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.
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