Theoretical pronouncements notwithstanding, the Hippocratic physician was first and foremost a craftsman plying his trade.1 He, and it was almost always he, might work from his own house, which thus served as his surgery or ‘medical workshop’, and remain largely within his own community, or he might, like Homer’s craftsman-doctor, travel in search of patients.2 He might practise alone, or in company with others, travelling around familiar territory or wandering further afield as a total stranger.3 With one exception, his income depended on finding patients prepared to pay for his services, supplemented by whatever else he might gain from his property or estates, if he had any. That exception was some form of state service, whether as a doctor with the army or navy on campaign or as a so-called ‘public doctor’. If Herodotus is to be believed, there was already a system of public doctors in Aegina and Athens by the late sixth century, for Democedes held such a post in both cities.4 But there is then a gap in the historical record of a century or so, and the most detailed evidence does not appear until Hellenistic times. To judge from this later information, the presence of a public doctor was no welfare state avant la lettre. Certain physicians, in Athens chosen by the assembly, received what amounted to a retaining fee to reside in the community and be on hand to treat the citizens.5 Whether their contract compelled them to offer treatment for nothing is a vexed question: their tombstones and the honorary decrees that record their distinguished service show that they did so at times, but it is more likely that free treatment was left to the doctors’ own discretion than that it was legally imposed on them.6 Social pressures in a small community might compel a doctor to treat the poorest citizens for nothing, but he is unlikely to have been willing to do the same always for the rich, or for non-citizens. Nor is there any need to assume that he had in the fifth century also the contractual duty of assisting at inquests or other official occasions on which a doctor might be called for (situations known from Graeco-Roman Egypt), or that the role of an expert witness in court was confined to public doctors.7 State service, however, was an option for only a small number of physicians; the others, along with midwives, bone-setters, herbalists and the like,
had to rely on what they could gain by their own efforts. They faced competition, as we have seen, from various quarters, and it would be rash to assume that if self-help failed to work the patient always went out immediately to seek a doctor.8 In such circumstances it was crucial for a doctor to make a good impression on his potential patient. He needed to be able to speak well, in terms of both content and style – the late text Precepts jokes that he should nevertheless avoid the flowers of poetry, since that might betoken time ill spent, away from medicine – to avoid being outclassed by those who were just good speakers.9 First impressions counted for a great deal: a wellstocked and appointed surgery, a neat bandage on another patient, a sound pronouncement about the sort of disease likely to be met with in the locality, appropriate dress and behaviour, an avowed willingness to help, but, at the same time, a reluctance to go too far with rash procedures that might end up damaging or even killing the patient.10 The comic poet Alexis joked that even one’s dialect mattered: an Athenian doctor who prescribed beetroot using its Attic name would be despised, but a non-Athenian who used the Ionic or Doric form would be highly respected.11 All these would help to create trust on the part of the patient, and trust, as the author of Prognostic stressed, was an essential element in the struggle against disease. In this struggle there were three protagonists: disease, patient and doctor.12 It was up to the patient to choose whether to collaborate with the doctor or to fight his or her disease unaided. In turn, the doctor could not succeed without gaining the patient’s co-operation, whether as informant or as the willing, competent and compliant recipient of his advice.13 How was this trust to be created and maintained? Ludwig Edelstein, in a famous chapter, pointed to the importance of prognosis in Greek medicine in the fifth and fourth centuries as the primary way in which the doctor could establish his credentials and, at the same time, protect himself against accusations of malpractice.14 By being able to predict the likely outcome of a disease, and by announcing it beforehand to the patient’s relatives and friends, he could gain obvious credit for a cure, particularly if things took the course he said, and, second, should the patient die, he had a strong defence if he had already announced that this was a likely outcome. Success in a doubtful case would add even more to his laurels; while failure would be better tolerated by a patient’s family already prepared for the worst.15 But even within the Hippocratic Corpus one can find dissatisfaction with this ‘tactical’ use of prognosis as both advertising and insurance.16 The author of Prorrhetic 2 opens his tract with an ironic account of splendid and marvellous cases of prognosis that he has witnessed or been told about. He describes doctors arriving at the bedside to give a second opinion and immediately predicting a recovery, but accompanied by paralysis or blindness, or, while passing through the marketplace, telling this or that trader that they will die or go mad.17 A serious illness they might blame on a minor divagation from an athlete’s training programme. This type of prediction
and explanation the author rejects as mere ‘mantic’, ‘divination’, not true prognosis, and he strongly denies that this is what he himself is doing.18 He is prepared to accept that some of these extravagant predictions do come true, but that is only because their maker has correctly identified and interpreted the important signs that any good doctor should know, or because the disease, which when the first doctor arrived had not yet established itself, has done so in the meantime, and is now easier to prognose. What matters, in his opinion, is accurate prediction, understanding the important indicators, and then drawing sober conclusions from them.19 How one predicts has thus as important a role to play as what one predicts, and the patient is subtly warned against those whose claims might not be backed up by results.20 This author, like that of Prognostic, allows the possibility of distinguishing between foreknowledge, prognosis in the strict sense of the term, and foretelling, but he regards such a distinction as irrelevant to medical practice. One cannot make a sound statement about the future without sound foreknowledge, and only a fool would choose to be swayed by the manner of the pronouncement rather than its potential accuracy.21 As this author implies, prognosis is more than a tactical device to impress patients: it is central to the practice of medicine as seen by many writers of the Corpus. It is essential to the understanding and treatment of the individual patient, ensuring that whatever is prescribed will be appropriate for that patient and his or her condition.22 It is more than just predicting how a disease is likely to progress and whether the outcome is going to be favourable or unfavourable. It provides a way of controlling the disease, of modifying, if necessary, treatment in accordance with a predicted pattern, and of focusing on what each individual patient requires. It offers a claim to understanding that marks the doctor off from many other types of healers, and, if practised correctly, it enables the true doctor to intervene effectively and quickly even in the most dangerous of acute diseases.23 In short, the doctor who professes the art of prognosis declares that his particular technique deals with the past, present and future of his patient, a bold claim incorporating what today would be termed obtaining the case history, diagnosis and prognosis.24 Advice on how to prognosticate appears in several different forms in the Corpus. Sometimes, as in Aphorisms, Coan Prognoses, Dentition and Prorrhetic 1, it is presented as short aphorisms, memorable sentences or apophthegms that can apply generally to all cases.25 Prognostic and Airs, Waters and Places are avowedly longer guides to the practice of prognosis, the first treating it in general terms, the second specifically in a way that will prepare a travelling doctor for arrival in a new town. The Epidemics represent an intermediate stage, in which case notes are selected and organised according to their potential usefulness for prognosis. Individual case histories are rewritten in a form that allows them both to be incorporated within the Constitutions and to serve as a data bank for future comparison.26 In addition, the author specifies what the doctor should consider the most significant features of any illness, the
so-called signs, which the author of Prorrhetic 2 also judged to be an effective basis for a decision about the future course of a disease and the treatment of the patient.27 The author of Epidemics 1 gave a long list of such features: the common nature of all things and the particular nature of the individual; the disease and the patient; the regimen prescribed and the prescriber; the constitution of the heavens and the region, in general and in particular; the custom, way of life, practices and age; talk, manner, silence, thoughts, sleeping or not; dreams, plucking, scratching, tearing; exacerbations, stools, urines, sputa, vomit; the stages of a disease and its potential for crisis and death; and sweat, rigor, chill, cough, sneezes, hiccoughs, flatulence, haemorrhoids and haemorrhages.28 These symptoms lie at ‘the threshold of the seen and unseen’.29 Some of what should be looked for fits neatly with modern diagnostics and involves shrewd, careful and accurate observation, relying on all the senses: the pattern of the remission and relapse of fevers; any sudden change, especially in the altering of consciousness;30 the sound; in both quantity and quality, of a patient’s breathing; the possibility that a blow to one side of the head may show itself in an impaired function on the other;31 the signs of suppuration and discoloration that portend serious wound infection; and changes in the way in which the fingers are held. The so-called facies Hippocratica (the ‘Hippocratic face’) that is described in graphic detail in Prognostic still remains an excellent indication of the imminence of death.32 Other signs have fallen out of use, notably what has been termed ‘carphology’, the way in which a sick patient appears to pluck imaginary objects from the immediate surroundings, even though the phenomena can still be seen in hospitals and old people’s homes.33 Others seem to depend more on an underlying prejudice than on any clinical judgment. The often articulated belief, persisting into very recent times, that children born in the eighth month of pregnancy were almost certain to die whereas those born in the seventh generally lived is impossible to sustain on the basis of modern statistics of infant deaths, let alone in a society where the length and beginning of pregnancy were far from agreed or easy to determine.34 Although numbers do play a role in establishing a prognosis, in this instance the numbers may be here to serve an exculpatory purpose: no one was at fault if this baby died, for it was born after the most unfavourable period of gestation.35 This emphasis on close observation of signs and symptoms, leading to an understanding of their cause and then to their recording as a guide to what might happen in the future, is not confined to strictly medical literature. The historian Thucydides follows such a pattern in his wide-ranging account of the plague of Athens, and demonstrates at the same time considerable acquaintance with the techniques and vocabulary of contemporary medicine.36 Indeed, his whole history, with its emphasis on seeking an understanding of the causes of the conflict and its wish to make of it a record for future consultation in similar conflicts, shows that medical ideas might
Figure 6.1 Marble tombstone of an Athenian physician called Jason, shown examining the swollen belly of a child. British Museum, Reg. No. 1865,0103.3. © The Trustees of the British Museum. IG 22 4513.