bipolarity from Ancient to Modern Times: Conception,

Birth and Rebirth." Journal of Affective Disorders 67(2001): 3-19. doi:10.1016/s0165-

0327(01)00429-3.

Apollonius, Rhodius. Argonautica. Translated by William H. Race. Loeb Classical Library.

Cambridge, Mass.: Harvard University Press, 2009.

doi:10.4159/DLCL.apollonius_rhodes-argonautica.

Aretaeus. "Aretaeus: Corpus Medicorum Graecorum ", edited by Karl Hude. Berlin: Akademie

Verlag, 1958.

———. "The Extant Works of Aretaeus, the Cappadocian." edited by Francis Adams. Boston:

Milford House 1972.

Ban, Thomas A. "Wilhelm Griesinger and Unitary Psychosis (Einheitpsychose)." Bulletin 29,

no. Neuropsychopharmacology in Historical Perspective. Education in the Field in the

Post-Neuropsychopharmacology Era (2018). Published electronically August 2.

http://inhn.org/home/central-office-cordoba-unit/education/thomas-a-ban-

102

neuropsychopharmacology-in-historical-perspective-education-in-the-field-in-the-post-

neuropsychopharmacology-era/bulletin-29-wilhelm-griesinger-and-unitary-psychosis-

einheitpsychose.html.

Bell, Matthew. "Introduction." In Melancholia, 1-32, 2014.

———. Melancholia: The Western Malady. Cambridge: Cambridge University Press, 2014. doi:

doi:10.1017/CBO9781107707122.

Bennett, Simon. Mind and Madness in Ancient Greece: The Classical Roots of Modern

Psychiatry Ithaca and London Cornell University Press, 1978.

Bentall, Richard P. Madness Explained: Psychosis and Human Nature London, England:

Penguin Books Ltd 2003.

Dally, J.F. Halls. "Life and Times of Jean Nicolas Corvisart (1755-1821): Section of the History

of Medicine." Proceedings of the Royal Society of Medicine 34, no. 5 (1941): 239–46.

Digby, Anne. "Daniel Hack Tuke (1827–1895)." (2004). doi:10.1093/ref:odnb/27804,

https://www.oxforddnb.com/view/10.1093/ref:odnb/9780198614128.001.0001/odnb-

9780198614128-e-27804.

"Emil Kraepelin (1856-1926) Psychiatric Nosographer." JAMA 203, no. 11 (1968): 978-79.

Engstrom, E. J., and M. M. Weber. "Kraepelin, E. (1887) Die Richtungen Der Psychiatrischen

Forschung: The Directions of Psychiatric Research by Emil Kraepelin." History of

Psychiatry 16 (2005): 350-64.

Engstrom, Eric J. "Emil Kraepelin’s Inaugural Lecture in Dorpat: Contexts and Legacies."

Trames. Journal of the Humanities and Social Sciences 20(70/65), no. 4 (2016): 337-50.

doi:10.3176/tr.2016.4.02.

103

———. "Kraepelin’s Clinical Research Methods." In Research Seminar at Virginia Institute for

Psychiatric and Behavioral Genetics, Virginia Commonwealth University, 2017.

———. "Tempering Madness: Emil Kraepelin’s Research on Affective Disorders." Osiris 31,

no. 1 (2016): 163-80. Published electronically Jan 1.

Engstrom, Eric J. , and Kenneth S. Kendler. "Emil Kraepelin: Icon and Reality." Am J

Psychiatry 172, no. 12 (2015): 1190-6. doi:10.1176/appi.ajp.2015.15050665,

https://www.ncbi.nlm.nih.gov/pubmed/26357868.

Engstrom, Eric J., Matthias M. Weber, and Wolfgang Burgmair. "Emil Wilhelm Magnus Georg

Kraepelin (1856–1926)." Am J Psychiatry 163, no. 10 (2006): 1710.

Goodwin, Frederick K, and Kay Redfield Jamison. Manic-Depressive Illness: Bipolar Disorders

and Recurrent Depression. Second ed.: Oxford University Press, 2007.

Healy, David. "From Mania to Bipolar Disorder." Chap. One In Bipolar Disorder: Clinical and

Neurobiological Foundations, edited by Mario Maj Lakshmi N. Yatham: Wiley Online

Library, 2010.

———. Mania: A Short History of Bipolar Disorder. Baltimore, Maryland: John Hopkins

Universtiy Press, 2008.

Hermsen, Lisa. "Mania Multiplies with Fury: Textbook Descriptions of the Psychopathology."

Chap. 1 In Manic Minds: Mania's Mad History and Its Neuro-Future, 13-36. Piscataway:

Rutgers University Press, 2011.

Hippocrates. Nature of Man. Translated by W.H.S. Jones. Loeb Classical Library 150.

Cambridge, MA: Harvard University Press, 1931. doi:10.4159/DLCL.hippocrates_cos-

nature_man.1931.

104

———. The Sacred Disease. Translated by W. H. S. Jones. Loeb Classical Library 148. Harvard

University Press 1923. doi:10.4159/DLCL.hippocrates_cos-sacred_disease.1923.

Hoff, Paul. "The Kraepelinian Tradition." Dialogues in Clinical Neuroscience 17, no. 1 (2015):

31-41.

Homer. Iliad. Translated by A. T. Murray. Loeb Classics Library 170. Cambridge, MA: Harvard

Universtiy Press 1924. doi:10.4159/DLCL.homer-iliad.1924.

Jablensky, Assen. "Living in a Kraepelinian World: Kraepelin's Impact on Modern Psychiatry."

History of Psychiatry 18, no. 3 (2007): 381-88. doi:10.1177/0957154X07079690,

https://www.ncbi.nlm.nih.gov/pubmed/18175638.

Jackson, Stanley W. Melancholia and Depression: From Hippocratic Times to Modern Times.

New Haven: Yale University Press, 1986.

Johnston, Patricia A, Attilio Mastrocinque, and Sophia Papaioannou. Animals in Greek and

Roman Religion and Myth. Cambridge Scholars Publishing, 2016.

Jouanna, Jacques. "At the Roots of Melancholy: Is Greek Medicine Melancholic?" In Greek

Medicine from Hippocrates to Galen, edited by Philip van der EijkBrill, 2012.

https://www.jstor.org/stable/10.1163/j.ctt1w76vxr.17.

Kahn, E. "Emil Kraepelin: Ein Gedenkblatt Zum 100. Geburtstag." Monatsschrift für Psychiatrie

und Neurologie 131 (1956): 190-92.

Katsambas, A, and SG Marketos. "Hippocratic Messages for Modern Medicine." Historical

Perspective 21(2007): 859-61. doi:10.1111/j.1468-3083.2007.02231.x.

Kendler, K. S., and A. Jablensky. "Kraepelin's Concept of Psychiatric Illness." Review,

Psychological Medicine 41, no. 6 (2011): 1119-26. doi:10.1017/S0033291710001509,

https://www.ncbi.nlm.nih.gov/pubmed/20809997.

105

Kotsopoulos, Sotiris. "Aretaeus the Cappadocian on Mental Illness." Comprehensive Psychiatry

27, no. 2 (March/April 1986): 171-79.

Kraepelin, Emil. Manic-Depressive Insanity and Paranoia. Translated by Mary R. Barclay.

Originally from Psychiatrie: Ein Lehrbuch Für Studierende Und Ärzte Achte Ausgabe

(Psychiatry: A Manual for Students and Physicians, Eighth Edition). Edinburgh: E.&S.

Livingstone 1921.

———. Memoirs. Translated by C. Wooding-Deane. Heidelberg: Springer-Verlag, 1987.

Kyziridis, Theocharis Chr. "Notes on the History of Schizophrenia." German Journal of

Psychiatry 8, no. 3 (2005): 42-48.

Marchand, Suzanne L. Down from Olympus: Archaeology and Philhellenism in Germany, 1750-

1970. Princeton University Press, 1996.

Marneros, A., and J. Angst. Bipolar Disorders: 100 Years after Manic-Depressive Insanity.

Springer Netherlands, 2007.

Martin, E.A., and Oxford University Press. Concise Medical Dictionary. Ninth ed.: Oxford

University Press, 2015. doi:10.1093/acref/9780199687817.001.0001.

McDonald, Glenda Camille. "Concepts and Treatments of Phrenitis in Ancient Medicine."

Newcastle University, 2009.

Merriam-Webster. "Catamnesis."

Millon, Theodore. Masters of the Mind: Exploring the Story of Mental Illness from Ancient

Times to the New Millennium. New Jersey: John Wiley & Sons, Inc., 2004.

Misbach, Judith, and Henderikus J. Stam. "Medicalizing Melancholia: Exploring Profiles of

Psychiatric Professionalization." Journal of the History of the Behavioral Sciences 42,

no. 1 (2006): 41-59.

106

Mondimore, Francis M. "Kraepelin and Manic-Depressive Insanity: An Historical Perspective."

International Review of Psychiatry 17, no. 1 (2009): 49-52.

Murphy, Kate. "The Conceptualization and Treatments for Phrenitis, Mania and Melancholia in

Aretaeus of Cappadocia and Caelius Aurelianus." University of Calgary, 2013.

Myrne, Pernilla. Female Sexuality in the Early Medieval Islamic World: Gender and Sex in

Arabic Literature. Bloomsbury Publishing, 2019.

Noll, Richard. "Kraepelin's 'Lost Biological Psychiatry'? Autointoxication, Organotherapy and

Surgery for Dementia Praecox." History of Psychiatry 18, no. 3 (2007): 301-20.

doi:10.1177/0957154X07078705, https://www.ncbi.nlm.nih.gov/pubmed/18175634.

Nutton, Vivian. "Humoral Alternatives." Chap. 14 In Ancient Medicine. London: Routledge,

2012.

Osler, William. The Evolution of Modern Medicine : A Series of Lectures Delivered at Yale

University on the Silliman Foundation in April, 1913. London, UK: Yale University

Press, 1921.

Pearce, J.M.S. "The Neurology of Aretaeus- Radix Pedis Neurologia." European Neurology

70(2013): 106-12. doi:10.1159/000352031.

Pigeaud, Jackie. "La Rhétorique D'arétée." La médecine grecque antique. Publications de

l'Académie des Inscriptions et Belles-Lettres 15, no. 1 (2004): 177-97.

https://www.persee.fr/doc/keryl_1275-6229_2004_act_15_1_1091.

Porter, Roy. Madness: A Brief History. Oxford ; New York: Oxford University Press, 2002.

"Preface." In Manic-Depressive Insanity and Paranoia, edited by George M. Robertson.

Translated 8th Ed. Of Emil Kraepelin Edinburgh: Livingstone 1921.

107

Pyatnitskiy, N.Y. . "To the Origins of The'unitary Psychosis' Doctrine: From Aretaeus to V.

Chiarugi." Zhurnal nevrologii i psikhiatrii imeni SS Korsakova 118, no. 5 (2018): 111-19.

Radden, Jennifer. The Nature of Melancholy: From Aristotle to Kristeva. Oxford University

Press, USA, 2002.

Rojas-Malpica, Carlos, Néstor de la Portilla-Geada, Adele Mobilli-Rojas, and Danilo Martínez-

Araujo. "Revisiting Unitary Psychosis, from Nosotaxis to Nosology." Salud Mental 35,

no. 2 (2012): 101-13.

The Oxford Classical Dictionary. Oxford University Press, 2005.

Scull, Andrew. "The Art of Medicine: Madness in Civilisation." The Lancet 385, no. 9973

(2015): 1066-67.

———. Madness in Civilization: A Cultural History of Insanity, from the Bible to Freud, from

the Madhouse to Modern Medicine. Princeton and Oxford: Princeton Universtiy Press

2016.

Shepherd, Michael. Conceptual Issues in Psychological Medicine. Psychology Press, 1998.

Shorter, Edward. "Bipolar Disorder in Historical Perspective ". In Bipolar Ii Disorder:

Modelling, Measuring and Managing, edited by Gordon Parker. United Kingdom

Cambridge University Press, 2008.

———. A Historical Dictionary of Psychiatry. Oxford University Press, USA, 2005.

Siegel, Rudolph E. "Clinical Observation in Hippocrates- an Essay on the Evolution of the

Diagnostic Art." 285-303.

Swann, Alan C. "Mixed Features: Evolution of the Concept, Past and Current Definitions, and

Future Prospects." CNS Spectrums 22, no. 2 (2017): 161-69.

doi:10.1017/S1092852916000882, https://www.ncbi.nlm.nih.gov/pubmed/28264741.

108

Taylor, Michael Alan, and Max Fink. "Melancholia: A Conceptual History." Chap. One In

Melancholia: The Diagnosis, Pathophysiology and Treatment of Depressive Illness, 1-14.

Cambridge Cambridge University Press 2006.

Thumiger, Chiara. A History of the Mind and Mental Health in Classical Greek Medical

Thought. Cambridge: Cambridge University Press, 2017.

Toohey, Peter. "Blurring the Boundaries of the Self." Chap. One In Melancholy, Love, and Time:

University of Michigan Press 2010.

———. Boredom: A Lively History. Yale University Press, 2011.

———. "Some Ancient Histories of Literary Melancholia." Illinois Classical Studies 15, no. 1

(1990): 143-61.

Trede, Katharina, Paola Salvatore, Christopher Baethge, Angela Gerhard, Carlo Maggini, and

Ross J. Baldessarini. "Manic-Depressive Illness: Evolution in Kraepelin's Textbook,

1883–1926." Harvard Review of Psychiatry 13, no. 3 (2005): 155-78.

doi:10.1080/10673220500174833, https://www.ncbi.nlm.nih.gov/pubmed/16020028.

Weber, Matthias M., and Eric J. Engstrom. "Kraepelin Diagnostic Cards the Confluence of

Clinical Research and Pre Conceived Categories." History of Psychiatry (1997): 375-85.

Zivanovic, Olga, and Aleksandra Nedic. "Kraepelin's Concept of Manic-Depressive Insanity:

One Hundred Years Later." Journal of Affective Disorders 137 (2012): 15-24.

Zucker, Arnaud. "Psychology and Physiognomics." In A Companion to Science, Technology, and

Medicine in Ancient Greece and Rome, edited by Georgia L. IrbyJohn Wiley & Sons

2016.

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Appendices

I have included two appendices to further highlight Kraepelin’s Zählkarten (Appendix

A), and Aretaeus’ case studies (Appendix B). In rounding out Chapter 2 on Emil Kraepelin, I have provided scanned images in Appendix A of four Zählkarten pertaining to the diagnoses of mania and MDI.434 This serves as a visual aid and provides insight into what information

Kraepelin decided to record. Notes on the Zählkarten such as “Convicted to: Emmendingen;

Pforzheim,” refer to the two asylums in which patients were transferred from Kraepelin’s

Heidelberg clinic (mentioned in Section 2.1.2). Appendix B provides the complete case studies in Greek and translation. These were found and extracted from Aretaeus’ chapters on

Melancholia and Mania.

Appendix A: Kraepelin’s Zählkarten

I received help in translation from Dr. Eric J. Engstrom and Dr. Reyes Bertolín Cebrián. I have obtained permission from the historical archivist Mr. Clemens Dücker of the Max-Planck Institut für Psychiatrie to use these Zählkarten [MPIP-K20/SK VI] in my thesis. The names of the patients have been omitted.

434 I was given access to the original materials of Kraepelin by Dr. Britta Leise, head of Historical Archives at the Max-Planck Institut für Psychiatrie in Munich. These scans were taken during my visit in July 2019.

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Patient A:

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Patient A Translation

This diagnostic card is pink, denoting that the patient was female. I have decided, with this card belonging to ‘Patient A’, to imitate the original format. Square brackets are used to denote clarification or to add my own commentary.435

Grossh. Heidelberg University Medical Center Diagnosis: False Diagnosis: Manic (1882) Name: [omitted for privacy] Born: Götter Age: 36 Born (date): 03.02.1862 Place of birth: Sulzfeld Last place of residence: Sinsheim Standing: single; married; widowed; divorced Children: 8; of which died: 1 Employment: Religion: Ev. [abbr. for evangelical] Day of admission: 09.06.1898, 08.09.1882 Day of discharge: 02.01.1899, 15.01.1883 Type of dismissal/discharge: healed; cured of the attack; reformed; unhealed (uncurable / curable); died Convicted to: Emmendingen; Pforzheim. Sinsheim [handwritten] Hereditary: Ø Aetiology: 29.III.98 birth, breastfeeding Prehistory: Normal development; at 17 J. Menses; previously slight excitement, lasted about 10 days, chatted, was very lively. Generally, quickly and heated. 1) Menses [cessirend- ceased?] for 1/2 years. Worked a few weeks ago, was very eager, wanted to do everything on her own, talked to the pastor into the sermon, inconsistent, chatted a lot, slept badly, cheerfully, uninhibited, calls everyone "you", wants to decorate herself, restless, fleeting ideas, laughs, [grimmassirt?], gesticulates, thirst for action, has seen shapes, temporary fear. Bares herself. aggressive, dancing, singing, alliterated, erotic, loud at night, restless, very violently excited. – [Heirath?] with 24 yrs. 2) Whining for 14 days at night, everything is broken, everything is torn. No longer slept, ate little, could no longer think properly, mixed up the clothes of the children, oh God, oh God, not right in the head, children laughed at her [perhaps this sentence has digressed into the hallucinations of the patient] 29.III. Boys born, breastfeed themselves until 5 weeks ago, ran in [d. \ Elserz \, \ Dach \] is gone, everything is screwed up, and has nothing left to eat. - Dazed, a little fearful, a little cyanotic, hardly answers "don't know", slowly follows requests. Unclean; moans monotonously, pushes away, restless. No negativity. Inconspicuous, torn statements. Regardless of visits, other sick people take away her food. Stiff, stuck under the covers. Eats a lot, suddenly jumps up when another sick person is fed. Punishes herself. Unclean. Manned giving. Editorial Note: (Next to stand: "8 children (1 gest.)"; Remark on the back: "K. 18. VIII.1900. / 26. VIII. Woman has been transferred from Pforzheim to Sinsheim since 10.Nov.99 and has…unchanged in their condition.) Relatives: Man: Dietrich Böhringer farmer in Sinsheim

435 I was provided aid with deciphering this entire card from Professor Dr. Eric J. Engstrom. Email Correspondence. July 2019.

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Patient B:

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Patient B Translation

This diagnostic card is white, denoting that the patient was male. There was great difficulty in reading the diagnostic cards of Patient B through to Patient D. In most cases it was illegible or there were medical abbreviations that were indecipherable.436 […] denotes a passage that could not be translated.

Grossh. Heidelberg University Medical Center

Diagnosis: Manic- Depressive

Aetiology: Hereditary. The father’s sister was mentally sick

Previous illnesses: Earlier he was healthy, he was hardworking and industrious, 1889 Typhus, and then he had for days, strong delirium. Then he was very weak, and then again healthy, in the winter of 96-97 he had influenza and then he was [versagt] defeated and he did not have any courage (lack of mood)/ discouraged. Since the beginning of May 97, he was quiet, did not go out very much, he laid a lot in bed, and it got worst after […] when he was young. He believes that he is despised, and he is mistreated, and he is always persecuted by a lawyer. He is fearful, he is […].

Beginning of the first disease: Tremor in the tongue. Right side of [Faciatus Rigor?] Right side

[…] The pupils are different, but they react. […] is weak, he has [hypoalgesia?]

Beginning of the current disease: He is [ausstosen?] […] when he speaks. He does not pay much attention, he answers slowly, and after a little bit of time, he is oriented, he is always in bed,

[pathisch?], he eats badly, he is [resistant?]. He always sees towards the left […].

436 I had a great deal of aid from Dr. Reyes Bertolín Cebrián in translating the diagnostic cards of Patient B through to Patient D.

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Patient C:

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Patient C Translation

The large cross seen on the right of the card is blue (marked in pencil or wax crayon). The blue cross means the patient has died. This card is pink, as such it was a female patient.

Grossh. Heidelberg University Medical Center

Diagnosis: melancholic depressive

Age: 46

Standing: married

Hereditary: no nerve or mind disease in the family. The parents and one sister died from [lung disease?].

Type of dismissal: died

Aetiology: Body well developed. The mind is small but [glaubisch, gullible?]. She has three children, one died early, one […] died from lung infection pulmonary ailment. One healthy, half a year ago he was obliged to go to the military and he […] dirt [stubenschmutz?] in the cake. In the cake, she gave him dust [?] in the room she put in the cake [?] against some kind of disease.

Since then, the son died on the 12th of December. She doesn’t have […] annoyed. She sleeps badly. She wanders at night around the house. She cries. On the 23rd of March, she was

[aufregen?] upset/ got worked up because of a gypsy woman who ranted about the cake and the dust. Since then, there was depression, unrest, constriction in the chest and body. She wants to jump out of the window. She has fear. She has white pupils. The pulse is quick, she has cold sweat. She has [tobsüchtig?] raging attacks. She says, “I am jinxed, I have poisoned my son.”

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She pulls and hits her head against the wall. 26/ March she is not well nourished, she has livid color. She has numerous hematomas. 120 pulse.

Development: […] in the chest. Pupils react. PSR is lively. She does not have a tremor. [Stiche stitches?] She is fearful during the night […] She is orderly, but she is not [besonnen?] […] She is not oriented. She does not have an appetite. [Katheterismus?] Catheterization is necessary

[perhaps of the urinary variety. If one thinks back to Kraepelin’s bodily symptoms of the depressed, bodily fluids are dry]. 42/3, 3.95. On 23/ March she plays with the fingers and hair.

She is […] confused [?] 29/ March, […]. 30/ March, she shouts nonsense […] and then she says

“? Outside of the bed”. In April, the pulse is bad, the […] is bad. They give her caffeine.

Cyanosis [?], coughing, not much eating. Drinking into the wrong pipe easily. Pulse 200, she is weak. 4/ April she died.

Diagnosis: Pneumonia in both […] Bronchitis in both […]. All tuberculosis spots. And there is

[…] in the kidneys and the pancreas. There is a beginning […] disease in the aorta [?]. Light meningitis. The brain is full of blood and […].

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Patient D:

118

Patient D Translation

Grossh. Heidelberg University Medical Center

Diagnosis: Manic-depressive; Age: 46; Born: 31[…], Children: 8, Type of discharge: improved

Heredity: unknown. Born out of wedlock.

Prehistory: She has five healthy children, three of them died in […], she had a miscarriage. She does not have […] she was healthy until she was 20. She was sad for […]. She cried when people/ thinking that people spoke badly about her, she often was [careful?] […], she is […] days in the hospital in […]. Progressive improvement. But she does not loving life as before

[…]. It started six weeks ago. She is [verstimmt?] annoyed, she hears voices, and the voices called her “old pig (insult) and whore.” Or they say that her husband is too good, and she warns her husband that someone was behind him and someone wants to kill him, but she does not have self-reproach. […] She hears sexual insults. No suicide attempts. She is strong, well-nourished, orderly, oriented, approachable, depressed, she moves slowly, she has an expression in the face that is worrisome. She often […]. She does not need to express herself. She is cooperative. […] mood, the heart […], she thinks she has to cry always; she has feelings of fear. Often has headaches. Does not have rest. She hears voices as described before. No name-calling, always in the third person. She distinguishes different voices, no self-reproaches. She is forgetful. She cannot put together thoughts. She is not like before […]. Progressively, constantly, she is better.

Without pregnancy.

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Appendix B: Aretaeus’ Case Studies

1. The first case study presents something that looks like melancholia but was not

considered to be.

λόγος ὅτι τῶν τοιῶνδέ τις ἀνηκέστως ἔχων, κούρης ἤρα τε καὶ τῶν ἰητρῶν οὐδὲν

ὠφελούν των ὁ ἔρως μιν ἰήσατο∙ δοκέω δ᾽ ἔγωγε ἐρᾶν μὲν αὐτὸν ἀρχῆθεν, κατηφέα δὲ

καὶ δύσθυμον [ἢ] ὑπ᾽ ἀτυχίης τῆς κούρης ἔμμεναι, καὶ μελαγχολικὸν δοκέειν τοῖσι

δημότῃσιν. οὗτος οὔτε μὴν ἦν ἔρωτα ἐγγιγνώσκων, ἐπεὶ δὲ τὴν ἔρωτα ξυνῆψε τῇ κούρῃ,

παύεται τῆς κατηφείης, καὶ διασκίδνησι ὀργήν τε καὶ λύπην, χάρμῃ δὲ ἐξένηψε τῆς

δυσθυμίης∙ καθίσταται γὰρ τὴν γνώμην ἔρωτι ἰητρῷ. Aret., SD 1.5.8 (Adams, 300).

A story is told that a certain person, incurably affected, fell in love with a girl; and when

the physicians could bring him no relief, love cured him. But I think that he was

originally in love and that he was dejected and spiritless from being unsuccessful with the

girl and appeared to the common people to be melancholic. He then did not know that it

was love; but when he imparted the love to the girl, he ceased from his dejection, and

dispelled his passion and sorrow; and with joy, he awoke from his lowness of spirits, and

he became restored to understanding, love being his physician.

2. ἐδεδίει γάρ τις ληκύθων ἔκπτωσιν…Aret., SD 1.6.6 (Adams, 302).

they are also given to extraordinary phantasies; for one is afraid of the fall of the oil

cruets…

3. ... καὶ ἄλλος οὐκ ἔπινε, δοκέων ἑωυτὸν πλίνθον ἔμμεναι, ὡς μὴ τῷ ὑγρῷ λυθείη.

Aret., SD 1.6.6 (Adams, 302).

…and another will not drink, as fancying himself a brick, and fearing lest he should be

dissolved by the liquid.

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4. μυθολογέεται δὲ καὶ τόδε∙ τέκτων ἤδη ἐπὶ οἴκου μὲν σαόφρων ἐργάτης ἦν, μετρῆσαι

ξύλον, κόψαι, ξύσαι, ξυγγομφῶσαι, ἁρμόσαι, ξυντελέσαι δόμον νηφαλέως, τοῖσι

ἐργοδότῃσι ὁμιλῆσαι, ξυμβῆναι, ἀμεῖψαι τὰ ἔργα μισθοῦ δικαίου. ὁ δὲ ἐπὶ μὲν τοῦ

χωρίου τοῦ ἔργου ὧδε εἶχε γνώμης∙ ἢν δὲ ἐξίῃ κοτὲ ἐς ἀγορὴν, ἐπὶ λουτρὸν, ἤ τιν᾽ ἑτέρην

ἀνάγκην, τιθεὶς τὰ ὅπλα πρῶτον ἔστενεν, εἶτα ἐπῆγεν ὤμω ἐξιών∙ ἐπὴν δὲ ἀπῆλθε τῆς τε

τῶν οἰκετῶν θέης καὶ τῆς τοῦ ἔργου πρήξιος καὶ τοῦ χωρίου, πάμπαν ἐξεμαίνετο∙ κἢν

παλινδρομήσῃ, ταχὺ αὖθις ἐσωφρόνεε. καὶ ἥδε τοῦ χωρίου καὶ τῆς γνώμης ἡ ξυμβολή.

Aret., SD 1.6.6-7 (Adams, 302-303)

this story also is told: A certain joiner was a skillful artisan while in the house, would

measure, chop, plane, mortice, and adjust wood, and finish the work of the house

correctly; would associate with the workmen, make a bargain with them, and remunerate

their work with suitable pay. While on the spot where the work was performed, he thus

possessed his understanding. But if at any time he went away to the market, the bath, or

on any other engagement, having laid down his tools, he would first groan, then shrug his

shoulders as he went out. But when he had got out of sight of the domestics, or of the

work and the place where it was performed, he became completely mad; yet if he

returned speedily he recovered his reason again; such a bond of connection was there

between the locality and his understanding.

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5. Under the subtitle ‘another form of mania’ Aretaeus explains a type of madness induced

by divine inspiration or divine in causation. This particular case is a puzzler, as Aretaeus’

chapters on melancholia and mania have been free from divine explanations, yet he

chose, at the very end of the chapter, to disclose this other form of mania. It is a type of

madness that is not permanent. It is reflective of madness in non-scientific literature,

those that belong to early epic, tragedy, and poetry (mentioned in Chapter 1). This case of

mania almost seems to be of an acute variety: patients are roused by music or drink but

make the seemingly abrupt choice (in-the-moment-choice) to cut their limbs.

Μανίης εἶδος ἕτερον.

τέμνονταί τινες τὰ μέλεα, θεοῖς ἰδίοις, ὡς ἀπαιτοῦσι, χαριζόμενοι εὐσεβεῖ φαντασίῃ∙ καὶ

ἔστι τῆς ὑπολήψιος ἡ μανίη μοῦνον, τὰ δ’ ἄλλα σωφρονέουσι. ἐγείρονται δὲ αὐλῷ καὶ

θυμηδίῃ, ἢ μέθῃ, <ἢ> τῶν παρεόντων προτροπῇ. ἔνθεος ἥδε ἡ μανίη. κἢν ἀπομανῶσι,

εὔθυμοι, ἀκηδέες, ὡς τελεσθέντες τῷ θεῷ∙ ἄχροοι δὲ καὶ ἰσχνοὶ καὶ ἐς μακρὸν ἀσθενέες

πόνοις τῶν τρωμάτων. Aret., SD 1.6.11 (Adams, 304).

Another form of mania

Some cut their limbs in a holy phantasy as if thereby propitiating peculiar divinities. This

is a madness of the apprehension solely; for in other respects they are sane. They are

roused by the flute, and mirth, or by drinking, or by the admonition of those around them.

This madness is of divine origin, and if they recover from the madness, they are cheerful

and free of care, as if initiated to the god; but yet they are pale and attenuated, and long

remain weak from the pains of the wounds.

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