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.
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