Contemporary medicine conceives total loss of consciousness as a global alteration of brain activity. It can have a neurological origin such as in seizures, strokes, head trauma or other aetiologies that ultimately affect the central nervous system (intoxications, infections, liver conditions, etc., where the damage is mediated by substances that compromise neurons). Alternatively, total loss of consciousness can be caused by impaired cerebral blood flow. Such cases can be the result of significant haemorrhages; but they can also be transient and self-limited episodes, which we define as ‘syncope’Footnote 1 or, less technically, swoons and fainting. The latter are usually preceded by dizziness, light-headedness and sometimes visual and auditory disturbances (pre-syncope). Three main varieties of syncopes are usually recognised: those that are neurally mediated (or vasovagal), which are due to a transient impairment of the autonomic nervous system; postural (or orthostatic) hypotension, in which the blood pressure drops when individuals stand up (and hence they faint), owing to a permanent disorder in the autonomic nervous system; and finally, cardiac syncope, secondary to arrhythmia or a structural heart disease (mainly valvulopathy or ischaemia). In contemporary times vasovagal syncopes are epidemiologically the most frequent and are typically triggered by strong emotions, pain and – often – the sight of blood. Accompanying signs can include pallor, sweating (diaphoresis), cardiac symptoms (especially palpitations), gastric symptoms (such as nausea and vomiting), hypoventilation and sudden muscle contractions (myoclonus). These episodes are sometimes described as near-death experiences.Footnote 2 This chapter analyses the way in which ancient doctors explained and treated these kinds of conditions.
In order to talk about total loss of consciousness, compounds of psuchê have often been used in the ancient Greek medical tradition, and compounds of anima in Latin. As we shall see, there is a distinction among most ancient medical writers (in some it is more subtle than in others) between two forms of this prototypical presentation: firstly, one that authors perceived to be related to the soul; and secondly, one framed as an eminently physical condition, where bodily symptoms predominated.
The discussion, therefore, will address what Helen King has denominated as ‘common to body and soul’. The tension between these two elements constituted a central topic of debate among philosophers in antiquity in terms of what pertained to the body, what to the soul and what was shared by both.Footnote 3 Closely related to this discussion is the debate concerning the authors’ support for either instrumentalism or materialism (the former being the idea of the body as simply an instrument of the soul, and the latter as the soul depending completely on the effect of bodily substances).Footnote 4 The above-mentioned two forms of understanding of total loss of consciousness will allow us to explore the extent to which medical writers engaged in these controversies, and how they negotiated between these opposite extremes.
In other words, the complete disruption of HOFs that occurred when a patient fainted – where wakefulness, cognition, perception and movement (that is, alertness, connectedness, responsiveness) were temporarily suppressed – can provide some clues about notions held by these medical writers, which went well beyond their ideas around consciousness. Indeed, implicit in those explanations are their perceptions concerning the soul, its relation to the body and occasionally, even their views on the boundaries between life and death.
It should be emphasised, however, that in no way does the following analysis pretend to be an exhaustive philosophical study on ancient psychology. As stated in the Preface, it will only address the notion of the soul as far as it is relevant to understanding these medical writers’ stances on impaired consciousness and it will only touch upon extra-medical sources (mainly philosophical) whenever they are key to illuminating some of these authors’ claims.
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:
ὅσοισιν ἢ ἐκψύχουσιν δεῖ τι ὠφελῆσαι … οὗτοι μὲν οἱ καιροὶ ὀξέες, καὶ οὐκ ἀρκέει ὀλίγῳ ὕστερον· ἀπόλλυνται γὰρ οἱ πολλοὶ ὀλίγῳ ὕστερον … ὅ τι ἄν τις πρὸ τοῦ τὴν ψυχὴν μεθεῖναι ὠφελήσῃ, τοῦθ’ ἅπαν ἐν καιρῷ ὠφέλησεν.
One needs to help those who faint (ekpsuchousin) … These opportunities are urgent, and a little later is not good enough, for most patients die a little later … whatever help one can offer before the psuchê breaks free is offered at the exactly right opportunity.
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):
… πνεῦμα μέτριον, ἔστι δ’ ὅτε καὶ ἅλες ἑλκύσας πάλιν ἀθρόον ἐξέπνει, ὥσπερ ὑπ’ ἀψυχίης, ἢ ὡς ἂν διὰ πνίγους πορευθεὶς ἐν σκιῇ καθεζόμενος ὥς τις ἀναπνεύσειε.
… moderate breathing: after drawing in a big gasp [of air], he would exhale it again suddenly, like somebody [who had] fainted, or like one who sits in the shade to recover his breath after walking in the heat.
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:
ὅταν ὑστέρη πνίγῃ, πνεῦμα δὲ σεύηται ἄλες ἄνω, καὶ βάρος ἔχῃ, καὶ γνώμη καταπλὴξ, ἀναυδίη, περίψυξις, πνεῦμα προσπταῖον, ὄμματα ἀμαλδύνηται.
When the womb suffocates, the air is driven upwards in gasps, torpor is experienced and the gnômê is struck. Speechlessness, shivering, laboured breathing and weakened eyes.
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
ψυχῆς ἀκρασίη ποτῶν καὶ βρωμάτων, ὕπνου, ἐγρηγόρσιος … καρτερίη πόνων … αἱ μεταβολαὶ ἐξ οἵων ἐς οἷα. ἐκ τῶν ἠθέων, φιλοπονίη ψυχῆς, ἢ ζητῶν, ἢ μελετῶν, ἢ ὁρῶν, ἢ λέγων, ἢ εἴ τι ἄλλο οἷον, λῦπαι, δυσοργησίαι, ἐπιθυμίαι. ἢ τὰ ἀπὸ συγκυρίης λυπήματα γνώμης, ἢ τὰ διὰ τῶν ὀμμάτων, ἢ διὰ τῆς ἀκοῆς καὶ διὰ τῆς γνώμης. οἷα τὰ σώματα, μύλης μὲν τριφθείσης πρὸς ἑωυτήν, ὀδόντες ᾑμώδησαν, παρά τε κρημνὸν παριόντι σκέλεα τρέμει, ὅταν τε τῇσι χερσί τις, ὧν μὴ δεῖται, αἴρη αὗται τρέμουσιν. ὄφις ἐξαίφνης ὀφθεὶς χλωρότητα ἐποίησεν. οἱ φόβοι, αἰσχύνη, ἡδονή, λύπη, ὀργή, τἄλλα τὰ τοιαῦτα. οὕτως ἐνακούει ἑκάστῳ τὸ προσῆκον τοῦ σώματος τῇ πρήξει, ἐν τούτοισιν ἱδρῶτες, καρδίης παλμός, τὰ τοιαῦτα.
Belonging to the sphere of the psuchê are:Footnote 21
bad balance of drink, nourishment, sleep and wakefulness … endurance to physical exercise…
the changes from some conditions to others.
Among [the changes] in the character: industriousness of the psuchê when inquiring, exercising, seeing or talking;
or any other [change] like grief, wrath, desire,
or the random disturbances of the gnômê whether through vision or hearing or through the gnômê itself.
Regarding the bodily [disturbances]Footnote 22
when a mill grinds, the teeth are put on edge;
when one walks beside a cliff, the legs shake;
when somebody lifts what he should not with his hands,
they tremble;
the sudden sight of a snake produces pallor;
fears, shame, grief, pleasure, anger, etc.: the corresponding part of the body reacts to each of them with its own response, which are sweats, heartbeats, etc.
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:
ἀνθρώπου ψυχὴ φύεται μέχρι θανάτου· ἤν δὲ ἐκπυρωθῇ ἅμα τῇ νούσῳ καὶ ἡ ψυχή, τὸ σώμα φέρβεται.
Man’s psuchê flourishes until death. If it gets consumed by disease, it [the psuchê] devours the body.
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.
The post-Hellenistic writers under study responded in various ways to both the Hippocratic and the Hellenistic traditions on total loss of consciousness, and their way of integrating these elements constitutes a clear testimony of their methodology, namely, encyclopaedism in On medicine, and lax eclecticism in Aretaeus’ work. A common trait that is shared by both authors is the fact that they deepened the Hippocratic dual understanding of this prototypical presentation. For them they were two independent phenomena: either a symptom that appeared in various circumstances – anima deficit, leipothumiê, fainting – or an independent disease – cardiacum, sunkopê.
Fainting versus sunkopê
In Celsus, for example, there seems to be a strong Hippocratic influence in the nomenclature and the presentation of fainting, but a radical difference in the underlying conception of the soul. Similarly, Aretaeus maintained, to a certain extent, the Hippocratic terminology (he used leipothumiê and leipopsuchiê), but his descriptions were less evidently influenced by the Hippocratic corpus (even if he did not explicitly contradict it). He was particularly concerned with explaining the physiological mechanisms underlying this presentation, in which the soul had limited involvement. The Hellenistic stamp, on the other hand, manifests itself very clearly in the approach to sunkopê that both authors express. As we shall see, this affection is regarded as primarily originating in the body, with some kind of alteration in consciousness and descriptions that are suspiciously evocative of our own idea of vasovagal syncope.
Fainting
The terminology that Celsus used to refer to swoons is anima deficere. As von Staden has accurately remarked, it is a Latin calque of leipothumia and leipopsuchia.Footnote 1 Also in syntony with the Hippocratic predecessors, fainting was conceived as a separation of the soul. We shall see, however, that Celsus’ anima is rather different from the Hippocratic psuchê.
in capite autem interdum acutus et pestifer morbus est, quem κεφαλαίαν Graeci vocant; cuius notae sunt horror calidus, nervorum resolutio, oculorum caligo, mentis alientatio, vomitus sic ut vox supprimatur, vel sanguinis ex naribus cursus, sic ut corpus frigescat, anima deficiat.
There is often an acute and destructive disease in the head, which the Greeks call kephalaia that presents the following signs: hot shivering; flaccid paralysis; blurred vision; delirium; vomiting, capable of suppressing the voice; or bleeding from the nose, capable of cooling down the body, and of causing fainting.
Suffice here to say that unlike the Hippocratic life force that suddenly and momentarily abandons the body leaving it lifeless, this passage offers a crescendo of symptoms until fainting eventually occurs. In other words, in this disease total loss of consciousness evolves through a progressive loss of capacities – movement, vision, cognition, speech – before the anima finally gets to withdraw.
A similar term to designate the same phenomenon is exanimo, a calque of the Hippocratic ekpsuchô, which also conveys the idea of separation of the anima:
ex vulva quoque feminis vehemens malum nascitur … interdum etiam sic exanimat, ut tamquam comitiali morbo prosternat. distat tamen hic casus eo, quod neque oculi vertuntur nec spumae profluunt nec nervi distenduntur: sopor tantum est.
A violent disorder also originates from the uterus of women … Occasionally it can even cause fainting (exanimat), in such a way that they are thrown to the ground like in an epileptic attack. It differs though from the latter, in that neither are the eyes turned, nor is there any foaming, nor spastic paralysis: such is the level of drowsiness.
Note how fainting in this passage is distinguished from an epileptic seizure (another form of total loss of consciousness) and assimilated to sopor (drowsy impaired consciousness). Unlike Celsus’ understanding of delirium, which presented – as discussed above – very clear boundaries with sleep, fainting was in its peripheries. This also becomes patent in the chapter on epilepsy (morbus comitialis), where the impossibility of lethargic patients waking up (exper gisci) contrasted with the spontaneous coming round (ad se revertitur)Footnote 2 of epileptic individuals. In other words, on two occasions the author explicitly discusses the difference between sleep and total loss of consciousness, which suggests that he perceived them as related or similar presentations.
It does make sense – from a purely clinical standpoint – that if sleep is an all-or-nothing phenomenon, with almost no intermediate states (as Celsus seems to have conceived it), sleep and fainting can be readily confused but not sleep and delirium. The idea seems perfectly reasonable when applying the anaesthetic model: in dreamless sleep (Celsus very seldom mentions dreams or parasomnia), as well as in drowsy states, alertness, connectedness and responsiveness are reduced. In the case of deep sleep – as in the total loss of consciousness – they are virtually abolished.
In summary, in agreement with Celsus’ constant search for the ‘middle way’, there is a formal (mainly terminological) agreement with the Hippocratic forerunners and a coincidence in the notion of separation, but – as I will argue below – a rather different idea of the soul.
Aretaeus’ take on this matter raises similar concerns:
ἔκλυσιν δὲ γουνάτων καὶ αἰσθήσιος πρόσκαιρον νάρκην καὶ ἀψυχίην καὶ κατάπτωσιν, λιποθυμίην καλέομεν.
The knees giving way, temporary numbness of perceptions, fainting (apsuchiê) and collapse is called ‘swoon’(lipothumiên).
First of all, it is worthwhile to remark that one of the components of lipothumiê is apsuchiê, thereby distancing – from a terminological viewpoint – from the absolute synonymy found in the Hippocratic collection. In this passage, apsuchiê does not seem to encompass the loss of perceptions (otherwise Aretaeus would not have needed to add them independently to the list). Additionally, this definition appears in the chapter devoted to paralysis, in which lipothumiê is framed as an extreme version of it. In other words, it is the total suppression of motor capacities and perceptions. As a result, the passage and the context in which it appears both suggest that movement and sensitivity were central components of swoons, and that they were both encompassed in the idea of leipothumiê but not in the notion of apsuchiê. The question still remains, though, whether Aretaeus was using these terms in a lexicalised manner or if he was implying some separation of the psuchê by using them.
The role of the psuchê in swoons is rather unclear, for most explanations involve humours (mainly blood), different forms of heat and tension. Aretaeus often discusses fainting in connection with excessive blood-letting,Footnote 3 and the role of the soul in them is erratic (to say the least). Only once does the psuchê appear as a relevant component where it separates from the body. It is in the treatment of pleuritis, where large phlebotomies are recommended:
… τὸ δὲ πλῆθος μὴ μέχρι λειποθυμίης· περιπνευμονίην γὰρ ἐπιφοιτῆσαι κίνδυνος, ἢν τὸ σῶμα ἐπιψυχθὲν τὴν ψυχὴν ἐκλείπῃ. εἴσω γὰρ τὰ ὑγρὰ ξυνθέει, τῆς ἐκτὸς ἀφαιρεθέντα θέρμης τε καὶ τάσιος.
… the amount [of blood withdrawn] should not be enough to cause a swoon, for this can add the risk of pneumonia if the chilled body releases the soul (psuchê). Indeed, the moisture accumulates inside, having been separated from the heat (thermê) and tension (tasis).
In this passage, Aretaeus relates the release of the psuchê in swoons to becoming cold after excessive loss of blood. Beyond the coincidence with Hippocratic (and Celsian) works, this example is quite illustrative of his lax eclecticism. Indeed, the particle gar seems to be suggesting that the soul – which can be either associated with heat (thermê) and tension (tasis), or only with tension if we interpret that the heat is exclusive to the blood – is being released along with the blood. We can point out, therefore, a faint family resemblance with two different traditions. On the one hand, blood was considered to be hot in humoural theories, hence its loss was equated with coldness. On the other, the assimilation of the psuchê with heat and tension reminds us of the pneuma as the key constituent of the soul, according to Stoic philosophy.Footnote 4 However, the blood is also moist in humoural theories (whereas the moisture stays in the body, according to this explanation), and there are no allusions to pneuma in this passage. Furthermore, the technical word that the Stoics frequently used to talk about tension was tonos rather than tasis.Footnote 5 Could Aretaeus be referring, instead, to the tone of the muscles, which is lost when one collapses? There is no explicit evidence of this either. Perhaps he is talking about yet another kind of tension: the tension presented in the chapter on sunkopê where the disease causes a ‘weakening of the tension of nature’.Footnote 6 Undoubtedly, the concept of family resemblance (which characterises Aretaeus’ eclecticism) describes this tangle of ideas quite accurately: we can see that his explanations have features in common with different traditions, but he is not strictly following any of them, because there are also important discrepancies.
Going back to the role of the psuchê in swoons, in most other descriptions, the soul is not mentioned. Such is the case with melancholia, which offers yet another example of Aretaeus’ method:
… σμικρόν [αἷμα] ἀφαιρέειν, ὁκόσον αἴσθηται τομῆς ἡ δύναμις οὐκ ἐλεγχθείη δὲ ἐπὶ τῷ τόνῳ … τόδε ἐστὶ τῆς φύσιος ὁ χῶρος καὶ ἡ τροφή. ἢν ὦν τοῦ δέοντος ἀφέλῃς, ἀτροφίῃ ἡ φύσις ἐξίσταται τῆς ἕδρης.
… a small amount [of blood] should be let; enough that the strength [of the patient] may perceive the incision, but not be tested as to its force … [for] this [the blood] is the location and the nourishment of the phusis. Thus, if you let more than is necessary, the phusis will be expelled from its seat due to lack of nourishment.
Here it is the phusis and not the psuchê that seems to be expelled with the blood in large phlebotomies. Additionally, this phusis is associated – like the psuchê before – with tension (tonos in this case), carried in the blood and assimilated to food. The tonos might well be referring to the phusis (like in sunkopê) and may be a synonym of tasis from the previous example.Footnote 7 However, we can once again only talk about family resemblance and not adherence to Pneumatic thought, because according to the Stoics, perceptions were part of the Psychic and not the Natural capacities, each of which represented a different level within the scala naturae.Footnote 8 Also against this hypothesis is the equivalence between psuchê and phusis, which the analogy between the commented-on passages appears to be suggesting.Footnote 9
Therefore, Aretaus’ understanding of fainting presents echoes, resemblances and discrepancies with other theories (one of them being the separation of the soul). However, none of them is clearly predominant nor followed consistently. As a matter of fact, his lax eclectic method consisted of combining different elements of different theories at his convenience, regardless of possible contradictions or incoherence between them.
Sunkopê
I will begin the post-Hellenistic authors’ approach to the second form of total loss of consciousness with the description of sunkopê that appears in the Anonymus Parisinus, because it offers a comprehensive exposition of certain elements that will partially reappear in Celsus, Aretaeus and other post-Hellenistic sources.
ὀνομαστὶ μὲν τοῦ πάθους οἱ παλαιοὶ οὐκ ἐμνήσθησαν ὡς καθ’ αὐτὸ γινομένου, ἐπιγινομένου … μάλιστα δὲ στομάχῳ, ὅ περ καλεῖται καρδία.Footnote 10 δι’ ὅ περ τινὲς καρδίας ὑπέλαβον εἶναι τὸ πάθος … γίνεσθαι δὲ αὐτὸ … ἐκτονιζομένου τοῦ πνεύματος καὶ λυομένου … τοῖς δὲ ὑπὸ συγκοπῶν ἁλοῦσι συνεδρεύει σφυγμὸς μικρὸς, συνδεδιωγμένος … ἀναπνοὴ συνέχεται, καὶ ὡς ἂν ἐκλείποντες ἀντιλαμβάνονται τοῦ ἀέρος … ἱδροῦσι δαψιλῶς τὰ ἄνω μέρη μάλιστα, ψυχρὸς δὲ αὐτοῖς ἐστιν ὁ ἱδρώς … βάρος θώρακος συναισθαίνονται … ἀποχωρίζουσι.
The ancients have not mentioned this affection by name as a condition in its own right. It originates … especially in the stomach, which is called kardia. Hence, some have assumed that it is an affection of the heart … It occurs because the pneuma loses tension and dissolves … The following symptoms accompany those suffering from sunkopê: small and fast pulse … chaotic breathing, they hold the air as if they had fainted … they sweat copiously, particularly in the upper parts. They have cold sweat … feel heaviness in the chest … [and] vomit.
As stated, there is no explicit mention in the Hippocratic collection of this disease (even if I have suggested above a feasible Hippocratic origin for it), and thus it is acknowledged by this author’s remark that ‘the ancients’ did not give a name to this condition. Also, this – as well as most other ancient descriptions of sunkopêFootnote 11 – appears to be compatible with our current understanding of vasovagal syncopes (with hypopnea, cold sweat, gastrointestinal symptoms, cardiac symptoms and hypotension – hence the changes in the pulse). However, in this source it is not clear whether consciousness is actually lost. In most discussions about sunkopê there are usually hints that point towards some kind of impairment in the level of consciousness (in this case it is the breathing ‘as if they had fainted’), but it is seldom explicit whether the patient actually passed out or not.
Celsus’ take on cardiacum matches the previous description quite closely. In his narrative, it is clearly differentiated from defectio animae, because the problem is in the body, specifically in the stomach:Footnote 12
id autem nihil aliud est quam nimia inbecillitas corporis, quod stomacho languente inmodico sudore digeritur. licetque protinus scire id esse, ubi venarum exigui inbecillique pulsus sunt … pedibus … et cruribus siccioribus atque frigentibus.
It [Cardiacum] is nothing else than excessive weakness of the body, which is wasted away by excessive sweating because the stomach is weak. It can be immediately spotted when the pulse of the blood vessels is small and weak … feet and legs are drier [than the other sweaty parts of the body] and cold.
Then, later in the chapter devoted to this condition (Med. 3.19) he warns si verendum est ne deficiat… (‘if it is feared that the patient might faint… ’).Footnote 13 This clarification indicates that anima deficere can certainly occur simultaneously with cardiacum, but is an occasional and independent symptom.Footnote 14 In other words, Celsus’ approach to this disease was eminently physical, and both clinically and theoretically different from other forms of swoons.
In Aretaeus’ text, on the other hand, the boundaries between sunkopê and leipothumiê are more blurred. Accordingly, there is no clear definition as to whether this disease primarily affects the body or the soul. The author begins the discussion by justifying the two names that he uses to designate the disease: sunkopê in the book on signs and causes, and kardiakos in the chapter devoted to its treatment. The former is due to the suddenness and strength of its presentation, whereas the latter points towards the affected organ. Trivial as this might seem, such an introduction positions the author at the opposite end of the ongoing debate concerning the locus affectus.Footnote 15 Aretaeus outspokenly rejects the esophagic/gastric hypothesis, and places the affection in the heart, thereby expanding on his views on this organ:
τί δὲ καρδίης ἄλλο καιριώτερον ἐς ζωὴν ἢ ἐς θάνατον; οὐδὲ τὴν συγκοπὴν ἄπιστον τῆς καρδίης νοῦσον ἔμμεναι, ἢ αὐτὴν σίνος τῆς ἐν αὐτέῃ τοῦ ζῆν δυνάμιος … ἔστι γὰρ τὸ πάθος λύσις τῶν δεσμῶν τῆς εἰς ζωὴν δυνάμιος, ἀντίξουν τῇ συστάσει τοῦ ἀνθρώπου ἐόν … ἔνθα καὶ ἡ ψυχὴ καὶ ἡ φύσις αὐτέης, εἰς ἣν καὶ τὸ πάθος ᾖ τῶν τῇδε δυνάμεων. ἔστι δὲ ἡ τῆς νούσου ἰδέη ἔκλυσις τοῦ τόνου τῆς φύσιος ἐπ᾽ αἰτίῃ ψύξει καὶ ὑγρότητι.
What is more decisive for life or death other than the heart? It makes sense to posit that sunkopê is a disease of the heart, or an injury of its capacities for living … Indeed, the affliction – being inimical to the human constitution – is the release from the bonds that fetter the capacity to live … In it [the heart] are the soul and its nature; hence, also against it [the heart] are the diseases of its capacities [of the soul]. The form of this disease is, namely, a weakening of the tension of nature due to coldness and moistness.
In order to understand the implications of this passage, it is useful to contrast it with Aretaeus’ own understanding of total loss of consciousness. There is a striking terminological and conceptual coincidence between leipothumiê and sunkopê in the treatise: the intervening faculties are the same, particularly the living-capacity (eis zôên dunamios); the psuchê and the phusis participate in both; the tension (tonos) has a similar role;Footnote 16 and the qualities cold and moist are as involved in sunkopê as they are in swoons (where heat is expelled during excessive phlebotomies, and humidity accumulates in the body once it releases the psuchê, CA I.10. CMG (H).V: 114, 5–6).
On the contrary, the importance of the blood has been overtaken in this passage by the heart. While blood seemed to be the seat of the psuchê and phusis in the passages on leipopsuchiê, in this description the heart plays that role. So far, therefore, we are presented with a condition that has many features in common with swoons concerning mechanisms and capacities affected, but a different location.
When looking at the symptoms the picture slightly changes:
σφυγμοὺς μικροὺς, ἀδρανέας, πάταγον τῆς καρδίης, ἐπὶ πηδήσι καρτερῇ, σκοτόδινος, λειποθυμίη, νάρκη, καὶ παρέσιες μελέων, ἱδρὼς ἄσχετος, πουλὺς, ψύξις ὅλου, ἀναισθησίη, ἀφωνίη.
Small and weak pulse, a loud heartbeat among strong palpitations, dizziness, swoon, numbness and weakness in the limbs, profuse uncontrollable sweating, coldness all over, insensitivity, speechlessness.Footnote 17
The description of physical signs is much more thorough than in swoons, where the clinical presentation is barely mentioned. It is at this point that lax eclecticism comes into play because Aretaeus presents pathophysiological similarities with his own idea of fainting, but a clinical description that matches the presentation of sunkopê in the other post-Hellenistic treatises. In this sense, I partially disagree with Pigeaud’s view that we cannot find in Aretaeus’ work the type of careful observation that characterised the Hippocratic Epidemics, because the patient and his ailment become lost when forced into classification.Footnote 18 In fact, his work could be regarded as halfway between the exclusively patient-centred Hippocratic descriptions and other heavily theory-laden post-Hellenistic works. As this approach to kardiakos reveals, Aretaeus draws a lot from his own experience and is quite detailed in his clinical descriptions. Unlike his contemporaries, he clearly found important coincidences in the presentations of both conditions (swoons and sunkopê), along with their differences.Footnote 19
In other words, Aretaeus conceived of two ways of losing consciousness: a simple one without accompanying symptoms (often triggered by excessive blood-letting) and a more complex one (with bradycardia, hypotension and sweating) which constituted a disease in its own right, namely sunkopê.Footnote 20 This lax eclectic approach, therefore, enables Aretaeus to never disregard his own observations and allows him to subtly distance himself from the predominant understanding of the affection, where leipothumiê and kardiakos were completely unrelated conditions. He does not need to fit any finding within a fixed broader theoretical framework, because he can always find a convenient model to explain unexpected, unusual or unforeseen phenomena. In this way, the lack of a strict adherence to any sect provides him with the freedom to always come up with a suitable theoretical justification for whichever clinical manifestation he encounters.Footnote 21 Naturally, such justifications are often suggestive of a certain system of thought, but they never completely fit within any single and distinct one.Footnote 22 Thus, without an important amount of non-textual assumptions, we can only speculate which authors were informing which explanations.
Total loss of consciousness and ideas of the soul emerging in post-Hellenistic authors
In post-Hellenistic authors both the tension between body and soul, as well as the idea of a life-giving power within psuchê/anima, are perhaps less emphatically stated (although still present) and strongly influenced by their methodological approach. Thus, Celsus, as an encyclopaedist in search of the ‘middle way’, compiled different sources – including several Hippocratic ideas, which he tweaked in order to make them compatible with later philosophical theories – and transferred that knowledge into Latin. Aretaeus’ lax eclecticism, on the other hand, allowed him to pick and choose more freely the elements that he needed from the various theories available to him.
Celsus: mens, animus and anima
Celsus offered no explicit philosophical speculation about the nature of certain constructs that he considered to be compromised in his descriptions of impaired consciousness. He gives no clear definition of the scope of the mens, the animus and the anima. As a result, his ideas about these matters can only be deduced from the way in which he used the terms, as well as how he explained the intervention of these concepts in his descriptions. So far, during the discussion on total loss of consciousness, I have mainly focused on the Hippocratic influence over Celsus in terms of vocabulary and his understanding of fainting as a separation of the soul.
Let us now revisit the above-quoted passage on kephalaia-associated total loss of consciousness and focus on an aspect that has remained undiscussed: the idea of the soul that emerges from it.Footnote 23
The text illustrates how motion, vision, involuntary symptoms (such as vomiting), delirium (mentis alienatio) and speech are all independent of the soul (anima), because they are lost due to the disease before fainting actually occurs, namely, before the soul separates (anima deficit). Such a distinction suggests that many capacities that belonged to the Hippocratic psuchê – particularly the mens (the rational part affected by vanas imagines in phrenesis) – are no longer subsumed in the Celsian anima; on the contrary, they are independent of it. This presentation, therefore, hints at a different way of understanding and grouping ideas about perception, cognition and movement, as compared to the Hippocratic predecessors, and questions the equivalence between the Hippocratic psuchê and the Celsian anima.
From the various alternative models of the soul available to Celsus, I consider that his choice leaned towards a view that shared Asclepiadean or Epicurean elements. In order to pursue this idea further, it is necessary to provide some context; namely, to outline some ongoing philosophical debates.
Polito, following some simplification by Galen, has drawn attention to a bipolar division of philosophical thought at the time.Footnote 24 On the one hand, there were the philosophers of the ‘mainstream tradition’, who – broadly speaking – considered matter as a continuum and a unity and believed in intentionality and rationality, both in nature and in human beings (namely, a teleological stance). On the other hand, a group that included Asclepiades and Epicurus advocated – with certain nuances – a mechanistic view of the cosmos, which was formed of particles and void. Despite Vallance’s reluctance to associate Asclepiades with Epicurus,Footnote 25 more recent scholarship has made a strong case for the important influence of Epicurean thought on Asclepiades’ theories. Through different approaches, LeithFootnote 26 and PolitoFootnote 27 agree that although there are some discrepancies, Asclepiades’ debt to Epicurus is considerable, both at the physical level and in his psychology. As we shall see, in his approach to impaired consciousness Celsus negotiated various positions within contemporary philosophical debates, whilst at the same time trying to make these ideas compatible with the Hippocratic texts. Considering his frequent citations of Asclepiades,Footnote 28 it should not surprise us to see Celsus’ narrative leaning towards the Asclepiadean/Epicurean side of the debate, even when trying to stick to the middle way.
In terms of vocabulary, several scattered allusions to psychological concepts remind us of Lucretius’ Epicurean use of terminology, especially the interchangeability between mens, animus and consilium, which I have previously mentioned in the description of the third type of insania (Men. III.18: 19, 21). Such a synonymy also appears in De rerum natura, where the poet refers to ‘consilium, which we designate as animus and mens’.Footnote 29 This finding is rather eloquent, because several more or less contemporary examples testify that this correspondence was not universally accepted in Latin.Footnote 30
Beyond the terminological coincidence, there seems to be a common theoretical background shared by On medicine and Lucretius’ On nature, totally alien to the Hippocratic corpus. It consists of the primacy of the mens and animus over the anima. The followers of Epicurus had considered the soul to be comprised of a rational part located in the chest (animus) and a non-rational part diffused throughout the body (anima).Footnote 31 Lucretius is quite explicit about it: he considers the animus to be in control of the anima and through it, of the body.Footnote 32
… facile ut quiuis hinc noscere possit
esse animam cum animo coniunctam, quae cum animi ui
percussast, exim corpus propellit et icit.
… From this, anyone could easily realise that anima is united with animus, and that when it is shaken by the animus, it then moves and pushes the body.
Similarly, Celsus presents a causal link between mens and anima:
denique omnis calor iecur et lienem inflat, mentem hebetat; ut anima deficiat, ut sanguis prorumpat, efficit.
Finally, heat produces inflammation in the liver and the spleen, and weakens the mens so that the patient faints (anima deficiat).
This excerpt illustrates the thorough work carried out by Celsus in order to achieve his middle way. Hippocratic doctors had certainly made a related claim in the Aphorisms, although they had not ventured any causation: τὸ θερμὸν βλάπτει ταῦτα … γνώμης νάρκωσιν … λειποθυμίας… (‘heat produces the following damages … benumbing of the gnômê … fainting spells … ’).Footnote 33 Celsus, while apparently translating these ideas into Latin, is actually tweaking his sources and adding a heavy Epicurean bias to them, which, furthermore, was opposed to the Hippocratic texts, where phronêsis, gnômê, sunesis and nous were subordinated to the psuchê. In this way – through the ut final clause – Celsus subordinated the alleged equivalent of the latter (the anima) to the former (mens/animus).
In a similar manner, we can find coincidences in the implications of such ideas. In On nature it is stated hic exsultat … pauor ac metus … hic ergo mens animusquest (‘here [in the chest] we feel terror … and fear … hence, here are the mens and the animus’).Footnote 34 Celsus avoids the theoretical explanation and the localisation in the body, but maintains the consequences of such an understanding, namely, the involuntary automatic bodily reactions associated with the psuchê in the Hippocratic collection such as teeth being on edge, fear, anger and pulse changes (Hum. CMG 9: 18, 3–13), which are caused in On medicine by the mens and the animus instead of the anima: is, qui menti suae non est … dentibus stridet (‘those whose mens is not sound … grind their teeth’);Footnote 35 eas [venas] concitare solet … metus et ira et quilibet alius animi adfectus (‘fear, anger and any other affection of the animus usually excites [the pulse]’).Footnote 36 Although the terms used by Celsus could suggest a Hippocratic mark to them, the idea underpinning the roles that he attributes to animus and anima appear to be rather Epicurean. Once again his translation is not innocent.
Another aspect that can be explained by Celsus’ adherence to this Epicurean-informed functional division of the anima into a rational and non-rational part is the way in which he conceived the relationship between the different presentations of impaired consciousness, particularly the drowsy one. I have mentioned in Part II of this book that unlike many predecessors and contemporaries, Celsus’ take on sleep avoided discussing HOFs, philosophical or physiological aspects.Footnote 37 Notably, On medicine did not mention intermediate states between wakefulness and sleep, but posited an utter separation between them, which strongly contrasted with the fuzzy edges that it did suggest between sleep and total loss of consciousness.
The Epicurean notion of the anima partially – not completely – expelled from the body during sleep (explicit in Lucretius)Footnote 38 can justify these fuzzy edges, for this idea is not far from Celsus’ notion of a swoon (anima deficere). In this way, an anima partially expelled during drowsy impaired consciousness and more fully expelled during total loss of consciousness would provide a sound theoretical explanation for the blurred boundaries between these two presentations. Furthermore, the idea of a complete lack of connectedness during sleep (even from one’s own perceptions)Footnote 39 would also be consistent with this idea of partial separation of the anima. As a matter of fact, it is the anima diffused throughout the body where perceptions belong, according to Epicurus’ followers.Footnote 40 In other words, the union between body and soul, which allowed sentience,Footnote 41 would be interrupted during sleep because of the partial separation of the anima.Footnote 42
Additionally, this model also explains the complete separation that Celsus suggested between delirium and sleep. In wakeful impaired consciousness it was not the anima, but the mens and the animus, that became affected. The independence of sleep from the mens seems to be hinted at by the above-quoted definitions of lethargy and phrenitis (as remarked, mens is mentioned in the explanation of the latter but not of the former).Footnote 43 The lack of a link between sleeping and the animus is also present:
ante adversam autem valetudinem … quaedam notae oriuntur, quarum omnium commune est aliter se corpus habere atque consuevit … si gravior somnus pressit, si tumultuosa somnia fuerunt, si saepius expergiscitur aliquis quam adsuevit deinde iterum soporatur; si corpus dormientis circa partes aliquas contra consuetudinem insudat … item si marcet animus… Med. 2.2: 1; 2–3.
But prior to poor health … certain signs appear, all of which share in common that the body becomes different from its usual state: … if heavier sleep oppresses, if there are turbulent dreams, if the patient wakes up more often than usual and then falls back into sleep; if the sleeping body sweats around certain parts that it usually does not … Similarly, if the animus languishes…
This passage makes a clear distinction between types of symptoms that announce poor health. Among them, there are, on the one hand, sleep-related disturbances and, on the other, affections of the animus. They are both similarly predictive of illnesses; however, they are presented as completely independent from one another.
Finally, as suggested by some Hippocratic doctors and by Epicurus himself,Footnote 44 Celsus considered the soul to separate with death. In the prooemium (42), ‘animam amittere’ designates death as a result of vivisection, thereby suggesting that by cutting the body the anima is lost.Footnote 45 An indirect hint of the close relationship between the separation caused by death and that caused by a swoon can be found in the terminology chosen in the pharmacological section. When discussing wounds in internal organs, Celsus recommends wine for those ex profluvio sanguinis intermorientes (‘fainting (intermorientes) of haemorrhage’).Footnote 46 The idea of dying (morior) is implicit in the term. There is a similar occurrence in the Hippocratic Epidemics V, where not only the resemblance of the condition, but also the verb chosen (ekthnêskô) refers to death: ἐξέθανε πεντάκις ὡς τεθνάναι δοκεῖν (‘she fainted five times, she even seemed to be dead’).Footnote 47 Once again, it might look as though the encyclopaedist was strictly following his Hippocratic predecessors; however, there is also an Epicurean explanation underpinning the choice of terms. Beyond the separation of the soul, the choice of anima and not animus or mens suggests an Epicurean influence. As Annas has accurately remarked, unlike the Stoics, who talked about the hêgemonikon (the ruling part) to refer to the soul as a whole, Lucretius uses anima (the non-rational part) for the same purpose,Footnote 48 as Celsus also seems to be doing.
Aretaeus: an erratic role of the soul in his eclectic approach to fainting
I have already pointed out the difficulty in defining a distinct notion of the soul in Aretaeus’ work. Accordingly, despite the fact that in this condition patients collapse, loose movement, sensitivity and cognition, the author conveys neither a clear nor a consistent association between body and soul, and presents important contradictions regarding the way in which the mental capacities relate to the notion of the psuchê. Once again, Aretaeus seems to be combining different theories that partially overlap and partially disagree with each other.
In terms of the body–soul tension, both types of loss of consciousness (leipothumiêFootnote 49 and sunkopê/kardiakos)Footnote 50 suggest a separation of the psuchê from the body, but – as stated – the notion is rather erratic. Not only because the author uses psuchê and phusis interchangeably in swoons, whereas nature (phusis auteês) seems to be subordinated to the soul (psuchê) in sunkopê, but also because in the former condition he implies that the psuchê is located in the blood, whereas in the latter its seat is the heart. (I have already mentioned how Aretaeus had distanced himself from the seemingly mainstream conception of sunkopê by choosing a different locus affectus – the heart instead of the stomachFootnote 51 – and by involving the psuchê and not merely the body.)
The role of the psuchê as a life force is explicitly mentioned as ‘the capacity to live’ in sunkopê (eis zôên dunamios). An idea akin to a life force is considered to be lost in leipothumiê-causing phlebotomies during the treatment of apoplexy: τὸ σμικρὸν αἷμα δυνατώτατον, καὶ [ἡ] ἀλέη τῆς ζωῆς τοῦ σκήνεος καὶ τῆς τροφῆς ἐόν (‘even a little blood is most powerful, for it is the heat of the life of the body and of nourishment’).Footnote 52 However, it is not clear whether this ἀλέη τῆς ζωῆς τοῦ σκήνεος καὶ τῆς τροφῆς is equivalent to the other form of heat (thermê), or in any way associated with tension (tasis, tonos), with the soul (psuchê) or with nature (phusis), all of which Aretaeus had also involved in leipothumiê caused by excessive blood-letting. In any case, it sounds intuitively coherent that this author conceived total loss of consciousness at the very boundary between life and death, if he understood that the heat of life was lost during swoons, as was the capacity to live during sunkopê. He seems to be suggesting that the loss of the psuchê or the phusis or their tension in the form of heat left an inert and cold body (not too different from a corpse).
Concerning the relationship between mental capacities and the notion of the psuchê, in the discussion on HOFs I briefly mentioned some contradictions. As opposed to his usual opposition aisthêsis–gnômê, Aretaeus opposed, in the prooemium to the books on chronic illnesses, aisthêsis to psuchê.Footnote 53 Moreover, in his discussions on leipothumiê and sunkopê the psuchê is involved, but there is no mention of the gnômê. Could this be suggesting, perhaps, that he was symphoretically thinking of them in these passages as related notions (especially considering that the gnômê also tended to be anatomically located in the heart)?
Although this hypothesis is plausible given Aretaeus’ lax eclecticism, there are passages that contradict such an identity. A rather puzzling phenomenon described during sunkopê – unheard of in the other sources – suggests a differentiation between psuchê and gnômê:
ἐπὶ δὲ τοῖσι καρδιώσσουσι καὶ αἴσθησις ὀξύτεροι, ὡς ἰδεῖν καὶ ἀκοῦσαι μᾶλλον ἢ πρόσθεν, καὶ γνώμῃ εὐσταθέστεροι, καὶ ψυχῇ καθαρώτεροι, καὶ τάδε οὐκ εἰς τὰ παρεόντα μοῦνον, καὶ ἐς τὰ μέλλοντα μάντιες ἀτρεκέες.
Amongst those who suffer from the heart, perceptions are sharper, so that they can see and hear better than before, their gnômê is clearer, their soul (psuchê) is purer and not only can they accurately prophesy about the present, but also about the future.
Beyond the inconsistencies with the other clinical features presented in the rest of the chapter, this situation of clairvoyance offers a division of the sphere of consciousness into three components, namely, aisthêsis, gnômê and psuchê (in the similar passage with prophetic visions caused by kausôn, the tripartite division included aisthêsis, gnômê and dianoia).Footnote 54
It appears that in an extreme version of Aretaeus’ lax eclectic approach, the idea of the psuchê that emerges from the analysis of total loss of consciousness is syncretic (in particular, the interplay between psuchê and phusis illuminates how some passages suggest a family resemblance with Stoic philosophy, whereas others contradict it). Like most of the other concepts and numerous theories within his reach (considering that he was a learned physician), Aretaeus used the soul variously in different contexts, which allowed him to explain certain findings. On most occasions though (psuchê is a relatively infrequent term), he disregarded the notion altogether and used alternative constructs to provide a theoretical correlate of his apparently vast practical experience.
Finally, in line with Aretaeus’ ill-defined psuchê, the connection between the different forms of impaired consciousness does not point directly towards the soul itself. However, the three prototypical presentations do evoke elements that were vaguely associated with the soul, such as heat, tension and pneuma.Footnote 55 These are the main components often related to the soul that – in one way or another – tend to be present in most discussions on conditions involving impaired consciousness.
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.
Tieleman has accurately remarked that Aristotle had set the agenda of topics regarding psychology questions to be addressed and that several philosophers followed his lead.Footnote 1 We have seen throughout our discussion that a few doctors also addressed similar queries.
Schematically, the main issues under scrutiny – according to Tieleman’s reading of Aristotle – were the existence of the soul as something in itself, its substance (ousia), the number and the type of its powers and its localisation in the body. As we have been seeing, all the medical writers under scrutiny (including the pre-Aristotelian ones) took the existence of the soul for granted. All of them started from the assumption that there is a soul and that it is a major player in impaired consciousness. The case of Galen should, perhaps, be nuanced because even if he insisted on how obvious it was, he did provide proof of the soul’s existence in On the doctrines of Hippocrates and Plato. The substance was not a key issue, although some medical writers did attempt physiological explanations based on assumptions concerning the substance of the soul.Footnote 2 The most important concern for all these authors was the type of powers, the organisation of those powers and their localisation in the body. In other words, most doctors did take a position on each of the philosophical debates concerning the psuchê, but they only addressed the issues that were relevant to their practice. Unlike philosophers, they did not feel the need to justify all their assumptions. Galen, again, is the exception in this regard because he took part in medical and philosophical discussions alike.
As far as total loss of consciousness is concerned, we have seen a unanimous understanding of this presentation as a near-death experience, which points towards an assimilation of the soul to a life force, as though during fainting the body was momentarily depleted of whatever kept it alive. Accordingly, we have seen that this ‘life force’, contained in the breath in the archaic literature (identified as psuchê and thumos), is represented among the Hippocratic doctors as a medicalised psuchê that temporarily abandons the body during swoons and permanently in death. Similarly, in Celsus’ On medicine, it is the irrational part – the anima – of his dichotomous soul that reversibly separates during fainting and permanently departs with death. In Aretaeus this vital power, which the body becomes deprived of during total loss of consciousness, is construed as a tangle of ideas such as the heat of life of the body, the tension, the pneuma (all of them vaguely linked to his ill-defined psuchê). Finally, in Galen we should add the nuance that although total loss of consciousness was not strictly at the boundary between life and death (for in his account the soul did not actually separate during swoons – only the pneuma did), he did consider that the separation of the psuchê from the body was synonymous with dying, thereby equating his tripartite Platonic soul to a lifegiving entity.
Regarding the role of the psuchê as an abstract notion that provides a unifying theoretical common ground to the different presentations of impaired consciousness, it could be argued that this is certainly the case for the Hippocratic doctors. Amongst them, the all-encompassing psuchê – affected during total loss of consciousness – subsumed other constructs such as sunesis, phronêsis, nous, compromised in wakeful and drowsy impaired consciousness. Also in Celsus, the twin concepts animus–anima explain the different presentations of the condition. Thus, the rational component, mens/animus/consilium, is altered in delirium, whereas as suggested above, the degree of separation of the irrational anima – subordinated to the former – determines whether the patient faints (complete separation) or simply sleeps (partial separation). The case of Aretaeus is slightly different, because although there are common pathophysiological phenomena often associated with the different forms of impaired consciousness, he did not elaborate a consistent notion of the soul in his extant work, and his scattered allusions to it are often contradictory. There is, however, a unifying abstract concept that appears to be compromised in all the presentations of impaired consciousness. In line with Aretaeus’ engagement with the debate around perceptions, it could be argued that aisthêsis plays in his argument a role similar to that of the soul in the other authors. This construct appears to be ubiquitously present and compromised in all these conditions: in swoons and sleep, perceptions are interrupted (more so in the former than in the latter, where pain can still be felt). In delirium, on the other hand, individuals perceive abnormal things while their thinking is intact (unlike other cognitive conditions – mental illness according to our current understanding – where the gnômê is compromised but perceptions are intact). In Galen, finally, the soul is again a common component of the different presentations of impaired consciousness: its rational part in delirium and sleep, and all three components – especially the spirited soul – in the different forms of fainting.
In terms of interaction between body and soul (and the instrumentalist versus materialist debate), our authors’ understanding of impaired consciousness suggests that all these medical models of the soul had a strong functional component. From the Hippocratic texts onwards we can see that their grasp of diseases where consciousness was impaired is based on the compromise of certain capacities (or the abolition of all of them in cases of fainting), and that medical debates focused on which those capacities were, how they were grouped (or subsumed into larger constructs) and where exactly in the body they were located.
From a chronological point of view one can see a progressive identification and isolation of such functions, particularly after the anatomical Hellenistic developments, where perceptions and movement started to play a more central role in most explanations, thereby reducing the relevance of more vague Hippocratic concepts, such as sunesis, phronêsis, nous. Simultaneously, the idea of a ruling part also reduced the debates on locations to the cardiocentric versus the encephalocentric stance. Notwithstanding all these simplifications, the tension between body and soul remained unchanged, in the sense that conditions like delirium, sleep and leipothumiê tended to be regarded as diseases where the soul (or its rational part) was primarily affected and, through it, the body (in other words, an instrumentalist stance), whereas sunkopê was mainly conceived as a bodily condition that interrupted several capacities that belonged to or depended on the integrity of the soul (the materialistic view). Of course, it is our current understanding of consciousness as a continuum and of syncopes as a form of swoon that allows us to understand this distinction as artificial.
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