After looking at delirium – mostly from the hyperactive end of the spectrum of consciousness – in this part I shall explore the hypoactive end, particularly sleep. This second ideal exemplar, which is a universal process, intrinsic to human existence, also presents challenges in terms of boundaries. Just as the fuzzy edges between delirium and mental illness enabled us to reflect upon the chronological changes in the notion of disease, the analysis of sleep will help us deepen our inquiry into the blurry boundaries between health and illness. Additionally, questioning the terminology used to describe alterations at both ends of the spectrum of consciousness and their recovery will be useful in understanding some of these doctors’ ideas about the mind.
Sleep has often been construed as a vaguely defined territory with fuzzy edges, in the midst of apparently contradictory tensions: beyond the difficulty in establishing when it should be regarded as a normal physiological process and when as a sign of disease, the boundaries that separate it from drowsiness and hypoactive wakeful impaired consciousness, on the one hand, and from total loss of consciousness, on the other, are rather blurry.Footnote 1 In other words, even the apparently self-evident contrast between wakefulness and sleep can be tricky. To quote Williams, sleep ‘furnishes us with a sense of what it means to be conscious, just as consciousness furnishes us with a sense of what it means to be asleep’.Footnote 2
To address these ambiguities – not always resolved by the medical texts – apart from the biological approach I will consider in my analysis some recent contributions by other disciplines, which have also explored the phenomenon and engaged in similar debates. Sleep is becoming an increasingly important field of research among sociologists and anthropologists, whose perspectives often illuminate relevant areas that medicine leaves in the dark.
In a pioneering paper, Taylor proposed to study sleep as a social rather than a biological phenomenon. He suggested that only physiology and medicine had addressed the topic so far, and their questions were only aimed at the ‘whats’ and ‘whys’. He claimed, instead, that there were still important inquiries to be made concerning its sociological dimensions, such as ‘How? When? Where? With whom? and What meanings can be attributed to sleeping?’Footnote 3 Considering that scientific ideas are often entangled with sociological beliefs, and medical concepts can be influenced by extra-medical realities, asking such questions about ancient societies can provide us with important information.
Not far from these approaches, Oberhelman offered a more anthropological take to the matter. He highlighted how sleeping, due to its inseparable link with dreaming, pervades various discourses on disease and healing in antiquity. Not only was it conceived as a symptom of disease, as part of a healthy regimen and as the treatment for certain illnesses, it also appears as a component of rituals under the form of incubation in temples, and is even associated with death in epic poems.Footnote 4
In other words, in order to explore the different ancient medical writers’ perceptions of sleep and their link to reduced/impaired consciousness – or unconsciousness – my analysis will place the phenomenon against a background of sociological and anthropological realities.Footnote 5 Such backgrounds will both inform the medical discourse and help us to define the fuzzy contours of sleep. Undoubtedly, the tensions wakefulness–sleep and health–disease confer a liminal status to this clinical presentation.Footnote 6 Furthermore, they illuminate the peripheries of sleep; namely, the areas where the discourse on sleep intersects with other forms of impaired consciousness, thereby illuminating the extent to which authors understood them to be related or easily confusable conditions.
Additionally, this prototypical presentation enables us to explore how the authors construed different depths of sleep. As described in Chapter 1, the cognitive model of classification based on ideal exemplars (chosen to define impaired consciousness) allows membership gradience. When applying this idea to sleep, one could argue that the degree of identification of any description with this prototype is inversely proportional to the level of consciousness that the author is trying to convey: the deeper a person sleeps (that is, the closer to the ideal archetype of sleep), the lower his level of consciousness. Conversely, as sleep wanes into drowsiness, the features become increasingly distant from that ideal exemplar, and accordingly, the level of consciousness increases.
Finally, this clinical presentation can also illustrate – when focusing on the terminology utilised to describe its hyper- and hypoactive peripheries – the idea of mind underlying the accounts of sleep and delirium. Accordingly, the analysis will show how the different sources perceived, described and organised the HOFs that were damaged during episodes of impaired consciousness, and how they subsumed some or many of these mental capacities within notions akin to our idea of consciousness, thereby suggesting that they had an embryonic or rudimentary intuition of this concept.
It seems as though scholars have paid much more attention to dreams than to sleep itself, even though allusions to the latter permeate the whole Hippocratic corpus.Footnote 1 Moreover, despite the fact that such allusions often describe patients disconnected from their surroundings, the link between sleep and impaired consciousness has been persistently overlooked.Footnote 2 In fact, the way in which this disconnection was interpreted defined how these doctors actually approached this process. Not only did it guide their stance in the debate about limits (that is, where sleep starts and wakefulness ends), but it also determined their view concerning the more theoretical challenges (namely, where each author set the boundaries between health/normality, disease/abnormality). Furthermore, as Thumiger points out, sensory perceptions allow the interaction of the body with the outside world, and the health of the mind is strongly dependent on that interaction.Footnote 3 Consequently, the disruption that occurs during sleep can also tell us about these doctors’ ideas about the mind.
Disconnection and the fuzzy edges of sleep
The ambiguities in the relationship between sleep and health are ubiquitous.Footnote 4 Some authors considered sleep as a natural healthy and physiological process, others as a pathological state where consciousness was altered. There is yet a third group that distinguished between a healthy and a pathological kind of sleep. Similarly, the fuzzy edges of the notion of consciousness manifest through the fact that in certain texts there is such an overlap between hallucinations, nightmares and visions that it is difficult to know whether the writer is talking about dreams, wakeful hallucinations or intermediate states.Footnote 5
Sleep as health
This approach is illustrated in the theoretical work On regimen. In book 4 sleep is described as the perfect and most active phase of the psuchê, where – while disconnected from the environment – κινεομένη καὶ ἐγρηγορέουσα διοικεῖ τὸν ἑωυτῆς οἶκον (‘setting itself in motion and being awake, it [the psuchê] administers its own household’).Footnote 6 Namely, by becoming detached from the outside world the psuchê is able to concentrate on and organise the body. Moreover, through this inwardly directed focus, it can provide, by means of dreams, valuable information about its current condition and emotional state.Footnote 7
In a like manner, in Aphorisms sleep is opposed to sick conditions, which it resolves: παραφροσύνην ὕπνος παύει (‘sleep puts an end to delirium’).Footnote 8 Also in Prognostic τὴν μὲν ἡμέρην ἐγρηγορέναι χρή, τὴν δὲ νύκτα καθεύδειν· … κάκιστον δὲ μὴ κοιμᾶσθαι, μήτε τῆς νυκτὸς μήτε τῆς ἡμέρης … ὑπὸ ὀδύνης τε καὶ πόνου ἀγρυπνοίη ἂν ἢ παραφρονήσει ἀπὸ τουτέου τοῦ σημείου (‘it is necessary to be awake during the day and to sleep at night’, and ‘worst of all is not sleeping whether by night, or by day’ because in such a situation ‘either are pain and distress causing insomnia, or it is followed with delirium’).Footnote 9 Through the ‘medicalisation’ of insomnia and sleep during untimely hours, this excerpt offers a glimpse into Taylor’s question ‘When do we sleep?’ Unlike other societies where sleep can be biphasic or polyphasic,Footnote 10 this medical writer seems to be privileging a nightly and monophasic pattern of sleep. Beyond the social regulation that could be read into this passage – labelling sleep as unhealthy at any time but at night could be useful in terms of social organisation and economic production – note how the two passages are a mirror image of each other: while sleep cures delirium, insomnia causes it.Footnote 11 Namely, the identification between health and sleep here is rather strong.Footnote 12
Sleep as disease
On the other hand, the author of On breaths suggests an opposing view, by considering both sleep and drunkenness as states of altered phronêsis.
ἡγέομαι οὐδὲν ἔμπροσθεν ὀυδενὶ εἶναι μᾶλλον τῶν ἐν τῷ σώματι συμβαλλόμενον ἐς φρόνησιν ἢ τὸ αἷμα. τοῦτο δ’ ὅταν μὲν ἐν τῷ καθεστεῶτι μένῃ, μένει καὶ ἡ φρόνησις· ἑτεροιουμένου δὲ τοῦ αἵματος μεταπίπτει καὶ ἡ φρόνησις … πρῶτον μέν … ὁ ὕπνος … μαρτυρεῖ τοῖς εἰρημένοισιν· ὅταν γὰρ ἐπέλθῃ τῷ σώματι … καὶ τὰ ὄμματα συγκλείεται, καὶ ἡ φρόνησις ἀλλοιοῦται, δόξαι τε ἕτεραί τινες ἐνδιατρίβουσιν, ἃ δὴ ἐνύπνια καλέονται. πάλιν ἐν τῇσι μέθῃσι πλέονος ἐξαίφνης γενομένου τοῦ αἵματος μεταπίπτουσιν αἱ ψυχαὶ καὶ τὰ ἐν τῇσι ψυχῇσι φρονήματα…
I believe that nothing in the body is more favourable for anyone towards phronêsis than the blood: whenever it remains in a stable condition, so does the phronêsis; as soon as the blood is altered, phronêsis also changes … First of all … sleep … is a testimony of what has been said. Indeed, when it falls upon the body … the eyes close, the phronêsis is altered, and certain other visions linger, which are called dreams. Again, during drunkenness, when the blood suddenly increases in quantity, the psuchai (plural) change, and so do the phronêmata that are in the psuchai…
The link between sleep and drunkenness should remind us of the two lads described above, where alcohol abuse was associated with wakeful impaired consciousness. This author seemingly considered that sleep shared important similarities with those conditions.
From a less medical perspective, the passage may be, again, reflecting socially regulated discourses. Just as nowadays inebriation and sleepiness are regarded as at-risk corporeal states,Footnote 13 perhaps, the negative connotation of sleep according to this author (he identifies it with alcoholic intoxication) may be related to the disapproval of excessive drinking in classical Greek culture. Along the same lines, the author of Epidemics V describes Timocrates’ case, in which he fell into a deep sleep or swoon after drinking heavily, and ἐδόκει τοῖσι παρεοῦσιν … τεθνάναι (‘looked like he had died to those surrounding him’),Footnote 14 thereby relating drinking with sleeping, fainting and death. Nissin has also found the negative connotation of sleep among the Romans to be related to death and to vices.Footnote 15 The usefulness of establishing socio-medical relations in this case is that they point to specific circumstances or moments during the day, in which sleep was associated with pathology. This illuminates a boundary that otherwise seems rather confusing in the purely medical discourse, and allows us to establish a provisional sociologically informed line between healthy and abnormal sleep.
Be that as it may, it is worth highlighting that regardless of their side in the debate, the authors seem to stress disconnection from the environment as a key feature of sleep. In On regimen 4, this disconnection is considered as a positive condition, because it allows the psuchê to offer valuable information – in the form of dreams – for us to interpret (Vict. CMG 4.86: 2, 12–13).Footnote 16 In On breaths, conversely, the author suggests that any enupnion (that is, any conscious disconnection) is pathological, causing a detachment from reality that makes sufferers ‘forget about the present evils and become hopeful about a pleasant future’.Footnote 17
Third position: healthy and ill kinds of sleep
The author of On the sacred disease adopts the third way, namely, only certain dreams and nightmares are associated with pathological states:
ἔν τε τῷ ὕπνῳ οἶδα πολλοὺς οἰμώζοντας καὶ βοῶντας, τοὺς δὲ πνιγομένους, τοὺς δὲ καὶ ἀναΐσσοντας τε καὶ φεύγοντας ἔξω καὶ παραφρονέοντας μέχρι ἐπέγρωνται, ἔπειτα δὲ ὑγιέας ἐόντας καὶ φρονέοντας ὥσπερ καὶ πρότερον.
I know that during sleep many groan and scream, others choke, and yet others stand up, rush outdoors and remain delirious until they wake up. They then become healthy and rational as before.
There is a clear connection in this passage between what we would nowadays designate as ‘parasomnia’ and delirium. Certain abnormal kinds of sleep are equated with a condition of illness – delirium (paraphroneontas) – from which health and reason only return with arousal. Although the author does not explicitly mention a normal kind of sleep, we can assume that those who do not belong to the many (pollous) who suffer this condition are unaffected by it, hence, healthy. A comparable dichotomous attitude towards sleep can be found in Epidemics VI. On the one hand, there is a list of τὰ ἐν τοῖσιν ὕπνοισι παροξυνόμενα (‘conditions that exacerbate with sleep’);Footnote 18 on the other, sleep belongs to the catalogue of ἔθος δέ, ἐξ ὧν ὑγιαίνομεν … ὕπνοισιν (‘habits from which we become healthy’)Footnote 19 – in Williams’ terms, the ‘healthicisation’ of sleep.
Peripheries of sleep and the boundaries of consciousness
The elusive distinction between normality and abnormality, health and disease is reinforced by the blurred boundaries between wakefulness and sleep. There are ambivalent descriptions with intermediate phenomena, where it is not clear if delirium happens with the patient awake or asleep.
… παραφρονέει˙ καὶ προφαίνεσθαί οἱ δοκέει πρὸ τῶν ὀφθαλμῶν ἑρπετὰ καὶ ἄλλα πανατοδαπὰ θηρία καὶ ὁπλῖται μαχόμενοι, καὶ αὐτὸς ἐν αὐτοῖσι δοκέει μάχεσθαι· τοιαῦτα λέγει ὡς ὁρῶν καὶ ἐπέρχεται, καὶ ἀπειλεῖ, ἢν μή τις αὐτὸν ἐᾷ ἐξιέναι … τῷδε δὲ γινώσκομεν, ὅτι ἀπὸ ἐνυπνίων ἀΐσσει καὶ φοβεῖται· ὅταν ἔννοος γένηται ἀφηγεῖται τὰ ἐνύπνια τοιαῦτα ὁρᾶν ὁποῖα καὶ τῷ σώματι ἐποίει καὶ τῇ γλώσσῃ ἔλεγε … ἔστι δ’ ὅτε καὶ κεῖται ἄφωνος ὅλην τὴν ἡμέρην καὶ τὴν νύκτα ἀναπνέων ἀθρόον πολὺ τὸ πνεῦμα. ὅταν δὲ παύσηται παραφρονέων, εὐθὺς ἔννοος γίνεται, καὶ ἢν ἐρωτᾷ τις αὐτόν, ὀρθῶς ἀποκρίνεται, καὶ γινώσκει πάντα τὰ λεγόμενα.
… he becomes delirious (paraphroneei): in front of his eyes there seem to appear animals, all other sorts of beasts and fighting soldiers. He even thinks he is fighting amongst them, speaks as though he could see such things and attacks and threatens if somebody does not let him out … In this way we can know that he is afraid and startled by a nightmare: when he regains consciousness (ennoos genêtai), he recounts what he saw in his dreams, which corresponds with what he did with his body and said with his tongue … There are also times when he lies speechless for the whole day and night taking sudden deep breaths. When delirium stops (pausêtai paraphroneôn), he immediately regains consciousness (ennoos ginetai) and if somebody asks him a question he answers accurately and is able to understand all that is said.
This passage offers a good compendium of different kinds of alterations of consciousness: the author first talks about delirium (paraphroneei), and then he seamlessly moves to sleep and nightmares (enupnion), without mentioning a transition, as though both were one and the same kind of phenomenon. It should be emphasised, nevertheless, that the author is grappling to separate dreams from wakeful hallucinations. As a result, although the findings in both are so similar that it is difficult to tell one from the other,Footnote 20 this doctor’s attempts at distinguishing them suggest that he conceived them as two different entities.
In other words, this passage is highlighting the fuzzy edges between two ideal prototypes of impaired consciousness (sleep and delirium), which become even more blurred when analysing the vocabulary of recovery or ‘lucidity’ (to use Pigeaud’s terms).Footnote 21 The terminology used to refer to the interruption of the nightmare (in other words, to waking up) is exactly the same as the author later uses to mention the end of the delirium, namely, ennoos ginomai. Ultimately, both processes – nightmares and hallucinations – and their recovery seem to be framed as similar and related phenomena, because waking up and becoming compos mentis were expressed with the same terms.
This and the other above-mentioned cases, where sleep is associated with a terminology akin to wakeful impaired consciousness (phronêsis alloioutai, Flat. CHF 14.2: 122, 4–6; paraphroneontas, Morb. Sacr. CUF 1.3: 3, 12) point towards wakeful impaired consciousness as a peripheral phenomenon of sleep, hinting that delirium should be understood as being beyond the outer edge of sleep.
There are other examples that illustrate a similar ambiguity between sleep and total loss of consciousness. In Epidemics V, thirty-year-old Appellaeus from Larissa had a disease that affected him at night after dinner:Footnote 22
τῇ δὲ ἐπιούσῃ νυκτὶ ἡ νοῦσος ἐπέλαβε δεδειπνηκότα ἀπὸ πρώτου ὕπνου, καὶ εἶχε τὴν νύκτα καὶ τὴν ἡμέρην μέχρι δορπηστοῦἤ ἔθανε πρὶν ἐμφρονῆσαι.
The following night the disease seized him, after having dined, as soon as he went to sleep. It persisted during the night and following day until the evening. He died before coming round (emphronêsai).
In this passage, sleep seems to be in the peripheries of (or poorly distinguished from) total loss of consciousness. Again, the vocabulary of recovery gives testimony to that: instead of egeirô or epegeirô (the most common Hippocratic terms to convey the idea of waking up) the use of the verb emphronêsai suggests that the writer conceived this hupnos as a loss of consciousness rather than normal sleep, and therefore waking up can be equated with coming round.
So far, the examples suggest that these medical writers conceived disturbed sleep and delirium, on the one hand, and deep sleep and fainting, on the other, as related clinical signs (or as phases of similar processes) beyond the normal and physiological type of sleep. A comparable phenomenon can be found between delirium and fainting. Thynus’ son in Epidemics VII regained consciousness (ephronei) after his swoon (apsuchiê).Footnote 23 Therefore, while sudden loss of consciousness (apsuchiê) was conceived as a temporary disconnection from the environment, coming round is referred to as the recovery of cognitive capacities (phroneô). In other words, the recuperation from fainting is expressed with the same terminology as the recovery from wakeful impaired consciousness, which again suggests that in the Hippocratic texts, delirium and swoons were different forms of ‘not phronein’ or ‘not being in their (right) minds’,Footnote 24 or conversely, that becoming compos mentis and coming round were identical processes.
To sum up, the type of disconnection that characterised agitated sleep was perceived by these Hippocratic doctors as a disorder, which they tried to distinguish from wakeful impaired consciousness and from normal healthy sleep. On the other end of the spectrum, the disconnection that occurred during deep dreamless sleep could be easily confused with fainting. Bearing in mind that delirium and fainting were also perceived as related phenomena, it is safe to argue that the three exemplars of impaired consciousness were perceived by these Hippocratic doctors – just as we do nowadays – as a group of medical conditions that shared some common clinical features (hence our methodological choice is not an artificial anachronic modern imposition on the ancient material).Footnote 25
Levels of consciousness
In line with the idea of a link between the three exemplars, it could be argued that the deepest and the most superficial depths of sleep – that is, the extremes of this spectrum – are, precisely, at the blurry borders where this prototype starts to blend with the others (fainting and delirium, respectively). As we shall see, Hippocratic medical writers resorted to two main linguistic devices when attempting to describe these changing levels of consciousness (and they found a correspondence between them and the seriousness of the diseases).
The widest used mechanism was nuancing and qualifying the specific terms through adjectives, adverbs or descriptive periphrasis: the writer of the first catastasis of Epidemics II describes – while talking about skin rashes in summer – a parallel progression between disturbed sleep (that is, a change in the level of consciousness) and the peak of the disease. He starts by explaining how women were not stuporous before the onset of the condition, and once it had started, πρόσθεν δὲ οὐ κάρτα ἦσαν κωματώδεις … κωματώδεις δὲ καὶ ὑπνώδεις τὸ θέρος καὶ μέχρι Πληϊάδων δύσιος, ἔπειτα μὴν ἀγρυπνίαι μᾶλλον (‘though stuporous and somnolent (kômatôdeis,Footnote 26 hupnôdeis) during the summer until the setting of the Pleiades, afterwards there were instead periods of sleeplessness (agrupniai)’).Footnote 27 The clarification that kôma was hupnôdes during that summer is not irrelevant, because in other cases it can be slightly different. In fact, in the third catastasis of Epidemics III, patients affected with ardent fever and phrenitis suffered ἢ τὸ κῶμα συνεχές οὐχ ὑπνῶδες, ἢ μετὰ πόνων ἄγρυπνοι (‘either continuous non-somnolent stupor (kôma suneches ouch hupnôdes), or sleeplessness with distress (meta ponôn agrupnoi)’).Footnote 28 Note the writer’s exquisite precision when separating the non-somnolent continuous stupor from sleepless restlessness with discomfort.
On other occasions doctors are less sophisticated and make do with simple adjectives. Certain severely ill patients who were stuporous (kômatôdees), ἢ βαρὺ κῶμα παρείπετο ἢ μικροὺς καὶ λεπτοὺς ὕπνους κομᾶσθαι (‘either suffered a deep stupor (baru kôma), or had light and short snatches of sleep (leptous hupnous)’).Footnote 29 Similarly, the author of Prorrhetic I states that κωματώδεες νωθροὶ οὐ πάνυ παρὰ αὑτοῖσιν (‘patients affected with heavy stupor (kômatôdees nôthroi) are not well in their senses’).Footnote 30
In all these cases, changes in the level of consciousness seem to be correlated with clinical worsening of the patient. Particularly explicit of this parallel progression between severity of disease and depth of sleep is the case of Python’s child: ὁ πυρετὸς παρωξύνετο, καὶ ἡ καταφορὴ διὰ τῶν αὐτῶν … αὐτίκα τὸ κῶμα ἐπέπαυτο, καὶ ὁ πυρετὸς ἐπεπρήϋντο (‘the fever peaked and so did drowsiness (kataphorê) to the same extent (dia tôn autôn)’). This doctor does not seem to distinguish between kataphorê and kôma, because after the treatment he states that ‘immediately drowsiness (kôma) stopped, and the fever became mild’.Footnote 31 Possibly this is a case of partial synonymy, which will be discussed later.
The other linguistic device to grade the depths of sleep, which was also common in modern times before the emergence of the GCS, is the use of diminishing suffixes.Footnote 32 Probably, the alteration of consciousness that the wife of Dromeades suffered on the fourth day after the onset of symptoms, hupekarôthê,Footnote 33 was slightly less than she would have had, had she been hit in the temples: πληγαὶ καίριοι καὶ καροῦσαι αἱ κροταφίτιδες γίνονται (‘blows to the temples are mortal and cause stupor (karousai)’).Footnote 34 Similarly, in Prorrhetic I (LCL 38) the writer claims that hupagrupniê is associated with diarrhoea. This prefixed derivation to grade levels of consciousness extends also to the syndromes related to hyperactive impaired consciousness (Theodorous’ wife elêrei and hupelêrei alternately, Epid. VII. CUF 25.2: 13; 3, 19).
It appears that these linguistic devices evidence an explicit effort among these doctors to study various and changeable degrees of disconnection from the environment, which paralleled the degree of compromise of their patients. Within the spectrum of consciousness, drowsiness, agitated sleep and wakeful hypoactive delirium, on the one hand, and deep unreactive states of disconnection and fainting, on the other, seem to both be in the peripheries of normal dormancy, just outside the limits of healthy sleep. Moreover, the more the clinical presentations differ from the ideal prototype of dreamless quiet sleep, the sicker the patient.
Terminology, mental capacities or HOFs, and the idea of mind
Terminology to describe the peripheries of sleep
Ever since Galen, scholars have tried to understand the exact meaning of the Hippocratic ‘vocabulary of insanity’.Footnote 35 A usual strategy in recent studies has been to link the specific terms to the verbs and abstract nouns from which they derive. Thus, diseases like phrenitis or symptoms like paraphronêsis and ekphrones were related to the verb phroneô (‘to think’ or ‘to be sound’) and its more abstract derived noun phronêsis.Footnote 36 Similarly, paranoia, paranoeô, paranoos, to an abnormal way of performing the verb noeô (‘to reason’) and its abstract construct nous, contrary to their sound and healthy opposite, katanoeô. The same could be claimed about suniêmi (‘to understand’, ‘to comprehend’), sunesis and their disturbed derivatives parasunesis, asunetos.Footnote 37 I consider this quest for a strict definition and delimitation of each term to be futile.
If we turn to our current technical language for such issues, there is no clear distinction between ‘delirium’, ‘derangement’, ‘confusion’ and ‘disorientation’. In fact, two doctors presented with the same case would not necessarily choose exactly the same term to describe it, because these words have fuzzy edges. The very nature of the phenomenon is characterised by constant fluctuations, which make it difficult to choose only one of these categories.Footnote 38 Even if the terms do have subtle semantic differences, in actual clinical practice, they tend to be used interchangeably.Footnote 39 In other words, our clinical vocabulary disproves Langslow’s postulate that unlike everyday language, where synonymy is mostly partial, in technical language synonyms are always absolute.Footnote 40 On the contrary, our medical vocabulary for impaired consciousness is mainly comprised of partial synonyms.
I have already highlighted this phenomenon when analysing the case studies in Part I (where different delirium terms such as parakruô, parakoptô, paraphroneô, etc. – some hyperactive and some hypoactive – were used interchangeably). I therefore do not agree with Thumiger’s claim that ancient terms are interchangeable in modern translations because the subtleties are inaccessible for modern readers.Footnote 41 I propose, instead, that they were also interchangeable among ancient doctors, and it could even be argued that the phenomenon is not limited to the vocabulary of wakeful impaired consciousness. We have just seen how it is also extensive in sleeping terminology, where kataphorê and kôma are both associated with drowsy impaired consciousness and used as partial synonyms (in Python’s child’s account),Footnote 42 whereas agrupniê tends to suggest a more agitated sleep.
In terms of the historical debate about the intellectual context, this vocabulary bears testimony to a certain regularity or a certain community of ideas within the diversity of the HC. This specialised terminology seems to share several common features and to be in a developed stage of evolution: the abundance of verbs,Footnote 43 the extensive coinage of terms by derivationFootnote 44 and the repeated use of certain prefixes show both that doctors felt familiar with these terms and that they had similar ways of thinking and making sense of the world through language. In other words, the symmetries in the way that terms are coined and used may be reflecting a converging relationship between thought and expression of new ideas among these medical writers.Footnote 45 Therefore, the development of this jargon, which enabled them to articulate relevant nuances for their novel theories, can be thought of as another sign of these physicians’ distinction as a group and their claim to authority ahead of competing opponents.
In a nutshell, the terminology to describe delirium, sleep and its peripheries seems to refer to changeable conditions that can acquire opposing types of symptoms. A group of similar terms is used to describe states of utter bewilderment and passivity in the peripheries of sleep, on the one hand, and hyperactive impaired consciousness and hallucinations, on the other. The fact that, despite such contrasting presentations, the authors used equivalent terms constitutes a strong hint that they regarded them as essentially similar illnesses or as different manifestations of the same condition. When collating the collocations and the descriptions of these terms throughout the different authors, treatises and conditions, there seems to be a certain interchangeability and affinity in the meaning, which reminds us of the partial synonymy in our own vocabulary for impaired consciousness.Footnote 46 Undoubtedly, in a delirious person signs and symptoms are in constant change and fluctuation: within one single episode, one can be sleeping, agitated, drowsy, talking nonsense or silently staring into the void. It is understandable, therefore, that the different terms accounted for all those findings in some texts, but for only some of them in others.
HOFs in the Hippocratic texts
Closely related to the above-commented terminology, there is a number of vague or ill-defined concepts that these authors considered to be relevant in discussions about impaired consciousness (the derivatives of which were used to describe delirious symptoms). Such concepts – phronêsis, sunesis, nous (among others) – seem to subsume various combinations of capacities that are nowadays included in our idea of consciousness, for example, perception, movement, speech and reasoning. In other words, they loosely group together constructs that correspond to what we nowadays regard as HOFs.Footnote 47
If we go back once again to the study cases discussed in Part I, for the author of Diseases I the hallucinatory and delirious component of phrenitis was caused by bile affecting the sunesis.Footnote 48 The same problem, according to another nosological treatise, On affections (Aff. LCL: 10), originated in a stricken nous (tou nou parakoptei), and yet another medical writer related hallucinations to the gnômê (an abstract derivative of the verb gignôskô, ‘to know, to perceive’). The latter discussed this idea in a short work that explores the different physiological and pathological aspects of glands:
ἡ γνώμη ταράσσεται, καὶ περίεισιν ἀλλοῖα φρονέων, καὶ ἀλλοῖα ὁρέων· φέρων τὸ ἦθος τῆς νούσου σεσηρόσι μειδιήμασι καὶ ἀλλοκότοισι φαντάσμασιν.
The gnômê is disturbed, and [the sufferers] end up both thinking and seeing aberrations – things that are different [from reality] – as they bear this disease with a grinning laughter and strange visions.
It is interesting to point out that the author perceives this phenomenon as being different from spasms (that is, movement disturbances), speechlessness and breathing difficulties, which he associates with a bewildered (aphronei) nous (Glan. 12.2. Brill(C.): 76, 13–15) in cases of apoplexy.
It seems that gnômê, sunesis, nous (and also phronêsis and dianoia) were associated according to these doctors with different combinations of HOFs, which played an important role in the workings of the mind, and therefore were involved in the development of impaired consciousness when affected.
In order to elucidate the way in which Hippocratic authors conceived, organised and subsumed the cognitive capacities, it is worth highlighting three outstanding features of these constructs: the divorce between the etymological stems of these terms and the vocabulary used in the clinical descriptions; their blurred boundaries, in other words, the vagueness and the overlapping of notions within each concept; and finally, the linguistic (non-etymological) connection between these theoretical ideas and the actual clinical manifestations.
Lack of etymological link between symptoms and these HOFs-constructsFootnote 49
The futility of an etymological analysis becomes evident in any description where some of the above-mentioned concepts appear associated with symptoms.Footnote 50 To name but a few, the young virgins suffer paranoia, paraphrosunê and they paraphroneoun, yet the problem does not seem to be in their nous (etymologically related to paranoia) nor in their phronêsis (etymologically related to paraphroneein). On the contrary, the thumos is affected. Similarly, the author of Diseases I talks about paranoeô-paranoia-paranooi ginontai, and paraphroneô, but he associates these abnormalities with a disturbed sunesis (again, neither nous nor phronêsis). In this sense, one could even wonder whether tou nou parakoptontos, characteristic of phrenitis in On affections (10), can be equated with the above-mentioned paranoia of the sunesis, given that both writers are describing the same condition. It appears that the derived compounds utilised to talk about clinical manifestations have become estranged from their etymological roots.Footnote 51
Various combinations of mental capacities within the constructs
Another salient feature of these concepts is their lack of standardisation, which causes contradictions, overlapping and vagueness concerning which mental capacities are included within them. None of these concepts is clearly or consistently defined. Actually, their scope can vary even within a single treatise.Footnote 52
Despite explicit attempts by the author of On the sacred disease to define phronêsis, some contradictions arise when analysing the treatise. Chapter 7Footnote 53 explains how the airflow that enters the brain enables phronêsis and ‘the movement of the limbs’ (CUF 7. 4: 15, 19–20), thereby distinguishing them as two separate capacities. Naturally, when the phlegm blocks the air, two consequences occur: on the one hand, due to the compromised phronêsis ἄφωνον καθιστᾶσι καὶ ἄφρονα τὸν ἄνθρωπον (‘the person becomes dumb and senseless’, which suggests that phronêsis subsumes intelligence or reasoning and perceptions;Footnote 54 on the other, the limbs suffer spasms and involuntary movements. Later on, chapter 16 reiterates the importance of air as the provider of phronêsis to the brain, but immediately afterwards it is stated:
οἱ δὲ ὀφθαλμοὶ καὶ τὰ ὦτα καὶ ἡ γλῶσσα καὶ αἱ χεῖρες καὶ οἱ πόδες οἷα ἂν ὁ ἐγκέφαλος γινώσκῃ, τοιαῦτα πρήσσουσι. γίνεται γὰρ ἐν ἅπαντι τῷ σώματι τῆς φρονήσιος, ὡς ἂν μετέχῃ τοῦ ἠέρος.
Eyes, ears, tongue, hands and feet can accomplish however much the brain can discern. The body has its share of phronêsis in the same proportion as it has its share of air.
Unlike the previous definition, in this passage all the functions that are impaired during a seizure are considered as part of phronêsis, including perceptions, speech and the movement of the limbs. Yet again, in chapter 17 the author establishes a clear contrast between diaphragm (phrenes), heart and brain: whereas the former two are able to perceive – ἡ καρδίη αἰσθάνεταί τε μάλιστα καὶ αἱ φρένες (‘the heart and the diaphragm do indeed perceive’)Footnote 55 – it is only the brain that partakes in phronêsis (CUF 17.3: 31, 7–8),Footnote 56 which suggests that perceptions are not part of what he includes within the notion. This example – even accepting the theory of different writersFootnote 57 – reveals the embryonic state of this terminology, insofar as words are clearly used with a technical intention but their usage is not standardised yet.Footnote 58 In this sense, I disagree with van der Eijk’s translations of phronêsis as ‘consciousness’ and sunesis as ‘understanding’.Footnote 59 We should regard these notions as rudimentary attempts to fragment what we nowadays include within the sphere of consciousness, but not as clearly defined and consistent concepts. As a matter of fact, things get even more complicated if we contrast these passages with the above-commented excerpt of On glands, in which the author fragments most of the same HOFs in a different manner and defines them as gnômê and nous.
Another ambiguous approach, where lack of standardisation manifests as overlapping of concepts, is offered in the highly philosophical treatise On regimen. This long and elaborate work addresses several topics under the general overarching premise that the human regimen has some influence over health.Footnote 60 As far as consciousness is concerned, its medical writer theorised about gnômê, dianoia (a compound of nous) and phronêsis. Although a priori they look like different concepts, their differences become sometimes blurred. Chapter 1, for example, opens by stating:
εἰ μέν μοί τις ἐδόκει τῶν πρότερον συγγραψάντων περὶ διαίτης ἀνθρωπίνης … ὀρθῶς ἐγνωκὼς συγγεγραφέναι πάντα διὰ παντὸς ὅσα δυνατὸν ἀνθρωπίνῃ γνώμῃ περιληφθῆναι…
If it seemed to me that any of those who composed treatises about the human regimen … had throughout composed them with correct knowledge (orthôs egnôkôs) about everything that the human gnômê can comprehend…Footnote 61
By the end of this same chapter, however, the author claims that ‘it is part of the same dianoia to know what was correctly said (gnônai ta orthôs) as well as to discover what was not [yet] said’.Footnote 62 The similar vocabulary connected to each term (orthôs egnôkôs and gnônai ta orthôs), along with the general sense of both statements, points towards notions that are similar. Further into the discussion, dianoia virtually disappears, nous is mentioned twice,Footnote 63 and the author claims that ‘the invisible human gnômê enables one to cognise visible things’,Footnote 64 as though this concept was an HOF related to perception. Nevertheless, by the end of the first book, in chapter 35, perception seems to depend on phronêsis, thereby producing, again, overlapping of the notions.Footnote 65
It is worthwhile taking a closer look at this long and complex passage, which many scholars have tried to make sense of.Footnote 66 Unlike other occurrences, in this excerpt phronêsis is regarded as a condition or a state of the psuchê,Footnote 67 with a variable aspect (discussed in chapter 35) that has control over movements, perceptions, cognitive functioning (including our idea of intelligence) and emotions.Footnote 68
According to the account, the nature of the phronêsis depends on the proportion of moistness or dryness within the fire and water in the psuchê. It is conceived as a spectrum that ranges between phronimôtaton (Vict. CMG 1.35: 150, 30) and aphronestaton (Vict. CMG 1.35: 152, 7).Footnote 69 Indeed, the whole passage is meant to show how different mixtures of the two elements yield different levels of phronêsis, which manifest as various degrees of delirium, affective vulnerability, intelligence, perception and motility.Footnote 70 It is in this sense that I consider that the concept can be likened to consciousness and disagree with Bartos, who equates it only with intelligence.Footnote 71 Undoubtedly, when consciousness is impaired some or many of these capacities can be compromised, and the seven possible mixtures described in the passage refer to various combinations of deficiencies at each level of phronêsis. Therefore, it is arguably not only ‘the physiology of thinking’Footnote 72 that this author is describing, but the physiology of consciousness more generally.
Inevitably, this reminds us of our current gradual understanding of consciousness through the GCS.Footnote 73 The reasoning underlying both systems is that a certain level of phronêsis or consciousness, respectively, corresponds to observable cognitive responses. Furthermore, the ancient doctor resorted to linguistic devices similar to the ones utilised by modern doctors when trying to describe progressive levels of impairment. The Hippocratic writer contrasts maniê, the most altered state of phronêsis, with a condition that can easily become maniê but has not reached it yet, defining it as hupomainesthai (Vict. CMG 1.35: 156, 4). In a similar manner, before the emergence of the numeric GCS, doctors used to talk about ‘comatose’ and ‘sub-comatose’ patients. The analogy not only highlights the gradual nature of the impairment in mental capacities (similar to the linguistic devices used to describe the different depths of sleep), but it also shows the need to quantify it, which doctors from such different worlds both felt in their actual practice. Additionally, it illustrates what Langslow has called ‘the preference of technical languages for certain forms of derivation’.Footnote 74
To be sure, the collocations and scope of all these terms reveal that they were in the process of becoming specialised vocabulary.Footnote 75 As Cross explains, ‘written prose most closely reflects the everyday conversational exchanges’.Footnote 76 Hence, sometimes they were used as technical terms, whereas on other occasions they appear to be non-specialised words. Like the above-discussed terminology to describe symptoms, this is another example of the emergence of prose as a means for Hippocratic authors to express new shared ideas (although, as the variation in meaning seems to suggest, in a lower stage of development).
Finally, there are other examples that not only illustrate the faint boundaries between these constructs, but also further reinforce the hypothesis about fuzzy edges between sleep and wakeful impaired consciousness. While in On breaths (CUF 14), sleep affected phronêsis, in Epidemics VI (LCL 8.5: 262), it disturbs (tarassetai) the gnômê, and in On regimen (Vict. CMG 4.86) it is a state of the psuchê. This could explain why delirium and sleep were sometimes clinically difficult to distinguish for these doctors: because they were explained through the alteration of related theoretical constructs. Or put in another way, these constructs that became altered during delirium and sleep can be framed as embryonic ideas of consciousness. As Thumiger has remarked, we can currently divide this tangle of ideas, concepts and capacities into more specific intellective functions (she distinguishes seven).Footnote 77 Even if some of them would not be nowadays considered to strictly belong within our definition of consciousness, they all become impaired in conditions that affect it. Therefore, it is useful to roughly frame these ancient concepts as rudimentary constructs of consciousness.
Phrasal terms: the linguistic link between clinical findings and theoretical constructs
Given the lack of an etymological correspondence between these sets of HOFs and the partial synonyms used to describe the symptoms of delirium, the last point that I aim to address is a plausible hypothesis about their correlation: despite this divorce, there is a clinical link between them. In order to understand this connection, it is useful to look at what Langslow has called ‘phrasal terms’.Footnote 78 These are lexicalised phrases that have the status of a technical term. The corpus abounds in such constructions that are comprised of a noun head, which – in our case – is abstract and can be assimilated to one of these constructs subsuming HOFs, and different kinds of determiners. A few examples are gnômês paraphoroi – ‘delirious gnômê’ (Coac. LCL 31: 12, 22), gnômê kataplêx – ‘stricken gnômê’ (Mul. II. LCL 92: 424, 15), tên gnômên blabentes – ‘confused, distracted gnômê’ (Acut. CUF 17.1: 2–3) and ekplêxies tês gnômês – ‘disturbances of the gnômê’ (Aer. CUF 23.3: 243, 5). Or even with other heads: dianoia thrasuterê – ‘a more insolent dianoia’ (Epid. VII. CUF 1.6: 48, 12), tou nou parakoptei – ‘the nous is deranged’ (Aff. LCL 10: 18, 9), parallaxies phrenôn – ‘aberration of the phrênes’ (Acut. Sp. LCL 1: 262, 12).Footnote 79 Common to all these instances is the metaphorical dimension of the determiner:Footnote 80 the nouns are abstract theoretical constructions, which the authors metaphorically linked to determiners that convey the idea of compromise, deviation or blow. Considering that these phrases are lexicalisations and bearing in mind the ‘shorthand nature’ of many compositions,Footnote 81 we can hypothesise that the verbs used in isolation (such as parapherô, parakrouô) evolved from previously lexicalised phrasal terms that lost their head through metonymy or brachylogy. In most cases, we cannot be sure whether the author was thinking of the gnômê, phronêsis, nous or any other of the abstract theoretical concepts into which the ancient authors subsumed the HOFs, but at least we can posit that an embryonic idea of consciousness was perceived as being compromised. In this respect, I disagree with Thumiger; I think that these abstract constructs (presupposed in the noun head, even when it was omitted) were often treated like concrete body parts, in the sense that they could suffer and be affected by disease.Footnote 82
In summary, the analysis suggests that the Hippocratic doctors did attempt to break down the abstract notion of consciousness into smaller HOFs, which they variously grouped into discrete concepts. These passages demonstrate that terminology to discuss HOFs was not fully developed, nor was the theoretical framework by which doctors understood these medical conditions. In this respect, Lloyd has accurately pointed out – while discussing Greek anatomical vocabulary – that the oscillation in the meaning of technical terms often indicates the backward state of theoretical speculation.Footnote 83 As a matter of fact, even now, scientific journals acknowledge the confusion and overlapping of concepts in the semantic field of consciousness (‘awareness’, ‘wakefulness’, ‘perception’, ‘vigilance’).Footnote 84
On a more theoretical level, the analysis supports the idea that delirium and sleep were often linked – in these doctors’ conception – to the impairment of what we could designate as an embryonic notion of consciousness. It is also in this regard that we can find a sense of consistency and unity across different authors and treatises within the HC.
The landscape slightly changed in the post-Hellenistic treatises due to the emergence of lethargy as a specific sleeping disease. It could be argued that the authors maintained the key elements of discussion that were apparent in the Hippocratic corpus, but they reformulated them. As a result, we are still able to find ambiguities and tensions between health and disease, consciousness and unconsciousness, as well as a redefinition of the kind of disconnection that characterised sleep, where the accounts are shaped by the particular interests and the specific methodological approach of each author.
Disconnection during sleep
The status of sleep in Celsus’ On medicine has some parallels with the Hippocratic corpus,Footnote 1 but it also has divergences. Indeed, the topic offers a good example of the author’s encyclopaedic approach, in which he makes different sources compatible by juxtaposing some coincidences and some discrepancies without evident contradictions. In this sense, Celsus maintains the characterisation of sleep as a disconnection from the environment; however, his idea of disconnection is much stronger. According to his view, individuals are not only insensitive to the world surrounding them while asleep, but they also seem to be unaware of their own bodily sensations.
The former and more Hippocratic type of disconnection is evidenced by the repeated insistence on applying physical stimuli to patients with lethargy: aegros … excitare, expergiscatur aeger (Med. 3.20: 1, 2). Such prodding constitutes an active attempt at reconnecting them with outside reality through external agents aimed at waking them up, such as strong unpleasant odours, or by provoking sneezing.
On the other hand, the interruption of one’s own perception during sleep, which is a more radical (and un-Hippocratic) kind of disconnection, is illustrated by the use of anodyna … quae somno dolorem levant (‘painkilling [drugs] that relieve pain through sleep’).Footnote 2 Undoubtedly, such an idea is not compatible with the psuchê in full control of its household while sleeping (Vict. CMG 4.86),Footnote 3 even less so with the description of the patient who was so in touch with his perceptions that he enacted his own dreams while having them, and was afterwards capable of giving a full account of his vivid nightmares (Int. LCL 48). As will be discussed below, this complete disconnection from the environment as well as from the body as described by Celsus will make it easier for him to relate sleep to total loss of consciousness.
Aretaeus’ take on this issue is evident in his discussion of lethargy, but he only adheres to the Hippocratic kind of disconnection. He considers that the patient is unaware of his environment because αἱ αἰσθήσιες πλέαι γίγνονται ἀτμῶν (‘perceptions are full of vapours’).Footnote 4 To cure the condition he also recommends – like Celsus – strong stimuli to wake sufferers up: ἐμβόησις· νουθεσίη ὀργίλη· δεῖμα ἐφ’οἳσι δειμαίνει (‘shouts, angry reprimands and violent threats).Footnote 5 Unlike Celsus, though, he does not seem to support the radical disconnection described in On medicine. Sleep does not prevent individuals from feeling pain, which suggests that they do not become disconnected from their own bodily sensations. There is proof of this in the treatment for kidney lithiasis. There, Aretaeus explains that once the urinary stone falls into the bladder, ἄπονοί τε γίγνονται, οὐδ’ ὄναρ δοκέειν τοῦ πόνου εἰθισμένοι (‘they become free from pain, so that not even in their dreams do they consider themselves to be in pain’), which hints that they could potentially feel pain while asleep.Footnote 6
Fuzzy edges, clear boundaries and peripheries: sleep–wakefulness, health–disease
Regarding the ambiguities around sleep, both these authors seem to have negotiated their positions in respect to their Hippocratic predecessors and their more contemporary sources.
The boundaries of consciousness: ways of being conscious and unconscious
The distinction between sleep and wakeful impaired consciousness appears to have been a well-worn debate in the post-Hellenistic era. Despite Aristotle’s statement that ἐνδέχεται γὰρ τοῦ ἐγρηγορέναι καὶ καθεύδειν ἁπλῶς θατέρου ὑπάρχοντος θάτερόν πῃ ὑπάρχειν (‘although wakefulness and sleep exist separately from each other, it is possible for both to somehow coexist’),Footnote 7 medical writers struggled to identify these intermediate states. Such is the case of Caelius Aurelianus’ version of Soranus,Footnote 8 who criticised Asclepiades for confusing sleep (somno) with stupor (pressura) caused by poppies:
his nos respondebimus differre pressuram a somno. contra naturam etenim pressura intelligitur, secundum naturam somnus. papavera autem pressuram, non somnum faciunt.
To him [to Asclepiades] we will reply that subduing differs from sleep, for the former is contrary to nature, whereas the latter is in accordance with nature. That is, the poppy subdues a person but it does not cause him to sleep.
In Celsus’ account, painkillers offer a good example of the above discussion. Like Asclepiades (and unlike Soranus/Caelius Aurelianus), Celsus does not seem to have distinguished this nuance. He related the poppy (papaver) to somnus,Footnote 9 thereby equating sleep with the hypoactive type of impaired consciousness that a compound containing poppy would likely have caused. However, he did clearly differentiate sleep from hyperactive delirium. His definition of lethargy in opposition to phrenesis illustrates this: in eo difficilior somnus, prompta ad omnem audaciam mens est: in hoc marcor et inexpugnabililis paene dormiendi necessitas (‘In [phrenesis] sleeping is difficult, and the mind is inclined to any kind of insolence. In [lethargy] there is drowsiness (marcor)Footnote 10 and a hardly bearable need to sleep’).Footnote 11
As a matter of fact, Celsus seems to have almost conceived sleep as an all-or-nothing phenomenon. Such a simplification might explain why On medicine leaves out a few conditions mentioned in other post-Hellenistic sources, where the boundaries between wakeful hallucinations, drowsy deliriums and nightmares were faint. Catalepsia or catochos and tuphomania, which are discussed in the pseudo-Galenic Medical definitions,Footnote 12 are not mentioned in his encyclopaedia. Furthermore, he even ignored the cognitive symptoms that other authors assimilated to lethargy, thereby further distancing sleep from conscious mental processing.Footnote 13
This lack of fuzzy edges between hallucinations and nightmares (present in most other authors) is replicated in the terminology. Unlike the Hippocratic treatises, there is no overlap in Celsus’ use of vocabulary: both falling asleep (dormire, somnus accedere/capere, soporare, etc.) and waking up or being awake (vigilare, excitare, expergisci, etc.) are expressed with a lexicon that is only used in relation to sleep, and completely different from the terms used in descriptions of wakeful impaired consciousness and its recovery.
On the other hand, Celsus did seem to recognise a certain similarity between swoons and sleep. Although he did not elaborate on the activity of the anima during sleep – and this is why it seems to be independent of the soul in a superficial analysis – sleeping is perceived as a phenomenon akin to total loss of consciousness (with a link that is mainly based on the clinical presentation, rather than on a physiological explanation).Footnote 14
Despite this asymmetry, where delirium seems to be totally unrelated to sleep as opposed to fainting, the explicit contrasts that Celsus makes between phrenesis, lethargy and cardiacum supports the hypothesis that the three ideal exemplars of impaired consciousness were somehow related in his understanding (and are not a mere modern idea forced onto his text), particularly considering that phrenesis was one among three possible presentations of insania, yet the only one worth explicitly opposing to the other prototypical presentations of impaired consciousness (cardiacum and lethargy).Footnote 15 This suggests that the second and third forms of insania (which we would now consider as mental illness) were so unrelated to impaired consciousness that they did not even need to be contrasted.
Aretaeus also construed phrenitis and lethargy as opposed conditions; however, his eclectic method did not prevent him from equating sleep with hyperactive impaired consciousness. Evidence for this conception is given in the discussion on pleuritis: γίγνονται δὲ παράληροι· ἔστι δ᾽ ὅτε καὶ κωματώδεες, καὶ ἐν τῇ καταφορῇ παράφοροι (‘[patients] become delirious (paralêroi); on occasion even stuporous (kômatôdees), and in their drowsiness (kataphorê) they are deranged (paraphoroi)’).Footnote 16 This passage illustrates rather explicitly the way in which drowsiness and delirium may become one and the same phenomenon. Also, during certain acute exacerbations of melancholia, patients seem to suffer from threatening nightmares that are hard to distinguish from reality:
κατηφέες, νωθροὶ ἔασι ἀλόγως … ἄγρυπνοι, ἐκ τῶν ὕπνων ἐκθορυβούμενοι. ἔχει δὲ αὐτέους καὶ τάρβος ἔκτοπον, ἢν ἐς αὔξησιν τὸ νόσημα φοιτῇ, εὖτε καὶ ὄνειροι ἀληθέες, δειματώδεες, ἐναργέες. ὁκόσα γὰρ ὑπερεκτρέπονται οὕπω οἱ κακοῦ, τάδε ἐνύπνιον ὁρέουσι ὥρμησε.
With drowsy sunken eyes [sufferers] become irrational … [moreover, they are] restless and disturbed from their sleep. If the disease progresses, they are dominated by unjustified terror as well as true-looking, threatening and vivid dreams. Indeed, they are scared because they can see in their dreams the things that horrify them the most (even though they are actually not under threat).
The passage, indeed, reminds us of certain elements present in Hippocratic descriptions of hallucinations and visions (Int. LCL 48, and Virg. CUF I.1). In this description, however, the uncertain limit between sleep and wakefulness enables Aretaeus to reflect upon one of his constant concerns, which is the truth behind real-looking apparitions (in this case, visions in dreams come under scrutiny). In other words, not only the phantasiai of delirious phrenitics (as commented above), but also the oneiroi alêthees and the enupnion of the drowsy melancholics, question the relationship between perception and reality.Footnote 17
We can posit, therefore, that these lax boundaries between wakeful and drowsy impaired consciousness – added to the overlap between fainting and sleeping – suggest that Aretaeus also perceived our three prototypes of impaired consciousness to be related.Footnote 18 Furthermore, we can even find hints of a more theoretical relation between swoons, sleep and delirium in Aretaeus’ pathophysiological explanations (apart from the clinical similarities just referred to).
There is an emphasis on the loss of heat during swoons (referred to as thermêFootnote 19 and aleê tês zoêsFootnote 20), which evokes the psuxis emphutosFootnote 21 of lethargic patients and opposes the alterations in the oikeiou thalpeosFootnote 22 during phrenitis. Ultimately, the distortion of any kind of heat, which was at the very boundary between life and death, also seems to cause some compromise of cognition, thereby unifying these three alterations of consciousness. In the context of Aretaeus’ eclectic method, this could be interpreted as an example of symphorêsis (or, to put it more simply, a lax use of terminology).
In terms of Aretaeus’ keen interest in perceptions, we have seen that an altered aisthêsis had a central place in the descriptions of delirium. The fact that in lethargy αἱ αἰσθήσιες πλέαι γίγνονται ἀτμῶν (‘perceptions are full of vapours’),Footnote 23 and that they are also mentioned in relation to swoons (SD I.7. CMG (H).III: 44, 20 and CD I.5. CMG (H).VII: 156, 7), only confirms their key role in consciousness, and that they are a further trait that is shared by the three prototypical presentations.
To sum up, the way in which these authors conceive the limits between different forms of impaired consciousness and sleep mirrors their understanding of the boundaries between consciousness and unconsciousness. While Celsus conceives a clear-cut separation between wakeful impairment of cognitive capacities and sleep, and a certain continuity between the latter and hypoactive impaired consciousness, Aretaeus’ take is more in harmony with Hippocratic ideas. Like his Hippocratic predecessors, he understood such limits to be rather blurred, with intermediate states between wakefulness, sleep and hypoactive impaired consciousness. Moreover, although both post-Hellenistic authors found links between the three exemplars, it could be argued that Celsus’ were mainly based on their similar clinical features, whereas in Aretaeus (and also in the Introduction) the connection was not only clinical, but also pathophysiological.
Boundaries between health and disease
Despite this discrepancy concerning the nature of sleep and its relation to wakefulness, Celsus and Aretaeus both seem to agree with their Hippocratic predecessors about the liminal zone between health and disease that the process occupies.
In the case of Celsus, this feature is illustrated in book 2, which offers a good example of his encyclopaedic prowess. In a passage that is virtually a translation from the HC, he is able to combine both Hippocratic and un-Hippocratic ideas.
… gravis morbi periculum est … ubi nocturna vigilia premitur, etiamsi interdiu somnus accedit; ex quo tamen peior est, qui inter quartam horam et noctem est, quam qui matutino tempore ad quartam. pessimum tamen est si somnus neque noctu neque interdiu accedit: id enim fere sine continuo dolore esse non potest. Neque vero signum bonum est etiam somno ultra debitum urgueri, peiusque, quo magis se sopor interdiu noctuque continuat.
There is danger of severe illness … when [the patient] is worn out by nocturnal wakefulness, even if during the daytime he gets some sleep. In the latter case, however, it is worse to sleep between the fourth hour and night-time, than between the morning hours and the fourth. Worst of all, though, is if sleep comes neither during the night nor during the day, for this can hardly ever happen without continuous pain. But it is not a good sign either to be oppressed by sleep beyond measure, and the more the stupor persists day and night, the worse it is.
This is part of a discussion on bad signs in illnesses and the text follows almost word by word Prognosis CUF 10. However, Celsus omits to mention the very last words, where μὴ κοιμᾶσθαι, μήτε τῆς νυκτὸς μήτε τῆς ἡμέρης… (‘lack of sleep, whether by night or by day… ’)Footnote 24 can be a predicting sign of imminent delirium (naturally, for him, delirium and sleep were unrelated). More remarkably, however, the author is acknowledging the existence of a good and a bad kind of sleep, thereby introducing its ambivalent status. Ultimately, three key concepts are enunciated in this passage: both excessive sleep and sleeplessness are detrimental, sleep is good during the night and insomnia is often associated with pain. In summary, like the author of Prognosis (and also the author of On the sacred disease), sleep can have positive or negative effects, but unlike them the process is completely alien to conditions where individuals are awake (that is, alert and hyperactive but disconnected, such as during hallucinations and delirium).Footnote 25
The ambiguous status of sleep regarding health and disease also manifests in Aretaeus through its dual capacity of being a cure for certain conditions and at the same time a disease in its own right (as is the case with lethargy). Interestingly, he also took inspiration from the same passage of Prognosis to sustain the status of sleep as a cure for or prevention of delirium in peripneumonia:
ἢν δὲ ἄϋπνοι ἔωσι δι᾽ ἡμέρης, ἠδὲ ἐγρηγορῶσι πάννυχοι, δέος μὴ ὁ ἄνθρωπος μανῇ, καὶ ποικίλων φαρμάκων ὑπνωτικῶν χρέος.
If they are sleepless during the day and remain wakeful during the whole night, diverse sleep-inducing drugs are needed for fear of delirium.
Unlike Celsus, Aretaeus does maintain the Hippocratic conceptual relationship between sleep disturbances and delirium. As mentioned above, phrenitis is also a delirious condition that can be cured by sleep.Footnote 26
In a similar manner, sleep is recommended as a treatment for saturiasis, a disease conceived as a permanent erection with delusion. The chapters tackling this particular condition offer an interesting nuance about the author’s conception of the peripheries of sleep. A subtle difference between its discussion in Aretaeus’ book devoted to causes and signs and the one devoted to treatment reveals some interesting aspects about the nature of sleep. In the book on causes and signs ἴησις, ὕπνος βαθὺς καὶ μήκιστος. ψύξις γὰρ καὶ πάρεσις και νάρκη νεύρων, ὕπνος πολύς (‘the cure is a deep and prolonged sleep. Indeed abundant sleep produces coldness, weakening and benumbing of the nerves’).Footnote 27 In the book on treatment, on the other hand, Aretaeus suggests utilising abundant blood-letting, for οὐδὲ γὰρ ἄκαιρον νῦν λειποθυμίην ἐμποιέειν, ἔς τε νάρκην τῆς γνώμης (‘it is not untimely to bring about fainting, in order to numb the gnômê’)Footnote 28 (the disease was located in the nerves and the gnômê). In other words, a deep and prolonged sleep is equated to fainting, thereby blurring the boundaries between sleep and total loss of consciousness. It seems that for Aretaeus, the loss of consciousness that occurs with sleep is regarded as a treatment for diseases where there is hyperactive responsiveness, that is, the delirium characteristic of both phrenitis and peripneumonia, and the delusions of saturiasis.
The other side of the coin is sleep in and of itself – without being associated with delirium – regarded as the key symptom of a disease. Like Celsus and the author of the Introduction, Aretaeus construes lethargy as the perfect opposite of phrenitis. Accordingly, the treatment of lethargy is the exact antithesis of the former.
ληθαργικοῖσι κατάκλισις ἐν φωτὶ καὶ πρὸς αὐγήν· ζόφος γὰρ ἡ νοῦσος· ἠδὲ ἐν ἀλέῃ μᾶλλον· ψῦξις γὰρ ἔμφυτος ἡ αἰτίη. κοίτη εὐαφὴς, τοιχογραφίη, στρώματα ποικίλα, πάντα ὁκόσα περ ἐρεθιστικὰ ὄψιος, λαλιὴ, ψηλαφίη ξὺν πιέσι ποδῶν … ἢν βαθὺ κῶμα ἴσχῃ, ἐμβόησις· νουθεσίη ὀργίλη˙ δεῖμα ἐφ’οἳσι δειμαίνει … πάντα ἐς ἐγρήγορσιν ἐναντίως τοῖσι φρενιτικοῖσι.
For lethargic patients, lying in the light surrounded by brightness; darkness is actually the disease. Preferably warm, for innate cold is the cause. Soft bed, paintings on the walls, colourful bedclothes, whatever stimulates the sight, conversation, touching with compression on the feet … If the patient falls into a deep stupor, shouts and angry reprimands [are needed] as well as threats about things that terrify them … contrary to phrenitis, everything is aimed at waking them up.
The way in which the treatment is described – unfortunately the relevant chapter in the book of symptoms and causes is not extant – suggests that Aretaeus conceived two opposing affections of consciousness: one at the hyperactive end (phrenitis), in which perceptions were exacerbated and needed to be assuaged, and the other at the hypoactive end (lethargy), where the exact opposite stimuli (visual, auditory and tactile) were required (again, perceptions are a key part of his construction). In the middle of both is the grey area where hallucinations and delirium can be confused with nightmares. Accordingly, therapy through the spoken word is opposed; unlike the non-upsetting conversation recommended for phrenetics, lethargy warrants an aggressive and distressing approach.
Clearly, for both authors, at the centre of the definition of sleep is the kind of perceptions that are preserved and those that go unnoticed, which determine the model of disconnection conceived. They both distinguished a healthy and unhealthy type of sleep dependent on its amount (too much or too little were bad), and on the hour of the day in which it happened. Moreover, due to the post-Hellenistic redefinition of certain diseases, and the emergence of others, sleep became the cure for those with hyperactive impaired consciousness, mainly phrenitis (but also saturiasis in Aretaeus’ account), and the main symptom of lethargy.
Some non-medical aspects of sleep
From a sociological point of view, beyond the seemingly well-established pattern of monophasic night-sleep in antiquity, the ‘medicalisation’ of excessive sleep and the ‘pharmaceuticalisation’Footnote 29 of sleeplessness, the texts mention certain rituals, environments and artefacts, which suggest that in the real world the theoretical blurred limits of sleep were, perhaps, less vague.
Particularly, the overriding of certain conventions seems to indicate that relatives must have been clear regarding the status of a patient, whether he was sick or healthy, awake or asleep. Only through this assumption can one explain the normalisation of ‘observed sleep during diseases’. Taylor points out that in a culture like ours, where sleep tends to be private, observed sleep reverts individuals to a powerless situation (like a baby or a patient).Footnote 30 Although we cannot automatically attribute the same connotations to the ancient descriptions, a passage by Galen (Morb. Diff. II. K.VI: 837, 5–10) that will be discussed later does suggest that sleeping was a quiet activity, with no external stimuli among healthy individuals. In other words, it would appear that infirmity operated also in antiquity as enough justification for intruding on an otherwise quiet and dark space. Similarly, aggressive therapies aimed at waking patients up from their lethargy broke the ‘entitlement of the sleeper’ (if such a thing ever existed in ancient societies).Footnote 31
On the contrary, when sleep is construed as a remedy for hyperactive impaired consciousness (for example, phrenitis) or insomnia, all the conventions and rituals are enhanced, and intimate and quiet surroundings are encouraged or recreated. Aretaeus mentions some sleep-favouring environments in the treatment of phrenitis, when he relates that everyone finds delightful rest in their usual milieu (the sailor in his boat in the middle of the sea, the musician accompanied by music, the teacher amid the voices of his students).Footnote 32 Moreover, the sleeping arrangements to favour sleep in phrenitis (or wakefulness in lethargy) also reveal the practical artefacts available (soft or hard beds, colourful bedclothes, plain versus decorated walls, etc.). Although Celsus offers fewer details about these matters, he does refer to suspensi lecti motus (‘hammocks, which [encourage sleep through their rocking] motion’)Footnote 33 and silanus iuxta cadens (‘the sound of falling water’).Footnote 34
All these details – which answer Taylor’s questions How? Where? When? – show that, blurred as the boundaries between healthy and abnormal sleep might theoretically seem, once a diagnosis was reached (and therefore the ambiguity health/disease vanished), completely opposing practical approaches were put into place (the same could be said regarding the ambiguity between wakefulness and sleep). As a result, it is reasonable to speculate that in the face of actual cases all the ambiguities needed to be resolved, and patients ended up being classified as either having healthy or disturbed sleep, and as either suffering from vivid dreams or wakeful hallucinations. Accordingly, the corresponding measures were put into place (for example, a quiet, comfortable environment, soft mattresses, plain walls and pleasant talk for favouring sleep versus shouts, prodding, hard mattresses and colourful bedding to prevent it).
Levels of consciousness
In accordance with his conception of sleep as an all-or-nothing phenomenon, there is only one passage in which Celsus seems to acknowledge different depths, and relates deep and disturbed sleep to more severe diseases. When discussing predictor signs of illness he mentions:
si gravior somnus pressit, si tumultuosa somnia fuerunt, si saepius expergiscitur aliquis quam adsuevit, deinde iterum soporatur…
if heavier sleep oppresses, if there are unsettling dreams, if somebody wakes up more often than usual and then becomes drowsy again…
In most other cases, Celsus seems to have regarded sleep and wakefulness as mutually exclusive phenomena, and accordingly, we can find in his work no further attempts at distinguishing different levels of drowsiness. Moreover, in the discussion on lethargy, the lack of interest in the depth of sleep becomes particularly evident. He utilises no adverbs, comparative adjectives or any other linguistic resource to nuance different degrees or intensities. It seems as though for Celsus the patient can be either asleep or awake but there are no intermediate states.Footnote 35
On the contrary, Aretaeus’ endeavours to define different levels of consciousness are particularly evident in his characterisation of peripneumonia:
Ἠν δὲ ἐπὶ τὸ θανατῶδες ἐπιδιδοῖ, ἀγρυπνίη, ὕπνοι σμικροὶ, νωθροὶ, κωματώδεες, φαντασίαι ἀξύνετοι· παράληροι τὴν γνώμην ἐκστατικοὶ οὐ μάλα.
If [the disease] becomes terminal, there is restlessness, interrupted sleep, sluggishness, stupor, unintelligible visions. Sufferers are deluded in their gnômê, although not extremely deranged.
The accumulation of nouns, qualifiers and adverbs suggests that Aretaeus is trying to describe different and apparently increasing levels of drowsiness. Considering that the condition seems to be reaching a deadly (thanatôdes) stage one could even suggest a correlation between severity of the disease and degree of disconnection, although this is less explicit than in the Hippocratic collection. Be that as it may, in clear agreement with the Hippocratic doctors, the author is describing discrete stages or levels of consciousness. Moreover, apart from the patient becoming progressively less reactive, he seems to be suffering – as part of the same phenomenon – phantasiai axunetoi and paralêroi tên gnômên, thereby, again, blurring the boundaries between delirium, wakeful hallucinations and visions in dreams.
Terminology and HOFs
As in the HC, the use of terminology among these authors is also revealing of their ideas about the workings of the mind. We have been seeing in the analysis of both hallucinations and sleep how perceptions acquired increasing relevance among post-Hellenistic authors (possibly connected to new insights into the functioning of the nervous system developed during the Hellenistic period).
Naturally, due to their abridged nature, HOFs are scarcely elaborated in the Introduction and the Medical definitions. Nevertheless, their compilers did associate a disturbed dianoia with descriptions of phrenitis and mania.Footnote 36 In the cases of Celsus and Aretaeus, there seems to be more reflection on the topic.
Although Celsus’ understanding of the mind and the soul are radically different from the ideas that emerged from the Hippocratic authors, it is precisely in the passages that show strong Hippocratic influence that his conceptions appear more clearly. Indeed, his use of partial synonymy and his coinage of phrasal terms, which follow (from a formal point of view) rather closely some Hippocratic models, reveal his underlying (un-Hippocratic) ideas on these matters. Similarly, in Aretaeus’ work we can see a use of language that reminds us of the HC; however, such similarities are only restricted to the formal aspects.
Persistent use of partial synonymy
A common practice among scholars has been to find correspondences between On medicine and some Hippocratic texts. By using this technique, Stok and Pigeaud have convincingly argued that the term delirium in Celsus is sometimes used as an equivalent of paraphrosunê and sometimes of parakopê.Footnote 37 I propose to reverse the method; in other words, to apply it in the opposite manner, in order to see which other words in Celsus’ text are used to talk about delirium (my emphasis):
si quid etiam abscessit, et antequam suppuraret manente adhuc febre subsedit, periculum adfert primum furoris, deinde interitus. auris quoque dolor acutus cum febre continua vehementique saepe mentem turbat … suffusae quoque sanguine mulieris mammae furorem venturum esse testantur.
Moreover, if an abscess appears, and before it suppurates it [the abscess] starts decreasing while the fever persists, it carries the risk first of delirium (furoris), then of death. Also, acute earache with continuously elevated fever often disturbs the mens (mentem turbat) … Women’s breasts, when flooded with blood, also attest to the fact that delirium (furorem) is about to occur.
This extract belongs to the second book within the dietetics section, where Celsus discusses generalities about diseases. In this particular passage he is addressing bad prognostic signs specific to certain ailments. Stok has shown how Celsus condensed within it three different fragments from the Hippocratic corpus.Footnote 38 The first appearance of furor corresponds to paraphronêsê in Prognosis 18.6, the second one to maniên in Aphorisms V.40. Mentem turbat, finally, is Celsus’ equivalent of paraphronêsai as it appears in Prognosis 22.1. The synonymy between furor and mentem turbare, therefore, is not only clear through comparison with their Greek sources, but also by the context in which they appear, for the repetition of the adverb quoque also suggests that they have similar meanings. Furthermore, Celsus recaps later in the pharmacological section of his work a fragment of this passage and paraphrases it:
aurium inflammationes doloresque interdum etiam ad dementiam mortemque praecipitant
pain and inflammation of the ears often trigger delirium (dementiam) and death.
In this way, dementia also seems to correspond to paraphronêsai in Prognosis 22.1, thereby becoming yet another partial synonym of furor as well as turbare mentem (and also of delirium if we take into account Stok and Pigeaud’s above-mentioned deductions). This use of partial synonymy suggests that – much like the Hippocratic doctors (albeit with a smaller number of terms) – Celsus also perceived the very nature of delirium as changing and variable. Like them, and as with present usage, these partial synonyms express subtle nuances – often difficult to define – within a broader continuum of wakeful impaired consciousness.Footnote 39
Another important aspect that these correspondences reveal is the intervention of the mens in wakeful impaired consciousness, both in the compound dementiam (with the negative prefix de-) and in the phrasal term turbare mentem. We shall see below that this concept, along with animus (and less frequently consilium) – which Celsus used interchangeably in his discussion on insania (Med. 3.18: 19–21) – are comprised of several HOFs and play an important role in his idea of consciousness.
In the case of Aretaeus, the sleep and delirium terminology also reflects his ideas about the mind, and partial synonymy is still present, even if the vocabulary has also been quantitatively reduced (that is, he utilises fewer words than the HC to discuss impaired consciousness). In this sense, I disagree with Pigeaud and Murphy, who argue that mainomai only refers to the delusions that characterise mania.Footnote 40 On the contrary, in some passages discussed above mainomai appears in the discussion on phrenitis, where it is semantically equivalent to paraphorê,Footnote 41 and in the distinction between substance-induced delirium and mania, where ekmainomai and paraphorê are again used interchangeably.Footnote 42
There are, however, certain nuances. The concept of lêrêsis, which was also a partial synonym of all these terms in the HC, has now become an independent entity: it refers to a disease in its own right (which we would now associate with dementia of the elderly).Footnote 43
Phrasal terms, HOFs and the organisation of the mind
The use of phrasal terms is particularly revealing of Celsus’ theoretical framework, especially because, in On medicine, such periphrastic constructions are less lexicalised than in the Hippocratic corpus.Footnote 44 Unlike the Greek technical vocabulary that was better developed and had become estranged from etymology, Celsus explicitly complained about the scarcity of Latin terminology, which led him to make careful choices in his vocabulary while trying to avoid polysemy.Footnote 45 As a result, when he refers to delirium with turbare mentem (Med. 2.7: 27) and dementia (Med. 6.7: 1A), the disturbance that he envisaged actually did affect what he understood to be the mens. Its compromise is expressed through other phrasal terms. Examples abound in descriptions of diseases with impaired consciousness:Footnote 46 in insania the mens labat (‘the mens declines’, Med. 3.19: 1); in apoplêxia – which is a case of hypoactive impaired consciousness – the mens stupet (‘the mens is stunned’, Med. 3.26); in hot weather the mens hebetat (‘the mens is weakened’, Med. 2.1: 11); and in kephalaian there is alienatio mentis (‘aberration of the mens’, Med. 4.2: 2). Some of these phrasal terms even have a direct correlation with the Hippocratic corpus. For instance a passage of On medicine where mens labatFootnote 47 matches a Hippocratic one where gnômê noseei,Footnote 48 thereby suggesting a correspondence between mens and gnômê.
The relevance of the mens for normal cognitive functioning is also emphasised in situations where consciousness is preserved (that is, in the ‘vocabulary of lucidity’). Thus it is possible that after insania, mens redit (‘the mens returns’, Med. 3.18: 23); in cardiacum the body is affected but the mens constat (‘the mens remains firm’, Med. 3.19: 1); in cold weather mens erectior est (‘the mens is more elevated’, Med. 2.1: 11); and a good sign after a wound is when mens consistit (‘the mens resists’, Med. 5.26: 26A). Throughout all these examples, mens seems to refer to different intellectual capacities, apart from ‘la faculté de penser’.Footnote 49
Furthermore, as stated in the discussion on insania, animus and mens are used interchangeably. Not surprisingly, there are also phrasal terms where the noun head is animus. Thus, fever-associated delirium is expressed as animus laborat (‘the animus suffers’, Med. 3.5: 11); in phthisis it is advisable to avoid anything that can sollicitare animum (‘disturb the animus’, Med. 3.22: 9). Finally, successful treatments in phrenesis – in which mens … [vanibus] imaginibus addicta est (‘the mens has succumbed to empty visions’)Footnote 50– contribute ad quietem animi (‘to the repose of the animus’, Med. 3.18: 5), and some phrenitic patients that are offered a treatment through the spoken word begin to convertere animum (‘change their animus’, Med. 3.18: 11).
When trying to delimit the scope of these terms, it becomes evident that sense-perception was often included within the notion of mens (a few excerpts, as well as the vanas imagines of phrenesis, testify to this).Footnote 51 Other examples suggest that mens was involved in the faculty of rational thought. This is particularly evident in the distinction made between the two subspecies of the third kind of insania: in the first one individuals perceive imagines even though their mens is intact, and therefore they can reason (the examples given are Orestes’ and Ajax’s delusion).Footnote 52 In the other subtype, where mens is used interchangeably with animus and consilium, their derangement makes the patient perperam aliquid dixit aut fecit (‘speak or act wrongly’),Footnote 53 which can point towards an alteration in judgement, speech or both.Footnote 54
In summary, mens is one among few other abstract terms (such as animus) used by Celsus to discuss HOFs or ideas akin to what we would nowadays include within the sphere of cognition and associate with consciousness. Although perceptions do play a privileged role in the genesis of phrenesis, on the more theoretical level, mens seems to subsume – much like the Hippocratic notions of gnômê, nous, phronêsis, etc. – different capacities in different contexts, amongst which perceptions do not have a higher hierarchy than judgement, reasoning or speech.Footnote 55
Aretaeus’ understanding of the mind, on the other hand, is strongly influenced by the opposition of gnômê and aisthêsis. This organisation of mental capacities emerges quite clearly from his distinction between delirium and mental illness. The contrast between phrenitis and mania/melancholia, which he strongly emphasised, suggests a dichotomous division of HOFs. He opposed the affection of the aisthêsis (located in the head, which triggered the hallucinations that characterised phrenitis) to a compromise of the gnômê (that caused impaired emotions, behaviours and thinking, by affecting the heart). In this manner he separated two main areas of cognitive functioning, thereby also avoiding taking a clear side in the encephalocentric versus cardiocentric debate: faithful to his lax eclecticism, he adhered to both. Indeed, particularly in discussions concerning what we now define as mental disease, gnômê is presented in opposition to aisthêsis as its complementary counterpart, as though Aretaeus was suggesting a dichotomous idea of the mind comprised of aisthêsis and gnômê.Footnote 56 This way of fragmenting the HOFs makes Aretaeus’ understanding more compatible with some Hellenistic conceptions about the nervous system.Footnote 57 However, as I mentioned before, there are also examples of syncretism that challenge the previous view (which should not surprise us considering his lax eclecticism).
Such is the passage where Aretaeus describes the above-normal perceptions that occur due to extreme dryness in kausôn (‘the aisthêsis is absolutely pure, the dianoia subtle and the gnômê prophetic’, SA II. CMG (H).II: 24, 2–3). According to this description, he divided the cognitive functions into three (instead of two): aisthêsis, dianoia and gnômê. This tripartition also appears in the chapter that addresses epilepsy: δυσμαθέες νωθείῃ γνώμης τε καὶ αἰσθήσιος … ὑποτείνεται δέ κοτε καὶ τὴν διάνοιαν ἡ νοῦσος, ὡς τὰ πάντα μωραίνειν (‘they are slow at learning, with sluggishness in their gnômê and their aisthêsis … sometimes the disease strains the dianoia so that they become completely foolish’).Footnote 58 Although expanded – as compared to the binary fragmentation that characterised the contrast phrenitis–mania/melancholia – the picture would still not be completely incompatible with the previous dichotomous opposition between aisthêsis and gnômê. The mind, in this case, would be divided into perceptions or aisthêsis, which are affected by diseases such as phrenitis; gnômê, which controls behaviours and emotions and is impaired in mania–melancholia; and finally, dianoia, which seems to refer to reason or the capacity to think.
However, on other occasions new components are mentioned. In the distinction between mania and lêrêsis of the elderly, the latter affects aisthêsis, gnômê and nous: λήρησις αἰσθήσιος γάρ ἐστι νάρκη, καὶ γνώμης νάρκωσις ἠδὲ τοῦ νοῦ ὑπὸ ψύξιος (‘[it] is numbness of aisthêsis and benumbing of both the gnômê and the nous due to cold’),Footnote 59 whereas in the prooemium to the books on chronic illnesses Aretaeus only separates aisthêsis and psuchê: ἀλλ᾽ ἐς πολλὰ τὴν αἰσθησίην ἐκτρέπει, ἀλλὰ καὶ τὴν ψυχὴν ἐκμαίνει (‘not only do [bad mixtures of the body] often alter perceptions, but they delude (ekmainei) the psuchê as well’).Footnote 60 Moreover, in the discussion on phrenitis, apart from the aisthêsis that I have already mentioned, there are allusions to the thumos and the phrên. The thumos is μειλίγματα γὰρ θυμοῦ σιτία (‘Food is melody for the thumos’)Footnote 61 or ἄριστος δὲ μειλίξαι θυμὸν ἐν παραφορῇ ([wine] ‘best sets the thumos to music during delirium (paraphorê)’), that is, wine and food appease the spirit.Footnote 62 The phrên, on the other hand, could be regarded as an example of sumphorêsis: it refers in one passage to an HOF affected by vinous fruits,Footnote 63 and it designates the diaphragm in another.Footnote 64
It could be argued, therefore, that despite a clear isolation of the aisthêsis as an independent key component of consciousness (and consciousness-affecting diseases), there is – as among the Hippocratic doctors – vagueness, overlapping and inconsistencies in Aretaeus’ descriptions of the other mental capacities (albeit with a reduced terminology, for phronêsis and sunesis do not appear in his lexicon).
Despite all these nuances, whenever Aretaeus wants to convey the idea of delirium or confusion in contexts where specific capacities are less relevant, that is, when he does not need to differentiate impaired consciousness from other specific cognitive compromises, he uses phrasal terms where gnômê is the nominal head. In peripneumonia there is gnômês aporiê (‘puzzled gnômê’, SA II.1. CMG (H).II: 16, 7); during acute affections of the liver the gnômê ou karta paraphoros (‘the gnômê is not extremely delirious’, SA II.6. CMG (H).II: 27, 27–8); in an acute disease of the hollow vein, patients are tên gnômên ou paraphoroi (‘not delirious in their gnômê, SA II.8. CMG (H).II: 29, 21); in suppurating diseases they are tên gnômên paralêroi (‘delirious in their gnômê’, SD I.9. CMG (H).III: 50, 12). On the contrary, in whiter jaundices patients become gnômê de phaidroteroi (‘brighter in their gnômê’, SD I.15. CMG (H).III: 59, 12).
It seems that gnômê is used in two different ways: as a general term to convey the idea of impaired consciousness, when no further nuances are needed, and as a more specific term to distinguish mental illness or delusion (which affect the gnômê) from impaired consciousness due to altered perceptions (in which gnômê is opposed to aisthêsis).
In summary, the analysis of HOFs reinforces what has already been said when analysing hallucinations and sleep. Aretaeus’ stress on disturbed perceptions as a key feature to explain diseases where consciousness was compromised is paralleled by the key role of aisthêsis as an independent capacity in the way he fragments the HOFs. When comparing his stance to Celsus’, we can still see the difference in emphasis that was highlighted in relation to the clinical presentation. Celsus only considered altered perceptions to be a key finding when addressing the symptoms, but they did not have a privileged status in his theoretical constructs such as mens or animus. In them, perceptions were just one component among others. Aretaeus, on the other hand, not only stressed the relevance of hallucinations in his clinical characterisation of the diseases, but also conceived aisthêsis as an individual HOF with the same hierarchy as, for instance, gnômê.
In line with his strict distinction between processes according or contrary to nature, in Galen’s comprehensive system there is less room for ambiguities: health and disease are clearly separated, and disease is characterised by a locus affectus, a specific type of imbalance, and a quantitative degree of imbalance.
Boundaries between health and disease: natural versus non-natural sleep
Naturally, this author recognised healthy sleep and a non-healthy state, kôma, which could be wakeful or drowsy. The normal process is described in On the distinction of diseases:
… ἐπεὶ καὶ κοιμώμενοι, καὶ ἄλλως ἐν σκότῳ καὶ ἡσυχίᾳ διάγοντες, ἢ κατακείμενοι πολλάκις οὔτε τι μέρος κινοῦμεν, οὔθ’ ὅλως αἰσθανόμεθα τῶν ἔξωθεν οὐδενὸς, οὐδὲν μὴν ἥττον ὑγιαίνομεν.
… when we sleep and spend time in the darkness, quietly lying, often without moving any part, and perceiving absolutely nothing from outside, we are not less healthy.
This is the passage mentioned above where sleep is described as a quiet activity: in the dark, without external stimuli (which would suggest that observed sleep was an unusual situation). On a more physiological note, disconnection from the environment (tôn exôthen) is a crucial feature of sleep. Apart from perceptions – which had appeared in Aretaeus – Galen highlights the lack of movement. Considering that both are capacities of the psuchê in Galen’s theoretical model, it is not surprising that the unhealthy kind of sleep will be considered together with the conditions that affect the ruling part of the soul (located in the brain):
… καὶ πρὸς τούτοις ἔτι δύο ἐξαίρετα, τὸ μὲν ἀγρυπνία, τὸ δὲ κῶμα … ἐφεξῆς δ’ ἂν εἴη τὰς τῶν ἡγεμονικῶν ἐνεργειῶν βλάβας διελθεῖν … ἔστι δὲ καὶ ταύτης … ὃ δὲ κάρος καὶ κατάληψις … τὸ δὲ οἷον ἐλλιπὴς καὶ ἄτονος [κίνησις], ὡς ἐν κώμασί τε καὶ ληθάργοις…
… apart from these [damages common to all perceptual activities], there are also two special ones: sleeplessness and kôma … Subsequently, the damages to the hêgemonikon [itself] should be discussed … Amongst [those that affect imagination] are … torpor (karos) and catalepsy … [and] something akin to a defective [movement] lacking tone, as in kômas and lethargies…
In a nutshell, non-natural sleep occurs when the psuchê is either affected in the aisthêtikon or the phantastikon (which in turn belongs to the hêgemonikon). Hence, the locus affectus is clear, and with it, the site to which the treatment should be applied:
καὶ μὲν δὴ κἀπὶ τῶν ληθαργικῶν οὐδείς ἐστιν ὃς οὐ προσφέρει τῇ κεφαλῇ τὰ βοηθήματα· καὶ τοῦτο γὰρ τὸ πάθος … γίνεται δ’ ἐγκεφάλου πάσχοντος, ἐν ᾧ τῆς ψύχης ἐστι τὸ ἡγεμονικόν.
Sleep and wakefulness as a continuum
The consequence of the above-mentioned disturbances is designated as kôma or kataphora, namely, impaired consciousness:
… δύο εἰσὶν εἴδη καταφορᾶς … commune enim ambabus est, quia elevare non possunt oculos, sed mox gravantur et dormire volunt, proprium autem alterius, quia hii quidem dormiunt mox et profunde et diu hii vero vigiles versute sunt, alia super aliam fantasiam adveniente et mentem movente et somnum incidente … sive igitur somnolenta sive vigil fuerit catafora, vocare coma est consuetudo ei, et nequaquam sibi invicem repugnant … quandoque quidem in vigiliis parvis invenietur coma quandoque autem in somno. etenim et catafora quandoque quidem somnolenta est, quandoque autem vigil; quare non habes dicere de catafora patientibus, quod vigilant vel non.Footnote 1
… drowsiness (kataphora) presents in two forms … common to both [of them] is the fact that [patients] cannot open their eyes but are soon weighed down and wish to sleep; but specific to one [form] is the fact that the former [sufferers from kôma] fall asleep quickly and deeply during the day, while the latter [sufferers from kataphora] are actually deceitfully awake, for dreamy apparitions come to their mind (mens) and move it, thereby interrupting their sleep … Regardless of whether the drowsiness (kataphora) is somnolent or wakeful we customarily call it kôma, and by no means do they [the two forms] oppose each other … kôma is sometimes found in short wakeful periods, and sometimes in sleep. Indeed, also drowsiness (kataphora) is sometimes somnolent and sometimes wakeful, wherefore you should not say whether patients who suffer drowsiness are awake or not.
The transition between abnormal sleep and wakefulness is so blurred that in conditions with impaired consciousness one cannot really tell one from the other. As a matter of fact, Galen is suggesting that it makes no sense trying to distinguish between them. In contemporary terms we would construe the concept as a single condition (kataphora, kôma, impaired consciousness) with various manifestations (drowsiness, hallucinations, confusion). Furthermore, such a view actually implies that somnolent and wakeful impaired consciousness are two presentations of a similar phenomenon. This stance is not only in utter contradiction to Celsus, who conceived sleep as an all-or-nothing phenomenon (where patients could only be either awake or asleep), but it also challenges the Hippocratic authors and Aretaeus. Indeed, although all of them did admit some grey areas with fuzzy edges between wakefulness and sleep, they nonetheless attempted to associate such conditions either with one or the other (as discussed within the sociological commentary, the specific treatment for each category required that kind of clarity in the classification).Footnote 2
The blurred boundaries, however, are not limited to the distinction between delirium and sleep. A passage where Galen contrasted certain diseases of the hêgemonikon with sunkopê illuminates the way in which he understood the relationship between the three prototypes of impaired consciousness:
οὕτω γοῦν ἐπιληψίαι τε διὰ τὸν ἄτονον στόμαχον ἐνίοις ἐπιγίνονται, καὶ κάροι, καὶ κώματα, καὶ καταλήψεις, παραφροσύναι τε καὶ μελαγχολίαι, τῆς κατὰ τὸν ἐγκέφαλόν τε καὶ τὰ νεῦρα συμπαθούσης ἀρχῆς. αἱ δὲ ὀνομαζόμεναι καρδιακαὶ συγκοπαὶ τῆς κατὰ τὴν καρδίαν τε καὶ τὰς ἀρτηρίας ἀρχῆς συμπαθούσης ἐπιγίγνονται.
In this way, epilepsy falls upon some due to a weak stomach, as do torpors (karoi), kômas, catalepsies (katalêpseis), deliria (paraphrosunai) and bouts of melancholia, providing there is sympathy towards the principle (archê) located in the brain and the nerves. The so-called cardiac sunkopai supervene as long as the sympathy occurs towards the principle (archê) located in the heart and the arteries.
First of all, the fact that Galen needed to contrast conditions with impaired hêgemonikon and phantastikon – such as epilepsy, torpor, kôma, catalepsy and delirium – with cardiacum (total loss of consciousness) suggests that he perceived them to be easily confused conditions.Footnote 3 In terms of their specific links, the three prototypes of impaired consciousness may well originate in the stomach, but they all ultimately affect a part of his tripartite soul: the psuchê.Footnote 4 The difference is that whereas the latter has sympathy towards the archê in the heart (spirited psuchê), all the others have it towards the brain (rational psuchê). The kind of disease that develops depends on where specifically the sympathy goes.
In other words, the problem begins in the stomach, but it is the second stopover that will determine the kind of affection: if it is the rational soul, it will trigger diseases of the hêgemonikon (with drowsy or hyperactive impaired consciousness), whereas if the spirited soul receives the sympathy, it will trigger a sunkopê (total loss of consciousness). The above shows that although the psuchê was affected in all the situations that we nowadays consider as impaired consciousness, there were nuances. As we shall see in Part III of this book, Galen consistently attributed delirium and sleep to the hêgemonikon, whereas fainting was sometimes related to a different part of his tripartite Platonic soul. When the emphasis was put on the loss of movement and perceptions that fainting causes, the affection of the hêgemonikon in the brain was emphasised. When, on the other hand the mechanism of swoons (the loss of blood) was under discussion, the attention was diverted towards the spirited soul in the heart, which carries the innate heat.
Levels of consciousness
For certain, Galen offers explicit speculation on the gradable physiology of both healthy and pathological sleep. As far as the former is concerned,
… κατὰ τοὺς ὕπνους ἤτοι παντάπασιν ἀργοῦσιν αἱ αἰσθήσεις, ἢ ἀμυδρῶς ἐνεργοῦσιν. εὔλογον οὐν ὀλίγην τινα ἐπιῤῥεῖν τηνικαῦτα δύναμιν ἀπὸ τῆς ἀρχῆς τοῖς κατὰ μέρος. καὶ τό γε βαθέως τε καὶ μὴ βαθέως κοιμᾶσθαι … ἐν τῷ ποσῷ τῆς ἐπιῤῥοῆς ἐστι. τοσούτῳ γὰρ μεῖον ἐπιῤῥεῖν εἰκός ἐστιν, ὅσῳπερ ἂν ὁ ὕπνος ᾖ βαθύτερος.
… during sleep, perceptions are either completely inactive, or they operate weakly. Hence, it is reasonable that in such circumstances there is little capacity flowing from the controlling centre towards them [the perception organs]. To fall asleep deeply and non-deeply depends on the amount of the flow: the lesser the flow, the deeper the sleep.
Galen explicitly conceives different levels of disconnection that manifest in progressive depths of sleep, and they depend on the quantity of perception capacity flowing from the archê (in the brain) towards the senses.
Concerning the abnormal kind of sleep, I have already pointed out that in Galen’s system, the antithetic character of the qualities (cold–hot, dry–moist) enables a rational explanation for opposite symptoms (such as insomnia–drowsiness). We should now add that the gradual nature of such qualities allows – and even encourages – reflection upon their intensity. For certain, qualities admit degrees, which makes it relatively easy for a doctor to correlate levels of heat, coldness, dryness or moistness to a corresponding severity of the compromise:
ὥσπερ οὖν ὕπνος καὶ ἀγρυπνία μᾶλλον τοῦ μετρίου γίνεται, τὸ μὲν δι’ ὑγρότητα, τὸ δὲ διὰ ξηρότητα κράσεως, οὕτως ἐν αὐτοῖς τούτοις τὸ μᾶλλόν τε καὶ ἧττον ἐν ἀγρυπνίαις τε καὶ ὕπνοις ἕπεται τῷ μᾶλλον καὶ ἧττον ἐν ὑγρότητι καὶ ξηρότητι.
Just like sleep and insomnia are produced by a mixture exceeded in the amount of humidity in the former, and dryness in the latter; in the same way, on these particular qualities [depend] the seriousness or mildness of insomnia and [the depth or lightness of] sleep, for they correspond to the increased or reduced amount of humidity and dryness.
Clearly, Galen’s system contemplates this perfect continuum between antithetical symptoms, which are correlated with opposed qualities. The same rationale underpins the polarity that contrasts lethargy with phrenitis. Consistently throughout his works, the former is hypoactive and caused by the coldest and wettest mixtures, whereas the latter is hyperactive and the result of the hottest and driest kraseis:
… φρενῖτις μὲν ξηρὸν καὶ θερμόν ἐστι νόσημα, καὶ διὰ τοῦτο ταῖς πρακτικαῖς ἐνεργείαις εὐρωστότατον· ὁ δὲ λήθαργος ἄῤῥωστον, ὑγρότητι δαψιλεῖ τε καὶ ψυχρᾷ…
… phrenitis is a dry and hot disease and this is why it is particularly strong in active functions [hyperactive]. Lethargy is weak [in active functions, that is, hypoactive] due to abundance of humidity and coldness….
Although Galen does not explicitly link these phenomena to the quantitative aspect of his humoural theory, he does illustrate his explanations with the same examples as those he had used to explore the gradability of the theory. Therefore, it is not unreasonable to think that – also in this regard – he did consider the levels of consciousness to be parallel to the degrees of the qualities: somnolenta igitur, quantum ad praesens, ipsis litargicis insidet, insomnem vero, que freneticis supervenit, temptandum distinguere. (‘Therefore, somnolent [kataphora] – which determines the degree of lethargy itself – should be distinguished from sleepless [kataphora], which can befall phrenitic patients’).Footnote 5 In other words, impaired consciousness (kataphora) can manifest with symptoms that extend from sleep – at the hypoactive end of the spectrum – all the way through to wakefulness, with a whole range of intermediate states. In such states, presumably, the degrees of heat, coldness, moistness and dryness determine the severity of the delirium or the depth of the sleep, which are ultimately two sides of the same coin.
From a less pathophysiological point of view, it is interesting to place this concept of correlations between depths of sleep and seriousness of ailments within a broader context and amid the non-medical discourses. There is an explicit philosophical formulation in Aristotle’s Generation of animals:
ὕπνος εἶναι δοκεῖ τὴν φύσιν τῶν τοιούτων, οἷον τοῦ ζῆν καὶ τοῦ μὴ ζῆν μεθόριον, καὶ οὔτε μὴ εἶναι παντελῶς ὁ καθεύδων οὔτ᾿ εἶναι.
Sleep seems to have this very nature: it is like a boundary between not living and living; for somebody asleep is neither being nor completely not-being.
If we consider that death is often the end stage of serious illnesses, and that according to these doctors becoming progressively sick manifests by becoming progressively drowsy, one can see how these closely connected ideas have possibly interacted and interfered with each other. Indeed, the liminality of sleep between life and death seems to have been deeply ingrained in ancient discourses (well beyond archaic epic poetry). It penetrated medicine to such an extent that even Celsus, who did not conceive a progression in the levels of consciousness, still regarded sleep as a sign of imminent death: eadem mors denuntiatur … ubi adsidue dormit (‘Death itself is announced … when one sleeps uninterruptedly’).Footnote 6
To sum up, the way in which these authors tackled sleep illustrates how strict definitions and clear boundaries sometimes obscure phenomena, rather than help to explain them. Celsus’ strict separation between wakefulness and sleep prevented him from considering intermediate conditions and stages that were present in other contemporary treatises. Furthermore, although he was interested – as most other post-Hellenistic sources – in the relationship between perceptions and reality, he only discussed the topic in connection with delirium but not with sleep (as Aretaeus and Galen did), thereby leaving out questions about the reality of dreams. In a similar manner, Galen’s clear distinction between health and disease did not allow him to see the gradual transition between both stages. He seems to have clearly understood the progression in the seriousness of illnesses, the related nature of wakefulness and sleep, and even the subtle transition between delirium and drowsiness, but not the link between healthy and disturbed sleep. Paradoxically, both authors took such boundaries for granted and made no effort to define where exactly they set them. Celsus did not explain how to distinguish wakefulness from sleep, nor did Galen clarify where healthy sleep ended and disturbed sleep began. On the contrary, those limits remain as purely theoretical constructions in the texts, which are only self-evident when considering the prototypical extreme situations, but are much less obvious in the intermediate stages.
This lack of explanation is perhaps due to the fact that the exact location of such limits was not established by medicine but by the culture of that time. If – as Williams states – every society organises and schedules the sleep of its members, we can suggest that the medical discourse is only providing explanatory models and solutions (in the form of treatments) for situations where the transgression of social rules is construed as disease.Footnote 7 Ultimately, the amount of sleep regarded as normal, the pattern of sleep during night or day and the level of sleepiness acceptable in an interaction are socially regulated conventions.Footnote 8 Taking this idea a step further, the whole concept of consciousness that emerges from this analysis of sleep could be regarded as the way in which these medical writers accommodated some medical theoretical frameworks to the various non-medical discourses on sleep available in their time and place.
Galen’s approach to HOFs, the mind and their terminology
Unlike the previous authors, where the idea of mind and the organisation of HOFs had to be deduced from hints in the descriptions, Galen was very explicit about it and delimited a systematic, coherent and consistent division of the different domains involved in the workings of the mind:
… τὰς ψυχικὰς [ἐνεργείας] … τέμνοντες εἴς τε τὰς αἰσθητικὰς καὶ τὰς κινητικὰς καὶ τρίτας τὰς ἡγεμονικὰς … πάλιν ἑκάστην τῶν εἰρημένων διαιροῦμεν εἰς τὰς ἐν αὐτῇ διαφοράς. ἡ μὲν οὖν αἰσθητικὴ τῆς ψυχῆς ἐνέργεια πέντε τὰς πάσας ἔχει διαφορὰς: ὁρατ<ικ>ήν, καὶ ὀσφρητ<ικ>ήν, καὶ γευστ<ικ>ήν, καὶ ἀκουστ<ικ>ήν, καὶ ἁπτ<ικ>ήν. ἡ δὲ κινητικὴ τὸ μὲν προσεχὲς ὄργανον ἓν ἔχει καὶ τὸν τρόπον αὐτοῦ τῆς κινήσεως ἕνα … ἡ λοιπὴ δὲ ἐνέργεια τῆς ψυχῆς ἡ κατ’ αὐτὸ τὸ ἡγεμονικὸν εἴς τε τὸ φανταστικὸν καὶ διανοητικὸν καὶ μνημονευτικὸν διαιρεῖται.
… Having separated the psychic [activities] into perception, movement and thirdly, authoritative (hêgemonikas) [activities] … we will divide them, again, into classificatory categories within each. The perceptual activity of the psuchê has five sub-categories: sight, smell, taste, hearing and touch. The motor [activity] has a single organ attached, and the form of its movement is also one … The remaining activities of the psuchê – which are controlled by the hêgemonikon (authoritative part) – [can be classified] into imagination (phantastikon), intellect (dianoêtikon) and memory (mnêmoneutikon).Footnote 9
In this passage, Galen is establishing clear boundaries of what constitutes ‘the psychic’, what its sub-divisions are and what are their corresponding activities or functions. It is within these theoretical limits that he will later discuss all the conditions that we nowadays consider as wakeful and drowsy impaired consciousness. We could be tempted to regard the activities of the hêgemonikon as similar to our current medical idea of consciousness.Footnote 10 However, other texts present minor variations in terminology and some nuances in the concepts, which prevent such a correspondence. In a more philosophical work, for instance, Galen states that ἡ λογιστικὴ ψυχὴ δυνάμεις ἔχει πλείους, αἴσθησιν καὶ μνήμην καὶ σύνεσιν ἑκάστην τε τῶν ἄλλων (‘the rational (logistikê) psuchê has several capacities: perception, memory and understanding (sunesin) of each of the others’).Footnote 11 When comparing the two extracts there appears to be some overlap and simplification between what he had defined as ‘psychic activities’ and what he is designating as ‘the capacities of the rational psuchê’. In yet another treatise the hêgemonikon is the site where ἐπιστήμης τε καὶ δόξης ἁπάσης τε διανοήσεως (‘knowledge (epistêmê), all the judgement (doxa) and intellect (dianoêsis) are to be found’),Footnote 12 and later on he states that αἱ μὲν τοῦ λογιστικοῦ τῆς ψυχῆς ἐνέργειαι καλείσθωσαν ἠγεμονικαὶ (‘the activities of the rational (logistikou) part of the psuchê should be called hêgemonikai [that is, belonging to the authoritative part]’).Footnote 13 Ultimately, although there are some discrepancies concerning what belongs to the rational psuchê in general and to the hêgemonikon in particular,Footnote 14 it seems that Galen is grouping together some HOFs, most of which are nowadays considered to belong in the sphere of consciousness.Footnote 15 Moreover, it could be argued that in this sense he remained remarkably consistent throughout his work. He considered all the diseases that affect these psychikai/hêgemonikai energeiai, or the logistikon tês psuchês to be related,Footnote 16 and he offered a comprehensive catalogue of them in his treatise On the distinction of symptoms:
καὶ τοίνυν αἱ βλάβαι τῶν αἰσθητικῶν ἐνεργειῶν κοιναὶ μὲν ἁπασῶν ἀναισθησίαι τινές εἰσιν, ἢ δυσαισθησίαι … καὶ πρὸς τούτοις ἔτι δύο ἐξαίρετα, τὸ μὲν ἀγρυπνία, τὸ δὲ κῶμα … τῶν δ’ αὖ κινητικῶν ἐνεργειῶν ἀκινησία μὲν καὶ δυσκινησία τὰ πρῶτα συμπτώματα … ἐπειδὰν … ἐμπροσθότονός τε καὶ ὀπισθότονος καὶ τέτανος … ἐπιληψία … καὶ ἀποπληξία ἢ παντὸς τοῦ σώματος παράλυσις ἅμα ταῖς ἡγεμονικαῖς ἐνεργείαις … ἐφεξῆς δ’ ἂν εἴη τὰς τῶν ἡγεμονικῶν ἐνεργειῶν βλάβας διελθεῖν, καὶ πρώτης γε τῆς φανταστικῆς. ἔστι δὲ καὶ ταύτης … ὃ δὲ κάρος καὶ κατάληψις … παραφροσύνη … τὸ δὲ οἷον ἐλλιπὴς καὶ ἄτονος [κίνησις], ὡς ἐν κώμασί τε καὶ ληθάργοις … καὶ μέν γε καὶ αὐτῆς τῆς διανοητικῆς ἐνεργείας … ἄνοια … μορία τε καὶ μώρωσις … παραφροσύνη.
The damages common to all the perceptual activities are certain anaesthesiai or dusaesthesiai … apart from these, there are also two special ones: sleeplessness and kôma … Again, the main symptoms of the motor activities are immobility (akinesia) and duskinesia … then, emprosthotonos, opisthotonos and tetanus, … epilepsy … and apoplexy or simultaneous paralysis of the whole body and the activities of the hêgemonikon [authoritative part] … Subsequently, the damages to the hêgemonikon [itself] should be discussed, and firstly those that affect the imagination (phantastikon). Amongst them are … torpor (karos) and catalepsy … delirium (paraphrosunê) … [and] something akin to a defective [movement] lacking tone, as in kômas and lethargies … And among those [damages] that affect the intellectual activities (dianoêtikon), there are … mindlessness (anoia) … folly (môria) and foolishness (môrôsis) … [and] delirium (paraphrosunê).
Although there are other classifications throughout the corpus with minor variations, as well as certain conditions that are not mentioned here (which Galen nonetheless considered to belong in this group),Footnote 17 there is consistency in terms of the anatomical and physio-pathological understanding. All these conditions affect the brain (because it is the seat of the rational soul), and they all occur as a consequence of an imbalance in the krasis,Footnote 18 namely, an approach with evident advantages in terms of therapeutic conduct, for it explained diseases in a way that enabled Galenic medicine to successfully treat them.
Regarding the organisation of the mind, Galen’s fragmentation of the HOFs blurred several distinctions that we now make (because they were irrelevant to his therapeutic approach). Thus, by describing all these conditions as affections of the psuchê,Footnote 19 and classifying them according to the type of psychic activity disturbed (perception, motion or ruling part) and the kind of compromise (complete, partial or deviant), the edges between impaired consciousness (wakeful or drowsy) and mental illnesses become fuzzy, for they are both diseases where the intellectual (dianoêtikon) activities of the ruling part of the rational psuchê – the hêgemonikonFootnote 20 – are damaged. Similarly, because the psuchikai energeiai are affected in delirium and mental illness, as well as in tetanus, epilepsy and the case of the youth with speechlessness and traumatic paralysis (already mentioned, Loc. Aff. CMG I.6: 284, 12–17. K.VIII: 50–1), the boundaries between what we now consider as neurological conditions, impaired consciousness and mental illness also become faint. In other words, although Galen subsumed the mental capacities within constructs that are broader than our idea of consciousness, he was able to clinically distinguish cases with impaired consciousness, and he did perceive an abstract notion to be compromised in such situations (albeit a notion comprised of more HOFs than we nowadays consider).
Concerning terminology, as Jouanna has remarked,Footnote 21 a parallel passage from On the causes of symptoms (II. 7. K.VII: 200–4) complements and introduces slight lexical nuances to this list. In this other version Galen calls môrôsis what he had previously designated as anoia, and defines it as a complete paralysis of the activities of the dianoêtikon. The partial impairment of such activities, which he had previously defined as môria and môrôsis, are now referred to as νάρκαι τοῦ λογισμοῦ τε καὶ τῆς μνήμης (‘reason and memory numbness’).Footnote 22 Interestingly, in this rendering he expands the notion of deliria (paraphrosunai) and includes some specific diseases such as phrenitis, mania and melancholikai paranoiai.
Undoubtedly, these passages reveal a fairly standardised and rather concise vocabulary. Galen’s use of terminology, therefore, is more in line with the post-Hellenistic authors than with the Hippocratic doctors, where we found an extensive use of partial synonymy. Although there was a certain instability (for example, between anoia/môrôsis when tackling the diseases of the dianoêtikon), in the last passages, his vocabulary reminds us of Aretaeus’: paraphrosunê seems to be the most common word for delirium (even if parakoptô is exceptionally used to describe similar phenomena).Footnote 23 Paranoia in the comment on melancholia was used to designate the specific kind of delusion that characterised that condition. Finally, paralêrêsis – as in Aretaeus – is the word chosen to talk about the mental disturbance of old age (what we would nowadays call dementia): διὰ τί τοίνυν εἰς ἔσχατον γῆρας ἀφικνούμενοι παρελήρησαν οὐκ ὀλίγοι τῆς τοῦ γέρως ἡλικίας ἀποδεδειγμένης εἶναι ξηρᾶς; οὐ διὰ τὴν ξηρότητα φήσομεν ἀλλὰ διὰ τὴν ψυχρότητα (‘Why do most of those who reach extreme old age act foolishly (parelêrêsan), if old age has been demonstrated to be dry? We shall reply, not due to the dryness but to the coldness’).Footnote 24 Once again, there is a humoural correlate that will guide the specific treatment of this clinical condition.
By framing sleep as a form of impaired consciousness, a common feature emerged in all the sources, namely, its ambiguous status in relation to various dichotomous oppositions. Indeed, when talking about dormancy, authors seem to be constantly navigating the tensions between health and disease,Footnote 1 wakefulness and unconsciousness, and in certain cases, even between life and death. Medical writers tended to be torn – to a greater or lesser extent – by some of these oppositions, and they struggled to locate sleep at a determined point between the polar extremes of one or several of these antithetical pairs.
Closely related to the previous finding is another feature that pervades the different periods: the perceived sense of gradual transition between the antithetic extremes, which brings us back to the questions about limits. Whether such extremes are envisaged as a continuous spectrum or as a sequence of discrete stages, the manner in which most of the authors (except for Celsus) discussed sleep points towards ideas of progression, rather than abrupt changes from one state to its opposite. Understandably, if biological processes are gradual, establishing boundaries between intermediate categories is not straightforward, for they have fuzzy edges. When juxtaposing these ancient medical ideas with our existing sociological understandings about sleep,Footnote 2 one can see that it is often the social conventions – such as what is acceptable and what is not – that establish clearer boundaries, thereby exemplifying a situation where sociological discourse has an influence over science.
Concerning the terminology, from a historical perspective, there is an evident quantitative shrinkage in the vocabulary of delirium from the Hippocratic authors onwards. The abundant glossaries and attempts at shedding light on the meaning of each termFootnote 3 suggest that those authors had used a larger terminology than their successors to talk about delirium. This reduction might further support the idea of partial synonymy. Ultimately, the Hippocratic corpus was written by many authors from different parts of the Greek world, and it is understandable that they utilised varied terms to talk about similar realities. On the other hand, the fact that the later authors that we looked at required (to describe similar cases) only a few of those terms might indicate that a more limited number of words was sufficient because many of them expressed similar symptoms.
In terms of the organisation and workings of the mind, the previous analysis has yielded other elements that remained constant throughout the different periods and authors, which points towards a general common understanding of impaired consciousness. To be sure, medical writers related the condition to certain abstract notions that they deemed to be compromised (whether we call them the mind, HOFs or a rudimentary idea of consciousness) and struggled to link – in a clear example of tension between theory and clinic – such concepts to the symptoms found in their patients. This becomes particularly evident when considering the extensive use of phrasal terms and their similar structure (a noun head with an HOF and a determiner in the semantic field of ‘damage’ or ‘compromise’). These lexicalisations, therefore, support the hypothesis that an underlying intellectual construct was shared, regardless of the specific nuances that each author gave it (in the case of Galen I have not mentioned any phrasal term, but the underlying constructs are explicitly described).
The tension that emerges from the interaction between these theoretical concepts and the actual clinical findings reflects how these authors – implicitly or explicitly – conceived the relationship between mind and body, cognition and behaviour, thereby characterising the singularity of each medical writer’s understanding. It is, certainly, this tension – which each author resolved in a different manner – that conditioned the changes or evolution in the idea of consciousness discussed throughout the analysis.
Finally, these theoretical constructs also illustrate the important degree of abstract reflection that all these authors reached, which they defended even to the detriment of some observational evidence. Indeed, these rudimentary notions of consciousness – first described with various terms by the Hippocratic texts – were powerful enough to organise most of the later theorisations of delirium, sleep and intermediate states that we have been discussing. Accordingly, the post-Hellenistic authors were happy to sacrifice coherence and consistency in their pathophysiological explanations but preserved these embryonic ideas of consciousness, whereas Galen devised a coherent anatomical and pathophysiological system, but could easily overlook some contemporary nosological classifications in order to preserve these constructs. In other words, the specificities about the way in which each of the authors fragmented or grouped the HOFs – that is, the particularities of each one’s rudimentary notion of consciousness – determined the clinical differences that they were able to see, as well as those that remained obscure.
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