In the Introduction I set out to explore accounts of impaired consciousness in ancient medical texts along two axes. In the longitudinal thematic one, I aimed to contrast the different approaches to the topic against their respective medical contexts and to establish relationships between texts, authors and periods. The transversal axis, on the other hand, focused on how the development of ideas and debates around impaired consciousness illuminates our understanding of other concepts about ancient medicine in general and about the authors referred to in particular. In summarising the main findings of this research I will first focus on the transversal axis, and then I shall add my final remarks about impaired consciousness itself.
Transversal axis: what has the analysis of consciousness revealed about the sources?
The Hippocratic beginnings: a limited terminology for a multiplicity of symptoms
The Hippocratic doctors were a self-recognised group that shared – despite their heterogeneity – a set of ideasFootnote 1 for which they developed a particular technical language that enabled them to claim authority and differentiate themselves from rivals and competitors. However, the degree of development and level of technicality of their vocabulary remains contested.Footnote 2 In this context, my hypothesis about these writers’ use of partial synonymy in discussing forms of impaired consciousness provided a feasible solution to some ongoing terminological disputes, even if it has challenged most of the recent scholarship around this particular semantic field. Contrary to the predominant view,Footnote 3 this analysis suggests that both in terms of usage and meaning, most of the words utilised by the Hippocratic authors to talk about delirium are often interchangeable (much like our own contemporary medical vocabulary, and despite their apparent variety and multiplicity). Furthermore, this partial synonymy is paralleled by a similar (though not identical) phenomenon that involves the terminology for HOFs. Indeed, the concepts that these medical writers used to refer to the mental and cognitive capacities compromised during impaired consciousness are also more or less equivalent throughout the texts.
The relevance of these findings is that they point towards a rudimentary notion that pervades various conditions within the whole spectrum of consciousness (as we nowadays construe it), and that is shared by a large number of Hippocratic authors. This, ultimately, suggests that these writers understood that certain related conditions (which we can liken to our understanding of impaired consciousness) occur when certain capacities (which are subsumed in our idea of consciousness) are disturbed. As exemplified, descriptions of all three clinical presentations, as well as the recovery terminology, are permeated by this embryonic idea akin to our notion of consciousness. Stated in a complementary manner: delirium, sleep, swoons and their termination – in other words, coming round and waking up – are discussed by the Hippocratic doctors using a similar group of words, compounds of such words and phrasal terms in which those words are the noun head. Such a coincidence suggests that all the conditions under scrutiny belonged in the same semantic field, and therefore were related in these authors’ conception. Hence, it is legitimate to posit that one of the notions that provides a certain unity to the plurality of the Hippocratic discourses is a shared underlying seminal idea of consciousness, which they considered to be compromised during the affections that we identified as prototypical of impaired consciousness.
Post-Hellenistic sources: organisation of knowledge and focus on nosology
The analysis expanded on the well-described multi-layered nature of the post-Hellenistic treatisesFootnote 4 by revealing the way in which the authors under scrutiny dealt with the numerous voices available to them. It emerged that despite the evident differences between encyclopaedic and eclectic approaches, both have shown significant inconsistencies in terms of explaining the mechanisms underlying diseases. Indeed, Aretaeus and Celsus alike (and also the authors of the Introduction, the Medical definitions and the Anonymus Parisinus) privileged comprehensive dichotomous taxonomic systems – sometimes even overlooking clinical descriptions – over consistency in their understanding of the pathophysiological mechanisms involved. These findings are in line with the proliferation of diseases, concepts and the primacy of taxonomical distinctions in this period.Footnote 5
Accordingly, starting from the diversity of post-Hellenistic medicine in terms of practitioners, theories, classifications and definitions,Footnote 6 the analysis points towards a fragmentation of impaired consciousness into smaller unities, that is, more specific diseases (as compared to the broader and vaguer Hippocratic syndromes). This phenomenon was favoured by the introduction of new nosological entities, by a more thorough delimitation of existing ones and by the development of specific treatments for each of them. Forcing the mutable reality of impaired consciousness into a strict theoretical framework inevitably distanced the medical writers from empiric clinical observation and diminished the perceived connection among the three prototypical clinical presentations. Nevertheless, the evidence suggests that despite these theoretical constraints the authors were able to relate delirium to sleep and swoons, which points towards an underlying shared idea of impaired consciousness.
Celsus and corpuscular theories
The inquiry into impaired consciousness suggests the significant influence of corpuscular theoretical systems in On medicine, which – to my knowledge – had never been mentioned before, despite the multiple scholarly studies on the influences and sources that its author used.Footnote 7 In analogy to what Beagon has remarked concerning Pliny’s Stoicism, it is possible to envisage an Epicurean/Asclepiadean background influence in Celsus, which pervades his understanding of several processes. It is never explicit, and it probably reflects a common phenomenon among the intellectual Roman elites, namely, the adoption of a ‘philosophical veneer’ or an ‘intellectual wallpaper’ that conditioned their world view.Footnote 8 The parallels found between Lucretius’ On nature and Celsus’ On medicine suggest the above.
Two important implications can be drawn from this finding. On the one hand, it offers further support to Polito’s and Leith’s ideas about the Epicurean influences on AsclepiadesFootnote 9 (thereby opposing Vallance’s hypothesis).Footnote 10 On the other, it should warn us – as readers of the treatise – that although Celsus claims to look for the ‘middle way’ and explicitly tries to be inclusive of different positions, we must be careful in our reading of his text, because there is a bias towards a materialistic corpuscular understanding of certain processes. In other words, his media quodammodo diversas inter sententias leans towards this Epicurean/Asclepiadean view of the workings of the human body in conditions where consciousness is impaired. It might be worth exploring – in future endeavours – whether this stance is also present in relation to other affections, where the interaction between body, mind and soul is not at stake.
Aretaeus and lax eclecticism
In the case of Aretaeus, most scholarly controversies have focused on his sectarian affiliation. I reject the predominant hypothesis to group him among the PneumatistsFootnote 11 or to simply highlight his coincidences with the Hippocratic authors,Footnote 12 and propose instead to overcome the debate by focusing on his method. By looking at the way in which he explained the different processes and occurrences in diseases with impaired consciousness, it would appear that he drew from an abundance of theories available to explain these phenomena without strictly sticking to any of them. Thus, ‘lax eclecticism’ emerges as an alternative solution to a dispute that cannot be settled with the evidence that we currently have about the Pneumatic and Eclectic sects. The notion of lax eclecticism, therefore, deflects the focus of the sectarian debate onto a methodological one and reflects Aretaus’ imperfect attempt at compiling a coherent, consistent and comprehensive explanation for diseases and their mechanisms, by taking components from different – and often contradictory – sources.Footnote 13 It would seem that through this eclectic approach he addressed competing sectarian voices and made his own choices, thereby establishing his authority.
Moreover, because lax eclecticism presupposes the inclusion of elements from such different theoretical frameworks, it reveals – on the one hand – that impaired consciousness was being actively debated; that is, it was a focus of interest for physicians, and no single answer had been unanimously considered as satisfactory. On the other hand, the multiplicity of theories addressed illustrates the extent to which the medical discourse incorporated ideas debated in other disciplines – particularly philosophy – in order to understand and elucidate its clinical findings. Indeed, most of Aretaeus’ explanations about impaired consciousness are strongly influenced by contemporary philosophical debates on the relation between sensory perceptions and the reality behind them, as Pigeaud has illustrated.Footnote 14
Galen: a totalising approach
The present analysis sheds light on some specific details about the workings of the body and the mind in Galen’s comprehensive medical system. At the same time, it illustrates the level of coherence, consistency and explanatory power that it achieved. As several scholars have pointed out, he was able to frame the conditions within a carefully articulated system that combined well-established theories (humours, qualities, elements) with cutting-edge advances in medical knowledge (particularly anatomical).Footnote 15 Contrary to Pigeaud’s view,Footnote 16 I have suggested that he also succeeded in rationally connecting – without strong contradictions – the pathophysiological mechanisms with the therapy for such conditions. In this way, even when he proposed the same treatment as his competitors,Footnote 17 he was able to claim authority by explaining the rationality of his choice (an ability which his opponents lacked).
In terms of Galen’s take on mental affections, the notion of impaired consciousness offers a more comprehensive model for the conditions that Devinant ‘tacitly identified as a nosologic space’, where the soul – more specifically its hegêmonikon – was affected.Footnote 18 I partially agree with his idea that (what I claim to be) delirium is sometimes grouped together with psychiatric conditions – as I described in relation to mania (but not with melancholia). However, the present study has illustrated how other conditions – such as abnormal sleep and fainting, which we nowadays associate with impaired consciousness – were equally related to a compromise in the rational soul.
On the other hand, the analysis also uncovered some limits to the system that are not usually discussed by the scholarship. Because Galen was mainly focused on organs and quantities as well as the qualities of the mixtures, he was less detailed in his reflections on specific conditions. Hence, his model was weaker than the post-Hellenistic ones in distinguishing impaired consciousness from some neurological and psychiatric diseases (the case of the paralysed child among diseases of the hêgemonikon and the lack of attention to mania illustrate this shortcoming). Similarly, the strict boundaries that his view presupposed sometimes obscured certain continuities. Such is the case of the total separation that he articulates between normal and abnormal sleep.
Longitudinal thematic axis: advantages of exploring impaired consciousness
Impaired consciousness – a notion scarcely referred to in recent scholarship – emerges from this analysis as a powerful concept that provides valid answers to several controversial debates and groups together three clinical presentations (delirium, sleep and fainting) that had not been perceived so far by researchers as connected entities. As a result, the ideas about the role of the mind and the soul – and their relation to the body – which emerge from their analysis as a whole had been so far disregarded. Up until now, such debates had been mainly addressed by focusing only on delirium and mental illness.Footnote 19
Moreover, the notion of impaired consciousness condenses in itself a tension between two conceptual movements in opposite directions, which mirrors a dichotomy present in medical thought more generally. On the one hand, there is an attempt to explain the diseases through increasingly concrete and limited elements that the medical systems can easily address, such as humours, secretions, qualities, obstructions. On the other, there is a tendency to create progressively abstract notions (the gnômê, the psuchê, the hêgemonikon, etc.), which subsume the whole phenomenon in complex theoretical systems. The doctors navigate these tensions, but it is always the successful treatment to regulate the concrete altered bodily component that prevails over the perfectly functioning abstract model.
In this sense, this medically informed approach to psychology-related debates has highlighted some aspects that are absent from purely philosophical treatises. Regardless of the specific model that each author envisaged, any speculation is ultimately subordinated to the pragmatic approach of medicine. Doctors only considered their theories to be valid if they were useful in guiding therapy, and the better the treatment the stronger the theory. No matter how philosophically minded the author might have been, the theory could only be validated by the clinical outcomes; that is, logic always yielded to the results. In other words, although theoretical coherence was valued, some philosophical contradiction could be tolerated (even by Galen as his use of hexis and phusis suggests) as long as there were positive outcomes.
Finally, with a view to organising these ideas in relation to current scholarly constructs, we should perhaps regard impaired consciousness as a distinct category that is independent from mental illness even if it shares fuzzy edges with it. Naturally, within each of these categories a number of nosological entities along with non-nosological processes (such as healthy sleep) can be singled out, which are also sometimes difficult to separate from one another, because they too share some fuzzy edges. Apart from avoiding misleadingly applying modern concepts to ancient constructs, the advantage of this framework is that it better reflects the fluidity of the boundaries not only between the concrete diseases concerned, but also between the notions of health and disease, wakefulness and sleep and even between life and death in the world of ancient medical discourse.
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