Two forms of losing consciousness among the Hippocratic doctors

Throughout several Hippocratic treatises, fainting is often construed using terms that etymologically suggest separation of, lack of or a diminished psuchê (leipopsuchiê, apsuchiê, oligopsuchiê, etc.).Footnote ¹ Such are the cases of bilious women who faint (oligopsuchiê empiptei)Footnote ² because their menses are retained; or cases of swoons when lifting from the seat; namely, examples of what we would nowadays frame as an orthostatic syncope. In Epidemics VII, a patient fainted (eleipopsuxei) on the ninth day of his disease ἐπὶ θῶκον ἀναστὰς (‘when standing up from the chair’).Footnote ³

Unlike descriptions of delirium where etymology was completely estranged from the meaning of the terms, these writers do seem to have been aware of the lexical components involved in the words they used, because in their view the soul was a key factor in this syndrome. Accordingly, the author of On diseases I seems to conceive fainting as a separation of the psuchê:

The previous example implies that for this author ekpsuchô evoked the idea of a release of the psuchê. Because the separation could become irreversible, thereby leading to death, his idea of soul suggests some kind of life force and warrants immediate help before the soul breaks free for good.Footnote ⁴ My interpretation questions Thumiger’s point of view that the idea of the psuchê was only relevant in very few texts.Footnote ⁵ On the contrary, it implies that it was present in several of these authors’ idea of swoons. In the previous example, it seems that the medical writer regarded fainting as a partial, temporary and reversible separation of the psuchê, compatible with a near-death experience.Footnote ⁶

Not surprisingly, in these near-death experiences the Hippocratic doctors paid particular attention to respiration: in a patient who had fainted (that is, someone non-alert, disconnected, unresponsive), breathing provided some evidence that could give the observer a valuable clue as to whether the patient was dead or had only momentarily lost consciousness. This is advised by the author of On regimen in acute diseases B: καταμανθάνειν δὲ καὶ ἐν τῇσιν ἐξαναστάσεσιν, εἰ λειποθυμέει ἢ εἰ τοῦ πνεύματος εὐφορίη αὐτὸν ἔχει (‘one should observe carefully whether the patient faints or breathes easily as he stands up’).Footnote ⁷ Similar examples can be found elsewhere (Acut. Sp. 23. LCL: 248, 16–17 and Epid. V. CUF 2, 2–3: 3, 1–5).Footnote ⁸ Polycrates’ physician is even more explicit when describing a specific type of breathing characteristic of fainting (we would nowadays define it as ‘agonal’ or ‘gasping’ respiration):

Apparently, in this transient separation of the psuchê, breathing continues throughout the whole swoon, and it is this very condition that reveals to the doctor whether the fainting patient still lived or if he had passed away.

A final remark with regards to this form of describing total loss of consciousness concerns its fuzzy edges with wakeful impaired consciousness. It is suggested in a case where orthostatic syncope is considered as an early sign of delirium (paraphrosunê): τοῦ πνεύματος ἀπορίη, ἢ διαναστὰς ἐπὶ θρόνον ἢ αὐτοῦ ἐν τῇ κλίνῃ ἢν ἀψυχίη ἐγγένηται (‘difficulty in breathing or if the patient faints while he is standing up from a seat or from his bed’).Footnote ⁹ In other words the momentary departure of the soul can presage conditions where the mind is unsound.

On the other hand, the Hippocratic doctors also found another way of describing total loss of consciousness, in which the soul does not seem to be involved. Head trauma, which we could even nowadays easily relate to suddenly becoming unconscious, is described in the following way: δῖνός τε ἔλαβε καὶ σκότος, καὶ ἐκαρώθη καὶ κατέπεσεν (‘he suffered vertigo, blacked out (elabe skotos), became drowsy (ekarôthê) and fell down’).Footnote ¹⁰ Note the assimilation of total loss of consciousness with drowsiness for this author through the verb karoô. As a matter of fact, instead of conceiving this sudden episode as a single concept, the writer seems to be describing concurrent, yet separate clinical symptoms.

The author of Diseases of women II offers a similar enumeration when describing what appears to be a swoon:

Again, the excerpt presents a periphrastic list of symptoms that resemble a swoon. There is a cognitive compromise, which is referred to through the phrasal term ‘struck gnômê’, and a strong emphasis on the bodily symptoms, particularly the attention to breathing (which was also present in the cases of leipothumiê and apsuchiê mentioned above) and the insistence in both excerpts on the blurring of vision (ὄμματα ἀμαλδύνηται and ἔλαβε καὶ σκότος).Footnote ¹¹ The cases of apoplexy – as Walshe has accurately remarked – are also conditions with ‘sudden loss of consciousness, paralysis, and collapse’.Footnote ¹² We have already seen an example when discussing HOFs, where the description of the author of On glands follows the same pattern of concurrent and simultaneous separate symptoms: movement disturbances, speechlessness, suffocation and a bewildered nous.Footnote ¹³

It seems as though where we nowadays simply perceive total loss of consciousness, the Hippocratic authors could perceive two subtly different realities. One was described using compounds of psuchê or thumos, which was conceived as a near-death experience; the second was a concurrent accumulation of physical losses that eventually led to passing out. This very nuance might be at the origin of the notion of sunkopê, a condition (also designated as cardiacum) probably described as a disease in its own right at some point during the Hellenistic period (it appears in most post-Hellenistic treatises, but is never mentioned as such in the Hippocratic corpus).

An all-encompasing Hippocratic psuchê

Several Hippocratic texts portray the psuchê as an all-encompassing concept which subsumed cognitive and bodily functions. We have already seen that the author of On breaths considered hai psuchai to contain phronêmata,Footnote ¹⁴ while the author of On regimen talked initially about phronêsis as a condition of the psuchê,Footnote ¹⁵ whereas later on he expanded the idea. In book 4, the psuchê is said to renounce its own dianoia during wakefulness in favour of the body – which suggests that it contains a dianoia – but once the body falls asleep, it wakes up and γινώσκει πάντα, καὶ ὁρῇ τε τὰ ὁρατὰ καὶ ἀκούει τὰ ἀκουστὰ, βαδίζει, ψαύει, λυπεῖται, ἐνθυμεῖται (‘recognises everything, sees what can be seen, hears what can be heard, walks, touches, suffers, assesses’).Footnote ¹⁶ The relevance of this comprehensiveness of the soul is that it is responsible for cognition, perception, motion, emotion and reason. Because this Hippocratic psuchê is active during sleep, present during wakeful life – even if it is τῷ σώματι ὑπηρετέουσα (‘subjected to the body’)Footnote ¹⁷ – and its absence means death, I disagree with the idea suggested by some scholars that this model presents strong Homeric echoes.Footnote ¹⁸

Beyond the sources commented on above, there is another Hippocratic text, On humours (a disjointed miscellany of observations about various medical topics),Footnote ¹⁹ which offers an even broader catalogue of domains that pertain to the psuchê.Footnote ²⁰

This passage suggests the involvement of the psuchê in several roles – a few of them already mentioned in On regimen (Vict. CMG 4.86). Interestingly, after including the gnômê within the sphere of the psuchê,Footnote ²³ the author focuses on bodily reactions that are beyond rational control, which he also attributes to the psuchê. This writer seems to be suggesting that the soul governs conscious involuntary reactions, thus further extending the scope of the notion. Perhaps the idea of the psuchê as ‘the most important life force’, which was common during the fifth century BCE,Footnote ²⁴ is associated with this comprehensive collection of functions: it is responsible for the cognitive and perceptual skills, it controls physiological vital capacities (nourishment, sleep, wakefulness), emotions (grief, wrath, desire) and automatic bodily reactions (sweating, breathing, trembling, beating of the heart).

The psuchê as the life-giving force

The Hippocratic corpus seems quite consistent regarding the idea of the psuchê as a life force, and death is often equated with its definitive separation from the body. We have just discussed a fairly explicit example, where fainting is construed as a temporary separation of the psuchê before its final disconnection, when it is too late for treatment.Footnote ²⁵ Other Hippocratic texts point in the same direction: in On internal affections both descriptions of typhus refer to death as ἀφῆκε τὴν ψυχήν (‘releasing the psuchê’).Footnote ²⁶ This departure of the psuchê or the thumos during death does have Homeric echoes;Footnote ²⁷ however, these medical writers go a step further. In the Iliad it is not implied that the psuchê abandons the body during swoons, nor does the departure of the soul during death have a destructive effect in itself on the body.Footnote ²⁸ On the contrary, the author of Epidemics VI presents a different relationship between body, soul and disease:

This diseased psuchê seems to have a lethal effect on the body, unlike the Homeric soul that silently moved towards Hades. These cases, therefore, also illustrate a shift in the understanding of the boundaries between life and death, as compared to archaic conceptualisations. In Homer, the psuchê left the body through the mouth when wounds were deadly, but it did not harm the body, nor could it come back once it had crossed the fence of teeth. As a matter of fact, the separation of the psuchê (and the thumos) is almost always synonymous with dying.Footnote ²⁹ There are very few exceptions where instead of death, swoons occur, and although the psuchê abandons the body, the character survives because breathing recommences and they come round.Footnote ³⁰ As Clarke has remarked, life can be lost through exhalation when the psuchê or thumos abandon the individual, but it can only be recovered in the form of the thumos’ vitality being ‘sucked into the lungs’.Footnote ³¹ Namely, both concepts are connected with breathing. In the Hippocratic cases of fainting, however, it is probably not so much the ‘life soul’ represented through the breath that the doctors are carefully observing. Instead, in this medicalised separation of the psuchê, breathing is the most obvious clinical sign that distinguishes life from death. Because it is not disrupted during the process, doctors need to notice it in order to know that the individual is alive and further treatment can be used (as also illustrated above, there is a particular kind of breathing characteristic of fainting, which confirms that it is maintained during such episodes).Footnote ³²

In summary, considering that delirium (and also sleep) were construed as alterations of the gnômê, sunesis, phronêsis or nous (that is, the constructs used by Hippocratic doctors to refer to HOFs) and that such concepts appear to be subsumed within the notion of soul, we could suggest another link between fainting, sleep and delirium. Beyond the shared vocabulary for recovery and the clinical relationship that has already been pointed out, we could also posit a more abstract theoretical connection. It appears that these authors conceived all three presentations as a group of related conditions affecting either the life-giving soul or some capacities subsumed within it. Thus, we could argue that many of these medical writers had a hierarchical understanding of what we nowadays regard as consciousness, in which the cognitive capacities (the mind) were dependent on a more abstract notion, the soul, which in turn enabled life. Following this idea further, impaired consciousness was regarded by them as either a complete or partial affection of the psuchê: the soul in its entirety was affected in fainting (sometimes causing near-death experiences), whereas its subordinated cognitive components (gnômê, phronêsis, nous, etc.) were altered or simply changed during delirium and sleep.