In the previous chapters I have highlighted the consistency of Galen’s system in tackling diseases. With all the other forms of impaired consciousness he felt quite comfortable discussing specific imbalances of qualities in determined locations, whether by primary affection or sympathy. With total loss of consciousness this partially changes: as with his predecessors, we can single out in his work two different forms, but one of them – leipopsuchiê – offers a breach in his otherwise consistent systematisation. The complete shutdown that occurs during swoons challenges his extremely compartmentalised and rational theoretical framework. As a matter of fact, it is not as frequently referred to as it was in the previous authors, and it is less clearly explained than any other type of alteration of consciousness. Sunkopê, on the other hand, fits better in this comprehensive model and is more widely discussed throughout his work.
Fainting/leipothumiê
The terminology for swoons seems rather standardised. Like in the Hippocratic corpus, words are used interchangeably and convey an idea of separation and withdrawal: leipothumiê, leipopsuchiê, ekluomai and ekleipô. However, neither the role of the soul nor its release from the body are explicitly mentioned, particularly because his approach to the locus affectus in this condition is erratic. Despite the loss of all possible cognitive functions, fainting is related to different archai, and not only the brain – the seat of his hêgemonikon – as one would expect if swoons were construed as a psychic condition:
ὑποφεύγει γὰρ κᾀν τούτοις ἐπὶ τὴν ἀρχὴν ἡ ἔμφυτος θερμασία λυομένη θ’ ἅμα καὶ κατασβεννυμένη. ὅπου δὲ θάνατον ἐπιφέρει τὰ τοιαῦτα τῶν παθῶν, οὐδὲν δήπου θαυμαστὸν εἰ καὶ λειποψυχίαν.
The innate heat released and quenched withdraws from them [patients in pain] towards its principle (archê). Where these affections bring about death, it is not surprising if they also cause swoons.
We can recognise some well-known elements associated with leipopsuchiê, namely the loss of heat and the idea of a near-death experience. The archê referred to is the heart, which carries the innate heat according to Galen’s system (UP 6.7 [III.436 K.]). This is – with some reservations – in agreement with a passage of On the affected parts, where he mentions ekluomenoi patients while discussing heart conditions:
ὁ θάνατος ἕπεται κατὰ δὲ τὰς ὀργανικὰς ἐξαιφνίδιος, ἀλλ’ ἐπὶ προηγουμένοις σημείοις, ὧν ἓν μέν ἐστι καὶ τὸ πρὸς Ἱπποκράτους εἰρημένον, οἷον οἱ ἐκλυόμενοι πολλάκις καὶ ἰσχυρῶς ἄνευ φανερῆς προφάσεως, ἐξαπίνης τελευτῶσιν.
[In large duskrasias] sudden death occurs when they affect the organs, but only subsequent to some predisposing symptoms, one of which was mentioned by Hippocrates: ‘those who faint (ekluomenoi) often and severely without an evident reason die suddenly’.
Because he was tackling diseases of the heart, it is reasonable to think that he is referring to that organ; however, he uses a plural (kata tas organikas), which leaves the matter rather vague. On the other hand, in On the doctrines of Hippocrates and Plato, after explaining that the soul dwells in the body of the brain, and that the pneuma is its primary instrument for perception and motion, he states:
κενωθέντος αὐτοῦ κατὰ τὰς τρώσεις αὐτίκα μὲν οἷόν περ νεκρὸν γίγνεσθαι τὸ ζῷον, ἀθροισθέντος δὲ αὖθις ἀναβιώσκεσθαι.
Once [the pneuma] is depleted through wounds, the animal immediately becomes like a corpse; when collected again, it revives.
Although there is no explicit mention of a swoon, Galen is – in all likelihood – describing a fainting patient, and he construes such fainting as a near-death experience. Of note is the fact that contrary to the previous passage, the phenomenon seems to be located in the brain and the main lost component is pneuma.
Finally, excessive blood-letting can also cause fainting: ἀφαιρῶ τοίνυν αὐτοῦ τοσοῦτον ἐξεπίτηδες ὡς λειποθυμίαν ἐπιγενέσθαι (‘I deliberately took from him enough [blood] to bring about swooning (leipothumiê)’).Footnote 1 The cooling effect of phlebotomies makes them the treatment of choice against continuous fevers, for εἰς ἐναντίαν κατάστασιν ἀφικνεῖται τάχιστα ψυχόμενον ἐν τῇ λειποθυμίᾳ τὸ σῶμα (‘the body cooled during a swoon (leipothumiê) reaches the opposite state [to the heat of fever] very quickly’).Footnote 2 However, the reason why such a bleeding causes fainting appears to be related to nourishment:
οὗτοί γε φέρουσιν, ἀλλὰ τὰς καλουμένας λειποψυχίας· ἐκλύονται γὰρ, εἰ μὴ τρέφοιντο συνεχέστερον οἱ τοιοῦτοι.
These [unconcocted humours can] bring about swooning (leipopsuchia). These patients faint (ekluontai) if they are not constantly nourished.Footnote 3
If we consider that food is turned into blood in order to be delivered throughout the body and nourish it, it is not surprising that the excessive loss of blood can be equated with insufficient or ineffective nourishment (uncooked humours do not feed the patients). However, in Galen’s system nourishment and the production of blood were related to the desiderative soul, and hence to the liver.
In summary, there is no single coherent explanation of leipothumiê in Galen’s work. He seems to be trying to make clinical findings (such as loss of heat, loss of blood and near-death experience) compatible with his system, where conditions could be addressed by determining a locus affectus and a specific duskrasia that disturbed it. Different combinations of those elements are certainly present; however, there is no consistency to them. Although the heart seems to have some pre-eminence, in different treatises a different part of his three-part psuchê seems to be involved. Possibly, the difficulty of linking this kind of fainting to the rational soul stems from Galen’s adherence to his all-encompassing model. The actual experience of fainting as a consequence of blood-letting must have made it difficult for him to associate the phenomenon with the hêgemonikon (despite the loss of all cognitive capacities): the blood was related to the heart and the arteries according to his physiology and not to the brain, which used pneuma.Footnote 4 As a result, it would have been difficult for him to justify that losing blood affected the mind without undermining his own physiological understanding.
Sunkopê
On the contrary, the notion of sunkopê is much better delimited and fitted for Galen’s system. Moreover, he seems to have come up with a solution to the above-mentioned ongoing debate about the locus affectus of sunkopê being either in the stomach (as Celsus and the Anonymus Parisinus suggested) or in the heart (as Aretaeus posited). He distinguished two different kinds of sunkopai:
ἴδιον δὲ πάθος ἐν καρδίᾳ γίνεται κατὰ μὲν ἁπλῆν δυσκρασίαν πολλάκις … ἕπονται δὲ πάλιν ταῖς τοιαύταις διαθέσεσιν αἱ καρδιακαὶ συγκοπαὶ, καθάπερ αἱ στομαχικαὶ ταῖς κατὰ τὸ τῆς κοιλίας στόμα … αἱ διαθέσεις δ’ αμφοτέρων τῶν μορίων, τοῦ τε στόματος τῆς κοιλίας καὶ τῆς καρδίας, ἤτοι διὰ δυσκρασίαν μόνην ἰσχυρὰν … εἰώθασι γίγνεσθαι … ταὶς μεγάλαις δὲ [δυσκρασίαις].
An intrinsic affection of the heart often occurs in simple [not compound] duskrasia [as well as in other diseases] … Cardiac sunkopê follows these kind of conditions [duskrasias and the others], in the same way as stomachic sunkopê follows conditions affecting the mouth of the bowels … The conditions of both parts, namely, the mouth of the bowels and the heart, … tend to be produced … either by a violent single duskrasia [or by the other diseases].
Despite this dual origin, namely, one affecting primarily the heart and the other one the mouth of the bowels,Footnote 5 Galen’s theory of sympathies referred them both to their common corresponding archê in the heart. Thus, whether the condition originated in the stomach or in the heart, it needed to affect the latter (directly or sympathetically) in order to be considered as a sunkopê:
αἱ στομαχικαὶ δὲ συγκοπαὶ … ἔκλυσιν ἐπιφέρουσιν, ἴσως δὲ καὶ τῆς δυσκρασίας αὐτοῦ διϊκνουμένης εἰς τὴν καρδίαν, ὡς κᾀκείνης ἐν δυσκρασίᾳ γινομένης ἀθρόαν κατάπτωσιν ἀκολουθῆσαι τῆς δυνάμεως.
Sunkopai of the stomach … can bring about swoons. In like manner, when its imbalanced mixture [the duskrasia of the stomach] penetrates the heart to such an extent that it [the heart], too, becomes imbalanced [in duskrasia], a sudden collapse of capacities [that is, sunkopê] follows.
As regards the discussion on consciousness, the relevance of this issue stems from the fact that unlike the other forms of impaired consciousness (which were all related to some compromise of the hêgemonikon in the brain), in Galen’s system sunkopai were never primarily a psychic condition regardless of its type. He even presents an experimental demonstration of this:
… ὅτι θλιβεισῶν μὲν ἢ τρωθεισῶν τῶν κατὰ τὸν ἐγκέφαλον κοιλῶν ὅλον τὸ ζῷον αὐτίκα γίνεται καρῶδες, οὐ μὴν ἀπόλλυται γε οὔτε ἡ κατὰ τὰς ἀρτηρίας οὔτε ἡ κατὰ τὴν καρδίαν κίνησις … ἐγκεφάλου μὲν γὰρ πάσχοντος ἕτοιμον παραφρονῆσαί τε καὶ ἀκίνητον καὶ ἀναίσθητον γενέσθαι τὸ ζῷον, καρδίας δὲ συγκοπῆναι μὲν καὶ ἀπολέσθαι, τῶν προειρημένων δ’ οὐδὲ ἓν παθεῖν.
… when the ventricles of the brain have been compressed or wounded, the whole animal becomes immediately drowsy (karôdes); however, neither does the movement in the arteries die nor [the movement] in the heart … For if the brain is affected, the animal becomes readily delirious (paraphronêsai), paralysed (akinêton) and loses sensation (anaisthêton), whereas if the heart [is affected] it suffers sunkopê and dies, but [with] none of the aforementioned symptoms.
In this description – which suggests a strong anatomical basis – Galen very clearly opposes symptoms that he considered to be psychic (karôdes, paraphronêsai, akinêton, anaisthêton) to the non-psychic sunkopê. In line with his theory, the former occur in the brain and the latter in the heart.
Additionally, the contrast between sunkopê and swoons provides us with further details about how the former fitted into Galen’s system.Footnote 6 In his Method of healing, sunkopê is defined as an ἡ συγκοπὴ κατάπτωσίς … ἐστιν ὀξεῖα δυνάμεως (‘acute collapse of the capacity’),Footnote 7 and some interesting tips are given to preserve such a capacity:
ἐξαίρετον δὲ εἰς ῥώμην δυνάμεως καὶ προφυλακὴν τοῦ μή ποτ’ ἐξαιφνίδιον ἐπιπεσεῖν παροξυσμὸν συγκοπτικὸν ἡ φυλακὴ τῆς εὐκρασίας ἐστί, πρῶτον μὲν τῶν τριῶν ἀρχῶν, ἔπειτα δὲ καὶ τῶν ἄλλων μορίων ὅσα τὰς ἀρχὰς εἰς συμπάθειαν ἐπισπᾶται ῥᾳδίως, οἷόν πέρ ἐστι καὶ τὸ τῆς γαστρὸς στόμα … συγκοπὰς ἐπιφέρον. ἡ μὲν οὖν προειρημένη διάθεσις τῶν ὠμῶν χυμῶν … ὀλέθριός τέ ἐστι καὶ συγκοπτική … καταπνίγεσθαι καὶ ἀλλοιοῦσθαι καὶ διαφθείρεσθαι τῆς κράσεως τὴν συμμετρίαν. οἱ μὲν γὰρ ὠμοὶ τρέφειν οὐ δύνανται πρὶν πεφθῆναι, οἱ δὲ πολλοὶ βαρύνουσιν· εἰ δ’ ἐμφράττουσι τὰς διαπνοάς σβεννύουσι τὸ θερμόν· εἰ δὲ μήτ’ ἐμφράττοιεν μήτε βαρύνοιεν οὐ συγκοπὰς οὗτοί γε φέρουσιν, ἀλλὰ τὰς καλουμένας λειποψυχίας…
It is crucial for the strength of the capacity and as a precaution to avoid ever falling into a sudden acute sunkopê, first to preserve the good balance (eukrasia) in the three principles (archai). Then, also, in the other parts that can easily attract them [the principles] towards sympathy, such as the mouth of the stomach … which can bring about sunkopai. Indeed, the aforementioned condition caused by uncooked humours … becomes deadly and predisposes one to sunkopai … by suffocating, altering and destroying the balance of the mixture. For those humours cannot nourish before they are concocted, but they do strain [the capacity] if they are abundant and quench the heat if they block the exhalations. If they neither block nor strain, such humours do not bring about syncopes, but the so-called fits of swooning (leipopsuchia)…
Again, a duskrasia in the stomach needed to affect the archê in the heart by sympathy in order to cause the condition. In this passage, moreover, the strong bodily components of sunkopê are highlighted in opposition to swoons. In a nutshell, the same kind of raw humours can produce either of them depending on their prevalent effect: if straining and blocking predominate, sunkopê occurs. Namely, sunkopê is caused by a cold duskrasia that manifests through clinically evident signs (quenched heat and blocked exhalations), whereas in leipopsuchia the humours only prevent nourishment, that is, they do not affect in a tangible way through their specific qualities. It is clear from the description that sunkopê fits perfectly well within Galen’s system, where a distinct humoural action enables an adequate treatment to counterbalance the alteration, and a clear location determines the site of the treatment.
Naturally, once the locus affectus and the quality of the humours are found, therapy becomes straightforward:
ἐφ’ ὧν δὲ διὰ χολὴν ξανθὴν ἀδικήσασαν τὸ στόμα τῆς γαστρὸς ἡ συγκοπὴ γένοιτο, ψυχρὸν τούτοις χρὴ προσφέρειν τὸ ποτόν. οἶνον μέντοι τῇ φύσει θερμὸν εἰς ἀνάδοσιν ὁρμῶντα τοῖς συγκοπτομένοις ἅπασι δοτέον
In cases where sunkopê is produced by yellow bile that harms the mouth of the stomach, it is necessary to administer a cold drink. For certain, wine should be given to all the patients who suffer sunkopê: due to its hot nature it stimulates the assimilation [of nourishment].
Again, the allopathic idea that opposites cure opposites is in play in the case of yellow bile: because it is hot it needs to be reversed by a cold drink. The use of wine is slightly different. I have mentioned above that sunkopai (as well as swoons) can be caused by uncooked humours, which do not nourish unless they are concocted. In this case wine is prescribed because – despite its hot nature – it helps to assimilate the nourishment. Further down Galen adds that ὁ μὲν μὰλλον, ὁ δ’ ἧττον, ἅπαντες δ’ οὗν … τονοῦσι … τὸν στόμαχον (‘all of them [the wines] … strengthen the stomach to a greater or lesser degree’).Footnote 8 Despite its apparently counteractive effect on the mixture, wine is indicated due to its favourable effect on the locus affectus.
From the analysis of Galen’s approach to total loss of consciousness it emerges that – as opposed to the vagueness surrounding fainting – he conceived sunkopê as a condition anatomically unrelated to the other psychic diseases, due to its utter independence from the hêgemonikon. Unsurprisingly, and much like other authors, he seems to have associated it with a bodily condition, for in his view the heart was the seat of the spirited part of the psuchê in control over bodily functions (unlike the hêgemonikon, which governed cognition, rationality and thought).
Galen’s tripartite soul and total loss of consciousness
The idea of the soul was a key concern for Galen in several works, and he devoted to it abundant philosophical reflection.Footnote 9 Very schematically, as we have seen, he organised the psuchê according to the Platonic model – into a rational, a spirited and a desiderative part – and described with thorough detail the subdivisions of the rational soul.Footnote 10 I have mentioned, so far, that this rational soul – and particularly its hêgemonikon – was variously compromised in both wakeful impaired consciousness and pathological sleep.
On the contrary, I have argued that from the two forms of total loss of consciousness – that is, leipothumiê and sunkopê – only the former was vaguely related to the ruling part of the soul. A possible element for such a link is the pneuma. Quite in line with Aretaeus, Galen’s understanding of swoons involved the release of heat (emphutos thermasia),Footnote 11 the lack of nourishmentFootnote 12 and also the loss of pneuma:
διὸ καὶ κενωθέν, ἄχρις ἂν αὖθις ἀθροισθῇ, τὴν μὲν ζωὴν οὐκ ἀφαιρεῖσθαι τὸ ζῷον, ἀναίσθητον δὲ καὶ ἀκίνητον ἐργάζεσθαι. καίτοι γε, εἴπερ ἦν αὐτὸ ἡ τῆς ψυχῆς οὐσία, συνδιεφθείρετ’ ἂν αὐτῷ κενουμένῳ παραχρῆμα τὸ ζῷον.
Therefore, when [the pneuma] is depleted, and until it is collected again, the life is not taken away from the animal, but lack of perceptions and movements result. For if [the pneuma] was indeed the substance of the soul, the animal would die immediately with its depletion.
Remarkably, in his view it is the pneuma, the primary element of the psuchê in the brain, but not the soul itself that dissipates in these conditions.Footnote 13 Of note is also the fact that he does not talk about leipothumiê but about total loss of perception and movement, which is virtually the same. This statement is quite strong when compared to all the other authors, who considered – in one way or another – that the entire soul was expelled during swoons. Additionally, two other interesting implications can be drawn from this passage: first and foremost, that this temporary loss of pneuma is compromising capacities in the rational soul, thereby linking total loss of consciousness to the other prototypical presentations; secondly, that although the soul referred to in this passage does not completely separate, it is still conceived as a life principle, for its loss is equated with death.
In other words, despite the contradictions that emerge from the various components altered during fainting, particularly the uncertainties regarding which specific part of the soul – or which archê – was affected (according to Galen the pneuma was associated with the rational psuchê in the brain, the blood to the spirited one located in the heart, and nourishment was related to the desiderative soul located in the liver), he was quite clear about the lethal effect of the loss of the psuchê.
On the other hand, sunkopai – whether they originated in the stomach or in the heart – ultimately compromised the archê in the heart (directly or by sympathy). In this regard, an interesting and rather puzzling comment appears in On the causes of symptoms. In the midst of a discussion on sweating Galen states:
μεταβαίνειν οὖν ἤδη καιρὸς ἐπὶ τοὺς ἱδρῶτας, ὑπὲρ ὧν εἴρηται μέν που τό γε τοσοῦτον ὡς ἀναλυομένης ἐνίοτε γίγνονται τῆς ἕξεως, καὶ καλεῖται τὸ πάθημα συγκοπή· τούτῳ δὲ ἐναντία κατάστασίς ἐστιν ἡ ἐν τοῖς κρισίμοις ἱδρῶσιν, ἐῤῥωμένην ἐνδεικνυμένοις, οὐ διαλυομένην τὴν φύσιν.
It is time to address sweats, amongst which I have already discussed those that are produced to such a degree that they release the cohesion of the body (hexis). Such an affection is called sunkopê. The opposite condition to this is sweating in critical periods, which are demonstrative of good health, for nature (phusis) is not dissolved by them.
As we have seen with the post-Hellenistic sources, the association between sweating and sunkopai is very well documented. However, the terminology in this passage is particularly surprising for Galen. He is employing two Stoic concepts, hexis and phusis, which he does not normally use in relation to this condition. Furthermore, he seems to be considering them as synonyms, although according to Stoic philosophy they belong on different levels within the scala naturae.Footnote 14 Of note is the fact that both terms describe a low level of cohesion (characteristic of objects and plants), that is, always below psuchê (which allows perception and movement).Footnote 15 Therefore, despite the uncharacteristic lack of philosophical accuracy, this might also be a hint of Galen’s understanding of sunkopê as an affection alien to the rational psuchê and the psychic diseases. Similarly, in another passage, where he discusses stomachic sunkopai, he attributes it to zôtikos tonos (‘weakness in the vital tension’).Footnote 16 If this notion is in any way related to the Stoic zôtikon pneuma, then again we have an affection that compromises the key element of the spirited part of the soul located in the heart: namely, different from the psuchikon pneuma produced in the brain,Footnote 17 and hence different from the psychical conditions.
In summary, all the discussion above seems to suggest that the rational soul could be thought of as the linking element between the three presentations of impaired consciousness. However, it is less explicitly emphasised than in the other authors. Although there are hints that the loss of the main substance of the rational psuchê – pneuma – causes swoons, there are also allusions to the other parts of the soul, thereby connecting leipothumiê with sunkopê.
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