The post-Hellenistic writers under study responded in various ways to both the Hippocratic and the Hellenistic traditions on total loss of consciousness, and their way of integrating these elements constitutes a clear testimony of their methodology, namely, encyclopaedism in On medicine, and lax eclecticism in Aretaeus’ work. A common trait that is shared by both authors is the fact that they deepened the Hippocratic dual understanding of this prototypical presentation. For them they were two independent phenomena: either a symptom that appeared in various circumstances – anima deficit, leipothumiê, fainting – or an independent disease – cardiacum, sunkopê.
Fainting versus sunkopê
In Celsus, for example, there seems to be a strong Hippocratic influence in the nomenclature and the presentation of fainting, but a radical difference in the underlying conception of the soul. Similarly, Aretaeus maintained, to a certain extent, the Hippocratic terminology (he used leipothumiê and leipopsuchiê), but his descriptions were less evidently influenced by the Hippocratic corpus (even if he did not explicitly contradict it). He was particularly concerned with explaining the physiological mechanisms underlying this presentation, in which the soul had limited involvement. The Hellenistic stamp, on the other hand, manifests itself very clearly in the approach to sunkopê that both authors express. As we shall see, this affection is regarded as primarily originating in the body, with some kind of alteration in consciousness and descriptions that are suspiciously evocative of our own idea of vasovagal syncope.
Fainting
The terminology that Celsus used to refer to swoons is anima deficere. As von Staden has accurately remarked, it is a Latin calque of leipothumia and leipopsuchia.Footnote 1 Also in syntony with the Hippocratic predecessors, fainting was conceived as a separation of the soul. We shall see, however, that Celsus’ anima is rather different from the Hippocratic psuchê.
in capite autem interdum acutus et pestifer morbus est, quem κεφαλαίαν Graeci vocant; cuius notae sunt horror calidus, nervorum resolutio, oculorum caligo, mentis alientatio, vomitus sic ut vox supprimatur, vel sanguinis ex naribus cursus, sic ut corpus frigescat, anima deficiat.
There is often an acute and destructive disease in the head, which the Greeks call kephalaia that presents the following signs: hot shivering; flaccid paralysis; blurred vision; delirium; vomiting, capable of suppressing the voice; or bleeding from the nose, capable of cooling down the body, and of causing fainting.
Suffice here to say that unlike the Hippocratic life force that suddenly and momentarily abandons the body leaving it lifeless, this passage offers a crescendo of symptoms until fainting eventually occurs. In other words, in this disease total loss of consciousness evolves through a progressive loss of capacities – movement, vision, cognition, speech – before the anima finally gets to withdraw.
A similar term to designate the same phenomenon is exanimo, a calque of the Hippocratic ekpsuchô, which also conveys the idea of separation of the anima:
ex vulva quoque feminis vehemens malum nascitur … interdum etiam sic exanimat, ut tamquam comitiali morbo prosternat. distat tamen hic casus eo, quod neque oculi vertuntur nec spumae profluunt nec nervi distenduntur: sopor tantum est.
A violent disorder also originates from the uterus of women … Occasionally it can even cause fainting (exanimat), in such a way that they are thrown to the ground like in an epileptic attack. It differs though from the latter, in that neither are the eyes turned, nor is there any foaming, nor spastic paralysis: such is the level of drowsiness.
Note how fainting in this passage is distinguished from an epileptic seizure (another form of total loss of consciousness) and assimilated to sopor (drowsy impaired consciousness). Unlike Celsus’ understanding of delirium, which presented – as discussed above – very clear boundaries with sleep, fainting was in its peripheries. This also becomes patent in the chapter on epilepsy (morbus comitialis), where the impossibility of lethargic patients waking up (exper gisci) contrasted with the spontaneous coming round (ad se revertitur)Footnote 2 of epileptic individuals. In other words, on two occasions the author explicitly discusses the difference between sleep and total loss of consciousness, which suggests that he perceived them as related or similar presentations.
It does make sense – from a purely clinical standpoint – that if sleep is an all-or-nothing phenomenon, with almost no intermediate states (as Celsus seems to have conceived it), sleep and fainting can be readily confused but not sleep and delirium. The idea seems perfectly reasonable when applying the anaesthetic model: in dreamless sleep (Celsus very seldom mentions dreams or parasomnia), as well as in drowsy states, alertness, connectedness and responsiveness are reduced. In the case of deep sleep – as in the total loss of consciousness – they are virtually abolished.
In summary, in agreement with Celsus’ constant search for the ‘middle way’, there is a formal (mainly terminological) agreement with the Hippocratic forerunners and a coincidence in the notion of separation, but – as I will argue below – a rather different idea of the soul.
Aretaeus’ take on this matter raises similar concerns:
ἔκλυσιν δὲ γουνάτων καὶ αἰσθήσιος πρόσκαιρον νάρκην καὶ ἀψυχίην καὶ κατάπτωσιν, λιποθυμίην καλέομεν.
The knees giving way, temporary numbness of perceptions, fainting (apsuchiê) and collapse is called ‘swoon’(lipothumiên).
First of all, it is worthwhile to remark that one of the components of lipothumiê is apsuchiê, thereby distancing – from a terminological viewpoint – from the absolute synonymy found in the Hippocratic collection. In this passage, apsuchiê does not seem to encompass the loss of perceptions (otherwise Aretaeus would not have needed to add them independently to the list). Additionally, this definition appears in the chapter devoted to paralysis, in which lipothumiê is framed as an extreme version of it. In other words, it is the total suppression of motor capacities and perceptions. As a result, the passage and the context in which it appears both suggest that movement and sensitivity were central components of swoons, and that they were both encompassed in the idea of leipothumiê but not in the notion of apsuchiê. The question still remains, though, whether Aretaeus was using these terms in a lexicalised manner or if he was implying some separation of the psuchê by using them.
The role of the psuchê in swoons is rather unclear, for most explanations involve humours (mainly blood), different forms of heat and tension. Aretaeus often discusses fainting in connection with excessive blood-letting,Footnote 3 and the role of the soul in them is erratic (to say the least). Only once does the psuchê appear as a relevant component where it separates from the body. It is in the treatment of pleuritis, where large phlebotomies are recommended:
… τὸ δὲ πλῆθος μὴ μέχρι λειποθυμίης· περιπνευμονίην γὰρ ἐπιφοιτῆσαι κίνδυνος, ἢν τὸ σῶμα ἐπιψυχθὲν τὴν ψυχὴν ἐκλείπῃ. εἴσω γὰρ τὰ ὑγρὰ ξυνθέει, τῆς ἐκτὸς ἀφαιρεθέντα θέρμης τε καὶ τάσιος.
… the amount [of blood withdrawn] should not be enough to cause a swoon, for this can add the risk of pneumonia if the chilled body releases the soul (psuchê). Indeed, the moisture accumulates inside, having been separated from the heat (thermê) and tension (tasis).
In this passage, Aretaeus relates the release of the psuchê in swoons to becoming cold after excessive loss of blood. Beyond the coincidence with Hippocratic (and Celsian) works, this example is quite illustrative of his lax eclecticism. Indeed, the particle gar seems to be suggesting that the soul – which can be either associated with heat (thermê) and tension (tasis), or only with tension if we interpret that the heat is exclusive to the blood – is being released along with the blood. We can point out, therefore, a faint family resemblance with two different traditions. On the one hand, blood was considered to be hot in humoural theories, hence its loss was equated with coldness. On the other, the assimilation of the psuchê with heat and tension reminds us of the pneuma as the key constituent of the soul, according to Stoic philosophy.Footnote 4 However, the blood is also moist in humoural theories (whereas the moisture stays in the body, according to this explanation), and there are no allusions to pneuma in this passage. Furthermore, the technical word that the Stoics frequently used to talk about tension was tonos rather than tasis.Footnote 5 Could Aretaeus be referring, instead, to the tone of the muscles, which is lost when one collapses? There is no explicit evidence of this either. Perhaps he is talking about yet another kind of tension: the tension presented in the chapter on sunkopê where the disease causes a ‘weakening of the tension of nature’.Footnote 6 Undoubtedly, the concept of family resemblance (which characterises Aretaeus’ eclecticism) describes this tangle of ideas quite accurately: we can see that his explanations have features in common with different traditions, but he is not strictly following any of them, because there are also important discrepancies.
Going back to the role of the psuchê in swoons, in most other descriptions, the soul is not mentioned. Such is the case with melancholia, which offers yet another example of Aretaeus’ method:
… σμικρόν [αἷμα] ἀφαιρέειν, ὁκόσον αἴσθηται τομῆς ἡ δύναμις οὐκ ἐλεγχθείη δὲ ἐπὶ τῷ τόνῳ … τόδε ἐστὶ τῆς φύσιος ὁ χῶρος καὶ ἡ τροφή. ἢν ὦν τοῦ δέοντος ἀφέλῃς, ἀτροφίῃ ἡ φύσις ἐξίσταται τῆς ἕδρης.
… a small amount [of blood] should be let; enough that the strength [of the patient] may perceive the incision, but not be tested as to its force … [for] this [the blood] is the location and the nourishment of the phusis. Thus, if you let more than is necessary, the phusis will be expelled from its seat due to lack of nourishment.
Here it is the phusis and not the psuchê that seems to be expelled with the blood in large phlebotomies. Additionally, this phusis is associated – like the psuchê before – with tension (tonos in this case), carried in the blood and assimilated to food. The tonos might well be referring to the phusis (like in sunkopê) and may be a synonym of tasis from the previous example.Footnote 7 However, we can once again only talk about family resemblance and not adherence to Pneumatic thought, because according to the Stoics, perceptions were part of the Psychic and not the Natural capacities, each of which represented a different level within the scala naturae.Footnote 8 Also against this hypothesis is the equivalence between psuchê and phusis, which the analogy between the commented-on passages appears to be suggesting.Footnote 9
Therefore, Aretaus’ understanding of fainting presents echoes, resemblances and discrepancies with other theories (one of them being the separation of the soul). However, none of them is clearly predominant nor followed consistently. As a matter of fact, his lax eclectic method consisted of combining different elements of different theories at his convenience, regardless of possible contradictions or incoherence between them.
Sunkopê
I will begin the post-Hellenistic authors’ approach to the second form of total loss of consciousness with the description of sunkopê that appears in the Anonymus Parisinus, because it offers a comprehensive exposition of certain elements that will partially reappear in Celsus, Aretaeus and other post-Hellenistic sources.
ὀνομαστὶ μὲν τοῦ πάθους οἱ παλαιοὶ οὐκ ἐμνήσθησαν ὡς καθ’ αὐτὸ γινομένου, ἐπιγινομένου … μάλιστα δὲ στομάχῳ, ὅ περ καλεῖται καρδία.Footnote 10 δι’ ὅ περ τινὲς καρδίας ὑπέλαβον εἶναι τὸ πάθος … γίνεσθαι δὲ αὐτὸ … ἐκτονιζομένου τοῦ πνεύματος καὶ λυομένου … τοῖς δὲ ὑπὸ συγκοπῶν ἁλοῦσι συνεδρεύει σφυγμὸς μικρὸς, συνδεδιωγμένος … ἀναπνοὴ συνέχεται, καὶ ὡς ἂν ἐκλείποντες ἀντιλαμβάνονται τοῦ ἀέρος … ἱδροῦσι δαψιλῶς τὰ ἄνω μέρη μάλιστα, ψυχρὸς δὲ αὐτοῖς ἐστιν ὁ ἱδρώς … βάρος θώρακος συναισθαίνονται … ἀποχωρίζουσι.
The ancients have not mentioned this affection by name as a condition in its own right. It originates … especially in the stomach, which is called kardia. Hence, some have assumed that it is an affection of the heart … It occurs because the pneuma loses tension and dissolves … The following symptoms accompany those suffering from sunkopê: small and fast pulse … chaotic breathing, they hold the air as if they had fainted … they sweat copiously, particularly in the upper parts. They have cold sweat … feel heaviness in the chest … [and] vomit.
As stated, there is no explicit mention in the Hippocratic collection of this disease (even if I have suggested above a feasible Hippocratic origin for it), and thus it is acknowledged by this author’s remark that ‘the ancients’ did not give a name to this condition. Also, this – as well as most other ancient descriptions of sunkopêFootnote 11 – appears to be compatible with our current understanding of vasovagal syncopes (with hypopnea, cold sweat, gastrointestinal symptoms, cardiac symptoms and hypotension – hence the changes in the pulse). However, in this source it is not clear whether consciousness is actually lost. In most discussions about sunkopê there are usually hints that point towards some kind of impairment in the level of consciousness (in this case it is the breathing ‘as if they had fainted’), but it is seldom explicit whether the patient actually passed out or not.
Celsus’ take on cardiacum matches the previous description quite closely. In his narrative, it is clearly differentiated from defectio animae, because the problem is in the body, specifically in the stomach:Footnote 12
id autem nihil aliud est quam nimia inbecillitas corporis, quod stomacho languente inmodico sudore digeritur. licetque protinus scire id esse, ubi venarum exigui inbecillique pulsus sunt … pedibus … et cruribus siccioribus atque frigentibus.
It [Cardiacum] is nothing else than excessive weakness of the body, which is wasted away by excessive sweating because the stomach is weak. It can be immediately spotted when the pulse of the blood vessels is small and weak … feet and legs are drier [than the other sweaty parts of the body] and cold.
Then, later in the chapter devoted to this condition (Med. 3.19) he warns si verendum est ne deficiat… (‘if it is feared that the patient might faint… ’).Footnote 13 This clarification indicates that anima deficere can certainly occur simultaneously with cardiacum, but is an occasional and independent symptom.Footnote 14 In other words, Celsus’ approach to this disease was eminently physical, and both clinically and theoretically different from other forms of swoons.
In Aretaeus’ text, on the other hand, the boundaries between sunkopê and leipothumiê are more blurred. Accordingly, there is no clear definition as to whether this disease primarily affects the body or the soul. The author begins the discussion by justifying the two names that he uses to designate the disease: sunkopê in the book on signs and causes, and kardiakos in the chapter devoted to its treatment. The former is due to the suddenness and strength of its presentation, whereas the latter points towards the affected organ. Trivial as this might seem, such an introduction positions the author at the opposite end of the ongoing debate concerning the locus affectus.Footnote 15 Aretaeus outspokenly rejects the esophagic/gastric hypothesis, and places the affection in the heart, thereby expanding on his views on this organ:
τί δὲ καρδίης ἄλλο καιριώτερον ἐς ζωὴν ἢ ἐς θάνατον; οὐδὲ τὴν συγκοπὴν ἄπιστον τῆς καρδίης νοῦσον ἔμμεναι, ἢ αὐτὴν σίνος τῆς ἐν αὐτέῃ τοῦ ζῆν δυνάμιος … ἔστι γὰρ τὸ πάθος λύσις τῶν δεσμῶν τῆς εἰς ζωὴν δυνάμιος, ἀντίξουν τῇ συστάσει τοῦ ἀνθρώπου ἐόν … ἔνθα καὶ ἡ ψυχὴ καὶ ἡ φύσις αὐτέης, εἰς ἣν καὶ τὸ πάθος ᾖ τῶν τῇδε δυνάμεων. ἔστι δὲ ἡ τῆς νούσου ἰδέη ἔκλυσις τοῦ τόνου τῆς φύσιος ἐπ᾽ αἰτίῃ ψύξει καὶ ὑγρότητι.
What is more decisive for life or death other than the heart? It makes sense to posit that sunkopê is a disease of the heart, or an injury of its capacities for living … Indeed, the affliction – being inimical to the human constitution – is the release from the bonds that fetter the capacity to live … In it [the heart] are the soul and its nature; hence, also against it [the heart] are the diseases of its capacities [of the soul]. The form of this disease is, namely, a weakening of the tension of nature due to coldness and moistness.
In order to understand the implications of this passage, it is useful to contrast it with Aretaeus’ own understanding of total loss of consciousness. There is a striking terminological and conceptual coincidence between leipothumiê and sunkopê in the treatise: the intervening faculties are the same, particularly the living-capacity (eis zôên dunamios); the psuchê and the phusis participate in both; the tension (tonos) has a similar role;Footnote 16 and the qualities cold and moist are as involved in sunkopê as they are in swoons (where heat is expelled during excessive phlebotomies, and humidity accumulates in the body once it releases the psuchê, CA I.10. CMG (H).V: 114, 5–6).
On the contrary, the importance of the blood has been overtaken in this passage by the heart. While blood seemed to be the seat of the psuchê and phusis in the passages on leipopsuchiê, in this description the heart plays that role. So far, therefore, we are presented with a condition that has many features in common with swoons concerning mechanisms and capacities affected, but a different location.
When looking at the symptoms the picture slightly changes:
σφυγμοὺς μικροὺς, ἀδρανέας, πάταγον τῆς καρδίης, ἐπὶ πηδήσι καρτερῇ, σκοτόδινος, λειποθυμίη, νάρκη, καὶ παρέσιες μελέων, ἱδρὼς ἄσχετος, πουλὺς, ψύξις ὅλου, ἀναισθησίη, ἀφωνίη.
Small and weak pulse, a loud heartbeat among strong palpitations, dizziness, swoon, numbness and weakness in the limbs, profuse uncontrollable sweating, coldness all over, insensitivity, speechlessness.Footnote 17
The description of physical signs is much more thorough than in swoons, where the clinical presentation is barely mentioned. It is at this point that lax eclecticism comes into play because Aretaeus presents pathophysiological similarities with his own idea of fainting, but a clinical description that matches the presentation of sunkopê in the other post-Hellenistic treatises. In this sense, I partially disagree with Pigeaud’s view that we cannot find in Aretaeus’ work the type of careful observation that characterised the Hippocratic Epidemics, because the patient and his ailment become lost when forced into classification.Footnote 18 In fact, his work could be regarded as halfway between the exclusively patient-centred Hippocratic descriptions and other heavily theory-laden post-Hellenistic works. As this approach to kardiakos reveals, Aretaeus draws a lot from his own experience and is quite detailed in his clinical descriptions. Unlike his contemporaries, he clearly found important coincidences in the presentations of both conditions (swoons and sunkopê), along with their differences.Footnote 19
In other words, Aretaeus conceived of two ways of losing consciousness: a simple one without accompanying symptoms (often triggered by excessive blood-letting) and a more complex one (with bradycardia, hypotension and sweating) which constituted a disease in its own right, namely sunkopê.Footnote 20 This lax eclectic approach, therefore, enables Aretaeus to never disregard his own observations and allows him to subtly distance himself from the predominant understanding of the affection, where leipothumiê and kardiakos were completely unrelated conditions. He does not need to fit any finding within a fixed broader theoretical framework, because he can always find a convenient model to explain unexpected, unusual or unforeseen phenomena. In this way, the lack of a strict adherence to any sect provides him with the freedom to always come up with a suitable theoretical justification for whichever clinical manifestation he encounters.Footnote 21 Naturally, such justifications are often suggestive of a certain system of thought, but they never completely fit within any single and distinct one.Footnote 22 Thus, without an important amount of non-textual assumptions, we can only speculate which authors were informing which explanations.
Total loss of consciousness and ideas of the soul emerging in post-Hellenistic authors
In post-Hellenistic authors both the tension between body and soul, as well as the idea of a life-giving power within psuchê/anima, are perhaps less emphatically stated (although still present) and strongly influenced by their methodological approach. Thus, Celsus, as an encyclopaedist in search of the ‘middle way’, compiled different sources – including several Hippocratic ideas, which he tweaked in order to make them compatible with later philosophical theories – and transferred that knowledge into Latin. Aretaeus’ lax eclecticism, on the other hand, allowed him to pick and choose more freely the elements that he needed from the various theories available to him.
Celsus: mens, animus and anima
Celsus offered no explicit philosophical speculation about the nature of certain constructs that he considered to be compromised in his descriptions of impaired consciousness. He gives no clear definition of the scope of the mens, the animus and the anima. As a result, his ideas about these matters can only be deduced from the way in which he used the terms, as well as how he explained the intervention of these concepts in his descriptions. So far, during the discussion on total loss of consciousness, I have mainly focused on the Hippocratic influence over Celsus in terms of vocabulary and his understanding of fainting as a separation of the soul.
Let us now revisit the above-quoted passage on kephalaia-associated total loss of consciousness and focus on an aspect that has remained undiscussed: the idea of the soul that emerges from it.Footnote 23
The text illustrates how motion, vision, involuntary symptoms (such as vomiting), delirium (mentis alienatio) and speech are all independent of the soul (anima), because they are lost due to the disease before fainting actually occurs, namely, before the soul separates (anima deficit). Such a distinction suggests that many capacities that belonged to the Hippocratic psuchê – particularly the mens (the rational part affected by vanas imagines in phrenesis) – are no longer subsumed in the Celsian anima; on the contrary, they are independent of it. This presentation, therefore, hints at a different way of understanding and grouping ideas about perception, cognition and movement, as compared to the Hippocratic predecessors, and questions the equivalence between the Hippocratic psuchê and the Celsian anima.
From the various alternative models of the soul available to Celsus, I consider that his choice leaned towards a view that shared Asclepiadean or Epicurean elements. In order to pursue this idea further, it is necessary to provide some context; namely, to outline some ongoing philosophical debates.
Polito, following some simplification by Galen, has drawn attention to a bipolar division of philosophical thought at the time.Footnote 24 On the one hand, there were the philosophers of the ‘mainstream tradition’, who – broadly speaking – considered matter as a continuum and a unity and believed in intentionality and rationality, both in nature and in human beings (namely, a teleological stance). On the other hand, a group that included Asclepiades and Epicurus advocated – with certain nuances – a mechanistic view of the cosmos, which was formed of particles and void. Despite Vallance’s reluctance to associate Asclepiades with Epicurus,Footnote 25 more recent scholarship has made a strong case for the important influence of Epicurean thought on Asclepiades’ theories. Through different approaches, LeithFootnote 26 and PolitoFootnote 27 agree that although there are some discrepancies, Asclepiades’ debt to Epicurus is considerable, both at the physical level and in his psychology. As we shall see, in his approach to impaired consciousness Celsus negotiated various positions within contemporary philosophical debates, whilst at the same time trying to make these ideas compatible with the Hippocratic texts. Considering his frequent citations of Asclepiades,Footnote 28 it should not surprise us to see Celsus’ narrative leaning towards the Asclepiadean/Epicurean side of the debate, even when trying to stick to the middle way.
In terms of vocabulary, several scattered allusions to psychological concepts remind us of Lucretius’ Epicurean use of terminology, especially the interchangeability between mens, animus and consilium, which I have previously mentioned in the description of the third type of insania (Men. III.18: 19, 21). Such a synonymy also appears in De rerum natura, where the poet refers to ‘consilium, which we designate as animus and mens’.Footnote 29 This finding is rather eloquent, because several more or less contemporary examples testify that this correspondence was not universally accepted in Latin.Footnote 30
Beyond the terminological coincidence, there seems to be a common theoretical background shared by On medicine and Lucretius’ On nature, totally alien to the Hippocratic corpus. It consists of the primacy of the mens and animus over the anima. The followers of Epicurus had considered the soul to be comprised of a rational part located in the chest (animus) and a non-rational part diffused throughout the body (anima).Footnote 31 Lucretius is quite explicit about it: he considers the animus to be in control of the anima and through it, of the body.Footnote 32
… facile ut quiuis hinc noscere possit
esse animam cum animo coniunctam, quae cum animi ui
percussast, exim corpus propellit et icit.
… From this, anyone could easily realise that anima is united with animus, and that when it is shaken by the animus, it then moves and pushes the body.
Similarly, Celsus presents a causal link between mens and anima:
denique omnis calor iecur et lienem inflat, mentem hebetat; ut anima deficiat, ut sanguis prorumpat, efficit.
Finally, heat produces inflammation in the liver and the spleen, and weakens the mens so that the patient faints (anima deficiat).
This excerpt illustrates the thorough work carried out by Celsus in order to achieve his middle way. Hippocratic doctors had certainly made a related claim in the Aphorisms, although they had not ventured any causation: τὸ θερμὸν βλάπτει ταῦτα … γνώμης νάρκωσιν … λειποθυμίας… (‘heat produces the following damages … benumbing of the gnômê … fainting spells … ’).Footnote 33 Celsus, while apparently translating these ideas into Latin, is actually tweaking his sources and adding a heavy Epicurean bias to them, which, furthermore, was opposed to the Hippocratic texts, where phronêsis, gnômê, sunesis and nous were subordinated to the psuchê. In this way – through the ut final clause – Celsus subordinated the alleged equivalent of the latter (the anima) to the former (mens/animus).
In a similar manner, we can find coincidences in the implications of such ideas. In On nature it is stated hic exsultat … pauor ac metus … hic ergo mens animusquest (‘here [in the chest] we feel terror … and fear … hence, here are the mens and the animus’).Footnote 34 Celsus avoids the theoretical explanation and the localisation in the body, but maintains the consequences of such an understanding, namely, the involuntary automatic bodily reactions associated with the psuchê in the Hippocratic collection such as teeth being on edge, fear, anger and pulse changes (Hum. CMG 9: 18, 3–13), which are caused in On medicine by the mens and the animus instead of the anima: is, qui menti suae non est … dentibus stridet (‘those whose mens is not sound … grind their teeth’);Footnote 35 eas [venas] concitare solet … metus et ira et quilibet alius animi adfectus (‘fear, anger and any other affection of the animus usually excites [the pulse]’).Footnote 36 Although the terms used by Celsus could suggest a Hippocratic mark to them, the idea underpinning the roles that he attributes to animus and anima appear to be rather Epicurean. Once again his translation is not innocent.
Another aspect that can be explained by Celsus’ adherence to this Epicurean-informed functional division of the anima into a rational and non-rational part is the way in which he conceived the relationship between the different presentations of impaired consciousness, particularly the drowsy one. I have mentioned in Part II of this book that unlike many predecessors and contemporaries, Celsus’ take on sleep avoided discussing HOFs, philosophical or physiological aspects.Footnote 37 Notably, On medicine did not mention intermediate states between wakefulness and sleep, but posited an utter separation between them, which strongly contrasted with the fuzzy edges that it did suggest between sleep and total loss of consciousness.
The Epicurean notion of the anima partially – not completely – expelled from the body during sleep (explicit in Lucretius)Footnote 38 can justify these fuzzy edges, for this idea is not far from Celsus’ notion of a swoon (anima deficere). In this way, an anima partially expelled during drowsy impaired consciousness and more fully expelled during total loss of consciousness would provide a sound theoretical explanation for the blurred boundaries between these two presentations. Furthermore, the idea of a complete lack of connectedness during sleep (even from one’s own perceptions)Footnote 39 would also be consistent with this idea of partial separation of the anima. As a matter of fact, it is the anima diffused throughout the body where perceptions belong, according to Epicurus’ followers.Footnote 40 In other words, the union between body and soul, which allowed sentience,Footnote 41 would be interrupted during sleep because of the partial separation of the anima.Footnote 42
Additionally, this model also explains the complete separation that Celsus suggested between delirium and sleep. In wakeful impaired consciousness it was not the anima, but the mens and the animus, that became affected. The independence of sleep from the mens seems to be hinted at by the above-quoted definitions of lethargy and phrenitis (as remarked, mens is mentioned in the explanation of the latter but not of the former).Footnote 43 The lack of a link between sleeping and the animus is also present:
ante adversam autem valetudinem … quaedam notae oriuntur, quarum omnium commune est aliter se corpus habere atque consuevit … si gravior somnus pressit, si tumultuosa somnia fuerunt, si saepius expergiscitur aliquis quam adsuevit deinde iterum soporatur; si corpus dormientis circa partes aliquas contra consuetudinem insudat … item si marcet animus… Med. 2.2: 1; 2–3.
But prior to poor health … certain signs appear, all of which share in common that the body becomes different from its usual state: … if heavier sleep oppresses, if there are turbulent dreams, if the patient wakes up more often than usual and then falls back into sleep; if the sleeping body sweats around certain parts that it usually does not … Similarly, if the animus languishes…
This passage makes a clear distinction between types of symptoms that announce poor health. Among them, there are, on the one hand, sleep-related disturbances and, on the other, affections of the animus. They are both similarly predictive of illnesses; however, they are presented as completely independent from one another.
Finally, as suggested by some Hippocratic doctors and by Epicurus himself,Footnote 44 Celsus considered the soul to separate with death. In the prooemium (42), ‘animam amittere’ designates death as a result of vivisection, thereby suggesting that by cutting the body the anima is lost.Footnote 45 An indirect hint of the close relationship between the separation caused by death and that caused by a swoon can be found in the terminology chosen in the pharmacological section. When discussing wounds in internal organs, Celsus recommends wine for those ex profluvio sanguinis intermorientes (‘fainting (intermorientes) of haemorrhage’).Footnote 46 The idea of dying (morior) is implicit in the term. There is a similar occurrence in the Hippocratic Epidemics V, where not only the resemblance of the condition, but also the verb chosen (ekthnêskô) refers to death: ἐξέθανε πεντάκις ὡς τεθνάναι δοκεῖν (‘she fainted five times, she even seemed to be dead’).Footnote 47 Once again, it might look as though the encyclopaedist was strictly following his Hippocratic predecessors; however, there is also an Epicurean explanation underpinning the choice of terms. Beyond the separation of the soul, the choice of anima and not animus or mens suggests an Epicurean influence. As Annas has accurately remarked, unlike the Stoics, who talked about the hêgemonikon (the ruling part) to refer to the soul as a whole, Lucretius uses anima (the non-rational part) for the same purpose,Footnote 48 as Celsus also seems to be doing.
Aretaeus: an erratic role of the soul in his eclectic approach to fainting
I have already pointed out the difficulty in defining a distinct notion of the soul in Aretaeus’ work. Accordingly, despite the fact that in this condition patients collapse, loose movement, sensitivity and cognition, the author conveys neither a clear nor a consistent association between body and soul, and presents important contradictions regarding the way in which the mental capacities relate to the notion of the psuchê. Once again, Aretaeus seems to be combining different theories that partially overlap and partially disagree with each other.
In terms of the body–soul tension, both types of loss of consciousness (leipothumiêFootnote 49 and sunkopê/kardiakos)Footnote 50 suggest a separation of the psuchê from the body, but – as stated – the notion is rather erratic. Not only because the author uses psuchê and phusis interchangeably in swoons, whereas nature (phusis auteês) seems to be subordinated to the soul (psuchê) in sunkopê, but also because in the former condition he implies that the psuchê is located in the blood, whereas in the latter its seat is the heart. (I have already mentioned how Aretaeus had distanced himself from the seemingly mainstream conception of sunkopê by choosing a different locus affectus – the heart instead of the stomachFootnote 51 – and by involving the psuchê and not merely the body.)
The role of the psuchê as a life force is explicitly mentioned as ‘the capacity to live’ in sunkopê (eis zôên dunamios). An idea akin to a life force is considered to be lost in leipothumiê-causing phlebotomies during the treatment of apoplexy: τὸ σμικρὸν αἷμα δυνατώτατον, καὶ [ἡ] ἀλέη τῆς ζωῆς τοῦ σκήνεος καὶ τῆς τροφῆς ἐόν (‘even a little blood is most powerful, for it is the heat of the life of the body and of nourishment’).Footnote 52 However, it is not clear whether this ἀλέη τῆς ζωῆς τοῦ σκήνεος καὶ τῆς τροφῆς is equivalent to the other form of heat (thermê), or in any way associated with tension (tasis, tonos), with the soul (psuchê) or with nature (phusis), all of which Aretaeus had also involved in leipothumiê caused by excessive blood-letting. In any case, it sounds intuitively coherent that this author conceived total loss of consciousness at the very boundary between life and death, if he understood that the heat of life was lost during swoons, as was the capacity to live during sunkopê. He seems to be suggesting that the loss of the psuchê or the phusis or their tension in the form of heat left an inert and cold body (not too different from a corpse).
Concerning the relationship between mental capacities and the notion of the psuchê, in the discussion on HOFs I briefly mentioned some contradictions. As opposed to his usual opposition aisthêsis–gnômê, Aretaeus opposed, in the prooemium to the books on chronic illnesses, aisthêsis to psuchê.Footnote 53 Moreover, in his discussions on leipothumiê and sunkopê the psuchê is involved, but there is no mention of the gnômê. Could this be suggesting, perhaps, that he was symphoretically thinking of them in these passages as related notions (especially considering that the gnômê also tended to be anatomically located in the heart)?
Although this hypothesis is plausible given Aretaeus’ lax eclecticism, there are passages that contradict such an identity. A rather puzzling phenomenon described during sunkopê – unheard of in the other sources – suggests a differentiation between psuchê and gnômê:
ἐπὶ δὲ τοῖσι καρδιώσσουσι καὶ αἴσθησις ὀξύτεροι, ὡς ἰδεῖν καὶ ἀκοῦσαι μᾶλλον ἢ πρόσθεν, καὶ γνώμῃ εὐσταθέστεροι, καὶ ψυχῇ καθαρώτεροι, καὶ τάδε οὐκ εἰς τὰ παρεόντα μοῦνον, καὶ ἐς τὰ μέλλοντα μάντιες ἀτρεκέες.
Amongst those who suffer from the heart, perceptions are sharper, so that they can see and hear better than before, their gnômê is clearer, their soul (psuchê) is purer and not only can they accurately prophesy about the present, but also about the future.
Beyond the inconsistencies with the other clinical features presented in the rest of the chapter, this situation of clairvoyance offers a division of the sphere of consciousness into three components, namely, aisthêsis, gnômê and psuchê (in the similar passage with prophetic visions caused by kausôn, the tripartite division included aisthêsis, gnômê and dianoia).Footnote 54
It appears that in an extreme version of Aretaeus’ lax eclectic approach, the idea of the psuchê that emerges from the analysis of total loss of consciousness is syncretic (in particular, the interplay between psuchê and phusis illuminates how some passages suggest a family resemblance with Stoic philosophy, whereas others contradict it). Like most of the other concepts and numerous theories within his reach (considering that he was a learned physician), Aretaeus used the soul variously in different contexts, which allowed him to explain certain findings. On most occasions though (psuchê is a relatively infrequent term), he disregarded the notion altogether and used alternative constructs to provide a theoretical correlate of his apparently vast practical experience.
Finally, in line with Aretaeus’ ill-defined psuchê, the connection between the different forms of impaired consciousness does not point directly towards the soul itself. However, the three prototypical presentations do evoke elements that were vaguely associated with the soul, such as heat, tension and pneuma.Footnote 55 These are the main components often related to the soul that – in one way or another – tend to be present in most discussions on conditions involving impaired consciousness.
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