Sometime in the late fifth century BCE, a doctor recorded this information about the daughter of Euryanax: for several days she drifted in and out of delirium, losing and regaining consciousness, too unwell to eat or drink and unable to speak, until she finally died ‘on the seventh day after the last delirium’ (Epidemics 3.1.6).
This book is a fascinating, though circumscribed, study of how ancient medical writers understood and dealt with cases like this, where sick people entered and exited what Pelavski describes as a state of ‘impaired consciousness’. The title of the book would seem to suggest a fairly wide coverage of material, but Pelavski’s focus is limited to a small number of case studies based on specific source material: the Hippocratic Corpus, Celsus, Aretaeus, and Galen. This is not surprising, as the book originated as a dissertation.
The book takes its inspiration from modern medical insights about patient behaviour. As Pelavski writes (p. 9),
In everyday practice, changes in consciousness are considered to belong in a continuous spectrum that ranges from patients who are ‘awake, alert and appropriate’ (that is, normally functioning individuals) to deep coma and vegetative states. Between these extremes, several levels of drowsiness, agitation, delirium and confusion have been singled out…ever since antiquity, physicians have strived to measure, grade and label these various states of consciousness and have devised tools to achieve this goal.
It’s stimulating to switch from modern observations about everyday medical occurrences to questions about how ancient doctors understood and handled the same things, and the author (who happens to be both a classical scholar and a consultant anaesthetist) clearly has a personal stake in the issues involved.
The aim of the book, therefore, is to analyse how ancient medical writers conceived of impaired consciousness, contextualise the viewpoints they put forward about it, and explore changes in thinking over time, from the fifth century BCE to the second century CE.
The argument develops in a sensible way, grounded in first principles. At the beginning the problem is posed: how do we define consciousness? The author points out that for medical doctors impaired consciousness is easy to recognise—‘not only in physiological processes, such as spontaneous sleep, but also induced by certain substances such as anaesthetics or recreational drugs…they are common during various types of disease, both mental and physical’ (p. 9). However, the concept itself is difficult to define, and perhaps no ‘universal, comprehensive, clear-cut definition’ is possible (p. 10).
The bulk of the book is then divided into three separate parts. In the first part, Pelavski deals with cases of delirium, a type of wakeful impaired consciousness. In the second part, the focus is on sleep, which is characterized as a type of impaired consciousness that has many fuzzy edges, being at the intersection of wakefulness and complete impairment. In the third part, Pelavski looks at cases of total loss of consciousness, the most extreme kind of impairment, such as instances where people faint. This structure makes it possible for Pelavski to explore impaired consciousness across a spectrum.
One of Pelavski’s main conclusions is that ancient authors, despite their theoretical differences, often shared similar underlying ideas of impaired consciousness. In the case of Celsus, there seems to be specific influence from corpuscular theoretical systems, which Pelavski attributes to philosophical influence among Roman elites. In the case of Aretaeus, Pelavski finds that this medical writer drew on an abundance of theories but apparently stuck to none of them strictly. Curiously, Galen emerges as less exact at distinguishing phenomena of impaired consciousness, which might surprise and amuse some readers. Pelavski’s concluding point—that impaired consciousness emerges as ‘a powerful concept’ that helps to shed light on a swathe of issues in ancient medicine—is convincing, but also raises the question of why the book didn’t end up exploring a wider range of case studies (e.g. a non-medical one) to see how this powerful concept played out elsewhere.
This book is not—and I apologise for the inevitable pun—for the faint-hearted. It is a serious, highly specialized monograph, almost every page of which expresses careful, intricately nuanced comments of a definitional, interpretative, or theoretical nature. At times, I did wonder whether Pelavski was trying to do too much in too small a space. A little more breathing room, and a little more discursiveness, might have helped the reader—its style is steeped in dissertation-speak. At other times, I wished that Pelavski had gone beyond his case studies and looked at ancient texts in a more extensive way, as this material could have helped to test or enrich his arguments; there was certainly plenty of space for him to do more (his conclusion ends at p. 204). Nevertheless, this is a rigorous and intellectually engaging study. Pelavski succeeds in opening up a new line of inquiry into ancient medicine, demonstrating that ‘impaired consciousness’ is a productive lens through which to reassess ancient clinical observation and theory. The book’s arguments are carefully constructed, and its conclusions will provide a firm foundation for further research in this area.